Preparing for PGY2

[Punkn]

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Hello all,

I'm excited to be finishing up intern year, but nervous about starting PGY2. I sort of feel like I'm starting over in a way! I was just wondering if folks had any advice for what we can do in the next few months to prepare for PGY2. I am finishing up a good TY program and have an outpatient PM&R month now with a private practice physician, but am unable to do much interventionally secondary to malpractice coverage at my staff's hospital (meaning, obviously I can do H&P's, but just observe any interventional procedure and most EMG's, although I have done some NCS).

I have Braddom, Easy EMG, Pocketpedia, PM&R Secrets, and Hoppenfields is on its way. I feel overwhelmed with what I should know, especially because I've spent most of my year learning IM topics. I'm sure most PGY2's have felt this way and people make it through fine. Thanks for any and all help. 🙂

 

[Bombesin]

I feel overwhelmed with what I should know, especially because I've spent most of my year learning IM topics.

At most programs, PGY2 is predominantly inpatient rehab. These "IM topics" will serve you well. I myself was surprised at the medical acuity of some of the patients I've seen this year.

Start working on getting your neuro exam down pat. MSK exam as well. Brush up on your innervations and neuromuscular anatomy in general. Don't worry about EDx studies yet. It's all foreign until you start doing them regularly.

And get yourself a Cuccurullo Board Review. It is not and should not be your primary study source, but it's good for a quick overview and to point you in the right direction for more in-depth study.

Congrats on finishing intern year and welcome to the family!

 

[PMR 4 MSK]

I would work on getting the proper mindset for PGY2. You are likely going to spend the entire year on inpt wards. You will see the same diagnoses over and over and over and over and over....

At the beginning, you will feel overwhelmed. In a few months, you will be quite confortable in your role. A few months later, you may be bored. It depends on what you make of it.

Most inpt rehab patients are not nearly as acutely ill as your medicine pts. Most of what you will do is prophylactic treatment, meaning if your patients do well, that's par. Any problems means you missed something. (Ok, not always, but it seems that way). You rarely get to be the hero. But keep your guard up at all times. Rehab pts can crump at any moment, even right before discharge.

Focus on learning about the disabilities you will encounter and what effect it has on your patients. Put yourself in their shoes, and see how your life would change with a CVA, TBI, SCI, etc. Use the "Mom" rule often - what would I do/recommend for this patient if they were my mom?

Read about everything you encounter. I did not do enough of this and regretted it later. See it, read about it, learn it. Rinse and repeat.

 

[Taus]

I wouldn't go too crazy w the reading...but i also wouldnt rec doing nothing. There's a reason residency is 3 years.

I think a realistic approach would be to brush up on your basic msk anatomy (innervations/roots/actions) and Neuro exam. I would casually read the neurorehab chapters in Pocketpedia to become familiar w some of the basics and most common issues.

Other than that, just read more in depth about whatever you're seeing and finding interesting on your current rotation

Hope that helps and good luck

 

[Taus]

Read about everything you encounter. See it, read about it, learn it. Rinse and repeat.

I believe that, right there, is the key to learning in residency. 30-60 mins of that each night consistently and you'll be golden.

 

[bkpa2med]

OP: I'm in the same boat. Couple of weeks of internship left and off to the world that I've been waiting for!

 

[Baritonebass]

Me too... although I'm more concern with finishing this last month of medicine with my sanity and moving AL to NYC than reading up...

 

[DOctorJay]

I would work on getting the proper mindset for PGY2. You are likely going to spend the entire year on inpt wards. You will see the same diagnoses over and over and over and over and over....

At the beginning, you will feel overwhelmed. In a few months, you will be quite confortable in your role. A few months later, you may be bored. It depends on what you make of it.

Most inpt rehab patients are not nearly as acutely ill as your medicine pts. Most of what you will do is prophylactic treatment, meaning if your patients do well, that's par. Any problems means you missed something. (Ok, not always, but it seems that way). You rarely get to be the hero. But keep your guard up at all times. Rehab pts can crump at any moment, even right before discharge.

