PYG1 Electives

[RangerBob]

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I'm currently filling out my scheduling form for my electives and I was wondering if anyone had any particular advice for PGY1 electives. Namely if it differs at all from electives recommended in medical school for someone going into PM&R. I was thinking the following would be good, any opinions?

Rheumatology
Neurology
Orthopedics
Sports Medicine
Neurosurgery
Psychiatry

Others that seemed like they could be helpful, but that I didn't feel would be as high yield (input would be appreciated), are cardiology, critical care, trauma surgery, urology, radiology.

PM&R is also an available elective, but I don't see the value in taking that when I'll be learning it for the following three years. I really want to take advantage of my PGY1 year and take electives that will complement my residency.

 

[Paddington]

Don't bother with a PM&R elective.

Definitely go with the Sport Medicine. Rheumatology might be good if the person you're working with does a lot of joint injections, especially if they're injecting some of the smaller joints which can be hard to get experience with in PM&R. Otherwise skip it. Orthopedic Surgery and Neurosurgery will be a complete waste of your time.

Do Neurology if you have an interest in the more academic or inpatient oriented side of the field.

Everyone does a Radiology elective. You can get better with MSK, and even if you don't, they won't much care if you show up to the rotation or not.

 

[RangerBob]

Don't bother with a PM&R elective.

Definitely go with the Sport Medicine. Rheumatology might be good if the person you're working with does a lot of joint injections, especially if they're injecting some of the smaller joints which can be hard to get experience with in PM&R. Otherwise skip it. Orthopedic Surgery and Neurosurgery will be a complete waste of your time.

Do Neurology if you have an interest in the more academic or inpatient oriented side of the field.

Everyone does a Radiology elective. You can get better with MSK, and even if you don't, they won't much care if you show up to the rotation or not.

Thanks. I'll think about radiology. As far as I know the orthopedics rotation is mostly or all outpatient, and the previous PM&R PGY1's took it and said it was a great elective and they really worked on their MSK exam.

It seems like a lot of categorical PM&R programs include a neurosurgery rotation--are you sure it wouldn't be helpful? I haven't been able to find out any specific information about the elective--it seemed like if it was just post-op floor care then it wouldn't be helpful, but I thought if it included trauma assessments, clinics, and some OR time (probably doing the same thing I did during my gen surg elective... retract...) that it might be helpful. I figured, neurosurg sends inpt rehab so many patients and outpt rehab sends neurosug a lot of patients as well, that it might help to rotate through it and get more familiar with some of the workups and surgeries.

 

[The JockDoc]

Not all rotations are created equal in all places, and its difficult to make accurate generalizations. Unlike Paddington, I think a PM&R rotation *can* be a worthwhile experience. I did one in my intern year where I rotated with residents in various parts of a large PM&R program other than where I did my "official" residency. I saw how things were done there, reinforced some rehab ideas, and it helped introduce me to new contacts. I would have made the same choice over again. On the other hand, if I were stuck with one physiatrist whose practice wasn't in a part of rehab I was particularly into, I may not have done it.

I had an ortho rotation during med school, and I think that experience helped me to this day. For example, there are procedures that are more easily understood if you see them than if you read about them or see x-rays.

Once again, your experience will be unique wherever you are an intern. I would try to maximize your learning opportunities. If an elective is not known to be educational, pick something else.

 

[RangerBob]

Not all rotations are created equal in all places, and its difficult to make accurate generalizations. Unlike Paddington, I think a PM&R rotation *can* be a worthwhile experience. I did one in my intern year where I rotated with residents in various parts of a large PM&R program other than where I did my "official" residency. I saw how things were done there, reinforced some rehab ideas, and it helped introduce me to new contacts. I would have made the same choice over again. On the other hand, if I were stuck with one physiatrist whose practice wasn't in a part of rehab I was particularly into, I may not have done it.

I had an ortho rotation during med school, and I think that experience helped me to this day. For example, there are procedures that are more easily understood if you see them than if you read about them or see x-rays.

Once again, your experience will be unique wherever you are an intern. I would try to maximize your learning opportunities. If an elective is not known to be educational, pick something else.

Thanks for the advice. I've been asking current interns what electives they thought were really educational and they all had great things to say about the orthopedics, sports, rheum, and neuro rotations. So I think I have those four settled. The coordinator knows interns a few years ago who had great things to say about the neurosurgery rotation, but in case things have changed she's going to get me in touch with a surgery resident.

Neither of the 2012-2013 PM&R interns took the PM&R elective. If I recall, they didn't think it was the best elective. I agree it's an incredibly valuable experience to see how other PM&R departments function. I've done three aways at different institutions, not including the one I matched at, and considering how small rehab is at the hospitals I'll be rotating at (there's no PM&R residency, but it's big enough for ortho, gen surg, psych, etc.), I don't think it'll be the highest yield given my situation. But if I had only done one rotation, I agree, it could be a very valuable experience.

