SCI Care: What Really Matters
SCI Care: What Really Matters
Trends in the Supply of Spinal Cord Injury Medicine Physicians in the United States: An Evolving Human Resource Shortfall
Key points:
1) The incidence and prevalence of spinal cord injury are rising due to an aging population, increased falls with incomplete cervical injuries and the impact of nontraumatic spinal cord injury.
2) With this increased incidence of traumatic and nontraumatic SCI, there is a growing need for Spinal Cord Injury Medicine specialists . This has resulted in increased training positions in the US.
3) However, many training positions in the US go unfilled and there is a growing need for trained SCI Medicine physicians. Proactive steps are needed to address this shortfall.
Host: Dr Michael Fehlings, Editor in Chief of Spinal Cord, Professor of Neurosurgery, Robert Campeau Family Foundation-Dr. CH Tator Chair in Brain and Spinal Cord Research, Vice Chairman Research), Co-Director Spine Program, Department of Surgery, University of Toronto
Speakers
Dr Jason Silvestre is a resident Physician at the Medical University of South Carolina
Dr Robert Ravinsky is a dual-fellowship trained, dual board-certified (Canada & USA) orthopaedic spine surgeon, Department of Orthopaedics and Physical Medicine at the Medical University of South Carolina
The opinions of our host and guests are their own; ISCoS does not endorse any individual viewpoints, given products or companies.
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The SCI Care: What Really Matters podcast aims to provide valuable insights and the most up-to-date information for those providing care to people with spinal cord injury (SCI) worldwide. The vision of the International Spinal Cord Society (ISCoS) is to "facilitate healthy and inclusive lives for people with spinal cord injury or dysfunction globally".
Contact us directly with any questions or comments at iscos@associationsltd.co.uk
Hello and welcome to our monthly ISCOS podcast.
Speaker 1:I'm Professor Michael Failings from the University of Toronto and I'm Editor-in-Chief of Spinal Cord, which is a flagship journal of the International Spinal Cord Society. Each month, as part of this podcast series, we feature an article in Spinal Cord that I feel is timely or very important to highlight. And this month we're featuring an article entitled Trends in the Supply of Spinal Cord Injury Medicine Physicians in the United States an Existing Human Resource Shortfall. And I'm pleased to be joined on this podcast by the first author of this paper, dr Jason Silvestri, who is a clinical research fellow at the Medical University of South Carolina in the Department of Orthopedic Surgery, and by the senior author, dr Robert Ravinsky, who's an associate professor of orthopedic surgery at the Medical University of South Carolina. So, gentlemen, thank you for joining this podcast and discussing our paper and, by way of acknowledgement, I also have to indicate that I am a co-author on this paper for full disclosure, very proud of that. So perhaps, jason, I'll start with you and can you perhaps briefly summarize the key points from this paper.
Speaker 2:Yeah, I think really the genesis of this paper was, as you know, spinal cord injury is increasingly a multidisciplinary effort, especially here at MUSC. We've sort of seen the complexity of these patients and we've collaborated with some of the other co-authors who aren't with us, who are physiatrists, and we wanted to look specifically at spinal cord injury medicine and to see what were the trends in sort of nationally in the US, what was the pipeline of these needed specialists, right, and I think the three main conclusions from the paper can be summarized as the following I think there's been over the past sort of decade a consistent growth in the training capacity for spinal cord injury medicine. It is a fellowship or a subset of, primarily for physical medicine and rehabilitation, although it is a multidisciplinary fellowship. There's been a constant growth of programs and training positions, however, secondly, there's been a somewhat not consistent increase in the number of applicants. So, depending on the year, the sort of rate of unfilled training positions would range somewhere between 35 to 50 percent. Overall, from the study period it was around 40 percent.
Speaker 2:And I think really what we wanted to discuss, you know, today and through the paper, was sort of the need to bring greater awareness to this need right. As you know, as you pointed out in prior studies, the sort of, the rates or the number of patients who are suffering from spinal cord injury is increasing. Yet, as we point out in the discussion, the number of diplomates and the a specialty society to encourage growth in this relatively nation field of medicine. How can we expose medical students earlier in the pipeline such that they are attracted to this field of medicine? And really I think that's sort of the the crux of the paper thank you.
