the PM&R Resident: July 2013

the PM&R Resident - July 2013
July2013

2013–2014 RPC Officer Elections

RPC seal

The Resident Physician Council (RPC) Nominating Committee will open the call for nominations on July 20 for the RPC board positions of president, vice president, and secretary as well as all committee and liaison positions. Please see the position descriptions for more details. You must be a current Academy member to participate in the election process, so be sure your membership is up to date.

Consideration shall be given to those candidates with previous service to RPC, strong organizational and leadership qualities, and a willingness to serve if elected. If elected, you will have the opportunity to gain invaluable leadership experience, insight into the specialty of PM&R, and an opportunity to serve on behalf of the resident membership of AAPM&R.

Any interested, current AAPM&R resident members (PGY1–3) may apply. All nominations, including personal statements and CVs, must be received no later than August 4.

To begin the nomination process, please click here.

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2013–2014 RPC Officer Elections

Fellowship Series: Cancer Rehab

Musculoskeletal Ultrasound Training and the PM&R Resident

A Letter From the PM&R Resident Editor

PM&R Now Has an Impact Factor!

Resident Leadership and Involvement Opportunities

Enhance Your Salary Negotiations With Insider Details

AAPM&R 2012–13 Resident Physician Council

Executive Committee

President
Andrew Gordon,
MD, PhD
PGY3—Johns Hopkins

Past President
Sunjay Mathur, MD
PGY4—RIC

Vice President
Justin Waltrous,
MD, MPH
PGY3—UMDNJ/Kessler

Secretary
Stephanie Rand, DO
PGY3—Montefiore


the PM&R Resident

Editor
Stephanie Rand, DO
PGY3—Montefiore

Contributing Authors

Fernando L. Sepúlveda-Irizarry, MD
Graduation Year 2014—University of Puerto Rico

Joshua Sole, MD
Graduation Year 2014—Mayo Clinic

Register for the Annual Assembly by August 5 to receive the early-bird discount!

Attending the Annual Assembly?

Expand your knowledge on the Exhibit Hall floor. Discover the latest devices, products, and services in the field of PM&R.

Use our new interactive floor plan to discover who will be there!

Corrections:

The June 2013 issue referenced that Amy Yin, MD, is a PGY2. However, she is a PGY3 at Harvard Medical School/Spaulding Rehabilitation Hospital.

In the June 2013 article written by Diane Mortimer, MD, the email version of the article mistakenly included the note "With special thanks to Jennifer Luz, MD; Kevin O'Connor, MD; and Ross Zafonte, DO."

Fernando L. Sepúlveda-Irizarry, MD

Fellowship Series: Cancer Rehab

With special thanks to Jesuel Padró-Guzman, MD, and Christian Custodio, MD

It is estimated that more than 1.5 million men and women will be diagnosed with cancer in the U.S. in 2013. The number of cancer patients and survivors alive today has been estimated to be close to 13 million. Survival rates have been increasing significantly during the last few decades, with the 5-year survival rate climbing from 50% in 1975–1977 to 65.8% from 2003–2009.1,2 This number can be attributed to the advances in early detection, prevention, and treatments of cancer. Many of these patients, however, present with significant functional limitations, as a result of their treatments or from the cancer itself. Among the rehabilitation issues these patients present with include lymphedema; fatigue; pain; malnutrition; spinal cord compression; peripheral neuropathy; joint contractures and immobility; cognitive impairments; and many others.3 Often, there are multiple impairments and disabilities to address within an individual patient. As a specialty focused on improving function, we are uniquely positioned to work alongside medical, surgical, and radiation oncologists, with the goal of improving patients' quality of life.

The challenges posed by this unique patient population present an interesting opportunity to apply different techniques used by physiatrists, such as advanced electrodiagnostic studies, botulinum toxin injections, musculoskeletal ultrasound evaluations, image-guided injections, and other interventional procedures.2 This subspecialty also provides an interesting patient mix, including pediatric and adult populations, along with the opportunity to practice in both inpatient and outpatient rehabilitation settings. The scarcity of specialists who focus on this growing segment of the population allows one the opportunity to become a leader in this field. Comprehensive cancer centers across the country are looking for specialists who are capable of providing the clinical care and research interests needed to expand the scope and recognition of this rehabilitation subspecialty.

