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thanks all!
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PGY2 Slump
- Thread starter Punkn
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Punkn, I feel your pain. I was actually just about to search around for one of those old posts where the PGY-2's talk about changing fields and the vets tell them to take it easy and tough it out...
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Don't you find it easier than PGY1 year when you were on call Q4? My PGY2 year in PM&R was home call which was much easier and the patients were relatively more stable than medicine inpatients.
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You mean you don't enjoy spending your day writing long progress notes, completing discharge paperwork, doing H&P's on patients with 3 inch thick charts and all the while playing internist-light with a small side of rehab??....what's wrong with you??
Jk... it really does get a lot better and should stop feeling like that shortly. Or I don't remember what it was like b/c I've been doing outpatient msk/pain/emg/etc for a while...
Jk... it really does get a lot better and should stop feeling like that shortly. Or I don't remember what it was like b/c I've been doing outpatient msk/pain/emg/etc for a while...
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YES! That sums up EXACTLY how I've felt since starting...
Thankfully we have home call which is awesome but I've also had very (VERY) little attending supervision since I started and I feel like I'm left to the dogs about what to read/what I should be learning... even how to go about learning. It's a deja vu of 1st year medical school anatomy almost where you know you have a lot to learn but don't really know how to go about learning it all...
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I'm lost as to whether it's my residency program that's the wrong choice or the specialty that's the wrong choice? Or maybe I just feel like a lost 1st yr med student again and need to stick it out and wait for it to get better.
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In our program PGY2s spend 6 months in the standalone facility, connected to main campus hospital via tunnel and we also had similar issues re:
- imaging (our pts were usually the last in the waiting line in the main hospital)
- labs (could never get the lab person to come back for whatever reason the blood wasn't drawn in the morning; our floor RNs did not do blood draws!! unless pt had a PICC)
- consults (neurosurgery never came to eval their own pts even if pt was leaking CSF - "Just send the pt to the ER and we'll see them there")
- reviewing charts (........nuff said)
and on and on.
I'm amazed at the fact that most patients actually got better, as the skill level of our nursing staff was mediocre at best, subpar most of the time. To give credit, we did have excellent therapists that probably made all the difference, not to mention residents
(some great, some not so great).
In summary, we really were internists, with very little physical medicine.
On the plus side, I am confident when it comes to dealing with rehab patients regardless of the level of support I have (ancillary, systems, etc).
And there are better days - PGY3 (mostly good); PGY4 (awesome year, looking foward to it)
- imaging (our pts were usually the last in the waiting line in the main hospital)
- labs (could never get the lab person to come back for whatever reason the blood wasn't drawn in the morning; our floor RNs did not do blood draws!! unless pt had a PICC)
- consults (neurosurgery never came to eval their own pts even if pt was leaking CSF - "Just send the pt to the ER and we'll see them there")
- reviewing charts (........nuff said)
and on and on.
I'm amazed at the fact that most patients actually got better, as the skill level of our nursing staff was mediocre at best, subpar most of the time. To give credit, we did have excellent therapists that probably made all the difference, not to mention residents
(some great, some not so great).
In summary, we really were internists, with very little physical medicine.
On the plus side, I am confident when it comes to dealing with rehab patients regardless of the level of support I have (ancillary, systems, etc).
And there are better days - PGY3 (mostly good); PGY4 (awesome year, looking foward to it)
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While I was somewhat joking about how I described academic inpatient rehab in the previous post.... what you described may really be a problem. There is certainly a lot of work to get done on the inpatient unit that is at times internal medicine-ish and mindless busywork/paperwork. Those are activities where PM&R attending input doesn't always have to be there as you are there to learn Physiatry. HOWEVER, a complete lack of guidance, at minimum with the rehab-related issues (even if just on walking/sit down rounds in the am) is not normal and if really true... a problem with the attending or program. If this occurred on specialty inpatient services (ie TBI and SCI) that would be even more disturbing... as even some of the general medical issues are dealt with differently due the primary rehab dx and do impact their rehab/function.
