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A Tale of Two Cities: Evolution of Academic Physiatry in Boston and Baltimore: Part 1: The Boston Marathon

2018; Wiley; Volume: 10; Issue: 6 Linguagem: Inglês

10.1016/j.pmrj.2018.01.005

1934-1563

Stanley F. Wainapel, Hilary Siebens,

History of Medical Practice

Today, a physiatrist boarding a train at Boston's South Station bound for Union Station in Washington, DC, could count 19 academic institutions with physical medicine and rehabilitation (PM&R) departments and residency programs along the way. That number represents approximately one quarter of academic PM&R departments for the entire United States. Almost all of these are located in institutions in the 4 major urban centers along Amtrak's Northeast Corridor—Boston, New York, Philadelphia, and Baltimore. Several previous articles in the PM&R's Historical Perspectives series have highlighted the development of PM&R in Philadelphia and New York through the careers of pioneering figures R. Tait McKenzie 1, Frank Krusen 2, Howard Rusk 3, and George Deaver 4, while also highlighting the critical philanthropy of Bernard Baruch 2, 3, 5. The stories of the evolution of the field of PM&R in Boston and in Baltimore draw some fascinating historical parallels. Of equal interest is the divergence of the Boston–Baltimore history from the Philadelphia and New York narratives. By the 1970s, all 4 cities had PM&R residency programs at several institutions. However, although those in New York and Philadelphia included the oldest Ivy League schools (The University of Pennsylvania and Columbia University), their counterparts in Boston and Baltimore (Harvard University and Johns Hopkins University) only opened their academic PM&R departments in the 1990s. This delay can be attributed to a complex web of interrelated external and internal factors. A step-by-step analysis of the process of evolution of the departments in Boston and Baltimore provides insight into this delay, highlights the challenges faced by the specialty during its first half-century, and may also serve as a cautionary tale for the specialty's future. Medical education in the United States predated even the Declaration of Independence. The University of Pennsylvania opened its medical school in 1765, followed in quick succession by Columbia University's College of Physicians and Surgeons in 1767 and Harvard Medical School (HMS) in 1782 6. Another early Boston facility, a precursor to Tufts/New England Medical Center (T/NEMC), was the Boston Dispensary, established in 1796 by local physicians to provide medical care for indigent citizens. HMS graduates worked at the Dispensary for a nominal salary, a first postgraduate experience and a stepping stone toward establishing a private practice (Richard J. Wolfe, MLS, AB, Former Curator of Rare Books and Manuscripts, Countway Library, & Joseph Garland Librarian, Emeritus of the Boston Medical Library, personal communication, 2017). The T/NEMC was built around the Boston Dispensary and the 2 institutions merged during the 1950s, at about the time that rehabilitation services at Tufts were making their first appearance. The 35-bed Rehabilitation Institute at NEMC, which featured medical, social, and vocational rehabilitation services, was the first comprehensive civilian inpatient rehabilitation facility in New England (Anna Pomfret, MD, personal communication, 2017). Supported by Hill–Burton grants for hospital care to underserved populations, the Institute opened in 1955 with great fanfare, including Boston Mayor John B. Hynes and Rehabilitation Services Administration Director Mary Switzer among the speakers 7. During its first decade, the Institute's physicians included John Lorentz, Hans Waine, and Heinrich Brugsh (Anna Pomfret, MD, personal communication, 2017). However, the first physiatrist with lasting name recognition and the first Chair of a formal academic PM&R Department was Carl V. Granger, MD (Figure 1). After residency training at Walter Reed Medical Center and work at Yale-New Haven Medical Center, Granger became chairman of the department at NEMC in 1968. This recruitment was through Frank Krusen, who in his later years was busy getting other rehabilitation departments established (Gerald Felsenthal, MD, personal communication, 2017) 2. Carl V. Granger, MD. Courtesy of the University of Buffalo, Physicians Group. Supported by a Research and Training grant from the Rehabilitation Services Administration in the U.S. Department of Education, the Tufts program grew significantly under Granger's leadership. Several areas of faculty