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Historical Perspective

4. Rehabilitation Medicine (1987-Present)
   1. The Department Deteriorates
   2. The "Penn Center for Rehabilitation"
   3. A New Chair is Appointed
   4. Rebuilding the Department

REHABILITATION MEDICINE (1987-Present)

The Department Deteriorates

In the summer of 1987, Laurence E. Earley, M.D., Chairman of the Department of Medicine, was assigned the title of Interim Chairman of Physical Medicine and Rehabilitation. With this move, the Department of Medicine assumed both administrative and fiscal responsibility for Physical Medicine and Rehabilitation which essentially became a division of the Department of Medicine.

The search for a new chair continued. During the search that began in July 1979 and was to last until July 1990, the Department of Physical Medicine and Rehabilitation lost many faculty members. By 1989, Jennifer Chu, M.D., an Associate Professor, was the sole faculty member and new faculty were impossible to recruit. Two other physiatrists, Keith Robinson, M.D., and Margaret Stineman, M.D., held primary appointments as Assistant Professors in the Section of General Medicine of the Department of Medicine.

The physical facilities of the Department in the hospital in the Piersol Building continued to deteriorate because of lack of repair and inadequate upkeep. Equipment became obsolete and was not replaced. In 1987, the Commission for Accreditation of Rehabilitation Facilities did not accredit the Piersol Rehabilitation Center because of insufficient clinical leadership and inadequate facilities. In 1988, accreditation was granted on the promise by the Hospital that new space and facilities would be found. In 1990, space was finally found for inpatients at the Veterans Administration's newly-constructed nursing home located on the University campus, a short drive from the University Hospital.³⁶

The "Penn Center for Rehabilitation"

In 1988, the Hospital of the University of Pennsylvania organized a "Penn Center for Rehabilitation" to provide the needed services of Physical Therapy, Occupational Therapy and Orthotics/Prosthetics. These departments became Hospital departments with no connection to Physical Medicine and Rehabilitation in the Medical School or to physiatrists. A rheumatologist, Bruce Freundlich, M.D., was designated Medical Director, responsible to an Associate administrator. The allied health professionals operated independently reporting only to Hospital administration. Before the Center was established, the Department of Physical Medicine and Rehabilitation had directed Physical Therapy, Occupational Therapy, and Orthotics/Prosthetics with a subsidy by the Hospital to provide that direction. Sadly, Rehabilitation Medicine at the University Hospital declined even further as the "team" approach dissolved and allied health professionals assumed the role of consultant physiatrists instead of consulting with physiatrists for direction.³⁷

The research and education activities needed for accreditation at a medical school teaching hospital setting fell by the wayside. The Department of Medicine which oversaw Physical Medicine and Rehabilitation ("PM&R") was not prepared to resuscitate it. The Division of PM&R had virtually no faculty of its own and no research space. The little research that was being done in rehabilitation medicine was carried on by physicians in the Aging Center or the Section of General Medicine of the Department of Medicine where two of the three remaining physiatrists were located. In 1989, the PM&R residency training program was placed on probation and rehabilitation practically disappeared from the undergraduate medical curriculum.

A New Chair is Appointed

In 1989, William N. Kelley. M.D., took the reins at the University of Pennsylvania Medical Center as CEO and Dean of the School of Medicine. Aware of the growing importance of rehabilitation and the decline of academic Physical Medicine and Rehabilitation Department at the University of Pennsylvania, Kelley determined to act quickly to resuscitate the Department. He turned to Alfred P. Fishman, M.D., William Maul Measey Professor of Medicine, pledging support in the creation of an academic department if Fishman would accept the Chair. Fishman, former head of the Cardiovascular-Pulmonary Division of the Department of Medicine at the University of Pennsylvania Medical Center, had established an international reputation as a scientist and clinical investigator of the heart and lungs. In over 50 years, Fishman's name had appeared as an author of 337 original papers and 332 editorials, chapters or reviews. He also authored or edited 15 books. For the first six years after his arrival at the University in 1969, Fishman had served as Associate Dean for Research and had continued without interruption as Consultant to the Dean until Kelley's arrival and for one year thereafter. Fishman brought expertise as an administrator and academician to the Department, which was reestablished as an independent entity separate from the Department of Medicine. The hospital-based Penn Center for Rehabilitation Medicine was dissolved and Fishman assumed the Directorship of the allied health professional departments in the hospital.