I would start with discussing with your upperclassmen or chiefs about how to guide your education while on your various rotations. Otherwise, just like in med school rotations, read about what your seeing during the day (sci, tbi, cva, etc issues) in either braddom or delisa. Also, don't expect your Attendings to spoon feed you.... ask questions
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Absolutely.
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It gets better. I had the same thoughts as you last year as a PGY2 and didn't believe the uppers. But it really does improve. It is most certainly internist-light, especially since patients are sicker and sicker these days (admit to rehab straight from ICU...ugh), but you do what you can and trudge on. Also, you learn more rehab, simply by exposure/osmosis, than you realize. Wait until next year's PGY2s start and you'll see how much you really picked up. Could be worse. Hang in there.
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I would use your patient list to guide your reading. SCI? read the SCI chapter in something basic like Braddom or Delisa to get started. All those textbooks have referenced the major articles which you can pull for more in-depth reading. Each rehab patient may have 12 active rehab problems that each could be a book chapter. (SCI, spasticity, neurogenic bladder, pressure sores, etc)
It's tough being PGY-2 on the wards because you are superfly at medicine but stupid at rehab at this point. Nurses will mock you for not knowing what a magic bullet is. PT staff will mock you for not knowing what an AFO is. OT will mock you for not knowing about tenodesis. SLP will not mock you, they are generally well adjusted people.
Hang in there, learning the lingo is half the battle.
It's tough being PGY-2 on the wards because you are superfly at medicine but stupid at rehab at this point. Nurses will mock you for not knowing what a magic bullet is. PT staff will mock you for not knowing what an AFO is. OT will mock you for not knowing about tenodesis. SLP will not mock you, they are generally well adjusted people.
Hang in there, learning the lingo is half the battle.
Agree with all of the above.
Go to radiology to view films--ALL OF THEM. Get to know the Rads residents and spend free time overreading MRIs (probably the skill I was worst at when I finished residency, and now a strength of mine).
And I beg to differ about the therapists, I always have found the OTs to be the nicest and least condescending (but then again, I married one). The SLP's always dress really well. The PTs will just hate you.
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Thanks, everyone! I definitely don't mean to put down my program or inpatient rehab in general; there are a lot of things I like about both. Just needed a place to vent. Glad to hear that it gets better!
The PTs will just hate you.
Why do PTs hate rehab docs?
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I know this thread was started to vent but I'm loving the advice on here re: how to study / not to feel stupid if you don't know what I magic bullet it (I just googled that). The therapists at my program are just downright awesome, they make my day fly by. However, when it comes to reading I'm lost... my senior residents told me to read Cuc and to give up on Braddom altogether. We're a super laid-back bunch so it's hard to get study-advice out of people... most people are either DO's who seem like they were born knowing this stuff.
In regards to the SAE's coming up, any suggestions? Do they really matter for fellowship/jobs later on? How hard should I be studying?
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Just read the thread on mid levels and PM&R.
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Why do PT's hate PM&R?
Well my reflections were mainly from residency and the culture of being a resident in a large academic institution. I think everyone hates residents because we drop in with a white coat and suddenly everyone has to call us doctor and pretend to follow our orders even though we haven't spent 10 years getting hazed and abused and clawing our way up the pecking order like the RN's, PT's. OT's etc. So they get bitter and try to pull you down.
Medicine is a breeze compared to hospital politics.
Well my reflections were mainly from residency and the culture of being a resident in a large academic institution. I think everyone hates residents because we drop in with a white coat and suddenly everyone has to call us doctor and pretend to follow our orders even though we haven't spent 10 years getting hazed and abused and clawing our way up the pecking order like the RN's, PT's. OT's etc. So they get bitter and try to pull you down.
Medicine is a breeze compared to hospital politics.
