Inclusion of physical medicine and rehabilitation in the medical curriculum: A step in the right direction

INTRODUCTION

Physical medicine and rehabilitation (PMR), also known as physiatry or rehabilitation medicine, aims to enhance and restore functional ability and quality of life of people with physical impairments or disabilities. A physician having completed training in this field is referred to as a physiatrist. Unlike other medical specialties that focus on a medical ‘cure’, the goals of the physiatrist are to maximize patients’ independence in activities of daily living and improve quality of life. Physiatrists are experts in designing comprehensive, patient-centred treatment plans and are integral members of the care team. The medical specialty of PMR was first introduced in India in the early 1960s¹ and since then, it has been expanding steadily, although at a slower pace compared to other fields of medical specialization. Although PMR was recognized as an optional rotation for undergraduate medical students in the 1990s, it was only in the 2018 that the Medical Council of India included it as an essential subject in the Bachelor of Medicine and Bachelor of Surgery (MBBS) curriculum, which was implemented from August 2019.2

There are misconceptions about the medical specialty of PMR among Indian healthcare professionals, which impede the overall management of people with disabilities. The prevalence of disability in India stands at 2.2% (National Sample Survey, July–December 2018),³ which presents an already stressed Indian healthcare system with an enormous challenge of providing access to health for all.4 Improving the level of familiarity of physicians with PMR would not only facilitate the provision of rehabilitative health service to this subset of patients but also enhance their quality of life through a more comprehensive approach to their problems.⁵

We designed this study to reflect upon the inclusion of PMR in the Indian medical graduate curriculum and to delineate awareness of different areas of PMR practice among healthcare professionals. We did this survey on already licensed practitioners to understand their viewpoint so that more robust and conclusive measures could be undertaken to increase awareness about PMR among medical students and physicians in the near future. Our hypothesis was that most healthcare professionals would be hesitant about the late expansion of the medical curriculum. A literature search failed to reveal any study discussing the late integration of PMR or illustrating its awareness among Indian healthcare professionals.

METHODS

We conducted this observational study based on a questionnaire over a period of 4 weeks from January 2021 to February 2021. The survey had 10 questions, which focused on the familiarity of healthcare professionals with the medical branch of PMR and also about their views on the late integration of PMR in the curriculum of MBBS graduates (Table I). The cohort of participants was recruited with the help of social media (Facebook, WhatsApp). An introductory message explaining the research project was shared through the social media accounts of the author. All the participants who gave their consent were then sent the survey through an online, cloud- based software (SurveyMonkey Inc.).⁶ Care was taken not to include any physiatrist. The survey used a combination of fixed and open responses. Upon completion of each survey, data were automatically uploaded to the software. Responses were gathered anonymously with no acquisition of any personal details (name, gender, age, hospital where they worked, state, designation and year of graduation). A descriptive analysis was conducted on the survey data.

RESULTS

The survey was sent to 120 healthcare professionals working in different medical specialties, of which only 64 participants (53.3%) responded. Surveys with incomplete responses (n=3, 2.5%) were not included in the analysis. The distribution of participants from different medical specialties is shown in Fig. 1. The responses of participants to the questions asked in the survey are given in Table I.

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FIG 1.