There are currently 2 fellowship programs in the country sponsored by MD Anderson Cancer Center4 and Memorial Sloan-Kettering Cancer Center,5 with more being developed (although it is unclear when they will be up and running). Since programs don’t participate in the match, the application process timeline varies, depending on the program. There is no subspecialty board certification available after completion of the fellowship. Both programs have a 1-year duration and offer a wide variety of clinical experiences, along with research opportunities. If you are intrigued by the prospect of subspecializing in the management of oncologic patients, an elective rotation in 1 of these programs would be an amazing experience to learn more about the day-to-day practice of cancer rehabilitation. Looking for cancer rehab rotations, research projects, and faculty mentors in this area during your PGY2 year or early in the PGY3 year would also help to start familiarizing yourself with this field and show interest.

A cancer rehabilitation fellowship provides the tools to work with an underserved and diverse population, using a wide variety of treatment strategies. Although there are few fellowship slots available, this promises to be a growing and exciting field.

References:

  1. Howlader N, Noon AM, Krapcho M, et al (eds). SEER Cancer Statistics Review, 1975–2010. National Cancer Institute. http://seer.cancer.gov/csr/1975_2010/. Accessed on July 16, 2013.
  2. Custodio CM. Electrodiagnosis in cancer treatment and rehabilitation. Am J Phys Med Rehabil. 2011;90(5 Suppl 1):S38–S49.
  3. Paul K, Buschbacher R. Cancer rehabilitation: increasing awareness and removing barriers. Am J Phys Med Rehabil. 2011;90(5 Suppl 1):S1–S4.
  4. Cancer Rehabilitation Fellowship. MD Anderson Cancer Center website. http://www.mdanderson.org/education-and-research/education-and-training/schools-and-programs/graduate-medical-education/residency-and-fellowship-programs/cancer-rehabilitation-fellowship.html. Accessed July 16, 2013.
  5. Cancer Rehabilitation. Memorial Sloan-Kettering Cancer Center website. http://www.mskcc.org/education/fellowships/fellowship/cancer-rehabilitation. Accessed July 16, 2013.

Source:

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Joshua Sole, MD

Musculoskeletal Ultrasound Training and the PM&R Resident

Unless you have been living under a rock, most PM&R residents are aware that musculoskeletal ultrasound (MSUS) has become increasingly prevalent and popular across multiple areas of PM&R, including musculoskeletal, sports, pain, spine, and neuromuscular medicine. There has been an explosion over the last decade in the amount of ultrasound training sought by PM&R clinicians. Improved research and training has increased the use of diagnostic MSUS, MSUS interventions (injections), and adjuvant MSUS use for EMG electrode and needle placement.1

PM&R physicians have a rich history in ultrasound medicine, including founding the American Institute of Ultrasound in Medicine (AIUM) in 1954.4,5 Although PM&R’s initial stake in ultrasound was as a therapeutic modality, MSUS has emerged as an accessible, portable, cost-effective, real-time, safe, dynamic, high-resolution imaging modality for the diagnosis and treatment of neurologic and musculoskeletal conditions common to PM&R. Ultrasound can be used to evaluate nerve, tendon, muscle, ligament, and blood vessels, as well as to guide interventions (e.g., injections, aspirations) targeting these structures. Furthermore, ultrasound is well tolerated and well accepted by patients and allows for side-to-side comparison of anatomic structures.1, 4–6 Some have deemed MSUS as the ideal imaging modality for PM&R, and many others have referred to MSUS as a vital extension of the physiatric clinical exam.1,3

