Welcome to our article about the history of rehabilitation medicine here in Chapel Hill. As you read, click on each photo to take our quiz!
Rehabilitation services within the University of North Carolina at Chapel Hill School of Medicine and UNC Health Care have significantly evolved over the last 40 years. In the 1970s, a hospital-based inpatient unit originally began as an eight-bed multi-service medicine unit.
During the early 1980s the School of Medicine attempted to sustain a creditable rehabilitation program through the collaborative efforts of the divisions of neurology, orthopaedics, rheumatology and neurosurgery. Suzanne Sauter, MD, a rheumatologist in the Division of Internal Medicine, provided medical direction for the Rehabilitation Program from 1980 to 1993, during which time the unit increased to 16 beds dedicated solely to rehabilitation and an outpatient rehabilitation clinic provided services one half-day per week. Steven Gudeman, MD, chief of the Division of Neurosurgery, assumed directorship from 1993 to March of 1994. While this initial collaborative arrangement was adequate, it provided a more categorical approach to rehabilitation services.
Establishment of UNC PM&R
In order to support and enhance existing rehabilitation programs and develop new programs, Stuart Bondurant, MD, then dean of the School o f Medicine, envisioned a Department of Physical Medicine & Rehabilitation to provide a coordinated and comprehensive rehabilitation program under the guidance of rehabilitation doctors (physiatrists). A new chair would be charged to develop a program of excellence in rehabilitation services, including clinical care, medical education and research. In March 1994 this vision became a reality as Michael Y. Lee, MD was named the first chair of the newly-formed department and medical director of the Rehabilitation Program.
Department & Program Highlights
Highlights of the past 15 years are outlined below. The department has experienced significant success and growth from its inception.
Shortly after his appointment as chair, Dr. Lee found himself the only faculty member, with one secretary. Nevertheless, Dr. Lee became PI of a $122,908 UNC research grant to study health outcomes and services for traumatic spinal cord injured patients. Dr. Lee began to organize the department and develop practice management procedures. He hired three physiatrists (including a pediatric physiatrist, Joshua Alexander, MD), a research MD, one PhD (rehabilitation psychologist) and an administrative director (Susan Evers, MPH).
With the help of these new specialists, Dr. Lee began to develop and implement multidisciplinary clinics in 1995, including adult and pediatric spina bifida, amputee, spinal cord injury, traumatic brain injury, as well as musculoskeletal and general PM&R, while the outpatient clinics moved to the ACC. He received another research grant for $160,000 from Amgen Inc. for a renal rehabilitation demonstration project. Meanwhile, the new faculty members presented to attendings, residents, medical students and clinical staff from Neurology and Neurosurgery and participated in AHEC continuing education.
In 1996 a day rehabilitation program began to serve as a critical part of the rehabilitation continuum, as outpatient clinics moved to the Neuroscience Hospital. Clinics also developed for neuropsychology testing and counseling through Karla Thompson, PhD, as well as mentorship in the APA-approved internship in clinical psychology. Junior faculty received small grants to develop a spine center database and other rehabilitation resources. The department also affiliated with the local Reeve-Irvine Research Center for a fund-raising activity (horse show).
Outreach activities expanded in 1997, with the development of our previous web site, as well as collaborations with Chapel Hill Health and Rehabilitation Center, Horizon Rehabilitation Center and Raleigh Pediatric Therapy. More interdisciplinary clinics followed, including vestibular dysfunction, post polio, pediatric feeding and spasticity clinics. Meanwhile, the inpatient unit underwent renovations.
Even in the midst of renovations, the inpatient rehabilitation unit was awarded the highest level of accreditation achievable by CARF, the Rehabilitation Accreditation Commission, in recognition of program quality and commitment to continuous quality improvement of comprehensive inpatient rehabilitation services. In 1998 the Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) approved a four-year program to include a total of 12 residents. Under the direction of Dr. Lee, the UNC PM&R’s was the only new residency program approved by the RRC in the past three years, exemplifying the department’s commitment to train future physiatric practitioners. That same year, Susan A. Gaylord, PhD, was appointed to the position of research assistant professor, bringing a program and funding for alternative and complimentary approaches to rehabilitation: the Program on Integrative Medicine.
In 1999 the outpatient clinic moved from Neuroscience Hospital to the first floor of Memorial Hospital, which provided more spacious and accessible examination rooms. With this move, the clinic also adjoined the department’s administrative suite and faculty offices, which previously had been spread out in separate locations.
