Physiatry in Motion Issue 12, Autumn 2018

Update from the AAP RFC Chair — Autumn 2018

The official announcement for abstract acceptances for Physiatry ’19 went out last week and we are excited to welcome a record number of PM&R trainees to the beautiful island of San Juan, Puerto Rico from February 19–23, 2019! The number of abstracts submitted has continued to rise, and more importantly, research abstracts increased dramatically this year. We hope that these experiences will encourage physiatrists to continue to perform high quality research throughout their careers, driving the field forward in the future.

The resident/fellow/medical student program for Physiatry ’19 is set to be the best yet! The incredibly popular half procedural skills workshop will be held again on Wednesday, February 19. Be sure to sign up for this hands-on experience when registering for the meeting. Additional workshops will cover important topics including how to get involved with research at any stage of training, writing wheelchair prescriptions, and solving challenging cases in ASIA classification. Career pearls sessions including advice on job/contract negotiations as well as roundtables with fellowship program directors will arm trainees with important information for the next stage of their careers!

The number of medical students interested in PM&R is growing rapidly! The inaugural AAP Medical Student Council has put together a series of sessions with program directors and residents on Saturday, February 23 to guide medical students towards success on their PM&R rotations and in the residency match.

The annual meeting also marks the time for transition in the RFC leadership. Neal Rakesh will be taking over RFC Chair duties, but all other positions are open and we are eager to welcome in a new group of leaders! This year, instead of written statements, we are asking applicants to submit a short video (2 minutes) introducing yourself and describing why you want to join the RFC. The video should be filmed in a single shot of you speaking in front of the camera — no props, fancy animation, special guests, or post-processing! We will be highlighting these videos on social media in the weeks leading up to the meeting, and encourage all AAP resident/fellow members to cast their votes. Position descriptions can be found here. Applications can be submitted online and are open now through December 31st. You must be present at the official election session at Physiatry ’19 to be eligible.

Finally, we are excited to announce that the Resident and Fellow Section of the American Journal of Physical Medicine and Rehabilitation is officially accepting submissions! Check out the author guidelines and submit your articles for peer-reviewed publication today!

The RFC is dedicated to representing all residents and fellows. Please let us know if you have any questions or comments about what we can do to help you grow into the future leaders in physiatry by emailing us at residentfellowcouncil@gmail.com or posting on the RFC forum.

You can also find out more information about the RFC on the AAP website and on social media!

Website: http://www.physiatry.org/page/AbouttheRFC

Facebook: AAP Residents/Fellows/Students

Instagram: @aaphysiatrists

Twitter: @AAPhysiatry_RFC

Allison Bean, MD, PhD, is a PGY4 at Mount Sinai Hospital in New York City and Chair of the AAP Resident and Fellow Council.

Just Ice It

By Brittni Micham, MD

Deep in the heart of hockey country, there is an annual contest only the brave dare enter. Where warriors gather with blades and sticks in an arena of ice to compete for the title of champion. It promises glory, delight, and a little good-natured embarrassment.

Just Ice It is an annual fundraiser for the Mighty Penguins sled hockey team. Every spring, residents and attendings from the Department of Physical Medicine and Rehabilitation at UPMC volunteer. There are sled hockey matches, meet-and-greets with players, and a raffle with prizes such as a signed Sidney Crosby jersey and other hockey paraphernalia.

Physician participants don protective gear and strap into adaptive sleds. The first match of the fundraiser pits residents against attendings and it quickly becomes obvious very few are actually skilled in the sport. In fact, for new players, deceleration is often abrupt and secondary to an unintended collision. This particular resident spent much of the first match trying, and ultimately failing, to simply keep the sled upright. The sport is challenging, but incredibly fun to both play and watch.

The experienced attendings usually prevail over the residents and go on to face the Mighty Penguins in the final match. It is here that the skill of true sled hockey players can be appreciated. They race back and forth across the ice, making hairpin turns and launching shots at goal. It is never a close match, even with the Pens taking it easy on us, but it’s always good fun. Not only does the event help provide funding for the team, but it also increases awareness and gives providers an opportunity to be involved in the adaptive sports community. It is a wonderful reminder of why we do what we do.