What they said, and I really was kidding, hence the "
". In reality, if you treat the therapists with respect for being the experts that they are, they will be an endless source of knowlege. One of the residents in my year got a nick name (by the therapists) his PGY-2 yr "Dr. *******". It was because he came in demanding to be called "Doctor", and would write stupid orders that the therapists had to follow. He would not be reasoned with. Luckily he got wiser by midway through, and ended up as our chief.
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I've been polling some of my PGY-2 friends in other specialties. They're all saying the same thing: "I finally get to do what I really like... It's awesome... I'm so psyched I entered this specialty... My choice was right on... etc."
What is wrong with PM&R that this PGY-2 slump is expected and accepted? That we should have to wait a year or two for things to "get better." I think we can and should do better in our residency programs. There's always something to learn, but that doesn't mean it's an optimal learning situation. This is residency. I have higher expectations. A year of my life and training is no small chunk of time. I'm surprised this goes on year after year and we as a specialty accept it.
What is wrong with PM&R that this PGY-2 slump is expected and accepted? That we should have to wait a year or two for things to "get better." I think we can and should do better in our residency programs. There's always something to learn, but that doesn't mean it's an optimal learning situation. This is residency. I have higher expectations. A year of my life and training is no small chunk of time. I'm surprised this goes on year after year and we as a specialty accept it.
Putting the old man hat on here. I don't think that life needs to be easy or that you have to like everything you do. Life as a physician is very hard, and not always "directed". It is important to learn "self-directed learning". These skills will help you in your future.
Most of you guys are going to have to pave your own way once you are in practice. Those people who are "self-starters" do best as physiatrists since despite more awareness, MOST PHYSICIANS AND PATIENTS HAVE NO CLUE AS TO WHAT YOU ACTUALLY DO!!
It has taken me 10yrs in my current community to build the kind of practice that I wanted. Despite this, last week an orthopedist told me "Your job is to manage my patient's rehab issues after I operate on them". He still expected me to be "his boy", despite the fact that I don't work for him, nor do I have a contract with the hospital (except as their occupational health director).
The PGY-2 year is hard and boring. But it teaches self directed learning. Yes, many programs can do a better job teaching residents, but remember: Only a certain type of person chooses to be an academic physiatrist on a General inpatient rehab unit. Suffice to say, they are not necessarily our strongest swimmers.
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I wonder why excellent physiatrists joining academics are only the minority...
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PM&R needs to be split into two specialities:
1. Rehab medicine which would be a fellowship after IM or Neuro (code brown!)
2. MSK Medicine which would be all outpatient
problem solved
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"PM or R"
PGY2 year is a tough year for some. I remember it feeling a lot like a repeat of intern year. Intern year was great but you worked hard and the learning curve is steep. For most, actually working in a rehabilitation hospital as a resident is very different from the typical residency structure. It can feel overwhelming because the rehab teams usually consist of a PGY2 and an attending only. You don't always have a senior resident (like in medicine) that helps show you the ropes. Furthermore, the medical students are not always the most helpful because they too are learning about the field and still trying to acclimate to the flow. This translates into a majority of the work to be carried by the resident.
That being said, there is a lot to be learned from inpatient rehabilitation that directly correlates with outpatient MSK medicine. I actually learned A TON more from my inpatient population about MSK compared to the typical outpatient population. They is a TON to learn from your stroke, spinal cord, and TBI patients.
It's a (relatively) tough year but in the bigger scheme of things it's not horrible compared to your other colleagues. If you simplify/minimize the year down to "I just need to get to the other side," you will miss out on this great opportunity. Never again will you be able to spend as much time with your patients practicing your examination skills. Make the best of it.
That being said, there is a lot to be learned from inpatient rehabilitation that directly correlates with outpatient MSK medicine. I actually learned A TON more from my inpatient population about MSK compared to the typical outpatient population. They is a TON to learn from your stroke, spinal cord, and TBI patients.