Over the next five years the department continued a positive financial performance in spite of declining clinical reimbursements and budget cuts. Clinical services expanded to more satellite and specialty clinics, including wound care, clinical neurophysiology and Sanford specialty clinics. Outpatient volume steadily increased each year, and the inpatient census continued to meet or exceed national rehabilitation program standards.
The department graduated the first class of residents in June 2003. Residents received comprehensive training in PM&R with exposure to a wide variety of rehabilitation patients through inpatient, sub-acute and outpatient rehabilitation, as well as via training in a variety of procedures and electrodiagnosis. The consistent 100 percent Board Pass Rate reflected the quality of the residents’ education. Many residents had the opportunity to present their research at national conferences, and several published articles in peer-reviewed journals. The majority of graduates pursued fellowship training in various sub-specialty programs across the country before settling into practice in academics, the government (VA and the military) and the private sector.
Also in the area of education, forty senior medical students rotated through PM&R annually as part of the required neuroscience selective; interns and fellows – representing a diverse spectrum from psychology to health policy and administration – also took part in educational opportunities. With funding from NIH, the Duke Endowments and other small grants, projects such as TelAbility (pediatric telemedicine) and the Program on Integrative Medicine received the seed money needed to expand to their current state-wide status.
A new 40,000-square-foot inpatient Rehabilitation Center, located on the 7th floor of Memorial Hospital, provided the opportunity for the interdisciplinary team to further promote clinical excellence with streamlined coordination in a state-of-the-art facility. Faculty, staff, residents, nurses and therapists began to sub-specialize in Physical Medicine & Rehabilitation while providing general rehabilitation services.
In the outpatient setting, the department expanded its procedure-based clinics to include spine injection, spasticity management and acupuncture, as well as electromyography and nerve conductions studies. Clinical accolades included the recognition of the PM&R clinic as a Top Five Clinic based on consistently high patient satisfaction scores as determined by Press Ganey surveys, a recognition which continued through 2009.
Collaboration with the Department of Orthopaedics placed a physiatrist with expertise in musculoskeletal and sports medicine rehabilitation into the musculoskeletal clinic and the multi-disciplinary spine clinic. To improve accessibility for amputee patients, the department aligned with UNC Hospital’s Atlantic Prosthetics and Orthotics to provide a comprehensive amputee clinic in Durham. In collaboration with Physical and Occupational Therapy, the department established a Lymphedema Program, which later received funding from the Susan G. Komen for the Cure, Triangle Affiliate, to cover treatment for uninsured and underinsured breast cancer patients with a secondary condition of lymphedema. We also continue to expand our rehabilitation psychology and neuropsychology services.
Beyond the campus borders, the department has successfully expanded efforts to advance the continuum of rehabilitation care in the surrounding community. In November 2007, we contracted with Select Specialty Hospital in Durham to provide medical rehabilitation directorship and consultation services for the long term acute care hospital. During March 2008, we launched an initiative with Rex Hospital to further develop sub-acute rehabilitation services at the Nursing Care Centers of Raleigh and Apex. The department assumed considerable risk to implement this program and invested significant resources into this venture, recruiting faculty and physician extenders to provide the medical rehabilitation direction and management of the sub-acute rehabilitation services.
From 2004-2008 the TelAbility telemedicine program provided 131 video-clinics or video-consult services, having a positive impact upon children with disabilities, as well as their families and service providers, throughout all of North Carolina. Evaluation data showed that participants were both highly satisfied and comfortable with using videoconferencing as a medium for consult services, as this decreased travel costs and travel time significantly.
In 2005, the department established the ongoing Annual State of the Art in Physical Medicine & Rehabilitation Conference, a comprehensive educational program taught by featured guests and rehabilitation faculty from the southeast United States and beyond. Residents and faculty from Virginia, North Carolina, Georgia and Florida regularly participate.
In 2009, the department reached landmarks in its maturation, assembling an outstanding team of faculty, residents and staff who synergistically elevated the clinical, research, educational and administrative activities to a higher level, including full accreditation of the department’s residency program.
From its modest beginning of one faculty member and one secretary, the department now includes nine MDs, four PhDs, 14 adjunct faculty members, two physician extenders at UNC-Rex Rehabilitation in Raleigh and Apex, and 16 staff specialized in different aspects of rehabilitation administration, from performing cost analysis to enhancing outside funding. In addition to our 12 residents, the department rotates six NIH T-32 fellows, as well as an array of medical students and other health science trainees.
