Spine Section Strategic Plan

Transcription

1 Spine Section Strategic Plan I. INTRODUCTION A. Definition of the subspecialty or section The section is comprised of those members of the American Academy of Neurology who have an interest in treating individuals with disorders of the spinal column, spinal cord or nerve roots. B. General statements on conditions it covers and pertinent procedures. The section addresses disorders of the spinal column, spinal cord or nerve roots. C. Overview of interaction with other specialties The sections with related interests are pain, neurorehabilitation and neural repair, government services (many spinal cord medicine neurologists work in VA) and MS (neuroimmunology). D. Purpose of this document why is it needed? This document is prepared at the request of the Academy. This section could serve to collect and disseminate information about the recognition and effective management of disorders of the spinal cord and spinal column. For example this section could contribute to the genesis of guidelines related to care of disorders of the spinal cord and spinal column. Neck and back pain are common conditions encountered by general neurologists and this section deals with the effective treatment of such. In addition, spinal cord medicine is an area that neurologists are migrating into. Treating neck and back pain is the life blood of many general neurologists. E. Overall mission statement The section exists to further the professional needs, both scientific and practice related, of neurologists who are interested in treated disorders of the spinal cord and spinal column. II. BACKGROUND/HISTORY OF THE SUBSPECIALTY OR SECTION A. Landmark early work/milestones The formation of a Spine Section within the American Academy of Neurology was the brainchild of Dr. Richard Pearl of Smithtown, New York. Dr. Pearl recognized the fact that neurologists see a lot of patients with spine disorders both clinically and to perform electrophysiology studies. He and Dr. J.D. Bartleson gathered the required number of signatures of Academy members expressing interest in the formation of a Spine Section, and in 1997, the Committee on Sections approved formation of the Spine Section. The newly formed Spine Section held its inaugural meeting on April 28, Since that time, the Section has dedicated its efforts to 1) educating Academy members about conditions that affect the spine, and 2) increasing the awareness within and outside the AAN of the important role neurologists can play in the diagnosis and treatment of spine conditions, especially those presenting with spine and/or limb pain, or neurologic symptoms that suggest disease of the spinal cord and/or spinal nerves. B. Growth of the subspecialty or Section to current status. The section is composed of two related groups of neurologists. The first and the group corresponding to the original core of this section are neurologists who focus on, or have a strong interest in, treating people with radiculopathy and pain associated with cervical and lumbar spine disease which is usually caused by osteoarthritis and/or inter-vertebral disc disease. This group of individuals is closest to the Section on Pain. This group wants to provide direction on the most effective ways of treating neurological sequelae of diseases of the spinal column. The second group consists of neurologists who treat individuals with spinal cord disease such as traumatic spinal cord injury, vascular injury to the spinal cord, spinal cord dysfunction due to demyelinating disease (most commonly advanced MS). The second member group of this section is most closely aligned with the section on neurorehabilitation and neural repair and the section on MS. This group is interested in getting more neurologists involved in spinal cord medicine and in educating neurologists about some issues specific to patients with spinal cord injury such as autonomic dysreflexia. Both groups within this section share interests in pain associated with disease of the spinal column and spine, appropriate surgical

