The incoming Resident Fellow Council: A new year of exciting initiatives

By Kunj Patel, MD

Outgoing 2016–17 AAP Resident Fellow Council (front) with Incoming 2017–18 AAP Resident Fellow Council (back)

The new Resident Fellow Council (RFC) was elected this past February 2017, at the annual Association of Academic Physiatrists (AAP) conference. The election was the best attended with the most voter participation of any election in AAP history. There were 369 registered voters, and some candidates, like Dr. Melissa Kirk (PGY-2), began their campaigns days before with prepared slogans on complimentary 100 Grand candy bars, pointing out her readiness to give a 100 Grand performance as AAP RFC Secretary. Even prior to the conference, the RFC election had a lot of build up, as one of the most anticipated events. Some candidates created YouTube videos and posted on social media (see RFC AAP Facebook) as an introduction to their platform. And without fail, the resident and fellow members of the AAP elected a truly remarkable and worthy RFC council. Many thanks for the successful election are owed to the prior RFC, including Dr. Charles Odonkor, and Dr. George Marzloff, who administered the new voting technology and created the pre-conference buzz that led to an incredibly successful election.

Already, this year’s RFC is embarking on a number of exciting projects. Among those concepts that are in discussion include organizing the first national medical student council for physiatry, revamping the AAP website, creating an online forum for AAP residents, and reinvigorating the AAP mentorship program. Additionally, we are helping with AAP’s fellowship initiative to create a central repository and resource for all PM&R accredited and non-accredited fellowship programs. We look forward to sharing our progress on these important initiatives throughout the year in this quarterly newsletter. Please stay tuned for these exciting updates! I am thrilled to be working with such an exceptionally qualified Resident Fellow Council of which I am fortunate to be a part.

Kunj Patel, MD, is a third-year resident in the Department of Physical Medicine and Rehabilitation at the Emory University School of Medicine, and 2017–2018 Chair of the AAP Resident Fellow Council.
Fellowship Spotlight: Pediatric Pain Medicine

Fellowship Spotlight: Pediatric Pain Medicine

By Andrew Collins, MD

Many people have pain during childhood with one in four experiencing chronic pain and one in twenty developing a severe disability. This disability can lead to school absence, decreased activity participation, increased parental burden, and increased healthcare utilization. As Clinch and Eccleston stated in 2009, “Childhood pain is a modern public health disaster.”

To address this, pediatric pain physicians work in interdisciplinary teams and use multimodal treatments with a primary goal of improving function. One increasingly common treatment for these children is intensive interdisciplinary treatment, often through inpatient or day rehabilitation programs. These programs coordinate physical and occupational therapy, psychological treatment, medical management, as well as various additional services. With this emphasis on function and frequent use of interdisciplinary teams, pediatric pain medicine fits well with foundational aspects of physiatry.

I first became particularly interested in pediatric pain while treating patients in our Functional Independence Restoration Program, which takes place on the inpatient rehabilitation unit at Cincinnati Children’s Hospital. While working with these patients, I relied heavily on skills and knowledge from earlier in residency, from performing a thorough musculoskeletal examination and assessing functional deficits to setting appropriate patient goals and working with an interdisciplinary team to achieve those goals. While I went into residency knowing I wanted to help children overcome disabilities, this experience helped me realize I wanted to do so both as a pediatric physiatrist and a pediatric pain specialist. Therefore, I decided to pursue further training in pediatric pain.

Training in pediatric pain can occur in multiple ways, including ACGME-accredited pain medicine programs that are housed at pediatric hospitals. As of 2016–2017, there are two such programs, at Boston Children’s Hospital and at Cincinnati Children’s Hospital, with potential for more in the future. These programs are accredited as pain medicine fellowships, not specifically for pediatric pain; therefore, clinical time is split between caring for children and adults. For example, my future fellowship in Cincinnati involves training at Cincinnati Children’s Hospital and the University of Cincinnati for adult patients. In addition to these programs, there are training programs that do not have ACGME-accreditation and ACGME-accredited pain medicine fellowship programs with options for pediatric rotations.

For programs participating in ERAS and the Match, the timeline for applying to fellowship is parallel to that for pain medicine programs without a pediatric focus. Applications open in late winter and Match Day is in October; for programs starting in 2018, applications opened December 1, 2016 and Match Day is October 4, 2017. For programs that do not participate in ERAS, including those that are not ACGME accredited, the process would be individualized to that program.

Pediatric pain is an exciting and evolving field that is ripe for increasing physiatric involvement. As the field grows and more training programs evolve, I hope to see more interest from applicants with a background in physiatry and pediatric physiatry.

