PGY1 Advice from PM&R Residents

5 Things You Should Know Before Starting a PM&R Residency

Shelly Hsieh, MD
PGY3, Rutgers New Jersey Medical School; Kessler Institute of Rehabilitation 

Moorice Caparo, MD
PGY3, Harvard Medical School; Spaulding Rehabilitation Hospital

PM&R is a Broad Field

An attending recently told me, “The field of PM&R is the only medical field not limited by a patient’s age, organ system or specific diagnosis.” It’s natural to feel a little overwhelmed at the beginning of every new rotation. Like in the movie Taken, you will learn a specific set of skills as you transition from one rotation to the next. From doing an ASIA exam on the spinal cord injury service to performing a subacromial joint injection in the sports medicine clinic, you will eventually expand your skill set and will be able to apply your knowledge in many different scenarios. For example, that very same paraplegic patient you took care of on your spinal cord injury service may see you for shoulder injections due to overuse injury from propelling his wheelchair. These challenges may seem very daunting, but they are one of the more rewarding aspects of our field.

Know the Limitations of a Rehabilitation Facility

At the end of your preliminary or transitional year, you may feel comfortable managing very sick patients. You should, however, be aware that the standalone acute rehab setting has its limitations. For example, “stat” labs may take 2-3 hours to result and IV medication use may be limited. In some cases, it may be better to send a patient to the ER if management will be delayed or limited. In addition, you should also consider if the patient is stable enough to participate in therapy. If your patient is too sick, they may benefit from a short stay at an acute care hospital to medically optimize them for rehab. As the saying goes, “When in doubt, send them out.”

Remember Your Medicine

That being said, in the acute rehab setting, you will continue to use your clinical judgement and manage medical conditions. You are also likely to cross-cover patients on overnight call. Rehab call is unlike your prior call experiences. You are usually the only physician in-house, potentially covering more than 100 patients at times. You will find your triaging skills and clinical sense very valuable. Most importantly, if there is a medical emergency, you will be in charge. Taking the BLS/ACLS recertification courses may just be “another thing” on your checklist, but it is crucial to learn these skills. 

You’ll Never Walk Alone, it’s a Multidisciplinary Team Effort

The PM&R team primarily consists of physicians, nurses, therapists, and case management. Everyone is an important player in taking care of the patient. The therapists and nurses tend to spend more time with the patients, so trust their judgement when they think something is “off.” Case management is important in fighting for more time for your patients as well as assuring a safe discharge. Work closely with them to give your patients their best chance.

During your day, spend time with your patients and therapists in the gym. You will learn knowledge from the physical therapists, occupational therapists, and speech therapists that you won’t learn anywhere else in your training. This is also how you will see your patient’s functional status, learn their goals, and celebrate with them in their achievements. You will find it the most rewarding part of your day. When I saw my aphasic patient count from 1-10 with speech therapy, it brought tears to my eyes.

Think Big Picture (#Goals)

In other medical fields, acute problems require acute answers. We are accustomed to thinking about problem X and solution Y. In PM&R, our biggest goal is to improve the patient’s quality of life and maximize independence upon discharge. The beauty of PM&R is that we always look at the big picture, and how to foresee and overcome any potential challenges a patient may face as they go home or to a skilled nursing facility. It’s always important to look at the patient’s individual goals. What is their home setup? What do they need for independence? What are their safety barriers? These are some questions that will help you become a better physiatrist and advocate for your patient.

Success in Your PGY-1 Year: A Panel Discussion from June 2, 2020

Making the Most of Your PGY1

Charles D. Kenyon, DO
PGY4, University of Washington

Dear colleagues, you made it!

After 4 years of college, 4 years of medical school, 2 sets of board exams, countless interviews, sleepless nights, and amazing life experiences, it’s official—you’re an intern.

This realization is likely met with a mix of emotions. The stress of your first call shift. The buzz of a new city. The uncertainty of your first code. The excitement of finally being called ‘doctor.’ No matter the structure of your preliminary or transitional year, the next 12 months will be filled with growth.

One of the biggest challenges of intern year is the feeling of limbo. You are not a medical student anymore, but it is easy to feel distanced from your ultimate goal of a fulfilling career in physical medicine and rehabilitation. Thirty-years ago the Resident Physician Council (now Physiatrist in Training Council) was founded to provide representation and leadership for resident physiatrists within the American Academy of Physical Medicine and Rehabilitation. As such, the PHiT board would like to welcome you to this next phase of your career development!

