Fellowship-trained outpatient physiarists

[MagSoldier]

Are there any fellowship-trained physiatrists on this board that are doing outpatient msk, spine, sports, emg (preferably in private practice)? How much of your skill and decision making in treating your patients do you attribute to the training you received in your fellowship vs. the training you received during your residency?

I ask this because I am having a real tough time ranking my top 2 for the match. Program A is much stronger in sports with overall better fellowship placement, and program B is stronger in spine/injections and also in the area that I want to go into private practice, but weaker in sports and fellowship placement. I think doing a sports & spine fellowship will be something that I will want and need to do coming from either program. Program B does not have a sports and spine fellowship nearby, so I would have to leave for a year before coming back (not a bad thing in my opinion).

Should I bypass the opportunities to network in the area that I want to practice, as well as racking up injections, to go to program A in order to put myself in a better position to get a good fellowship down the road. Or if I were to work hard at program B, would I still be able to land a solid fellowship? Is there a wide gap between the top fellowships and the lesser ones? What do fellowship directors look for in applicants? Why do you think you were accepted into your fellowship (sports/spine experience during residency, research, letters of rec, residency program reputation)?

If I’m thinking too far ahead, let me know, but I am curious as to what people’s opinions are in regards to the importance and impact of doing a fellowship. Thanks for any responses.

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[bedrock]

It's a difficult question to answer at your level of training. Just like the third year of med school, it's difficult to know how much you really love sports med or spine procedures until that's all you're doing for a month straight.

A few things to keep in mind include- 1- Do both programs give you at least two months of elective time? I can't emphasize how important this is. Some of your priorities and perspectives may change by the time you're halfway through your PGY-3 year, and you may decide you want to do a pure sports fellowship or a pain fellowship etc, or stick with sports & spine.
2- It's becoming more and more important to do a fellowship to get jobs and be credentialing doing spinal procedures(even if you did quite a few as a resident, the procedures you do as a fellow are given more weight).

I'm in private practice and like many who did sports & spine fellowships I was attracted to both aspects of musculoskeletal care. I now find that I'm enjoying and focusing much more on spine interventions, although I would have thought the exact opposite when applying for residency when spine interventions were something I knew I wanted to include, but more of an afterthought compared to sports.

The other thing is that your job search will be be significantly impacted by whether or not you did a pain fellowship. I was surprised how much my job options were limited because I did a sports and spine fellowship instead of a pain fellowship. Most recruiters and websites just don't understand the sports & spine skill set. Some will listen if you explain, but there are a lot of places that just want the words "pain fellowship grad". With interventional spine training there are still a fair amount of jobs, but good luck trying to land a job in one of the popular metropolitan areas without the words ACGME pain fellowship on your resume.

Frankly I think the best route is a PM&R residency with a lot of sports exposure, followed by an ACGME pain fellowship. It's much easier to pick up extra sports pointers after residency/fellowship, than to gain procedural experience performing the spinal interventions you didn't learn. You'll have many more job options, and you can always choose to do more sports later (after you've secured a job where you want to live).

 

[drusso]

It's a difficult question to answer at your level of training. Just like the third year of med school, it's difficult to know how much you really love sports med or spine procedures until that's all you're doing for a month straight.

A few things to keep in mind include- 1- Do both programs give you at least two months of elective time? I can't emphasize how important this is. Some of your priorities and perspectives may change by the time you're halfway through your PGY-3 year, and you may decide you want to do a pure sports fellowship or a pain fellowship etc, or stick with sports & spine.
2- It's becoming more and more important to do a fellowship to get jobs and be credentialing doing spinal procedures(even if you did quite a few as a resident, the procedures you do as a fellow are given more weight).

I'm in private practice and like many who did sports & spine fellowships I was attracted to both aspects of musculoskeletal care. I now find that I'm enjoying and focusing much more on spine interventions, although I would have thought the exact opposite when applying for residency when spine interventions were something I knew I wanted to include, but more of an afterthought compared to sports.

The other thing is that your job search will be be significantly impacted by whether or not you did a pain fellowship. I was surprised how much my job options were limited because I did a sports and spine fellowship instead of a pain fellowship. Most recruiters and websites just don't understand the sports & spine skill set. Some will listen if you explain, but there are a lot of places that just want the words "pain fellowship grad". With interventional spine training there are still a fair amount of jobs, but good luck trying to land a job in one of the popular metropolitan areas without the words ACGME pain fellowship on your resume.

Frankly I think the best route is a PM&R residency with a lot of sports exposure, followed by an ACGME pain fellowship. It's much easier to pick up extra sports pointers after residency/fellowship, than to gain procedural experience performing the spinal interventions you didn't learn. You'll have many more job options, and you can always choose to do more sports later (after you've secured a job where you want to live).

Good insights.

 

[Disciple]

Frankly I think the best route is a PM&R residency with a lot of sports exposure, followed by an ACGME pain fellowship. It's much easier to pick up extra sports pointers after residency/fellowship, than to gain procedural experience performing the spinal interventions you didn't learn. You'll have many more job options, and you can always choose to do more sports later (after you've secured a job where you want to live).

I'm not so sure that's an optimal way to do it either, nowadays, or in the near future. Alot of volunteer sports opportunities I looked into after entering practice wanted Sports Med boarded physicians.

I don't see why our professional societies and board don't help out the younger Physiatrists with this by improving and streamlining the training, so that they can continue advancing the specialty. We shouldn't push our trainees to choose between doing something they enjoy, and doing something else they enjoy + $$.

Nobody wants to do 2 fellowships. That's 6 years. May as well have gone into a medicine or surgical subspecialty if you're going to have to do that.

 

[PMR 4 MSK]

I don't see why our professional societies and board don't help out the younger Physiatrists with this by improving and streamlining the training, so that they can continue advancing the specialty.

Because too many of the upper echelon physiatrists (same guys and gals who rotate through as presidents and editors of the various organizations and journals, as well as heads of the big programs) like the status quo and are not will, strong enough or confident enough to change things

The age of inpt rehab is coming to an end, but residency is still done like it is 1980 in many places. They are training the new guys the same way they were trained. Some programs have embraced the future, others are stuck in the past.

The Academy officials have little desire to radically change things, in light of an uncertain economic future for rehab and medicine in general, combined with a chronic field-wide identity crisis and a severe lack of numbers of physicians to force a change.

Too much, residents are there to help the program make money, and if possible, to learn things. There really is no excuse for the amount of time wasted during residency. You have such a short time to learn so much, and all the heads seem to want is warm, living bodies to write notes, do admits and discharges.

If i had my way, I'd completely overhaul the entire medical training system from Med school through fellowship. It's all done in a completely archaic system being cremated by modern economics.

 

[RUOkie]

So most of us who are in private practice are in agreement that we need to blow up the current medical education system and start over. But How? The ultimate question is where do the $$$ come from to train residents in MSK medicine? Most resident salaries get paid to hospitals to pass through to resident education. The hospitals use the money for labor.

 

[Disciple]

I don't understand what's holding us back, other than, maybe, lack of motivation. Training residents in musculoskeletal medicine doesn't have to be a finanacial loss to the department. Don't farm residents out to other sites to do their MSK training.

