progressive vs. traditional programs

[jonnylingo]

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It was previously posted that "if you're looking for more outpt training, pick one of the more progressive programs."

I think it would be helpful to us 4th yrs who are now researching programs to know which programs are "progressive" with emphasis on outpt training and which are "traditional" with emph on inpt training.

Please reply to this post with any thoughts/numbers/experiences that suggest different programs leaning one way or another.

 

[axm397]

It was previously posted that "if you're looking for more outpt training, pick one of the more progressive programs."

I think it would be helpful to us 4th yrs who are now researching programs to know which programs are "progressive" with emphasis on outpt training and which are "traditional" with emph on inpt training.

Please reply to this post with any thoughts/numbers/experiences that suggest different programs leaning one way or another.

I think many of the older bigger programs have the reputation of being more inpt heavy - like RIC, Baylor, Kessler, U Wash, Mayo, U Mich, Temple, etc. BUT that being said, those programs also have some of the major players in outpt MSK/sports/spine/pain. i.e. Jay Smith, Joel Press, etc.

Many of the more "traditional" programs are making efforts to include more outpt training because of more demand for that type of training.

If you are absolutely sure that outpt is the only thing you want to do and you are NOT interested in inpt at all, then perhaps you can consider the more "progressive" programs. Just know that many of those "progressive" programs tend to be smaller and less known so that may also influence the fellowships you are able to land. I suppose if you are not interested in fellowships and want to use residency as the time to learn procedures, then "progressive" is what you want.

I myself chose a bigger balanced program because I wasn't sure what I wanted to do and wanted to leave as many options open. The alumni association and network of these older and bigger programs are also something to consider - as many physiatry jobs are NOT publicized via ads, etc. Many of my friends got jobs via these connections.

Just some things to think about...

 

[drusso]

This is "the thing" to try to determine at your interviews...you'll need to carefully probe residents, program directors, and the department chair (if you get to meet him or her) about what the program's educational mission is, how they view the field, and how they are preparing residents for practice. You have to be aware that these are topics where people hold strong opinions, so you'll want to see DATA. You will want to see some data on where residents go after graduating (private practice, fellowship, academia, etc). You'll also want to know how successful residents have been at getting good jobs or fellowships. You might want to contact residency graduates and read program reviews on sites like Scutwork.Com. Remember, the program is trying to recruit you so don't be afraid to ask!

You should familiarize yourself with the Specialty Curriculum requirements contained within the ACGME PM&R Residency Program Requirements:

Program Requirements for Residency Training in PM&R

For example, these requirements specify that PM&R residencies contain *AT LEAST* 12 months of dedicated training in inpatient rehabilitation. So, it might be reasonable to expect to see a range of inpatient training months varing between 12-18 at various programs. If a program has substantially more (like 20-24) that might reflect an interesting set of educational priorities that you would certainly want to know more about this during your interview.

The ACGME program requirements also specify that PM&R residencies have *AT LEAST* 12 months of outpatient experience excluding EMG so you want to probe your interviewers and hosts about where these months are spent and what exactly you're learning when you're in these setttings. Notice that the program requirements do not specify ANY time spent on hospital consult months though clearly some minimal exposure to this area of physiatric practice is essential in PM&R and most programs have residents rotate on consult services. If a particular program is doing 20 months inpatient, 12 months outpatient, and 4 months of consults that would certainly reflect an interesting set of priorities that you would want elaborated!

Finally, the ACGME actually quantifies the amount of EMG experience you should have---200. What percentage of residents meet and exceed this number? What kind of EMGs are done? Is it all carpal tunnel and radiculopathy or do residents get some interesting polyneuropathy, motor neuron disease, and neuromuscular disorders as well?

I think that axm397 is right on about "balance." Even if you think that you might eventually sub-specialize you want your base training to be sufficiently broad that you're not just a "one-trick pony."

 

[Disciple]

It was previously posted that "if you're looking for more outpt training, pick one of the more progressive programs."

I think I posted that.

Agree with most of what is said in the other responses, and since there are no official rankings for outpt training, a good place to start would be to use the search function on this forum, talk to as many PM&R attendings/residents/fellow residency candidates as you can and see which names come up most frequently.

Important questions to ask yourself and to think hard about before you start clicking boxes on ERAS:

1. Do you specifically know what you want to do post-residency? If not, "balanced" is probably the way to go.

2. Are you dead set on the fellowship track? If so, I suppose you could theoretically go with the program with the best rep & biggest names (traditional programs included) to get the fellowship. Mind you, this would help with PM&R fellowships, not necessarily Anesthesia Pain, Neurology Electrophysiology (EMG) or Primary Care sports fellowships. Note, there is only PM&R subspecialty certification in SCI, Peds, Pain and soon Neuromusc and D/Os and Acq. Brain D/Os (TBI). There likely will not be any "new" PM&R pain programs created over the 11 already in existence. PM&R MSK/sports/spine fellowships may give you additional skill, but no additional certification at this time.