It's a (relatively) tough year but in the bigger scheme of things it's not horrible compared to your other colleagues. If you simplify/minimize the year down to "I just need to get to the other side," you will miss out on this great opportunity. Never again will you be able to spend as much time with your patients practicing your examination skills. Make the best of it.
D
deleted185747
Here is how to get thru PGY-2 year:
1. Read 'House of God'
2. Think back to the sucky parts of internship
3. Have faith in the future because it's really awesome up here 😀
4. Exercise
1. Read 'House of God'
2. Think back to the sucky parts of internship
3. Have faith in the future because it's really awesome up here 😀
4. Exercise
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Bingo. And my attending is barely ever around. I wish I had time to teach the med students something so they would be more helpful and have a better experience.
I agree!
This is the general attitude of most PGY-2's I encounter and the mantra of my upper level residents. Read the annual PGY-2 Slump thread and this is what everyone keeps saying, except for you Fozz.
I wish this were true. The vast majority of my day is spent sitting at my desk writing notes/looking at a computer, inputting orders, calling consultants, etc. I would suggest we get subq heparin for DVT ppx except that the risk of bleeding would be too great from slamming our heads against our keyboards in frustration.
The census and turnover and lack of good hand-offs from other services dictate that I sit in front of the computer the vast majority of my day. Emphasis is on quantity not quality. I hear this echoed from others. I think residencies need some guidelines about how to make PGY-2 a better educational experience. Census caps, admission caps, protected didactics, amount of time the attending should be on service, etc. Yes I am more of an outpatient MSK guy but I still want a good inpatient experience.
I had a variety of experiences depending on the service I was on. You should talk with your chiefs and/or residency director on how to make it a more educational experience for you.
Been there and through it (recently.) I even contemplated switching to IM about 2 months in. However, I had a heart to heart with an attending who told me to wait until the 3rd and 4th month of PGY2. In his experience, it takes about that long for PGY2s to feel more like a physiatrist. Trust me, it's kind of like "Karate Kid" training where all of it a sudden it clicks. I just tried to take it one day at a time and try to find a learning experience every day. That's a shame that seniors are kind of perpetuating the mood.
The lack of good hand-offs is a crucial point and indicative of our medical education system. Across the board, new graduates leave their med schools knowing nothing about what our field is about. It's no wonder that they don't know how to prepare a patient for transfer. Unfortunately, at my institution, there was not a lot of education for the transferring teams on our end from the leadership end as well.
Hang in there guys!
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The handoff from ICU or the acute hospital side is the PMR consult service job and not the admitting services job. This way your DVT, GI proph, skin check, b/b program, and degree of med stability/ tolerability is done and known and your admit hp is giftwrapped for rehab.
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because the pay sucks, and the politics are ridiculous. Oh, and if you don't already have grant money, real research is difficult.
For example. During my brief stint in academics (as a division of ortho), one of the spine surgeons and I tried to set up a "study" to determine the "standard of care" for Grade I spondylolisthesis without radiculopathy (back pain). We wrote a survey to be sent to NASS members. We expected a great deal of diversity based upon specialty (ie. NS and ortho would operate, interventional pain would do injections, non-interventional PM&R would try PT/meds). We figured we needed around $5000 for funding (paper/printing/stamps). We could not get the funding.
I am a far happier person since I got out of the morass of Academic medicine.
Agreed. I should clarify my previous statement that PM&R consults have probably the most important job because they are the first line people to set the "tone of flow." In my discussions with the transferring teams, I would very clearly write down the orders and "to do's" which did not always get done timely or correctly. What I found was that the primary teams often do not understand why we need things to be done in a certain way to help transfer care. Once I explained that the medical care focus shifts from "staying alive" to "how to live again" they seem to "get it" a little better. Bottom line, it's important for them to understand our goals as well which they do not understand. They often will not because they were never taught in the first place. Again, a medical education chronic issue.