First, it takes a committment by the Chairman and program director, who then need to hire some young, hungry, polically saavy musculoskeletal Physiatrists.

Take your new attendings aside and tell them that they are being hired specifically to uplift the musculoskeletal training in the program, and to build a patient base for the services they will be offering.

Pay them well and give them incentives to go out and get referrals from or collaborate with the Orthopods, Neurosurgeons, PCPs, therapists, etc. within your hospital system. Keep your residents busy doing procedures, EMGs, MSK consults, doing histories and examinations for IMEs, etc.

We've seen all the editorials, articles, etc. so there are clearly some academicians who subscribe to this line of thinking.

Yes, it might upset some other departments in the hosptal. Then again, we're talking about the future of the profession.

 

[specepic]

I think the recent editorial by Cifu summarized the 'old school' PM&R line which is: fellowships are not needed, unless of course you want to do inpt rehab in that case a fellowships are fine.

 

[axm397]

The Academy officials have little desire to radically change things, in light of an uncertain economic future for rehab and medicine in general, combined with a chronic field-wide identity crisis and a severe lack of numbers of physicians to force a change.

The Academy (AAPM&R) has nothing to do with residency training. The Board (ABPM&R) and the ACGME-RRC have more to do with residency training. When I last spoke to the Board (ABPMR), they told me the ABPMR's primarily priority (i.e. the people they serve) is the public and they are not there to serve the physiatrists. The ACGME-RRC hasn't been too responsive about this issue either. A couple years ago, several fellows/attendings(some here on sdn) gave a presentation at the AAP (Academic Physiatrists = i.e. program directors and chairs) discussing whether procedural training should be part of residency and apparently that was not received too well.

 

[Disciple]

When I last spoke to the board, they told me the ABPMR's primarily priority (i.e. the people they serve) is the public and they are not there to serve the physiatrists.

Sounds like a convenient excuse to me.

If their main concern is protecting the public, you would think, that given the fact that most Physiatrists nowadays base their practices on musculoskeletal medicine, that the board would want to make sure that there was a certain quality in the service being provided. For this to happen, obviously, the training has to be more standardized and consistent.

And, aren't the councils of the AAPMR supposed to be making recommendations to the AAPMR board, who in turn communicate and make recommendations to the ABPMR?

 

[axm397]

And, aren't the councils of the AAPMR supposed to be making recommendations to the AAPMR board, who in turn communicate and make recommendations to the ABPMR?

No - there's no mechanism to do that and honestly the ABPMR certifies physiatrists and administers the board exams, and have very little control over the actual residency training. Although I suppose if they added more MSK/pain content to the board exam and perhaps add a MSK/neuro physical exam component to the oral boards, it would force the residencies to provide better training.

The councils are there to help with exchange of information, collaboration with research, scope of practice issues, and other related topics. Majority of Academy members are private practice physiatrists.

The AAP and the ACGME-RRC are the two entities that could really make a difference. The ABPMR certifies physiatrists and administers the board exams. The "protecting the public" answer was what I got when I approached them about the timing of the board exam (got moved to August a few years ago) adn the fact that they did not accept credit card as form of payment at that time. They did budge on the credit card issue.

I definitely agree with all of you that the level and content of training needs to be elevated in the PM&R residencies. My personal opinion is that subpar residencies should not be accredited and if that means less slots and less number of physiatrists, so be it. It only takes a couple bad apples in the community to help ruin it for the rest of us.

I think all Physiatrists should graduate with basic MSK competencies including a good physical exam, EMG/NCS skills, basic musculoskeletal and neuro radiology interpretation, sports medicine and knowledge of common sports injuries, ability to cover a sports event and do pre-participation physicals, competence with basic pain medication management, adjuvant medication therapy, orthotics and biomechanical evaluation, basic interventional procedures including all joints and at least lumbar epidurals.

I don't know how many residencies provide that level of training. The Academy has already published data that most graduating residents are going into outpatient MSK/pain/spine practices in some form or another. Some are doing combination of outpatient/inpatient. Very few are doing pure academic inpatient. The PDs and Chairs are aware of that and some have done more to respond to those needs (hiring more academic MSK/pain physiatrists, etc.). Then there are those who can't even meet the basic inpatient rehab requirements much less the outpatient MSk stuff.

 

[lobelsteve]

No - there's no mechanism to do that and honestly the ABPMR certifies physiatrists and administers the board exams, and have very little control over the actual residency training. Although I suppose if they added more MSK/pain content to the board exam and perhaps add a MSK/neuro physical exam component to the oral boards, it would force the residencies to provide better training.

The councils are there to help with exchange of information, collaboration with research, scope of practice issues, and other related topics. Majority of Academy members are private practice physiatrists.

The AAP and the ACGME-RRC are the two entities that could really make a difference. The ABPMR certifies physiatrists and administers the board exams. The "protecting the public" answer was what I got when I approached them about the timing of the board exam (got moved to August a few years ago) adn the fact that they did not accept credit card as form of payment at that time. They did budge on the credit card issue.

I definitely agree with all of you that the level and content of training needs to be elevated in the PM&R residencies. My personal opinion is that subpar residencies should not be accredited and if that means less slots and less number of physiatrists, so be it. It only takes a couple bad apples in the community to help ruin it for the rest of us.

I think all Physiatrists should graduate with basic MSK competencies including a good physical exam, EMG/NCS skills, basic musculoskeletal and neuro radiology interpretation, sports medicine and knowledge of common sports injuries, ability to cover a sports event and do pre-participation physicals, competence with basic pain medication management, adjuvant medication therapy, orthotics and biomechanical evaluation, basic interventional procedures including all joints and at least lumbar epidurals.

I don't know how many residencies provide that level of training. The Academy has already published data that most graduating residents are going into outpatient MSK/pain/spine practices in some form or another. Some are doing combination of outpatient/inpatient. Very few are doing pure academic inpatient. The PDs and Chairs are aware of that and some have done more to respond to those needs (hiring more academic MSK/pain physiatrists, etc.). Then there are those who can't even meet the basic inpatient rehab requirements much less the outpatient MSk stuff.

What's a Physiatrist?

 

[bedrock]

I think all Physiatrists should graduate with basic MSK competencies including a good physical exam, EMG/NCS skills, basic musculoskeletal and neuro radiology interpretation, sports medicine and knowledge of common sports injuries, ability to cover a sports event and do pre-participation physicals, competence with basic pain medication management, adjuvant medication therapy, orthotics and biomechanical evaluation, basic interventional procedures including all joints and at least lumbar epidurals.

I don't know how many residencies provide that level of training.

What's a Physiatrist?

I think axm and steve hit it on the head. The biggest problem with PM&R musculoskeletal training is that referring physicians can't rely on what a physiatrist is. They need to be able to trust that anyone who has done a PM&R residency has a certain skill set. Just as you know that any cardiologist or nephrologist, etc can handle certain things when referring to them.

That's a big reason residents feel they need to do pain or sports med fellowships as this makes finding jobs are easier because recruiters and physician groups are then confident you've acquired a certain set of skills if you are pain or sports boarded.

I think what axm suggested as the basic graduating musculoskeletal competencies are very reasonable. It's disappointing how out of touch many of the PM&R department chairs are with where the field is going. You shouldn't need a fellowship to acquire those core MSK skills and practice good outpatient MSK medicine.

