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Introducing the 2018–2019 Resident Fellow Council

Introducing the 2018–2019 Resident Fellow Council of the AAP!

The AAP Residents/Fellows Council is a group of physicians in training at an accredited PM&R residency or fellowship program. Their mission is to promote the participation of PM&R resident physicians-in-training in the areas of education, research, and the practice of PM&R within the academic arena. The RFC also plays a pivotal role in developing and strengthening leadership skills among the resident physicians who in the future will be responsible for maintaining the standards set by the Association of Academic Physiatrists.

We’d like to extend a thank you to our previous leadership over the 2017–2018 year for all their hardwork, leadership and initiative:

The new Resident Fellow Council (RFC) officials were elected at the annual Association of Academic Physiatrists (AAP) 2018 conference in February in Atlanta. Several residents were in attendance with hundreds more voting online in a very tight race (some positions were decided between with a single vote!)

We are proud to announce the following winners:

Congratulations again to our winners, and we look forward to see what exciting initiatives you'll bring forth in the new year!

Past Experiences, The Current State of PM&R and What The Future May Hold: An Interview with Dr. Bruce Gans, M.D.

Past Experiences, The Current State of PM&R and What The Future May Hold

An Interview with Dr. Bruce Gans, M.D.

By Gary Panagiotakis, DO

What first drew you to the field of PM&R?

My story begins with my mother telling me that I want to be a doctor. I thought I wanted to be a nuclear physicist. And so, the compromise was that I was going to be: a doctor. I wound up selecting engineering schools, and attended Union College, a small liberal arts school in Schenectady, NY. While majoring in electrical engineering, I realized I did want to go to medical school. I stayed full time as an engineering major, but was able to build my own curriculum around the pre-med requirements. After completing all the pre-med requirements, I decided that I didn’t want to walk away from engineering. I also didn’t want to walk away from medicine. So, I said, I’ll do both.

I applied to universities that had both graduate engineering programs and strong medical schools. I didn’t apply to a unified program but both independently. Much like you do when you are young, I jumped into it and the pieces fell into place. I became dually enrolled in both schools. The funny thing is that the Biomedical Engineering department had a fellowship grant program, and I qualified for their program. It turns out that my tuition was paid by a stipend as a graduate student, which covered several of my years of medical school, so I actually got paid to go to medical school!

For my engineering degree, I was interested in research on the relationship between the electrical and mechanical force generation of muscles. I needed a lab space and I was working with a neurologist who had an association with the engineering school. I ended up getting my own lab in the basement of the hospital at the University of Pennsylvania. It was the rehabilitation department’s lab, but no one was making use of it. I built my own computer to study the generation of force and electrical energy of surface EMG.

It turns out that the Piersol Unit was just down the hallway. This was the rehab hospital unit at the University of Pennsylvania. I had no idea who — or what — was there. I walked up to the door and physically bumped into the chief resident, who turned out to be Frank Bonner. After I apologized for hitting him, I asked him “what are you guys doing there anyway?” He took me around and my head exploded when I saw what rehab was. I had no idea that this specialty within medicine existed. I got so excited when I realized that this specialty, PM&R, allowed me to figure out how to apply engineering problem-solving principles to the human condition.

I looked for a mentor to provide guidance, and met the chair of the department. Bill Erdman was a wonderful man who was also chief of staff for the hospital. I remember him telling me that I shouldn’t stay there for residency; I needed a stronger program than he had to offer at that time. I will never forget the selflessness of a program director to let me know that my interests were not consistent with what his program had to offer. And so, I did a cross-country ten-week camping trip with my wife and sister-in-law, looking at residency programs. That was how I ended up discovering the University of Washington.

Throughout your career, you have been an advocate for people with disabilities, and early on, your focus was on advocating for the pediatric population. What interested you most about pediatric rehabilitation?

Early on, I had a rotation at the children’s hospital, and I fell in love with providing care for these patients. I also fell in love with the idea of applying engineering principles to solve problems for children with disabilities. They are so adaptable! Some of my favorite experiences involved working with non-vocal kids with cerebral palsy, or addressing the challenges of seating and mobility for these kids. I saw how I would be able to help. I knew at that point I wanted to specialize in pediatric rehabilitation.

It’s interesting. In those days, there was no training whatsoever. If you wanted to specialize in pediatric rehab, you just had to declare that you were doing it. I worked with the program chair to spend as much time as possible rotating at the children’s hospital. I developed a good friendship with the rehab doctor who was there, Morris Horning, and received his mentorship. I started to look for jobs. The University of Washington invited me for an interview, and wound up telling me that they would offer me a job as faculty. They also told me that they had no idea what my specific assignment would be- they hadn’t figured that out yet.