3. Do you want to get most of your outpt skills during residency and forego a fellowship?
-Go with a "progressive" program. I truly believe that if a program provides quality training with enough "flexibility", a fellowship may not be necessary from a purely "acquisition" of skills standpt, not necessarily a "certification" standpt.

Other factors include

-Overall rep of your program, more important for PM&R jobs, less so for multispecialty groups (i.e. Neurosurg/Ortho/Primary Care/large Pain groups). Here, overall rep of the hospital may be more helpful.
-Alumni network for job hunting (size and # of years program has been active are probably important here).
-Geographic location which will help with job connections (East Coast?, West Coast?, specific cities e.g. Chicago?) You will meet alot of people during your residency who will be able to help you out in this regard.

BTW, many "traditional" programs are also "progressive", some are not. With the current trends, programs that provide very little outpt training are becoming a minority, so there is a good chance you'll have decent outpt exposure at most programs.

As you can see, you need to talk to alot of different people and will get alot of different opinions.

PM me if you want my personal opinions on programs.

 

[Disciple]

I think that axm397 is right on about "balance." Even if you think that you might eventually sub-specialize you want your base training to be sufficiently broad that you're not just a "one-trick pony."

I think the demand for Physiatrists who are good at inpt and outpt (FPs of the Physiatry world?) are decreasing.

This is purely anecdotal, but from what I've seen recently, most employers want either an interventional pain doc, a musculoskeletal Physiatrist (EMGs and some injections), an "inpt machine" (admits, rounds and call at multiple hospitals/SNFs) or an academician (MSK, TBI, SCI, Peds, general inpt, etc.).

There are those who think (including former instructors I have had) that too many Physiatrists have become "needle jockeys"/"one-trick ponyish", letting their other skills erode and ignoring basic Physiatric philosophies. This may be true to some extent.

However, I think over the next decade we will see Physiatrists emerge who possess an inclusive set of advanced/comprehensive Musculoskeletal, interventional and electrodiagnostic skills.

To me, this type of skill set is plenty broad/unique and difficult to acquire. Personally, I'm estimating another 2-3 years of training before I can come close to this.

Again, this borders on the issue of a dedicated pain residency, but that's another discussion.

 

[rehab_sports_dr]

One concern I've heard voiced by many of the leaders of PASSOR and NASS is that some physiatrists are becoming too focused on injections, and thus are simply less well-trained anesthesiologists.

If we are going to have value in the competitive medical market, we have to have some value added, beyond merely procedural training.

What we have to offer is a comprehensive knowledge of function. The current training in PM+R is comprehensive in the diagnosis of functional loss and restoration of function. Something would probably be lost if the training were to become too progressive.

I can think of a few examples where our comprehensive training is valuable in the assessment of MSK patients:

1. There have been several occasions where the referring physician thought the patient had a cervical radiculopathy, but actually had a cervical myelopathy. I believe our training in SCI makes us cognizant of the warning signs of myelopathy.

2. Because of our experience in managing amputees, our knowledge of ground reaction forces transmitting up the kinetic chain gives us an advantage in the prescription of orthoses.

3. Our knowledge of pressure ulcer management is helpful for cyclists who develop road rash.

4. Our experience in pediatrics helps us develop a greater knowledge of hip biomechanics (because of the specific problems associated with many pediatric disorders).

These are just a few examples that pop into my head. I don't think the inpatient aspects of my training (stroke, TBI, SCI, peds, etc) has been incidental to my overall development as an outpatient MSK physiatrist. I think something would have been lost if I had been allowed to focus exclusively on the MSK aspects of my training.

 

[drusso]

Something would probably be lost if the training were to become too progressive.

I don't disagree with anything you said except the above. I don't think that "progressive" equals "procedural." Progressive is a very mushy word, but I think that it means thinking outside of the proverbial physiatric box--extending and expanding the concept of "rehabilitation."

I think what is really in demand in the marketplace are comprehensively trained physiatrists--i.e. those who can expertly diagnose, treat, non-operatively manage, and rehabilitate a variety of conditions. To that end, incorporating procedural training (axial injections, EMGs, MSK ultrasound, chemodenervation, etc) is vital. My idea of a "progressive" program is one that embraces the idea of physiatrists as comprehensively trained experts in NEUROmusculoskeletal rehabilitation. Two years ago at the AAPM&R RPC meeting, Jay Smith, MD (current President of PASSOR) gave a very workable (and progressive) definition of a physiatrist, "Experts in the comprehensive provision and orchestration of neuromusculoskeletal medicine."

 

[rehab_sports_dr]

> Progressive is a very mushy word, but I think that it means thinking outside of the proverbial physiatric box--extending and expanding the concept of "rehabilitation."

Fair enough. My perception, however, is that when many medical students ask about whether a program is progressive, many times what they are getting at is whether they can spend months learning procedures instead of inpatient rehabilitation.

> To that end, incorporating procedural training (axial injections, EMGs, MSK ultrasound, chemodenervation, etc) is vital.

