Physical Medicine and Rehabilitation in SF City

Yesterday I finished my two-week elective rotation in physical medicine and rehabilitation. Physicians who are board certified in PM&R have completed a four year residency. Post-Grad Year 1 (PGY1) is a traditional rotating/FP intern/IM intern year, and then PGY2-4 is PM&R. Most of these docs go on to complete a fellowship in their area of interest- sports med, pain med, spinal cord injury, brain injury, neuromuscular medicine, etc. In this field it is easy to become inspired by motivated patients who work hard to overcome or adapt to their disabilities. According to an attending who responded to a post of mine on SDN, doing this kind of work, "requires practicality, rationality, resourcefulness, creativity, motivation, and inspiration."

I shadowed Dr. Lewis at St. Luke's in SF City these last two weeks. He focuses on outpatient pain management, medico-legal consults and QME's for worker's comp, EMG's, and rehabilitation following orthopedic surgery (he is in the same office as Dr. Akin, the orthopedic surgeon whom many kids from Touro and UCSF rotate with as a part of our surgery requirement).

Dr. Lewis seemed to be swimming in the legal paperwork, but despite the stress from that he would make his patients feel like he had all the time in the world for them. While in the exam room with Dr. Lewis and his PA Jim Buck, I assisted with corticosteroid injections (decreasing joint inflammation), hyaluronic acid injections (lubrication for the integrity of collagen and elastin), and Electromyography and Nerve Conduction Tests. For a little over half of his patients, I would go in and start the appointment- taking H&P's and really solidifying my ortho exam skills. I usually managed to slip in a little osteopathic manipulative treatment (OMT) accidentally ;)

After the appointments, I would get on the electronic medical records and do the charting/dictation. Its amazing how much time this takes, even with the use of templates. Dr. Lewis told me that one of his colleages has a free day each week, but she uses it to go to the office just to finish the notes for her patients and complete unfinished paperwork. There has to be a more efficient way of charting than that- it may mean staying in the office until 6-7pm at night, though. As an example, I completed the dictation for a woman whom we wanted to receive a motor scooter from medicare and it came back the next day with a list of 19 things we needed to put into the dictation in order for her to qualify. Apparently people were receiving free scooters from medicare and selling them, so medicare made the qualifications more stringent. The total amount of time I spent on that note was about 1.5 hours inserting all of the requirements, when these notes should normally take 15 minutes. Really an interesting sneak preview of one of the downsides to medicine these days- jumping through hoops and getting over the red tape dealing with loads of paperwork. Not even a specialty like Ortho Surg is free of this burden, but from what I hear, family practice (FP) has the largest burden in this regard.

Completing my PM&R rotation and reading about the specialty has really turned my world upside-down. I applied to medical school with the intention of going into primary care, FP to be exact. I think the reason I am attracted to PM&R is because it is very much like family medicine in the continuity of care aspect (in outpatient settings), but it also emphasizes musculoskeletal/neuro. I can see myself being able to perform OMT and manage patients on a long term basis in both specialties. During the last week or so I have been making sure that I get my audition rotation applications out to our clinical education department for the FP/OMT residencies, while simultaneously weighing the differences between FP/OMT, Integrated FP/NMM, and PM&R. Here is what I have come up with:

A) It is clear that I like the neuromusculoskeletal aspect of these specialties and I want OMT to be a regular part of my daily practice. I would be able to do this with both.

B) It appears that PM&R is potentially a longer residency, but with better hours, much less call, and better pay. As a PM&R doc, there would also be no call. This is because by definition, patients ready for rehab in the hospital are no longer acute.

C) The work in PM&R may not be quite as diverse as FP, where you would maybe treat a 75 year old man with an acute gouty flare up/ diabetes neuropathy/ congestive heart failure, a pregnant woman with back pain, and a newborn with a cold all in the same day. That is part of what makes PM&R appealing to some, though, because many do want to become an expert in their chosen field and have that be what they deal with every day. I can picture myself working with chronic pain patients- treating them with OMT, complemetary alternative therapies, and other necessary medical interventions- but then again, the chronic pain population means dealing with more drug-seeking behavior, and possibly dealing with the fact that many of your patients don't seem to get better (you get them after most preventive methods would have helped).

D) I do not want to eliminate the possibility of treating newborn babies, and the only exposure to children I would get in PM&R are children who have already been diagnosed with cerebral palsy, muscular dystrophy, etc- very sad cases. They would also benefit from some forms of OMT, but I think for my own sanity and the feeling of having patients who actually get better, FP may be the way to go. Or, do I want to go into PM&R and potentially do some efficacy research regarding these patients and OMT?

E) There is extreme need for primary care docs, and with Obama care we're hopefully headed in the direction of more emphasis on prevention. Although who knows- if he isn't re-elected in 2012, everything may be turned upside-down again. Bottom line is that reimbursement is not going to be even in my top 10 list of priorities when I am deciding between these specialties.

So as you can see, I flip-flop on these thoughts quite a bit, and unfortunately it is quite distracting. Since this is about the time I should be narrowing it down, its scary to be considering these things almost equally.

In other news, though, I start my psychiatry rotation on Monday! Four weeks commuting to Stockton, although I have heard the drive isn't bad because its against traffic and he lets students out around noon on some days, so I would actually be home much before I would if I were rotating anywhere else. After these next four weeks, I start FP at brookside (finally!) It is amazing that I have considered FP for so long and have not even completed my core rotation in it! Anyway, sorry for the longer blog, but hopefully it has helped some of you who are also considering these specialties.

