disenchanted pgy-2

[AndyDufrane]

so I know this maybe too early in the year, but I am on a consult month(alot of trauma, CVAs, B*ll**** c/s too) and I just feel like what is our field about, I mean, last week i had trauma surgeon bullying me to take a TBI pnt who was only tolerating 30 mins of therapy, and made a huge fuss, and it goes on and on, I feel like other services view us as some kind of joke, I mean, I have gone to do a consult and the social worker is telling me this person is going to inpatient rehab and I am like "then what the hell is your service consulting us for", it so offensive I feel like, I have never seen anthing like this, I was on a couple of consult months during my prelim year and no hem-onc or cards attending would put up with the crap I have seen, getting pushed around by of all people surgeons,ugh..I dunno, I am beginning to wonder , I just hope it get better although I hate having thei "must survive mentality" cause that is what I had during my internship years, I hate to go through another year like that, sorry, had to vent

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[PMR 4 MSK]

Surgeon = Type A personality, PM&R = Type B.
Surgeon = Alpha Dog, PM&R = Not so much.

I saw similar during residency (although we didn't do consults until PGY3). PM&R often looked at as a dumping ground +/- easy discharge. Bullies exist everywhere, and some surgeons have mastered the art of bullying ever since the 1st grade. Let your attending take them on when you feel like you're being pressed to do the opposite of what you believe to be right. Maybe your attendings are in need of vertebral infusions and have let the service act as a dumping ground for too long, in which case you won't change anything long-term.

When I was on SCI, we had a pt on the neurosurg side of the SCI floor who our attending did not think was stable enough to come over to the rehab floor. The head of neurosurg came into the nurses station a little while later and said "Ahem! Mr. Smith will be transferring to the rehab service today. Thank you." And he walked out. I let the attending know, so he just wrote to transfer from neurosurg service to rehab, and we left him on their side until he stabilized.

There are docs who feel PM&R is "a joke" I've heard 'em say it with my own ears. I tell 'em it's a really funny joke, one that has me laughing on my way to the bank at 4 pm on my way home each day, while they stay for the next 15 hours of in-house call.

What you should concentrate on at this point is learning who is appropriate for inpt rehab and who is not. Decide in your mind who is and who is not, and let the politics play itself out seperately. Also learn how to stand up for yourself against the medical bullies, without getting drawn into a contest of who can beat their chest louder.

From some persectives, even to a lot of us in PM&R, general inpt rehab is little more than babysitting patients until they can go home. The therapists and nurses do most of the leg work, we just write the orders and/or authorize stuff. Insurance carriers recognize this - when I was a resident, 6-8 weeks on inpt rehab s/p CVA was the norm. What's it now, 2 weeks? 3 tops? Your notes start looking the same most every day, and you're not writing much in the way of new orders. You mainly look for things you can try to prevent - DVT's, decubs, contractures, etc. But you dilligently write your daily notes so the dept can get paid for what you do.

Fact is, the trauma surgeon you talked about doesn't want to babysit the TBI anymore, and he probably doesn't know what to do with him anymore - that's not his training or desire. He's pissed because it's one more pt he has to round on each day, and he figures he's gleamed all he is going to from this pt, and his "skills" would be better utilized on a more acute pt.

Waaahhh! Let 'em bitch. Let 'em cry. Let 'em stomp their feet and posture themselves. Most of the time it's the Alpha Dog showing off for the residents or nurses. "Sorry, he does not meet the criteria yet to be admitted to inpt rehab." Walk away.

Fact is, anyone can be trained to take care of inpt rehab pts, but most docs don't want to, so PM&R fills the void. I've seen plenty of small hospitals where an internist admits most of the rehab pts.

 

[Disciple]

so I know this maybe too early in the year, but I am on a consult month(alot of trauma, CVAs, B*ll**** c/s too) and I just feel like what is our field about, I mean, last week i had trauma surgeon bullying me to take a TBI pnt who was only tolerating 30 mins of therapy, and made a huge fuss, and it goes on and on, I feel like other services view us as some kind of joke, I mean, I have gone to do a consult and the social worker is telling me this person is going to inpatient rehab and I am like "then what the hell is your service consulting us for", it so offensive I feel like, I have never seen anthing like this, I was on a couple of consult months during my prelim year and no hem-onc or cards attending would put up with the crap I have seen, getting pushed around by of all people surgeons,ugh..I dunno, I am beginning to wonder , I just hope it get better although I hate having thei "must survive mentality" cause that is what I had during my internship years, I hate to go through another year like that, sorry, had to vent

My condolences.