Furthermore, research has shown that improvements in ultrasound imaging quality and affordability over the last decade have contributed to increased use in clinicians from nonradiology backgrounds (e.g., physiatrists). In fact, 1 study quoted a 12,025% increase in clinician MSUS use between 1996–2006.2 Moreover, a review of 2006 Medicare data showed the majority of MSUS was performed by clinicians rather than radiologists, with less than 50% of MSUS in 2006 being performed by radiologists.2 Another 2005 email survey of 565 U.S. physiatrists and neurologists showed that 65% were interested in using MSUS in clinical practice, and 18% were already using MSUS. This was further accented by an international PM&R survey that revealed 18% of physiatrists were using MSUS in daily practice, 75% would perform MSUS given access to a machine, and 90% felt that physiatrists should be performing MSUS.3 A more recent survey of 225 AAPM&R members revealed that 85% not trained in MSUS expressed strong interest in receiving training and incorporating MSUS into their clinical practices. This ultimately led to the creation of MSUS training opportunities via AAPM&R to meet this growing interest.5 Given the increased advocacy and training opportunities for MSUS by AAPM&R, other multispecialty societies incorporating physiatrists combined with the increased amount of MSUS vendors at aforementioned society conferences, you can safely presume that MSUS will continue to be utilized extensively by PM&R physicians.

So where does MSUS fit into PM&R residency and fellowship training? As I open my second survey this month regarding MSUS exposure in PM&R residency, I realize I am not alone in seeking answers to this query. Even with the PM&R MSUS boom, the widespread incorporation of MSUS training into PM&R residency education, didactics, and rotation experiences remains in its infancy. Like most medical specialties, the foundational education physiatrists receive is during residency.5 Residency serves as a time to be exposed to the breadth and depth of our diverse field, and it seems reasonable that residents be exposed to all areas related to PM&R during their training. However, the Accreditation Council for Graduate Medical Education does not require MSUS education, training, or exposure during residency.5 Our radiology colleagues have noted that ultrasound requires more hands-on training and expertise than any other imaging modality and cited the musculoskeletal system as 1 of the more difficult systems to master with ultrasound. Moreover, there are too few musculoskeletal radiologists to meet clinical demand both in the inpatient and outpatient setting.7

Given the preponderance of PM&R interest in MSUS and growing clinical need for well-trained MSUS clinicians, the inclusion of MSUS into PM&R residency training seems like the next logical step. The feasibility and steps needed to implement a diagnostic and interventional MSUS curriculum has been well documented in the physiatric literature.5 However, creating an MSUS curriculum does come with several difficulties that may account for the lack of program-wide implementation. A successful MSUS curriculum requires a sufficient amount of faculty adequately trained in MSUS to teach and supervise residents and fellows. Additionally, ultrasound machine access is crucial. A 2010 paper showed that a 1:1:5 machine to faculty to resident ratio was adequate. Moreover, ample didactic time and access to cadaveric specimens to practice ultrasound-guided interventions were recommended.5 Needless to say, a template exists that can be further molded to individually fit each PM&R residency program.

Some might be wondering, "What do I do if my program offers little or nothing in regard to MSUS training?" One initial piece of advice would be to encourage your PM&R faculty to seek out continuing medical education opportunities for MSUS training, so they can return and serve as mentors for your program. Additionally, you might consider blazing a trail by seeking out non-PM&R faculty that utilize MSUS (e.g., specialists in rheumatology, orthopedics, primary care, sports medicine, radiology) for exposure and training opportunities. You could even go as far to ask these clinicians to put on a single, hands-on educational module for your residency program. There is evidence that even a 1-day course significantly improves awareness and comfort with MSUS.3 Additionally, if you have access to an ultrasound machine, practicing on yourself or another colleague is vital. Many of the MSUS pioneers in our field learned this way and it is well accepted that repetition and practice are the best ways to learn MSUS.

Here are some resources that I recommend to PM&R residents interested in utilizing MSUS in their training and future practice:

  1. Buy an MSUS textbook.
    • Fundamentals of Musculoskeletal Ultrasound (Fundamentals of Radiology) by Jon A. Jacobson, MD, is a great beginner’s book and excellent reference for normal and abnormal MSUS structures.
    • Ultrasound of the Musculoskeletal System (Medical Radiology/Diagnostic Imaging) by Stefano Bianchi and Carlo Martinoli is also a great resource for more advanced reading.
  2. Utilize free educational resources. Check out the European Society of Musculoskeletal Radiology protocols.
  3. Attend an ultrasound course or volunteer to be a course scanning model.

