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.
No comments:
Post a Comment