We encourage you to engage with the Academy throughout the year, build a strong foundation for your future training, and enjoy every step of the process. Below are some quick tips and resources to achieve these goals:

1. You are a physiatrist!

   Proclaim it with authority: I am a physiatrist! Odds are that last year during your interviews, you spoke highly of your love for patient care and focus on function. Now, let your actions lead the way. Be an advocate for our specialty. Many of your staff, co-residents, and medical students will have limited exposure to PM&R. Take this advice from Stephanie Tow, MD, PGY-6 and current pediatrics fellow at the University of Colorado/Children’s Hospital of Colorado:

   “Teach others in your intern year program about PM&R when opportunities arise! There are still many physicians who don’t fully understand the values of PM&R and what we do, and it’s important to help them understand when they should involve the PM&R specialty in their patients’ care. I used to carry an ‘Intro to the PM&R’ specialty PowerPoint in my email, and whenever I found an opportunity to teach someone about our specialty, I would whip it out and go through it quickly to give them an overview.”

   As a physiatrist you will be valued in your preliminary/intern year for your unique perspective on patient care. Take advantage of opportunities such as morning reports to discuss wound care or issues related to neurogenic bladder. Volunteer to present at the noon conference on the latest physical activity guidelines, or give a presentation on ICU acquired weakness and the latest research on early mobilization during your critical care month. Embrace your identity as a physiatrist from day one of orientation.

2. Master the fundamentals

   Stay positive. We all have the same thoughts at one point or another during internship, “I just need to survive this year.” It is easy to look ahead of intern year, but always remember that this is your year to establish a foundation of knowledge for success during R2 year and beyond. Your early inpatient rehab rotations will rely heavily on your ability to assess common issues such as management of chest pain, UTI, pneumonia, CHF/COPD, etc.

   One of our Academy goals is to establish physiatrists as essential medical leaders integrated early and throughout the continuum of care for patients with neuromusculoskeletal and disabling conditions. As such, many residency programs are taking on increasingly more medically-complex patients such as LVADs, transplants, and cancer rehabilitation. Many of your patients will be coming out of extended ICU stays. Put in your work now so you when you pick up the phone at 3 am and the nurse is telling you about your patient with new-onset hemiparesis and slurred speech, you know how to handle the situation with confidence.

   Take your boards early! Preferably in the first 3-6 months after starting your internship. Step 3 and Level 3 are comprehensive exams and the longer you wait, the further you will be from certain subjects like OB-GYN and pediatrics. The tests do take preparation, but bite the bullet and start on your Certification Qbank of choice early. Don’t reinvent the wheel. Stick to the same strategies that brought you success for Step 2/Level 2, from my experience as the material was grossly similar. Even though this makes for more work up-front in the year, you will free up a lot of stress and additional time to dedicate to the finer details of clinical practice as the year progresses.

3. Stay connected with the Academy

   As noted above, your focus for the year is to establish the fundamentals in order to hit the ground running as an R2. However, we at the PHiT Council want you to know that we are here to support you through this transition. There are many ways to connect with AAPM&R during your intern year, whether through social media, attending the Annual Assembly in San Antonio, or by maintaining your membership in order to access the incredible resources at www.aapmr.org.

   Social Media:

   AAPM&R is active across many platforms including Facebook, Instagram, and Twitter. Also be sure to visit pmrismorethan.org (or via Facebook and Twitter) to learn more about the stories from patients, family members, and physiatrists who work to improve lives and function while creating unity in our specialty. Post and engage with other physiatrists throughout the year using the hashtag #pmrismorethan across all social media platforms

   Maintain Membership:

   Even as an intern there are numerous resources at www.aapmr.org that can help you stay connected. You can find the resident membership application here! This will enroll you in the resident newsletter to help you stay in the loop on topics directly related to resident education and advocacy, but you will also gain access to several key resources on the AAPM&R website and beyond.

   These resources include PhyzForum, a discussion board for various physiatric topics and communities based on clinical and practice needs and or based on identity. Browsing these forums throughout the year can help you keep a pulse on emerging issues in PM&R from those physicians on the front lines.

   Also check out PM&R Knowledge NOW^®. The collection of articles here has been developed over the last several years and is an incredible place to build your knowledge in fundamental topics related to PM&R. Do you have a passion for a topic that is missing? Volunteer to write a review to be added to the database. This is an incredible way to build your CV and contribute to the field.

   The latest news, webinars, and research are all highlighted on the www.aapmr.org website. And of course, membership also includes access to the PM&R Journal. Be sure to sign up as a resident member to take advantage of all these tremendous resources.

   Attend the Annual Assembly:

   This year’s Annual Assembly will take place November 14-17 in San Antonio, TX. Attending the Assembly is the #1 way to network and engage with your future PM&R colleagues. Time is definitely at a premium during intern year, however many programs do have educational days set aside to allow you to attend and get a much-needed respite from the daily grind of internship. Attending the Assembly gives you a boost of energy to propel you throughout the rest of the year.

