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(or more) of these medical problems. For instance, in many practices, there are physicians who subspecialize in pediatric rehabilitation and take care of only these younger patients.

Physiatrists coordinate the rehabilitative care of physical impairments and disabilities using a multidisciplinary approach. They prescribe pharmacologic agents to treat conditions such as spasticity, musculoskeletal pain, and neurologic pain. Along with prescribing medicines, physiatrists formulate specific physical and occupational therapy regimens — exercises that address each patient's individual needs. Every regimen is tailored to prepare the patient to meet a particular goal.

It is the physiatrist, with the help of the rehabilitation team, who sets goals for the patient. This interdisciplinary team includes physical therapists, occupational therapists, psychologists, nurses, dietitians, social workers, case managers, speech pathologists, and audiologists. With the PM&R specialist as team leader, they meet at appropriate intervals during a patient's hospital stay to discuss the patient's progress, goals, and any pertinent social or psychological issues. The team also includes, in an important sense, the patient and his or her family, with whom the physician also meets to ensure open lines of communication. Education of both patient and family is essential to increase the likelihood that the patient's physical and social needs are met. Ultimately, this means a successful integration into society.

Other essential responsibilities include prescribing assistive and adaptive devices to augment the patient's level of functioning: a wheelchair or walker to increase mobility, a communication device, or extensions to allow greater independence in performing daily tasks. To do so, physiatrists assess the difference between a person's functional level and the functional level required to perform a specific task. Physiatrists evaluate whether a wheelchair is the appropriate size and the seat is positioned at the right angle. They are experts at determining the energy expenditure required of patients with orthotic and prosthetic devices and prescribe these devices accordingly.

In rehabilitation care, the patient's basic neurologic and musculoskeletal function is essential, as well as the many psychosocial issues that affect the patient's participation in the community. PM&R is holistic care because it does more than prevent disease. This includes a program that attempts to solve the social and economic problems that may interfere with the patient's recovery.1 As public policy and education advocates, physiatrists play a major role in public awareness of safety. In this specialty, therefore, you will find many opportunities to fight for patients' rights.

Physiatrists not only determine the rehabilitation goals, but also decide whether or not an individual is a proper candidate for rehabilitation. A physia-trist has the right and responsibility to withhold inpatient rehabilitation from ineligible patients, such as hospice patients who are not expected to regain much function before the end of their lives. As you can tell, an entire array of possible ethical situations can confront a physiatrist. But just like any other area of medicine, patients are free to obtain second opinions. Conceivably, one physiatrist may not accept a patient for rehabilitation while another deems her or him an appropriate candidate.

Other ethical issues physiatrists face include concerns of distribution and access to health care resources. Like other primary care physicians, they may find themselves spending increasing amounts of time convincing an insurer that physical rehabilitation will benefit the patient and ultimately save money and resources. Of course, in many of these instances, the bottom line is the incentive to cut costs, but perhaps the idea of spending resources on those with disability also plays a role. "As human rights and the dignity of the human being overcome archaic prejudices and economic priorities, new legislation will be passed to assist the disabled and the handicapped to take their rightful place in society."2 Unfortunately, physicians can spend much time and effort fighting for human rights through paperwork, telephone conversations, and lobbying. For those involved in this struggle, this time-consuming advocacy work has been largely successful and quite rewarding. Equal rights acts such as the 1990 Americans with Disabilities Act came into fruition. Disabled people now have greater access to public places and transportation making possible greater functioning at home and work. Physiatrists, along with other advocates, lobbied to propel these issues to the forefront and influence the political system. Ultimately, they sought to better meet the needs of people by promoting health and quality of life.

Physiatrists do not just treat patients with severe disability, however. In recent years, the field of PM&R has also attracted many who are interested in sports medicine—working with trained athletes and dancers. Sports medicine doctors can become athletic team physicians. The goals of care for the professional athlete and the performer are obviously different than for a patient who has moderate to severe disability. In these cases, the physiatrist is focused on enhancing performance or is treating an injury due to repetitive movements. For both the athlete and performer, PM&R specialists are trained in dynamic interventional techniques that can enhance balance and proprioception and increase range of motion and strength.

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