Update from the AAP RFC Chair — Winter 2019

By Allison Bean, MD, PhD

Happy New Year! It’s hard to believe that in only a couple of weeks we will be heading to beautiful San Juan, Puerto Rico for Physiatry ’19! With more than 500 trainees in attendance, it is certain to be a great time to catch up with old colleagues and meet new ones. It will be a bittersweet time for me as I hand over the reins to the current Vice Chair, Dr. Neal Rakesh. Serving as a member of the RFC been one of the most rewarding experiences of residency, and I will miss working with this talented and passionate group of individuals.

I am incredibly proud of the work that the RFC has done over the past two years and would like to highlight just a few of these accomplishments:

AAP Medical Student Council — The RFC selected the first national PM&R Medical Student Council, a fantastic group of future physiatrists who have accomplished a great deal in a single year including podcasts and a virtual journal club. Additionally, over 100 medical students are registered for Physiatry ’19 and the MSC has arranged a great program to provide insight on audition rotations and how to match into a PM&R residency. We can’t wait to see what the newly elected council comes up with next year!

AJPM&R Resident Fellow Section — With an invitation from Dr. Walter Frontera, Editor-in-Chief of the American Journal of Physical Medicine & Rehabilitation, and mentorship from Dr. Dinesh Kumbhare, the RFC spearheaded the development of a new section of AJPM&R dedicated to publishing peer-reviewed articles authored and reviewed by PM&R trainees. The journal is currently accepting several different categories of submissions and is also looking for two new rising PGY-3 residents to join as section editors next academic year.

Physician Wellness — The RFC recognizes that burnout is a significant issue in PM&R training and plans to take an active role in promoting resident wellness in the future. RFC research representative, Dr. Allison Schroeder, has spearheaded Words of Wellness, where AAP members at all levels describe their own approaches to maintaining wellness. The RFC will also be electing its first Education/Well-Being Representative this year, which will lead to expanded initiatives and hopefully improve the well-being of PM&R trainees and physicians going forward.

Physiatry ’19 Resident/Fellow Track — One of the most important tasks of the RFC is to plan the resident/fellow track at the annual meeting and we are excited about this year’s program. We will kick off with the annual half-day procedure workshop where trainees will have the opportunity to learn skills in EMG, ultrasound, fluoroscopy, and spasticity management. Additional interactive sessions will provide trainees with insights on how to become involved with research, write detailed wheelchair prescriptions, and appropriately diagnose challenging cases in spinal cord injury using ISNCSCI classification. Career pearls sessions focused on negotiations and contracts will help residents and fellows navigate the future job market. As always, we will conclude the annual meeting with the election of the new Resident/Fellow Council and then celebrate with Trivia Night sponsored by Allergan. You can find out more about all of the incredible candidates running for positions for next year’s council here!

Before I sign off for the last time as RFC Chair, I would like to thank everyone on Resident/Fellow Council for all of their hard work and dedication over the past two years. It was wonderful to get to know all of you and I look forward to seeing everyone grow in their careers in the years to come. I would also like to thank the AAP staff, particularly Jackie Dilsworth and Tiffany Knowlton, for their support of the RFC and their assistance with making all of our ideas a reality. To next year’s RFC: the future of physiatry is so bright with you as leaders, dream big!

See you all in Puerto Rico!

Allison Bean, MD, PhD is the 2018–2019 Chair of the AAP Residents/Fellows Council and a PGY-4 Chief Resident in the Department of Rehabilitation Medicine at the Icahn School of Medicine at Mount Sinai. Follow her on Twitter: @AlliBeanMDPhD

PM&R Residents and the Board: An Evolving Partnership

By Carolyn Kinney MD, Executive Director, ABPMR

At the American Board of Physical Medicine and Rehabilitation (ABPMR), we often hear that residents see the Board only as purveyors of the board exams, those looming tests lurking somewhere at the end of your training.

We’re more than that, of course: We interact with your Residency Program Directors and Coordinators to provide guidance on the scope and breadth of your training as it relates to certification; we track your progress throughout training using records from your program and annual evaluations; we provide guidance and resources for studying and what to expect; and yes, we work with our volunteers, the top physicians working in PM&R today, to design and administer board examinations that are valid and reliable tests of the knowledge and skills you’ve acquired during your training.