Andrew Collins, MD, is a PGY-5 resident in the Pediatrics and PM&R combined residency program at Cincinnati Children’s Hospital and will be the first PM&R-trained Pain Medicine fellow at Cincinnati Children’s next July.
  1. King S, Chambers CT, Huguet A, MacNevin RC, McGrath PJ, Parker L, MacDonals DJ. The epidemiology of chronic pain in children and adolescents revisited: A systematic review. Pain 2011; 152: 2729–2738.
  2. Huguet A and Miro J. The Severity of Chronic Pediatric Pain: An Epidemiological Study. The Journal of Pain 2008; 9(3): 226–236.
  3. Palermo T. Impact of Recurrent and Chronic Pain on Child and Family Daily Functioning: A Critical Review of the Literature. Developmental and Behavioral Pediatrics 2000; 21(1): 58–69.
  4. Clinch J and Eccleston C. Chronic musculoskeletal pain in children: assessment and management. Rheumatology 2009; 48: 466–474.
  5. ACGME Pain Medicine (Multidisciplinary) Programs, Academic Year 2016–2017. Accessed April 6, 2017. Link: https://apps.acgme.org/ads/Public/Reports/ReportRun?ReportId=1&CurrentYear=2016&SpecialtyId=152&IncludePreAccreditation=true&IncludePreAccreditation=false
  6. ERAS 2017 Participating Specialties & Programs. Accessed April 6, 2017. Link: https://services.aamc.org/eras/erasstats/par/display8.cfm?NAV_ROW=PAR&SPEC_CD=530
  7. Anesthesiology Match. Accessed April 6, 2017. Link: http://www.nrmp.org/fellowships/anesthesiology-match/
Johns Hopkins PM&R Expo

Early physiatry exposure for medical students: The Johns Hopkins PM&R Expo

By Anne Kuwabara, Stanley Guillaume, Samiran Bhattacharya, and James Pendleton

On January 28th, 2017,the first annual “PM&R Expo” was held at the Johns Hopkins School of Medicine. This special event was supported by the Association of Academic Physiatrists. Medical and undergraduate students from University of Maryland, Johns Hopkins University, Howard University, and Georgetown University attended and participated in this event.

The purpose of this event was to provide exposure to the multifaceted field of PM&R and promote collaboration and partnership between the different local medical schools. Exposure to PM&R varies among medical schools, and Johns Hopkins Medicine PM&R Interest Group wanted to initiate a partnership for students to gain access to resources and become immersed into the field, regardless of the amount of exposure provided by their home institution.

Lymphedema Station

The Expo consisted of 5 different stations, through which groups of students rotated. Each station was independently constructed and overseen by an attending, therapist, and a student and provided an overview lecture on the specific subject followed by opportunities for the students to engage and to practice newly learned techniques. The goal was for students to acquire a sense of the the broad topics the field encompasses and the various tools used within each.

Dr. Charles Odonkor, Anne Kuwabara, and Stanley Guillaume coordinated and facilitated the group rotations and ongoing event logistics. The stations that were part of this Expo included the following:

Dr. Cristina Sadowsky, Ms. Enjeen Woolford, and James Pendleton conducted the spinal cord injury (SCI) station. Here, students learned some of the nuances in the presentation and evaluation of patients at acute and chronic phases of SCI. The differences in approach and application between compensatory and restorative therapeutic techniques were also discussed. Furthermore, students were introduced to activity-based restorative therapies (ABRT) and functional electrical stimulation (FES) as therapeutic techniques for SCI patients during the chronic phase of recovery. Basic science and clinical research in mitigating nervous tissue damage following SCI as well as various cell-based therapies were presented.

Dr. Pablo Celnik, Ms. Sowmya Kumble, and Dr. Samiran Bhattacharya helped lead a station on neurorehabilitation. Students learned about the wide scope of neurorehabilitation, from the role of physiatry in the neurocritical care unit, to the growing scope of research in the field related to non-invasive brain stimulation. Students had the opportunity to learn about research initiatives with stroke subjects, and brain stimulation techniques such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS).

Spasticity Management Station - Eugene Khoroshan

Dr. Sam Mayer, Mr. Eugene Khoroshan, Dr. Christina Kokorelis, and the Allergan team ran the spasticity management station. This station put emphasis on teaching students about the definition of spasticity and the importance of its management and treatment. The management and treatment of migraines were also explained. Thanks to the Allergan team, we were able to use electronic injector simulation models to allow students to learn how to do these injections. The models were crucial to this station because they also projected the muscles with which the injector tips come in contact. Therefore, not only were students learning how to inject, but they were receiving more knowledge on the anatomy of the upper and lower extremities.