4. Self-Care
   
   Overwhelmed yet? No worries, I was too! The past year has been a whirlwind of new challenges. Outside of residency, my wife and I welcomed our first child (Wilke James) on March 28, 2018 and we just finished moving our entire lives across the country to start R2 year. There will be times when you feel overwhelmed by all of the stresses, and there will be times where you realize the tremendous joy and privilege to embark on this career in medicine. But don’t forget about yourself. Your family, friends, and patients need you at your best.
   
   Maintain honest and open communication with your spouse/significant other/family/friends. Let them know when you are on a particularly strenuous rotation such as ICU or night-float. Setting expectations will be key as you and your support network navigate through the challenging, yet rewarding year. At the same time, set aside time for date night, a matinee movie on your off day, or a day trip to a nearby destination. Just as with setting expectations with your support system, it is important to be clear about your priorities with your program. Off days mean no pager and dedicated time with your family.
   
   Remember to sleep, eat well, exercise, and have communities and hobbies outside of medicine. Outside of my wife and family, my grounding force throughout the year was splurging and joining a group fitness gym. Given our location in rural central Texas, away from our extended families, this gave me an outlet and support network outside of the hospital. At times, this meant waking up at 4 am to feed the baby before a 5 am workout and on the wards by 6:30 am, but this craziness always helped me have a moment of clarity before an otherwise hectic day.

With my parting words of advice, I recommend 2 key purchases to maintain some semblance of nutrition in the midst of pizza and fried foods that will be inevitably given during noon conference:

• Insta-Pot/Slow Cooker: one pot can prep several days of food and many recipes can be found online. Find a favorite food blog for intern-proof, minimal-hassle, high-nutrition recipes.
• Quality Blender: with an unpredictable schedule, a smoothie in the morning or evening may be your only chance to cram in an entire day’s worth of fruits and vegetables. Pick your favorite flavors, and this guide from Precision Nutrition can be a helpful template.

Have a great year everyone! Remember all of the hard work and preparation that got you to this point. Take on the year with confidence and enjoy the journey.

Please be on the lookout for more PGY1 and resident newsletter updates throughout the year. We look forward to your future successes!

A New Step in Your Journey: Advice for PGY1s From Our Collective Experiences

Maaheen M. Ahmed, DO
PGY2, Baylor College of Medicine, H. Ben Taub Department of Physical Medicine and Rehabilitation 

Denesh Ratnasingam, MD
PGY2, Detroit Medical Center/Wayne State University, Rehabilitation Institute of Michigan

 Well, you made it. You actually did it. After years of giving everything you had, you’ve graduated medical school and are officially a physician. Beyond that, you are now a physiatrist. We don’t know about you, but on July 1 of intern year, we were full of mixed emotions - we couldn’t believe we were wearing our long white coats…every time we took a step something swept behind our calves, it was exhilarating! We had initials after our last names on our badges, and yet both terms – physician and physiatrist – seemed so distant to us.  Despite the expected “imposter syndrome”, we felt lucky, we were surrounded by a group of PGY-1’s in the same shoes us.  We were all starting on a fresh journey together. The transition from medical school to residency can be challenging; here are some things we wanted to pass along from our experience so far.

Transition from Medical School to PGY-1

Whether it is a Preliminary Internal Medicine, Surgery, or Transitional Year, you are taking the next step in your journey. You are no longer the med student with pockets full of miscellaneous items in hopes you’ll be of some help during rounds or surplus of notes scribbled or typed out in case that certain nugget becomes important. You are now an intern. 

• Time Management
  • Take the first few days of each of your rotations to figure out how much time you need to prepare for rounds, become familiar with your follow ups, prepare your discharges, and create checklists (physical or mental) for completing admissions. If you find you are staying into the evening to finish notes or finding yourself looking up patients at home before coming to work, don’t be afraid to reach out to your upper year residents. Ask them for strategies they used on their rotations; it is important to keep work at work and to be present at home when you’re there.
  • We carried around our surface pros/laptops during rounds on most of our rotations to place orders as we were rounding or to take notes on things to follow up on. This was a huge-time saver when it came time to write notes and/or call consult teams.
  • When, it’s lunch time – it’s lunch time. Don’t forget to take a break, eat, etc. Initially, we would try to finish notes, orders, or prep an admit and put off eating until afterward; however, we quickly realized that if we just took 10-15 minutes to eat and take a mental break, we could complete those tasks much more efficiently and effectively than if we had just hauled though the lunch time while our stomachs panged from hunger. Taking a break also meant having time to bond with co-residents. We were all going through the same thing and it was a good way to decompress with people who understand what are going through firsthand.