And today, I’m writing to you with a new message: We want you to become involved with the ABPMR long before you register for the Part I Examination.

As part of a recently approved strategic plan, the ABPMR wants to partner with PM&R residents and fellows in order to further innovate our assessment processes. Specifically, we’re looking for ideas to make Part I and Part II more formative — that is, more educational in nature. These plans are in the beginning stages, so stay tuned for more details soon.

In the meantime, I want to be sure you’re aware of currently available opportunities through the ABPMR for residents and fellows:

• Bank a PIP. Documentation of quality improvement activities is part of your requirements following certification. Now, residents and fellows can “bank” a practice improvement project (PIP) completed during training. Fill out our simple form online with information from your QI efforts during residency and check off one requirement even before you become certified!
• Free gift at booth. New this year, the ABPMR is offering residents and fellows a free gift at our booth in the exhibit hall at #Physiatry19, taking place later this month in San Juan, Puerto Rico. Come and find us at booth #225 and let us know you’re a resident or fellow.
• CertLink Session at Physiatry ‘19. Have you heard about the new platform we’re piloting for knowledge assessment and learning after certification? CertLink uses longitudinal assessment, an evidence-based method for learning, to provide education and assessment over a physician’s career. If the pilot is successful, this is one tool you’ll be using after becoming certified. Come to the CertLink session at 7:30 a.m. on Friday, February 22, to learn more.
• What’s the difference? video. The Board, the AAP, the Academy… do you sometimes get confused about the similarities and differences between each organization? We created this fun whiteboard video to help you get acquainted with all the professional organizations you’ll interact with as a physiatrist.

I’ll be attending Physiatry ’19 this month; if you happen to see me there please introduce yourself! And don’t miss stopping by the ABPMR booth (#225) in the exhibit hall for your gift and resources for those upcoming examinations.

Dr. Carolyn Kinney is the Executive Director of the ABPMR and Assistant Professor of Physical Medicine and Rehabilitation at Mayo Clinic in Arizona.

Rehabilitation Services Volunteer Project (RSVP): Expanding Rehabilitation Services in our Community

By Jean Woo, MD

Our story with RSVP began when two of our PM&R residents met patients with impaired mobility at a hospital parking lot to donate used wheelchairs to them. The residents were from Project UNION, a non-profit organization founded by PM&R residents at the Baylor College of Medicine / University of Texas Medical School at Houston (UT Houston) Alliance. The organization was founded in 2009 with the objective of securing and distributing used, but free, Durable Medical Equipment (DME) to uninsured individuals with disabilities who otherwise could not afford them. Over the next several years, Project UNION continuously advertised its presence and purpose around the Texas Medical Center and grew in size while recruiting skilled therapists and receiving financial support in addition to countless DME donations from various sources.

Project UNION later merged into another local nonprofit organization, RSVP, which at the time was providing outpatient rehabilitation services to uninsured or underfunded patients who had suffered brain, spinal cord, or amputation injury. Since the merger, PM&R residents at Baylor College of Medicine and UT Houston have continued their support for and involvement with RSVP as volunteers. Nowadays, the residents volunteer during RSVP’s monthly DME distributions, each of which hosts 40-50 patients on average. They are often paired with physical therapists, occupational therapists, and equipment vendors to assess patients’ needs in order to provide them with most appropriate equipment. They also help with cleaning donated equipment, organizing RSVP’s warehouse, repairing patients’ equipment, and translating for patients.

Over the years, RSVP has provided our residents with numerous opportunities to serve patients with disabilities in the greater Houston area. One of the most memorable contributions of our residents to RSVP is their work during Hurricane Harvey. In August 2017, Hurricane Harvey flooded the city of Houston and forced many patients to evacuate their homes in hurry with their equipment left behind. Being the first to recognize this issue, RSVP quickly utilized social media to ask for equipment donations from the public to help the affected individuals. Over the next week, the organization received truckloads of manual wheelchairs, walkers, canes, incontinence supplies, and bathroom equipment from all over the country. When RSVP subsequently held a super-sized DME distribution, over 100 volunteers, including many residents who had already worked days and nights to manage their inpatient rehabilitation units during the hurricane, showed up to help RSVP with its distribution for nearly 200 patients.

