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PGY1 Advice from PM&R Residents

PGY1 and Marriage

Yoon, Esther_PhotoEsther 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.

 


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

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

 

  

Caparo, Moorice PhotoMoorice 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.

 


Choose Your Adventure: Intern Year Edition

Lindsey MiglioreLindsey 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 Pointers

David Jacobs PhotoDavid 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.

 


Making the Most of Your PGY1

Charles KenyonCharles D. Kenyon, DO
PGY2, 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!