2 intervention in spinal cord and spinal column disease, prevention of injury to the spinal cord and medicolegal issues associated with diseases of the spinal column or spinal cord. There are many members of this section who share interests in managing disorders of the spinal column and spinal cord. The Spine Section has maintained a healthy membership and promoted steady, if not expanding, educational programs at the Annual Meeting. Increasing recognition of the important role that neurologists play in the care of patients with spine disease led to a Case Studies Plenary Session entitled, How Should We Treat the Patient with Persistent Painful Lumbosacral Radiculopathy? given by Dr. Bartleson at the 59 th Annual Meeting in Boston on May 2, The number of potential members increased with the involvement of individuals trained in spinal cord medicine. Since its inception, this section has grown from 123 members to 189 members. C. Genesis of pertinent journals and societies. There are many dedicated spine meetings, organizations, and journals. Most spine-related publications are published in dedicated spine journals such as Spine, The Spine Journal, The European Spine Journal, or The Journal of Spine Disorders and Techniques. Many spine-related articles are published in orthopedic, neurosurgical, and physical medicine specialty journals; some are published in general medical journals such as JAMA and The New England Journal of Medicine. In addition to dedicated specialty societies that deal with the spine (neurosurgery, orthopedics, physical medicine and rehabilitation, anesthesiology), there are a number of international multidisciplinary societies that are dedicated to the care of patients with spine disease. These organizations include The North American Spine Society, The Cervical Spine Research Society, The International Society for the Study of the Lumbar Spine, The Spine Society of Europe, The Scoliosis Research Society, and many national subspecialty organizations. D. Current Board certification and other sub-specialty organizations/boards. There is no Board Certification specifically for conditions of the spinal column. However, there is ABMS certification in Pain Medicine, which would address the interests of neurologists who treat back and neck pain. There are Boards through the ABPM&R on Spinal Cord Medicine a neurologist can be eligible for this certification provided that the individual has fellowship training (in the past one could be certified based upon a history of working in the field). For non-surgeons, there is subspecialty certification in pain medicine by the American Board of Psychiatry and Neurology. Pain medicine subspecialists see many patients with spine and limb pain. Neurologists can become subspecialty certified in pain medicine with one year of subspecialty training beyond the basic neurology residency requirements. E. Other professional and disease-related organizations relevant to the subspecialty. No one organization encompasses the wide interests of the spine section. Organizations with interests that overlap those of individuals with practice interests in spinal column diseases include the American Pain Society and the North American Spine Society. Professional organizations that address issues important for spinal cord medicine include: ASIA American Spinal Injury Association and APS American Paraplegia Society. Support organization for people with spinal cord disease (traumatic SCI or other disease such as MS) include the MS Society and Paralyzed Veterans of America. III. CURRENT STATE OF THE SECTION A. Patient care/practice The practice interests of this section include: back and neck pain, radiculopathy and myelopathy predominantly associated with cervical and lumbar spine disease, spinal cord disorders including traumatic spinal cord injury, vascular injury to the spinal cord and spinal cord dysfunction due to demyelinating disease (most commonly advanced MS). B. Research There is some clinical/health service research directed at evaluating the effectiveness of different strategies for treating diseases of the spinal column. There is basic animal studies research on spinal column disease,