Agreed. With the exception of electrodiagnostics, however, I am not sure it is reasonable to expect independence in the practice procedures without supplemental training (e.g., fellowship). Residents should certainly understand the indications and contraindications for these procedures, but many of these skills (alcohol blocks, cervical epidurals, MSK ultrasound) require a volume of training to truly be competently independent. I doubt that a resident could reasonably develop more than 1 of these skills within the scope of residency training without missing out on some of the more fundamental aspcets of residency training.

 

[drusso]

I doubt that a resident could reasonably develop more than 1 of these skills within the scope of residency training without missing out on some of the more fundamental aspects of residency training.

No doubt the possession of both knowledge and skills are important to be a competent specialist. Typically, it's the academic centers who are on the "bleeding edge" of innovation and hence possess the numbers to give trainees adequate exposure to patients and the opportunity to become competent.

In physiatry, some academic centers have actually *lagged* behind the field in some domains. So, I think when prospective applicants evaluate programs and ask how traditional or progressive a program is I think that they are trying to gauge what skills they are going to have when they finish residency. From just a casual browsing of the ads in the Archives, it is not an unreasonable question to ask.

I think Napolean Dynamite summed it up well, "Girls only want boyfriends who have great skills...nunchuck skills... bow hunting skills... computer hacking skills...you know..."

 

[Disciple]

One concern I've heard voiced by many of the leaders of PASSOR and NASS is that some physiatrists are becoming too focused on injections, and thus are simply less well-trained anesthesiologists.

If we are going to have value in the competitive medical market, we have to have some value added, beyond merely procedural training.

What we have to offer is a comprehensive knowledge of function. The current training in PM+R is comprehensive in the diagnosis of functional loss and restoration of function. Something would probably be lost if the training were to become too progressive.

I don't think the inpatient aspects of my training (stroke, TBI, SCI, peds, etc) has been incidental to my overall development as an outpatient MSK physiatrist. I think something would have been lost if I had been allowed to focus exclusively on the MSK aspects of my training.

The problem is that some programs do not even provide their residents the baseline musculoskeletal skills that Physiatrists are supposed to be known for. Read the occasional commentaries from attendings on this board. We have no standards regarding MSK education. We have the PASSOR guildlines, but these are suggestions, not ACGME requirements.

Sometimes, I don't think our leadership is doing what is best for our specialty. If many employers want Physiatrists with superior MSK, EMG and injection skills, it would make sense that we would provide our residents with this training and not handcuff ourselves by requiring fellowships, of which there are relatively few.

Maybe we should require 1 fellowship year for injections and advanced procedures, a 2nd year for advanced EMG training (to cover NMD in depth) and then a 3rd year to qualify us to treat "high-level" athletes, on top of the broad exposure we all get in residency. I'm being facetious, but you see what I'm getting at.

And I would disagree that one cannot get a well rounded education/training experience (fulfilling all ACGME requirements) and still knock out 150-200+ epidurals. This should be enough for most MSK or Spine docs to practice competently. Several programs provide this, particularly those affiliated with spine centers.

 

[rehabmd]

I recently heard one of the large NYC programs was asked by hospital administration to slash its inpatient unit beds in half(the hospital believes that that giving those beds to med-surg would be a better investment of resources). Resdients will now recieve high quality experiences at a top freestanding rehab facilty in exchange for that general acute inpatient rotation. Hopefully this will be trend as hospitals begin to recognize the limited benefits of acute inpatient rehab to everyone except administrators and therapists in academic rehab departments.

 

[Disciple]

I think there is clear benefit of inpt rehab, but I also think it is justifiable and reasonable (in the name of saving money), for general inpt rehab units to be run by PAs and NPs, under the supervision or distant supervision of a Physiatrist.

 

[drusso]

The problem is that some programs do not even provide their residents the baseline musculoskeletal skill that Physiatrists are supposed to be known for. Read the occasional commentaries from attendings on this board. We have no standards regarding MSK education. We have the PASSOR guildlines, but these are suggestions, not ACGME requirements.

Disciple,

There actually are, but I don't think that residents are aware of them. They're in the RRC common program requirements, but are sufficiently vague to give programs some leeway. Residents should review this requirements and list program deficiencies for RRC review committees during program visits.

http://www.acgme.org/acWebsite/downloads/RRC_progReq/340pr706.pdf

 

[Disciple]

I stand corrected, but without a defined body of knowledge (maybe at least some specific objectives), there is no such thing as musculoskeletal medicine.

Some of the inpt requirements were vague as well, but then again, I don't know of many programs deficient in geriatric rehab.

 

[paz5559]

Disciple,

There actually are, but I don't think that residents are aware of them. They're in the RRC common program requirements, but are sufficiently vague to give programs some leeway. Residents should review this requirements and list program deficiencies for RRC review committees during program visits.

To what end? So your program can be put on probation? Ratting out your program while you are a current resident serves only to disparage the good name of your program.

I would instead advocate that, if your PD or chair are reasonable people, that you attempt to work from within your program or department if PM&R is a division at your institution. I would only go to the RRC as a last ditch effort.

