PMR On Point.

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Thank you for reading our PM&R newsletter, which taps the brainpower of our clinicians, scientists and alumni to highlight our specialty from every angle. Our goal: to deliver actionable insights and valuable takeaways to your inbox — on time, on topic and on point.

Are you planning to attend the AAPM&R annual meeting Nov. 6-10? Visit us at Booth 1227 in the PM&R Pavilion and don't miss these presentations from Shirley Ryan AbilityLab physicians and alumni.

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• Feature. Understanding Implicit Bias and Structural Barriers to Care — and How Physiatrists Can Help Counteract Them
• Influencer. Scott Primack, DO, FAAPMR, FAOCPMR (’92 Residency)
• CME Opportunity. Functional Neurological Disorder: From Symptoms to Solutions

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Allison Kessler, MD, is a physiatrist working with patient populations that often are marginalized. She also is a person living with a disability.

In the following Q&A, learn how she’s building awareness about implicit bias in healthcare and structural barriers at play — and ways that we, as a community, can work to overcome them.

Let’s start with the basics: How do you define implicit bias, and how pervasive is it? 

As human beings, we are all subject to cultural and generational stereotypes.* Implicit bias may be related to a person’s age, weight, gender, sexual orientation and more.

Studies suggest that the vast majority of humans harbor some sort of bias. Doctors are not exempt. Zooming in on the patient population we care for, a study led by my colleague Tara Lagu, MD, of Northwestern University found that 20% of doctors will not treat people with disabilities — particularly troubling given that 61 million Americans have some type of impairment. This reluctance stems from many factors — from not having proper equipment and staffing to not having appropriate education to treat these patients. This bias can influence diagnosis, treatment decisions and levels of care.

We know from research that exposure can reduce bias. Although there is some data that shows physiatry residents have lower biases caring for people with disabilities than do residents from other specialties, we all have ingrained biases to overcome. The stakes are high.

Having these biases does not make us bad people or mean we have to act on them; it means that we need to be aware of our automatic internal hurdles and responses so that we can work to counteract them. As physicians, we have a moral and ethical obligation to do so.

What are some structural barriers that exist that might feed into these issues?

So many structural issues exist. For instance, as medical complexity goes up, reimbursements for physicians are declining. A 15-minute allocation simply is not enough time to care for a patient who has a cognitive, speech or physical impairment. Furthermore, physicians can even lose money when caring for patients who require additional supports, such as a translator or interpreter.

Many medical spaces are not accessible, which can add to appointment time and frustration on the part of both patients and practitioners. Of course, adding accessible elements, including wheelchair ramps and adjustable-height tables, is an expensive endeavor.

Finally, physicians do not receive the needed training to anticipate the needs of people with disabilities and provide the comprehensive care they require and deserve.

What has spurred you to study — and try to reduce — implicit bias? 

I am a physiatrist working with patient populations that often are marginalized. I also am a person living with a disability.

Physicians hold plenty of biases against disabled people that can interfere with their care. The most dangerous tend to be related to judgments about one’s quality of life. If you assume someone has a poor quality of life, you’re going to be less aggressive about treatment, offerings and the counsel you provide. It’s key to not make assumptions about people’s lifestyle, experiences or needs based on their ability level, but instead to ask appropriate history questions as with any individual.

My background doesn’t mean I’m free from implicit bias — I’m just more aware of its existence. Like everyone else, I need to harness strategies to counteract biases so that they don’t cloud my judgment or inform my decision making.

My efforts have been focused on education and training. Currently, I’m collaborating with Shirley Ryan AbilityLab’s Leslie Rydberg, MD, and Harvard’s University’s Dorothy Tolchin, MD, outlining steps physiatrists can take to help combat bias. Collectively, we need to get this message out more broadly. 

What can physiatrists do to help mitigate implicit bias and eliminate some of the barriers you’ve outlined? 

We already know that doctors experience implicit bias just like anyone else, and that harboring such bias has real implications for patients’ care and outcomes. We also know that very challenging structural barriers exist.

As physiatrists, we are natural leaders in this space. We owe it to ourselves, our patients and our community to take up the mantle and champion awareness and change. There are so many actions — both large and small — that we can initiate at our organizations and, more broadly, in medicine and society:

1. Identify messaging and cues your organization projects that could feed into unconscious bias and perpetuate stereotypes. 
   