3 but this is not a focus of this section. There is a wide range of research ranging from basic research on neural repair to health services research on care delivery in the field of spinal cord medicine. This section would be good at working in the area of health services research to evaluate ways of treating disorders of the spinal column and spinal cord. In particular many members of this section have interests in evaluating non-surgical modalities for treating spinal column disorders, which could expand the scope of neurological care and provide common ground with the section on interventional neurology. C. Education Training in treating spinal column disease is an essential part of any neurology residency training program. The training that most neurology residents receive in spinal cord medicine is inadequate. Residents, in general, do not see many patients with spinal cord disease and are not taught basic management skills such as treatment of bladder and bowel issues, skin care and managing/preventing disorders associated with immobility. The poor state of education in managing individuals with spinal cord disease may change as the ACGME is requiring training in neuro-rehabilitation (although the scope of what is to be covered is not well defined hence spinal cord medicine training may continue to be short changed). There are fellowship programs in spinal cord medicine that are available most administered by PM&R trained physicians. A few programs are directed by neurologists. These programs, whether run by a physiatrist or not, are open to residency-trained neurologists. The physiatry principles in spinal cord medicine programs are essential for an individual to become a spinal cord medicine physician. Neurologists may have trouble with a mind set change. The focus in spinal cord medicine training programs is on longitudinal care rather than acute intervention. Acute intervention issues are important for reducing the persisting deficits resulting from the initial injury or exacerbations. The majority of an individual s life who has spinal cord injury is influenced by how well day to day issues are managed. Neurologists may have issues with a team approach that is based on a horizontally rather than vertically organized team. The physician may direct the team, but an effective team cannot be dominated by one member. D. Medical economic issues A large amount of medical care dollars and workers compensation dollars are related to disorders of the spinal column. The appropriate management of spinal column disease is important for the entire North American economy. This section could be involved with helping to direct treatment strategies. Spinal cord medicine is fortunately a small fraction of overall medical care in North America. There are aspects of spinal cord medicine that are important to a larger population of patients seen by neurologists, specifically patients with advanced MS who need effective bladder/bowel and skin care management to prevent costly complications. E. Legislative Issues In spite of the frequency of spinal column disorders, there is no legislative lobby for this condition other than personal injury lawyers who advocate for maintaining the current system of injury compensation. Although involving <100,000 people in the US, individuals with spinal cord injury have very effective lobbies that were able to effect changes such as accessibility issues via the Americans for Disability Act. There are potent lobbying forces such as ASIA and the PVA for individuals for spinal cord injury. IV. SWOT ANALYSIS OF THE SUBSPECIALTY A. Current strengths in each of the five areas (patient care, research, education, economic, legislative) 1. Patient Care The strengths of this section are largely potentials - this section could help to generate strategies for effective management of managing spinal column diseases and this section could provide access to information on spinal cord medicine. 2. Research This is not a strong point for spinal column disease. There are neurologists involved with neural regeneration and repair research related specifically spinal cord disorders. 3. Education This section has attempted to support several courses at the annual meeting. Courses that just deal with management of back and neck pain are not very successful. This section has contributed to more general pain courses that will include neck and back pain. This section does provide a half-day course

4 on spinal cord medicine, which has been well received. This section could become a resource for education on the management of spinal column and spinal cord disorders. 4. Economic This section is not extensively involved in medical economics, although that might be an appropriate future direction. 5. Legislative Neither segment of this section have been involved with legislation. The segment associated with spinal column disease is subject to legislative efforts to alter or preserve the current system of tort claims associated with spine injuries. B. Weaknesses in the five areas 1. Patient Care The potential strengths of this section are not yet realized. This section should have a more prominent role in addressing practice standards for treating spinal column conditions. 2. Research There are few research initiatives related to spinal column disorders associated with neurologists, we are surrendering this area to others. There is extensive research that is going on involving the genesis of spinal cord injury. There is also a moderate amount of health services research going on related to the delivery of care for individuals with spinal cord disorders. However, this section does not have a strong role in developing research directions. 3. Education This section does not have a strong interaction with residency training for either spinal column or spinal cord disorders. 4. Economic The conditions of interest to members of this section have strong implications for health care costs. Spinal column disorders are responsible for large health care dollar expenditures due to the high prevalence of spinal column disorders. Spinal cord disorders fortunately have low prevalence, but the lifetime costs are high for individuals with tetraplegia. This section is not involved in initiative to assign reimbursements for treatments of disorders of the spinal cord or spinal column. 5. Legislative This section has not been extensively involved with medical legislation. C. Opportunities for growth in each area 1. Developing guidelines for treatment of spinal column and spinal cord disorders, 2. Providing a mechanism for neurologists to learn more about spinal cord medicine and 3. Strategies for the prevention of spinal cord and spinal column disorders (this authors bias is that AAN has not been as actively involved in preventive medicine as it could be ex: The AHA advocates for initiatives to reduce stroke risk more than AAN appears to). D. Threats to achieving goals in each area 1. Patient Care There is a major threat that has emerged from the Council for Accreditation of Rehabilitation Facilities (CARF). CARF has changed the requirements for an individual to direct a spinal cord injury unit. In the past and in the case of other clinical entities that CARF accredits, an individual needed to have a track record of clinical experience in treating specific conditions or be Board Certified in a the area being evaluated (ex: Spinal Cord Medicine). The regulation by CARF has changed with respect to Spinal Cord Medicine and now a Director of a CARF-accredited spinal cord medicine facility must be board-certified in Spinal Cord Medicine. It is no longer possible for an individual to be eligible to take the ABMS Spinal Cord Medicine Boards unless one has completed a fellowship in spinal cord medicine. Eligibility to take the spinal cord medicine boards based upon prior experience in spinal cord medicine had expired. As noted above the Spinal Cord Medicine Boards are administered by PM&R. This will exclude neurologists who have been directors of spinal cord medicine treatment facilities from continuing in their positions unless they had taken the Spinal Cord Medicine boards in the past. This will displace qualified neurologists who were previously directors of spinal cord medicine facilities from continuing in their prior capacities. A potential concern is that the treatment of disorders of the spinal column could come under the control of medically naïve bean counters who are directed