Around February of my last year, I was rotating with Morris Horning again, and he said, “Bruce, I just wanted you to know that I’ve decided to leave. I’m moving to Alaska and I will be leaving the beginning of April.” I replied, “I really wanted to work more with you, Morris. What am I going to do now? Somebody else is going to start working here.” I went to the chairman of the department, Justus Lehmann. He was a very intimidating individual, who was the first department chair at the University of Washington. I approached him and said, “Dr. Lehmann, I would really really like to have the position at the children’s hospital, but Dr. Horning is leaving in April, and I don’t finish until July. Can that be my assignment when I finish?” He responded with, “I’ll tell you what I’m going to do, you will finish your residency three months early and I will let you take over this position. However, I can’t afford to pay you as an attending, so I’ll still pay you as a resident. Also, I can’t replace you as a resident so you’ll have to function as your own resident.” I was such a sucker; I wanted that role so desperately that I took that deal! Little did I know, one can’t just finish residency early! It doesn’t work that way! In reality, I was still a resident- just with double the work.

So, one Friday afternoon in April, I left the hospital as the resident on-call. That following Monday morning, I returned as the Pediatric Department Director. The reality is, I had no intention of jumping straight into an administrative leadership role; but it happened. I had to learn on the job. I had to try to manage all sorts of interesting experiences and people. Funnily enough, I discovered that a lot of management is just like an engineering project; there are many different components to pay attention to, such as budgets and outcomes. All told, it fortunately turned out to be less challenging and complicated than I originally thought. I guess I had some natural aptitude for it.

Can you expand on your path into academic leadership?

About a year later, I was just starting to get settled into my new position when I was approached by Paul Corcoran at the Academy meeting. He told me he was searching for an associate chair for his program (Tufts) and asked if I was interested in moving to Boston.

I said, “Wow, it’s really great to meet you Paul, but I’m not looking for a job yet. I’m just getting settled in.” Well, one thing led to another, and after discussing it with my wife, I went to the interview. While we loved living on the West Coast, both of our families were from the East Coast. I was forced to really think about whether I was going to continue down the path of academic administration. If so, this opportunity was knocking, and was doing so really loudly!

We moved to Boston. On my first day, Paul meets me at the door. He shows me to my office and then proceeds to tell me he was leaving for one month, and that I was in charge. I didn’t even know where the bathrooms were! About two years later, Paul accelerated his decision to leave as chair. I was appointed acting chair for a year, while they searched and searched and searched. Their search ultimately led them back to me, and that’s how I became the chair of the department.

The next crazy thing that happened was after about eight or nine years of being in Boston. I was in my office and the phone rang. On the line was a great pediatric rehab physician named Leonard Bender who was the President of the Rehabilitation Institute of Michigan (RIM) in Detroit. He said, “Hi Bruce, I’m watching the methotrexate drip into my arm because I’m coming to the end of my fight with cancer, and I’m looking for my successor.” I said, “I’m terribly sorry to hear about your illness Len. I have no interest in moving to Detroit, but I am very flattered and appreciate it.” Before I knew it, I got a call from the chair of the board — and medical director for Ford Motor Company — Duane Block. He asked me to seriously consider the offer, and inquired whether he would be able to fly out to meet me just to discuss it. I then went home to my wife and told her that I really feel bad saying no to these people, sight unseen. Maybe I should fly out there, if only to make it clear why it was not a good idea. My wife said, “yeah have a nice life, don’t think I’m moving to Detroit!” I said to her, “I’m sure this isn’t going to work out, but I just can’t turn it down without seeing it.”

So, I went there and was blown away by the opportunities. My visit convinced me that I did want to go to Detroit. What attracted me was just how impossible the job seemed. It was President of the rehabilitation hospital, Senior Vice President of Detroit Medical Center for all post-acute care, and Chairman of Physical Medicine and Rehabilitation at Wayne State. I had gone as high up the administration ladder as I was able to in Boston; there was nothing more I was able to achieve there. If I wanted to do more — and I did — I would need to move. By this time, I had learned that one can really accomplish things at a certain level if one has control over the budget, as well as administrative and leadership responsibilities, to direct an organization.

I then approached my wife and told her that I would only accept this job if the family voted and agreed to it, but only after a site visit. On the plane, I remember my thirteen-year-old daughter screaming “I’ll kill myself if I have to leave Wellesley,” where we were living at the time. On the way home, she screamed “I’ll kill myself if we don’t move to Detroit.” That was how we moved to Detroit as a family.