 

[bedrock]

I'm not so sure that's an optimal way to do it either, nowadays, or in the near future. Alot of volunteer sports opportunities I looked into after entering practice wanted Sports Med boarded physicians.

I'm surprised to hear the "volunteer" sports opportunities were so stringent. I know lots of physiatrists doing volunteer sports med without being sports med boarded. Marathons, triathlons, high school and Division II-III teams. If they're not paying you, I can't see them requiring sports boards, but would be glad for the help. I can see problems covering professional sports and Division I college teams without being sports boarded, however.

 

[SSdoc33]

I'm surprised to hear the "volunteer" sports opportunities were so stringent. I know lots of physiatrists doing volunteer sports med without being sports med boarded. Marathons, triathlons, high school and Division II-III teams. If they're not paying you, I can't see them requiring sports boards, but would be glad for the help. I can see problems covering professional sports and Division I college teams without being sports boarded, however.

the physician themself often has to pay to cover a pro team.

bedrock is right, tho. the quality of any particular physiatrist is exceptionally variable. this is directly related to our training. there are too many bozos in our field because of lack of standards and, quite frankly, the ease at which sub-par students can match into PM&R residency programs. id love to see the poorer programs close and resident education overhauled. but, id also love a yacht. money talks here, and the only way that training will change is if either A) inpatient rehabilitation becomes less profitable or B)outpatient MSK becomes more profitable. i dont think there is enough of a financial incentive right now to make the changes to resident education. perhaps that will be the case in the future.

 

[DistantMets]

I think the recent editorial by Cifu summarized the 'old school' PM&R line which is: fellowships are not needed, unless of course you want to do inpt rehab in that case a fellowships are fine.

As I posted in another thread...Dr. Cifu was ASKED to take the position of being againt fellowships. He even found it weird/confusing that he personally has started multiple fellowships in our department and that Dr. Plastaras did not do a fellowship but wrote the pro-fellowship opinion. Cifu's big thing is that we need to bolster residency training across the board to make being a physiatrist mean something. Dr. Cifu and Dr. McKinley are always making changes and getting us new exposure. Cifu spent most of his academy presidency trying to get the old guard to budge.

 

[specepic]

As I posted in another thread...Dr. Cifu was ASKED to take the position of being againt fellowships. He even found it weird/confusing that he personally has started multiple fellowships in our department and that Dr. Plastaras did not do a fellowship but wrote the pro-fellowship opinion. Cifu's big thing is that we need to bolster residency training across the board to make being a physiatrist mean something. Dr. Cifu and Dr. McKinley are always making changes and getting us new exposure. Cifu spent most of his academy presidency trying to get the old guard to budge.

I accept your point that in person he may have a different stance. You seem to know him much better, I know him very little. So maybe he is not the 'old guard' but...

If he was asked to provide an argument that he did not agree with then why do it? I would assume someone would not write something in this type of a publication that was not accurate to their beliefs. That is either cavalier or worse. Actually his editorial was quite problematic in a number of ways. How can you argue for mentorship, then against fellowships.

 

[axm397]

Journals frequently have "point counter-point" type articles and the authors are not necessarily for the argument they are giving. I know Dr. Cifu fairly well and I can tell you that he is NOT an "old guard". He is very supportive of the fellowships available at VCU and of residents in general. If you look at the Academy Board roster you will see that it really isn't filled with the "old guard" types.

I think change is going to be tough but needs to start at the grass-roots level. It may mean that residents will have to self-organize and look for resources together to learn the basic MSK skills mentioned above. I know at my residency we followed the PASSOR MSK physical exam curriculum outline and had annual physical exam series, spinal injection course, joint injection course, and also had access to courses on how to do a McKenzie evaluation, etc. Some of those courses were fellows/residents led and organized with support from the faculty. (like the weekend spinal injection course)

It may also mean engaging the inpatient faculty about relevant topics - like pain medicine in the post-op period, shoulder issues in a patient in a wheelchair, etc. Too often the perception of the inpatient academic attendings is that the residents only want procedural experience. If you show them that it's the body of knowledge behind the procedures that you are interested in, rather than pure procedural skills (which you can teach a med student to do - i know cuz i've seen that happen), then maybe they will come around. the residents would have to be prepared to put in extra hours and work though - like doing workshops on weekends and meeting after the inpatient rehab responsibilities.

It's easy to complain about the old guards but some of the responsibility of education received during residency has to fall on the residents as well.

 

[SSdoc33]

Journals frequently have "point counter-point" type articles and the authors are not necessarily for the argument they are giving. I know Dr. Cifu fairly well and I can tell you that he is NOT an "old guard". He is very supportive of the fellowships available at VCU and of residents in general. If you look at the Academy Board roster you will see that it really isn't filled with the "old guard" types.

I think change is going to be tough but needs to start at the grass-roots level. It may mean that residents will have to self-organize and look for resources together to learn the basic MSK skills mentioned above. I know at my residency we followed the PASSOR MSK physical exam curriculum outline and had annual physical exam series, spinal injection course, joint injection course, and also had access to courses on how to do a McKenzie evaluation, etc. Some of those courses were fellows/residents led and organized with support from the faculty. (like the weekend spinal injection course)

It may also mean engaging the inpatient faculty about relevant topics - like pain medicine in the post-op period, shoulder issues in a patient in a wheelchair, etc. Too often the perception of the inpatient academic attendings is that the residents only want procedural experience. If you show them that it's the body of knowledge behind the procedures that you are interested in, rather than pure procedural skills (which you can teach a med student to do - i know cuz i've seen that happen), then maybe they will come around. the residents would have to be prepared to put in extra hours and work though - like doing workshops on weekends and meeting after the inpatient rehab responsibilities.

It's easy to complain about the old guards but some of the responsibility of education received during residency has to fall on the residents as well.

inpatient attending dont know outpatient medicine. how can they teach it when they are doing the same (lousy) residencies we did.

if you have to teach yourself how to examine a shoulder or how to do an epidural (ie: the stuff we do in practice everyday), then what good is residency? i see very little cross-over between inpatient pain medicine and wheelchair shoulders with what most physiatrists do. nice idea, but it doesnt work like that. an orthopod doesnt learn how to do a bowel resection in residency, then replace joints all day.

 

[Disciple]

money talks here, and the only way that training will change is if either A) inpatient rehabilitation becomes less profitable or B)outpatient MSK becomes more profitable. i dont think there is enough of a financial incentive right now to make the changes to resident education. perhaps that will be the case in the future.

Procedures, ultrasound, EMGs, IMEs, Work-Comp.

How do you get more profitable than that?

vs. general inpt heavy on Medicare/Medicaid, etc.

 

[Disciple]

No - there's no mechanism to do that and honestly the ABPMR certifies physiatrists and administers the board exams, and have very little control over the actual residency training.

Hmmm... That's not what was being said at the council meetings.

It was my understanding that the RRC served simply as inspectors.

Surely, the ABPMR must have something to do with what is included on the PIF for residency programs. I know when any new subspecialty is created, the sponsoring board must submit an application to the ABMS explaining why the subspeciality is needed, the knowledge base from the which the curriculum will be created, etc.