   Are your spaces accessible? Does your clinic have such accommodations as larger exam rooms — or even just one exam room with universal design — overhead lifts and scales that can be used by wheelchair users?
   
   Additionally, is your signage inclusive? Recently, I suggested to my organization’s leadership that we adopt the more dynamic wheelchair symbol throughout our hospital, which reinforces motion and autonomy.
    
   The update, although relatively simple, goes a long way in changing perceptions.
2. Create educational opportunities for the next generation of physicians. 
   
   In our field, we work every day to care for people with functional impairments. However, we’re only one piece of the medical puzzle.
   
   Many physicians feel they didn’t get adequate training for how to care for a person with a disability. We still need to ensure that primary care doctors, cardiologists, gynecologists and other specialties are trained to work with this population. We must educate medical students and residents, give lectures, share best practices and propose actionable solutions that will improve patient experiences and outcomes. 
   
   As part of this education, we need to teach the social model of disability, which examines the bigger picture, framework and structures at play, versus the traditional medical model, which tries to fix the disease process.

3. Advocate on the national stage. 

   History reminds us that larger societal pushes lead to change. As such, we need to be part of a bigger social movement, advocating for our patients and lobbying for new laws — focused on how care is reimbursed and more — that support and protect them.

   We can all play a role that pushes toward change, but it doesn’t need to be the same role. For instance, I give lectures, lead research and publish papers on bias. I may not lobby on Capitol Hill, but some of my colleagues do. We are all rowing in the same direction; no action is too small and all action moves the needle.

*Test your own bias through Harvard’s Project Implicit.

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For 16 years, PGY3s and PGY4s in Shirley Ryan AbilityLab’s residency program with Northwestern University Feinberg School of Medicine have participated in a unique two-day course. Using ultrasound, they learn how to create and interpret images of joints, muscles, tendons and nerves, and how to complete procedures like targeted joint and soft tissue injections that require ultrasound expertise.

This course — the Dr. Scott Primack Physiatric Applications of Ultrasound Course — is named for one of our program’s distinguished alumni. Dr. Primack is the first physiatrist ever to recognize and document the use of ultrasound in physiatry. He also donated the very first ultrasound machine to RIC for dedicated use by our PM&R residents.

“My feeling was, whatever I could do for the residency program, that's what I wanted to do. They needed an ultrasound machine, so I donated one,” said Dr. Primack. “There's no way I would be here today without the opportunities I had as a resident. This was a thank you for training me.”

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When you were a resident, ultrasound was an emerging technology and not used in physiatry. How did you learn about it, and what made you think it could be a useful tool?

In 1991, I read a paper in The Journal on Bone and Joint Surgery — I'll never forget it — written by Dr. Doug Harryman, Dr. Laurence Mack and Dr. Rick Matson. They were all part of the Shoulder-Elbow service at University of Washington. Their research was an outcome analysis looking at pre- and post-operative integrity of the rotator cuff tendon complex and its correlation with function. What was most interesting to me was their choice of documenting the integrity of the cuff. They used diagnostic ultrasound. This article spoke to me because it could be done in the office and give a diagnostic anatomical construct of the tendon and it correlated with function.

What about that study resonated?

At the Rehabilitation Institute of Chicago (now Shirley Ryan AbilityLab), we trained under Ian McLean, who was the head of the Electrodiagnostic Lab and by far one of the most brilliant people I've ever been around. He really drilled into us that electrophysiologic testing, like any other test, ought to be an extension of the history and clinical examination. By this method, we should already have an excellent understanding of the diagnosis. The study would be almost confirmatory in nature. When I read this article, a few things came to mind. First, as physiatrists, we are all about outcomes. Also, we are all about finding what we can do in the clinic that can augment the patient’s experience and facilitate a discussion related to the diagnosis and ultimate course of  treatment. I saw how ultrasound could be used to see what was previously unseeable.

After that article sparked your curiosity, what came next? A fellowship?

