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

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 at Harvard and a national in rehabilitation for polio to when his polio at his summer in in New York, where he received medical he also came to MGH in and in at for and training in by a and to Dr Interestingly, it was years later that a about Roosevelt's would from a Boston Richard time from his work to his on after years Roosevelt's including of in Countway (Paul J. Corcoran, MD, personal communication, 2017). He that Roosevelt's polio led him to the his he had been an of was only from time with at all with that he acquired and of the and their and Because he to with at and from there with the American he was and many during those with history at MGH, Dr Frank B. Granger, as head of the department at Boston City Hospital, also was in teaching principles of physical therapy to and graduate at MGH from to As early as MD, was at the Department of Physical at MGH and articles on physical therapy and physical medicine During this time, he was also a of the American Board of Physical Medicine and Rehabilitation in the American Medical Association He also the of some Baruch Committee by for medical in PM&R as well as some grants recruited to Boston to on the in and they their research on exercise in As an and reported on the of the by and to their work a that had the when that many physicians were to to their By at MGH was of Physical Medicine In he was the Medical Director of the Rehabilitation which from with the MGH was located on the MGH to and other and included vocational programs with and at MGH through at at which time he was an Professor of Medicine at to at national and in other services were The MGH department a spinal cord injury The Hospital established a pediatric unit at MGH in into a new to the hospital in with more beds During these early training at until MGH the MGH School of in only In the of Massachusetts the hospital to grant academic The new program was as the MGH Academic and years later the MGH Institute of Health in been training physical and among other (Figure is among a individuals to have been in all of Boston's PM&R He was a department chair in 2 of him a His the and After residency training at he 2 additional years of training with MD, at the University of the PM&R Department at Columbia under the leadership of Robert MD, in 1968. His pioneering research on the of brought him national and a on this in and The of Rehabilitation Medicine Paul J. Corcoran, MD. Courtesy of the Rehabilitation Freed at BU from to He was to on the of Rusk, his and chair at who would that he could only they had a and who He realized that many rehabilitation patients their and to their their in New York, became with and they provided of in with he He also the of the there were better in of for at and for personal care to Corcoran, with other and through with the Massachusetts was to in for care to a program that provided personal care for people with those in people with had the to and at was a in the Boston Center for Independent Living which was first located in an BU The served as a model for hundreds of other centers established throughout the United States 7. Granger as chairman at Tufts in and his social and with the As chair, he PhD, to research the for outcomes of individuals through were to this research to support for the changes required for for people with MD, succeeded in and the 4 years as of the PM&R department at the Boston Administration Medical Center and later worked for a years in New to serve as chairman from until had to his academic and at a early to delay those to him a in the of Harvard's chairman at had been to serve on a Harvard established in to Harvard a PM&R The committee that the specialty was not as an academic research and with to provide it is to led to this was that HMS did not new departments in this early committee him to better with Harvard MD, an internist who had a and with internist J. MD, a in rehabilitation (Paul J. Corcoran, MD, personal communication, 2017). Interestingly, as an pioneering work, the of a of research in exercise physiology at the Harvard and by rehabilitation Dr at the University of J. MD (Figure and were was a and of the Rehabilitation Hospital had as the and other in New England more PM&R who had more training in rehabilitation on of rehabilitation In with that he for the of a department of PM&R at and that it would be at J. MD. Courtesy of the Rehabilitation had been built by as a to the MGH, and in when to were the facility was to a rehabilitation hospital and later was by the At that time, there was only one physiatrist at MD, who had at Rusk a of Paul Corcoran, and was a of the faculty at MGH, and a in and In recruited physiatrist MD (Figure was an HMS graduate to rehabilitation can be to an experience had while a medical on a During with the and MD, the a patient a was by the that could be the was to the patient an The to that was being at which with 2 into about have a at Institute of MD, personal communication, 2017). on to PM&R residency at the Medical of while a in that included research with MD. was an at Hospital, for research and work in analysis and the and research on was in During that was the leading in about a department of PM&R at University of and was the lead along with PM&R faculty and other of the of the Committee at in personal communication, MD, in the Rehabilitation Hospital Courtesy of the Rehabilitation to Boston in academic was in the Department of at MGH under the new chair, B. MD, had the as a Professor of at Of was the first chair of a department at MGH MD, PhD, personal communication, 2017). previous experience had been at the University of where the PM&R department was by a PM&R MD. had been to that PM&R department at that had 2 in and a of Physical Medicine and Rehabilitation department after and was to the of an PM&R department at and in grant support led to the establishment of a analysis at from and to the Committee of the Council for Medical for of a new for the establishment of a Harvard PM&R residency However, all