Inpatient admissions increased from 434 in FY2004 to 603 in FY2009, with a mean length of stay of 14.6 days and an occupancy rate of 87 percent. Utilizing outcomes data from the Uniform Data Systems for Medical Rehabilitation (UDSMR), which encompasses over 800 rehabilitation facilities nationwide, the department has consistently maintained a score at or above the national adjusted average. Key measures include a discharge rate of 75-79 percent of our patients to the community, high scores in length of stay efficiency (greater patient improvement in a shorter length of time) and compliance with the CMS 60 percent rule. The Rehabilitation Center also launched its first annual Spinal Cord Injury Awareness Week in November with information booths and guest speakers Erika Bogan (Ms. Wheelchair America 2010) and Todd Richardson (2007 National Bicycle Criterium Champion). Heather Walker, MD, director of spinal cord injury at the Center and assistant professor in Physical Medicine & Rehabilitaiton, directed the event.
The department continues to build its leadership infrastructure, balancing considerable growth with deliberate and conservative management of available resources. Although the department continues to be spread out, with some research faculty relocated to Wing D and providing services in Durham, Wake and other counties, practitioners and programs have maintained the highest standards and accreditation. Several physiatrists have achieved “Best Doctors in America” for multiple years. A new faculty member, James J. Hill III, MD, MPH, has taken over medical leadership of the University Employee Occupational Health Center as of October 2009. The department also is strategically positioned to play an integral role in the new UNC Spine Center. In NIH research funding for PM&R departments, the department now ranks 7th nationwide – a strong accomplishment considering its relatively smaller size as compared to other PM&R departments.
Additionally, due to its highly regarded reputation as a training program of choice, the department has secured 100 percent of our residents from US medical schools through the National Residency Matching Program – a significant achievement, as the national average indicates less than 50 percent of residents in the field are US medical school graduates. Additionally, 100 percent of our graduates passed the boards in the last five years. The residency program gained a new associate director, Heather Walker, MD, a physiatrist double-boarded in PM&R as well as Spinal Cord Injury Medicine. The plan is for Dr. Walker to assume directorship of the program in the near future.
The residency program also established a Global Partnership in Medical Rehabilitation in 2009, when Dr. Lee and two residents visited and presented at the Medical School and hospital of Universidad Nacional de Trujillo in Peru.
As in many countries worldwide, there are no formally trained physiatrists in Peru, resulting in a tremendous need to educate their available clinicians in the practice of rehabilitation medicine. We will continue to explore opportunities for global outreach in Africa, Asia and South America.
The department is realizing its vision of becoming a globally-recognized program of excellence in PM&R. In addition to the Global Partnership in Medical Rehabilitation, and hosting visiting scholars representing cultures as diverse as Slovenia, Colombia, Brazil, Japan and Korea, the department also is launching other initiatives, such as telemedicine collaboration: pediatric telemedicine in Australia and adult telemedicine in Brazil.
As the department realizes that its local mission includes the global village, expansion of state-wide programs continue to benefit disabled residents right here in North Carolina. By securing an NIH T-32 research fellowship grant in complementary and alternative medicine (CAM), the Program on Integrative Medicine is creating a foundation for future trials and participation in the development of innovative tools and measurements for CAM and integrative approaches to care.
Other new state-wide initiatives include expansion of the TelAbility Program, including a new fund raising event specifically for pediatric rehabilitation programs (Run Walk & Roll). The Stroke Telemedicine Access Recovery Project (STAR) utilizes the existing telemedicine videoconferencing infrastructure established by TelAbility to provide stroke specialty consults and follow-up to stroke survivors at a rural community hospital in Robeson County. Patricia Gregory, MD secured funding from various sources for this project, including The Duke Endowment Fund. She and another PM&R faculty member, Vera Moura, MD, shared the benefits of telemedicine to colleagues in Brazil in April 2010. The department also expanded funding to help patients in North Carolina through a Spinal Cord Home Adaptation Program, thanks to generous funding from a private donor. The department also formalized an Acupuncture Clinic with recruitment of Jongbae Park, KMD, PhD, LAc, and Paul Thananopavarn, MD. Dr. Park, who also holds the patent for a device used worldwide in acupuncture studies, continues to secure research grants to support the study of acupuncture’s efficacy for rehabilitation patients.
The past fifteen years have been an exciting and rewarding experience for Dr. Lee, who has seen the department overcome small obstacles with leaps and bounds. The emphasis remains creating the vision and long-term strategic planning to move forward locally and globally.