Fishman set out to develop an academic department that would be excellent in clinical care, teaching, and research. As a start, he undertook an academic review of the Department by two outstanding physiatrists (Theodore Cole, M.D., of Michigan, and Barbara DeLateur, M.D., of Seattle, Washington) and a highly respected neuroscientist whose research related to rehabilitation medicine (Wise Young, Ph.D., M.D., of New York University). Based on their advice, he developed a plan to revive the department and to launch new initiatives. A first step in its rebirth was a change in the name of the Department from Physical Medicine and Rehabilitation to Rehabilitation Medicine. Planning was complicated by the decision of the Medical Center to demolish the Piersol Inpatient Center, thereby forcing the Department into a two- year migratory existence, i.e., from the Veterans Administration Nursing Home and temporary administrative facilities in the Morgan Building, to its current space in the Ravdin and Gates Buildings of the University Hospital.

By 1992, the reorganization of the Department was well under way. Physical Therapy, Occupational Therapy and Orthotics/Prosthetics became divisions of the Department of Rehabilitation Medicine for programmatic development and medical direction; the Directors of these hospital departments continued to be in charge of service activities with joint reporting lines to Hospital administration and to the Chair of the Department of Rehabilitation Medicine. Fiscally these departments remained under the aegis of the University Hospital. The Gift Shop on the Ground Floor of the White Building was relocated to the Silverstein Building in order to make way for a modern outpatient rehabilitation facility designated "The Erdman Clinic." A new, modern acute rehabilitation facility, "The George Morris Piersol Rehabilitation Unit," consisting of 24 acute care beds, gymnasia, and other relevant facilities for occupational and physical therapy, was installed on the sixth floor of the Ravdin Building of the University Hospital. The Piersol Unit revived the team concept, i.e., a team of professionals led by a physiatrist was to manage each patient's rehabilitation program.

Rebuilding the Department

In 1993, the Piersol Inpatient Rehabilitation Unit and the new William J. Erdman II Outpatient Center, both located in the University Hospital, were officially dedicated. Along with these units came a new facility for Orthotics and Prosthetics in the basement of the Gibson Building and a new gymnasium for physical and occupational therapy on the first floor of the Ravdin/White Building.

Along with the new facilities, Rehabilitation Medicine took on a whole new approach. In addition to revitalizing its clinical services, the Department placed renewed emphasis on teaching and research. The Department now offers five divisions as subspecialties within Rehabilitation Medicine: Geriatrics, Musculoskeletal Disorders, Neurorehabilitation, Pediatric Rehabilitation and Electrodiagnosis. Pediatric Rehabilitation is provided at Children's Seashore House, a regional facility adjacent to the University Hospital. In collaboration with the Department of Orthopedic Surgery, and in response to a "musculoskeletal initiative" created by Dr. William N. Kelley, a multi-department ("one-stop shopping") Spine Center was created.

Soon after accepting leadership of the Department, Fishman set out to rebuild the residency program and to reclaim the rehabilitation medical service at the Veterans Administration Hospital (which had been ceded to Temple University). All full reaccreditations for the inpatient activities of the Department were in place by 1991 and the number of institutions used off-site for residency training was reduced from 15 to three (Children's Seashore House, Veterans Administration Hospital, Our Lady of Lourdes Hospital). Recruitment of faculty for the rejuvenated Department was remarkably successful with little turnover. As of January 1996, the faculty of the Department had increased to 14 full-time faculty members, 11 residents, and four postdoctoral fellows. Several faculty members held individual NIH grants in addition to grants from the Agency for Health Care Policy and Research of the Department of Health and Human Services.

Investigators in the Department of Rehabilitation Medicine sought cooperation with established scientific components of the University for scientific training and collaboration. This strategy brought the experience of established investigators and laboratories from other departments and schools to rehabilitation medicine. In addition, efforts were made to encourage collaborative clinical activities. A five-year research training grant, from the National Institutes of Health, operated conjointly with the Moss Rehabilitation Institute, provided for four research fellows per year. (In 1997, this research training grant was renewed by the National Institutes of Health.) Collaborative research was undertaken with faculty in other departments such as Biophysics and Biochemistry, Bioengineering, and Medicine. Keith Robinson, M.D., Assistant Professor and Board certified in both Internal Medicine and Rehabilitation Medicine, was given a two- year leave of absence by the Department for supplementary training in cognitive research. By 1993, the Department had jumped from last to second place in research funding by the National Institutes of Health. In 1996, this success in research funding was topped by a large grant from the Department of Defense in support of fundamental research on the "fatigue syndrome" in veterans of the Persian Gulf War.