Speaker 1:That's um uh, you know, an excellent uh summary, and certainly the paper is very uh topical. Uh, dr rovinski rob, perhaps I might ask you, as the senior author on this paper, to give your perspectives yeah, I, you know, I think that you know.
Speaker 3:uh, dr savastri summarized that. You know I can. My perspective is is the following, and I suspect it's somewhat similar to your own. You know, dr Phelans, I mean, you are one of the foremost researchers in the world on spinal cord injury and apart from being very familiar with the literature, I'm sure that you yourself have seen in recent years that the number of spinal cord injuries that we are seeing clinically, you know, at Toronto Western Hospital and likewise at, you know, at large tertiary care centers like our own in South Carolina, are increasing significantly. It's not necessarily younger people with high energy injuries, but certainly the rate of central fluid injuries is going up.
Speaker 3:And you know, I think we are also increasingly recognizing that the surgical care or the possible surgical care these patients experience at their initial sort of presentation to hospital is really a small part of the complexity of their long-term care.
Speaker 3:We as surgeons are very heavily reliant on our spinal cord injury medicine colleagues in our center. That is, the PMNR inpatient service and then the rehabilitation service at our rehab facility, which are sort of the counterpart to our big house per se. These patients have incredibly complex medical and even psychosocial needs and they really do require a very nuanced, very holistic, multidisciplinary approach to receive sort of optimal care in the long term, even outside of the initial period of treatment. Six months down the road, one year, two years, three years down the road, if you look at some of the data that exists regarding the costs of care in patients with spinal cord injuries, the costs of care are significant on an annual basis for years after their initial presentation, and the reason being that they do have such complex and nuanced medical needs. So I do fear that we are at a place where we really are lacking in some of the human resource manpower, if you will to provide the care these patients certainly require.
Speaker 1:I think this paper is extremely timely and I want to thank both of you for driving this research forward. It is interesting to reflect on the fact that, despite very successful prevention efforts, which have reduced the incidence of workplace injuries and high-velocity injuries such as road traffic accidents, there's reductions in drunk driving and so on and so forth Paradoxically, the incidence of traumatic spinal cord injury has remained stable and might actually be slightly increasing, and certainly, I think, an evolving trend that we see is this entity that we have now referred to as non-traumatic spinal cord injury. And, Rob, I wonder if you could maybe just reflect on this in your own practice, how you're kind of seeing this issue of non-traumatic spinal cord injury, maybe your own reflections on what this means and why this is an important area.
Speaker 3:Even though I work at a level one trauma center and it's kind of a big referral center for the region I see far more of the non-traumatic spinal cord injury that you're describing people with pre-existing spondylosis who are experiencing really low energy traumas, ground level falls. Sometimes they have, uh, undiagnosed or, um you know, very mild myelopathic issues that were present at baseline. That can come out later on in the history when you're kind of getting into the weeds of the patient. And a lot of these patients do have very good clinical outcomes, they do seem to make neurological improvements. But there is also the odd patient who comes in with a very profound deficit and these typically tend to be the patients who have long-term neurological dysfunction.
Speaker 3:And this is really the subgroup that I think benefits from a long-term multidisciplinary care. You know, just to go beyond that a little bit, you know we are experiencing lots of additional strains that were not present 5, 10, 15 years ago in the American health care system, where there are increasing costs of care, increasing challenges regarding access to timely care. Certainly, in this type of changing landscape, having a deficiency in terms of the number of experts who are providing this type of very important and extremely nuanced long-term care is concerning, to say the least.
Speaker 1:Yeah, thank you. You know. What's interesting to note is that the spinal cord injury, of course, is a global phenomenon, and the incidence of spinal cord injury is higher in middle and low-income countries than it is in highly resourced countries. There's likely a gap in terms of the number of specialist physicians with training in spinal cord injury medicine and the number of people that would benefit from this type of care. So that's really quite an interesting perspective, you know an interesting perspective and it I think it speaks to issues related to equity in healthcare delivery as well. So, Jason, you know you're getting near the conclusion of your training, but you're probably closer, I guess, to medical school training than Rob and certainly myself. How do you think that we could perhaps reach out to younger physicians in training and specialists in training to bring to light, perhaps, the opportunity to consider a specialization in the area of spinal injury medicine?
