The 21st century is well underway and we are experiencing a worldwide juggernaut of medical research and progress in medical practice. This has created an ever-changing environment in which physicians try to stay current with the latest developments in their field. As a consequence, there is a movement toward greater medical specialization. More and more physicians are entering subspecialization, i.e. gaining expertise in a niche within a specialty.
Physical Medicine and Rehabilitation (PM&R), a medical specialty that has been around since the 1940s, provides expertise in the care of persons with disabilities and should be familiar to every person living with spinal cord dysfunction. There are 80 accredited residency programs in PM&R in the United States. A physiatrist is a physician specializing in PM&R. Many physiatrists choose to pursue additional advanced degrees (MS, PhD) or complete fellowship training in a specific area of the specialty. Fellowships are available in such areas as musculoskeletal rehabilitation, pediatric rehabilitation, traumatic brain injury, stroke, pain management, spinal cord injury (SCI) and multiple sclerosis (MS).
The annual number of spinal cord injuries and new MS diagnoses is about the same—roughly 11,000—in the USA. The prevalence of chronic SCI and established MS are also in the same range, estimated at 250,000 for spinal cord and 400,000 for MS. So we would expect approximately an equal number of physiatrists to be subspecialized in these two conditions. There are, however, surprisingly few MS physiatrists—perhaps a dozen in North America—while there are over 500 in SCI. This is partly due to a shortage of training programs in MS. While there are twenty fellowships in SCI around the country, there is only one established program in MS. This makes it extremely difficult to meet the need for physiatrists with MS specialization.
The one MS fellowship for physiatrists is at the University of Washington. It began in 2001 with a grant from United Spinal Association. George H. Kraft, MD, the Alvord Professor in the Department of Rehabilitation Medicine at the University of Washington, has been the director of this program since its inception.
So far, the training has graduated four fellows, including Ted Brown, MD, MPH, who now operates an MS clinic in Seattle, Washington.
Orbit: How did you become interested in multiple sclerosis?
Ted Brown: Every physical medicine and rehabilitation resident becomes interested in MS, because it is such an important and unpredictable disease. It can manifest in many ways, from vision loss to paralysis of two or even four limbs. The course of the disease is extremely variable. Some people have a few “attacks” of neurological problems over decades, while others deteriorate much more rapidly and progressively. The amount of physical or cognitive disability depends on the aggressiveness of the disease and on what parts of the central nervous system (brain or spinal cord) are afflicted. Typically, it strikes people at the prime of their lives and so patients often have ages and backgrounds similar to a PM&R resident. In my case, I had vivid memories of the MS patients who I met during residency. This made MS feel very personal and very significant.
Orbit: How did you find specialty training in MS?
Dr. Brown: I got lucky! I had trained under Dr. Kraft during my residency in PM&R at the University of Washington back in the early nineties, when no MS fellowships existed. Then, I spent nine years working at a rehabilitation hospital in Thailand. It was a fascinating experience. There is very little MS in Thailand. There may be genetic and environmental reasons for that. Eventually, I wanted to return to the USA for further training. I started looking around for fellowship programs and asked my mentor, Dr. Kraft, for advice. He surprised me by saying, “If you are looking for a fellowship, why don’t you study MS with me?” I said, “”But I have only seen three cases of MS in the past nine years.” He replied, “That is why you should do the fellowship.” That is what I did from 2003 to 2004.
Orbit: What was the fellowship like?
Dr. Brown: It was a terrific learning experience. I worked at Dr. Kraft’s MS rehabilitation clinic at the University of Washington. There I could apply rehabilitation principles to the care of MS patients and see many more MS patients than I could working in a general rehabilitation clinic. I worked with Dr. Jodie Haselkorn, another physiatrist at the MS clinic of the Puget Sound VA Medical Center. I spent time with two neurologists, Dr. James Bowen and Dr. Jeffrey Dunn, who helped bring me up to speed regarding the medications used to treat the underlying immune imbalance in MS. These medications are called disease modifying therapies and there are five of them available at present. When I did my residency in the early nineties, there were none. These drugs all have differences and it requires a lot of study to get thoroughly acquainted with them. The neurologists taught me how to do a proper neurological exam and how to diagnose MS as a neurologist is required to do. I worked with nurse practitioners, psychologists, PTs and OTs who are interested in MS. I also got to see MS patients on my own, which helped me to adapt what I had learned from all of my instructors. It was an intense learning experience, but one that I truly enjoyed.
Orbit: Were you able to see how MS care is practiced at other centers?
Dr. Brown: Yes I was. The fellowship provided support for attending workshops, seminars and national meetings on the topic of MS, even an MS consortium meeting in Canada. At these meetings, I learned much more about MS and got to know “who’s who” in MS. It is still a small field, especially when it comes to physiatrists.
Orbit: What about research?
Dr. Brown: I was expected to develop an MS research project. This was a real learning experience in and of itself, since it took us the better part of my fellowship just to obtain funding and approval from the institutional review board. The project was just presented at a national conference in June 2005. Dr. Kraft let me participate in other projects as well. His research program is one of the biggest in MS in the USA with over 20 health professionals studying many aspects of MS rehabilitation.
Orbit: What effect did it have on your career?
Dr. Brown: The impact was huge. During my fellowship, I saw a great need to get more physiatrists into MS care. I got a few job offers to do general rehabilitation work and some of them were attractive. But I had been fortunate to get special training in MS care and I wanted to make the most of it, in terms of helping people with MS. So I narrowed my search to a few MS centers that were looking for a physiatrist. By the time I started working at one of them, I felt that my training had really paid off. Now I work with a neurologist and other health professionals in a nonprofit MS center.
Orbit: What would you like to do in the future?
Dr. Brown: Stay focused on MS patient care. I got my first independent research grant a few months ago and hope to work on some of the important rehabilitation questions about MS. Why do people with MS fall and how can we prevent it? What advice should we give people about exercise and how can we motivate them? How can we reduce disabilities related to cognitive function, bladder function and sexual function? I would also like to encourage young physiatrists to enter this field, just as I have been encouraged.
Orbit: What does the future hold for MS?
Dr. Brown: Let’s all hope that there will be a cure. There seems to be a trend toward concentrating MS care at specialty centers. In five years, it may be common to combine the injectable drugs that are now being used with oral medications that complement their effect or promote neuroprotection (preserving axons). It is likely that we will have a blood test that is highly predictive of MS and other blood tests that help us to track the activity of MS. In the next ten to twenty years, a huge breakthrough should be succeeding in repairing nerve damage due to MS. Several intriguing possibilities are already being investigated.
Orbit: Anything else?
Dr. Brown: I want to thank United Spinal for having supported my fellowship. I would like to think that it was a good investment!