• Comfort with Your Pager/Messaging System
  • Yep, it can either be a useful tool or a source of loathing… we found our grooves in the way we would respond to pages in a time-efficient manner; if it was more than a call back number, it was really helpful to open a chart, review the information needed, and to be on the same page. Realize that both you and the person you’re replying to want a quick answer so be kind and direct with your response. If something needs a long explanation, say that you will come by the patient’s room or nurses’ station. Our intern year, we used both a pager and a messaging texting app. The messaging app was useful when we were in didactics or in patient’s room during rounds, we could use the app to text a response or reply that once we were out of “(insert location here)” we would call them, or address the issue at hand.

• Become Comfortable with Your EMR
  • We were lucky to be at a Preliminary Internal Medicine program where we had two different EMR’s (Epic and PowerChart). It took us a few days at the start of each rotation to remember where to look up certain things, but we created macros, smart phrases, and links to favorite our orders and created order sets that streamlined our time on the EMR. Working smarter is the key to efficiency.

• Stay Balanced
  • Whether you are an introvert or an extrovert, take time for yourself outside of work.
  • If you have a family you care for outside of work, make sure you are present and make an effort be keep work and home life separate.
  • Don’t let go of your hobbies.
    • “I loved running long distance and one of things that really kept me sane intern year was prepping for and running a marathon. Beyond that, spending time with my father and building memories when I returned from the hospital and post-call days helped to keep me balanced.” - Denesh
    • “I stayed sane by keeping up with exercise and joining a spin class. I also have done a lot of work with animal rescue, staying involved with a local non-profit spay and neuter clinic really helped me stay grounded and helped me maintain friendships outside of medicine.” - Maaheen
  • Befriend your fellow interns, go out to eat, explore the city! You’ll find that these are the people who know what you are going through firsthand, people that you can talk it out with and laugh about your shared experiences with. Some days are better than others and you need to surround yourself with people who understand and empathize with what you are going through; these people can be the Christina Yang to your Meredith Gray… they can be your “person,” many times your fellow interns will become your closest friends, people that will always have your back on this exciting journey.

• Learn Along the Way
  • Residency is different from med school – where every rotation had its own high yield review book and Qbank.  Most days you are going to be learning management of patients along the way. UpToDate was our best friend, a good resource for looking up guidelines and supplemental resources to help defend the reasoning behind your management decisions. Most of the time, attendings will agree with what you want to do if you can explain the rationale behind why you came to that decision. Be sure to know your limitations; when you have a question, ask a consultant, your upper year, or your attending. Don’t be overconfident and think you can manage something if you don’t feel comfortable doing it. Chances are, an upper year has been in your shoes and can tell you what they did or give you advice on what options you may have.
  • Our Preliminary Program provided us with the opportunity to do a QI project; as tedious as it was as an intern to be part of this, it was a really beneficial learning opportunity to learn along the way, the steps necessary to prepare, submit for IRB approval, conduct the study, review data, and present a poster. Whether you are interested in research or not, you will likely need to do at least one research project during your residency and taking the opportunity to learn how to do it is incredibly valuable.
  • Learn to teach; you are now in the position where medical students are looking to learn from your medical expertise – whether it’s when you discuss a topic, walk the students through how to do an exam or procedure, or take time to answer their questions after rounds. Remember that you too were once in their shoes. Be the kind of the resident you aspired to be and wanted to have when you were a medical student.

• Experience Death and Morbidity
  • It’s going to be really difficult and a challenging pill to swallow, but chances are you will have a patient with serious complications or one that pass away on one of your rotations. First and most importantly, you must take time to process what has happened and reach out to your other residents and attendings if you need to. If you are continuing to struggle with the situation, reach out to the wellness team your residency provides and utilize the resources available.
  • Become comfortable in those situations. On an ICU night shift as an intern, we had a code blue called overhead and as we walked to the room, our attending calmly told us, “If I were to run to the room, I would be out of breath, have to raise my voice, and would look stressed/uncomfortable. If you are leading the situation – code or rapid response – be calm, speak clearly and at a normal volume, assess the situation, and the code will run much more smoothly and effectively. By the time you arrive, BLS or early ACLS should have been started for you to state you are running the code, assign roles, and drive the situation. Don’t be afraid to give feedback on those bagging, doing chest compressions, getting IV access, documenting, or getting meds. Providing feedback during a code helps everyone in the team. If you steer the ship confidently, everything will go smoothly.” It was some of the best advice we could have received. Of course, there is always room to improve when running a code or dealing with a rapid response, but with each rapid or code experience, you will gain insight on what works and what doesn’t.

• Seek Out PM&R in Your Rotations
  • We would find the PM&R in each rotation we did as a PGY-1. Whether it was in the ICU pushing early bed mobility and ambulation, on the internal medicine wards with debility, or on elective rotations like Rheumatology or Palliative Care. We did a Wound Care elective working with the nurses to identify, stage, dress, and treat different types of ulcers and wounds. Neuroradiology allowed us to feel confident reading CT and MRI images of the brain and spine. A PICC team elective provided us with the time and place to practice placing lines which became a valuable skill in a stand-alone rehab facility. If your program gives you the chance to do a PM&R elective, do it. Intern Year can be long and trying at times and having an elective to remind you what you love doing and why you are doing what you’re doing really helps.