For more information about the Mighty Penguins, please visit http://penguinssledhockey.org/.

Brittni Micham, MD, is a PGY4 at the University of Pittsburgh Medical Center who is also the Technology Chair of the AAP Resident and Fellow Council.

Pearls and Pitfalls for Early Career Physiatrists

By Chris Cherian, MD

Dena Abdelshahed, M.D. is a an Assistant Attending Physiatrist at the Hospital for Special Surgery (HSS) in New York, NY and Assistant Professor of Clinical Rehabilitation Medicine at Weill Cornell Medical College. At HSS, she is Associate Director of Education for the physiatry department. Prior to pursuing her fellowship, Dr. Abdelshahed was a resident at Rutgers New Jersey Medical School/Kessler Institute for Rehabilitation, including serving as the Academic Chief Resident in her final year. Dr. Abdelshahed completed the Spine and Sports Medicine fellowship at HSS this past July of 2018. I sat down with her to discuss her transition from fellowship to attending, including pearls and pitfalls for early career physiatrists.

Dr. Abdelshahed, thank you for taking the time out of your busy schedule to answer a few questions about your recent transition from fellow to an attending. How has your first few months been as a new attending?

“It’s definitely my pleasure to talk about my experience. It has been at a lot of fun and challenging in different ways. At the end of fellowship, you feel relatively prepared in terms of your medical knowledge, but the real world it is just a little bit different so it definitely took some getting used to it. While training, I had an attending physician in the room with me when I was doing a procedure or to turn to when I had a tough case and had to figure out the diagnosis. However, now as a practicing attending, you have to learn to trust your clinical acumen. But probably the aspect that you have to get used to the most is the behind the scenes work that you’re sort of spared from in all of your medical training in residency and fellowship. There is so much that goes on from coordinating care for your patients, getting them in to see a specialist, or getting an MRI authorized, or even figuring out the type of procedure and scheduling, all those aspects of practice just take a little bit of getting used to. However, once you do you kind of hit your stride, it starts to feel like everything that we already know how to do.”

What are some unique aspects of the transition that you did not expect?

“Sometimes the most challenging aspect can be knowing what the right course of action is for a patient, but having some sort of obstacle in your way, such as getting insurance to approve the treatment you propose that you believe will benefit the patient.

“For example, I recently had a patient that had history and physical exam findings such as weakness and a diminished reflex consistent with a lumbar radiculopathy which I documented in my notes. I ordered an MRI of the lumbar spine and it was rejected. I called the insurance company and eventually completed a peer to peer to advocate on the behalf of my patient. The person representing the insurance company explained that because I didn’t document a change in sensation, it didn’t meet their arbitrary criteria to approve the MRI. I then had to explain to the individual what my clinical reasoning was and why the lack of changes in sensation didn’t mean it wasn’t a radiculopathy, especially when all these other signs point in the direction of that diagnosis. So from my perspective, coming to a diagnosis that was so clear and obvious to me, but having to explain that and sort of go that extra step helped me realize that sometimes even simple things can become difficult and they just take extra time or extra effort.”

During your training, were you provided with any lectures or guidance to help with the transition?

“Definitely. I think some of the most important things I learned aside from all the medical knowledge is learning to find the correct mentors and also learning how to be a good mentor. One important part to realize is it’s not as perhaps intuitive as you might think. Especially if you’re someone interested in working in academics and being involved in residency or fellowship training, learning to be a good mentor is a skill. I had some lectures on that and luckily in my fellowship, we had some sort of formal and informal lectures on that topic. It really is an part of transitioning from a trainee to a full-fledged attending. Also, during my fellowship training, I was exposed to formal didactics aimed at learning about coding and billing, about starting a practice, contrasting academics versus private practice, and various medical legal topics those are very important aspects of medicine that you sometimes forget about but can be just as important as the medical knowledge that you gain during your training.”