 

[lobelsteve]

I just had another birthday and realize I am becoming the old guard.
We, the new old guards, are outsiders to Physiatry. Crappy residency training that prepared me to pass boards and take care of very few things I do on a day to day basis. Excellent fellowship that trained me to do everything on a day to day basis.

I don't care if inpatient fails. I visit hospitals every 2-3 weeks to implant a device. I don't do call or overnights. I write eval and treat on 90% of my PT scripts because I have 2 PT's in the office and they already know what to do. I have one amputee, but I see him for his spine fractures. I do facet blocks fo periscapular pain, then I recommend they try Wii Fit Yoga. I have one SCI patient (happened after she was a patient of mine for Rheum pain). TBI, CVA - huh?, Cardiac rehab- where does a Physiatrist have any role in a cardiologist own rehab center? Peds? Glad someone likes it- my old Chair was fantastic with Peds- I never got it.

So what do I need AAPMR/ABPMR/AAP/SIGs/Member Councils for? I am disinterested, disenfranchised, and I'll take my boards every 10 years of so to maintain my Subspecialty Certification.

 

[SSdoc33]

I just had another birthday and realize I am becoming the old guard.
We, the new old guards, are outsiders to Physiatry. Crappy residency training that prepared me to pass boards and take care of very few things I do on a day to day basis. Excellent fellowship that trained me to do everything on a day to day basis.

I don't care if inpatient fails. I visit hospitals every 2-3 weeks to implant a device. I don't do call or overnights. I write eval and treat on 90% of my PT scripts because I have 2 PT's in the office and they already know what to do. I have one amputee, but I see him for his spine fractures. I do facet blocks fo periscapular pain, then I recommend they try Wii Fit Yoga. I have one SCI patient (happened after she was a patient of mine for Rheum pain). TBI, CVA - huh?, Cardiac rehab- where does a Physiatrist have any role in a cardiologist own rehab center? Peds? Glad someone likes it- my old Chair was fantastic with Peds- I never got it.

So what do I need AAPMR/ABPMR/AAP/SIGs/Member Councils for? I am disinterested, disenfranchised, and I'll take my boards every 10 years of so to maintain my Subspecialty Certification.

i seriously wish i didnt agree with you.

 

[olafa]

You have to appreciate honesty and your candidness. You post made me laugh.

I just had another birthday and realize I am becoming the old guard.
We, the new old guards, are outsiders to Physiatry. Crappy residency training that prepared me to pass boards and take care of very few things I do on a day to day basis. Excellent fellowship that trained me to do everything on a day to day basis.

I don't care if inpatient fails. I visit hospitals every 2-3 weeks to implant a device. I don't do call or overnights. I write eval and treat on 90% of my PT scripts because I have 2 PT's in the office and they already know what to do. I have one amputee, but I see him for his spine fractures. I do facet blocks fo periscapular pain, then I recommend they try Wii Fit Yoga. I have one SCI patient (happened after she was a patient of mine for Rheum pain). TBI, CVA - huh?, Cardiac rehab- where does a Physiatrist have any role in a cardiologist own rehab center? Peds? Glad someone likes it- my old Chair was fantastic with Peds- I never got it.

So what do I need AAPMR/ABPMR/AAP/SIGs/Member Councils for? I am disinterested, disenfranchised, and I'll take my boards every 10 years of so to maintain my Subspecialty Certification.

 

[bedrock]

Procedures, ultrasound, EMGs, IMEs, Work-Comp.

How do you get more profitable than that?

vs. general inpt heavy on Medicare/Medicaid, etc.

I wonder if the dearth of well trained musculoskeletal physiatry attendings in many PM&R residencies stems from a lack of vision/motivation on part of the PM&R chairs vs the lack of desire on the part of these high-earning physicians to give up 50% of their income to be academic physiatrists?

Academic attendings take a financial hit in every specialty. Why does PM&R in particular struggle to appropriately staff their residencies with attendings trained in interventional procedures, ultrasound, etc? I think part (but not all) of the answer lies in what steve mentioned. I think many outpatient physiatrists become disenfranchised with the specialty at some point in training/first few years in practice, and feel it didn't give them that much for those three years of residency training during the prime of their lives, so they feel less inclined to give back by pursuing academic careers.

 

[axm397]

Hmmm... That's not what was being said at the council meetings.

It was my understanding that the RRC served simply as inspectors.

Surely, the ABPMR must have something to do with what is included on the PIF for residency programs. I know when any new subspecialty is created, the sponsoring board must submit an application to the ABMS explaining why the subspeciality is needed, the knowledge base from the which the curriculum will be created, etc.

The councils and various Academy members have and are trying but my point is that there is no existing mechanism or formal relationship - i.e. the Board and the ACGME-RRC and/or the AAP don't have to listen to feedback from the Academy.

There are some people who are on leadership positions in those organizations who are also part of the Academy - they know the issues - and I know they are trying to change things. There is and will be ongoing dialogue. There are many likeminded people trying to make changes. I think the more responsive PDs and chairs have responded. It's the rest of the programs that need to hear this. Some of those programs without strong MSK/pain training also don't have strong inpatient rehab training. So I agree with those above who said that those programs simply just shouldn't be allowed to exist status quo - even at the cost of having less physiatrists in the country.

My point was that too often people point to the Academy as the evil when actually the Academy is the only organization that represents private practice PM&R physicians. The AAP is academic, the ACGME-RRC cares about accreditation (like disciple said), and the ABPMR cares about the board exam and subspecialty certification.

There are some great people on the Academy councils and there are many indirect ways to try to influence residency training. You will see the results of that soon. For example, the councils are helping the medical education committee write "practicing curriculum documents" identifying topics that should be covered in future "study guide" type educational material. The pain medicine part of the curriculum is in draft form and I have to say it looks very comprehensive and good. The same type of thing will be done for musculoskeletal topics and other relevant topics. I think there's a good chance that these "practicing curriculum documents" can influence "residency curriculum".

We have some department chairs and program directors who are involved in some of the leadership positions in the Academy, which allows them to hear some of this feedback - either via others sitting with them on committees or from the issues brought up in their committees. I would highly encourage all the MSK/Pain private practice docs to volunteer to serve on council projects/leaderships and Academy committees. Having personal interactions with these PDs and Chairs can go a long way. The councils have a lot of work to do but much of it is very relevant and time-sensitive.

 

[axm397]

I wonder if the dearth of well trained musculoskeletal physiatry attendings in many PM&R residencies stems from a lack of vision/motivation on part of the PM&R chairs vs the lack of desire on the part of these high-earning physicians to give up 50% of their income to be academic physiatrists?

Academic attendings take a financial hit in every specialty. Why does PM&R in particular struggle to appropriately staff their residencies with attendings trained in interventional procedures, ultrasound, etc? I think part (but not all) of the answer lies in what steve mentioned. I think many outpatient physiatrists become disenfranchised with the specialty at some point in training/first few years in practice, and feel it didn't give them that much for those three years of residency training during the prime of their lives, so they feel less inclined to give back by pursuing academic careers.

I think that is part of the issue. The more progressive PDs are looking to private practice outpatient MSK/pain docs to provide some educational opportunities for their residents. I think that is a great idea because too often residents are very ignorant about the financial aspect of medical practice. Of course, this means the private practice doc will have to sacrifice their time and therefore $$ to teach the residents. I'm planning on getting involved in resident education and have found a few other community docs who are willing to help. Our plan is to split the time so we are not teaching all the time - I think 1-2 half days a week is reasonable.