Do you have a strategy for evaluating opportunities? How do you know which organization would be the best to get involved with?

It’s the magnitude of the potential impact. I always want to make a difference. I get frustrated with the system when it works against people. For example, in Seattle, computerized devices were beginning to become available for communication for non-vocal kids with CP. However, they were ridiculously expensive and insurance companies and Medicaid would not pay for them. This was unacceptable. Because I wanted to advocate for my patients, I began getting involved and created an organization: The Pacific Northwest Non-Vocal Communication Group. It is a multidisciplinary group, includes families and patients, and advocates for getting kids access to these devices.

I learned that the best way to advocate for your patients is to organize a group of people to form that voice, and we turned around insurance companies and the Medicaid program. When I moved to Boston, I was able to form the Northeast equivalent of this group and go way beyond the boundaries of my organization.

You need to look for opportunities that will allow you to change the system. You need to realize that it always about the money, and policy drives access to these services.

How would you suggest residents/fellows get involved with leadership while still in training?

We have created a few programs for future leaders, such as the Program for Academic Leadership(PAL) through the AAP, and the Academy Leadership Program through AAPM&R. Both are aimed towards early-career physiatrists. Looking into your own program’s leadership and you will find that many have served on councils such as the Resident Fellowship Council (RFC) and are very involved in the national community.

A lot of residents are very disinterested in looking outside of developing their technical skill knowledge and figuring out how to get a job. But once you start working in the real world, the economic realities and policy kick in. It hits you like a ton of bricks how important it really is.

You need to look at the big picture. The concern should be to look at larger scale issues, not with immediate gratification issues. You also have to be comfortable accomplishing work through others. Part of that is delegating, but most physicians are selected and trained to learn how to do things with their own two hands.

We are already unique as a specialty because we understand the value of having a team. As such, you have to delegate certain tasks to the team. To see the real strength of us as physicians, you have to look at our executive strategic ability to direct resources, our vision about how things should be, and our ability to orchestrate these resources to get that vision executed.

Are there any underemphasized skills that you believe trainees should focus on?

I look at it from a patient-centered, humanistic point of view. What makes us unique as physiatrists is our ability to see patients as people in the context their community and society. Our field’s core value is staying patient-centered and focused on their function in the context in which our patients need to work and live. This is why many of us tend to get involved in public policy, advocacy and fighting for the patient, because it’s affecting the person in the context of their resources and society. It comes a little more natural to us. We have such a broad range of technical skills packaged within our specialty. The ability to also understand how multiple people can be orchestrated to serve the patient’s needs is another strength.

What is your vision for the future of our field at the national level?

Starting with PM&R as a practice, we are so pluripotent and our practice can go in so many directions. It is inconceivable to me that we will have a hard time finding creative satisfying clinical work. It may evolve and change, depending on what the tools and opportunities are, but the core principles and values that we learn in our specialty are going to be well-utilized in many potential pathways. I think there is a tremendous future.

On the healthcare delivery system scale, we always need people who understand the different levels of service. We need people to help make connections across the different parts of the system. Through our hospitals and different ventures throughout the country, we are promoting the physiatrist as the one who can identify when a patient can transition from one level of care to another and take advantage of the various acute and post-acute pieces of the system.

One thing we’ve fallen into a trap about at the institutional setting is focusing way too much on the rehab and not nearly enough on the medical care. If you ask what’s the difference between a nursing home and a hospital, it’s the nursing care and the doctors. That should help differentiate which people should belong in which setting.

There is a big need and opportunity in our field to influence the continuum of care. With the American Medical Rehabilitation Providers Association (AMRPA) I have been pushing things like the continuing care hospital. Together, we have developed a model where we get rehab hospitals, acute care hospitals, nursing homes, LTACs, home health agencies and the payer to come together in advance to do post-acute care in a better way. We want to have shared economic opportunity and risk and make the right clinical decision the first time. This is the idealist in me, and the clinical optimist in me believes that one has to at least put those grand ideas out there. We have amazing traction with this idea of a continuing care network. It’s a great place to move forward. At the end of the day, we are taking care of people. Patients always come first, the business will follow, and it is our responsibility not to lose sight of why we are in the field of medicine.

Bruce Gans, MD

Bruce Gans MD is the Executive Vice President and Chief Medical Officer, Kessler Institute for Rehabilitation and National Medical Director for Rehabilitation, Select Medical Corporation. He is a past President of the AAP, AAPM&R, and Board Chairman of AMRPA.