Spasticity Management Station - Sam Mayer

We had two teams of animal assisted therapy (AAT) specialists; Barb Carvelius with Molly and Linda Solano with Siren, as well as therapists Catherine Scott and Kristin Stressing, run the animal assistive therapy station. AAT is combined with occupational, physical and speech therapy to work on sensory stimulation, cognitive and visual perception, tone inhibition, range of motion, balance, mobility, coordination, speech, and mental health. Patient progress is monitored over a period of time based on personal goals and objectives. AAT is not for everyone such as patients with a fear of animals, allergies, open wounds, dermatitis, and immunosuppression. Commonly used tools include brushes, tables, balls, leashes, collars, chairs, dog toys, and bubbles.

Animal Assisted Therapy

Ms. Jyo Supnekar, Ms. Dawn Kutcher, and Ms. Kathryn McGinty ran the stations on laser therapy, lymphedema, kinesiotaping, and orthoses. Lymphedema is an abnormal accumulation of protein rich fluid in the interstitium, which causes chronic inflammation, and reactive fibrosis of the affected tissues. It is treated with complete decongestive therapy, manual lymphatic drainage, compression bandaging, remedial exercises, meticulous skin and nail care. The Biolase class IV laser, PhysioTouch, LymphoTouch were provided as tools also used for lymphedema for the students to have hands-on experience. Students also had the opportunity to learn and examine different orthoses. Orthoses are used to describe a single, rigid or semi rigid device that supports a weak or deformed body part or restricts motion in an injured part of the body. Orthoses also can be used for mobilization of joints. Orthotics can be provided or fabricated by an occupational therapist or certified hand therapist who is trained in assessment, education and fabrication. A referral to occupational therapy and an order for the orthotic is required in order to have the orthotic fabricated and covered by insurance.

Lymphedema Station

We hope to continue this tradition and forge collaboration between different schools and support the promotion of PM&R at the undergraduate level to increase exposure and recognition of our outstanding field.

PM&R Interest Group Leadership Board

About the authors: Anne Kuwabara, Stanley Guilaume, Samiran Bhattacharya and James Pendleton are medical students at Johns Hopkins Medicine in Baltimore, Maryland and active leaders in the school’s PM&R Interest Group.

Branding PM&R

Branding PM&R: Should the approach be more evidence-based?

By Ada Lyn Yao, MD

Physical Medicine and Rehabilitation was born in 1936. Our field has existed for 10 decades; yet to this day, a cloud of enigma looms over our heads.

“What is it exactly that you do?”

This is the nagging query we so often hear, a question that goes hand-in-hand with a puzzled look from patients and from colleagues within the industry. By virtue and by nature of what we do, we are diverse and divergent, creating — if I may say— bewilderment in the minds of the general public. Unless there is an obvious “rehabilitative need,” the PM&R brand exudes imprecise value, with its products or services remaining largely undefined. We are unlike our physician colleagues in other specialties, who more often than not have a concrete and definite role.

Yes, we recognize our specialty’s problem and by all means, it is on point. Without a doubt, we have moved forward and upward from our first inception and put forth much effort to define who we are. But, our obscurity is so compelling, should we not rethink our strategy?

As doctors, we are built to think scientifically. Discoveries were made and progress was achieved through organized thoughts. We approach research by identifying a problem, creating a null hypothesis, framing the correct question, collecting the pertinent data, and analyzing these data to eventually arrive at a concise conclusion of findings with the welfare of patients in mind.

In parallel, the branding of our medical specialty should be approached systematically and methodically as with any other industry. Basic business principles apply — market research and strategic planning, as well as product definition and positioning.

There are recognizable fundamental differences, however, between healthcare and free-market business advertisement. As healthcare professionals, it is ingrained in us to perceive what we do as a mission in life. Nowhere in our training are we shown to think in terms of attribute-aggregation towards a branding process. We then step away from the protective walls of medical school, residency, and fellowship, altogether clueless of how to properly position our profession within the environment. We are conditioned to view marketing and branding in ethical terms, constricting us from thinking outside of our self-imposed clinical arena. As a result, we leave the marketing to those not privy to our world. We let marketing firms design advertisement campaigns that are often ineffective, as one cannot convey precisely what to market.

The brand must come before the marketing, and marketing simply means why one thinks one is the best choice for one’s target audience. Branding is a centripetal force — “This is who we are!” It is an inward vector, a pull that makes us define and signify the essence of our specialty. Marketing is centrifugal, pushing the brand outwards to create a want — “This is what you need from us!” A branding and marketing campaign is meant to be tailored to each specific audience — our patients (level of care), our colleagues (referral source), or the public (brand awareness).

The responsibility for the PM&R brand lies within our own hands. We know ourselves the best. It is with a collective, properly-defined brand that we can begin to market who we are. Immersing ourselves in the knowledge of business and taking advantage of the best evidence-based approach available in this field are pivotal. It is our job to know who our audiences are (peers, patients, public), and to study each of their attributes. Only then can we send messages that others will hear; and only then can we uniquely and convincingly stamp our brand.

Ada Lyn Yao, MD

Ada is a PGY-3 PM&R resident at Johns Hopkins Hospital in Baltimore, MD.