 

[drusso]

A couple years ago, several fellows/attendings(some here on sdn) gave a presentation at the AAP (Academic Physiatrists = i.e. program directors and chairs) discussing whether procedural training should be part of residency and apparently that was not received too well.

1) Tail wagging the dog. Merge the AAP with the Academy and make them an academic council. This would consolidate resources and bring everyone under one tent. Our specialty is too small to be this fractioned.

2) Develop regional training networks attached to residency programs. There are many private practice attendings who would "host" residents in their practices for rotations; offer the private practice attendings adjunct clinical faculty appointments.

3) Develop standardized multimedia web-based MSK curricula for residency programs.

 

[axm397]

inpatient attending dont know outpatient medicine. how can they teach it when they are doing the same (lousy) residencies we did.

if you have to teach yourself how to examine a shoulder or how to do an epidural (ie: the stuff we do in practice everyday), then what good is residency? i see very little cross-over between inpatient pain medicine and wheelchair shoulders with what most physiatrists do. nice idea, but it doesnt work like that. an orthopod doesnt learn how to do a bowel resection in residency, then replace joints all day.

I agree - but it's something residents can do to try to show their interest to the PDs and chairs. It's better than complaining and becoming disgruntled. Inpatient attendings don't really know outpatient medicine but getting them involved and interested may help with department politics. If you ask your stroke attending to show you the physical exam findings and mechanics of a "wheelchair shoulder" or your ortho rehab attending to show you how to manage post-op pain, you're engaging them. I know that there's not that much cross-over but finding those cross-over topics may help build some bridges. I think reaching out to those "old school" inpatient rehab attendings is better than further alienating them and frustrating them.

Attacking the issue of residency training should be multi-faceted - there's the big picture policy/procedures/requirement approach via ABPMR/RRC, there's the political approach via the AAP, but there can also be internal approach via existing faculty members and residents. Too often I have seen residents complain about an issue but yet when they are given the opportunity to do something about it but it requires sacrifice on their part, they do not step up to the plate. I remember my co-residents complaining about having to wake up early on a Saturday morning to go to a spine injection course put on by our fellows and faculty members. But that course showed the outpatient MSK faculty members support for their efforts, and also showed the PD and other inpatient faculty members our genuine interest in the topic. Since then, it has become an annual tradition.

How about asking your chief resident to invite known MSK experts to come give a lecture at your program? Or using journal club to talk about the latest spine issues? How about engaging other departments at your institution like the neuroradiologists, orthopods, rheum, etc. to have some cross-communication/educational opportunities?

I know that what I'm suggesting does not replace good quality MSK residency training. But if you do nothing, then nothing will change.

 

[drusso]

I just had another birthday and realize I am becoming the old guard.
We, the new old guards, are outsiders to Physiatry. Crappy residency training that prepared me to pass boards and take care of very few things I do on a day to day basis. Excellent fellowship that trained me to do everything on a day to day basis.

I don't care if inpatient fails. I visit hospitals every 2-3 weeks to implant a device. I don't do call or overnights. I write eval and treat on 90% of my PT scripts because I have 2 PT's in the office and they already know what to do. I have one amputee, but I see him for his spine fractures. I do facet blocks fo periscapular pain, then I recommend they try Wii Fit Yoga. I have one SCI patient (happened after she was a patient of mine for Rheum pain). TBI, CVA - huh?, Cardiac rehab- where does a Physiatrist have any role in a cardiologist own rehab center? Peds? Glad someone likes it- my old Chair was fantastic with Peds- I never got it.

So what do I need AAPMR/ABPMR/AAP/SIGs/Member Councils for? I am disinterested, disenfranchised, and I'll take my boards every 10 years of so to maintain my Subspecialty Certification.

There are many in your position and quite frankly I don't think that we understand *how* individuals become disenfranchised. Clearly, there is a mechanism that explains how this happens.

Maybe the Membership Committee should do a study to figure out how some physiatrists end up estranged from their professional community.

I have a few hypotheses...

I propose the term "Phino's." Physiatrists in name only.

 

[axm397]

1) Tail wagging the dog. Merge the AAP with the Academy and make them an academic council. This would consolidate resources and bring everyone under one tent. Our specialty is too small to be this fractioned.

2) Develop regional training networks attached to residency programs. There are many private practice attendings who would "host" residents in their practices for rotations; offer the private practice attendings adjunct clinical faculty appointments.

3) Develop standardized multimedia web-based MSK curricula for residency programs.

1) - that believe it or not, has been tried. Who do you think was resistant to that idea?? Over the years, there have been many attempts - but there's a lot of politics (actually more like one individual) preventing this from happening.

2) - this is a great idea and it's already happening in some areas. I think when the Academy's more saavy social networking type website launches, there will be even more opportunities and mentors identified for residents.

3) - I think those products will come out - but it's up to the PDs to incorporate them into resident education. Of course, residents can access the Academy's educational content which they could use regardless of PDs/faculty members.

 

[ampaphb]

I agree - but it's something residents can do to try to show their interest to the PDs and chairs. It's better than complaining and becoming disgruntled. Inpatient attendings don't really know outpatient medicine but getting them involved and interested may help with department politics. If you ask your stroke attending to show you the physical exam findings and mechanics of a "wheelchair shoulder" or your ortho rehab attending to show you how to manage post-op pain, you're engaging them. I know that there's not that much cross-over but finding those cross-over topics may help build some bridges. I think reaching out to those "old school" inpatient rehab attendings is better than further alienating them and frustrating them.

Attacking the issue of residency training should be multi-faceted - there's the big picture policy/procedures/requirement approach via ABPMR/RRC, there's the political approach via the AAP, but there can also be internal approach via existing faculty members and residents. Too often I have seen residents complain about an issue but yet when they are given the opportunity to do something about it but it requires sacrifice on their part, they do not step up to the plate. I remember my co-residents complaining about having to wake up early on a Saturday morning to go to a spine injection course put on by our fellows and faculty members. But that course showed the outpatient MSK faculty members support for their efforts, and also showed the PD and other inpatient faculty members our genuine interest in the topic. Since then, it has become an annual tradition.

How about asking your chief resident to invite known MSK experts to come give a lecture at your program? Or using journal club to talk about the latest spine issues? How about engaging other departments at your institution like the neuroradiologists, orthopods, rheum, etc. to have some cross-communication/educational opportunities?

I know that what I'm suggesting does not replace good quality MSK residency training. But if you do nothing, then nothing will change.

RIC appears to have been a special place, where resident input and initiatives were incorporated into curriculum changes. Few other institutions are that progressive.

Even when resident initiatives are implemented, they require ongoing effort by future incoming residents, which rarely happens. While resident-based programmatic changes are laudatory, most incoming residents aren't sufficiently knowledgeable of the deficiencies their program has, and the nuances of the institutional politics, to modify things till their last year, when their time is largely filled with applying for fellowships, jobs, etc.

Most (not all) program directors rise in the academic world by NOT making waves. They rarely are agitators because such folks are viewed as troublemakers, and make enemies along the way. Since they rarely rocked the boat during their rise to prominence, it seems unlikely that these leopards would change their spots once they reach positions of power.