Focus on learning about the disabilities you will encounter and what effect it has on your patients. Put yourself in their shoes, and see how your life would change with a CVA, TBI, SCI, etc. Use the "Mom" rule often - what would I do/recommend for this patient if they were my mom?

Read about everything you encounter. I did not do enough of this and regretted it later. See it, read about it, learn it. Rinse and repeat.

This is sage advice as are most of the posts by PMR 4 MSK.

I will add however that the acuity is going way up so your medicine skills are more important nowadays. Our rehab unit has higher medical complexity than any other unit in our hospital outside of the ICUs. Your residency will teach you rehab. Make sure you know your basic medicine so you can keep your pts on your floor.

 

[kstarm]

This is sage advice as are most of the posts by PMR 4 MSK.

I will add however that the acuity is going way up so your medicine skills are more important nowadays. Our rehab unit has higher medical complexity than any other unit in our hospital outside of the ICUs. Your residency will teach you rehab. Make sure you know your basic medicine so you can keep your pts on your floor.

I will second this...especially at the unit affiliated with our academic center we are seeing very complex and (relatively) acute patients. There is pressure there to take patients to rehab sooner and sooner.

 

[padresp]

I am just finishing my PGY2 year now. I agree with the previous posters about the medical complexity going up. The things I recommend to all the incoming PGY2s at my institution is:

1. Learn your medicine. Don't expect to be a rehab expert on day one. Even though patients (and your friends/family) may expect it, that's why you're in residency - to learn. If you have a good foundation in medicine, you will learn the rehab stuff as you go and you will learn it much more in-depth.
2. Learn how to cross-cover. Don't have your first cross-cover experience for a fever be on a spinal cord patient. The rehab "nuances" are so much easier to learn when you know how to take care of a "normal" patient.
3. Learn how to be efficient. If you can find something that takes an hour initially but will save you 5 minutes every day, it's worth doing.
4. Learn your medicine.
5. Along with #2 above, if there are a few things that you should learn first, it would be the "what do I do in a rehab emergency?" topics. Fever in SCI, autonomic dysreflexia, TBI "storming," stroke signs/symptoms, etc. These are the things that will be good to know in an acute situation.

And after having done my PGY2 year, here's what I'd recommend doing during your PGY2 year:

1. See "learn how to be efficient" above. Repeat.
2. Spend an extra 5 minutes with every patient when they are first admitted. Calm their fears. Make sure they have some water to drink (if they're not NPO). If they are comfortable with you on hospital day one, you will have a better relationship with them throughout their whole stay, which benefits both of you.
3. Work on your sixth sense. You know, the sense that says "this person is sick - they need to be transferred" or the one that says "why is everyone freaking out? I think this patient is just fine." It takes time/experience, but is very important.
4. I know everyone says to read, read, read... but personally I didn't. I wanted to, but chose other things to do (family/exercise, mostly). However, I never miss a lecture, and if I don't know the answer to something during rounds (or I haven't heard of it), I look it up right away. Saying that, I still wish I read more!
5. Keep up with your exercise.
6. Realize that inpatient PM&R is a much more team-oriented atmosphere than what you've previously been in. Learn everyone's name.

Good luck and congratulations on finishing your intern year. Welcome to intern year #2. 😉

 

[prefontaine]

Consider improving your writing skills.

 

[Louisville04]

This is sage advice as are most of the posts by PMR 4 MSK.

I will add however that the acuity is going way up so your medicine skills are more important nowadays. Our rehab unit has higher medical complexity than any other unit in our hospital outside of the ICUs. Your residency will teach you rehab. Make sure you know your basic medicine so you can keep your pts on your floor.

How can that be? 😕 Wouldn't patients on a general medicine or surgery floor have a higher level of medical complexity then an acute rehab floor?

 

[Bombesin]

How can that be? Wouldn't patients on a general medicine or surgery floor have a higher level of medical complexity then an acute rehab floor?

One of our units effectively functions as a step-down unit. We've been known to have admissions straight from the ICU (seldom, but it happens). Reasons why a solid intern year is essential. "Cush" internships might leave you up a creek without a paddle.