Back then, there were no fellowships in PM&R. You had to figure out how to get training on your own. So, I did the only thing I could do. I wrote to those study authors asking if they’d let me do a fellowship or rotation in their department. They wrote me back; I still have the letter! They offered me a rotation, but without any pay. I responded, “If I were to do research and training in Seattle and try to bring musculoskeletal ultrasound into a clinical setting, since I could not take orthopedic call, you have to put me in a department or let me moonlight” — which was practically verboten then. I got another letter back: “We like your persistence. Come on out, and yes, you can moonlight.”

What was your experience at University of Washington like?

For almost one year, I would leave my day job at the University of Washington’s Shoulder-Elbow service at 6 p.m. Then, I would drive to start the second half of my day, moonlighting in the belly of SeaTac Airport at the 24-hour clinic, providing diagnosis and subsequent ultrasound imaging for musculoskeletal injuries found in flight mechanics, bag handlers and those in other roles. That place was a physiatrist’s dream, because most of the injuries were non-operative in nature and could be treated with rehabilitation. The key was utilizing musculoskeletal ultrasound in order to augment the diagnosis and treatment of the injured workers. I collected an incredible volume of scans to sharpen my ultrasound skills. By the time my post-residency work at University of Washington was over, I had enough material and published “Musculoskeletal Ultrasound: The Clinician’s Perspective” in the Radiologic Clinics of North America.

What was the reaction from your fellow physiatrists to your research?

At the 1993 AAPM&R meeting in Orlando, I presented my research at a session. There were nine people there — including my wife, my daughter and my mom. The session format, which was typical in those days, included a moderator. When I was done, that moderator literally said, “This is one of the single biggest wastes of time that I've seen.” 

I continued to practice in Denver and continued with my research. A few years later, while giving a lecture regarding the efficacy research, there were 400 people in attendance. It was mind-blowing thinking how I went from presenting in a room that was 33% composed of my family members to a packed house!

You’re obviously passionate about ultrasound, since you’ve devoted your life’s work to it. What is the best thing about this procedure’s effect on the practice of PM&R?

It really puts physiatry where it should be: as a critical component in the continuity of care. Not in the basement — why are so many physiatrists in the basement? — but on the first floor. Whether it is a situation of “no operation,” “preoperative intervention” or “post-operative care,” physiatrists should be at the center of care, and ultrasound actually gets you there. For instance, say you have a scan of a person's shoulder and there is just the beginning of atrophy and just the hint of fat in a rotator cuff tear. That person needs to go to the OR really, really fast, because the more fat that infiltrates, the poorer the outcome. On the other hand, let us say you have a patient with a partial thickness rotator cuff tear and shoulder pain, but the scan shows the muscle looks great without atrophy. There is no reason that person needs to be in the operating room. They may just need some good old physiatric encouragement and coaching. This is the sweet spot for us to be in.

Another example is chronic pain. With ultrasound, you get a better understanding as to the “why.” Do the patients have fatty infiltration in muscle? Do they still have a lot of atrophy and need a little more encouragement for rehabilitation in PT? This happens after ACL surgeries. I see a lot of post-op ACLs, and I can see the volume of the atrophy, and I keep saying, “I know you’re hurting but you've got to do more. This is the reason why you're not where you want to be.” Most people like that sense of feedback, which ultrasound provides.

What do you see as the future of ultrasound use in PM&R?

The new frontier is in the ultrasound of nerves. We are now able to image nerves quite readily with improved technologies. What a remarkable thing to have an anatomical model of the nerve and an anatomical model of the muscle! Combining this understanding with what we know about electrophysiology, it is the best of everything. Dr. Jay Smith at Mayo Clinic has a device that does carpal tunnel release under ultrasound guidance. There’s so much we can do that was once unheard of, but there's still so much more we can do. 

If I were to give a lecture to residents tomorrow, I would recommend they look at the population of people who have had amputations. Now, with the newest ultrasound technology, we can see what happens to muscle as the mechanical integrity of joints changes following limb loss. This is a really exciting time!

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Perceptions about functional neurological disorder (FND) have evolved over recent decades, with continued research highlighting changes in attitude toward its treatment. Join us for this on-demand course, which provides an overview of positive clinical signs leading to a diagnosis of FND, dispels common misconceptions, and emphasizes communication skills and interprofessional teamwork while working with this patient population in the rehabilitation setting. See full details and accreditation info.

Register for the program.

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