Distribution of participants from different medical specialties

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DISCUSSION

PMR is an independent clinical branch of medicine that emphasizes the prevention and treatment of disorders, especially of the neuromusculoskeletal, cardiovascular or pulmonary aetiology, at any age, acquired or congenital, that may produce temporary or permanent activity limitation, disability or participation restriction in society including loss of quality of life.⁷ It follows the WHO International Classification of Functioning, Disability and Health and is involved with the prevention and reduction of disability and handicap arising out of physical impairments along with the provision of medical management of disability from a physical, psychological and vocational point of view.7 The 76th round of NSS (July– December 2018) concluded that the overall prevalence of disability in India was 2.2% with 2.3% in rural and 2.0% in urban areas.3 In a population of 1.353 billion (2018), a disability prevalence of 2.2% translates to approximately 30 million people with a disabling illness. In 2017, WHO launched the ‘Rehabilitation 2030’ initiative to draw attention to the profound unmet need for rehabilitation worldwide and highlight the importance of strengthening of health systems to improve rehabilitative services. Further, the ‘WHO Rehabilitation Need Estimator tool’ estimated that by 2019, approximately 2 in 7 people could benefit from rehabilitation in the South-East Asia Region with the highest need in India, where 410 million people could benefit from rehabilitation. Furthermore, there has been an 86.9% increase in years lived with disability between 1990 and 2019.8 With such a huge proportion of Indian population being in dire need of rehabilitative services, it seems that the late inclusion of PMR in graduate medical training is a step taken in the right direction. The latest Indian undergraduate curriculum follows Harden’s ladder of integration and suggests that integration should not exceed 20% of the total curriculum at recommended levels. Thereby, the clinical branch of PMR has been included in graduate training with 43 lists of objectives and 41 total integrations.²

The results of our study did not agree with the initial hypothesis. It was hypothesized that most of the healthcare professionals would be unaware of the scope of PMR as a medical specialty, but an overwhelming 96.9% (62) of the study participants recognized PMR as a postgraduate medical specialty. Notably, they were also of the opinion that the inclusion of PMR in the MBBS curriculum would help in dispelling confusion regarding the specialty and further help in familiarization of healthcare professionals with the entire continuum of its scope. It should be noted that approximately 60% of the participants were introduced to PMR in their medical schools which in turn reflects that the late inclusion of PMR would facilitate better coordination among health services. On a similar note, health experts from various countries in central Europe are also advocating for inclusion of PMR or rehabilitation medicine or physiatry in graduate medical training as the need of the hour.⁹ It has been successfully integrated as an essential component of medical training in various developed nations such as Australia, Belgium, Canada, France, Germany, Spain, Sweden, the UK and the USA.¹⁰

The most recognized procedures of PMR in our study were injections (intra-articular, peri-articular and ultrasound-guided) and the least recognized were urodynamic evaluations and cystoscopy. Almost two-thirds of the study participants said that they had referred their patients to a physiatrist, depending upon the circumstances. However, most of the referrals were for pain management, rehabilitation for CNS disorders and therapeutic exercises. Over the years, pain management has expanded to include interventional procedures in addition to pharmacological and non-pharmacological measures. This could be a plausible explanation for the injections and nerve blocks being among the most recognizable interventions of PMR and one of the most common causes for patient referral. Similar observations were made by Raeissadat et al. where the most recognized areas of PMR involved CNS disorders and the most common reason for referral was for therapeutic exercises.⁵ For the other domains of PMR, with the least recognition such as urodynamic evaluations or electrodiagnostic studies or cardiovascular rehabilitation, the low familiarity of healthcare professionals with the scope of PMR could have contributed to this observation. Collaboration of physiatrists with healthcare professionals of different medical specialties should, therefore, be encouraged so that optimum utilization of healthcare services could be facilitated seamlessly.

Almost 60% of participants in our study mentioned an introduction to PMR in their medical schools. Analogous observations have been made by Vlak et al. who observed that the introduction of PMR in undergraduate medical training promotes the acquisition of medical acumen necessary to manage persons with disabilities while contributing significantly to the general medical education obtained by clinicians.¹¹ Similarly, Raeissadat et al. also concluded that familiarization of medical students with the field of PMR has a positive impact on their present, and likely their future association and attitude towards this specialty.⁵ It is worth mentioning that physicians with no introduction to PMR during their training, have been found to have incomplete knowledge about disability, inability to assess disability and lack of experience in overcoming disability as well as lack of awareness of the possibilities of PMR as a medical specialty.^9,12,13 Further, as any patient may require rehabilitation, it is required that all physicians should be familiar with at least a basic knowledge of rehabilitation, while recognizing the importance of timely transfer of a patient to a physiatrist. It is thus important that PMR be taught in all undergraduate medical faculties.14