expertise included assistive technology, computerized speech recognition, pediatric rehabilitation, and traumatic brain injury. Of special importance was Granger's early pioneering work on functional assessment while at T/NEMC 8. At that time, the specialty was being criticized that it was because of natural history, not rehabilitation, that patients got better. Therefore, Granger's leadership in developing valid functional outcome measures was essential for the more nuanced research required to tease out rehabilitation's added benefit to patients' recovery trajectories and outcomes. Another pioneering area in the Department was the Independent Living model, described herein 7. Granger's career-spanning research in functional assessment and outcomes from rehabilitation interventions and programs was fully realized after years of additional work while at the University of Buffalo beginning in 1983 and still ongoing 9. His work, leading to the development of the Functional Independence Measure and the establishment of a national database for research and program evaluation, the Uniform Data Set for Medical Rehabilitation, continues to this day. Dr Granger served as President of the American Academy of PM&R in 1975. He received the Frank Krusen Award in 1993 and delivered the honorary Walter J. Zeiter lecture at the AAPM&R's Annual Assembly in 1997 10. A mile down Harrison Avenue from the Rehabilitation Institute of NEMC, Frank B. Granger, a pioneer physiatrist (no relation to Carl V. Granger), came to the Boston City Hospital, where he served as head of physical therapeutics from 1907 to 1928 and developed a nationally well-regarded and innovative hospital-based Department of Physiotherapy and served as Chairman of the Council of Physiotherapy of the American Medical Association 11, 12. As a nationally recognized expert, he also served as head of physical therapy (physical medicine) for the U.S. Army at Walter Reed Hospital during WWI. He was succeeded in 1929 by a neurosurgeon, Donald Munro, MD, who had been exposed to rehabilitation medicine during his own training at the University of Pennsylvania. Munro developed a leading inpatient service devoted to patients with spinal cord injury in 1936 across the street from the Boston University (BU) School of Medicine 13. BU sponsored rehabilitation training for various rehabilitation health care professions at its College of Health and Rehabilitation Sciences (Sargent College) starting in 1929, when it acquired the Sargent School of Physical Training, an educational institution founded in 1881 14. Years later, Walter R. Frontera, MD, PhD, Harvard's first PM&R department chair, earned his doctorate in exercise physiology from Sargent College. Paul J. Corcoran, MD, who chaired the search committee that chose Frontera for that position, was on his dissertation committee in 1986 7. In 1961, Murray M. Freed, MD (Figure 2), a graduate of the New York University residency program established by internist and physiatrist Howard Rusk, MD, was recruited to start a PM&R department at BU 3. The spinal cord injury unit moved from Boston City Hospital to the BU Hospital and, with strong financial support from the Liberty Mutual Life Insurance Company, grew to 25 beds and became the New England Regional Spinal Cord Injury Center under Freed's leadership. An above-knee amputee and survivor of the Battle of the Bulge in 1944, Freed led the BU PM&R department from 1965 until 1992 (Paul J. Corcoran, MD, personal communication, 2017). He was dedicated to improving the lives of other people with disabilities, especially the many hundreds of individuals with paraplegia and quadriplegia treated by him during his many years in Boston. Murray M. Freed, MD. Courtesy of American Academy of Physical Medicine and Rehabilitation Archives. Freed gained recognition in Boston and throughout the Massachusetts Commonwealth and nation. He was Chairman of the Boston Mayor's Commission for the Handicapped and served on the Advisory Committee of the Rehabilitation Services Administration in Washington, DC. In 1972, Freed was named Massachusetts Physician of the Year, and the President's Council for Employment of the Handicapped honored him with a citation for meritorious service. Freed served as president of the Association of Academic Physiatrists in 1971, the AAPMR in 1982, and vice chair of the American Board of PM&R in 1985-1987. In 1988, he received the Distinguished Clinician Award from the AAPM&R, and after his death in December 1995, the AAPM&R gave him its Distinguished Service Award posthumously 15. Although HMS did not follow