What advice would you offer to a person finishing up fellowship or residency, that in retrospect, would’ve helped with the transition?

“Probably the biggest advice is identifying good mentors that will give you honest advice whether that’s about what job you should take, what’s fair compensation, or somebody that you can text/call/email with a clinical question when you just need that sort of back up. So I’ve been very lucky in having those are sort of mentors. Also, something that can be helpful is to identify someone that you’ve come across in training that you can also serve as a mentor for. Someone that you know their work from your interactions, that you can provide that sort of real world and clinical advice. I also feel that one thing that we may not have so much experience with until you transition is negotiating a contract. It’s sort of nerve wracking and certainly for me it was the first job contract that I had negotiated; it can be awkward as well as challenging. I realized that you should not be afraid to ask for certain perks or equipment you may be interested in. Really the worst that can happen is they say no and that’s okay! So identifying the things that are important to you and not being afraid to advocate for yourself is really important. No job will be perfect, but you should strive to be happy and I definitely am very happy where I am now. However, you never know where you’ll be in five or ten years so you should really think about what’s important to you, what your goals are, where you see yourself in the future, and then be your own advocate.”

Chris Cherian, M.D. is a PGY-4, Chief Resident in the Department of Physical Medicine and Rehabilitation at Rutgers New Jersey Medical School/Kessler as well as the Advancement Representative on the AAP’s Resident-Fellow Council.

Advocacy and Healthcare Policy

By Ellia Ciammaichella, DO, JD

As physiatry residents we are often reminded that we are our patients’ advocate. We are taught to advocate for application of best practices. We are taught to advocate for the patient’s safety in the hospital, in the home, and outside the home. When patients are denied care that is vital to their health and independence, we hear how the attending physician works through community resources and the insurance process through prior authorizations, peer-to-peer review, and appeals. A physiatrist’s role in patient advocacy, however, is not limited to the individual patient that is under his or her care.

An integral and fundamental part of patient advocacy includes actively participating in shaping healthcare policy to improve healthcare to many more patients than you can see in you clinic. This means participating in various medical organizations to promote access to healthcare that is vital in every person’s health, wellness, and independence at home and in the community. Specialty organizations such as Association of Academic Physiatrists, Academy of Physical Medicine and Rehabilitation, and other physiatry centered organizations are important in advocating for the needs of our patients.

In addition, our patients also benefit from patient advocacy from other more encompassing organizations such as county, state, regional, and federal medical societies. These medical societies often encompass a variety of specialties and often allow resident physicians to contribute to healthcare policy through the process of resolution submission to their house of delegates. For example, I had the privilege to submit a resolution entitled “Supporting Reclassification of Complex Rehabilitation Technology” to the resident and fellow section of the Texas Medical Association (TMA), which was adopted and submitted to the Texas House of Delegates. The Texas House of Delegates understood how important it was to improve access to complex rehabilitation technology equipment for individuals with substantially disabling and chronic conditions in the home and outside the home and adopted the resolution. Because of this process, an issue that is near and dear to the hearts of many of our patients was clearly communicated to a group of people who would likely have not identified this barrier. TMA is now empowered to speak to Texas politicians. In addition to this, the Texas delegation to the American Medical Association (AMA) submitted a companion resolution so that the AMA would also support the reclassification of complex rehabilitation technology. While the AMA chose to refer to resolution to the AMA Council on Medical Service for further study, I have continued to work with both the AMA and TMA for continued research and support for this resolution.

Admittedly, most physiatry residencies do not educate or encourage resident physicians to become thoughtful leaders in healthcare advocacy efforts. However, if you feel the calling to shape healthcare policy, you do not need to wait until you complete residency — start now. I recommend joining a medical organizations that provide resident physicians a forum to contribute to healthcare policy. Often, organizations have a resident section and/or provide opportunities for resident physicians to join committees or delegations. Delegates represent the membership of the organization and are given the task to propose and deliberate over healthcare policy initiatives through resolutions. A well crafted resolution incorporates standard of care and identifies the needs and concerns of the membership. To do this, first, identify potential sources of improvement in healthcare. If you are unaware of any potential sources of improvement, ask your colleagues or attending physicians. Second, gather information from other medical professionals about the issue. Third, research the topic and obtain data supporting and contradicting your idea. Fourth, amend your idea based on all the information you have gathered. Finally, bring these ideas to your organization. In this way, even resident physicians can propel the change in healthcare policy that our patients need to live a healthy and independent lifestyle.

