When Ameet Nagpal, M.D., came to MUSC in late 2022 to lead the newly created Physical Medicine and Rehabilitation Division, he had big plans: treating more patients, training more doctors and expanding the geographical reach of modern PM&R services. Today, the Division of PM&R employs a range of subspecialists who take the long view in treating patients, whether they’ve suffered trauma in accidents, are dealing with the effects of cardiopulmonary disease and cancer, have had a stroke or are facing any other illness with a long road to recovery.
Critical to Nagpal’s mission and that of his fellow caregivers: Helping patients, as well as doctors, to understand just what PM&R is.
How do you explain PM&R to someone who's never heard of it?
The way that I describe it to people is that we are inherently doctors of function. No matter what subspecialty of PM&R we practice in, our common goal is to improve the function of someone who has some sort of dysfunction due to a disability. There’s a wide spectrum of the types of people who practice PM&R and a wide spectrum of the types of patients we treat.
There are people who work in the inpatient consult setting or the inpatient rehabilitation hospital setting and are treating patients with catastrophic injuries like spinal cord injuries, traumatic brain injuries, amputations, stroke. And then there are people like me who practice in the chronic pain setting. There are other PM&R physicians who treat chronic musculoskeletal painful conditions.
For example, my practice involves performing a lot of interventional procedures to help people with chronic musculoskeletal pains, which, on the surface, don’t seem as disabling as a spinal cord injury or a stroke, but people who have chronic back pain or shoulder pain or knee pain or can testify to the fact that it can really change your outlook on life, your mental wellness, your everything. And so, as physicians, our goal through our treatments is to optimize and restore function in our patients.
What kinds of care providers make up the PM&R department?
The doctors all did PM&R residencies. We have some nurse practitioners and athletic trainers who help us. We now have residents here at MUSC, who we didn't have before – PM&R residents. We rely heavily on our physical therapists, occupational therapists and speech therapists to help us treat our patients as well.
Are there misconceptions about PM&R? Do people lump it in with PT and OT?
Yes, they'll sometimes say, “My surgeon has a PA or nurse practitioner; they could do the same thing you could do. Why do I have to see you?” We're physicians. We're doctors, and this is our specialty. We do a four-year residency, and then a lot of us do a fellowship. I did a fellowship in pain medicine, so that's four years of med school, four years of residency and a year of fellowship. So the expertise level is clearly high, and it's what we should be good at.
To frame this distinction, then, PT and OT are treatments that are prescribed?
Most of the time, yes. It is a place where people can get an exercise program. But they're not going to manage your medications. They're not going to offer you intervention procedures. They're not going to help you if you have a spinal cord injury, and your bowel and bladder are paralyzed, and you need to have a way to have a bowel movement or urinate. That's a physician who needs to do that, and that's going to be the PM&R doc. We rely heavily on our colleagues in PT and OT to help our patients improve, and they are integral members of our team, but we have distinct roles in the treatment paradigm for our patients.
Did you come to MUSC to change this awareness while building a program here?
That was a huge part of it. When I interviewed, I was shocked that a place this big, with this many beds, that's a Level 1 trauma center, didn't already have a big, robust PM&R program. MUSC had the vision and foresight to know that that was a problem. At this point, we have a group of 13 full-time physicians and five affiliate faculty, and we have started a residency. And we have almost a million dollars in research funding. We've done that in less than four years. And we treat a lot of patients, which is the most important thing.
The idea of helping to grow something that didn't exist, to impact an entire population of people like we have in the Lowcountry, was the whole reason I wanted to start the PM&R program at MUSC. I wanted to be able to look back 10 years from that time and say, “Look what we built. Look what we did. We really made a crazy difference in the lives of so many people.” It wasn't fixing something and tweaking something that already worked really well; it was building something from scratch.
Three years ago, you said you wanted to raise the quality and availability of PM&R, and healthcare generally, to rural parts of South Carolina.
We're trying to solve that at MUSC by the fact that we've acquired hospitals across the state, and to take the level of care and quality of care that we've provided at MUSC in Charleston and put that everywhere else in the state to offer the same quality of care, so that we come to you.
