Inpatient PM&R

[fozzy40]

I'm a 3rd year interested in PM&R. I've been reading about the role of the PM&R doc. What do they mean exactly when they say that PM&R docs coordinate care for long term rehab or managing medical problems of serious musculoskeletal disorders? Can someone elaborate on the details of what tasks a PM&R doc needs to complete after (lets say) a stroke pt?

Thank you for your time.

fozzy40

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[blokjok]

I'm a 3rd year interested in PM&R. I've been reading about the role of the PM&R doc. What do they mean exactly when they say that PM&R docs coordinate care for long term rehab or managing medical problems of serious musculoskeletal disorders? Can someone elaborate on the details of what tasks a PM&R doc needs to complete after (lets say) a stroke pt?

Thank you for your time.

fozzy40

Fozzy
PM&R docs serve the same tasks as a glorified physician assistant. They will pretend to direct the physical therapists and call every single possible consult when the patient gets sick.

 

[fozzy40]

Fozzy
PM&R docs serve the same tasks as a glorified physician assistant. They will pretend to direct the physical therapists and callled every single possible consult when the patient gets sick.

Can you give me some specifics on what a "glorified physican assistant" does?

 

[blokjok]

Can you give me some specifics on what a "glorified physican assistant" does?[/QUOTE
The same tasks as a PA

 

[DOctorJay]

take the above posts by blokjok with a grain of salt. he's most likely an anesthesiologist and is a needle jockey by trade who seems to be more interested in amassing material wealth than managing his patients' long term care (see the pain medicine forum and you'll quickly see what I mean).

anyway, if you're interested in PM&R check out the stickys in this forum for more information and also check out http://www.aapmr.org/condtreat/what.htm. www.physiatry.org is another good site to learn more about the field. PM&R is a great field that allows you to work with very acute injuries in the hospital (SCI, TBI, CVA) to elite athletes as a musculoskeletal medicine specialist and all areas in between, but you've probably already read about that.

To elaborate on the stroke pt, my experience is that the physiatrist manages all medical issues a pt may have while on the rehab unit, serves as the team leader at interdisciplinary meetings, and guides other treatments to occur (i.e. PT,OT,ST as well as discharge planning and will also oversee procurement of equipment needs such as specialized powered wheel chairs as an example). After D/C the pt may return as an out pt to the physiatrist possibly for botox injections to spastic muscles after a stroke so that they may continue to progress in out pt PT. O&P decisions may need to be made/ prescribed.

this isn't the whole story but at least a piece of what you would expect to encounter. perhaps some of the residents can elaborate more.

-J

 

[Nikiforos]

Inpatient PM&R is VERY heavy on the social work aspect of the hosptal stay. In that sense physiatrists are glorified social workers or discharge planners. A former attending admitted that physiatrists provide a considerable amount of custodial care.

Most practicing physiatrists are ill-equipped to practice acute care medicine. After their internship year most do not keep up with changes in acute care medicine. That is why they pan consult as extensively as they do.

 

[drusso]

I'm a 3rd year interested in PM&R. I've been reading about the role of the PM&R doc. What do they mean exactly when they say that PM&R docs coordinate care for long term rehab or managing medical problems of serious musculoskeletal disorders? Can someone elaborate on the details of what tasks a PM&R doc needs to complete after (lets say) a stroke pt?

Thank you for your time.

fozzy40

Physiatrists are responsible for medically managing patients undergoing inpatient rehabilitation. CMS guidelines require that patients be "medically stable" for admission to inpatient rehabilitation facilities. Often, however, patients may be come ill for a variety of reasons, or suffer secondary complications of their original injury, during their rehabilitation stay. It is up to the physiatrist to recognize, diagnose, and treat these problems. Here's a small sample of the unrecognized medical issues (missed by a variety of physicians including anesthesiologists) I've identified on the rehab unit. I seriously doubt that a PA would have done better:

1) A variety of strokes (cortical, subcortical, you name it)
2) MI's
3) PE's
4) DKA
5) AAA
6) Dissecting thoracic aneurysms s/p MVC
7) Baclofen toxcity/withdrawl
8) AIDP/CIDP
9) Myasthenia gravis (original admission diagnosis was "deconditioning"
10) Ischemic limbs

 

[fozzy40]

Thanks for everyones input. I don't mind doing alot of the administrative work that goes along with coordination. However, I am concerned that that is ALL of what would be doing in the inpatient setting. I have talked to another PGY-2 who said that they have alot of medical issues at their institution that they have to keep up their medical knowledge.