Does anyone have any opinions on psych? I only get six electives, and if I take neurosurg I'm already at five including the four I mentioned above. Considering I did a neuroradiology elective, would most of you recommend psych over radiology? I thought psych might be relevant for TBI/Stroke (I believe I rotate at the state hospital), as well as the general psychosocial sensitivity required for pain patients, amputees, etc. At least to me, psych seems like a helpful thing to get more practice in.

I'm going to be honest--if a radiology rotation as an intern is similar to as a medical student
(just looking over someone's shoulder), I'd hate to spend a month doing that. But if interns are actually reading images, I can see how that would be valuable (aside from the extra time to study for Step 3, but with all the outpatient rotations I have I'm not too concerned about that).

 

[MedBronc23]

Rheum, inpatient Neuro, cards (yes cards), GI ( got lots of procedural experience doing scopes) anesthesia/pain, Radiology, and ortho were the electives in ms4 and intern year that helped me the most.

 

[cbest]

Neuro, Rheum, sports medicine have been helpful. Ortho and neurosurgery were good as a student but wouldn't do them as a resident. Pain would also be solid probably. Cards is always good to know no matter what specialty you're in.

As much as I disliked the medicine and MICU time I had during internship, there's definitely times I'm glad I went through it when patients get sick during inpatient rehab rotations. Having said that, would t spend more time than necessary.

 

[IamnotFreud]

Not all rotations are created equal in all places, and its difficult to make accurate generalizations. Unlike Paddington, I think a PM&R rotation *can* be a worthwhile experience. I did one in my intern year where I rotated with residents in various parts of a large PM&R program other than where I did my "official" residency. I saw how things were done there, reinforced some rehab ideas, and it helped introduce me to new contacts. I would have made the same choice over again. On the other hand, if I were stuck with one physiatrist whose practice wasn't in a part of rehab I was particularly into, I may not have done it.

I had an ortho rotation during med school, and I think that experience helped me to this day. For example, there are procedures that are more easily understood if you see them than if you read about them or see x-rays.

Once again, your experience will be unique wherever you are an intern. I would try to maximize your learning opportunities. If an elective is not known to be educational, pick something else.

I think doing ortho makes great sense. I learned a ton in my ortho rotation and it is immensely helpful for the physical exam and particularly if the place you are at has a high volume of patients, where you can see a bunch of things. Also, doing heme/onc or rad onc I think makes sense as well, particularly if you are at a place in your PMR residency that has a dedicated cancer rehab experience.

 

[RangerBob]

So what I've gathered is:

+/- Neurosurgery
+ Radiology
+ Orthopedics, esp outpt
+ Sports
+ Rheum
+ Neuro
+ Cards
Psych: no one seems to say it's helpful or harmful. But I think now cards would be more helpful (also helps for all my other IM months...)
Pain: recommended, but while our program offers anesthesia, you only spend about two weeks in pain clinic, with the rest in the OR. It doesn't seem to me to be as high yield as the others (but please correct me if you think it's more valuable than the main six I listed. It is apparently a very good elective, but I just prefer the others.)
GI: Sounds like it'd be a lot of fun and helpful, but same problem--I don't know if it would be as high yield for me. Also, I don't know about the quality of the rotation.
Heme/Onc: Agreed it would probably be valuable, but I personally feel less so than the others. Unfortunately I can only take so many (and I'm lucky to get 6 electives).

So I guess I'll go with all the "+"s and then add anesthesia, psych, then neurosurg as my backups (they try and give my my top choices, but we have to list more in case they can't give us all 6. Fortunately we can usually swap so if I feel I need more medicine months, it shouldn't be an issue to add them.).

Thanks everyone for your support/recommendation!

For the future PM&R students/residents: I personally highly recommend neuroradiology--you'll get a much better idea of what you're looking at when someone puts a CT or MRI head or spine in front of you. If your school offers it, I also thought neuroanatomy was a fantastic elective. So was ICU--I know some schools don't require it, but I think every physician should spend at least one month in the ICU. Everyday I prayed my patients in the ICU would make it to rehab. Some did, some didn't. Honestly I hated the rotation because you usually can't even talk to your patients and so many will do so poorly. But it felt so great when one left the floor... Also, I can see how as cbest said, it'll help you when your patients get sick on the floor. And it'll help to understand what they went through before they got to rehab.

Otherwise my 4th year electives were in PM&R or just more general-medicine stuff (wards sub-i, prep for IM internship (lecture/practicum-based), and two months of TAing the 1st and 2nd years.