Gary Panagiotakis, DO

Gary Panagiotakis DO is a fourth year resident in the Department of Physical Medicine and Rehabilitation at Kessler Institute for Rehabilitation/Rutgers New Jersey Medical School and the 2017–2018 Social Media Ambassador for the Resident Fellow Council of the AAP.

Wellness in residency: Preventing burnout

Wellness in residency: Preventing burnout

By Venessa Lee, MD

As residents, managing a full plate of responsibility is merely our default setting. We attempt to squeeze more work, more family time, more studying and more social events into the same 24-hours that was already not enough time. Increased advancements and tools have been developed to help manage the workload, but at the same time, allowing us to be spread thinner because of the illusion we have freed up more time.

The frenetic pace the average resident operates at has produced alarming statistics regarding the mental and physical fitness of our colleagues. According to the article Burnout in Medical Residents: A Review, the burnout rate ranges from 18-percent to 82-percent and, sadly, this is said to be trending upward. Another worrisome statistic is the prevalence of depression and depressive symptoms among the resident population. In the 2015 article, Prevalence of depression and depressive symptoms among resident physicians: A systematic review and meta-analysis, the researchers stated that 29-perecent of residents were depressed.

More staggering, if we look inside our own house, 38-percent of PM&R residents were said to be depressed, based on the annual survey by the GME Wellness Office. The toxic coupling of burnout and depression statistics that are clearly heading in the wrong direction have mobilized programs across the country to confront this growing problem in an attempt to reverse the tide.

At the University of Utah, we are beginning to roll-out wellness programs that focus on building a sense of community and comradery. We are planning break the program down into ten 1-hour sessions spread throughout the year. Half of the sessions will center on various resiliency strategies with an emphasis on meditation. While the other half will focus more on discussion debriefing groups, which will be led by a licensed clinical psychologist. We have also implemented a Big Sibs program, which pairs senior residents with junior residents to encourage mentoring and comradery, as well as offer guidance related to residency and community integration.

In addition to these ten hourly sessions, our program will also implement two structured activities that promotes an outside-the-hospital team building event like camping, hiking, rock climbing, etc. The goal of these events is to promote discussion on trust, inclusion and vulnerability.

At Mayo Clinic’s Florida campus, the internal medicine program has instituted “Humanities Thursday”, which is a monthly conference that focuses on the arts. The fellows and residents gather and participate in water color paintings, origami and screen paintings. They also have discussions about artists, art techniques, works of art and history of different art periods.

Stanford University has seen much success in their wellness program. Their campus is home to the WellMD Center, which offers their residents many wellness programs like Mindfulness-Based Stress Reduction for Physicians, Cultivating Compassion for Physicians, Physician Peer Support and Literature and Medicine. The goal for these programs is two-pronged: to improve residents’ resilience skills and to spend time connecting with their fellow colleagues. They also have had good success with their Balance in Life program, which focuses on leadership training, stress reduction and team building to support and promote physical, psychological, social and professional well-being.

Burnout has been a hot topic at recent medical conferences and for good reason. It is having devastating effects on overworked residents and the overall care patients receive, so it is certainly a step in the right direction that more and more programs are recognizing the importance of wellness and resilience. We invite residents to check out the new PM&R forum at www.physiatry.org/RFCforum to share what their programs are doing to improve wellness in an attempt to improve wellness throughout all institutions.

Venessa Lee, MD

Venessa Lee, MD is a PM&R resident at the University of Utah and current delegate to the Organization of Resident Representatives for the Association of Academic Physiatrists.

New treatments in traumatic brain injury: A clinical trial of repetitive transcranial magnetic stimulation

New treatments in traumatic brain injury: A clinical trial of repetitive transcranial magnetic stimulation

By Reza Ehsanian, MD, PhD

Traumatic brain injury (TBI) is one of the leading causes of death and disability worldwide [1]. According to the Centers for Disease Control and Prevention (CDC), in 2010 there were approximately 2.5 million emergency department visits, hospitalizations, and deaths due to TBI in the U.S. alone. In 2015, the CDC estimated that approximately 16% of annual hospitalizations due to traumatic injury were related to TBI [2]. A substantial cost results from TBI, as there were 21.4 billion dollars in charges for TBI-related admissions in 2010 and 8.2 billion dollars in charges for ED visits [3]. Severe TBI is particularly devastating [4, 5], but for the families and patients remaining in states of disordered consciousness following severe TBI there may be hope. There is mounting literature that cortical processing can occur even while patients are unconscious, and evidence of late recoveries continues to accumulate, suggesting that disordered consciousness is a potentially modifiable condition [6–11].