 

[Disciple]

My perception, however, is that when many medical students ask about whether a program is progressive, many times what they are getting at is whether they can spend months learning procedures instead of inpatient rehabilitation.

Many of these residents are going to learn to do injections one way or another, either during residency, fellowship or on their own.

When we provide them with inadequate MSK training, they have no knowledge base or diagnostic skills to justify the volume of injections they perform or narrow scope of patients they treat, and thus arises the sometimes valid criticism that too many Physiatrists are becoming needle jockeys.

 

[paz5559]

Many of these residents are going to learn to do injections one way or another, either during residency, fellowship or on their own.

When we provide them with inadequate MSK training, they have no knowledge base or diagnostic skills to justify the volume of injections they perform or narrow scope of patients they treat, and thus arises the sometimes valid criticism that too many Physiatrists are becoming needle jockeys.

The above being he second time in as many days you ahve used the term, I wondered if you could define "needle jockey" so I, for one, can recognize if I am personally being criticized (just a tad bit of paranoia, yes I know)

 

[drusso]

To what end? So your program can be put on probation? Ratting out your program while you are a current resident serves only to disparage the good name of your program.

I would instead advocate that, if your PD or chair are reasonable people, that you attempt to work from within your program or department if PM&R is a division at your institution. I would only go to the RRC as a last ditch effort.

Of course, it's a good idea to work within the program first, but there are reasons why the RRC exists and should be appropriately involved in residency education issues including the remediation of perceived program deficiencies. And, what do you do if your PD or Chair are less than reasonable, disinterested, distracted, or out of touch?? 🙂

 

[paz5559]

Of course, it's a good idea to work within the program first, but there are reasons why the RRC exists and should be appropriately involved in residency education issues including the remediation of perceived program deficiencies. And, what do you do if your PD or Chair are less than reasonable, disinterested, distracted, or out of touch?? 🙂

What do you do if your Chair or pd are out of touch? Go to the Dean, first of GME, or of the HSC, if GME is buddies with the higher-ups in your dept/div.

I would still argue that telling tales to the RRC can only get your program on probabtion, or significant dings toward their next review. In neither event does that serve the current residents, becuase before the fixes are implemented, you will all be gone, so the only thing you can do is harm the name and reputation of the prgram and insitution your diploma be entittled with.

 

[drusso]

What do you do if your chair or pd are out of touch? To to the Dean, first of GME, or of the HSC, if that doesnt work.

I would still argue that telling tales to the RRC can only get your program on probabtion, or significant dings toward their next review. In neither event does that serve the current residents, becuase before the fixes are implemented, you will all be gone, so the only thing you can do is harm the name and reputation of the prgram and insitution your diploma be entittled with.

Are recruiters looking up ACGME program deficiencies??? I might be more afraid of personal retribution than professional harm...

 

[chauffeur]

I recently heard one of the large NYC programs was asked by hospital administration to slash its inpatient unit beds in half(the hospital believes that that giving those beds to med-surg would be a better investment of resources). Resdients will now recieve high quality experiences at a top freestanding rehab facilty in exchange for that general acute inpatient rotation. Hopefully this will be trend as hospitals begin to recognize the limited benefits of acute inpatient rehab to everyone except administrators and therapists in academic rehab departments.

i don't know if i totally agree with this statement. many acutely ill pts are able to benefit from pt/ot/speech-language/rehab engineering/neuropysch before they are officially transferred to rehab. there are benefits to acute inpatient rehab. you can't always wait to start rehab until a pt is stable enough to transfer/be accepted at a free-standing rehab hospital. take burn rehab for example. pain management, nutrition, wound care, and ROM are all important parts in the acute rehab setting. stroke rehab must also start once stable in the acute setting. in an acute inpatient setting you have better f/u with the medical team in transplant pts, etc. however, if pts are admitted without clear goals and don't stand to benefit from their stay, you ultimately end up running a step-down unit.

 

[Sanchik]

are u by any chance talking about NYU? they recently cut their inpt number by half.

 

[rehabmd]

are u by any chance talking about NYU? they recently cut their inpt number by half.

I did not know that about NYU. So I guess both Columbia and NYU have cut back. I agree that acute inpatient rehab serves a great purpose (eg SCI, post-stroke), but it provides a disservice to physiatry residents who have already done a medicine internship, since most will not do intern level medical managemnt for the rest of their career, especially when most other specialties use NP/PAs for those services, and there is so much to learn about the physiology of pain management, movement science/kinesiology, biomechanics, gait analysis, physiotherapy, sensory integration, eval and treatment of neuropsych disorders (such as autism/PDD for which PT/OT/ST/Feeding/Neuropsych eval and therapy is currently managed mostly by nonphysician Special Educators who take correspondence courses and charge $300-$3000 per 1-3 hour neuromusuclar and neuropsych eval by administering a battery of multiple choice tests to patients), acupuncture/ayurveda, nutrition, developmental, neuromuscular and sports medicine and exercise physiology that other referring physicians and the public associate with rehabilitation medicine.