Given the cost, manpower, and time needed for MSUS training, it is understandable why some PM&R residency programs might be hesitant to implement a formal MSUS curriculum. However, I believe it is important for the next generation of physiatrists to consider the positive impact of MSUS training on the future of our evolving specialty. MSUS is a highly desired and useful skill for physiatrists with utility permeating across multiple areas of PM&R, including areas like sports, pain, interventional spine, and neuromuscular medicine. Physiatrists are continuing to expand their use of novel and exciting applications such as nerve mapping, elastography, and ultrasound-guided regenerative therapies. The future of ultrasound’s role in physiatric practice and research appears boundless, and we should continue to advocate for its vital role in PM&R residency education and the training of future physiatrists.

References:

  1. Primack SJ. A physiatrist's perspective on musculoskeletal ultrasound. Phys Med Rehabil Clin N Am. 2010;21(3):645–650.
  2. Jacobson JA, Musculoskeletal ultrasound: focused impact on MRI. AJR Am J Roentgenol. 2009;193(3):619–627.
  3. Ozçakar L, Tok F, Kesikburun S, et al. Musculoskeletal sonography in physical and rehabilitation medicine: results of the first worldwide survey study. Arch Phys Med Rehabil. 2010;91(2):326–331.
  4. Smith J, Finnoff JT. Diagnostic and interventional musculoskeletal ultrasound: part 1. Fundamentals. PMR. 2009;1(1):64–75.
  5. Finnoff JT, Smith J, Nutz DJ, et al. A musculoskeletal ultrasound course for physical medicine and rehabilitation residents. Am J Phys Med Rehabil. 2010;89(1):56–69.
  6. Smith J, Finnoff, JT. Diagnostic and interventional musculoskeletal ultrasound: part 2. Clinical applications. PMR. 2009;1(2):162–177.
  7. Forster BB, Cresswell M. Musculoskeletal ultrasound: changing times, changing practice? Br J Sports Med. 2010;44(16):1136–1137.

AAPM&R MSUS Training: A Good Place to Start

AAPM&R has a track record for developing the best breed of ultrasound training, which means you will receive up-to-date information and best practices that you can immediately apply in practice. The 2013 Annual Assembly, being held October 3–6, in National Harbor, MD, offers a preconference course, ticketed workshops, and intensive, hands-on workshops covering a variety of ultrasound applications. An added bonus: Resident volunteer opportunities are available! Click here to learn more. You can also read the article below to learn more.

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A Letter From the PM&R Resident Editor

Dear PM&R Resident,

This newsletter—the PM&R Resident—is the official web-based newsletter of the RPC of AAPM&R. It features monthly contributions, experiences, and issues that concern PM&R residents written by PM&R residents. Our goal is to promote and highlight issues of interest to PM&R residents around the country.

As always, we are looking for interested authors to submit articles for review and publishing in the PM&R Resident. We are especially interested in the following topics:

  • Alternative medicine that complements physiatry
  • How physiatry intersects with other specialties
  • "Hot topic" residency issues
  • Finding/landing a first job
  • Bioethics or ethical dilemmas in rehab

In addition to sharing your perspective, opinions, and ideas with your peers and colleagues and inspiring and educating others, having a publication in our newsletter will enhance your CV. This is not a peer-reviewed journal, so clinical research is discouraged.

Frequently Asked Questions:

  • Do I need to be a member of AAPM&R?
    Yes.
  • Is there a required length or word count?
    It is generally advised that articles be no longer than 500 words.
  • Are there any format requirements?
    The document should be sent as a Word document file. Whenever applicable, references should be cited. Also, please be sure to include your name, program, and title and/or graduation year as you would want it to appear in the publication.
  • What else do I need to submit with my article?
    With your article, please send a headshot photograph in .jpeg or .gif format.
  • How do I submit the article?
    Email the article and your headshot photograph to me at drstephrand@gmail.com.
  • When are the articles due?
    As the newsletter is published on an ongoing monthly basis, we accept new submissions every month.
  • What happens after I submit my article?
    Your article will be reviewed by me, Stephanie Rand, DO, the current editor for the PM&R Resident. I will work with you, if needed, to make your article appropriate for publication. You will be notified by email if your article has been selected for publication. If your article is not published immediately, it will be archived for potential later publication.

Please feel free to contact me with any further questions at drstephrand@gmail.com.

Sincerely,
Stephanie Rand, DO
Secretary, AAPM&R RPC Executive Board
Editor, the PM&R Resident

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PM&R Now Has an Impact Factor!

