As an intern, I'm finding that I really enjoy floor medicine...call me crazy. Is there a particular area in PM&R where you are expected to manage more medicine than your average inpatient physiatrist?
PM&R Field with a lot of Medicine
- Thread starter fozzy40
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then you r really going to enjoy your PGY2 yr at RIC!!
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Probably TBI, SCI, and cardiopulmonary rehab
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SCI. High Cervical vent-dependent SCI.
All the inpatient medicine you could EVER want!
All the inpatient medicine you could EVER want!
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I used to think of it as, "internal medicine without the intrigue," or plain old humpty-dumpty medicine...
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I think I might enjoy it too if I had interns/residents to make all the phone calls, write orders, carry the pager and do all the H&Ps/discharge summaries. 😀
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The sad thing is that most of us won't get too bold with the IM (CYA) even if we want to, which pretty much leaves us with just the scut work.
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IM? What about our surgical skills?
I once removed a 3cm pedunculated schwannoma on the rehab floor. The attending asked that he be off the floor for the procedure. A little local with epi, a sterile procedure tray with an 11 blade and some pointed Mayo scissors and voila- the guy took 3 sutures to close the wound. We fit his BKA prosthesis the next day and the wound held up fine. If I did not do this he would have spent a week on the rehab floor getting transfer training and woul not have been as likely to walk with the BKA. You'd think the surgeons would have clipped off the little bugger when they took off the lower leg in preparation for a prosthesis.
I once removed a 3cm pedunculated schwannoma on the rehab floor. The attending asked that he be off the floor for the procedure. A little local with epi, a sterile procedure tray with an 11 blade and some pointed Mayo scissors and voila- the guy took 3 sutures to close the wound. We fit his BKA prosthesis the next day and the wound held up fine. If I did not do this he would have spent a week on the rehab floor getting transfer training and woul not have been as likely to walk with the BKA. You'd think the surgeons would have clipped off the little bugger when they took off the lower leg in preparation for a prosthesis.
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Fozzy,
You are not crazy. Many of us whose practices are more centered in neurorehabilitation deal with "internal medicine" issues every day. When I was a resident, I enjoyed studying/treating medical issues too.
Then I became an attending, and increasingly became aware that the issues I found so interesting were illnesses with potentially dire implications for the human beings I was treating. I still find the issues interesting, but the "enjoyment" aspect has diminished. Further, I recognized that there are consultants who have greater knowledge and experience than I in specific medical co-morbidities, and I recruit their assistance to help me when I can. For the neuromedical issues that are specific to our neurorehabilitation patient population, it is gratifying to know that I/our specialty has a knowledge base that places us in a unique position to help these patients.
BTW, "floor medicine" skills will be useful to you in most rehabilitation fields, not just in neurorehabilitation.
You are not crazy. Many of us whose practices are more centered in neurorehabilitation deal with "internal medicine" issues every day. When I was a resident, I enjoyed studying/treating medical issues too.
Then I became an attending, and increasingly became aware that the issues I found so interesting were illnesses with potentially dire implications for the human beings I was treating. I still find the issues interesting, but the "enjoyment" aspect has diminished. Further, I recognized that there are consultants who have greater knowledge and experience than I in specific medical co-morbidities, and I recruit their assistance to help me when I can. For the neuromedical issues that are specific to our neurorehabilitation patient population, it is gratifying to know that I/our specialty has a knowledge base that places us in a unique position to help these patients.
BTW, "floor medicine" skills will be useful to you in most rehabilitation fields, not just in neurorehabilitation.
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Mehul_25, you are at GW? Are you offering any electives?
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(quoting disciple): "I think I might enjoy it too if I had interns/residents to make all the phone calls, write orders, carry the pager and do all the H&Ps/discharge summaries. "
No question, these aspects and others (paperwork from insurance companies, outpatient/home health nursing, etc.) are formidable negatives that I associate with the inpatient rehabilitation experience. Still, most medical subspecialty/fields have some downside associated with them, and these aren't enough to prompt me to leave inpatient neurorehabilitation. Besides, if you can afford a nurse practitioner to help with the paperwork, and have partners that take good care of their patients so that call is tolerable, then the trade-offs of inpatient neurorehab are quite favorable.
No question, these aspects and others (paperwork from insurance companies, outpatient/home health nursing, etc.) are formidable negatives that I associate with the inpatient rehabilitation experience. Still, most medical subspecialty/fields have some downside associated with them, and these aren't enough to prompt me to leave inpatient neurorehabilitation. Besides, if you can afford a nurse practitioner to help with the paperwork, and have partners that take good care of their patients so that call is tolerable, then the trade-offs of inpatient neurorehab are quite favorable.
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I think what soured me on inpt rehab was the 48 hours admits as a PGY-2 (definitely volume driven).
Alot of work doing the consult, H&P, orders. Come back on Monday morning and told to start writing up the discharge summary, f/u appointments and scripts.
I did that quite a bit in residency. Acute rehab unit used as a holding facility because the Med/Surg floors needed the beds and all the community SNFs/nursing homes were full.
It was tolerated to keep the consults coming in.
6 months of that and I decided I would never do it again.
Alot of work doing the consult, H&P, orders. Come back on Monday morning and told to start writing up the discharge summary, f/u appointments and scripts.
I did that quite a bit in residency. Acute rehab unit used as a holding facility because the Med/Surg floors needed the beds and all the community SNFs/nursing homes were full.
It was tolerated to keep the consults coming in.
