AAPM&R PHiT Board member, Charles Kenyon, DO sat down with Janna Friedly, MD, FAAPMR in December 2018 to gather insights into her career in academic physiatry, #WomeninMedicine, future directions for PM&R, and the perpetual search for balance in medicine.
What was your initial interest in medicine and how did that path evolve as you pursued a career in physiatry?
During college I was interested in health psychology and health education. When I graduated, I worked for the medical director of a health plan in Oregon. As part of this role, I reviewed data related to emergency room denials and discovered that it was a significant cost to health plans to deny ER claims and undergo an appeals process (where most of the denials were overturned). This was also causing overwhelming patient burden and stress. Another one of my roles there was putting together the first Healthcare Effectiveness and Data Information Set (HEDIS) quality report cards (looking at variations in care between providers and benchmarking against quality standards). I remember reading some of Dr. Rick Deyo’s studies relating to variations in care for people with low back pain, especially lumbar fusions–I found this work fascinating and decided to go to medical school to get the training to lead a health plan or large organization to make systematic improvements in the way we care for patients that made sense from both a quality and cost perspective. In medical school, I discovered PM&R as a specialty and was immediately drawn to working with people with disabilities. During residency training at the University of Washington (UW), I applied to the Rehabilitation Medicine Scientist Training Program (RMSTP) and started thinking about health services research to bring together my interest in improving health systems and understanding variations in the way we provide care in an academic setting. Serendipitously, Dr. Deyo was a faculty member at UW and I reached out to him. Together, we developed a grant proposal to examine national trends in the use of epidural steroid injections for low back pain conditions and variations in their use geographically. This launched my academic research and set the trajectory of my career.
Please describe your current clinical practice and research interests.
I have been on faculty at the University of Washington since graduating residency in 2005. Clinically, I run the amputation rehabilitation program at Harborview Medical Center. Most of my research still revolves around treatments for low back pain conditions, although I also participate in research related to neuropathic pain conditions after amputation. My research experience has been very broad. I started analyzing large national datasets (Medicare and VA), have led a multicenter clinical trial of epidural steroid injections for spinal stenosis (the LESS trial), have conducted observational studies, systematic reviews, and meta analyses.
How have you seen opportunities evolve for women in medicine and research since you started your medical training? What advice would you have for up-and-coming female physiatrists?
There are clear disparities in medicine regarding women in research, academics, and leadership positions in medicine. This has been true when I started medical training and continues to be true now. We need to actively promote inclusion of women in academics and leadership. I am fortunate that my institution (UW) and our Academy take this seriously and continue to work toward creating a culture in our specialty that is inclusive and equitable. We are at a time when we must be explicitly thoughtful about how we help support women in medicine to ensure that women are appropriately represented in leadership roles. For example, research has shown that women are typically underrepresented on editorial boards of medical journals and underrepresented as first and senior authors on publications. As Editor-in-Chief of PM&R, one of my priorities is to ensure that the make-up of the editorial board reflects our specialty in terms of gender, ethnicity and experience. This is one step toward ensuring that women (and people of all backgrounds) have a voice and opportunities for leadership roles. In PM&R, there are many, many outstanding and unbelievably talented and successful women to serve as role models for female junior faculty and trainees. I would advise all up-and-coming female physiatrists to seek out strong female mentors. #WomeninMedicine
When did you cultivate your passion in research? What were some early opportunities that led you down a research-focused career?
The RMSTP program was instrumental in launching my research career. Going into medical school, I really thought that I would be an administrator or be involved primarily in health policy. As I went through medical school and residency, I realized how much I enjoyed clinical care, so I started focusing on an academic career where I could do clinical care, research and administration. The RMSTP program helped me to develop the skills and mentoring plan I needed to succeed in research. Dr. Deyo was my primary mentor and Dr. Leighton Chan was my secondary mentor. These two mentors have helped guide me throughout my career and both have opened many doors for me in terms of my research and academic pursuits.
What advice do you have for young physiatrists interested in pursuing research during their training and future career?
I think research is critically important to advance our specialty and the field of medicine in general. What I learned in my own journey is that there is no one right way to go about building a research career. If you have passion, commitment and tenacity, you will be able to incorporate research into your career. I am an example of how to do everything wrong (according to the books), but still end up with a satisfying and successful career. Probably the single most important thing that helped me along the way was mentorship–I was fortunate to have some of the best mentors I could imagine. Working within a well-rooted team that had great mentors was key for me. I also didn’t worry too much about the long-term–when I made decisions about which projects to pursue or get involved with, I was most concerned with whether or not it would be enjoyable, whether I liked the people I would be working with and whether I believed in the mission of the project. This is probably not the advice you would get from every researcher–many feel that you should stick closely to things that advance your direct line of research in order to build your portfolio in a cohesive way. For me, I think the variety of my work and the breadth of my research has led me down the path to becoming Editor-in-Chief of PM&R and served me well to be able to critically evaluate and edit a wide array of studies.