Commitment to outcomes research has been an outstanding strength of the department. Margaret Stineman, M.D., Director of Program Evaluation and Quality Assurance, conducts a nationally prominent program in outcomes research largely supported by grants from the National Institutes of Health. She is at the forefront of national planning for cost-effectiveness and quality improvement in rehabilitation medicine.

Clinically, the Department has taken on a new life. Indeed, it has developed so rapidly that the new facilities were soon outgrown. The multi-departmental, interdisciplinary Spine Center, under the Direction of Curtis W. Slipman, M.D., is expanding to new sites off-campus. Krista Vandenborne, Ph.D., Research Assistant Professor, has embarked on projects involving NMR imaging and spectroscopy of muscle. In this research, she works closely with John Leigh, Ph.D., her former mentor in Radiology, Biophysics and Biochemistry. Leigh has made NMR imaging and spectroscopy available to Vandenborne, thereby paving the way for a collaboration that has led to the studies of Gulf War veterans noted above. Robert J. Goldman, M.D., a Board certified physiatrist, is conducting research on electromagnetic induction of wound healing with colleagues in the Department of Orthopedics and Bioengineering. M. Elizabeth Sandel, M.D., Director of the Neurorehabilitation Program, began collaborative research with neuropsychologists, psychologists, and therapists in the rehabilitation of patients who have suffered mild brain injury.

Other clinical activities were initiated or nurtured. The electrodiagnosis laboratory expanded its activities to include pioneering research by Jennifer Chu, M.D., on intramuscular stimulation of muscle (IMS). Chu continued to play a central role in the teaching of electromyography to residents and in teaching them the fundamentals of nerve conduction studies and of somatosensory evoked potentials. Acupuncture, a traditional clinical activity of the Department, became a nodal point for the development of complementary medicine by the Department. The pediatric rehabilitation division, located at the Children's Seashore House, has achieved national recognition for excellence in pediatric rehabilitation under the direction of Linda J. Michaud, M.D. and Stephanie Ried, M.D.

As the Department returned to its former stature, its presence in the medical curriculum increased. Four week clinical clerkships were resumed in Musculoskeletal Rehabilitation, Neurorehabilitation, General Rehabilitation, and Pediatric Rehabilitation. The Scott family sponsored summer student fellowships for two post-first year students to be introduced to the field under close mentoring by David A. Lenrow, M.D. Currently, a new medical school curriculum is about to be implemented. Rehabilitation Medicine is thoroughly integrated into the new curriculum.

The original plans in 1990 for the renaissance of the Department called for the allied health activities, i.e., Physical Therapy, Occupational Therapy, and Orthotics and Prosthetics, to return to the aegis of the Department. However, implementation of this design was delayed by other priorities imposed by the rapidly evolving health scene and the needs of the rapidly emerging University of Pennsylvania Health System. Nonetheless, allied health activities continued to expand. In 1996, the time of this writing, the Hospital of the University of Pennsylvania created and acquired an off-campus facility for physical and occupational therapies and other facilities strategically dispersed throughout the University of Pennsylvania Health System. Concomitantly plans were revived to shift control of the allied health activities from the hospital to the Department.

The renaissance of the Department was welcomed not only by alumni of the Department, but also by physiatrists elsewhere who recalled the days when the Department had been preeminent in the field. They interpreted the institutional recommitment to rehabilitation medicine as a sign of a reversing trend at a time when the need for rehabilitation services was increasing exponentially. In 1994-1995, 54 of the 128 medical colleges in the United States (41%) had no department of rehabilitation medicine; in 18 medical schools, Rehabilitation Medicine was part of other specialties, such as Orthopaedic Surgery or Preventive Medicine. The revival of the Department in a distinguished research-oriented university augurs well for the specialty.