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Scope of residency disappointing

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Idon'tknow??

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In February, I completed a 4 week rotation of inpatient/outpatient PM&R at a fairly well known program, and I'm frankly disappointed. I'm wondering if I got a good sampling or not? It seemed that we rounded daily inpatient and really didn't do much as far as care. Any medical problems, and we consulted. Any other type of rehab management was primarily directed by PT/OT. Is this the case at the top 5 or so programs? Did I have undo expectations of the scope of practice for inpatient PM&R?

Thanks....................
 

Dr. G

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thats why the trend has been towards doing some type of fellowship (sports/spine, msk, emg, pain) so that physiatrists can practice outpatient medicine after residency.
 

Finally M3

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I thought money was the bigger reason as to the migration of PM&R towards outpatient practice...

As for the inpatient experience, I think it's site dependent. One of my rotations sounded like what your experience was like, IDon'tKnow (commun. hosp), while the others we had devoted 'gym rounds' and were encouraged to follow our patients during PT/OT/etc. as well as be active participants in the rehab management. And we handled most of the medical problems ourselves (thus my doing a prelim medicine year v. transitional).
 

bbbmd

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I agree with M3... As a PGY2, I think it really is site/attending dependent. Some attendings really do not want to handle "medical problems" (mostly private MD/DOs) and others do NOT consult anyone (even to the point of doing extensive sharp bedside debridement of wounds for SCI patients- that kinda made me nervous!!!).

In my experience, at private hospitals, every service gets consulted for little things and rehab basically leads the rehab team and ANTICIPATE medical problems that would effect activities. I guess there is a "network" that goes on among the attendings, but I will not go into that.

In the County or the VA system, we manage EVERYTHING until we really run out of options.... Acute pain management so the patient can participate, Blood transfusions if needed for anemia causing fatigue or SOB, Initial W/U for Chest pain on the rehab floor, Orthostatic intolerance, Fall work-up, Depression, DVTs (refer out PE's), WOUND management and referral only for SURGICAL DEBRIDEMENT, CHF treatment with diuretics (refer out for thoracentesis if needed) as we get lots of CABG patients, spasticity management if needed with medications or BOTOX... These are just some of the things we do on a typical general rehab rotation where the attendings let you run the floor.... But most importantly we are trained to RECOGNIZE and ANTICIPATE the complications that can typically occur in the rehab patient. It can get rather busy, but if you catch these things before your patient crumps, and you manage it early and effectively, the patient can participate in therapies and have better outcomes in the end.

You are also expected to know the REHAB that goes on, but that is another topic that I can go on and on about... for example (a simple one)... there are certain goals that need to be achieved for the best possible outcome of a Total Knee Arthoplasty (bread and butter PM&R patient). In order to achieve these goals, the patient must be ABLE to participate in aggresive AAROM, Balance, Progressive ambulation, strenthening and transfers... But if you, the Physiatrist, do not effectively manage acute pain (off the PCA pump), do not catch a slowly decreasing H/H (common in a knee replacement), or an infected incision or a UTI, your patient will NOT achieve the expected REHAB goals and usually functional outcome is worse!!!! I can go on and on about this now that I have experience on the rehab floor, but let me stop here unless y'all have questions.

Initially I had the same concerns and questioned the PM&R doc's importance. Now I know that we are probably the MOST important kind of physician (BIASED, OF COURSE) in ensuring the best possible FUNCTIONAL outcome of all PATIENTS!!! The best surgeons can do a wonderful job on a knee, but if the rehab is not done properly, then the patient might as well not have undergone the surgery!!!!

This is my PGY2, two cents on inpatient rehab... I welcome comments or additions from fellow residents! :D
 

bbbmd

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Actually, you can make a FORTUNE off inpatient rehab as well. You'll be busy with consults while running an inpatient unit, but from what I was taught re: re-imbursements, the potential is there!!! Although, personally id prefer an outpatient practice because I would not have to be on-call!!!
 

drusso

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I think that it is mostly site dependent. At academic institutions it seems that the acuity of the typical rehab patient is increasing. Thus, physiatrists find themselves doing more internal medicine than rehab per se. For most of us, this is not the reason we chose PM&R! Nevertheless, it is an important part of the training. I don't like it and don't see myself running a hospitalist practice (I agree that the income is there for those interested) but I do see the experience as useful in terms of understanding the broad spectrum of disability, impairment, and disability-related complications (ie iatrogenic catastrophes).
 

fozzy40

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I definitely want a rotation experience that exposes me to similar things that bbbmd is referring to. Can anyone suggest a rotation site?
 

phd2b

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drusso said:
I think that it is mostly site dependent. At academic institutions it seems that the acuity of the typical rehab patient is increasing. Thus, physiatrists find themselves doing more internal medicine than rehab per se. For most of us, this is not the reason we chose PM&R! Nevertheless, it is an important part of the training. I don't like it and don't see myself running a hospitalist practice (I agree that the income is there for those interested) but I do see the experience as useful in terms of understanding the broad spectrum of disability, impairment, and disability-related complications (ie iatrogenic catastrophes).

It seems to me that someone who completed one of the 5 year combined IM/PMR residencies (one of what, 2-3?) would be ideally suited for this kind of hospitalist role, no?

Already checking into this...
 

drusso

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phd2b said:
It seems to me that someone who completed one of the 5 year combined IM/PMR residencies (one of what, 2-3?) would be ideally suited for this kind of hospitalist role, no?

Already checking into this...

That would be good combination, but I think it would be a little overkill. The medicine you need to know to take care of even the sickest rehab patient is basic intern level medicine. Do a good transitional year or prelim year in medicine at a place where you get a lot of hands on experience managing sick chonically ill patients and you'll be fine.
 

bbbmd

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fozzy40 said:
I definitely want a rotation experience that exposes me to similar things that bbbmd is referring to. Can anyone suggest a rotation site?

Try doing a rotation at a BUSY freestanding acute rehabilitation hospital. You'll get that kind of exposure in that setting! Im at Baylor/UT and I am sure the other programs with BUSY freestanding rehab hospitals will have similar experience. Rusk? Spaulding? RIC? Kessler? Yup, the patients are getting sicker and sicker!!!
 
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