Would I be correct in saying that you do still have to be able to Dx and Tx conditions listed by drusso? Is PM&R (at least during residency) so rehabilitation intensive that you lose basic medical knowledge/skills?

Thanks again.

fozzy40

 

[blokjok]

Thanks for everyones input. I don't mind doing alot of the administrative work that goes along with coordination. However, I am concerned that that is ALL of what would be doing in the inpatient setting. I have talked to another PGY-2 who said that they have alot of medical issues at their institution that they have to keep up their medical knowledge.

Would I be correct in saying that you do still have to be able to Dx and Tx conditions listed by drusso? Is PM&R (at least during residency) so rehabilitation intensive that you lose basic medical knowledge/skills?

Thanks again.

fozzy40

Fozzy
You need to talk to people outside PM&R and ask them what they think about the medical knowledge of physiatrists.

 

[njdevil]

Fozzy
You need to talk to people outside PM&R and ask them what they think about the medical knowledge of physiatrists.

Well, the medical intensity of a inpatient job depends on what kind of acute care setting. There are acute units within a a hospital and then stand alone rehab units. The acute units within a hospital are designed to get a patient to rehab more quicky, when they are less stable. In this case, there will probably be multiple speciaties consulted on a complicated case.

Let's say for example a 70 yo male fell eight feet and had a T8 burst fracture. This results in a complete paraplegia. Well that is straight forward enough. Rehab issues are independence at a wheel chair level including, neurogenic bowel, bladder, skin issues, TLSO, , dvt prophylaxis, spasticity, being aware of heterotopic ossification & autonomic dysreflexia. A physiatrist can manage him, with a follow-up with the spine sx, 6 weeks post-op.

Now, take that patient and say that he requires neo gtt after his injury secondary to "spinal shock". With these pressors, he infarcts part of his colon and requires a colostomy. Then the pathology comes back positive for adenocarcinoma. Post operatively, he develops bilaterally empyema, and with his poor lung effort secondary to age, smoking and sci injury, he requires intubation. Despite anticoagulation and compression boots, he throws a clot into his lungs. With a hep gtt, his spine incision developes a hematoma, therefore it is d/cd and he gets an IVC filter placed. He has chest tubes placed x3. Then he develops infection in his original incision.

This is a complicated case: Requires trauma sx, neuro/spine sx, pulmonology, invasive radiology, hem-onc. Well, yes the medical knowlege in this situation would beyond the scope of physiatrist.

It also depends on the interest of the doc, some would rather consult IM, because they would rather focus on the rehab issues and see more pts or even followup outpt (inpt rehab require follow-up). Others, they focus on the medicine too (many are dual boarded). The issue these days is that the patients are forced to rehab faster (less stable) because of insurance.

By the way, for blokjok, many docs would prefer that rehab consult them, because it gives them more business. Not sure what you level of your training is but there are many perspectives to consider.

 

[blokjok]

Njdevil
Don't confuse Fozzy. In real life rehab docs don't even manage blood pressure medications.

 

[fozzy40]

Thank you for the input again. I really am interested in PM&R for the complex cases, continuity of care, MSK disease, and manual medicine. I just don't want to lose all of my basic medical knowledge and I want a field that will motivate me to keep it up if I'm in the right setting (i.e. a rehab hospital.)

From what I understand PM&R is what you make of it. If I decide to do mostly outpatient care then I assume that most of my acute management skills will be lost with time. I'm guessing I would have to know more medicine if I were in the right inpatient setting.

Anyone care to agree or disagree?

 

[axm397]

Having just done my stroke rotation in a "real life" rehab, I can say you really do need to know your medicine as well as rehab specific stuff.

First, you need to know the different types of strokes, neuroanatomy and what kind of symptoms to expect from lesions in which area. You need to know about neglect syndrome, types of aphasias, motor defecits, visual defecits, proprioception, etc. etc.

