inpatient rehab

[anboptop]

I just rotated on an inpatient rehab unit where at least 50% of the patients have a serious illness, including metastatic cancer, heart transplants, liver transplants, glioblastoma, etc. The case manager told me that "this is the way inpatient rehab is headed".

Could this be true???? I was thinking about inpatient rehab, but if I wanted to do transplant medicine and have a bunch of deaths on my service, I would have done internal medicine.

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[normalforce]

Yep its true. Inpatient rehabilitation is quickly moving towards accepting patients who are "more critical". If you want to do rehab, esp the inpatient variety, work hard in medical school and get a good IM background. Do an internship where you get good exposure to IM, ICU/CCU, and post-surgical management. You will usually always have the benefit of good consultants in the academic medical center setting, but when you get to private practice, inpatient rehab medicine will have a strong "medicine" component. It is best that you be ready for this. On my current, inpatient peds service I have patients with acute ATN, recent heart transplant, recent multi-organ failure. We are getting patients admitted directly from ICUs. My advice-be ready for anything.

 

[axm397]

I just rotated on an inpatient rehab unit where at least 50% of the patients have a serious illness, including metastatic cancer, heart transplants, liver transplants, glioblastoma, etc. The case manager told me that "this is the way inpatient rehab is headed".

Could this be true???? I was thinking about inpatient rehab, but if I wanted to do transplant medicine and have a bunch of deaths on my service, I would have done internal medicine.

I think we get a skewed view in academic inpatient rehab. community rehabs (where you'll likely get a private practice job) are very different. I rotated through a community rehab for two months and the rotation was a breeze after what I went through during my inpt rehab months at RIC. The community rehab pts are usually much more stable and less acute. I rounded on max 10 patients and took home call. I might have gotten paged once a night at the most - mostly about orders that needed to be clarified or someone had fallen or had a fever. the internists usually followed their own patients and were happy to "consult" since they could bill for consultation.

In academic medicine residents don't get paid extra for seeing consults so there is an atmosphere of hostility when you order a consult. I didn't see that in the community setting. Docs were more laid back and seemed to respect each other more.

Even in the academic setting - if you are looking for a setting with less medically complex patients - spinal cord injury is a nice niche where most patients are young with very little comorbidities and most community rehabs don't take vents so you'll probably take care of more paras and incomplete quads.

 

[ampaphb]

I think we get a skewed view in academic inpatient rehab. community rehabs (where you'll likely get a private practice job) are very different. I rotated through a community rehab for two months and the rotation was a breeze after what I went through during my inpt rehab months at RIC. The community rehab pts are usually much more stable and less acute. I rounded on max 10 patients and took home call. I might have gotten paged once a night at the most - mostly about orders that needed to be clarified or someone had fallen or had a fever.

The problem with these settings is that, as the 75% Rule gets implemented over the next few years, all of these will have to convert to far less lucrative SNF status.

 

[Louisville04]

The problem with these settings is that, as the 75% Rule gets implemented over the next few years, all of these will have to convert to far less lucrative SNF status.

It is definitely less lucrative for the facility. However, I don't think the physician fee changes. You just can't write notes on them everyday.

 

[ampaphb]

It is definitely less lucrative for the facility. However, I don't think the physician fee changes. You just can't write notes on them everyday.

But it is REALLY hard to write notes when the facility closes!

 

[axm397]

I didn't get the feeling that they were worried about closing down anytime soon. They had a relationship with the neuro dept so we got lots of strokes and brain tumors and other neuro stuff like post polio s/p neurosurg, etc.

They had a group w 2 inpatient docs, 1 EMG (incl single fiber), and 2 interventional spine docs - each took one week home call and one weekend day rounding/notes every 5 weeks. The group also consulted at a subacute/SNF once a week and had clinics including lymphedema clinic.

 

[Disciple]

I just rotated on an inpatient rehab unit where at least 50% of the patients have a serious illness, including metastatic cancer, heart transplants, liver transplants, glioblastoma, etc. The case manager told me that "this is the way inpatient rehab is headed".

Could this be true???? I was thinking about inpatient rehab, but if I wanted to do transplant medicine and have a bunch of deaths on my service, I would have done internal medicine.

It's a catch 22. With the 75% percent rule and to maintain patient volume, patients will generally be sicker and less rehab will be going on. Transfers and labs/imaging/consults will become more frequent thus cutting into the lump sum payment per patient. Rehab docs in these settings function more like an overqualified intern.

In contrast to AXMs experience. Some of my unpleasant memories of community rehab rotations: Cardiac patients going into V-Tach in the middle of the night, TBI patients tachycardic/septic on Imipenem among others.

 

[anboptop]

What about at VA facilities?

 

[Disciple]

The VA is generally for those who want long-term security and prefer a slower (sometimes much slower) pace.

However, things are done in a certain way at VAs.

An unpleasant memory from residency: On the way to the VA for weekend rounds and start getting emergency pages. Mr. So and so is having chest pain (no cardiac history). Finally get to the hospital and realize that Mr. so and so is the patient I had scheduled for an appointment to have his AV graft examined by vascular. Apparently, Mr. so and so bled profusely all over the bed and began to have chest pain, so the vascular service took him back to the rehab floor and left him there, not paging me or giving report to the nursing staff. Patient ends up having an MI and gets transfered to the ICU.


Stuff like that goes on with alarming frequency at VAs.

 

[Finally M3]

It's a catch 22. With the 75% percent rule and to maintain patient volume, patients will generally be sicker and less rehab will be going on. Transfers and labs/imaging/consults will become more frequent thus cutting into the lump sum payment per patient. Rehab docs in these settings function more like an overqualified intern.

In contrast to AXMs experience. Some of my unpleasant memories of community rehab rotations: Cardiac patients going into V-Tach in the middle of the night, TBI patients tachycardic/septic on Imipenem among others.

I agree with you. I think 75% is going to relegate a lot of acute rehab to quaternary (sp?) medical centers, dealing with patients that are a whole heckuvalot sicker than what we have heard about (unilateral joint replacements without significant comorbs) back in the good ol' days. My father (a physiatrist) is mildly to moderately horrified when I tell him about some of the inpatients I've dealt with on our floor.

 

[ShrikeMD]

There is a clear trend toward admission of sicker patients to the inpatient rehab setting, but there are multiple factors at work here. For one thing, not all rehabilitation settings are the same; some are better situated to accommodate the needs of a sicker patient than others. Some facilities have their own in-house consultants, while others have strong relationships with referring centers, facilitating transfer of patients back to the ICU when needed. Some facilities have both of these, others have neither.

I also believe we receive pressure from our referral sources to accept sicker transfers, and from own hospital administrations to keep the beds full, as administration personnel tend to be more concerned about referrals than about individual patient outcomes. To the extent that physiatrists have acquiesced to these demands, this is a trend that we have allowed. In the interest of keeping referrals coming to rehab, and perhaps away from long-term acute care hospitals (although some rehab units are LTACs), some physicians simply accept sicker patients.

I do NOT accept patients that I believe are likely to be in danger of death or acute care transfer, or that I am uncomfortable with due to requirements for consultations that have historically proven unreliable. However, other physicians at my own facility will accept them. As a result, I have fewer deaths on my service (and conscience). In fairness to my colleagues, they have helped some people I wouldn't have been willing to take a chance on. If I had more reliable consultants or inter-facility transfer agreements, I might have been more willing to accept a sicker patient. My bottom line remains as follows: It is more important to put the interests of the patient before the interests of the referral source. Implementing these principles in practice remains a challenge that every inpatient attending physician faces every day.