Many of us can relate, because alot of what you said it true.


During my PGY-2 year, I felt exactly the way you do now, but I enjoyed my 3rd and 4th year, and hopefully you will to.


No guarantees though.

 

[lobelsteve]

My condolences.


Many of us can relate, because alot of what you said it true.


During my PGY-2 year, I felt exactly the way you do now, but I enjoyed my 3rd and 4th year, and hopefully you will to.


No guarantees though.

Ditto, except I did not enjoy PGY3 or 4. Fellowship was great though.
Think about it like this- PMR consult service is a fancy way of saving the hospital money on ICU beds. THey can get from ICU to floor to Rehab and that saves the hospital money. You make statements like, bowel/bladder program, DVT proph, GI bleed proph, enough with the Haldol guys. Cont PT/OT/ST. None of it gets done or matters until they come to Rehab with a small ulcer, a Temp of 101.5, and a DVT. THen you consult all of those other services back to help out. Needs GI to see him for the bleed, vasc for the Greenfield, ET nursing for the G3 decubitus, etc.

It's pushing paper to make money. If you would just stop caring about the patient's best interest- you can do well on a consult service.


Disclaimer: I had a bad time in residency and my personal bias (while true) is just my own observations.

 

[Dr. Ice]

so I know this maybe too early in the year, but I am on a consult month(alot of trauma, CVAs, B*ll**** c/s too) and I just feel like what is our field about, I mean, last week i had trauma surgeon bullying me to take a TBI pnt who was only tolerating 30 mins of therapy, and made a huge fuss, and it goes on and on, I feel like other services view us as some kind of joke, I mean, I have gone to do a consult and the social worker is telling me this person is going to inpatient rehab and I am like "then what the hell is your service consulting us for", it so offensive I feel like, I have never seen anthing like this, I was on a couple of consult months during my prelim year and no hem-onc or cards attending would put up with the crap I have seen, getting pushed around by of all people surgeons,ugh..I dunno, I am beginning to wonder , I just hope it get better although I hate having thei "must survive mentality" cause that is what I had during my internship years, I hate to go through another year like that, sorry, had to vent

The residency training in PM&R is, in my opinion a complete waste of time. I had the same thoughts as you as I was going through my PGY2 year, and then it got worse when I was in my PGY3 year. PGY4 year was ok, but I was one of those "chiefs" and had to do a lot of administrative bs. Consult service was crap, inpatient even worse, and I found that I was really just putting people in PT during outpatient....I felt like you could probably train a chimp to do what I was doing.

I feel like you will probably learn the most and appreciate what you do during your first year as an attending (perhaps even during fellowship). As an attending this year, I am making my own decisions, doing EMGs without supervision, and learning a lot about billing/coding. Its def a trial and error period, but I am learning more so far than I did during my entire residency.

Keep your head up...it will get better...at least a little. But if you feel like you really "wanna make a difference" then you should have probably gone into peds or OB/GYN....

 

[SSdoc33]

i couldnt agree more with what has been already said. inpatient PMR dominates the early part of residency and it is often, dare i say, "beneath" the better residents. this is not to say that good work cannot be done in inpatient PMR, but the scenario you describe is all to frequent, and simply a waste.

a word to the wise. get yourself out of the hospital if you can. at least see what its like on the outpatient side.

what happens a lot of the times is that the mediocre residents become mediocre attendings at the inpatient level. so, you are learning from mentors that take pride in thinking that they make a difference in whether the pt goes to inpatient rehab or a SNF or whatever. and that this decision is the most imprtant thing that happens to/for the patient. sometimes recs we can make (like with a new SCI on a unit that is not experienced with this) are important, but all too often, those recs are ignored and dealt with as an inpatient.

AAGGHH, i feel like you opened up a subject that i have tried so hard to repress. make it stop!!!!!

btw, i am very happy with the work i do now, even though i echo steve's sentiments about residency.

 

[lobelsteve]

3 cheers for the AAMPR.

In the Physiatrist newsrag I received yesterday, it lumped Pain with Neuromuscluar as a special interest in the desire to come up with 5 basic groups to simplify the divergence of the field. How about Pain/Spine/Sports into one group. Beats me.

 

[drusso]

3 cheers for the AAMPR.

In the Physiatrist newsrag I received yesterday, it lumped Pain with Neuromuscluar as a special interest in the desire to come up with 5 basic groups to simplify the divergence of the field. How about Pain/Spine/Sports into one group. Beats me.

I think that this is going to change....