I have patients who drive hours to see me in Charleston because there just isn't a physician where they are who can treat them in many instances.
We want, eventually, to be able to do that everywhere, have PM&R meet you where you are and enable you to receive the majority of your care in your rural community and have it be the same quality that you would get in Charleston.
When would a patient ask his or her doctor for a referral to PM&R?
If you've got musculoskeletal pain, it would be reasonable to see a PM&R specialist to see if any other things could be done beyond what your PCP has already initiated. And obviously, if you have a catastrophic injury, like a spinal cord injury or brain injury, stroke or amputation – any of those things. Or a genetic or congenital condition, like cerebral palsy, muscular dystrophy, and you don't already have a PM&R doctor. You should ask.
Are there people who see a PM&R doctor who might otherwise just have surgery?
Some of the things I do are considered “surgery sparing.” PM&R offers options to try first, but many of our patients do go on to have surgery. Of course, some of the patients we see have already had surgery and are now dealing with the effects of their initial injury, which we are helping them manage.
When would a provider refer a patient to you? Do they know to refer a patient to PM&R?
Some do, some don't. A lot of times, it has to do with where they trained in residency and whether there was PM&R there. So, hopefully, as we develop our program, there will be fewer people who aren't aware of what PM&R is here, but the same situations and circumstances that I just suggested a patient should ask about should be the same ones providers think about us.
Is it safe to say that PM&R tends to have a long story arc? It's not ‘get this injection; you're fine.’
Sometimes that happens. There are situations where we might do one or two injections, and you are good to go. But most of the time, it's a long-lasting relationship that you’re building with the patient to guide them through their injury or their treatment.
You’ve realized plenty of your goals already. What's next?
Well, our rehab hospital is expanding. We have 49 beds, but we're building 20 more. So by this time next year, we'll have 69 beds. We want to continue to build our research platform and pursue additional funding for research so that we can investigate new ways to treat patients. I want to continue to grow our faculty complement here in Charleston because we have an access issue. Even though we've hired all these doctors, and we're all seeing as many patients as we can, some of us are still booking out two, three, even four months to see a new patient, which isn’t acceptable in the long term.
The only way to fix that problem, if everybody is seeing the maximum number of patients they can, is to hire more physicians. There is really no other way to do it. In addition to the fact that I want to hire a few more in Charleston, we also want to grow the Regional Health Network. We want to start getting PM&R docs out into these other parts of the state – hire docs who work there, who live there, understand the community, understand the people there, understand the local geography.
Are there new treatments, programs?
The team is expanding access to multidisciplinary care through our new clinics. Recently, we opened a peripheral nerve injury clinic in partnership with orthopedic surgery and general surgeons. There, specialists work together to diagnose nerve damage and explore advanced diagnostic surgical options, including procedures that reattach healthy nerves from other parts of the body to restore function to the part that's injured. One of our PM&R doctors, Matthew Sherrier, M.D., is a co-director of that clinic.
We are in the process of launching a multidisciplinary amputee clinic this summer, led by Campbell Miller, D.O. The clinic will bring together a PM&R physician, a prosthetist and a physical therapist to support patients as they adjust to life with prosthetic limbs. The goal is to help patients through every stage – from fitting and learning to use their new prosthetic limb to improving their gait – while also monitoring for potential medical issues, such as skin breakdown, to ensure the best possible outcomes.
You were also planning to establish a residency in PM&R, and now you have.
That's right. We just matched our second class of residents. Our first class of residents is about to become second-year residents. It's a four-year residency, so two years from now we will have a full complement of residents. It has been phenomenal watching our team grow so meaningfully. Our program director, Lindsay Mohney, D.O., and our program coordinator, Missy Durante, have been working non-stop to first start and now maintain a robust educational program for our residents.
Sounds like people are pretty motivated there.
I think so, and I think part of that is when I hire people, I tell them, "Don't come here if you're afraid of working hard." We have a lot of people to see, and they have been neglected unintentionally by the fact that PM&R hadn’t existed here. And I want to help as many of those people as we can.
