Residency: inpt consult months

[ConantheWiseguy]

My dear physiatry ppl,

I'm having last-minute re-considerations about my top choices for PM&R residency. They are fairly strong academic institutions, though I don't want to practice inpatient rehab exclusively. I actually made my ROL with the idea that I'll get minimal or near-minimal (per ACGME) inpatient experiences. Which brings me to my point.

In weighing pros and cons for each program I largely neglected the duration of consult experiences. Most programs I interviewed with boasted about keeping close to the minimum number of inpatient rehab months, but were less detailed about what their consultation months entailed. I haven't been too worked up about the consult experience because I sort of figured they're mostly pretty similar, but some programs have surprisingly more consult time than others. If I am hoping to eventually have a practice with equal inpt/outpt should this be a make-or-break issue for me?

I'm disappointed (and yeah, okay, a little embarrassed) that I made such a significant oversight. At this point I'm not likely to change my ROL, but I am hoping someone could educate me if I'm underestimating the importance and diversity of consultation training. Just as personal background, my home institution doesn't have a pm&r program, and I didn't get much consult experience during my away rotation. The programs I'm talking about are BCOM, Emory, U Penn, Stanford, and UWash, just for reference.

I'd appreciate any advice, positivity (or negativity) toward their own training experience in consultation, et cetera. Thanks!

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[RangerBob]

My dear physiatry ppl,

I'm having last-minute re-considerations about my top choices for PM&R residency. They are fairly strong academic institutions, though I don't want to practice inpatient rehab exclusively. I actually made my ROL with the idea that I'll get minimal or near-minimal (per ACGME) inpatient experiences. Which brings me to my point.

In weighing pros and cons for each program I largely neglected the duration of consult experiences. Most programs I interviewed with boasted about keeping close to the minimum number of inpatient rehab months, but were less detailed about what their consultation months entailed. I haven't been too worked up about the consult experience because I sort of figured they're mostly pretty similar, but some programs have surprisingly more consult time than others. If I am hoping to eventually have a practice with equal inpt/outpt should this be a make-or-break issue for me?

I'm disappointed (and yeah, okay, a little embarrassed) that I made such a significant oversight. At this point I'm not likely to change my ROL, but I am hoping someone could educate me if I'm underestimating the importance and diversity of consultation training. Just as personal background, my home institution doesn't have a pm&r program, and I didn't get much consult experience during my away rotation. The programs I'm talking about are BCOM, Emory, U Penn, Stanford, and UWash, just for reference.

I'd appreciate any advice, positivity (or negativity) toward their own training experience in consultation, et cetera. Thanks!

I can't really comment on most of those programs consult experiences--I either didn't apply to the program, or if I did, I don't remember anything about their curriculum. I do know UW residents are typically quite busy on their consult rotations. I would not call UW or Stanford light on inpatient--they're actually very well balanced programs. Perhaps they're near the minimum number of months, but expect to be busy. I generally recommend medical students try to avoid going to programs that will limit them--this includes programs that are way to heavy on inpatient (seen more often in Northeast programs I'm told--I really didn't apply to that region), as well as programs that are too heavy on outpatient.

Consult rotations do not count towards the inpatient minimum. It was one of my busiest rotations of residency, and also one of my favorites. It's a great chance to go all over the hospital, educating staff and patients about our specialty and what we can do for patients. I would say consult experience is incredibly important if you're considering practicing inpatient rehab--it's when you will focus the most on assessing which patients are appropriate for inpatient rehab, and which ones are likely to benefit the most. When you're on inpatient, you just take the patients that are admitted to you. On consults, you decide. In practice, you will likely screen and approve patients for admission to your unit (or perhaps your medical director would do most of the screening).

I consider consult experience essential in PM&R training. However, it should be noted that many inpatient rotations include doing consults--while we had a dedicated block of inpatient consults in my program, we also often did our own consults on certain services (SCI resident did all SCI consults, general rehab did all amputee, TBI did TBI consults, consult resident did all stroke, debility, polytrauma, etc. etc.) So if one program has fewer or no dedicated consult months, it doesn't necessarily mean they get less experience.

Best of luck with the match!

 

[AndyDufrane]

I would say its best to minimize inpatient months and consult experiences, as those are not too difficult to master, and for the most part, pretty useless, I mean, you want to be heavy on the outpatient MSK, procedure heavy rotations (such as MSK U/S, fluoro guided spine injections), having too many inpatient months is a huge waste, I think at most 12 months is fine, maybe 1-2 months of consults.

 

[Tromner]

Consult experience is important but I would look for a few things.

• Are they getting reflex consults or thoughtful consults (i.e. does every postop ortho pt get a rehab consult regardless of the surgery)?
• Is your PM&R consult service getting diverse questions or just "rehab dispo" on every one?
• Are you seeing a few SNF consults (this will continue to increase in the coming years)?

A dysfunctional consult service could be just an political bee hive where you rush around doing paperwork for insurance.

Sometimes there are too many consult months because it's a good money maker for the department and resident labor is cheap. Consults are one of the best RVU generators for attendings, especially if you spend 5 minutes co-signing a resident note. Attendings will be incentivized to get as many consults as possible, regardless of how pointless or un-educational the dx. And don't forget the 3 A's of a good consult - Availability, Affability and (coming in a distant third place) Ability.

Overall I wouldn't be as concerned with the number of each rotation in residency as the quality of those rotations. They might advertise lots of time in MSK that turns out to be 3 straight months of BS low back pain and not learn much. Go with your gut