PM&R—AAPM&R’s official scientific journal—now has more impact than ever. Your Academy is excited to announce that PM&R, which is only in its fifth year of publication, officially has an impact factor! This is an incredible accomplishment for such a young journal!

PM&R’s impact factor is 1.372. The journal is ranked 31 out of 63 in the rehabilitation category and 42 out of 84 in the sports science category. This impact factor measures how many times PM&R articles published in 2010 and 2011 were cited in 2012 relative to the total number of PM&R citable items published over the same 2-year window.

This is a significant and exciting milestone for your Academy’s journal. Having an impact factor adds to the prestige of the journal. PM&R is now more valuable than ever to its thousands of AAPM&R members and readers across the globe. And as AAPM&R celebrates its 75th anniversary this year, this news adds to the celebration of the year.

Help elevate your journal to be the go-to resource for rehabilitation and sports science. Submit your research to PM&R.

Ask Your Institution’s Library to Subscribe to PM&R

Complete this brief form to recommend PM&R to your favorite library.

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Resident Leadership and Involvement Opportunities

As a resident member of the Academy there are multiple opportunities to get involved and to strengthen your leadership skills. Many of the opportunities are easy to sign up for and have flexible time commitments. Check out this list for ways to stay competitive, learn new skills, and gain more exposure to the PM&R community.

Resident Involvement Opportunities

Research and Authorship

  • Residents may author an article for publication in the PM&R Resident.
  • Residents may serve as a coauthor to develop a 1,700 word summary of a clinical topic on PM&R Knowledge NOW®.
  • Residents may serve as an abstract reviewer to help choose which abstracts are included in the Annual Assembly program. Opportunities will be available in January 2014.

In-Person Volunteering

  • The Foundation for Physical Medicine and Rehabilitation requests Academy residents to volunteer at the 5K Run/Walk & Roll during the Annual Assembly. Contact Phyllis Anderson at panderson@foundationforpmr.org for more information.
  • Residents may volunteer to assist at workshops and courses during the Annual Assembly. Receive complimentary access to session and remuneration ($100/day for most). Currently seeking volunteers!
  • Residents may volunteer as a model for ultrasound courses held throughout the year. New opportunities will be available in 2014.

Provide Feedback

  • Residents can provide feedback by participating in Academy surveys, such as the Member Survey and the Resident Census Survey.

Grassroots' Advocacy Efforts

Networking

  • Residents can connect with residents at the Annual Assembly at networking events, such as the Resident and Fellow Town Hall Meeting and the Residents’ Reception.
  • Residents can connect with residents and other Academy members via PhyzForum.
  • Residents can connect with residents and other members through the AAPM&R Facebook page.
  • Residents may join all 5 Member Councils, increasing their exposure to the PM&R subspecialties.

Resident Leadership Opportunities

During Residency:

  • Residents can be elected to serve on the RPC Board Executive Committee.
  • Residents can be appointed as resident liaisons to the strategic coordinating committees through RPC.
  • Residents can participate in Member Council advisory groups by becoming a member of each Council.
  • Residents can become a mentor to medical student members through the AAPM&R Medical Student Mentor Program. (This opportunity is also available for after residency.)

After Residency:

  • Residents who become board certified may submit a nomination to serve on a Member Council executive committee, the Board of Governors, or an Academy committee.
  • Members can still participate in Member Council advisory groups by remaining a member of your Council.
  • Academy Leadership Program: This program is best suited for Academy fellows who are early-career physiatrists who have completed residency and/or fellowship training, and have been in practice for roughly 4–10 years and who want to fill leadership positions in the future or those who may be ready to pursue leadership positions in midcareer.

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Enhance Your Salary Negotiations With Insider Details

Finding the right job out of residency can be overwhelming. Be informed during your job search—know how much you should be compensated based on your:

  • Location
  • Years of experience
  • Board certification
  • Practice setting
  • And much more!

The 2012 PM&R Compensation Survey Report is a detailed, 46-page report based on a survey of more than 1,700 physiatrists. The findings are PM&R specific, so that you can better negotiate contracts, get paid what you're worth, and understand where you stand in the job market.

Click here to learn more and to purchase the report. Resident members save $50!

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