• Take Step 3
  • Some of us took COMLEX/USMLE before starting PGY-1 in the break between med school graduation and intern year, some of us took it a few months into intern year, and others took it in the Spring of PGY-1. Regardless when you take it, we would recommend completing the respective question banks and practice tests. Review your biostatistics and brush up and any weak areas you knew you had on Step 2 (Peds, Surgery, OB/GYN, OMM) because you likely won’t be exposed to those patient populations during intern year as much, unless you choose a transitional year.
  • Everyone prepares in their own way but when it comes to balancing the preparation for boards and taking care of patients during the day, we found doing a few questions before we had to go into work and reviewing topics on our days off/post call after we took a nap helped us feel like we were steadily preparing for the exam rather than cramming everything in the weeks leading up to the exam.

Transitioning to PGY-2 and PM&R Residency

• “We’re Not in Kansas Anymore”
  • A Rehabilitation Hospital is very different from the Acute Hospital. It’s important in those first few weeks to get accustomed to what is available, what is feasible or not to manage – basically just how things work. Build a rapport with your nurses, PT, OT, SLP, Neuropsych, P&O, Case manager/Social Worker, as well as with patients’ caregivers/families. Rehabilitation has a multidisciplinary team approach, and everyone has a role to play in the patient care.

• Reviewing Your Anatomy, MSK, and Neurology
  • There is an attending who frequently states, “We are not just rehab docs – we are also physical medicine docs.” For most of us, it had been a while since we had sat down and reviewed anatomy. Sure, we could do a good neuro exam, but we knew that we needed to brush up on musculoskeletal anatomy/orthopedic testing and neurology. We made sure to review how to perform an ASIA exam and looked up the 2019 updates AIS classification and Zone of Partial Preservation. Take the time early on to go through an ASIA exam/Orthopedic exam with an upper year/attending if you feel uncomfortable.

• Retain Your Medicine/Surgical Foundation
  • You have spent a PGY-1 year building a strong foundation on top of your medical school knowledge. Keep that knowledge present during rounds and keep learning from consultants on best practice management of our patients.
  • You are usually the one in charge for falls, rapids, and codes on primary rehab patients; maintain your knowledge and be able to confidently manage those situations.
  • Depending on your attending preference and rotation, we sometimes manage the medicine as well as the rehabilitation. If you are comfortable working up hyponatremia in a patient with TBI, do it. Again, know your limitations as you always have upper year residents, attendings, and consultants to reach out to for advice.
  • It may take some time to transition but learn to manage your time and focus on the rehabilitation aspects, while allowing a consultant to help manage the medical comorbidities of your patients if you are feeling overwhelmed.

• Read a Little on Each Rotation
  • Now is the time to do what you love; I would often read up on topics of each patient and focus on the rehab management of it. Like the PGY-1 experience, you will be learning management along the way but by taking the initiative to read a bit, you will start to build a strong PM&R foundation.

• Carpe Diem
  •  If you want to do a joint injection, botulinum toxin injection, interrogate and fill a baclofen pump, complete an ASIA, use an ultrasound, perform an EMG, work with P&O on fitting a prosthesis or orthosis, then do it. Now is the time to learn and be supervised on technique and learn the reason behind doing something. If you have an interest, let your attending and program coordinator and director know to create elective time or opportunities for you.

PGY1 Pointers

David K. Jacobs, MD
PGY4, Schwab Rehabilitation Hospital and Care Network/University of Chicago

What I wish I knew during intern year:

1. There will be times when you are calling consults and you feel like you barely know the patient. While calling the consult, know the HPI, and have the patient’s medical record in front of you. It’s okay to say, “I will get back to you with that piece of information” as this is better than having the consultant on hold for 5 minutes while you hunt for a certain piece of information.
2. A lot of PGY1 internal medicine is a balancing act (i.e., in a patient with CHF and CKD diuresing the patient may cause an AKI. Consult the specialists available, cardiology and nephrology, to get their opinion and have them work together with the primary team to come up with a plan A, B, and C.
3. Uptodate.com is your friend. At first, you will take lots of time searching for the answer to your question, but halfway through PGY1 you will get much quicker finding what you want to know.