Programs need to be encouraged, whether by the Board, the Academy, the AAP, ACGME, or RRC to adopt MSK/Spine/Pain initiatives. Part of the reason RIC and Mayo are at the forefront are that they are PRIVATE institutions, with money available for initiatives. A lot of State-based institutions do not have the sophistication to finance such forays (albeit UTSW, Utah, Colorado, and others seem to be the exceptions).

The Academy has the ability, although never tapped into, to function as a liason between industry and the field. MONEY talks. The Academy could bring industry-based resources to these issues at a program level, rather than just once a year to sponsor the Annual Assembly. US, Stim, RF, and C-arm manufacturers, phamaceutical manufacturers, and EMR companies, could provide MSK/Spine/Pain unrestricted educational grants, that could then be distributed based on the initiatives and needs of the individual programs.

This would undoubtedly widen the divide between good and bad programs. Some residents would still be poorly trained. Who received such grants would clearly be somewhat political. That being said, it would be one more metric with which resident applicants could evaluate programs.

 

[PMR2008]

I wanted to add my 2 cents.
I am a PGY2 in a medium sized free standing rehabilitation Hospital in the midwest. Our program has never been known to be strong in outpatient/msk education. The residents have made some changes over the last 1 1/2 years that have significantly improved our knowledge and exposure. This can serve as a an example for residents at other programs

1) Monthly MSK lectures by one of our attendings that is based on the PASSOR MSK physical examination competencies list. A 3-4 hr hands on workshop each month where we go over one region in depth.

2) Recently I set up MSK U/S hands on workshop with one of the local experts to be repeated quarterly. Our program purchased a MSK ultrasound machine 2 years ago and all the inpatient attendings received training on how to use them. But the residents still have to encourage the attendings to actively use MSK U/S when diagnosing and injecting.

3) I was able to get in touch with a few local Ortho sports attendings and now we have the option to cover local high school and college events as early as PGY2.

4) Assigned lectures will be started soon for all residents. Considering our class size it will be divided so that the PG4 end up giving lectures more often. I was able to make the list with the help of the chief residents, recent fellows, PD and a few attendings.

5) We have reached out to local PM&R, Neurology, Rheumatology, ENT and Orthopedic physicians and we frequently have lectures given by them.

6) Hands on peripheral injection workshop given my our PD that was recently started.

7) Monthly journal club in which residents are encouraged to present articles on current issues in MSK, spine, sports etc

Basically all the above was started over the last year and a half and so far it has been a huge success. The residents reached out to the attendings for help in educating us and they are all stepping up to the challenge. But the most important thing is to show initiative.

 

[axm397]

The Academy has the ability, although never tapped into, to function as a liason between industry and the field. MONEY talks. The Academy could bring industry-based resources to these issues at a program level, rather than just once a year to sponsor the Annual Assembly. US, Stim, RF, and C-arm manufacturers, phamaceutical manufacturers, and EMR companies, could provide MSK/Spine/Pain unrestricted educational grants, that could then be distributed based on the initiatives and needs of the individual programs.

Drusso and I brought something like this up when we were on the RPC - the issue is that the Academy provides courses that count for CME credits and the ACCME is very particular about industry funding and educational courses.

I do like the idea of grants for programs to use for educational opportunities/courses. I'll ask around about that.

 

[ampaphb]

Drusso and I brought something like this up when we were on the RPC - the issue is that the Academy provides courses that count for CME credits and the ACCME is very particular about industry funding and educational courses.

I do like the idea of grants for programs to use for educational opportunities/courses. I'll ask around about that.

If the Academy functions as conduit, then the courses are tacitly Academy funded.

CME courses benefit those who have completed their training. Residents gain no benefit from CMEs, so the notion that the Academy would be duplicating its efforts is simply inaccurate. Plus, almost all Academy spine courses fill, so demand typically exceeds supply.

Attempting to read between the lines, your comment seems to imply that the Academy might be more interested in generating revenue from their courses than furthering the education of residents. Or am I misreading?

 

[rehab_sports_dr]

This may be redundent, but just trying to clarify the different roles of the different organizations.

The board (ABPMR) and academy (AAPMR) work seperately from one another

The ABPMR does accredit practicing physicians. It's not clear to me what else they do

The AAPMR's focus is on helping practicing physiatrist's practice. This includes educational endeavors, as well as lobbying and the development of practice guidelines.

I think the AAPMR is a great organization that does it's best to help. One of the current initiatives, for example, is the development of a curriculum for physiatrists who have already graduated, both to stay up to date, but also to fulfill the maintenance of certification (MOC) requirements that are necessary to stay boarded.

Many of the activities of the AAPMR are driven by volunteer efforts of the academy members. And volunteering really means you are paying to help, since you are taking time away from your practice.

All that said, the efforts of the AAPMR are primarily (although not exclusively) targeted toward practicing physiatrists, although this does certainly overlap with needs of residents. There are also some resident specific functions within the academy.

The AAP is a seperate organization that is designed to develop the academic aspect of PMR, and therefore is more targeted toward development of education for residents. There is a resident specific course that takes place on the Wednesday of the annual meeting, and resident specific activities throughout the week. Beyond that, this is where the leaders of residency programs meet to deal with the structure of the residencies. Much of this is infrastructural, but there are some discussions of content.

 

[SSdoc33]

This may be redundent, but just trying to clarify the different roles of the different organizations.

The board (ABPMR) and academy (AAPMR) work seperately from one another

The ABPMR does accredit practicing physicians. It's not clear to me what else they do

The AAPMR's focus is on helping practicing physiatrist's practice. This includes educational endeavors, as well as lobbying and the development of practice guidelines.

I think the AAPMR is a great organization that does it's best to help. One of the current initiatives, for example, is the development of a curriculum for physiatrists who have already graduated, both to stay up to date, but also to fulfill the maintenance of certification (MOC) requirements that are necessary to stay boarded.

Many of the activities of the AAPMR are driven by volunteer efforts of the academy members. And volunteering really means you are paying to help, since you are taking time away from your practice.

All that said, the efforts of the AAPMR are primarily (although not exclusively) targeted toward practicing physiatrists, although this does certainly overlap with needs of residents. There are also some resident specific functions within the academy.

The AAP is a seperate organization that is designed to develop the academic aspect of PMR, and therefore is more targeted toward development of education for residents. There is a resident specific course that takes place on the Wednesday of the annual meeting, and resident specific activities throughout the week. Beyond that, this is where the leaders of residency programs meet to deal with the structure of the residencies. Much of this is infrastructural, but there are some discussions of content.

thanks, it is not redundant.

the problem remains: how do we fix the residencies?

each governing body seems to have to no real responsibility in terms of the quality of residency programs and the content therein. seems to me, it SHOULD be the responsibility of ABPMR and RRC.

 

[axm397]

Attempting to read between the lines, your comment seems to imply that the Academy might be more interested in generating revenue from their courses than furthering the education of residents. Or am I misreading?

misreading - I meant to say that Academy - Industry relations are closely scrutinized because the Academy provides CME courses. I wasn't commenting on the possibility of industry funded resident courses. I do like the idea of educational grants and will find out more about that possibility.