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Absolutely, but this only holds true when it's your consult team inside your home institution that also houses the rehab unit. However, this is infinitely more difficult when accepting patients at a stand-alone rehab facility. The quality and utility of the PM&R consult in the transfer records (if there even was one) is at best marginal. Typically, once PM&R rec's acute rehab (and that patient is not going to the consult teams facility).....their input is done unless they were specifically asked to comment on something like meds for spasticity or cognition. The final say re "stable for d/c to rehab" is left to the primary team (can only hope they were put on a medicine/hospitalist service)
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teaching programs have been unable to adapt to the rapid decline in rehab stays, reimbursement, and admittable diagnoses. Quads used to stay on rehab for a year, paras for 6 months at least, etc. If you took on a tenuous patient you had weeks to stabilize them and usually they would not decompensate after that. So you did some medicine and watched them rehab for weeks to months. Now you're lucky if you get a month for a new para. Rehab is used to offload overflowing medicine units. You admit constantly because turnover is so fast and your census increases because you need 3 patients to reimburse what 1 used to. You barely stabilize them and then they get a few days of rehab and go home. You don't see much rehab anymore. Everyday is an admit and discharge sprint. Ages ago you admitted 1-2 patients a week because your unit was full of long stay patients. This is turning inpatient rehab into a 2.5-3 year IM internship. Even PGY2 IM's have interns to scut out.
But look at it this way, you're a doctor so you're duty is to practice medicine even if it's not all rehab. So take pride that you're still THE doctor.
But look at it this way, you're a doctor so you're duty is to practice medicine even if it's not all rehab. So take pride that you're still THE doctor.
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Oh yeah, that's why I stopped doing inpt rehab! Now I remember.
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Currently, I am a PGY-2 at a pretty good rehab program. However this year has been one of the most frustrating years since I started medical school. I came across this page and I am glad that others have been where I have. The PGY2 year is extremely frustrating due to all the inpatient rehab. I have contemplated switching out and going into Internal Medicine. I came into PMR as a route to do Spine and Sports but its hard to not just slam my head in frustration. My felt more fulfillment during my internship than I do right now, the excitement and logic.
MY question for the people that did answer this a couple years ago; how do you guys feel now? Was it the right decision to tough it out like I keep on hearing? Did you guys end up switching?
MY question for the people that did answer this a couple years ago; how do you guys feel now? Was it the right decision to tough it out like I keep on hearing? Did you guys end up switching?
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Well the difference between pgy-2 and 3 for me was night and day. Clinic, EMG free time to cover sporting events was well worth it. Now I'm just waiting til pgy-4 so I can disappear. If PM&R clinic sports/spine is your goal then you have 12 months from application begins vs transfer and restarting.
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I am happy that I stayed. And I was miserable enough that I did consider doing something else. It wasn't just that it was all inpatient though - it was the *lack* of the key items people mentioned above: good teaching, good handoffs, good consult service to liaison, etc. For a variety of reasons, I actually ended up transferring programs (nearly impossible to do BTW). But I've had an awesome PGY3 (including some inpatient) at my new program which has a strong MSK experience. Actually the year has flown by.
Some programs don't front load all the inpatient, but instead give a variety of experiences during the PGY2 year. That's the way my new program does it and I see the PGY2's actually seem pretty happy. I know there are other programs like this. The rule is every program has to have 12 months inpatient rehab and 12 months outpatient rehab. The other 12 months are at the discretion of the individual program. I think programs with 18+ months of inpatient are doing a disservice. The best situation is to have several months of electives - then you can do what you want. But that's another topic.
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I think front loaded programs are great. I am at a notoriously "malignant" program and life is good
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Even my friends who really enjoy and currently practice inpatient/neurorehab did not generally enjoy their pgy2 year.