the lead of Tufts and Boston Universities in establishing PM&R departments, Harvard was nevertheless involved in providing rehabilitation. Broader rehabilitation principles were visible in some early developments at Massachusetts General Hospital (MGH). After supporters founded MGH in 1811, they added a hospital in 1816 entirely devoted to the treatment of those with mental illnesses, a real novelty at the time. The treatment there was a rehabilitation model that, in addition to avoiding restraints, provided productive work, games, and diversions and outdoor exercise. Dr Rufus Wyman, the first superintendent of the facility, reported in 1822 that these approaches “have a powerful effect in tranquilizing the mind, breaking up wrong associations of ideas, and inducing correct habits of thinking as well as acting” 16. In 1905, MGH, through the leadership of Dr Richard C. Cabot, started to establish the first outpatient medical social service department to better meet “human values” critical to patient care 17. Because of its success, the service was extended to the inpatient services, and the department acquired its first chief, Ida M. Cannon. This new department would “employ and train experts who would spend all their time helping patients and their families to adjust to the changes which illness and incapacity had brought to their lives” 18. Interestingly, by 1935 all hospitals “worthy of the name” in the United States had departments of medical social service and the origins of current case management had begun 19. More specific physical medicine developments at MGH included an orthotics clinic, which was housed at one of the several Harvard teaching hospitals, beginning in the early 1900s. Franklin Delano Roosevelt's diagnosis of polio in the summer of 1921 was confirmed by Robert Williamson Lovett, MD, Professor of Orthopedic Surgery at Harvard and a national leader in promoting rehabilitation for polio survivors 20-22. Lovett traveled to see Roosevelt, when his polio symptoms began, at his summer residence in Canada. While Roosevelt lived in New York, where he received medical care, he also came to MGH in May 1922 and again in June 1923 at Lovett's recommendation for reassessment, brace adjustments, and training in crutch walking by Wilhemine Wright, a physiotherapist and assistant to Dr Lovett. Interestingly, it was years later that a keen observation about Roosevelt's presidency would come from a distinguished Boston psychologist, Richard Goldberg PhD 22. Goldberg took time off from his clinical work to author his book on Roosevelt after spending years investigating Roosevelt's life, including review of Lovett's notes in HMS's Countway Library (Paul J. Corcoran, MD, personal communication, 2017). He posits that Roosevelt's polio led him to the presidency. Why? Before his polio, he had been an adequate politician but of patrician origins. It was only from spending time with “regular folk” at Warm Springs, all dealing with polio's effects, that he acquired sensitivity and understanding of the “common” man and woman, their strengths and struggles. Because he learned to connect with them at Warm Springs, and from there connect with the larger American public, he was elected and effectively touched so many Americans during those difficult years. Continuing with our evolving history at MGH, Dr Frank B. Granger, mentioned previously as head of the department at Boston City Hospital, also was instrumental in teaching principles of physical therapy to undergraduate and graduate students at MGH from 1911 to 1925 23. As early as 1943, Arthur L. Watkins, MD, was at the Department of Physical Therapy at MGH and published review articles on physical therapy 24 and physical medicine 25. During this time, he was also a founding member of the American Board of Physical Medicine and Rehabilitation in 1947, representing the American Medical Association 26. He also likely oversaw the use of some Baruch Committee funding by 1946 for medical fellowships in PM&R as well as some small grants 27. Watkins recruited Thomas L. DeLorme to Boston to collaborate on the latter's promising results in muscle strengthening 28 and together they published their seminal research on progressive resistance exercise in 1948 29. As an aside, Todd and colleagues reported on the origin of the words used by DeLorme and Watkins to describe their work 28. Through a telephone interview, Delorme's wife Eleanor shared that she had suggested the term “progressive resistance exercise” when DeLorme complained that too many physicians were reticent to recommend “heavy weightlifting” to