recognized that a more and nationally recognized physiatrist was a for making the residency program a and for the leadership for development of an academic department at In because of of a at NEMC that was not in his that, as he was from in the recovery he was by his and who a Corcoran, as the of rehabilitation at could the around which an academic department would This is the in which be the of the Harvard PM&R he his an he could not In his this as was still up from of and would in and out of as his was time would would An an to of the on for more and an with a of the a had also in the recovery to of could and 7. he was more fully from that had the work of the for the residency program and that analysis at established that research would be of the of the became the department was still a under the MGH with the of faculty at MD, who was one of the first graduates of became Interestingly, HMS had only until a of was started in was among these HMS from through in HMS by that was a for HMS was to the for the of Harvard's medical school as by being the first chair at the At a that included Corcoran, and at and can it a department personal communication, 2017). from to department could have not had not that on the also a in the for a chair with chairman of the MGH Board of financial support 2 to establish the PM&R The residency in its first in the in which Walter R. Frontera, MD, PhD, was named its first leadership the decade, the department grew in and research At that he could from the in where his and had been R. Frontera, MD, PhD, personal communication, 2017). Harvard is nationally and recognized for its and research programs in PM&R under the leadership of the chairman the establishment of the The still about the department developed only in the even years as other PM&R departments through strong financial support for PM&R academic centers and residency training came from the Baruch Committee on Physical a of and experts brought by and Bernard The Baruch Committee established the of academic centers with grants for research at Columbia New York and Commonwealth University and research grants to additional including HMS and Of the medical schools with these would establish PM&R departments in was not among The may well in the that specialty leadership was not on to for the new department of Harvard's and may have to the because it with its a to their areas of In there may have been the at Harvard that and for through was not However, by as it was the of and it was the of for PM&R's in the Harvard academic The leadership became to first new department in other major developments and a more toward the the with its of that led to the of inpatient rehabilitation across the in the and the of the Medical Advisory Committee in and the establishment of a for rehabilitation research at the of Health in In and President a that the of hospitals for inpatient care under from a model to a This new the significantly inpatient as hospitals to and graduate medical education for many this had the effect on PM&R practice and residency the development of rehabilitation inpatient and inpatient rehabilitation received for rehabilitation services in these hospital in addition to for hospital services The number of rehabilitation beds from to as a of the The of patients from inpatient rehabilitation programs in was by it had to of the relation and of rehabilitation services is the that the number of and hospitals to about in from in an training programs and at a during this the for new and services and also because of the of the which the for in PM&R to be by were only in This was a about the specialty for U.S. medical one that led to an in American medical school graduates residency throughout the and The importance of research and the for research by medical school faculty was recognized at the national MD, in his AAPM&R is the that the of Academic PM&R and the of The AAPM&R and Association of Academic Physiatrists Committee on Research and established in approaches to research and in the and was the of research training support at the Department of Institute on and Rehabilitation Research in the early (Richard personal communication, 2017). During the for an program in rehabilitation medicine research the in the Department of Health and Services was In the Center for Medical Rehabilitation Research to support rehabilitation medicine research the and it became in the were a of in PM&R in to the by the an of U.S. medical school graduates PM&R as a because of a of the specialty in by the and a on research in the establishment of the Center for Medical Rehabilitation Research the in the early 1990s. developments provided academic and financial to the medical specialty of PM&R and the institutions that the importance of these it was the of individuals that brought the of a Harvard PM&R department and of and academic to a these individuals a of and of his for of rehabilitation services and his of and other and his of Corcoran, as added as an nationally recognized being a to the of new by research to a of established with other departments, a research and for a residency and provided critical support and This of 2 a a and an internist were a functional by and are 4 to be from this research to be because it is one of the to academic with departments that are of patients and academic support to be early and changes in the medical care in its be as an for as a to of of can be to the of complex and toward a medical specialty with and other other years of work by several including from Harvard to this The rehabilitation of and especially of individuals with disabilities, not been at the of academic which may the it for the field to at Harvard and at Johns while several other major academic institutions still PM&R 4 principles be in the about to in 2 of this are to these individuals and this Paul J. Corcoran, MD, John MD, Walter R. Frontera, MD, PhD, MD, Pomfret, MD, Richard and Richard on and historical of PM&R were as were John of the history of spinal cord injury rehabilitation and in to the early Boston

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