 

[ampaphb]

This may be redundent, but just trying to clarify the different roles of the different organizations.

The board (ABPMR) and academy (AAPMR) work seperately from one another

The ABPMR does accredit practicing physicians. It's not clear to me what else they do

The AAPMR's focus is on helping practicing physiatrist's practice. This includes educational endeavors, as well as lobbying and the development of practice guidelines.

I think the AAPMR is a great organization that does it's best to help. One of the current initiatives, for example, is the development of a curriculum for physiatrists who have already graduated, both to stay up to date, but also to fulfill the maintenance of certification (MOC) requirements that are necessary to stay boarded.

Many of the activities of the AAPMR are driven by volunteer efforts of the academy members. And volunteering really means you are paying to help, since you are taking time away from your practice.

All that said, the efforts of the AAPMR are primarily (although not exclusively) targeted toward practicing physiatrists, although this does certainly overlap with needs of residents. There are also some resident specific functions within the academy.

The AAP is a seperate organization that is designed to develop the academic aspect of PMR, and therefore is more targeted toward development of education for residents. There is a resident specific course that takes place on the Wednesday of the annual meeting, and resident specific activities throughout the week. Beyond that, this is where the leaders of residency programs meet to deal with the structure of the residencies. Much of this is infrastructural, but there are some discussions of content.

While their mission statements may differ, this remains a distinction without a difference due to the frequent cross-fertilization of the Board memberships. At present, Drs. Micheo, Kowalski, Geiringer, and Robinson all sit on more than one Board simultaneously. Current Board members DeLisa, Smith, Francisco, Frontera, Bockenek, Clinchot, and Chiodo have held or currently hold other Board or high positions with multiple entities recently.

We are a small field, and the circles of power have a good deal of overlap. Thus assigning specific responsibilities or tasks to individual entities carries far less import when you realize that a significant number of the primary players are engaging in a game of musical chairs across Board memberships.

 

[rysa4]

Are there any fellowship-trained physiatrists on this board that are doing outpatient msk, spine, sports, emg (preferably in private practice)? How much of your skill and decision making in treating your patients do you attribute to the training you received in your fellowship vs. the training you received during your residency?

I ask this because I am having a real tough time ranking my top 2 for the match. Program A is much stronger in sports with overall better fellowship placement, and program B is stronger in spine/injections and also in the area that I want to go into private practice, but weaker in sports and fellowship placement. I think doing a sports & spine fellowship will be something that I will want and need to do coming from either program. Program B does not have a sports and spine fellowship nearby, so I would have to leave for a year before coming back (not a bad thing in my opinion).

Should I bypass the opportunities to network in the area that I want to practice, as well as racking up injections, to go to program A in order to put myself in a better position to get a good fellowship down the road. Or if I were to work hard at program B, would I still be able to land a solid fellowship? Is there a wide gap between the top fellowships and the lesser ones? What do fellowship directors look for in applicants? Why do you think you were accepted into your fellowship (sports/spine experience during residency, research, letters of rec, residency program reputation)?

If I'm thinking too far ahead, let me know, but I am curious as to what people's opinions are in regards to the importance and impact of doing a fellowship. Thanks for any responses.

Fascinating thread guys. But back to the OP. Assuming your analysis is factual in description; choose program A and stay in touch with connections in the area of program B. Spinal injections are great to learn but can be an issue setting up in private practice and may not be economically efficient. The relationship you can build with your pen in referring out these type of procedures could be much more efficient for you in many ways. Go with the best education you can get, leaving the most bridges to the next step.

 

[bedrock]

Spinal injections are great to learn but can be an issue setting up in private practice and may not be economically efficient. The relationship you can build with your pen in referring out these type of procedures could be much more efficient for you in many ways.

You'll have to explain the economics of that one to me as anyone focusing on spine procedures makes twice as much as a general physiatrist.

But your quote above includes similar phrases that many residents have heard from their program/department chairs when requesting that education in spine interventions be added to their residency curriculum and frankly it sounds much like the old guard way of thinking that we've been discussing.

Old guard chairmen and residency directors are reluctant to provide residency training in spinal procedures because they're worried that interventional procedures will be the sole focus of the future practices of their residents. Unfortunately this very approach of limiting residency training in spinal interventions frequently backfires because in the current educational atmosphere, to learn even basic spine procedures most residents now have to do a spine or pain fellowship and there they learn all kinds of interventional procedures with varying amounts of evidence and now after spending this extra year of training they end up focusing on procedures (ala pain docs).
I postulate that interventional spinal procedures would not be overused to the degree they are today if basic spine interventions were integrated into a well-rounded PM&R residency education which would include inpatient rehab, EMGs, outpatient MSK/spine with basic spine interventions (lumbar epidural/facet injections, etc.)

If more practicing general physiatrists could provide basic spine interventions as part of their core musculoskeletal clinical skill set and not have to refer these patients out to pain docs for epidural X 3, RF X 2, spinal cord stimulators, adios......., then patients, our specialty, and the health care system would be better served. (obviously, not all pain docs follow that algorithm but you do see it quite frequently)

 

[RUOkie]

You'll have to explain the economics of that one to me as anyone focusing on spine procedures makes twice as much as a general physiatrist.

That is today. Just look at what Noridian is doing to Facet joint injections. That should teach everyone to not put all your eggs in one basket. The primary interventionalists may be starving soon if the current trend continues.

I postulate that interventional spinal procedures would not be overused to the degree they are today if basic spine interventions were integrated into a well-rounded PM&R residency education which would include inpatient rehab, EMGs, outpatient MSK/spine with basic spine interventions (lumbar epidural/facet injections, etc.)

If more practicing general physiatrists could provide basic spine interventions as part of their core musculoskeletal clinical skill set and not have to refer these patients out to pain docs for epidural X 3, RF X 2, spinal cord stimulators, adios......., then patients, our specialty, and the health care system would be better served. (obviously, not all pain docs follow that algorithm but you do see it quite frequently)

But the economic reality does not support this. I am that generalist you mention. I am trained in Lumbar ESI, Facet injections, and I injections. (ISIS Basic Spine). I used to do them. I then moved to my current state, and if I did Fluoroscopic spine injections, my malpractice went from a Class Ia to a IIb. (a $11,000 increase in yearly premiums). Guess what. I have not done a spine intervention in 7 years. I send my injections to the local "pain doc", and now I do his EMGs.
Now, the rates have changed again (I changed malpractice carriers) so if I chose to, I could do them again. I am not going to, though. If you don't do a lot of these injections, your time is not spent in an efficient manner, and they do not become worth it. I also do not want to disrupt the politics of the community at this point.

By the way, I think that rysa4 is a very reliable source for the economics of medicine (it is what he does for a living!)

 

[Ludicolo]

Great discussion. Sorry I’m late.