 

[drusso]

so I know this maybe too early in the year, but I am on a consult month(alot of trauma, CVAs, B*ll**** c/s too) and I just feel like what is our field about, I mean, last week i had trauma surgeon bullying me to take a TBI pnt who was only tolerating 30 mins of therapy, and made a huge fuss, and it goes on and on, I feel like other services view us as some kind of joke, I mean, I have gone to do a consult and the social worker is telling me this person is going to inpatient rehab and I am like "then what the hell is your service consulting us for", it so offensive I feel like, I have never seen anthing like this, I was on a couple of consult months during my prelim year and no hem-onc or cards attending would put up with the crap I have seen, getting pushed around by of all people surgeons,ugh..I dunno, I am beginning to wonder , I just hope it get better although I hate having thei "must survive mentality" cause that is what I had during my internship years, I hate to go through another year like that, sorry, had to vent

Inpatient rehabilitation has....how shall we say...a marketing/image problem when it comes to recruiting residents into its industry. Moreover, the vast majority of general physiatry consults are useless. No one reads them. They just skim down to the bottom line: Yes, appropriate for rehab. No, not appropriate.

And you are right: The other services do think you're a joke. In fact, they probably think that you are, in the common parlance of the neighborhood kids these days...an "a**clown."

But, patients do benefit from rehabilitation and your efforts are not *totally* superfluous. And, the way inpatient rehab is practiced in academic centers is totally the opposite of private practice inpatient. So you should persevere.

Remember, right now you are nothing but cheap labor for a clinical department/hospital service line that is likely considered a "bottom feeder/loss leader" for your institution by the bean counters. You are the bottom of the bottom. You can't change that. Your institutional prestige as a physiatry resident is slightly below the hospital janitor---and at least he or she has "due process" protection for being fired---they can get rid of you at any moment!

Just get through it. Try to meet more people who work at your hospital. Learn to like Scotch.

 

[medicineman1]

why would anyone stay in a field he/she hated? Practice cannot BE THAT MUCH different than residency?! A fellowship though can certainly provide an opportunity for a different flavor-

 

[ShrikeMD]

The residency training in PM&R is, in my opinion a complete waste of time. I had the same thoughts as you as I was going through my PGY2 year, and then it got worse when I was in my PGY3 year. PGY4 year was ok, but I was one of those "chiefs" and had to do a lot of administrative bs. Consult service was crap, inpatient even worse, and I found that I was really just putting people in PT during outpatient....I felt like you could probably train a chimp to do what I was doing.

I feel like you will probably learn the most and appreciate what you do during your first year as an attending (perhaps even during fellowship). As an attending this year, I am making my own decisions, doing EMGs without supervision, and learning a lot about billing/coding. Its def a trial and error period, but I am learning more so far than I did during my entire residency.

Keep your head up...it will get better...at least a little. But if you feel like you really "wanna make a difference" then you should have probably gone into peds or OB/GYN....

PGY2 was very difficult for me too. Way too much inpt, no balance. (Kessler improved things during my years and afterward, but that PGY2 year only evokes unhappy professional memories..a lot of self-doubt, thoughts of changing careers.) We lose too many resident physiatrists because of Program Directors/Chairs/Programs that fail to provide reasonable balance in exposures during residency training. Indeed, going into my residency I wanted to become a MSK physiatrist! It was during the "dark days" of my early residency training that I had a fairly poor BI rotation, discovered that this (particular) field really needed help (as did the patients), and decided that I could probably make a bigger difference in the world being a BI Medicine physician than a MSK physician. I will never know if I was right, but I have not regretted taking the path of BI...it has treated me well.

Dr. Ice, there is no question that time could be better allocated and spent in many PMR programs. Mine was not a complete waste of time, but there was too much time wasted. Fortunately, I was too young and inexperienced to know it for certain at the time. Moreover, there is no question that the learning curve increases as you move into fellowship/initial years as an attending.

I can't speak to your situation, but my experience prompts me to disagree with the assertion about physiatrists not "really making a difference". No disrespect intended to my colleagues in peds or OB, but I have faced critical clinical decisions (too) many times. It isn't ICU medicine, but it is real medicine, and we can and do make a difference.

 

[LTS6776]

I've noticed that quite a few residency programs are putting PGY-2s on consult services, which I'm not really sure is appropriate, especially so early in residency. It is much better to do consults as a PGY-3, when you actually know some rehab. I never really minded my consult rotations as a resident, although occasionally got into spats with surgical interns who couldn't identify their patients from a line-up about appropriateness for rehab. It helps when you have strong attending back-up; not sure that this is the case for you given your post. I think it varies quite a bit by institution, but if you demonstrate your value in a patient's care, they will recognize your value. It helps if you befriend the social workers and care managers too! I spend about 1/3 of my time now seeing hospital consults and actually very much enjoy the experience. You are very often the first person the newly disabled and their family meet who offers them some hope and talk to them about eventually going back home, to work, or whatever it is they like to do. If you spend the time to counsel patients in these situations, they will continue to ask for you, and the primary service will appreciate you more. Doing ortho consults still sort of suck though.