Match Day 2017

Trends in physical medicine and rehabilitation as a medical specialty: PM&R residency and fellowship match trends

Carrie Gould, MD, MBA

The Match

In medical schools nationwide, Friday, March 20th, was not just a historic day for graduating seniors, a day when with trepidation and excitement each senior student received an envelope holding their future three to seven years of training. March 20, 2017 also marked the largest ever NRMP Match Day since its inception. Over 35,000 U.S. and international medical school seniors and graduates participated in matching to 31,757 positions, the most ever offered in The Match (with an almost 1,000 increase in first-year positions from the year prior).

The American Association of Medical Colleges (AAMC) notes that 94% of U.S. applicants overall successfully matched into a residency position. Of these, 78% were matched into one of their top three choices. Given that the AAMC anticipates a physician shortage of 104,900 physicians nationwide by 2030, this was promising news toward the future of healthcare.

PM&R residency match

Physical Medicine and Rehabilitation (PM&R) in particular is one of the specialties that has become more popular, and therefore more competitive, among medical students in recent years. For those unfamiliar with this small but growing specialty, PM&R was formally established in 1947 with the focus of restoration of patients’ functional ability following disease or impairment, such as spinal cord injury, stroke, brain injury or amputation, but it has since grown to include much more.

In the NRMP Match, 32 categorical (PGY-1) PM&R programs offered 119 positions with only one unfilled position nationwide for a 99.2% total match rate (62.6% of U.S. seniors matching). Sixty-two advanced (PGY-2) PM&R programs offered 294 spots that were all filled for a 100% total match rate.

The National Matching Service (NMS) for the American Osteopathic Association (AOA) likewise reported that the four osteopathic PM&R residency programs were successful in filling 14 positions with 100% match rate.

Fellowship Trends

Physiatry residents also demonstrated success with fellowship match in the ACGME-certified specialties of brain injury medicine, spinal cord injury medicine and pediatric rehabilitation medicine. Ninety-one percent (91%) of physiatry fellowship applicants successfully matched into a fellowship position.

In brain injury medicine (which also included one neurology program and non-accredited ACGME programs), there were 16 enrolled programs offering 17 positions in brain injury medicine. For brain injury medicine, all U.S. applicants seeking a position were matched (100% match rate), while 88.2% of brain injury medicine fellowship positions filled, leaving only 2 unfilled positions.

In pediatric rehabilitation, 23 positions were offered. Of the 11 U.S. graduates applying in pediatric rehabilitation medicine, 10 were matched in positions (91% match rate). Sixteen of 23 (69.5%) pediatric rehabilitation positions were filled (which is an improvement from 61.9% pediatric rehabilitation positions filled in 2016). Sixteen of 18, or 88.9%, of applicants in pediatric rehabilitation were successfully matched to a position.

In spinal cord injury medicine, 19 programs offered 27 positions. Of the 12 U.S. graduates applying in spinal cord injury medicine, 11 were matched into a spinal cord injury position (92% match rate). Twenty spots were filled in the match for an overall program match rate of 74%, with 7 spots going unfilled in the match (which is an improvement from 50% spinal cord injury position match rate in 2016). For all graduates applying in spinal cord injury medicine, 87% were successfully matched.

Carrie Gould, MD

Carrie Gould, MD, MBA, is a PGY-3 Resident Physician at Marianjoy Rehabilitation Hospital, part of Northwestern Medicine.

  1. “AAMC Recognizes Successful Match Day Amid Physician Shortage and Immigration Concerns.” (March 17, 2017). AAMC. Retrieved April 7, 2017 from https://news.aamc.org/press-releases/article/match_day_03172017/
  2. “Advanced Data Tables: 2017 Main Residency Match.” (March 2017). National Resident Matching Program. Retrieved April 7, 2017 from http://www.nrmp.org/wp-content/uploads/2017/03/Advance-Data-Tables-2017.pdf
  3. “Rehabilitation Medicine — 2017.” National Resident Matching Program. Retrieved April 7, 2017 from http://www.nrmp.org/wp-content/uploads/2017/01/AY2017-Rehabilitation-Medicine-Match-Results-Statistics.pdf
  4. “Results and Data: Specialties Matching Service. 2017 Appointment Year.” National Resident Matching Program. Retrieved April 7, 2017 from http://www.nrmp.org/wp-content/uploads/2017/02/Results-and-Data-SMS-2017.pdf
  5. “Summary of Positions Offered and Filled by Program Type.” National Matching Services, Inc. Retrieved April 7, 2017 from https://natmatch.com/aoairp/stats/2017prgstats.html

More Physiatry in Motion:

Please also visit Medium.com for our full April issue, including the Rehab Tech articles, this month featuring step-by-step instructions on building an app to test fine motor skills!

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