their patients. By 1949, Watkins's position at MGH was Chief of Physical Medicine 30. In 1951, he was the Medical Director of the Bay State Rehabilitation Clinic, which remained separate from yet closely affiliated with the MGH 31. It was located on the MGH campus, allowing easy access to consultants and other professionals and included organized vocational programs with MGH's barber shop, accounting department, and pharmacy 32. Watkins remained at MGH through at least 1962, at which time he was an Assistant Clinical Professor of Medicine at HMS, continuing to present at national conferences and publishing profusely in multiple journals 33. Meanwhile, other rehabilitation-related clinical services were evolving. The MGH orthopedics department ran a spinal cord injury unit. The Shriner's Hospital established a 5-bed pediatric burn unit at MGH in 1964, moving into a new building next to the hospital in 1968 with considerably more beds 34. During these early years, another significant training institute evolved at MGH. From 1873 until 1981, MGH operated the MGH School of Nursing, granting diplomas in nursing only 35. In 1977, the State of Massachusetts authorized the hospital system to grant academic degrees. The new program was launched as the MGH Academic Division and 3 years later renamed the MGH Institute of Health Professions in 1980. It has been actively training physical and occupational therapists, among other professions, ever since. Corcoran (Figure 3) is among a few individuals to have been leaders in all 3 of Boston's clinical/academic PM&R programs. He was a department chair in 2 of them, giving him a unique perspective. His career links the pre-Harvard and post-Harvard eras. After residency training at NYU, he spent 2 additional years of fellowship training with Justus Lehmann, MD, at the University of Washington before joining the PM&R Department at Columbia University, under the leadership of Robert Darling, MD, in 1968. His pioneering research on the energy cost of ambulation brought him national attention and a chapter on this topic in Downey and Darling's groundbreaking text, The Physiological Basis of Rehabilitation Medicine 36. Paul J. Corcoran, MD. Courtesy of the Spaulding Rehabilitation Network. Corcoran joined Freed at BU from 1972 to 1976. He was able to act on the inspiration of Rusk, his former boss and chair at NYU, who would say that he could rehabilitate anybody if only they had “a home, a job, and someone who loved them” 37. He realized that many rehabilitation patients lost their jobs and access to their homes. Often their closest relationships ended. While in New York, Corcoran became friends with disability rights movement activists, and they provided names of activists in Boston, with whom he made contacts. He also visited Berkeley, California, the birthplace of the independent living movement 38. Conditions there were considerably better in terms of access for students at Berkeley itself, housing opportunities, and state funding for hiring personal care attendants. Returning to Boston, Corcoran, with other activists and through negotiations with the Massachusetts Medicaid program, was able to achieve success in diverting funds originally earmarked for nursing home care to a program that provided personal care assistants for people with disabilities. Now, like those in California, people with disabilities had the option to avoid institutionalization and remain at home. Corcoran was a leader in founding the Boston Center for Independent Living (BCIL), which was first located in an old BU dormitory. The BCIL served as a model for hundreds of other independent living centers subsequently established throughout the United States 7. Corcoran replaced Granger as chairman at Tufts in 1977 and continued his social activism and involvement with the BCIL. As chair, he hired Gerben DeJong, PhD, to research the evidence for successful outcomes of individuals living outside nursing homes through community supports 39-41. Activists were able to use this research to grow support for the policy changes required for promoting independent living for people with disabilities. Associate chairman, Bruce A. Gans, MD, succeeded Corcoran in 1981, and Corcoran then spent the next 4 years as director of the PM&R department at the Boston Veterans Administration Medical Center and later worked for a few years in Manchester, New Hampshire. When Gans left Tufts, Corcoran returned to serve as acting chairman from 1989 until 1992. Corcoran had planned to end his academic career and retire at a relatively early age, but circumstances conspired to