 

[rehab_sports_dr]

I am agreement that many programs have over-emphasized inpatient rotations, not because of a perceived educational need, but merely because they needed the residents to staff the inpatient services. This is similar to the internal medicine problem, where the inpatient heavy training does not reflect the life for the non-hospitalist attending.

Where I am concerned is that when many residents speak of progressive, that is very often code-speak for interventional pain procedures. There aren't many residents who are complaining about their lack of lymphedema managment training, that they need more skills in the management of pressure ulcers, or that they need more outpatient P+O rotations, even though they are every bit as much a part of the scope of physiatry. In the case of P+O, it's also an area of training that is more deficient nationally, as gauged by the national performance on board scores and SAEs.

Some in this thread have argued that it is possible to perform large numbers of interventional pain procedures in residency and still have competently mastered the fundamentals of the field. I am extremely skeptical this is true.
Even at the elite top 5 consensus programs, many residents are deficient in some core skills sets. Nationally, many residents are struggling to independently perform and interpret 200 electrodiagnostic evaluations, as just one example.

I find some of the discussion here disingenuous- some say they want better defined skills as a resident, when what they really want is to become an interventional proceduralist in 1 less year. I apologize if I am misreading the underlyin message.

 

[drusso]

I find some of the discussion here disingenuous- some say they want better defined skills as a resident, when what they really want is to become an interventional proceduralist in 1 less year. I apologize if I am misreading the underlyin message.

That's all good and well, but like the old adages goes, "If you keep on doing what you've always done, then you'll keep on getting what you've always got." I don't know if that qualifies as double-speak or not, but in my mind, "progressive" means pushing the frontier of the field instead of just doing the same old same old.

It's always struck me as interesting that in most other medical specialties academic centers are at the leading edge of innovation, but I'm not certain that's always true in physiatry. Certainly, P&O, physical modalities, and neurologic rehab are the foundation of the field, but those are not the core skills that the adverts in the back of the Archives want.

As science cumulates something has got to give. You either re-prioritize and re-focus the training (as many other specialties have done--psychiatry, radiology, and emergency medicine for example) or lengthen the training. Physical therapists have acknowledged the same facts by developing the DPT degree and aggressively lobbying for direct access in most states.

Physiatrists, in my biased opinion, have the capacity to be the authoritative non-operative MSK physician in both diagnostic and treatment realms. Currently, it's like being able to diagnosis heart failure and not being able to prescribe diurectics. Competency in basic lumbar axial spine injections ought to be well within the domain of any graduating physiatry resident. These are not technically difficult, but they do require carefully defined formal training and instruction which is the purpose of residency training.

Afterall, many anesthesiology residency graduates do these procedures (with fluroscopic guidance) after their residency and no pain fellowship at all despite the fact that the typical anesthesiology resident gets about 2 months of pain medicine experience in their residency. Yet, their residency programs deem them competent in performing these procedures the day they graduate despite a woeful lack of skills and training in neuromuscular diagnosis and treatment. It's instructive to read how the Anesthesiology RRC sanctions this competency:

k) Twenty-five new patient evaluations for management of patients with acute, chronic, or cancer pain disorders. Residents should have familiarity with the breadth of pain management, including clinical experience with interventional pain procedures.

Anethesiology Residency Program Requirements

That's 25 patient evaluations and FAMILIARITY with interventional pain procedures. So, what should physiatry do? Should it advocate on the behalf of its patients as stakeholders by promoting the competency of residents in both the technical and diagnostic relms or just let other fields train technicians to do these procedures?

 

[rehab_sports_dr]

> Afterall, many anesthesiology residency graduates do these procedures (with fluroscopic guidance) after their residency and no pain fellowship at all

I don't know the percentages, but many anasthesia residents (my impression is most) who intend to become primarilly interventional spine physicians also complete a pain fellowship. And if anasthesiologists- who are fundamentally proceduralists, feel the need for an additional year of fellowship, that is certainly reasonable for physiatrists to obtain the extra year of training.

I agree that PM&R training should require a familiarity with the indications for procedures. I also agree that attendings are overly conservative in letting residents have hand-on experience.

I disagree that basic competence in lumbar axial injections should be part of the core residency curriculum. I think it is too much to learn.

 

[paz5559]

I disagree that basic competence in lumbar axial injections should be part of the core residency curriculum. I think it is too much to learn.

I love what I do, and I have fun doing it, but come on - what we do isn't complicated, and most fellows at the Emory PM&R fellowship program are at least comfortable with the concept of LESI's, MBB, and L/S RF after the first MONTH of training. I would love to believe what we do is sophisticated, but you could even train a CRNA to do this stuff (I certainly wouldn't, but you could) 🙂

 

[drusso]

I love what I do, and I have fun doing it, but come on - what we do isn't complicated, and most fellows at the Emory PM&R fellowship program are at least comfortable with the concept of LESI's, MBB, and L/S RF after the first MONTH of training. I would love to believe what we do is sophisticated, but you could even train a CRNA to do this stuff (I certainly wouldn't, but you could) 🙂

Paz, I think that you're right and I think that you make the argument why a PM&R graduate could be competent within the course of training of a PM&R residency. The technical and procedural skill sets for basic lumbar axial injection is not terribly advanced.