If I can touch upon a couple of things that rehab_sports_dr mentioned earlier regarding organizational roles: yes, the ABPMR accredits physiatrists. They do this by testing competency and by granting initial and maintenance of certification. They establish the educational and professional standards deemed sufficient to practice independently, not just for the specialty of PM&R but all of the associated ACGME-recognized subspecialties (peds, SCI, sports, neuromuscular, pain, hospice/palliative). They assess candidates using the “six core competencies” framework set forth by the ACGME, assessing medical knowledge, patient care, professionalism, interpersonal/communication skills, practice-based learning, and systems-based practice. By doing so, the board most certainly affects resident/fellow education and training. They set the bar for residents/fellows to clear. The AAP helps PDs figure out how to get their people over the bar. The ACGME/RRC should be responsible in determining if programs are consistently and safely helping their trainees clear the bar. Whether the bar needs to be raised or adjusted to reflect a more outpatient/MSK bias, something that would match market demand as well as the career desires of graduating residents, is what we’re talking about. I personally think it should.

The AAPMR is a different beast entirely. Its role IMHO should involve marketing, health care policy, advocacy, networking, and CME. In other words, providing education and assistance to practicing physicians already finished with training. And it needs to satisfy the demands of its dues-paying members. As of right now, we remain a broad field, one that still appears to be in danger of splintering. I thought that was supposed to be one of the functions of the Member Councils? Finding areas of overlap, facilitating cross-talk amongst the subspecialties, bringing the field together. If lobelsteve is representative of the constituency, then they aren’t doing a very good job, are they?

ampaphb is very astute w/ his observations. There has been MASSIVE overlap amongst the leadership of the various alphabet soup organizations over the years, so these individual organization roles become blurred, and individual agendas become ingrained. And even though the majority of the Academy membership is private practitioners, the leadership within the AAPMR (the BOG, the council leaders) is overwhelmingly comprised of academicians. Mostly old academicians at that.

 

[axm397]

ampaphb is very astute w/ his observations. There has been MASSIVE overlap amongst the leadership of the various alphabet soup organizations over the years, so these individual organization roles become blurred, and individual agendas become ingrained. And even though the majority of the Academy membership is private practitioners, the leadership within the AAPMR (the BOG, the council leaders) is overwhelmingly comprised of academicians. Mostly old academicians at that.

The AAPM&R BOG - the next two presidents are private practice docs. The current president works for kaiser. Out of the 12 board members, 5 are academic.

The council leadership definitely has more of an academic bend - but the council leadership is supposed to be elected by the council members every year so the leadership can change - I would encourage more private practitioners to get involved with council activities and run for leadership positions.

 

[rehab_sports_dr]

Getting back to the original question (at least I think it was) ... why don't we cover these essential outpatient MSK skills in residency

Short answer- because it is hard too

Longer answer-
You can cover a lot of different topics at a superficial level in residency training, but to develop true competence in skills like a good physical examination, ultrasound, EDX, and spine injections is hard to do

Take just the physical examination, for example. I remember when I was a fellow, and we had a physical examination course for the residents. I was reviewing the ankle jerk, and it just so happened that the resident who was our model had a true 4+ ankle jerk reflex. Even with me working with the residents one-on-one for several minutes, most residents were unable to elicit ankle clonus on her reflex. And these were very good residents (by any objective measure some of the top 10% of residents in the country).

That's just one physical exam maneuver- the ankle jerk is very hard to do well. I know I spend a lot of time working on physical examination techniques with my residents, and the subtleties of each individual examination maneuver can take a long time to grasp.

Move on to EMG. It takes a long time to just learn the innervation and insertion points for EMG. Waveform analysis is another animal altogether- I know that even good residents can struggle in distinguishing endplate spikes from fibrillation potentials. Concepts like recruitment frequency can be challenging to grasp. And these are the basics.

Move on to spine injections. L5 transforaminals, which are a bread and butter procedure, can be challenging for even experienced injectionists. It can take time to adjust to subtleties like low-lying transverse processes, or injecting at levels where there is significant spondylolisthesis. How about reviewing vascular patterns? These things take repitition and time to understand

Move on to ultrasound. You have to learn a whole new set of anatomical landmarks. Trying to remember subtleties like that interdigitation of the subscapularis tendon in short axis view is normal, etc.

To develop competence, as opposed to exposure, takes a lot of time. My experience with teaching residents is that residents want to have the skills, but not all residents are interested in putting in the time that is necessary to acquire those skills, which requires a significant amount of investment made with their discretionary time in reading and practice.

And if someone isn't invested in their own success, it's hard to address this as an educator, no matter how hard you try. Education ultimately has to come from the resident and their own initiative. As educators, all we can do is provide opportunity, support, and feedback.

 

[Disciple]

each governing body seems to have to no real responsibility in terms of the quality of residency programs and the content therein. seems to me, it SHOULD be the responsibility of ABPMR and RRC.

Of course it should.

The PIF for residency programs didn't magically write itself.

 

[DrMarchMadness]

Everything you say is very true.

Because too many of the upper echelon physiatrists (same guys and gals who rotate through as presidents and editors of the various organizations and journals, as well as heads of the big programs) like the status quo and are not will, strong enough or confident enough to change things

The age of inpt rehab is coming to an end, but residency is still done like it is 1980 in many places. They are training the new guys the same way they were trained. Some programs have embraced the future, others are stuck in the past.

The Academy officials have little desire to radically change things, in light of an uncertain economic future for rehab and medicine in general, combined with a chronic field-wide identity crisis and a severe lack of numbers of physicians to force a change.

Too much, residents are there to help the program make money, and if possible, to learn things. There really is no excuse for the amount of time wasted during residency. You have such a short time to learn so much, and all the heads seem to want is warm, living bodies to write notes, do admits and discharges.

If i had my way, I'd completely overhaul the entire medical training system from Med school through fellowship. It's all done in a completely archaic system being cremated by modern economics.

 

[DrMarchMadness]

You'll have to explain the economics of that one to me as anyone focusing on spine procedures makes twice as much as a general physiatrist.

But your quote above includes similar phrases that many residents have heard from their program/department chairs when requesting that education in spine interventions be added to their residency curriculum and frankly it sounds much like the old guard way of thinking that we've been discussing.

Old guard chairmen and residency directors are reluctant to provide residency training in spinal procedures because they're worried that interventional procedures will be the sole focus of the future practices of their residents. Unfortunately this very approach of limiting residency training in spinal interventions frequently backfires because in the current educational atmosphere, to learn even basic spine procedures most residents now have to do a spine or pain fellowship and there they learn all kinds of interventional procedures with varying amounts of evidence and now after spending this extra year of training they end up focusing on procedures (ala pain docs).
I postulate that interventional spinal procedures would not be overused to the degree they are today if basic spine interventions were integrated into a well-rounded PM&R residency education which would include inpatient rehab, EMGs, outpatient MSK/spine with basic spine interventions (lumbar epidural/facet injections, etc.)

If more practicing general physiatrists could provide basic spine interventions as part of their core musculoskeletal clinical skill set and not have to refer these patients out to pain docs for epidural X 3, RF X 2, spinal cord stimulators, adios......., then patients, our specialty, and the health care system would be better served. (obviously, not all pain docs follow that algorithm but you do see it quite frequently)

I agree with most of what you say.

 

[lobelsteve]

The AAPM&R BOG - the next two presidents are private practice docs. The current president works for kaiser. Out of the 12 board members, 5 are academic.

The council leadership definitely has more of an academic bend - but the council leadership is supposed to be elected by the council members every year so the leadership can change - I would encourage more private practitioners to get involved with council activities and run for leadership positions.

Spoken like an AAPMR membership chair. Congrats.