 

[ShrikeMD]

so I know this maybe too early in the year, but I am on a consult month(alot of trauma, CVAs, B*ll**** c/s too) and I just feel like what is our field about, I mean, last week i had trauma surgeon bullying me to take a TBI pnt who was only tolerating 30 mins of therapy, and made a huge fuss, and it goes on and on, I feel like other services view us as some kind of joke, I mean, I have gone to do a consult and the social worker is telling me this person is going to inpatient rehab and I am like "then what the hell is your service consulting us for", it so offensive I feel like, I have never seen anthing like this, I was on a couple of consult months during my prelim year and no hem-onc or cards attending would put up with the crap I have seen, getting pushed around by of all people surgeons,ugh..I dunno, I am beginning to wonder , I just hope it get better although I hate having thei "must survive mentality" cause that is what I had during my internship years, I hate to go through another year like that, sorry, had to vent

Consults can be challenging, no two ways about it. In many (dare I say MOST) places, your role is to "clean the beds"...move the patients, they don't care where, just out of here. Often, they also don't care what you have to say about managing the patient, what they want to know is when you will take the patient. As your administrators will tell you, if you don't take the patient, someone else will. Blustering neuro & trauma surgeons are common, and "always certain, seldom wrong."

Good news. Some of us DON'T take the BS that they are dishing out (well, at least not since becoming an attending), and we CAN decide which patients we will try to help. When I had residents, I told them that if you take everyone's garbage, don't be surprised if they think of you as a garbageman, and your unit as a dumping ground. (The administrators often have a cow when I say that, because they will take anyone who has funding, but YOU don't have to do that.) Sometimes I have less business than others who have no problems eating BS, but then again, sometimes the blustering neuro & trauma surgeons have a patient that they really want to do well, and then they call me. I am fortunate that there are enough neurosurgeons who actually care about what happens to their patients to keep my practice going.

 

[AndyDufrane]

thanks everyone, I do feel a little better that others also have had these thoughts that I am having and its not just me, its just that I feel like Dorthy at the end of The Wizard of Oz, while going through the hell of internal medicine internship year I yearned for the light at the end of tunnel in PMR, but now I feel like there is another light at the end of tunnel, the end of PMR residency, and I hate to feel that way, I mean, I really want to come out as a good clinician and I think it is a good choice, compared to crapy you have in internal medicine or surgery, thanks everybody

 

[Hemisphere]

another thing to understand is where that heat comes from the other services are giving you, and that is due to the increased pressure on those attendings to move the patients out, to decrease length of stay, this all comes from the bean counters, and the admin onto those service. So don't take it personally as those attendings are disagreeing with your assessment, they are just feeling the heat that they cannot keep their patients for too long.

one analagy i have found useful on consults is to think of yourself as a 'bouncer.' of a very elite rehab club. if the patients do not meet your criteria, do not have nice shoes, do not have a respectable hemoglobin, bounce them, LOL. You need to have a spine because people always want to get into elite clubs, people will do anything to get in, yell, kick, scream, act too nice, act too mean, make up ****, act like 'alpha dog.' Just let them do what they do, keep a straight face, then say sorry no beds, or we've decided not to take the patient because of x, we will re-assess later. Of course your attending has to be on board too or you will look like an ass if you reject somebody and they end up coming cos your attending took them that day.

As far as recommendations not being listened to, remember they are trying to get rid of the patient, not start new things. One thing you can do if you feel they are not doing something important, when they pressure you why you are not taking them, say you recommended such and such and you'd like that done before they come to rehab. it might be useful to have them check dopplers before you take those patient's with DVT's if there is high suspicion.

well, good luck!

 

[drusso]

another thing to understand is where that heat comes from the other services are giving you, and that is due to the increased pressure on those attendings to move the patients out, to decrease length of stay, this all comes from the bean counters, and the admin onto those service. So don't take it personally as those attendings are disagreeing with your assessment, they are just feeling the heat that they cannot keep their patients for too long.

one analagy i have found useful on consults is to think of yourself as a 'bouncer.' of a very elite rehab club. if the patients do not meet your criteria, do not have nice shoes, do not have a respectable hemoglobin, bounce them, LOL. You need to have a spine because people always want to get into elite clubs, people will do anything to get in, yell, kick, scream, act too nice, act too mean, make up ****, act like 'alpha dog.' Just let them do what they do, keep a straight face, then say sorry no beds, or we've decided not to take the patient because of x, we will re-assess later. Of course your attending has to be on board too or you will look like an ass if you reject somebody and they end up coming cos your attending took them that day.