6 months of that and I decided I would never do it again.
I had a hard time dealing with it b/c i there was a LOT of incompetence around. The attendings, nurses, clerks, social workers, and some of the therapists quite frankly did not do a good job. That leaves the majority of the burden of getting the patient what they needed in terms of quality care on your shoulders. Now, I'm sure this varies from hospital to hospital, but I think that you will find, in general, that rehab hospitals employ lower quality nursing, pharmacists, and support staff. Thats a lot of crap to deal with that I wasnt willing to do.
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Regrettably, I think your experience is shared among many physiatrists during their training. In some rehab units/centers, particularly those that are owned by the larger medical center, our beds are filled with patients whose suitability for admission is determined by the center's need for acute care beds, not the patient's appropriateness for rehabilitation. Residents then see that the physiatrist's role in patient care is diminished, relegated to that of a caretaker/"innkeeper"/nursing home attendant, as opposed to intervening to help patients who can best benefit from the knowledge and services we provide.
While I don't pretend that some of this (rehab admission of patients with inappropriately limited functional potential) doesn't occur in even the best of rehabilitation centers, I can honestly say that this is not the norm in my practice or my center. Residents who can experience working and learning in better environments leave these exposures with a better sense of who they can help, and what they can do (other than paperwork) for the patient. When I worked in the academic setting, I took great satisfaction in seeing the number of residents who left our program to begin neurorehabilitation-oriented fellowships and pursue academic/neurorehabilitation careers. There is a lot of good that we can do, and I would like to believe my residents saw this by the time they finished their rotation.
The inpatient/outpatient neurorehab life does have its drawbacks. It's not for everyone. It's been good for me.
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Can I ask where your practice is located (I would have asked this by PM, but you don't appear to have allowed them)
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I'm not anti-inpt rehab. When the time comes, I hope I have access to it instead of being dropped off at a nursing home.
What I have a problem with is the typical structure for inpt rehab training. It is no longer economically feasible to have a low volume unit where patients rehab over the course of weeks. Instead of loading up the census for the resident (no longer an intern), why not hire mid-levels so that the resident can have a positive experience and not be driven away from the inpt side of Physiatry.
Residents in other fields do scut as well. In IM you do scut, but also medicine. In surgery you do scut, but also surgery. During inpt PM&R training, in many cases, you do scut, so you can do more scut.
I had brought up the idea before, but why not redefine the role of a Physiatrist to be a medical director supervising a team of PAs or NPs? ala the Anesthesia care team model. What about developing an inpt residency track that would provide training in administration and a parallel MSK/Sports/Spine/Occ Med track? The average starting salary for inpt rehab would be higher, the overall cost to run a unit would be lower, a greater number of residents would be attracted to careers in neuro-rehab. Reimbursements (inpt) were good in the 80s and that's all Physiatrists did back then. I know this could be opening up a can of worms regarding mid-level autonomy. But, just a thought.
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Given my lack of experience - I probably shouldn't comment -
But wouldn't administration = more paperwork??
Ugh, that would substantially decrease my interest in neurorehab.
I'm not sure anesthesia is the best model - do we really want PM&R to be filled with the equivalent of CRNA vs "MDA" threads. Sure anesthesia went through an interest slump - but it became more popular again. I think these variations in interest in fields are normal and I wouldn't give away patient care responsibilities for a short term increase in money. Hiring NP's to decrease the paperwork burden seems like a good idea. As long as the MD is responsible for seeing and taking care of patients - thinking through their interesting neuromedical issues - I don't have a problem with midlevels assisting with paperwork. It's the midlevels see the patients and physicians do paperwork model that is much less attractive.
Actually my guess is with the advances in the science of neurorehab and the resultant expansion of therapeutic interventions - neurorehab will become more attractive in the future.
But wouldn't administration = more paperwork??
Ugh, that would substantially decrease my interest in neurorehab.
I'm not sure anesthesia is the best model - do we really want PM&R to be filled with the equivalent of CRNA vs "MDA" threads. Sure anesthesia went through an interest slump - but it became more popular again. I think these variations in interest in fields are normal and I wouldn't give away patient care responsibilities for a short term increase in money. Hiring NP's to decrease the paperwork burden seems like a good idea. As long as the MD is responsible for seeing and taking care of patients - thinking through their interesting neuromedical issues - I don't have a problem with midlevels assisting with paperwork. It's the midlevels see the patients and physicians do paperwork model that is much less attractive.
Actually my guess is with the advances in the science of neurorehab and the resultant expansion of therapeutic interventions - neurorehab will become more attractive in the future.
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This seems to be the model at Walter Reed. When I was there on rotation this year, there were 2 attendings, 1 consult resident, 2 inpt residents, 1 intern, 1 med student, and 3-4 PA's. Made things go much more smoothly.
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This is so true!!!
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You have to remember, in Anesthesia (1990's), when salaries dipped and jobs were scarce, programs did not fill. Variations in interest are hardly random.
Your "paper-work" would not really be the same in an inpt administrative role. Instead of answering pages for sleep meds and filling out discharge scripts, you would be creating budgets, making sure your facility is CARF accredited and going over staffing needs with the nursing director.
Ideally, one Physiatrist would oversee the unit and have a small personal census of complex patients. The rest of his/her time could be spent with their administrative duties, clinics, etc. Patients admitted for short stays or "deconditioning" to fill the beds could be managed by mid-levels with report given to the director 1-2X week.