It is our hope that organizations like RSVP become widely available to patients with disabilities to help them remain more functional and mobile. It is also our hope that more physiatrists-in-training around the country become involved with such organizations so that they could not only serve their communities in ways that are unique and relevant to rehabilitation medicine, but also learn about some of the most prevalent social and financial challenges that their patients are often confronted with in the process of receiving their rehabilitative care.

Special thanks to Dr. Craig DiTommaso, a former president of Project UNION, for sharing his story.

Jean Woo, MD, is a PGY-4 at Baylor College of Medicine, Resident Representative of RSVP board, and Secretary for the AAP Resident and Fellow Council.

Back to Basics

By Manoj Mohan, DO

As Physical Medicine and Rehabilitation (PM&R) residents, a daily complaint of low back pain (especially in the outpatient world) from patients is almost a guarantee. It is no secret that low back pain is one of the leading causes of morbidity and healthcare expenditure in the country, with estimated costs of $100 billion dollars annually. [1,2] The multiple potential etiologies of pain can be difficult to delineate, though at a minimum the initial history and exam should distinguish between axial versus radicular pain. While radicular pain can follow dermatomal patterns and have corresponding myotomal or reflex deficits, axial back pain often requires careful parsing of the history. Axial pathology is also treated differently than radicular pain from an interventional standpoint. Common mechanical causes of axial pain include facet arthropathy, discogenic pain, spondylolysis, and SI joint pain.

Of these different etiologies discogenic pain is one the most prevalent. It accounts for 26-42% of back pain patients, and is often the most frustrating to treat. [3] While the pathophysiology is complex, internal disc disruption of the annulus and/or nucleus pulposus can stimulate cytokine production resulting in pain signals from innervating nerves in the posterior annulus. Brown et. al studied the cartilaginous endplates and underlying bone obtained from patients who were status post operation from pathologically degenerative discs, and found an increased density of nociceptors in conjunction with the inflammatory markers and granulation. [4] This suggests that the pain generator in severe discogenic pain may be the end plates and vertebral bodies as opposed to solely the posterior annulus.

While transforaminal epidural steroid injections (TFESI’s) have good therapeutic outcomes for radicular pain caused by a disc herniation (75% efficacy with low grade compression) there is no indication for this intervention for solely axial pain. [5] Manchikanti et al did not detect significant differences in any outcome scores between patients who received epidural steroid and lidocaine injections versus those who received only lidocaine. [6] Other proposed treatments such as methylene blue and Intradiscal Electrothermal Annuloplasty (IDET) remain controversial in the literature and have not shown consistent evidence for providing benefit. IDET is a form of ablation therapy theorized to provide pain relief by destroying intra-discal nociceptors. The two main randomized studies evaluating IDET were conducted by Pauza et al and Freeman et al; Both ended with contrasting results. Freeman et al concluded that IDET did not confer any significant benefit compared to shame therapy, while Pauza et al found significantly greater improvements in VAS and ODI scores for IDET when compared to sham therapy. [7,8] It should be noted that the Freeman et al study patient population had a higher baseline of disability noted on ODI and SF-36 scores. Peng et al reported a significant improvement in pain reduction from discogenic pain after methylene blue injection when compared to sham treatment. [9] These results however have not been reproduced by any other RCT and therefore should be interpreted with caution. Reports in the literature also suggest that methylene blue may be neurotoxic to surrounding dural and epidural structures that lie adjacent to the intervertebral discs. [10,11] Levi et al showed increased ODI and pain scores at 1 month after intradiscal PRP into the suspected pain generators, though 47% of patients reported at least a 50% improvement in pain, with 30% reduction of ODI scores at 6 months post-injection. [12] Further studies need to be conducted to examine the efficacy of intradiscal PRP, especially as insurance coverage for this procedure currently remains an obstacle for sustainable financial feasibility.