 

[Taus]

One of our units effectively functions as a step-down unit. We've been known to have admissions straight from the ICU (seldom, but it happens). Reasons why a solid intern year is essential. "Cush" internships might leave you up a creek without a paddle.

Also reasons why many residents decide early on that they'll be doing outpt MSK/Pain...

 

[DOctorJay]

How can that be? 😕 Wouldn't patients on a general medicine or surgery floor have a higher level of medical complexity then an acute rehab floor?

One would think. However our complexity is tracked by the main institution and as a chief I have heard this at numerous meetings.

Consider the fact that we get the subset of tough pts from all the other services where on that floor only 2 or 3 would be complex out of the entire census.

This isn't meant to scare anyone. Simply to realize you are closer to medicine as a pgy2 than your attendings and your skills will be called upon. Know your limits and know when to call for help.

 

[Prof Moriarty]

Also reasons why many residents decide early on that they'll be doing outpt MSK/Pain...

Bingo.

Thanks Punkn for asking the question that is on many of our minds.

I have heard 2 perspectives on this. One is the "know your medicine" mantra. The other bucks this trend and says "get really good at your field, starting *now*."

The director of GME at my internship specifically advocated the latter, suggesting I use elective time to gain exposure and experience in areas of interest within my field instead of spending the time with cardiology, pulmonology, etc. He said "I'm a cardiologist. When you need me, just give me a call. When I need you, I'll want you to be the best physiatrist out there, not the second best who also knows a little cardiology." Obviously he was being somewhat hyperbolic to make a point.

Personally, I tried to take the middle path. We'll see how it goes. But I will say that if I wanted to be an intensivist or an internist/hospitalist, I would have chosen a different residency. This emphasis on "know your medicine" has to be taken with a grain of salt. We have one year of medicine. And if your year was anything like mine, much of it was just spent learning how to get $h!t done in the hospital. I expect to be out of my league on plenty of "medical" issues and I will have no qualms about seeking the input of my colleagues with greater experience than me.

Know your limits and know when to call for help.

 

[Taus]

Bingo.

Thanks Punkn for asking the question that is on many of our minds.

I have heard 2 perspectives on this. One is the "know your medicine" mantra. The other bucks this trend and says "get really good at your field, starting *now*."

The director of GME at my internship specifically advocated the latter, suggesting I use elective time to gain exposure and experience in areas of interest within my field instead of spending the time with cardiology, pulmonology, etc. He said "I'm a cardiologist. When you need me, just give me a call. When I need you, I'll want you to be the best physiatrist out there, not the second best who also knows a little cardiology." Obviously he was being somewhat hyperbolic to make a point.

Personally, I tried to take the middle path. We'll see how it goes. But I will say that if I wanted to be an intensivist or an internist/hospitalist, I would have chosen a different residency. This emphasis on "know your medicine" has to be taken with a grain of salt. We have one year of medicine. And if your year was anything like mine, much of it was just spent learning how to get $h!t done in the hospital. I expect to be out of my league on plenty of "medical" issues and I will have no qualms about seeking the input of my colleagues with greater experience than me.

I look at it this way.... I am training to be the best damn Physiatrist I can be and am frankly not very interested in general medical management (ie as you put it - I would have gone into IM or FP if I was)

However, you NEED to learn the following in internship:
-basic bread and butter medical management with day-to-day issues and how to initiate common workups
-"know what you don't know" - ie be able to recognize when a problem is complicated and know who to call.
- how to differentiate between SICK and not sick (ie develop your doctors intuition)
- how to get work done efficiently the hospital setting.

If you can do the above after your intern year you should be set

 

[PMR 4 MSK]

Also, learn who the IM residents are, get to know them and be nice to them. You will need them for consults, or possibly emergently for transfers. If they don't know you or like you, you may be trying to keep a patient alive while they finish their coffee. Try to get the departments reciprocal - you take their rehab patient off their hands for easy discharges, they promptly do consults on your patients when you need them.

Once you get out in the "real" world, you need these interpersonal skill to survive.