Ellia Ciammaichella, DO, JD, is a PGY-4 at McGovern Medical School at UTHealth and will be a spinal cord injury medicine fellow next year at the University of Utah.

The Secret Life of a Rehabilitation Chair: An Interview with Dr. Joel Stein

By Neal Rakesh, MD, MSE

As a part of our rehabilitation chair series, I spoke with Dr. Joel Stein who is the current Physiatrist-in-Chief and Chairman at NewYork-Presbyterian Hospital which includes the Department of Rehabilitation Medicine at Columbia University College of Physicians and Surgeons as well as Weill Cornell Medical College. What follows is a transcript of a small part of our discussion on his road to chair. The full podcast will available soon.

How did you choose your residency?

“I initially matriculated in an internal medicine residency. I did that at Montefiore and I had a notion of becoming a primary care physician. I didn’t have a clear vision for my career at that point. It was a little bit of a default decision. As I was working as an internal medicine resident, I was frustrated by the feeling that I wasn’t making people better in the way that I wanted to. Their lives weren’t better. They would come into the clinic or hospital. I would make a diagnosis, but they weren’t necessarily able to do anything the next day that they couldn’t do the prior day or feel better. Treating their diabetes or hypertension wasn’t as satisfying as I hoped it would be.”

How did you end up going into a rehabilitation residency?

“Well the short story is I ended up in rehab because my wife was in the field and she seemed much happier. I said to myself “Maybe I might be missing something here”. I was able to take an elective during my medicine residency as a PGY-2, and I chose to spend it on the inpatient rehab unit at Columbia (University Medical Center). And I loved it. I was using some of those medical skills that I was working to develop. But I felt that I was helping people achieve more independence and more function, which is, of course, the essence of rehabilitation. So during my PGY-2 year in medicine, I actually decided that I was going to complete a PM&R residency and applied during my medicine residency.”

Did you know what you wanted to do after residency?

“It was pretty clear from the outset when I started my residency that I really gravitated towards neurologic rehabilitation. That was from day one and that was what drew me to the field. And inpatient particularly was where my interest was. I was quite confident that I was going to focus on spinal cord injury. I never liked taking care of patients with back pain and that remains a consistent theme in my practice (making sure these patients aren’t scheduled in my practice is the first item in my orientation for new staff). When I actually finished my residency and started looking for a job, I quickly came to realize that there were no suitable vacancies for SCI jobs within the geographic region where I wanted to live. But there was a job at Spaulding Rehabilitation Hospital in stroke rehabilitation, and I decided to give that a try that.”

What led you into leadership and research?

“While I have always enjoyed clinical practice, I missed having longer-term goals and projects, rather than simply dealing with today’s problems in the here and now. I felt that if I focused exclusively on clinical practice, I would get frustrated over time. I think some of the burnout issues that people experience may come from that sense of this endless line of patients waiting to be seen. It’s like the old episode of I Love Lucy with the conveyor belt. It’s a classic scene where she can’t keep up with the conveyor belt. And that’s what a lot of clinicians feel. No matter how hard they work, they feel like they are on a treadmill and need to work as fast as they can to keep up.

“I find both my administrative duties and my research activities provide very different perspectives and goals. These areas certainly have their own challenges, but having a diverse work portfolio provides me with a sense of balance. I would never want to give up my clinical work, but prefer to keep clinical medicine fresh and exciting by balancing it with these other activities.”

What advice do you have for medical students, residents and fellows interested in research, but don’t know how to go about it?