Adding to the frustration of treating discogenic pain is the absence of a gold standard diagnostic test. The performance of discograms remains controversial in the literature, with the primary concern being that the puncture of the disc induces trauma that outweighs any diagnostic utility. Caragee et al stated that “modern discography techniques using small gauge needle and limited pressurization resulted in accelerated disc degeneration, disc herniation, loss of disc height and signal and the development of reactive endplate changes compared to matched controls. [13]

From anecdotal experience, one of the most difficult (but frequent) conversations I have with patients is explaining how there is no current recommended procedural intervention that can alleviate their pain. These patients are typically younger (mean age of 44), often physically active, and frequently display skepticism when counseled about core stabilization via physical therapy as the focus of treatment planning. Having personally suffered debilitating pain from disc herniations in the past I can empathize with the frustration of essentially being told to exercise as first line treatment for incapacitating back pain. What I have learned through observing our spine attending physicians (and my own trial and error) is that the explanation resonates clearer when a framework is laid out. A nearby spine model is extremely helpful in providing patients with visual reinforcement to deliniate between discs, facets, and nerve roots as potential pain generators. I have found that patients are much more receptive to physical therapy when the rationale is explained to them. I often start by explaining that the deep core muscles include the transversus abdominus, lumbar multifidus, obliques, and quadratus lumborum. These muscles directly attach to the spine and are responsible for primary spinal stability. The shallow core muscles include the rectus abdominis, erector spinae, and hip muscle groups. Most of these muscles are not directly attached to the spine, but connect the pelvis to the lower extremities which provides additional spinal control. [14] The combination of deep and shallow core groups generates a torque to counterbalance external forces which provides a protective effect over the spine.

Despite the persistent ambiguity and lack of firm diagnostic criteria for discogenic pain, there are promising developments on the horizon. Mapping of human vertebral nerves highlighted the presence of the basivertebral nerve which follows the course of nutrient arteries and provides innervation to the endplates. [15] The density of nociceptive fibers in conjunction with increased density of endplate and vertebral innervation by the basivertebral nerve when compared to the disc annulus suggests that discogenic back pain is perhaps actually vertebrogenic. [16] Fischgrund et al conducted a multi-center, double blinded, randomized, sham-control trial to investigate pain relief and disability outcomes after radiofrequency ablation to the basivertebral nerve in patients with well-defined chronic low back pain. [17] They concluded that “RF ablation of the BVN nerve complex exhibited statistically superior relief of disability and a higher response rate than those treated with the sham procedure.” [17]

Discogenic axial back pain remains challenging from both a diagnostic and treatment standpoint. Careful scrutiny of the history, reproduction of dural tension signs on physical exam, and evidence of high intensity zones and Modic changes (Type 1 and 2 changes) on MRI are existing tools that are commonly used to make the diagnosis. It is the responsibility of current and future spine practitioners to have a firm grasp of the existing literature to provide patients with the most current evidence-based care.

References:

1. Katz JN . Lumbar disc disorders and low back pain: socioeconomic factors and consequences . J Bone Joint Surg Am 2006 ; 88 ( suppl2 ): 21 – 4 .
2. Hart LG , Deyo RA , Cherkin DC . Physician offi ce visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a US National Survey . Spine 1995 ; 20 : 11 – 9 .
3. DePalma, Michael J., Jessica M. Ketchum, and Thomas Saullo. "What is the source of chronic low back pain and does age play a role?." Pain medicine 12.2 (2011): 224-233.
4. Brown MF, Hukkanen MV, McCarthy ID, Redfern DR, Batten JJ, Crock HV, Hughes SP, Polak JM (1997) Sensory and sympathetic inneration of the vertebral endplate in patients with degenerative disc disease. J Bone Jt Surg Br 79(1): 147-153.
5. Ghahreman, Ali, Richard Ferch, and Nikolai Bogduk. "The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain." Pain Medicine 11.8 (2010): 1149-1168.
6. Center, Daly City. "Systematic review of lumbar discography as a diagnostic test for chronic low back pain." Pain physician12 (2009): 541-559.
7. Pauza KJ , Howell S , Dreyfuss P , et al. A randomized, placebo-controlled trial of intradiscal electrothermal therapy for the treatment of discogenic low back pain . Spine J 2004 ; 4 : 27 – 35 .
8. Freeman BJ , Fraser RD , Cain CM , et al. A randomized, doubleblind, controlled trial: intradiscal electrothermal therapy versus placebo for the treatment of chronic discogenic low back pain . Spine 2005 ; 30 : 2369 – 77 ; discussion 78.
9. Peng, Baogan, et al. "A randomized placebo-controlled trial of intradiscal methylene blue injection for the treatment of chronic discogenic low back pain." PAIN® 149.1 (2010): 124-129.
10. Schultz P , Schwarz GA . Radiculomyelopathy following intrathecal instillation of methylene blue. A hazard reaffi rmed . Arch Neurol 1970 ; 22 : 240 – 4 .
11. Sharr MM , Weller RO , Brice JG . Spinal cord necrosis after intrathecal injection of methylene blue . J Neurol Neurosurg Psychiatry 1978 ; 41 : 384 – 6 .
12. Levi, David, et al. "Intradiscal platelet-rich plasma injection for chronic discogenic low back pain: preliminary results from a prospective trial." Pain Medicine 17.6 (2015): 1010-1022.
13. Carragee, Eugene J., et al. "2009 ISSLS Prize Winner: does discography cause accelerated progression of degeneration changes in the lumbar disc: a ten-year matched cohort study." Spine 34.21 (2009): 2338-2345.
14. Ekstrom, Richard A., Robert A. Donatelli, and Kenji C. Carp. "Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises." journal of orthopaedic & sports physical therapy 37.12 (2007): 754-762.
15. Fras, Christian, et al. "Substance P–containing nerves within the human vertebral body: an immunohistochemical study of the basivertebral nerve." The Spine Journal 3.1 (2003): 63-67.
16. Fagan, Andrew, et al. "ISSLS prize winner: the innervation of the intervertebral disc: a quantitative analysis." Spine 28.23 (2003): 2570-2576.
17. Fischgrund, Jeffrey S., et al. "Intraosseous basivertebral nerve ablation for the treatment of chronic low back pain: a prospective randomized double-blind sham-controlled multi-center study." European Spine Journal 27.5 (2018): 1146-1156.

Manoj Mohan, DO, is a PGY 3 at Stanford with an interest in Spine and Musculoskeletal medicine.

Personal Finances in Residency

By Jay Panchal, MD

I still remember one of the most frightening days of medical school, the financial aid exit interview. It was a day where the school’s financial aid department would give lectures about debt management and options for loan forgiveness before each person was handed an envelope. The paper in the envelope detailed every loan one had taken for their education thus far. More surprisingly, those lectures about economics, money management, and personal finance were all fit into one day of four years of medical school. It was not long before my classmates were all panicked and concerned about their personal finances. Worst of all, no one knew where to start. Personally, I was lucky to be introduced to investing and personal finance very early on by my parents and brother. I contributed to a 401k retirement plan with my very first job at Best Buy when I was 16 years old! As medical school ended, many students were beginning their first job ever, as a resident training in the specialty of their choice. This usually comes with large piles of paperwork including the very familiar onboarding documents, immunization records, and mandatory trainings. However, there were many documents that most residents were not prepared to sign. These included their first ever contract, choosing a health insurance plan that was separate than their parent’s plan, and their retirement options. As a PGY-4 resident, many of my colleagues are still unaware of their options for retirement plans, whether their institution matches contributions (essentially free money!), and how they should be planning for their financial independence. But where to start?

I always recommend the first place to start is “The White Coat Investor: A Doctor's Guide To Personal Finance And Investing” by James M Dahle. Dr. Dahle is an emergency medicine physician who noticed many of the things mentioned above during his training and decided to help his fellow white coats. He wrote his book which is invaluable for the financially naïve physician. His mission, outlined on his website, is as follows: “The White Coat Investor has a three-prong mission that has served us and our community well over the years:

1. To help those who wear the white coat get a “fair shake” on Wall Street (i.e. boost financial literacy among high income professionals)
2. To feed my entrepreneurial spirit (build something larger than ourselves, create jobs, and make a few bucks ourselves)
3. Connect our community with the “good guys” in the financial services industry (thankfully there are a few of them out there)”