delay those plans long enough to allow him a starring role in the creation of Harvard's department. While acting chairman at Tufts, Corcoran had been asked to serve on a Harvard committee, established in 1975, to consider whether Harvard should form a PM&R department. The committee concluded that the specialty was not yet sufficiently mature as an academic research discipline. With hindsight and with no available documents to provide evidence, it is difficult to say what information or opinions led to this conclusion. It was true that HMS did not create new departments very often. Nevertheless, Corcoran's participation in this early committee allowed him to become better acquainted with Harvard Dean, Eleanor Shore, MD, an internist who had once referred a patient, and with internist Manuel J. Lipson, MD, a cross-town leader in rehabilitation (Paul J. Corcoran, MD, personal communication, 2017). Interestingly, as an aside, Corcoran's pioneering work, the energy of gait, continued a tradition of research in exercise physiology initiated at the highly respected Harvard Fatigue Laboratory (1927-1947) and by another rehabilitation pioneer, Dr Frances A. Hellebrandt at the University of Wisconsin, Madison 5, 42. Manuel J. Lipson, MD (Figure 4), whose indefatigable energy and persistence were legendary, was a cardiologist and Chief Executive Officer of the Harvard-affiliated 200-bed Spaulding Rehabilitation Hospital (SRH). SRH had internists as the key attending physicians. Corcoran and other physiatrists in New England felt SRH needed more PM&R physicians, who had more training in rehabilitation methods, on staffs of rehabilitation hospitals. In response, Lipson shared with Corcoran that he harbored long-term ambitions for the creation of a department of PM&R at Harvard, and that it would be based at SRH. Manuel J. Lipson, MD. Courtesy of the Spaulding Rehabilitation Network. SRH had been built by businessman Josiah Spaulding as a nursing home close to the MGH, and in 1968, when Medicare payments to nursing homes were severely restricted, the facility was converted to a free-standing rehabilitation hospital and later was purchased by the MGH. At that time, there was only one physiatrist at Harvard, Bhagwan Shahani, MD, DPhil (Oxon), who had trained at NYU's Rusk Institute, a classmate of Paul Corcoran, and was a member of the neurology faculty at MGH, and a well-known specialist in electrodiagnosis and neuromuscular diseases. In 1991, Lipson recruited physiatrist D. Casey Kerrigan, MD (Figure 5). Kerrigan was an HMS graduate whose pathway to rehabilitation can be traced back to an experience she had while a medical student on a clinical rotation. During morning rounds with the distinguished neurologist and award-winning teacher Marty Samuels, MD, the students witnessed a patient having a stroke. Unilateral muscle strength was disappearing by the minute. All that could be done, the neurologist opined, was to give the patient an aspirin. The team then went to lunch. Kerrigan remained very disturbed that nothing else was being done, at which point Samuels responded with 2 recommendations: “You should go into rehab. They will do something about this. We don't have a department, so go look at RIC (Rehabilitation Institute of Chicago).” (D. Casey Kerrigan, MD, MS, personal communication, 2017). Kerrigan went on to complete her PM&R residency at the Greater Los Angeles Veterans Affairs Medical Center/University of California, Los Angeles while concurrently earning a master's degree in kinesiology that included research with Jacquelin Perry, MD. Perry was an orthopedic surgeon at Rancho Los Amigos Hospital, renowned for her research and clinical work in gait analysis and the postpolio syndrome 43. Kerrigan and Perry's research on spastic gait was published in 1991 44. During that residency, Kerrigan was the leading resident participant in meetings about creating a department of PM&R at University of California, Los Angeles and was the lead resident author, along with 5 PM&R faculty and 3 other residents, of the document, “Report of the Ad Hoc Physiatry Committee at U.C.L.A.” in 1989 (Siebens, personal communication, 2016). D. Casey Kerrigan, MD, MS, in the Spaulding Rehabilitation Hospital Gait Lab. Courtesy of the Spaulding Rehabilitation Network. When she returned to Boston in 1991, Kerrigan's initial academic appointment was in the Department of Neurology at MGH under the new chair, Anne B. Young, MD, PhD. Young had arrived the same year as a Professor of Neurology at HMS. Of note, she was the first female chair of a department at MGH (Anne