PGY1 to PGY2 transition:

1. You will be the provider who knows the most about your patients, so perform a thorough H&P. Be sure to get a detailed social history with regard to the patient’s prior baseline functional status, who the patient lives with and in what type of building, how many stairs they have at home, and what assistive devices or durable medical equipment they have at home. This will help tremendously with discharge planning.
2. Read about your patient’s medical conditions at night; this truly will make it stick in your head. Read for a textbook and search pubmed.gov.
3. Ask the physical and occupational therapist what modalities they are using for the patient and to explain what deficits they are working on with the patient in therapy.
4. Even though its early, ask the PGY3s and 4s what their fellowship/job plans are for after graduation. If you think you will want to participate in research, begin this process early. Ask the other residents what attendings they worked with in regard to research projects and see if you can collaborate. Create a list of conferences you would like to attend, the AAPM&R Annual Assembly for example, and keep track of the deadlines for abstracts/posters submissions. These deadlines will approach quickly. Consider creating your own IRB-approved research project and seek out the IRB coordinator at your institution for assistance with submitting paperwork.

Knowing Your New Role and Being Proud of It

Gerard J. D’Onofrio, MD
PGY2, New York Presbyterian Hospital (Columbia and Cornell) PM&R Program

You’ve spent the last year learning how to be a doctor and how to treat sick patients. Those are invaluable skills that you will continue to build on. Now, you are making the transition to being a physiatrist and ultimately realizing a lifelong goal. Your first day on inpatient, first encounter as an outpatient, first consult, etc. will all feel different because patients desire a skill set from you that you do not yet have. Similar to your first six months as an intern, you will need to be comfortable being uncomfortable. Below are some helpful tips I picked up along the way:

Speak Up

You are now no longer a medicine resident, although you may still feel like one (except for the cool reflex hammer). One of the best skills you’ve honed over the past few years is how to ask an intelligent consult question and do your due diligence prior to picking up the phone. In the event you are unsure of how to handle an issue or feel that your current setting is ill-equipped to handle it properly, pick up the phone and ask for help. I struggled with this because I was so used to the feeling of complete ownership on a medical team with available resources such as a respiratory therapist, STAT phlebotomist, and IV medications. Enlist the help of consulting services, and if they are unavailable, make the decision that keeps the patient safe. A day of therapy is a great thing to shoot for, but patient safety is the top priority.

Think Like a Physiatrist

Ah, one of the hardest parts of the transition! Approach problems not with the knee-jerk reflex required in the ICU, but with a contemplative approach that minimizes overmedicating patients and optimizes their function. There is a nuanced medication management on inpatient rehabilitation units that balances participation in therapy with what medications would be suitable as they transition home. Remember, our goal is to get patients to their highest function in the community! For instance, a hemiplegic patient, even with great family support, will have difficulty injecting insulin coverage for hyperglycemia. Therefore, start transitioning to orals as soon as p.o. intake is sufficient. Similarly, when you consult on a patient, consider tapering pain medications to the appropriate etiology. If the pain is neuropathic, there are diminishing returns to escalating opioids instead of up-titrating gabapentin.

Be Proud

Our specialty is one that provides great value to patients and our healthcare system. Educate other services about what we can offer, and you will notice just how much they appreciate your input. Stay true to the fundamentals, learn from those around you, and utilize the resources available to you such as AAPM&R. You’ve earned your spot as a physiatrist and our specialty is incredibly collaborative. Good luck, and see you at the next conference!

Making an Efficient and Effective Transition

David M. Robinson, MD
PGY3, Spaulding Rehabilitation Hospital
Harvard Medical School PM&R Program

Medical school graduation has come and gone, and in the process you’ve gained two coveted letters after your name. One day you’re tailing behind a resident trying any way you can to provide assistance, and the next you’re a doctor fearing the outcomes of each decision you make. Will giving this patient a dose of Seroquel prolong their QTc, send them into an arrythmia and then inevitably a cardiac arrest? The fear that decisions will now all be on you looms large, but it shouldn’t. The oversight will still exist, questions will be welcomed and everyone on your team wants to see you succeed. Nobody expects you to come with the medical knowledge of a third-year resident on day one. My advice is to hone your time-management skills and maintain a view of the end goal.

Learn the EHR and how to maximize using the glorious smart phrase. Don’t put off contacting consultants and radiology—nothing is worse than staying an hour late to hear back on what lab tests you should order for tomorrow. Start honing your hospital efficiency a couple months into the year, after you’ve mastered the daily workflow. AKA: when there is any hospital down-time, do work you would do at home. PGY-2 year is fantastic. Many days on inpatient, you’ll spend the afternoon waiting on and slowly prepping incoming admissions. However, if fellowship is in your future, you may find yourself with multiple non-hospital time commitments: research, committees and volunteer activities. Learning to make the most out of working hours will allow you to integrate many of these activities into your day next year, without making you feel as though you have no time for yourself.