What began as a book has now evolved into a website with incredible resources about retirement, disability insurance, student loans & refinancing, and many other topics every physician should be aware of. A few of my favorites tips from the white coat investor include:

1. Live within your earned income

• Residency years are busy enough with all of the requirements during those challenging years. This is not the time to splurge on unnecessary purchases, but rather the time to start paying down loans with an income-based repayment plan (for federal loans)

2. Build emergency reserve (3-6 months)

• Always prepare for emergency situations which can put a lot of stress on finances

3. Pay down credit cards

• Avoid high interest debts including credit cards

4. Contribute to your institutions available retirement plan (likely a 403b) and find out if your employer matches contributions. Matching contributions means that for every dollar you put into your retirement fund, your employer will match it up to a certain percentage (usually 3-4%)

5. Ask Questions!

• Speak to other physicians, senior residents, family members in medicine, certified financial advisors (ideally those who do not work on commission) to find what works best for you and your situation.

6. Visit https://www.whitecoatinvestor.com/faq-frequently-asked-questions/ to get started with some basics!

As medicine continues to evolve with changes in insurance, reimbursement, and hospital systems, every physician should empower themselves to strive for their financial independence. It all begins with education, and while I know that white coats have always succeeded with education, it is time to educate ourselves on personal finance.

Jay Panchal, MD, is a PGY-4 at Rutgers New Jersey Medical School – Kessler Institute for Rehabilitation who is doing a Spine and Sports Medicine Fellowship at the Hospital for Special Surgery next year.

Strength in Numbers

By Komal Patel, DO

Being on a rehabilitation unit, the concept of a team is crucial. With constant communication amongst the team members as well as official team meetings, physical medicine and rehabilitation as a specialty is built to be run by a team. We see how much better patients do when there is a group of people encouraging and supporting them rather than just one person.

How do we take this team concept that is so ingrained within the field of physical medicine and rehabilitation and expand our work structure to other medical specialties?

The field of medicine can be very regimented in certain aspects and breaking that mold by collaborating amongst departments can help to not only enhance patient care but also advance the field of medicine altogether. As the current brain injury fellow at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, I have had the opportunity to learn this skill of collaboration as a part of my training.

There are multiple avenues to create this teamwork atmosphere amongst the varying departments. Some of the methods that I was allowed to partake in during my fellowship training year included:

1. Rounding with the different specialty teams on patients I was following
2. Sitting in on grand rounds/lectures provided by other departments
3. Creating common goal research projects with other specialties
4. Rotating or spending off time learning from other specialties

All of these experiences provided me with additional knowledge with regards to how other specialties offer patients their services, on top of what I am expected to know through my physical medicine and rehabilitation background. Through these interactions we can provide ideas and thoughts on how to improve or adopt certain processes. There is so much know within medicine and it is even more fascinating that we still probably know less than what we do not know. Each medical specialty provides a different insight and understanding that may allow us to accomplish our goals in a more efficient manner. It is important to learn the mindset and technicalities of other specialties in order for us to collaborate on a common goal.

Collaboration with newly started research projects has allowed me to complete more of my projects than I ever expected during this one year. Seeing what other specialties have to offer and how they go about helping patients has allowed me to prepare patients prior to sending them to a consultant.

At the end of the day, we, as medical professionals, are all in this to help people. Proper communication and teamwork only helps us to accomplish our goals related to patient care and advancing the medical field more easily.

Komal Patel, DO, is a current Brain Injury Medicine Fellow at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health.

Interview with Dr. Ankur Verma, Current Sports Fellow at Baton Rouge General

By Wyatt Kupperman, DO

Within all branches of medicine, an increasing number of residents are interested in fellowship. One such fellowship, non-operative sports medicine, continues to gain popularity in our field. But like the adage “all roads lead to Rome,” there are multiple paths that lead toward sports. I discussed some of these finer points with Ankur Verma, DO, former chief resident at University of Chicago/Schwab Rehab and current sports fellow at Baton Rouge General, where he covers Louisiana State University athletics.

Why did you decide to pursue a sports fellowship given your already extensive background in musculoskeletal medicine?

