On physical medicine and independent practice, AI, and Making America Healthy Again

For years, physicians may have considered physical medicine and rehabilitation to be hospital functions.

But the specialty has branched out to independent practice. John C. Cianca, MD, FAAPMR, the current president of the American Academy of Physical Medicine and Rehabilitation, has done so for years.

“It was about providing care, and the monetary means or monetary rewards were secondary,” Cianca told Medical Economics. He discussed the current state of the specialty, how it fits with developing artificial intelligence (AI) technology, the Make America Healthy Again movement, and what primary care physicians should know about physical medicine and rehabilitation.

Medical Economics: Based on your own experience as an independent practitioner, what are the biggest challenges right now to maintaining independent practice?

John C. Cianca, MD, FAAPMR: That is actually a giant challenge for many of my colleagues, in so far as survival, being financially viable, of being able to keep pace with the demands of a health care system that is, let's say, challenging, meaning the administration thereof and the payment of it. Many, many small practices have been bought in some way or another, either by large institutions or by private equity or by other groups, so that in some respects — well, there definitely is power in numbers. And that could be at the level of still an independent practice that's just bigger. But it also could be at the hands of somebody else who's overseen that practice, and, saying that in a kind way, because it really has changed the way that kind of care, outpatient care, is being delivered. It has become very bottom-line focused, very much an efficiency model, and that's challenged the care part of it, if you will. So I think many of my practitioners have had to, not by choice, have had to fold themselves into a situation that was different, less autonomous is a better way to say it, than it had been. I, on the other hand, have gone the other way and have become more and more independent. I was probably fortunate that I started that before there was a critical need to make a change. So many of my colleagues have gotten caught up in this sort of churn of outpatient practices becoming big, institutionalized practices.

Medical Economics: Could you talk more about your own experience and what influenced you to work in a cash only practice?

John C. Cianca, MD, FAAPMR: Well, it is an interesting question, because I, as I said earlier, it started doing it 22 years ago, when there was people doing it, but it wasn't so unusual in the sense of what we have now, which is these vast systems. I did it primarily to allow myself to see people the way I thought was best for me and for them. I recognized early that I don't like or excel at treating fast and in volume. I much prefer to see people at a pace that allows me to spend time with them, speak to them, teach them and affect them, not just do something to them, but to change their course. That requires time. I don't know how else to do it. And therefore I sort of chafed at was what was being presented to me, which was, well, you got to see more patients to make your salary. And I was so ardent about what I wanted to do, I even suggested, well, why don't you just change my salary so we don't have that pressure? And that got resistance, believe it or not, and I kind of understand that, there's sort of a given template for how a hospital or a medical college needs to pay their employees, and that just didn't fit. So at that point, I left the medical college that I was associated with, Baylor, amicably and started alongside of them, meaning as an adjunct, doing my own thing without insurance — without private insurance, I still took Medicare for many years after that. And that allowed me then to reduce volume and not reduce income. What I'll be careful to say is, I didn't get involved in that to make more money. In fact, I make less money than most of my colleagues who are treating volume and trying to keep up with the financial pace that they had before. That wasn't central for me. It was about providing care, and the monetary means or monetary rewards were secondary. So over the years, I've gotten more efficient and things work better. But it was a struggle early on. Despite feeling better about the care I was delivering, financially it was difficult. That's a hurdle you have to deal with if you're going to go the way I've gone. You can't just expect that your office is going to be full. I had 11 years in this area, so people did know me, and it was still hard. So it's a challenging way to go. I was fortunate to get in early before people really were feeling the pressure of new styles of practice, which is higher volumes, less time with people, more administrative demands and difficulties.

Medical Economics: Can you talk about how physiatrists are using AI in their practices? Where is the specialty merging with AI?

John C. Cianca, MD, FAAPMR: AI in and of itself, is going to be a huge influence, probably positive and possibly negative. And I think that's true across society, right? I mean, it could literally change the way we live, and yet, we don't know how yet. We've seen it very rapidly change things and I think we're just scratching the surface. But with respect to what we do, and this is really a concern of my society, the American Academy of Physical Medicine and Rehabilitation, for instance, how do we deliver education? Well, historically, we did it through in-person learning, and then we evolved to more online learning and microlearning through various forms of technology that allow immediate access. With AI that may all go away. So we're having to adjust, how are we going to deliver education? Do we even need to deliver education? Because it's so readily available by just tapping into AI, and in fact, that is happening at the resident level. It's just so easy for them, rather than to go and read an article, to just tap into AI and find out what the consensus of literature is now, not just one article, but multiple articles, condensed and summarized. It ultimately could be a good thing, but it's going to affect us as a society, meaning my professional society. And I think that's true across all medical societies, they're trying to figure out, how are we going to use this without getting made obsolete from it?

But on the other hand, as I mentioned earlier, it could be very good for making health care efficient, because you've got all that information now right at your fingertips, without having to take the time to consolidate and track it down and or if you don't even have access to it by way of presence, you have it virtually. So, remains to be seen. It's going to be a big influence and how we adapt, or adopt it, may be better, is it's going to influence whether it is a positive or negative.

Medical Economics: In our country right now, under the current administration, there is an initiative to Make America Healthy Again. How do you think physical medicine and rehabilitation as a specialty contributes to that national initiative?

John C. Cianca, MD, FAAPMR: It's not news to us. That's the way we've been going all along, and it's sort of by necessity, right? When you're dealing with somebody's function, not their broken bone or not their brain bleed, but the results of that, you have to very quickly understand their environment and how to make things work, both from their internal locus as well as the external locus. We have long done work outside of the hospital with people, sending them home on a weekend to get into their adaptive apartment so that they can then be ready to go to their own apartment or home in a more safe and functional way. I think Making America Healthy Again, we've been doing that. I mean, we've all long recognized the need for movement and exercise as being central to care, central to health. And the addition of diet probably is something that may be relatively new to my field, but it's not really. I mean, I think we've always had that outward facing view on how to help people adapt and be able to thrive. It's just something that is part of the way we thought and the part of the way we delivered care. It wasn't isolated, it wasn't so narrow and focused. Rather, it's more about their big picture, and to me, that's why I think we've always been effective. One of my colleagues said to me about the area of lifestyle medicine, which is a burgeoning field. She was encouraging me to get involved, and then she said, well, but you've already been doing this anyway. Which is true, it's just something that we do, sort of by way of our training, but also the problems that we have to treat. It demands that outward focus.

Medical Economics: Our main audience is primary care physicians. What would you like to say to them? Or what would you like them to know?

John C. Cianca, MD, FAAPMR: We're happy to partner with them, I mean, with something that we look at as the entrance to our practice. Primary care, for many, many, many years, has been the gateway, and we have really tried to educate primary care practitioners as to what our capabilities are. I think some of those were obvious when you're dealing with people in the hospital who need rehabilitation — OK, let's get a physiatrist involved. However, in the areas that I'm in, which is a little bit more subtle and historically been the sort of focus of orthopedics, that's been a slower revelation. For me, it's important that we continue to communicate our capabilities and our expertise to such specialties, primary care, whether it's family practice or internal medicine or pediatrics, that we can do this. And in fact, it's probably we're better suited to it than most because of the breadth of how we look at a problem, rather than a simple focus on, I can fix this or I can't. We do more than fix, we help people adapt. So that's really where I think the ongoing message to primary care needs to be. It's like, what do you need and who can best provide that? And I think that is what we can do.