During those long hours on inpatient medicine floors, interest may fade if the condition you’re treating is one you know you’ll rarely see in physiatry. Take the time to start working on your physiatric history skills and knowledge base. That musculoskeletal problem may not be an urgent hospital issue, but it’s there to be diagnosed and provide you a case to think back on down the road. PM&R Knowledge NOW^® is a great resource to read up about your patients’ physiatric issues and give you a jump start on PGY-2. You might as well learn a thing or two PM&R-related to remind you there are more fun things to treat than COPD and CHF exacerbations.

The year will fly by, and you’ll learn plenty of useful stuff for when friends or family call with medical questions. When the grind is getting to you, just remember that it’ll get a ton better in a short while. Those poor IM residents have two more years of it.

Choose Your Adventure: Intern Year Edition

Lindsey Migliore, DO 
PGY3, MedStar GUH National Rehabilitation Hospital

This is not what I signed up for.

The shrill screech of the night float beeper resonates through the small shared call room.

You ease yourself off of the top bunk, careful not to further disturb the sleep of the senior resident who lies below.

It’s 3:30 am, and you have been asleep for a scarce hour, long enough to have been inside REM and still confused by the fleeting remnants of a panicked call night dream, and short enough to leave you more tired than when your head hit the pillow.

Once out of earshot, you return the page while logging into the electronic medical records. Your foggy mind requires 4 separate attempts to get your password correct (which ex-girlfriend did you change it to this time?).

Mrs. Smith is hypertensive to 185/110 and is not due for any blood pressure medication.

Like the choose-your-own-adventure novels popular at elementary school book fairs in the 1990s, your choice in this moment can have a profound impact on your story.   

Which of the following doors do you choose?

Door number 1: Give the 5mg Amlodipine scheduled for 6 am now.

The laziest of options, it allows you to put in a simple communication order and attempt to return to sleep before the glare of the computer screen further throws off your circadian rhythm and depletes your scant reserve of melatonin irreparably.

You glance at the vitals trend over the past week and quickly determine the primary team has been slacking. This woman’s antihypertensive management is in need of some TLC.

Door number 2: Shoot some IV Labetalol into her peripheral line.

Knock out that acute hypertension, and get the nurses off your back until she gets her morning medication. By then, you’ll be long gone, to the comfort of your own bed and some artificial melatonin induced ZZZs.

Door number 3: Increase the AM Amlodipine, and add a STAT dose of Lisinopril.

If you remember one thing from the diagrams of the loops of Henle and dark haze of boredom that were medical school nephrology lectures, it was to increase current anti-hypertensives prior to adding another agent.

The melatonin is really beginning to fade now, and your mind gains a level of clarity only owls should have at 4 am. Amlodipine will not cause any noticeable change to the blood pressure for at least a day.

You dive deeper into her chart and realize that, due to the previous sepsis-induced AKI, this diabetic’s ACE-inhibitor was held by the ICU team. Now that she has been transferred to the medicine floors, and her creatinine has returned to baseline, time to protect those glomeruli!

With career ambitions set upon outpatient physiatric practice and a possible sports medicine fellowship, the ins and outs of blood pressure management may not seem sexy.

That is what the primary care doctor is for, am I right?

You could choose door number 1 or door number 2, and push the responsibility and decision making off to another sleep-deprived intern.

You could glide through your intern year, leaving the medical decisions up to the budding nephrologists and cardiologists who sat at rapt attention while soaking up every detail about sodium potassium channels while you played Candy Crush in the half-empty lecture hall. At least you bothered to show up to class.

Or you could try door number 3.

Behind every door is the eventual end of intern year, and the start of what you actually signed up for: “actual residency.”

Behind every door is a PGY2, most of whom will be responsible for call shifts at an inpatient rehabilitation hospital. Most will be alone, truly alone in the hospital for the first time.

How will you handle that?

How will you respond to the late-night calls for hypertension, hyperglycemia or uncontrolled pain when the patient does not have a peripheral line in and there is no senior resident to make the important decisions for you. 

As physiatrists, we integrate multiple specialties of medicine together to not simply add years to a patient’s life, but rather to add life to their years. We treat patients, not diagnoses.

It is the lessons you learn in intern year, on the nights when your triceps ache from performing CPR for the third time and you have not gotten non-supplement induced rest in weeks that you will draw upon when it is your turn to make the decisions, when it is your team to be the code leader. 

Which door do you choose?

PGY1 and Marriage

Esther D. Yoon, MD
PGY3, Temple University Hospital/Moss Rehabilitation PM&R Program

“I now pronounce you husband and wife.” That happened 2 weeks after I graduated medical school and 2 weeks before I started my intern year in internal medicine. If navigating the new-found responsibilities of being a “doctor” was not challenging enough, adding a new marriage into the mix definitely made it a year of significant personal growth. Both are very exciting events; however, it can feel overwhelming if happening all at once.