However, the combination of physiatric knowledge & diagnosis with basic procedural and technical skills *IS* feasible if training programs make it a priority. To that extent, I think that a program's "progressiveness"--i.e. openess to change and be forward-looking with respect to evolving technology in rehabilitation--should be at the top of the list for prospective applicants when they interview at programs.

Perhaps, its a subtle cultural or organizational quality to try to assess in a one-half day experience. Maybe, for fun, someone would like to take the other side of the argument??

 

[Disciple]

The above being he second time in as many days you ahve used the term, I wondered if you could define "needle jockey" so I, for one, can recognize if I am personally being criticized (just a tad bit of paranoia, yes I know)

What I meant and what I think most others refer to when they use the term. A high volume injectionist who does not perform appropriate pt work-ups either because they lack the knowledge/skill or because they choose not to. "Appropriate" being ambiguous in itself I suppose.

Not to offend anybody. I know the term is sometimes used loosely at times.

 

[rehab_sports_dr]

I agree that fellows can get up to speed pretty quickly when they learn the procedures. They also (hopefully) have a well establised base of knowledge upon which they are building, which is part of what allows them to assimilate the knowledge they need to make the appropriate evaluations and understand the anatomy for the procedures.

My experience as a fellow is much different than when I was starting as a resident. I came into residency with more experience than the typical resident, since I had a PhD in anatomy and taught medical school anatomy for many years. That said, my ability to distingush the many lower back pain generators by history and examination was very limited. It took 3 solid years of good residency training to get to the point to feel comfortable knowing the indications for the appropriate procedures. As a a resident, it was very common to have patients referred to us for "sciatica," but who truly had a likely pain generator (e.g., SI joint arthropathy, z-joint arthropathy, femoral-acetabular impingement, etc.), that were clearly NOT indications for lumbar epidurals.

As my fellowship mentors like to say, the real skill is not in knowing how to do interventional procedures, but in knowing WHEN to do the procedures. I am extremely skepitcal of the ability of most (if not all) residency programs to provide both adequate core musculoskeletal training, AND to give enough hands on training in interventional spine procedures to be truly independent.

Moreover, I think many medical students are being enticed into programs by the allure of more interventional exposure, and are not fully aware of how much comprehensive MSK skills they need to acquire. It has long been a concern of the PASSOR leadership that residents already are deficient nationally in core MSK skills. I share their concern that the growing desire to develop interventional training during residency will come at the expense of solid core MSK training.

 

[Disciple]

I am agreement that many programs have over-emphasized inpatient rotations, not because of a perceived educational need, but merely because they needed the residents to staff the inpatient services. This is similar to the internal medicine problem, where the inpatient heavy training does not reflect the life for the non-hospitalist attending.

It's not so much the quantity of the inpt training as the quality/efficiency. At many programs, PGY-2 year is like Intern year #2. IM programs have a hierarchy where PGY-2s/3s do more decision making and less scut and thus increase their knowledge base tremendously during these years. Starting academic inpt rehab positions often carry the same job description as a PGY-2 except that the new attending's name is now on the chart.

Most other specialties use mid-levels. I have seen them used in outpt PM&R practices but never in inpt.

 

[Disciple]

I am agreement that many programs have over-emphasized inpatient rotations, not because of a perceived educational need, but merely because they needed the residents to staff the inpatient services. This is similar to the internal medicine problem, where the inpatient heavy training does not reflect the life for the non-hospitalist attending.

Where I am concerned is that when many residents speak of progressive, that is very often code-speak for interventional pain procedures. There aren't many residents who are complaining about their lack of lymphedema managment training, that they need more skills in the management of pressure ulcers, or that they need more outpatient P+O rotations, even though they are every bit as much a part of the scope of physiatry. In the case of P+O, it's also an area of training that is more deficient nationally, as gauged by the national performance on board scores and SAEs.

These skills generally are not in "high demand". While they are necessary to keep with our tradition, provide a broad educational experience and would serve you well in an academic setting, the bulk of community inpt jobs are typically high volume, not allowing a new grad to personally implement and monitor these theraeutic interventions.

Basic O&P skills are a necessity for virtually all Physiatrists, but how many are actually going to become specialists in amputee care?

The typical PM&R job with a Neurosurgical or Orthopaedic spine group will require that you be able to provide comprehensive musculoskeletal care, prescribe and oversee appropriately detailed rehab programs, interpret spinal radiographs, CTs and MRIs, perform basic spinal injections (so they can document failure of conservative care) and probably discography, and be adept at EMG/NCS. If an applicant does not possess these skills they are pretty much SOL. Some practices may be willing to train a promising candidate, but these are much harder to find.

I list this generic example only because these types of jobs are present in abundance.

 

[rehab_sports_dr]

Many comments in defense of the "progressive" education have been of a form of "well, that's what the job market demands."

Residency training programs are appropriately conservative in responding to hot trends and job recruitment. In my limited exposure to PM+R, I can think of a few fads that have phased through, but have for economic reasons have been downsized.