A paucity of treatments exists to induce or accelerate functional and adaptive recovery for individuals with severe TBI [12–14]. Current neurorehabilitation strategies for individuals with disordered consciousness involves sensory stimulation and pharmacotherapies, such as amantadine [11, 15]. Researchers are actively investigating other potential treatment modalities for those suffering from disordered consciousness after a TBI. Over the past two years I have had the honor of being part of an exceptional team of physicians and scientists trying to investigate a targeted treatment, repetitive transcranial magnetic stimulation (rTMS), as part of a clinical trial (NCT02366754) titled “rTMS: A Treatment to Restore Function after Severe TBI”. The purpose of the trial is to investigate the therapeutic effectiveness of rTMS by studying the functional and structural neural changes that occur post-rTMS. The rTMS protocol employed in the clinical trial is based on pilot data collected from 3 participants. Despite poor recovery likelihood, all three pilot participants made neurobehavioral gains during rTMS and each maintained these gains at follow-up. Although an incidence of seizure activity was apparent in one pilot subject, the safety data from the pilot subjects largely confirms a lack of adverse events related to rTMS [16].

For further information on the study, its locations, and the sponsors and collaborators, please visit: https://clinicaltrials.gov/ct2/show/NCT02366754?term=NCT02366754&rank=1.

Reza Ehsanian, MD, PhD

Reza Ehsanian, MD, PhD is a PM&R Resident at Stanford University and 2017–2018 Research Representative to the Resident Fellow Council of the Association of Academic Physiatrists.

References:

1. Leo, P. and M. McCrea, Epidemiology, in Translational Research in Traumatic Brain Injury, D. Laskowitz and G. Grant, Editors. 2016: Boca Raton (FL).

2. Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation, C.f.D.C. Prevention, Editor. 2015, Centers for Disease Control and Prevention: Atlanta, GA.

3. Marin, J.R., M.D. Weaver, and R.C. Mannix, Burden of USA hospital charges for traumatic brain injury. Brain Inj, 2017. 31(1): p. 24–31.

4. Kayani, N.A., et al., Health and economic burden of traumatic brain injury: Missouri, 2001–2005. Public Health Rep, 2009. 124(4): p. 551–60.

5. Relyea-Chew, A., et al., Personal bankruptcy after traumatic brain or spinal cord injury: the role of medical debt. Arch Phys Med Rehabil, 2009. 90(3): p. 413–9.

6. Menon, D.K., et al., Cortical processing in persistent vegetative state. Wolfson Brain Imaging Centre Team. Lancet, 1998. 352(9123): p. 200.

7. Moritz, C.H., et al., Functional MR imaging assessment of a non-responsive brain injured patient. Magn Reson Imaging, 2001. 19(8): p. 1129–32.

8. Owen, A.M. and M.R. Coleman, Detecting awareness in the vegetative state. Ann N Y Acad Sci, 2008. 1129: p. 130–8.

9. Schiff, N.D., et al., fMRI reveals large-scale network activation in minimally conscious patients. Neurology, 2005. 64(3): p. 514–23.

10. Fernandez-Espejo, D. and A.M. Owen, Detecting awareness after severe brain injury. Nat Rev Neurosci, 2013. 14(11): p. 801–9.

11. Giacino, J.T., et al., Placebo-controlled trial of amantadine for severe traumatic brain injury. N Engl J Med, 2012. 366(9): p. 819–26.

12. Pape, T.L., et al., Preliminary framework for Familiar Auditory Sensory Training (FAST) provided during coma recovery. J Rehabil Res Dev, 2012. 49(7): p. 1137–52.

13. Lancioni, G.E., et al., An overview of intervention options for promoting adaptive behavior of persons with acquired brain injury and minimally conscious state. Res Dev Disabil, 2010. 31(6): p. 1121–34.

14. Consensus conference. Rehabilitation of persons with traumatic brain injury. NIH Consensus Development Panel on Rehabilitation of Persons With Traumatic Brain Injury. JAMA, 1999. 282(10): p. 974–83.

15. Zafonte, R., et al., Pharmacotherapy to enhance arousal: what is known and what is not. Prog Brain Res, 2009. 177: p. 293–316.

16. Pape TLB, Rosenow JM, Patil V, Steiner M, Harton B, Guernon A, Herrold A, Pacheco M, Crisan E, Ashley WW Jr, Odle C, Park Y, Chawla J, Sarkar K. (2014) rTMS safety for two subjects with disordered consciousness after traumatic brain injury. Brain Stimulation, 7(4):620–622.

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