Then, you need to know how a stroke pt recovers. What comes back first? When do you start worrying about spasticity? What types of therapies are there for stroke patients? Need to know the basis of constraint therapy, body wt supported treadmiss therapy, available adaptive technology, melodic intonation therapy, e stim, etc etc. Need to know what kind of medical pblms to expect in a post stroke pt. BP, gluc control (if diabetic), DVT/PE, aspiration pneumonia, etc. Many of my pts had co-morbidities which confused the picture.

Need to know various medications for spasticity, neurostimulation, etc. Need to know the difference btwn tone, spasticity, contracture. Need to know when to order botox injections. Need to know EMG/NCS and how to use them as well as do them. Need to know when to consider baclofen pumps. Need to know how to do a proper musculoskeletal exam. (most non-physiatrists never had training on this.) Need to know how to handle/manage bladder/bowel issues. Need to know how to handle agitation/confusion (No, can't just snow them - cuz then they can't participate in therapy) etc etc.

Then, need to be able to plan for discharge. Where will the patient go after rehab? What kind of needs will they have? How much more recovery can you expect?

AND, on top of all this, you have to have a PLEASANT TEAM PLAYER type personality to be able to work as a team with the therapists, nurses, and case managers AND be able to talk to sometimes difficult families.

Do PAs and social workers know how to do all this? I don't know. maybe That sure would make my life easier.

 

[aspiring_painMD]

Blockjok is a total joke, he trolls the pain medicine forum, check out his posts.

PM&R docs who work in an inpatient setting and are good know an equal amount of knowledge as general internal medicine docs. I will admit some do consult medicine occasionally for simple things because they don't want to waste time managing certain issues. In a stand alone rehab hospital, PM&R docs at my school run codes, and know how to manage subacute medical conditions very well.

In other words, PM&R docs know much more internal medicine than "block jokes."

 

[blokjok]

Blockjok is a total joke, he trolls the pain medicine forum, check out his posts.

PM&R docs who work in an inpatient setting and are good know an equal amount of knowledge as general internal medicine docs. I will admit some do consult medicine occasionally for simple things because they don't want to waste time managing certain issues. In a stand alone rehab hospital, PM&R docs at my school run codes, and know how to manage subacute medical conditions very well.

In other words, PM&R docs know much more internal medicine than "block jokes."

Aspiring
No need for personal attacks. I agree with you that rehab docs consult medicine for simple things like B/P, UTI, CAD etc because they are busy writing their PT/OT prescriptions. I guess they can't call a consult for a code.

 

[Disciple]

Inpatient PM&R is VERY heavy on the social work aspect of the hosptal stay. In that sense physiatrists are glorified social workers or discharge planners. A former attending admitted that physiatrists provide a considerable amount of custodial care.

Inpt rehab is often the last stop before discharge. Who do you expect to handle these issues?

Most practicing physiatrists are ill-equipped to practice acute care medicine. After their internship year most do not keep up with changes in acute care medicine. That is why they pan consult as extensively as they do

It all depends on how you want to run your practice. I know physiatrists who cover inpt units at several hospitals in addition to an outpt practice. They pan consult to keep their inpt rounds to half a day. Others who focus on inpt rehab take it upon themselves to manage the medical issues.

BTW, you really need to get over your bitterness about spending 3 yrs in a PM&R residency only to find out it wasn't the specialty for you.

 

[Disciple]

Blokjok,

The OP is looking for some honest answers about the field.


So keep your nonsense on the pain forum, you seem to be giving everyone a pretty good laugh over there.

 

[blokjok]

Disciple
We are just trying to help Fozzy. BTW interesting statement "They pan consult to keep their inpt rounds to half a day". That means; they don't take care of anything except PT/OT prescriptions so they can go somewhere else. I don't think Nikiforos is bitter. He is just uncovering the inadequacy of rehab medicine.

 

[Disciple]

See the second half of my statement.

It all has to do with generating revenue, which you seem to be focused on. I mean, with your 40 procedures a day and all.


Just a thought, but I'd like to put a mixture of 8-10 acute to subacute to chronic spinal cord injury patients under your care and see how many of them die or fail to progress functionally within 6 months.

 

[blokjok]

Disciple
Fozzy wants to practice medicine and keep her/his medical skills. I am a specialist in doing nerve blocks and don't pretend to be anything different.

 

[Disciple]

If you're a specialist in nerve blocks then you shouldn't comment on the ability of Physiatrists to medically manage conditions you know nothing about.