B, Young, MD, PhD, personal communication, 2017). Young's previous experience had been at the University of Michigan, where the PM&R department was directed by a prominent PM&R leader, Theodore Cole, MD. She had been surprised to find that no PM&R department existed at HMS. So, now that she had 2 physiatrists in her department, Drs Shahani and Kerrigan, she created a Division of Physical Medicine and Rehabilitation within her neurology department shortly after her arrival, and she was receptive to the idea of an independent PM&R department at HMS. Kerrigan's intellectual curiosity and diligence in securing grant support led to the establishment of a gait analysis laboratory at SRH. With encouragement from Lipson and Young, Kerrigan applied to the Residency Review Committee of the Accreditation Council for Graduate Medical Education for approval of a new curriculum for the establishment of a Harvard PM&R residency program. However, all 3 recognized that a more senior and nationally recognized physiatrist was a prerequisite for making the residency program a reality and for the necessary leadership for future development of an academic department at HMS. In 1992, because of recurrent episodes of tachycardia, Corcoran underwent a prolonged cardiac ablation procedure at NEMC that was unfortunately not successful. Corcoran recounts in his memoir that, as he was emerging from anesthesia in the recovery room, he was visited by his friend and colleague, Manuel Lipson, who made a bold proposition: Corcoran, as the chief of rehabilitation at SRH, could become the lynchpin around which an academic department would finally coalesce. This is the moment in which Lipson might be called the godfather of the Harvard PM&R program, since he made his somewhat-sedated colleague an offer he could not refuse. In his memoir, Corcoran describes this almost farcical scene as follows: I was still waking up from my eight hours of anesthesia and would drift in and out of consciousness as Manny presented his plan. I was hesitant, so each time I would come to, Manny would add another “perk”: An executive secretary, an administrative assistant, freedom to replace any of the six physiatrists then on Spaulding's staff, money for more staff and fellowship positions, an office with a view of the Charles River, a salary larger than I had ever earned. My wife Pat, also present in the recovery room, understandably tried to get rid of Manny so I could rest and recover. But eventually I accepted 7. When he was more fully recovered from anesthesia, Kerrigan reassured Corcoran that she had already completed the heavy work of writing the application for the residency program and that her grant-supported gait analysis laboratory at SRH already established that research would be part of the bedrock of the department. When Corcoran became acting chairman, the department was still a division under the MGH neurology department. Along with Young's advocacy, the dean of faculty affairs at HMS, Eleanor Shore, MD, MPH, who was one of the first female graduates of HMS, became another important supporter 45. Interestingly, HMS had trained only men until a 10-year trial period of admitting women was started in 1945. Shore was among these “trial” women students, attending HMS from 1951 through graduation in 1955. HMS decided by 1958 that gender was no longer a consideration for HMS admission. Shore was understandably sensitive to the need for increasing the diversity of Harvard's medical school faculty, as exemplified by Young being the first female chair at the MGH. At a meeting that included Lipson, Corcoran, Kerrigan, and Shore, Shore looked at Kerrigan and said, “I think we can just make it a department now.” (Dr Casey Kerrigan, personal communication, 2017). Evolution from division to department could have taken years, not months, had Shore not made that decision on the spot. Kerrigan also played a central role in obtaining the funds needed for a permanent chair position. Through meetings with Alfred (“Al”) Fuller, chairman of the MGH Board of Trustees, she secured enough financial support (approximately 2 million dollars) to establish the PM&R chairmanship. The residency program, inaugurated in 1993, graduated its first class in 1996, the same year in which Walter R. Frontera, MD, PhD, was named its first permanent chair. Under Frontera's leadership over the next decade, the department steadily grew in size, stature, and research productivity. At long last, Corcoran felt that he could retire from the physiatric scene in Boston, where his influence and impact had been truly monumental (Walter