programs with strong internal med focus

[bonjuju]

Hey folks.
I am interested in programs that are strong in medicine as well as PM&R. After hearing stories of farming patients to Med, I know that I wasnt to be in a program that trains its residents to manage multiple aspects. Any votes for programs to look at?

 

[TUCOMSam]

I guess I don't understand the idiom, but what does "farming patients to med" mean? Not trying to be sarcastic, I've just never heard that term before...

 

[Finally M3]

You know, the patient rolls in the door, might be a touch hyperglycemic, and internal medicine is consulted to manage blood sugars.

If you want to do a lot of internal medicine, come to UMich. You'll do as much as you feel comfortable with (and some you're not)

 

[axm397]

I would think many of the free standing rehabs will be more medicine heavy since it's a little more difficult to get medicine consult on every little issue that pops up. It also depends on the attending and how comfortable he/she feels handling certain issues.

 

[CasaElGato]

University of Washington fo' sho'.

 

[eddo]

I would think many of the free standing rehabs will be more medicine heavy since it's a little more difficult to get medicine consult on every little issue that pops up. It also depends on the attending and how comfortable he/she feels handling certain issues.

Can't agree with axm397 more! I was medicine bound prior to finding PM&R and I know I wanted to get a lot of IM during my training. I can't speak for other programs, but during my medical student rotation at Santa Clara Valley Medical Center (Stanford's County/Regional Rehab affiliate) I got a chance to manage vented patients and symptomatic anemia patients on the rehab floor. SCVMC also has a Rehab Trauma Center - more in the following post: http://forums.studentdoctor.net/showthread.php?p=3961372&highlight=stanford#post3961372
Good luck with the process. It's long and hard, but you will get through it 🙂

 

[Hemisphere]

even at hospital-attached rehabs though, you can't always consult medicine for every little issue or you piss off the IM residents doing the consults... I have seen this happen the attending fielding complaints, etc. from upset IM residents... guess it might depend on the culture at the specific institution what the standard is, but I have never seen a hospital attached rehab where they just "farm every little issue" as some have said, if it happens i haven't seen it. Then at hospital attached rehabs sometimes they tend to send the patients out to rehab a little earlier too since it's (unfortunately viewed as a dumping ground) by some for patients too sick to go home and who are spending too long on the floors so they might have some residual IM issues left over too lol. you can also work with the consultants, for example, one time i consulted rheumatology at a hospital attached rehab and they come rather quickly since it's down the hall. you can order the labs they request before they get there, talk directly to them face-to-face implement recommendations, etc. you can involve yourself and communicate if you desire to learn from the encounter, or if you just pass the ball completely they might get upset too since you are still the primary. then there are those hospital attached rehabs accused of being called an ICU step-down as well if you're up for that kind of medicine 😎

 

[caedmon]

I'm sure at most rehab institutions, the amount of medicine that will be handled on the rehab unit will very from attending to attending. Some will want to handle most medical issues, others will want to handle only the minor things. If you a resident who is well educated and comfortable handling such issues, they may feel more confident it letting you handle these kind of things. All this to say, if you're really interested in medicine, do a medicine prelim year that you know will have a strong educational component. Work hard and try to keep up with the medicine interns in regards to following the literature etc.

 

[paz5559]

I'm sure at most rehab institutions, the amount of medicine that will be handled on the rehab unit will very from attending to attending. Some will want to handle most medical issues, others will want to handle only the minor things. If you a resident who is well educated and comfortable handling such issues, they may feel more confident it letting you handle these kind of things. All this to say, if you're really interested in medicine, do a medicine prelim year that you know will have a strong educational component. Work hard and try to keep up with the medicine interns in regards to following the literature etc.

Has nothing to do with comfort, confidence, or anything clinical - as with most things in life, it's all about the money - if your staff gets referals, and the internists get paid to handle medical matters, expect that the refereals will be early and often. If your attendings are salaried, they will manage the medical issues themselves, since the internists will object to having to do extra work.

 

[Hemisphere]

i agree the money thing plays a big role, but still it is attending specific how money-minded they are. it also limits how much work-up and sleuthing pm&r docs can do, which i think is one of the draws of IM- the detective work. rehab is reimbursed a set fee based on the diagnosis on admission, so the more tests during the admission the more it eats up the resources for rehab services (and profits...) my question is if someone comes to consult does it still eat at the fund from the DRG if they order the tests?