“If you are interested in research you should get started right away. I think there is no reason to delay. The real path to success is to develop a plan to establish dedicated protected time to really sink your teeth into your research program and activities to really define your interests. This provides you with a good bit of momentum and an opportunity to learn the skills that you will need to be successful when competing for extra-mural funding and advancing your research program. There are a variety of career development programs such as K award programs from the NIH that allow protected time to develop a research program. But to successfully apply for a K award, a candidate needs a strong proposal that takes time to develop. A research fellowship can provide an on-ramp for people to really dedicate time to research and develop a K application. That’s the path to success. To try to establish a research career on the fly, on nights and weekends while engaged in full-time clinical work, is very difficult and infrequently leads to a substantive research program. It’s not that it can’t happen, but it is a much more difficult and a less reliable path.”

Neal Rakesh, MD, MSE is the 2018–2019 Vice-Chair of the AAP Residents/Fellows Council and a PGY-3 in the Department of Rehabilitation and Regenerative Medicine at NewYork-Presbyterian Hospital (Columbia University College of Physicians and Surgeons & Weill Cornell Medical College)

Residents Get Burned Out Too!

A pilot study assessing burnout in PM&R residents

By Aubree Fairfull

While many recent studies have examined the symptoms of attending physician burnout and discussed the correlated negative effects of depression, increased medical errors, and decreased patient satisfaction, there is limited data about resident physicians and effects of burnout on their personal wellness and contribution to patient care. Given that residents function in a demanding work environment with minimal autonomy, fluxing expectations, and compromise of their personal priorities, I was surprised by the lack of data; however, this disparity only confirms that residents are often overlooked despite being involved most intimately in patient management. As a PM&R Acting Intern, I sought to determine to what degree residents at Penn State’s PM&R program experience burnout and to identify opportunities to promote wellness as a counterforce to burnout.

After a systematic literature review related to burnout and resident-specific data, I created a custom survey by referencing the style of questions used in validated surveys which assess burnout, such as the Maslach Burnout Inventory (MBI). To examine the impact of burnout on the PM&R residents in the Penn State residency program, an online survey of six questions related to subjective burnout level, work satisfaction, and wellness opportunities was conducted at the Penn State Rehabilitation Hospital during August 17–19, 2019.

Results were collected from nine respondents from the 2018–2019 cohort of PM&R residents at Penn State in the early months of their post graduate year 2, 3 or 4. Results showed that 77.8% of residents reported not feeling burned out at the time of the survey conduction; however, 66.7% of the same resident cohort reported feeling or having felt burned out during Year 2 of the program. Resident burnout was attributed to unrealistic expectations with duties, late admissions, excessive administrative tasks and documentation, and frustration with not having patient orders properly followed by staff. Reported current level of stress during a typical work day was 4–6 on the likert scale of 1–10 for ⅔ of the respondents. Current satisfaction with work life balance was 55% extremely satisfied or satisfied. When asked about awareness of what wellness opportunities the Penn State residency program provides, four of nine residents said “unsure,” while others identified access to gym membership, department picnics, and optional meditation workshops.

Burnout is a major problem affecting the well-being and productivity of physicians, especially residents. Through retreats and dedicating time for resident appreciation events, there is potential to foster a sense of supportive community and promote self care, both of which could mitigate burnout. After years of propagation of the fallacy that self-care and patient care are competing interests, it has become essential to support development of medical professional identity defined by seeking optimal personal wellness to put forth optimal healthcare practices. I believe this re-acculturation can begin with establishing wellness as a professional competency and quality indicator of resident programs, for example implementing an annual wellness survey and analyzing the results to create interventions that both address burnout and enhance well-being for a certain population of residents. Specifically at Penn State, I found that we can begin by increasing awareness of wellness opportunities, targeting year 2 with extra support, and providing more frequent structured options throughout the program years. Future studies will need to explore more extensively how wellness can be most effectively utilized to prevent burnout in residency and if there are interventions that can be applied more generally across various residency programs.

Aubree Fairfull is a current MS4 at Penn State College of Medicine.

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