5 toward maximizing practice profit rather than patient care. Another concern is the reimbursement incentives could drive non surgeons out of the treatment of spinal column disorders so that back pain would come under the control of anesthesiologist/orthopedist pain specialists. 2. Research If spinal column disorders come under the control of surgeons and anesthesiologists, then the research in disorders of the spinal column will fall out of the realm of neurologists. Neurologists will stop being involved with research related to spinal cord disorders. 3. Education If spinal column disorders come under the control of surgeons and anesthesiologists, then the area of spinal column and spinal cord disorders education for medical students may be lost to neurologists. 4. Economic The funding for treatment of spinal column disorders with invasive procedures could continue to be out or proportion compared with conservative treatments that may be better for the patient in the long term. The payments for long term care of individuals with spinal cord disorders could continue to decline in the private sector resulting in sub-optimal long term care. 5. Legislative Legislation could be directed at medico-legal issues rather than patient care. V. SPECIFIC VISION/GOALS AND OBJECTIVES FOR THE SUBSPECIALTY/SECTION A. Short Term (over next 5 years) 1. Specific defined goals and targets a. Goal - increase involvement of this section in resident education and neurologist updating b. Target have members of this section involved in the practice guidelines committee. 2. Operational strategies to achieve goals Develop educational initiatives. 3. Specific action items for each goal Get concurrence of the section members on this plan. 4. Role of AAN in achieving goals Involve section members in planning and guidelines generation related to spinal column and spinal cord disorders. 5. Benefit to AAN and the subspecialty in achieving goals Improve the care of individuals with spinal column and spinal cord disorders. 6. How will subspecialty assess and address success/failure for each goal/area? Through evaluating the role of this section in the education of neurologists and the number of neurologist involved with spinal cord medicine. B. Long Term (over the next 5-10 years) 1. Specific defined goals and targets a. Develop ties with groups representing primary care givers so that there can be a common ground for treating individuals with spinal column disorders. b. Develop ties with PM&R so that neurology is equal partner in the field of spinal cord medicine. 2. Operational strategies to achieve goals Develop forums to consider how neurology is practiced and how practice can be improved in a manner that is economically sustainable. Such forums would consider input from different care systems including primary care and rehab medicine. 3. Specific action items for each goal Establish care delivery forums indicated above. 4. Role of AAN in achieving goals The AAN would need to determine that it wishes to take a role in considering how care for individuals with disorders of the spinal column and spinal cord should be practiced. 5. Benefit to AAN and sub-specialty in achieving goals The AAN could become a leader in molding the course of future neurology care delivery. 6. How will sub-specialty assess and address success/failure for each goal/area? The success or failure will be determined by what happens to healthcare delivery as well as to neurology.

6 VI. SUMMARY/CONCLUDING STATEMENT A. Summary of mission/vision/values for subspecialty. The mission of this section is to enhance the care of people with disorders of the spinal column and spinal cord and to advocate for the neurologists treating these patients. B. Global conclusion and assessment of subspecialty s place within the larger scope of the AAN, other specialties, neurology in general, and related fields This section advocates for a subset of the field of neurology disorders of the spinal column and spinal cord.