 

[paz5559]

i agree the money thing plays a big role, but still it is attending specific how money-minded they are. it also limits how much work-up and sleuthing pm&r docs can do, which i think is one of the draws of IM- the detective work. rehab is reimbursed a set fee based on the diagnosis on admission, so the more tests during the admission the more it eats up the resources for rehab services (and profits...) my question is if someone comes to consult does it still eat at the fund from the DRG if they order the tests?

You are missing the ecconomic drive - if you call the IM doc to see your pts and they earn consult fees, the next time they have a pt to send to rehab, they will preferentially send to your facility, rather than they guy's down the street.

 

[Disciple]

To the original question: I would caution against a program too heavy in medical management of rehab patients. During my residency, I rotated through community, tertiary care, county and VA settings.

During community inpt rotations I spent alot of time calling the ambulance (Cardiac pts going in and out of V-tach, pts with flash pulmonary edema, acute GI bleeds, septic/tachy TBI patients on Imipenem). As a freestanding for profit facility, of course the beds were always full of sick patients.

In the tertiary care setting I spent alot of time putting in orders, reporting to and arranging for diagnostic testing for the various consultants (Renal, Neurosurg, ID, Endocrine, Rheum, Transplant, Plastics, etc.)

During the county rotations, some of the patients would be admitted then transferred straight to the ICU (do not stop at GO).

Of course, patients in these situations are too ill to tolerate 3 hours of therapy per day. Spending the bulk of your time managing medical issues is an inefficient use of your residency (remember, rehab units generally do not have monitored beds or good acute care nurses and generally discourage hanging drips so you can't really sharpen your IM skills a whole lot). The time spent in these endevours directly takes away from time that could be spent training in PM&R i.e. planning therapeutic interventions, interacting with therapists in the PT gym, observing pts during PT/OT/speech, etc.

Though Medicine residents may be annoyed by your consults during training, in private practice, no one going to be pissed at you for consulting them (they're usually grateful for the business).

If you're really into IM, go to a combined program. Otherwise, you may be sacrificing valuable PM&R training time becoming a highly qualified intern.

 

[Hemisphere]

You are missing the ecconomic drive - if you call the IM doc to see your pts and they earn consult fees, the next time they have a pt to send to rehab, they will preferentially send to your facility, rather than they guy's down the street.

true, but only if it works that way... some hospital attached rehabs the consultants are contracted and thus do not get consult fees from the rehab hospital they are contracted by the main hospital. the tests ordered, though, still come out of the rehab fund which is why they would try to limit the consults.

and reply to disciple above, thanks for the perspective on that, nice post.

 

[caedmon]

I agree with paz regarding "real life" medicine. Often times in academics, however, "real life" medicine is not practiced. The original question was regarding residencies with a strong internal medicine focus. Most residencies are at academic institutions. I can speak only for a few institutions that I've spent time at. During my intership at a private hospital, the physiatrists managed minor issues, working up fevers etc, but if a patient was borderline coming from the floor, or developed a problem out of their reach, they did not hesitate to get im involved. They also didn't screw with a patient's daily meds. At academic institutions that I've rotated at and am at now, it seems to vary greatly. Some attendings want to manage insulin, blood pressure meds etc. Some don't but will let the intern get involved if they want to. Others just get im involved.

I just want to reinforce this point. If you're really interested in medicine and pm&r either do a comibined, or both, or get a very strong foundation during internship. Once you're in PM&R, you can carry a lot of patients, and those patients can have a lot of medical issues. You then have to ask yourself if you're time is best spent managing their medical issues or the rehabilitation issues. Internists train for 3 years to manage medical issues. You'll do at most 10-11 months of medicine (if you're lucky, ha!) during your internship. By the time I was done with my TY I was getting comfortable managing some things on my own. Other things I saw rarely, but I haven't seen it now in 3 months, and I'd rather focus on my neuro/musculoskeletal exam techniques and rehab issues than Current Mecial Diagnosis and Treatment or Uptodate.

Just my 2 cents