Speaker 2:Yeah. So really the crux of the discussion kind of highlights two or maybe three key takeaways. I think at least graduate medical education and American education from the you know 60s is sort of still largely stagnant. Uh, over the past 50 years, right, um, you'll have your core organ-based learning curriculum cardiology, gastroenterology, nephrology, pulmonology, etc. But over the past sort of 10, 20 years you have seen a lot of these newer subspecialties. Even physical medicine and rehabilitation in the US is a relatively recently boarded and even spinal cord injury medicine is that sort of recently recognized, especially within that over the past sort of 20 years.
Speaker 2:And so I think there's a real need to bring musculoskeletal medicine, physiatry, physical medicine, rehabilitation, get sort of medical schools integrating this into their curricula earlier in the pipeline, right. I think there's a lot of literature showing you can peak interest and increase exposure during those early kind of what I call vulnerable or susceptible areas. Right, we've all can think of a really influential mentor that we've had early in our career. That's helped shape us and I think, if you know, especially societies and PNMR are able to sort of coordinate those working with different student interest groups, providing scholarships, networking opportunities, travel grants for medical students to engage earlier in the specialty. I think is an important work moving forward.
Speaker 2:Secondly, I think once you get sort of physicians in PM&R, you know, in the pipeline, I think there's a need for longitudinal mentorship for physical medicine and rehabilitation doctors to be exposed to spinal cord injury medicine earlier in their training as well, within the four years, the first two or three years, getting earlier exposure to this complex patient population.
Speaker 2:And then, lastly, I think there's a need to sort of maintain, through physician advocacy efforts, sort of the attractiveness of spinal cord injury medicine as a subspecialty, because, as we're seeing here in the US, there's a constant sort of financial disincentive to at times, pursue additional subspecialty levels of training. And so, you know, imagine a recent graduate is presented with two opportunities remain a generalist with higher financial compensation or, you know, receive further clinical subspecialty training for somewhat commensurate or even less, you know, financial opportunities. I think that presents oftentimes an opportunity cost that's too high. And so, you know, through physician advocacy efforts and working with, you know, the regulatory body, cms, et cetera, I think we need to preserve sort of the financial rate of return for, you know, this important resource that is being provided here in the States and elsewhere. So I think that's really the sort of the crux.
Speaker 1:Yeah, thank you so very eloquently stated, so perhaps I'll just make a few summary comments then in closing.
Speaker 1:So, in summary, we've been discussing an article which has recently come out in Spinal Cord, entitled Trends in the Supply of Spinal Cord Injury Medicine of Physicians in the United States, involving human resource of shortfall, and we've been joined by the first author, dr Jason Silvestri, and by the senior author, dr Robert Ravinsky from Linden University of South Carolina, and in essence, this article has summarized the fact that the incidence of a spinal cord injury, both in traumatic and non-traumatic forms, is actually rising in highly resourced countries such as the United States, and this has been recognized in the fact that the number of training positions has increased.
Speaker 1:Paradoxically, the number of physicians who are undertaking this type of subspecialty training has not increased and, as a result, there's an evolving shortfall from a human resource perspective. And this is concerning in that the US, of course, is a highly resourced country and one might imagine that such shortfalls would be even greater in middle and lower income countries, and I think this article serves a great service to the field by highlighting an area, and it presents many opportunities for further discussion and knowledge translation, and from a personal perspective as Edinburgh Chief of Spinal Court, I felt that this article was very important to highlight in this podcast and in an effort to pursue this knowledge translation. There will be the opportunity to disseminate this podcast further, so on that note I'm going to close this podcast. Rob and Jason, thank you so much for taking a few minutes out of your busy clinical days to discuss this very interesting article and, in particular, thank you very much for putting this article together, which I feel represents an important contribution to the field.
Speaker 3:Professor Failings, we just want to just thank you for your gracious invitation to have us and it's such a privilege and a pleasure and we know like it's great to see you again. So thank you so much, you're welcome.