To humor your "block jok" internet persona,

How about this?

I'm a specialist in doing peripheral joint injections. Honestly, how stupid does that sound?

The way you describe your skill set or "specialty" as you call it, anyone can do it.

Even a **gasp**

CRNA

 

[blokjok]

Disciple
Fozzy is not interested in your personal insecurities. Best advice for Fozzy is to stay away from PMR if he/she wants to practice real medicine.

 

[Disciple]

Uhhh, yeah.....

Great comeback.


So what field would you suggest Fozzy enter to practice "real medicine"?

How about yours? I'm sure he/she would happily waste 13 years of education to learn a few silly steroid injections.

Note I am not referring to true pain medicine, mind you.

I think you're just upset that the PM&R spine guys made diagnoses that you couldn't make while using your "block every nerve near the spine until we figure out where the pain is coming from" algorithm.

 

[blokjok]

Disciple
I can't suggest any field for Fozzy. As for me, I love to do blocks and let the PM&R guys to do the PT/OT evals.

 

[axm397]

Fozzy, I want to apologize for this conversation getting off the original topic. Hopefully, you will read the posts of responsible "real life" Physiatrists and PM&R residents, talk to physicians you trust from other specialties, and make your own decision. No one will try to "sell" PM&R to you on this forum. You also have to remember everyone has their own agenda. People who make blanket statements and dont' back it up with data should be taken with a grain of salt. I hope as a 3rd yr med student, you can tell the difference btwn people who are truly concerned about you getting the correct information and people who have agendas, insecurites, etc.

I hope that you can sort through the garbage and get what the field of PM&R is all about. I would also refer you to the AAPM&R website and the mentor databse to find out more. Good luck!

 

[drvlad2004]

Disciple
I can't suggest any field for Fozzy. As for me, I love to do blocks and let the PM&R guys to do the PT/OT evals.

Wow, we have one person obviously trolling on this forum. Talking about the perceived negative aspects of PM&R is one thing but being misinformed is another. It's unfair when a poster like block jock gets off topic without answering the OP's original question. It's also bad enough when former physiatrist (that is b/c he was only interested in pain meanagement and did not do his research why he really wanted to go into PM&R) also lets the conversation go off topic. It shows a lack of maturity.

Now back to original question by Fozzy. In an acute inpatient setting, it should be obvious that patient has to be deemed medically stable before coming to the rehab unit, although it may not necessarily may be the case due to medical insurance issues and politics. In fact, more patients have been coming to acute rehab very unstable and I have had to do more workup and have many other issues that were not at all addressed in the med/surg floors. In other words, no specialty is perfect nor better than another.

For a stroke patient, as a physiatrist, I am concerned about the effects of stroke such as motor recovery, different types of post-stroke shoulder pain (RSD, inferior subluxation, rotator suff tear, etc.), spasticity management, management of bladder/bowel dysfunction, aphasias, swallowing difficulties, DVT prophylaxis, occurence of seizures, etc. We have to comprehensively coordinate and managed the care of stroke patients with PT/OT/ST, social work, and other medical personel (neuro, urology, etc.). Inpatient rehab still requires a lot of medicine but it is not at all the same as IM. The ultimate goal is to get the stroke patient to optimal function and in a safe living setting. PM&R docs will consult other specialties, if the issue may be beyond our expertise. Consults are a great source of revenue. Also, consults are done for medicolegal reasons.

Fozzy, you will find PM&R very different from other fields. If you like a teamwork approach to medical care, then PM&R is a good fit for you. I may not be crazy about inpatient rehab but it serves its importance. Definitely, do a PM&R rotation or two (even in a private practice setting). You will get a better idea of what PM&R is about instead of filtering through the garbage of blanketed statements.

 

[fozzy40]

Fozzy, I want to apologize for this conversation getting off the original topic. Hopefully, you will read the posts of responsible "real life" Physiatrists and PM&R residents, talk to physicians you trust from other specialties, and make your own decision. No one will try to "sell" PM&R to you on this forum. You also have to remember everyone has their own agenda. People who make blanket statements and dont' back it up with data should be taken with a grain of salt. I hope as a 3rd yr med student, you can tell the difference btwn people who are truly concerned about you getting the correct information and people who have agendas, insecurites, etc.