 

[Xardas]

A different approach is to see the things you may never get to see again as a physician but have an interest in. Remember you have your *whole life* to master this field. Doing a rotation or two in some elective is not going to make or break the residency.

Just as an FYI when I was in academics I always used to tell my students to try and do a derm rotation; skin complaints are one of hte most common things out there and its always a good thing to have some knowledge in no matter what specialization within physiatry you do. You can find ones that are not just teen acne clinics too but with a good mix of pathology.

Radiology is the other good one too.

Otherwise have fun and explore stuff.

 

[RangerBob]

I have another question--I have to do a total of 4 months of Inpt IM, gen surg, and/or critical care. Would you all recommend doing all four months on IM, or maybe adding a gen surg or cc month in place of an IM month?

 

[ChargerBo8]

General consensus from the people I have spoken with is at least one month of ICU is beneficial: vent management, codes and understanding really sick patients which may eventually make it to the rehab floor.

 

[cbest]

3 months IM, 1 CC

 

[Prof Moriarty]

Agree with 3 months IM, 1 month ICU. Another month of IM or inpatient neuro/acute stroke could be useful if it's an option. Agree with the inpatient medicine subspecialties: cards, nephro, etc. Also outpt neuro. You may see plenty of GI bleeds on your IM rotation and not need a GI rotation.

I also enjoyed rheum, outpatient PM&R, and integrative medicine. If you are interested in OMM, a dedicated rotation could be a golden opportunity to solidify or pick up new skills. Hard to come by this dedicated time later.

Neurosurg, ortho, gen surg... not so much. Maybe ortho outpt clinic.

Agree with the opportunity to do something you may never get another chance to do, e.g., I know people who enjoyed a path rotation.

Rads would be good, especially if you can score some neurorads or MSK rads, or get hands on with some interventional.

Also highly recommended if you can find a good rotation: Hospice/Palliative Medicine service. Learn excellent communication skills, learn how to effectively elicit patient and family goals/values, learn how to effectively interact as a consultant to other services, learn and practice effective methods for communicating difficult news, and learn the best in symptom management - highly valuable skill wherever you go. Not to mention, learn an approach which has been shown to improve QOL while increasing length of life and decreasing system costs.

Probably most important thing is that every place has its own strengths and weaknesses when it comes to PGY-1 rotations. If your hospital has an awesome (highly educational, highly regarded by residents) ID rotation, I'd do that over a cardiology or pain mgmt rotation that is known to be low yield or malignant. If you train with good faculty you will pick up useful stuff, regardless of their specialty. If you train with bad people, you won't get much out of it (except what not to be like).

 

[Paddington]

In terms of hospital inpatient stuff, the best things to learn are management of HTN (with oral medications) and DM, and common complications, especially UTI's. Having a good "feel" for a new, hospital onset PE or DVT will help. Get a good feel also for orthostatic hypotension.

One thing I never learned, but that you might want to get experience with is management and insertion of foley catheters. Nursing staff (at your internship) will think you're wierd, but it will come in handy later. The reason is that foley complications are common on rehab units, especially at night time when the most clueless nurses are on. It's a mega hassle to then get the Urologist on the phone, and even harder to get them to the hospital.

 

[RangerBob]

Thanks for the advice everyone. I think that was good advice to take electives in things that are interesting that I won't get the chance to see--I looked into it and we do have a palliative care rotation that is highly regarded by the residents, so I may take that. It seems really interesting and also has some applicability to PM&R. It also sounds unanimous about adding in an ICU month in place of one of the four IM months.

 

[Taus]

In hindsight.... palliative care would have likely been very helpful...I never thought about doing that. Some of those skills may help you with difficult issues and conversations with patients and families during future rotations on SCI, TBI, chronic pain, etc. During internship I did a month of sports med with fp, pain w/ pm&r, radiology w/ neurorads and IR time. Did outpt ortho and rheum in late 4th year of med school. All were helpful and generally enjoyable for various reasons. My required few solid months of IM floors, a month of ICU and ER were helpful and plenty sufficient for me during inpatient rehab. ER was a lot more helpful than I thought it would be.

 

[Punkn]

I also agree with 3 IM floor and 1 ICU. I had 2 IM floor months and 2 ICU (req by program), and while I felt more comfortable in the ICU the second time around, I not sure if it helped me be a better PM&R resident. Also had a required ED month which helped hone the spidey-sense of "this patient is sick and quicker getting sicker".

Also agree that to some degree the "best electives" are relative to your program. Ask upper levels for good educational experiences. I did 1 month each of inpatient ID consults (interesting cases and good lectures), Radiology (focusing on neurorads and MSK), Neurology (outpatient clinic), and outpatient PM&R elective (could not get into Sports Med, Rheum, or Ortho outpatient clinic electives that month which I ranked in front of the PM&R elective). I would've liked a palliative care option.