As far as recommendations not being listened to, remember they are trying to get rid of the patient, not start new things. One thing you can do if you feel they are not doing something important, when they pressure you why you are not taking them, say you recommended such and such and you'd like that done before they come to rehab. it might be useful to have them check dopplers before you take those patient's with DVT's if there is high suspicion.

well, good luck!

This is great advice. I used to enjoy sparring with mid-levels/interns/DC planners from the surgical services.

"Medically Stable" does not equal "Ready for Rehab."

I remember a trauma patient they wanted to send to rehab who was still on pressors and receiving blood transfusions. I listed as a potential rehab goal, "Patient will be min. assist with hemodynamics."

Work on cultivating your sense of ironic detachment....

 

[lobelsteve]

This is great advice. I used to enjoy sparring with mid-levels/interns/DC planners from the surgical services.

"Medically Stable" does not equal "Ready for Rehab."

I remember a trauma patient they wanted to send to rehab who was still on pressors and receiving blood transfusions. I listed as a potential rehab goal, "Patient will be min. assist with hemodynamics."

Work on cultivating your sense of ironic detachment....

I believe DP once added , "Mod assist with flat iron in self-care"
And spent 1 hr of PT/OT getting the patient better hair.

 

[Xardas]

so I know this maybe too early in the year, but I am on a consult month(alot of trauma, CVAs, B*ll**** c/s too) and I just feel like what is our field about, I mean, last week i had trauma surgeon bullying me to take a TBI pnt who was only tolerating 30 mins of therapy, and made a huge fuss, and it goes on and on, I feel like other services view us as some kind of joke, I mean, I have gone to do a consult and the social worker is telling me this person is going to inpatient rehab and I am like "then what the hell is your service consulting us for", it so offensive I feel like, I have never seen anthing like this, I was on a couple of consult months during my prelim year and no hem-onc or cards attending would put up with the crap I have seen, getting pushed around by of all people surgeons,ugh..I dunno, I am beginning to wonder , I just hope it get better although I hate having thei "must survive mentality" cause that is what I had during my internship years, I hate to go through another year like that, sorry, had to vent

I enjoy watching you break out of Shawshank every time they show you on TNT/TBS

(sorry couldn't resist)

 

[dc2md]

Luckily in my residency, we have a GREAT variety of rotation starting from PGY-1 (we're categorical). I was able to do a couple months of interventional pain and some outpt msk work during my PGY1. It's great because we don't have a sh**ty 12 months in a row doing inpatient rehab. Outpt MSK and lots of peripheral and axial injection experience really breaks up the "harder" inpatient months.

And the hospital we do inpatient rehab at isn't much different from most. It's all about the benjamins!! If a patient has funding, we'll take em...even if it's VERY questional if they're gonna be able to participate for 3 hrs a day. But at least we don't take the ones that should be on acute. And I gotta admit, I've been surprised quite a few times with patients that I thought would be horrible rehab candidates (refusing to participate at first; way too much sedation/lethargy; no endurance; cognitively wasted) that actually ended up doing well.

Andy, hopefully you got into PM&R b/c you really liked some aspect of it. If u jumped on board the PMR train b/c you thought you'd like inpatient rehab, get off at the next stop. If you liked outpatient MSK or sports or interventional pain then hang in there.

 

[ampaphb]

I think that this is going to change....

I called and spoke to the folks in Chicago, and was told these are fixed in stone for the next year.

I was told David Bagnall was the person to speak with, in case anyone wants to bend his ear.

 

[ampaphb]

the terms "change" and "aapm&r" rarely occur in the same sentence

oh, an organization that encompassed sports, spine, pain, and msk? it was called PASSOR

 

[Disciple]

The AAPMR has been sending out e-mails asking for nominations for the inaugural leadership and committees for each of the 5 councils.

Let's make sure we get the right people on top. Or, volunteer yourself.

Whatever political inroads PASSOR has made into spine, Occ Med, and pain management over the past 15 years need to be continued.

 

[lobelsteve]

I nominate drusso and ampaphb.

It will be a matter of availability and desire to commit time to a cause where an old gaurd still wants do nothing know nothings for leadership.