R. Frontera, MD, PhD, personal communication, 2017). Harvard is now nationally and internationally recognized for its clinical, teaching, and research programs in PM&R under the leadership of Ross Zafonte, DO, the second chairman since the establishment of the department. The question, however, still lingers about why the department developed only in the 1990s, rather than 20, 30, or even 40 years earlier as other PM&R departments had? From 1944 through 1952, strong financial support for PM&R academic centers and residency training came from the Baruch Committee on Physical Medicine, a group of educational, research, and clinical experts brought together by philanthropist and statesman Bernard Baruch. The Baruch Committee established the funding of 3 academic centers with very large grants for research at Columbia University, New York University, and Virginia Commonwealth University 5 and smaller research grants to 9 additional facilities, including HMS and MGH. Of the 12 medical schools with these grants, 10 would establish PM&R departments in relatively short order 27, but Harvard/MGH was not among them. The answer may well lie in the fact that sufficient specialty leadership was not on site to advocate for the new department vision. Some of Harvard's clinical and administrative staff may have responded coolly to the idea because it represented change, with its unknowns, and/or a potential threat to their “turf” areas of influence. In addition, there may have been the inherent view at Harvard that sufficient research, and possibility for funding through grants, was not yet available. However, by 1992, as Charles Dickens might say, it was the best of times, and it was the best of teams for PM&R's emergence in the Harvard academic milieu. The right leadership finally became available to create HMS's first new department in 40 years. Three other major developments likely favored dramatic growth and a more positive attitude toward the specialty: the Prospective Payment System, with its use of Diagnostic Related Groups (PPS/DRG) that led to the expansion of inpatient rehabilitation facilities across the country in the 1980s and 1990s; the report of the Graduate Medical Education National Advisory Committee (GMENAC) in 1982; and the establishment of a center for rehabilitation research at the National Institutes of Health (NIH) in 1990. In 1983, Congress passed, and President Ronald Reagan signed, a law that changed the method of reimbursing hospitals for inpatient care under Medicare from a cost-based model to a fixed, prospective, case-based model. This new system, the PPS/DRG program, significantly reduced inpatient lengths-of-stay as hospitals sought to reduce costs and enhance income 46. While adversely affecting graduate medical education for many specialties, this legislation had the opposite effect on PM&R practice and residency training. It spurred the development of rehabilitation inpatient units and freestanding inpatient rehabilitation facilities. Hospitals received payment for rehabilitation services in these qualified PPS/DRG-exempt units or hospital programs, in addition to payments for acute medical-surgical hospital services 47. The number of rehabilitation beds doubled from 1980 to 1990, primarily as a result of the PPS/DRG system. The percent of Medicare patients discharged from such inpatient rehabilitation programs in 1984 was 39%; by 1989 it had risen to 65%. Additional proof of the causal relation between PPS/DRG and expansion of rehabilitation services is the fact that the number of such units and hospitals increased to about 1019 in 1994 from 554 in 1984, an 87% increase 48. Residency training programs and positions expanded at a rapid rate during this period, given the demand for new and expanded clinical services and programs, but also because of the 1982 recommendations of the GMENAC, which estimated the need for specialists in PM&R to be 4000 by 1990 49. There were only 1608 board-certified physiatrists in 1980. This was a highly favorable message about the specialty for U.S. medical students, one that led to an increase in American medical school graduates filling residency positions throughout the mid- and late-1980s 50. The importance of research and the need for greater research productivity by medical school faculty was clearly recognized at the national level. William Fowler, MD, in his 1981 AAPM&R Presidential Address stated: “…research is the single most important factor that will directly determine the acceptance of Academic PM&R and the viability of physiatry” 51. The AAPM&R and Association of Academic Physiatrists Joint