Cardiology Elective @ DMC - 2 weeks

On Friday I finished my 2 week cardiology elective at Doctor's San Pablo. I had such an incredible time rotating with Dr. Weiland- he is probably one of the best in this field. To give you an idea of how cool it was, the very last thing we did in my 2 weeks rotating there was watch Dr. Weiland do a thrombectomy and angioplasty on a man who just had a STEMI at the gym 40 minutes prior. STEMI= ST Elevated myocardial infarction (heart attack). I glanced at the ECG in the emergency room, which showed the most classical anterior MI with ST elevations in leads V1-V6 and AVL, with reciprocal ST depression in the inferior leads. On the cath monitor we could see that the LAD (left anterior descending artery) was 100% occluded when he started, with mild disease in other coronary arteries. When Dr. Weiland was done, we could see on the monitor that the blood flow had been restored completely. After the procedure, Dr. Weiland asked the patient, "Do you have chest pain?" and the patient responded, "What chest pain?" I would say that is a job well done :)

On this rotation, I did get to actively assist with patient care. One of the coolest opportunities I had was to shock a patient back into sinus rhythm. The staff makes sure the patient is sufficiently sedated and you set the biphasic system to the amount of joules you want, clear the area, charge the defibrillator, and press shock- pretty simple. The patient is jolted awake and sinus rhythm is the desired result.

For those of you considering doing cardiology at DMC with Dr. Weiland (which I highly recommend), read on. On the cardiology service at DMC you see on inpatients during the morning, write SOAP notes, and then gather for rounds with Dr. Weiland around 8:30am. During the course of the day you see inpatients on all floors, in all departments. He is constantly getting phone calls and needing to be in 3 places at once, but he balances all of this very well and stays very grounded- its a great example for people who may want to go into a specialty where their services will be in high demand. You also visit the clinic to see outpatients in the afternoon sometimes. Weekends are free, but plan on being in the hospital until 6:30pm or so each night, wear comfortable shoes, and bring snacks because you go long periods without being able to have a meal. You will see lots of great pathology at DMC and you will be able to learn about cardiovascular disease prevention, management, and rehabilitation.

Bottom line, 2 weeks is just NOT ENOUGH TIME for a cardiology rotation. I don't even think 4 weeks is enough. I'll just have to try to get much more exposure to cardiovascular disease management during my FP and IM rotations this year. During 3rd year we don't have much time for electives. I used my vacation to study for boards, did a 4 week OMM elective, so the only choice I had was to split up with month into 2 electives. On Tuesday I start PM&R with Dr. Lewis in San Francisco. I heard he mostly does outpatient care with an emphasis on musculoskeletal rehabilitation. Should be very interesting! Stay tuned for a report on that in a couple of weeks ;)

Orthopedic Surgery @ DMC

As a famous orthopedic surgeon once said, "If you can't pin it or cast it- then screw it." Just finished ortho surg, and I have to say that I had a tremendous amount of fun. If you are assigned to Dr. Welborn, you not only get to see him in action, but the other surgeons at DMC also reach out to you, teach you surgery, knots, and have you first assist on cases. During the course of this rotation I experienced several awesome things, a few of which I'll mention here:

1. First assisting Dr. Lyon during an ORIF of the femur in a space suit X2. Really a sterilization technique that is expensive and more for protection of the surgeon than the patient, but fun to do. On those cases, Dr. Lyon had me create the spaces for the screws and screw in the plate. He taught me the two-handed knot and I am finally good enough at it to help the surgeon close up without taking too much time.

2. First assisting Dr. Barry with a rodding of the femur in a diabetic patient. This was extremely nerve wracking for me, but mostly for Dr. Barry and the OR staff. Luckily their competence and care for the patient always prevails. I think I was exposed to more than a minute of X-rays during that surgery unfortunately but I was wearing a lead suit so I hope that helped.

3. Working with the lovely OR staff @ DMC! So hilarious, laid back, but of course strict about sterilization procedures, etc. What a fun-loving environment. Only one thing though- if you have seen this in my facebook status I'm sorry to repeat it here, but if I had to listen to "Like a G6" one more time while I was trying to concentrate on assisting, I would have had to personally go out and steal one for the anesthesiologist so he would stop playing the song. And I am not even sure if having one would make him stop playing that song. Geez.

Overall, I learned tons from the orthopods I shadowed, I enjoyed spending time with patients at clinic, and I'm super happy that I get to experience several other rotations at DMC. It feels great to have such a short commute and to be able to rotate in an environment that is so conducive to learning.

And of course, I didn't want to leave out my favorite jokes about orthopedic surgeons (and no one loves these jokes more than the surgeons themselves):

What do you call 2 orthopedic doctors reading an EKG?
A double blind study!

Patient: Doctor, Doctor, I broke my arm in two places!
Doctor: Stay out of those places!

Q. What is the difference between God and an orthopedic surgeon
A. God doesn’t think he is an orthopedic surgeon.

I know, how lame! I guess when you're mentally and physically exhausted, and slightly delirious, these jokes can make you crack up for minutes. Or maybe that's just me? :)

Actually I am no where near as exhausted as was when I had my peds and OB/Gyn rotations, but every rotation has been different, fun, and incredibly rewarding thus far. Tomorrow I start my 2wk cardiology rotation @ DMC and I'll finish up January with a PM&R rotation in SF City.

This year is going to be exciting and challenging. I have a number of personal goals regarding my health and fitness that I have been working on and hope to make more progress in the coming months. I also have Step 2 of my boards, audition rotations, residency applications, interviews, and a wedding to plan! Here's to a healthy, smooth, and productive 2011!