I hope that you can sort through the garbage and get what the field of PM&R is all about. I would also refer you to the AAPM&R website and the mentor databse to find out more. Good luck!

Not to worry. I've been on SDN for quite sometime and I know enough to do my own research outside in the real world. I have talked with several residents in the field, looked on several websites (i.e. aapmr and physiatry.org), and planning to do a 4wk rotation of inpt PM&R at the beginning of my 4th year. I have shadowed one PM&R doc who I did not particular take to their style of practice. However, I am quickly learning that PM&R docs practice in a variety of fields and have different styles. This is actually what has drawn me to PM&R is the flexibility. I realize I will not function to the exact same capacity as an internist but I do want a field that allows me to practice medicine to a certain degree. Do I want to be totally responsible for a rehab pt with new onset CP or putting in central lines? Not really. I would like to still be able to work up the case, do my physical exam, order labs, consult cardiology or stablize them for transfer. If I am able to function to this capacity and still incorporate rehabilitation, MSK medicine, and sports medicine (my other interest), I think I've found the field I'm looking for.

My draw to PM&R is the MSK aspect and procedures, patient continuity, establishing long term relationships with the pt and family, and team approach to care. It does seem like there is a good amount social work involved and therapy prescription, which I don't mind. However, I don't think I'l be happy if that's ALL I do in the inpatient setting. Which is why it 's comforting to know that such responsibilities is variable across different residency programs/hospitals.

Ultimately, I know that it is in my best interest to do a rotation and see for myself. That being said, any suggestions on places where I can get a good inpatient rotation?

Once again, I appreciate everyone's input.

 

[blokjok]

Good idea Fozzy. Start with your local school.

 

[axm397]

Would go to an academic institution with a residency. That way, you can also make contacts, talk to residents, etc. If you are truly considering PM&R, would also go to a place you consider a "reach", or would consider going for residency. Obviously, there are logistical concerns and if you have a place to stay or contacts at a particular place, that helps. You can PM me if you have questions about Northeast programs or RIC. You can look at the SDN roster on this forum and PM ppl at specific programs OR use the mentor database on the AAPMR website. I did electives at Kessler and JFK in NJ, and am now at RIC. I know Kessler has UMDNJ students and RIC has northwestern students who are required to do PM&R rotations and you may have to compete with them for spots. Good luck, let me know if I can be of help.

 

[PMR TX MS]

In addressing the attacks on the different fields, I think it's pretty stupid to insult any other specialty in the field of medicine. This example of infighting is one of many problems facing the medical community. Why insult another field of medicine? Have we forgotten that patient care should come first? Knowledge is infinite but any one person's capacity to learn tends to be finite. I am happy to see physicians willing to consult when they feel that something is over their heads. I am pleased to see a physician putting patient care before his/her personal ego or agenda. I understand that many consults happen because of the "business end" of medicine. However, let's remember that we have different specialties with the idea that we as a whole can provide better care. When we begin to fight, all we do is hurt patient care and our own specialty.

I apologize for this soap boxish nature of this post.

 

[Nikiforos]

PM&R docs who work in an inpatient setting and are good know an equal amount of knowledge as general internal medicine docs. /QUOTE]

That is one of the silliest statements (if not the dumbest) that I have seen on this forum. Paging Dr. Suster, patron saint of all physiatric pain specialists.

 

[aspiring_painMD]

PM&R docs who work in an inpatient setting and are good know an equal amount of knowledge as general internal medicine docs. /QUOTE]

That is one of the silliest statements (if not the dumbest) that I have seen on this forum. Paging Dr. Suster, patron saint of all physiatric pain specialists.

Is it really that ridiculous? Consider this, how many PM&R docs who work inpatient in a reputable academic setting were once great internists? There are plenty who are double boarded in internal medicine and PM&R.
Also consider the increasing acuity of PM&R patients. With this, comes the need to be the primary hospitalist for the patient. You are essentially filling the role of IM doc to these patients. In my experience, consults are not done out of ignorance but rather for medico-legal reasons or to save time/effort.

Nikiforos, I think you are mistaking knowledge for practice. A pm&r doc does not routinely manage an issue such as DKA or ACS, but will know what treatment is to be implemented. The best PM&R docs I have seen will keep up with the latest evidence based practices even if they do not routinely manage the medical issue.