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I'm finishing my residency now. I think the worst part about PGY-2 year for our specialty is that it is a second intern year. You're the low man on the totem pole for two years in a row... I am at a high-volume, complex inpatient facility and I didn't like it then, but am now glad I did it. I found that my PGY-3 year was tough in a new way - suddenly you have to switch from inpatient, which you did the first two years of your residency, to outpatient and everything is again brand new. PGY-4 year is amazing, however, because you've finally been through it all, and you get the big picture. You can focus on your weaknesses and learn what you want to learn. I'm going into an outpatient field and I don't regret doing the heavy inpatient work, though I didn't like it at all at the time.
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Just tough it out, so long as in the end you receive the training you need to have the the type of practice you want. If you don't have a clear pathway to this, that's when you may want to start considering switching programs or specialty.
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What are you doing your fellowship in, if you don't mind me asking? Also, how does the outpatient job market compare to the inpatient one?
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I feel EXACTLY the same way. I am currently in my PGY2 year at a decent PMR program. I just feel the loss of excitement and drive to go to work in the morning, it is truly depressing. Despite the long and crazy hours internship had - I enjoyed the work and the daily learning. In Rehab, I feel my attendings don't teach, I am monitoring bowels and bladder on a daily basis and the most I've learned in the past 3 months is how I can get my narcotic-addicted patients to take a real good bowel movement. It is just boring and dull and I feel - is this PMR? Is this my life? Because I'd rather do call q4 day than have my weekends and go to work on a daily basis and feel unfulfilled.
I am now at the point where I am considering to transfer out and go into Internal Medicine and need to hear some guidance from PMR vets - as well as residents going through this as well. Has anyone switched to Internal Medicine? Anyone recommend this - I am now three months into my residency and pretty miserable, does it get better? Any advice is appreciated. Thanks!
Okay, what do you want to do long term. I can say that while my PGY2 yr was indeed scut city (and it was 20yrs ago), it was one year of my life. I do not regret my career choice one bit. But my friends in IM who work in outpatient clinics do regret it. Most are looking for non-medical things to do with the rest of their lives, or looking at doing another residency or fellowship (Rads for example). There is no respect for general IM, since people go to specialists for everything, and you are called a provider, not a doctor (because the insurers think that ARNPs and PAs are your equivalent)
The ones that are happy are the hospitalists, but that is because their days are predictable and it is basically shift work.
Whereas I still love my job. I AM the specialist, and my patients and the other docs respect me and my opinion. My friends who do primarily INPT are also happy with their careers (although the happiest seem to work either for the VA or Kaiser).
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Thank you so much for replying. ... What I want to do long-term is interventional pain - but not for money, I really don't care about the money (I am swamped in debt at this point and pretty comfortable on my small paycheck) - i am really interested in cancer and pain control, because I actually would like to help this population. I would ideally like to work in a hospital and provide pain management for inpatients. I don't really care for having my own practice (and I know that's where the money is, but that is not my main priority). Right now, I have done spinal cord injury and inpatient and I have not felt any interest towards these avenues - whereas in medicine - at least some days you would have some pretty interesting cases. While during my PMR residency, often times I go months without being stimulated intellectually - because most of the spinal cord patients are chronic and management issues are the same.
So here I am, do I stick it out for three years in a residency where the content is not really making me happy or excited to learn - JUST so I can get to fellowship, and even that is no guarantee because of the immense competition. Or do I change out of a career and become a hospitalist. This is the crossroads I am at right now. I don't have much time to make a decision, because being a J1 visa holder I need to make a decision fast - prior to the completion of my 2nd year. And unfortunately all the exposure I have had up until now has just been SCI and inpatient and both are not doing anything for me.
Another concern for me as well - is the availability of jobs for J1 visa holders. I would like to preferably reside in New York City (or nearby) to be close to my significant other.... and I feel that i may not have the same job prospects or options as I would with Internal Medicine jobs. Any more advice - pros/cons about both fields, I would really appreciate it.