To be honest, I had a difficult time prioritizing my life at first. My goal for intern year was to absorb as much knowledge about medicine as possible, so that I can better manage my patients when I start my PM&R residency the following year. This meant that through the long hours of work, difficult patients, and difficult cases, I needed to dedicate my focus and energy into learning and improving my craft as a physician.

However, being in a new marriage, it was equally important for me to invest my time and energy in my relationship and in learning to be a new family unit. I realized that my choices did not only affect me anymore and I could no longer be selfish with my time if I wanted this marriage to be healthy and succeed. As simple and obvious as that sounds, it was a challenging shift in mentality because I was so used to prioritizing my studies and my career for many years. For example, instead of just resting and having “me” time after a long day or week at work, I now needed to make sure I had enough energy saved up to spend quality time with my husband in going out and doing different activities together.

I learned that communication is key. Reassure your partner that he or she is very important to you and that work is not prioritized above them – it just currently takes up more time and energy. Give your partner a heads up on when your very difficult rotations (i.e., ICU, CICU, heart failure, etc.) take place so that they are also mentally prepared for your longer hours or for dealing with a more tired and maybe crankier you. I am very blessed with a husband that tries to be understanding of my quest in a career he knows very little about. It takes effort on both sides of the relationship. Intern year is definitely not easy, but it also gets better. If you can work through a new marriage in that environment, your relationship will have a stronger foundation because of it.

Bridging the Gap Between PGY1 and PGY2 Year

Jeremy Roberts, MD
PGY3, NewYork-Presbyterian Department of Rehabilitation & Regenerative Medicine

July 1.  Where it all begins…again.

Some tips to help ensure a successful transition from PGY-1 to PGY-2 year.  This was made with the caveat that every program has different requirements and different senior residents to give even more specific advice.

CLINICAL

BE CONFIDENT IN YOUR KNOWLEDGE BASE

After a full year of Medicine/Surgery, you should have a vast knowledge base and be able to triage nearly every encounter.  While covering your floor, either during an inpatient rotation, or on call, you will deal with many scenarios you have already seen during PGY-1 year.  They will range from redosing blood pressure medications, assessing altered mental status, to calling a rapid response for a patient with organ failure.  Have confidence that you have seen all these things before, you can delineate the emergent from the routine, and you can start basic management or rally other troops necessary for ideal patient care (including transfer to acute hospital). 

SHORE UP YOUR NEURO EXAM

As a starting point, you should have a thorough neuro exam drilled down. During your residency you will quickly accumulate clinical skills for a comprehensive physiatry exam along with other specialty tests to diagnose specific pathologies. 

FOCUS ON EXAMS & PLANS. DON’T SWEAT THE PROCEDURES

On day one, it is more important to learn why you are sending a patient to the pain clinic for a spinal injection along with the indications for such than to be excellent at transforaminal injections.  By the end of intern year, you should be able to present a one-liner and plan for a patient. In the same way, for a rehab patient, you should be focusing on the assessment & plan. You will obtain & practice procedural skills along the way. 

LOGISTICS

GET THE LOGISTICAL THINGS DONE EARLY

During orientation or your first couple weeks, finish up CITI training for research, Human Resources & training modules, paperwork for your department, etc. As you get more involved in clinical work, research, volunteering, coverage, these above logistical items, while important and educational, will add to your workload. Some are unavoidable, but the 20 hours spent during a lighter period are better than what will accumulate to dozens more during your residency. 

PURSUE YOUR CURIOSITIES - NOT EVERY PROJECT NEEDS TO BE ACADEMIC

Since intern year was one year, most of us didn't have the time to focus on longitudinal projects.  This year, you will have more time to chase these.  Don't be afraid to ask around if attendings have interesting cases to write up, if fellows can teach you ultrasound, if investigators are working on a research project, etc.  Please note that it may take multiple asks to different people before an opportunity comes along.  Even if you don't get a yes on every single request, your enthusiasm will be noted, and you will usually will be directed to someone who can help.  

Additionally, you will run into a host of colleagues who have vastly different interests, not all of which are academic in nature.  Try and find a way to incorporate these interests into your residency.

IF YOU DO PURSUE AN OPPORTUNITY, MAKE SURE YOU COMMIT

It is better to take one project through to completion than to have five incomplete projects that are not touched during your residency.  You do not need to start an IRB Protocol or Quality Improvement Project on July 1.  You should take a couple of weeks or months to explore the field, learn your attendings’ interests, and think about your own path.  That way, if someone is willing to collaborate with you on a community service project, book chapter, research, etc., you can make that commitment.

OVERALL

To summarize, on July 1, you will NOT be expected to:

- Start an IRB protocol, a Quality Improvement project, spend extra time in the fluoroscopy suite, cover a football game, and finish your board questions. 

You will be expected to:

- Have completed Intern Year

- Be prepared for an amazing three years ahead of you.