Congratulations on your new position as incoming Editor-in-Chief of PM&R, what are some of the roles and responsibilities involved in this position?
As Editor-in-Chief, I am responsible for overseeing the editorial board (8 senior editors and approximately 60 associate editors). I read, edit and make decisions about publication of all submitted manuscripts–working closely with my editorial board and the peer reviewers to make fair and appropriate publication decisions.
We have heard there are many changes coming to PM&R such as a new publisher. Outside from the shift from the well-known ‘purple journal’ cover to the new motif, what changes should we expect over the next few years as the journal evolves?
We are still the purple journal, but the cover has gotten a new, modern design. The new journal cover reflects the diversity of the specialty and the patients we serve as well as the pieces that work together to complete the puzzle of our specialty.
Given my commitment to diversity and inclusion, we have broadened the expertise and diversity in the editorial board and peer reviewers. This will help us to publish a wide range of clinically and scientifically important rehabilitation studies that demonstrate the value of Physical Medicine and Rehabilitation broadly.
I also feel strongly about the importance of understanding research methodology. I teach research methodology and statistics to the UW PM&R residents and plan to incorporate more educational features related to methodology and statistics to help people in our field who want to do their own research or who just want to better critically appraise the evidence that we are presented to make sound clinical decisions. In addition to our regular ‘Statistically Speaking’ column, we are also introducing a ‘Methodology Matters’ column this year.
How does the mission of the journal support the Academy’s overall vision and efforts in ‘Advancing PM&R Bold’?
PM&R is the official journal of AAPM&R and exists in large part to help educate and engage our specialty. One of the things that presents both an opportunity and a challenge for me as Editor-in-Chief is the breadth of our specialty. We care for a wide range of patient populations with a variety of different conditions in a variety of practice settings. I believe that the journal is a place that can bring us together as a specialty and embrace this diversity–the research and features we publish represent the entire field and we don’t shy away from tackling different and sometimes conflicting perspectives.
As the incoming Editor-in-Chief of the PM&R, you have stated a need to promote ‘innovative and clinically-important research that highlights the value rehabilitation medicine brings to patient care.’ Can you expand on these qualities you and your editorial board are looking at as you evaluate research for inclusion in the journal?
First and foremost, I am looking for sound science. All studies must be conducted ethically, thoughtfully and transparently. The study design must be appropriate to answer the research question at hand. We want PM&R to be the go-to journal for clinically relevant, cutting edge research and science that will lead the field of PM&R into the next era. We want research that represents the breadth of the field–we are interested in all aspects of PM&R and want to appeal to people practicing in a wide variety of practice settings. When people make clinical decisions based on the research published in PM&R, we want to feel confident that they are making the best decisions with the best available evidence. By doing so we will ensure that our field continues to provide high quality patient care.
What recommendations do you have for physiatrists in training looking to improve the quality of their research efforts?
Never be afraid to reach out to senior faculty, mentors and leaders for feedback about your research plan. You’d be surprised by how willing people are to ensure that you are designing a research project or plan that will allow you to successfully answer your question. This is also how collaborations and mentorship relationships are formed–I have never regretted reaching out to authors of papers that were relevant to what I wanted to do. I have formed great collaborations worldwide and friendships with people by reaching out as a trainee and junior faculty to get advice.
Always remember that every project will take at least three times as long as you anticipate, and this is okay. It is part of the process. Ask as many people as possible to review your plan before you start and as you are working on it. Present your findings to people to get input about how to interpret and present your data.
Always keep an open mind. Do not do research only to prove that what you are doing clinically is correct. Do research to find out the most effective ways to care for patients and modify your clinical practice to reflect that best evidence. Ask the harder questions. Is what I have been trained to do the best way to go about this? Is it the most efficient, most cost-effective, and least harmful way to do things?
On top of your achievements as a clinician, researcher, and leader in physiatry, those who know you well have had the privilege of seeing you graciously balance these responsibilities while also raising a beautiful family and having robust interests outside of medicine. Any words of wisdom for upcoming physician leaders in maintaining balance in your career and family life?
Maintaining balance is always challenging and something that needs to be worked on throughout the various phases in life. I try never to take any one thing too seriously and am constantly reminded that there is no one right way to do things (and no one is perfect). I always have to be flexible and figure out how to accomplish the things I want to do given the many hats I wear. I have learned to be efficient, to never waste time, to multi-task and to prioritize.
When I think about balance, I always think about a great children’s book called “The Three Questions” that is based on a Leo Tolstoy story. It is about a boy who wants to be good, but sometimes is unsure of how to act. He is curious about three questions “When is the best time to do things?” “Who is the most important one?” and “What is the right thing to do?” Over the course of the story, by helping others as they need help, he is taught that “there is only one important time, and that time is now. The most important one is always the one you are with. And the most important thing is to do good for the one who is standing at your side. For these, my dear boy, are the answers to what is most important in the world.” This is what I always try to keep in mind so that I can give everything I have to each moment and each person in my life–I may have a long list of things to do, but what is most important is being present in the moment with the people and the tasks at hand.
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