Committee on Research Mission and Strategy, established in 1981, suggested approaches to improve research capacity and productivity in the short and long term. One result was the creation of research training fellowships support at the Department of Education's National Institute on Disability and Rehabilitation Research in the early 1980s (Richard Verville, JD, personal communication, 2017). During the same period, advocacy for an active program in rehabilitation medicine research within the NIH in the Department of Health and Human Services was increasing. In 1990, NIH formed the National Center for Medical Rehabilitation Research to support rehabilitation medicine research within the NIH and it became operational in 1991-1992 47, 52. Thus, the 1980s were a period of rapid growth in PM&R in response to the altered fiscal climate produced by the PPS/DRG system, an increasing proportion of U.S. medical school graduates choosing PM&R as a career path, because of a greater awareness of the specialty generated in part by the GMENAC Report, and a heightened focus on research culminating in the establishment of the National Center for Medical Rehabilitation Research within the NIH in the early 1990s. These developments certainly provided greater academic credibility and financial benefits to the medical specialty of PM&R and the institutions that embraced it. Despite the importance of these developments, it was ultimately the efforts of 5 individuals that brought the vision of a Harvard PM&R department and expansion of clinical and academic functions to fruition. Like a championship basketball team, these 5 key individuals produced a winning combination of shot-making, rebounding, assists, defensive guarding, and overall unanimity of purpose. Lipson contributed his long-range goal for expansion of rehabilitation services and programs, his mastery of fiscal and other administrative skills, and his powers of persuasion. Corcoran, as acting chairman, added stature as an eminent, nationally recognized physiatrist-leader. Kerrigan, despite being a relatively untested young physiatrist, rose superbly to the challenge of her new position by bringing research gravitas to a fledgling division of another department. She established key alliances with other departments, set a research foundation, and secured substantial funding for a residency program. Young and Shore provided critical support and assistance. This winning team of 2 physiatrists, a cardiologist, a neurologist, and an internist were successful using a highly functional interdisciplinary process, lubricated by mutual respect and friendship. There are 4 important lessons to be learned from this success story. First, physiatric research needs to be prioritized, because it is one of the keys to academic acceptance. Second, forming positive alliances with departments that are likely sources of both patients and academic support need to be instituted early and assiduously cultivated thereafter. Third, changes in the medical care reimbursement system or in its regulation should be viewed as an opportunity for growth rather than as a threat to survival. Fourth, no one, regardless of brilliance, reputation, or tenacity of purpose, can be expected to singlehandedly alter the attitudes of individual leaders or complex and long-established professional cultures toward a relatively young medical specialty with fewer human and other resources than other specialties. It entailed years of work by several individuals, including committed “insiders” from Harvard itself, to accomplish this transformation. The rehabilitation paradigm of patient-centered and interdisciplinary care, especially of individuals with disabilities, has not always been embraced at the highest levels of academic medicine, which may explain the decades it took for the field to flourish at Harvard and at Johns Hopkins, while several other major academic institutions still lack PM&R departments. These 4 principles will be encountered again in the narrative about Baltimore's road to PM&R, in Part 2 of this series. We are indebted to these individuals whose recollections and comments greatly enhanced this paper: Paul J. Corcoran, MD, John Ditunno, MD, Walter R. Frontera, MD, PhD, D. Casey Kerrigan, MD, MS, Anna Pomfret, MD, Richard Verville, JD, and Richard Wolfe. Mr Verville's broad perspective on clinical, political, and historical aspects of PM&R were particularly enlightening, as were John Ditunno's knowledge of the history of spinal cord injury rehabilitation and detailed assistance in finding documents relating to the early Boston history.