Sports medicine means different things to different people: musculoskeletal, ultrasound, procedures, team coverage. To me, it meant being associated with a team and improving my knowledge in sports-specific injuries and primary care issues such as sports cardiology.

How did you decide between applying to family and PMR sports programs?

Programs emphasize different things and have their own merits, independent of their background. I looked at each program individually and determined whether it fit my goals.

What is your favorite part about fellowship?

Seeing the relationships I built with athletes, coaches, trainers, student-trainers, nutritionists, and psychologists play out during practice and game day.

What are some of the challenges you face as a physiatrist in a family sports fellowship?

After a week of LSU football training camp, I realized something: I could diagram the brachial plexus, but didn't know how to treat a cold! Luckily, my family medicine co-fellow was able to help me get better at IVs and blood draws. You know, the things I refused to do as an intern.

Another challenge is overcoming bias. People look at me like I'm from Atlantis when I tell them I didn't just manage pain meds in residency. It blows their mind.

What are some of the benefits from being a physiatrist in sports medicine?

There's something to thinking like a physiatrist. It has seeped into the way you approach patients and understand the multidisciplinary nature of sports. Plus, just like I stole my Z-pack skills from my co-fellow, he reworked his neurological exam based on what he's seen from me.

What is SEC football really like from the sidelines?

It feels like I've been transported directly into Tiger Stadium from my NCAA 2004 video game I played sophomore year of high school. It's loud, glitzy, and chaotic.

What are your long term plans after completing fellowship?

I'm hoping to meld sports medicine with my love of sports analytics in the future. I created a website at www.injurymetrics.com to explore that interest.

Aside from the regenerative movement, where do you see sports medicine in the next 10-20 years?

I'm just a fellow, so I'm not an expert. But I think the increasingly available biometric and analytical data, particularly in high-level sports, will play a role.

What advice would you give to PM&R residents applying for sports?

Only you know your goals. You will hear a lot of things that may not line up with them. Also, what someone else judges about you isn't necessarily true.

Wyatt Kupperman, DO, is currently a PGY4 at Schwab Rehab/University of Chicago and will be a Spine Medicine Fellow at the Cleveland Clinic next year.

Getting Involved in Research as a Medical Student: An Interview with Dr. Justin Weppner, Brain Injury Fellow at the University of Pittsburgh Medical Center

By Eben Alexander, OMS-4

What is the best way to get involved in research as a medical student during the first and second year?

Well I think that the hardest part of getting involved in research in first and second year would be figuring out what you want to do. The key to it all is finding an area of interest that is interesting to you and a mentor that has those same interests. Figuring out what clinical area or aspects of research that you are passionate about may take some introspective reflection. Especially as a medical student, you may not know how to go about research. Everyone has different backgrounds in undergrad. I think that finding a research mentor in the area that you want to explore would be key.

What’s the best way to get involved during your clinical years? Would it be any different than your first two years?

I think that having a research mentor is still key. In addition to research projects, the clinical years may pose opportunities for scholarly activity. There are a lot of things clinically that you can do your third and fourth year like write up interesting cases with clinical mentors that may not be the same as your research mentor. Finding someone in the clinical realm that is doing you want to do and exploring case reports, poster presentations, case series may be helpful third and fourth year.

What do you suggest if you are at a school that is not affiliated with a large academic hospital or there are not physicians in the specialty that you want to apply into? I know that this applies to many of the osteopathic students who will read this.

AAP has a summer externship that you can do between your first and second year. If you’re not affiliated with a physiatry program, doing that externship and meeting both clinicians and researchers in PM&R would be really helpful. Unfortunately, by the time people figure out they want to be physiatrists this may have already passed. But if you’re not affiliated with a medical school that has a hospital that has a physiatrist, that would be one way to go about that. The AAP offers the Medical Student Summer Clinical Externship (MSSCE) with 16 programs participating the summer of 2018. MSSCE students spend eight weeks immersed in didactics, outpatient and inpatient clinical experiences (roughly 50% each), simulation exercises and mentorship with a clinician-educator at the sponsor site. Participants are given a $4,000 stipend, and the sponsor site also covers registration and travel to the AAP's Annual Meeting, where students will present a case report and build their network. The AAP also offers the Rehabilitation Research Experience for Medical Students (RREMS). In 2018, seven medical students participated in the program. RREMS students spend eight weeks working on their proposed research plan at the sponsor site of an accomplished PM&R mentor. In addition to the research completed during the program, many students are also given the opportunity to spend time in the clinic with their mentors. Participants are given a $4,000 stipend, and the sponsor site also covers registration and travel to the AAP's Annual Meeting, where students present scientific papers. That would help you get exposure to PM&R and get exposure to a mentor in the field. More information may be found on the AAP’s website.