For example, in the late 80s-early 90s, there was a desire to cash in on stand alone acute rehab facilities, since they were immune to the DRG payment schedule. But now that acute rehab facilities. are reimbursed based on patient mix and DRGs just like acute care hospitals.

Then the trend became to avidly pursue EMGs as the next cash cow. That still exists to some extent, but there has been growing concern about abuses in electrodiagnostic evaluations, and that cash cow has been dissolving.

So, I agree that many ortho and neurosurgery groups are avidly recrutiing interventionalists, since that is the most lucrative aspect of our field. But strongly disagree that solid curriculums should be reworked in favor of this trend without taking in the bigger perspective of what it means to be a physiatrist. At some point (in 1 year? 5 years? 10 years?) interventional procedures will no longer be disproportionately reimbursed, and at that time, what will define a physiatrist?

Without an appropriate emphasis on function, we will be simply less well trained anasthesiologists. And that will be a shame.

I feel that many of these posts have focused on the inefficiency in our inpatient educational experiences, and equated that with a need to be more interventional. I agree that many inpatient rotations are unbalanced in the service/educational ratio, but that does not change where the emphasis should be in our outpatient training.

The fact is that nationally, our specialty is not adequately trained in (as drrusso likes to say) neurosmusculo-skeletal function. And until we better establish that base, I think we have to be careful as a field in moving too aggresively into the fad of interventional procedures.

 

[Disciple]

How would you feel if as a Physiatrist you had to refer your pts out for knee, subacromial or tendon sheath injections? Remember, many PM&R programs provide zero spinal injection training. As was stated previously, basic spinal injections are not technically difficult. How about EMGs? What if you needed to do a Neuromuscular or Neurology based Electrophys fellowship to do your carpal tunnel studies?

I am not advocating we train in Stim placement or Perc Disc Decompression during residency, but that we give residents the skills to at least get by.

The argument that we are less well trained Anesthesiologists may be valid in certain instances. Standardizing injection training during residency would help to cement these interventions as within our scope of practice and may help to eliminate some of the skepticism about our technical skills. We have no control over the manner in which Physiatrists are going to practice. All we can do is to provide the most complete training possible, so that those who do alot of injections will at least have the knowledge base and musculoskeletal skills to support what they are doing.

This would require a defined body of knowledge and specific educational objectives. Due to differences is departmental philosophies amongst PM&R programs, the edict would have to come from above, i.e. likely the ABPMR.

 

[Disciple]

It took 3 solid years of good residency training to get to the point to feel comfortable knowing the indications for the appropriate procedures. As a a resident, it was very common to have patients referred to us for "sciatica," but who truly had a likely pain generator (e.g., SI joint arthropathy, z-joint arthropathy, femoral-acetabular impingement, etc.), that were clearly NOT indications for lumbar epidurals.

As my fellowship mentors like to say, the real skill is not in knowing how to do interventional procedures, but in knowing WHEN to do the procedures. I am extremely skepitcal of the ability of most (if not all) residency programs to provide both adequate core musculoskeletal training, AND to give enough hands on training in interventional spine procedures to be truly independent.

This is our favorite criticism against Anesthesiolgists, just as a favorite criticism against interventional Physiatrists is that we are just "less well trained Anesthesiologists". Neither is valid in many cases.

I would disagree that it takes 3 yrs to learn to identify spinal pain generators, basic musculoskeletal medicine, indications for spinal interventions and to perform an adequate # of basic spinal injections. Two good hands-on spine rotations during the PGY3 or 4 year plus a few good general MSK/Sports rotations should be adequate.

This is how I was trained and a good number of other Physiatrists I know were trained.

To efficiently complete all these objectives within a 3 yr residency, the key is the spine rotations as opposed to sending residents to rotate through an Anesthesia pain clinic. These rotations are beneficial regarding pain medicine, but one will not learn musculoskeletal medicine here.

 

[drusso]

I think that this has shaped up into a pretty good discussion. I still think, at the heart of the matter, the root issue comes down to the organizational culture of the field and the training programs.

For example, you never here of "interventional dermatologists." If there is a derm condition that requires a derm intervention or treatment (such as a biopsy) short of plastic surgery, dermatologists don't engage in hand-ringing about whether it is appropriate for a dermatologist to be doing that procedure. It's a no brainer for them: It's a skin problem, they're skin doctors. Duh.

The same is not true in physiatry. It seems, as a whole, physiatrists still can't agree on what it is we do. If we're non-operative, MSK-specialists, and experts in human functional restoration regardless of etiology (neurological, MSK, burn, trauma, etc) then I argue that the training should be directed toward any and all appropriate modalities to meet that end...just short of surgery. Implantable technology is clearly a very advanced skill requiring fellowship level training. Neurolysis and RF neurotomy require a training environment with sufficient volume that probably necessitates a dedicated fellowship. Ditto for cervical procedures.

However, there are enough patients with axial lumbar pain in general physiatric clinics to support resident skill development in basic axial interventions. It just requires the will-power and vision of academic PM&R training programs to assert themselves as experts in these modalities. If cardiologists didn't do the same thing 25 years ago, interventional radiologists would still be doing all the cardiac catheterizations and percutaneous interventions...and they probably would have preferred it to stay that way.

 

[rehab_sports_dr]

> I think that this has shaped up into a pretty good discussion

I too have enjoyed this discussion. As I go through my fellowship right now, I am having an internal struggle to define my role, so it helps clarify my thoughts.

> I still think, at the heart of the matter, the root issue comes down to the organizational culture of the field and the training programs.

I agree. I do not think the leadership in the AAPM&R or AAP has clarified their position on the role of interventional training in residency. Therefore, by default, inertia in programs and market forces have been dictating the shape of the field. I think we would be well served to have a conscious decision of where the field should be going.

>For example, you never here of "interventional dermatologists."

You do hear, however, of people doing fellowships to learn the Mohs procedure. This seems to me like a trivial step beoynd a normal biopsy, but for whatever reason they have deemed it neccessary for additional techinical experience.

> However, there are enough patients with axial lumbar pain in general physiatric clinics to support resident skill development in basic axial interventions. It just requires the will-power and vision of academic PM&R training programs to assert themselves as experts in these modalities. If cardiologists didn't do the same thing 25 years ago, interventional radiologists would still be doing all the cardiac catheterizations and percutaneous interventions...and they probably would have preferred it to stay that way.

Cardiologists, of course, require fellowship training beyond IM, of course. And then they require subspecializatio training beyond that for the more advanced procedures, like nodal ablation (which is a pretty close analogue to RF ablation.

I imagine the reason IM requires the additional training is NOT primarily because of the technical skills, which culd probably be learned pretty easilly within the scope of an IM residency. They are probably concerned that without proper training, some docs would start cathing anyone who MIGHT have CAD, leading to a lot of cathing of patient's who have GERD, asthma, etc. (one might argue this happens anyway).

In my mind, there a few reasons to encourage fellowships for interventional physiatry:
1. To get an adequate foundation in general MSK care during residency. I know PAZ and Russo, and I have no doubt about the adequacy of your training. But I also have seen the skills of some very bright residents at very well regarded residency programs, and I am not comfortable with the overall competency of PM+R residents nationally. I know for myself, I consider myself well trainined, but there are MANY things that I need to learn to really feel comfortable. For example, my MRI reading skills are poor, there are many common peripheral injections I have never performed (Morton's, psoas bursa, DeQuervain's). And I know that if I am missing these skills, many other residents are also.
2. Seeing common interventional mistakes with an experienced eye in the room. Maybe some other people are brighter than I am, but it is still taking my eye some practice to distinguish vascular flow patterns from other types of contrast patterns. There have also been times when I have been dribing the needle and not able to get it do where I want, but my mentors pointed out that there was a "hidden" osteophyte, which became apparent by obliquing the c-arm. That is the kind of thing that is learned with experience, and I am glad I am learning with mentors IN THE ROOM while I am doing the injections.

There are other reasons, but those are reasons that I can't imagine not having fellowship training.

Put simply, I would not be comfortable sending a family member for an injection from someone without fellowship training.

[/QUOTE]

 

[Disciple]

I'm not sure I would equate training in lumbar epidurals (which are relatively safe), to Cardiac Catheterization and the knowledge base required to effectiveley treat cardiac disease.

So, you wouldn't feel comfortable sending a family member for an injection to a Physiatrist without fellowship training.

But, would you let a family member who suffered a stroke be cared for by a Physiatrist without fellowship training? Likely.

What does this say about our specialty? Especially if you don't trust the skills of many residents from well regarded programs. Graduating residents can care for pts in an inpt setting, but not for simple cases of acute/subacute radicular pain requiring maybe 1 transforaminal injection and a proper course of PT.

What I think needs to be done is this. MSK/basic injection training needs to be standardized amongst PM&R residencies so that most graduating Physiatrists will be able to treat bread-and-butter MSK cases. Patients and referring physicians will have an idea on what kind of abilities they can expect from their neighborhood Physiatrist. This will also help to assuage some of the apprehensions regarding our technical skills by other specialists who perform injections. The concern over Physiatrists gaining poor injection skills through weekend courses would no longer be an issue.

Just curious, but why would a resident who is learning lumbar injections in a spine rotation not have "an experienced eye" in the room?

Musculoskeletal medicine needs to become its own sub-specialty (whatever we decide to officially call it), so that PM&R fellowship training actually carries some weight/significance within the rest of the medical community, instead of being used in many cases to remediate poor musculoskeletal training during residency, and unless you want yourself and any of your colleagues who perform lumbar injections to be labled as, held to the same standards, knowledge base and scope of practice as pain docs for the rest of your career. At the present time, saying a fellowship is PASSOR approved is going to mean nothing to an employer unless they are a Physiatrist themself.

Pain fellowships would continue as they are, as multidisciplinary endevours to the betterment of training those who wish to manage chronic pain of any etiology.