Does getting involved in any topic of research versus research in the specific field that you’re interested make a difference?

I don’t think it does make a difference. I think the import part especially early on is getting experience in the research process, in the research method, writing an IRB proposal, dealing with an institutional review board. Those are all important concepts to gain. Early on, a lot of my research had nothing to do with physiatry and I think it was all beneficial in understanding the research process, understanding the IRB process, and honing those research skills.

Are there certain types of research that residencies look for (such as meta-analysis vs case report) as opposed to the number of publications that a medical student has?

Everywhere it’s going to be different on what they expect. The expectation at program A is probably different than the expectation at program B. Doing original research would be great if you can do that but doing a meta-analysis or doing a poster presentation still shows interest in the field; it still shows interest in the research process. The higher level research you can get involved in the better, but I’m not sure there’s a bench mark. It’s kind of a hard question to answer. The higher the level research you’ve done the more competitive you may be, but I don’t think that research is an absolute requirement to match into PM&R right now. It’s just a helpful piece.

Is there any financial support involved in the research process as a medical student?

MSSCE and RREMS both provide a stipend of $4,000 as of 2018. Additional funding would depend on the area of research being studied. A good mentor would be an expert in financial support available in your field of study. The AAPM&R also has some guidance available on their website.

https://www.aapmr.org/career-center/residents/research-guidance-and-funding-opportunities

What other resources would you recommend to medical students that can help them produce high quality research and help guide them (websites, how to resources, etc.)?

That goes to having a good mentor. There is a program called Research Badges. UC Irvine started it. Basically, it helps you identify the knowledge and skills required to conduct research, answer some of the most commonly encountered questions as you undertake research and publication. You find a mentor and you can go through these steps. It can be used to nurture the mentor-mentee relationship and to increase your research literacy as you work on a research project. This guide is especially helpful if you come from a program that does not have the resources to provide mentorship in research.

https://www.physiatry.org/page/ResearchBadges

Do you see having research as becoming more important for applying to residencies in PM&R than it used to be?

I don’t think that research is a requirement for application to PM&R residencies. I think that it could enhance your application by having research especially if you want to have research as a focus of your future career it would be nice to get started early. However, I can say right now that it is not a requirement and people are still matching into PM&R that do not have extensive research backgrounds.

Are there certain things that you would recommend for medical students to do to set themselves up for successful research during residency?

Well, number one, have a research mentor, it doesn’t have to be an MD or DO, it could be a PhD somewhere that’s in your area of clinical interest. Two, would be to look at residencies that have opportunities in that area of interest. So if you’re interested in prosthetics and orthotics research, try to go to an institution that is doing research in that area or research at all, but especially research in your clinical area.

How easy do you think it is to work with a PhD with all the demands of residency?

I know plenty of people that have done it. It depends on what your clinical focus is. Sometimes it’s going to be an MD or a DO. Sometimes it’ll be a PhD though. Sometimes it might not even be in your specialty. If you’re interested in sleep and disability, maybe your mentor is a PhD sleep researcher or a neurology sleep specialist, so it just depends what your focus is going to be. Many people won’t have a research focus going into residency, and that’s ok, and if that’s the case just keep an open mind. If you don’t have a research focus going into residency and don’t have a clinical focus going into residency try to pick a program that’s well rounded that does all areas of rehab well, so you have all the opportunities available in research and the clinical aspects of PM&R.

Eben Alexander is an OMS IV at Via College of Osteopathic Medicine, Virginia Campus, and is the AOCPMR Student Council Vice President.