In reviewing residency applications, physical medicine and rehabilitation residency programs will place considerable emphasis on your performance during the physiatry rotation or clerkship. In the 2016 NRMP Program Director Survey, "grades in clerkship in desired specialty" was an important factor used by physical medicine and rehabilitation residency program directors in deciding whom to interview. Program directors rated it 4.5 in terms of importance on a scale of 1 (not at all important) to 5 (very important).
The importance of the rotation goes beyond the clerkship grade. Ninety-three percent of program directors cited "letters of recommendation in the specialty" as an important factor in making interview decisions.
Many medical students seeking a career in the field will perform away or audition electives. These electives are also very important in the residency selection process, with 80% of program directors using "audition elective/rotation within your department" to make interview decisions.
Given the importance of the physical medicine and rehabilitation rotation in the residency selection process, I am often asked for advice on how medical students can make a favorable impression on attending physicians and residents. Below are some very specific recommendations for success.
Prepare For Your Rotation Properly
Your preparation for the physical medicine and rehabilitation rotation begins with an understanding of the setting in which you'll work and the patient population you'll serve. Will you be working with stroke, spinal cord or traumatic brain injury patients? Or will you be rotating through a pediatric rehabilitation unit where you will care for patients with cerebral palsy, muscular dystrophy, or spina bifida.
Once you identify the emphasis of your rotation, you can tailor your background reading to reflect the conditions you'll encounter. Some recommended resources to expand your knowledge include Physical Medicine and Rehabilitation Pocketpedia, PM&R Secrets, and Physical Medicine and Rehabilitation Pocket Companion.
Review High-Yield Pharmacology
Physiatrists commonly evaluate and manage patients with pain and spasticity. The following resources will provide a review of the pharmacology used in the treatment of these conditions:
I recommend that you make a review of high-yield pharmacology a priority in your preparation for the rotation.
Become Familiar with History Taking in Physical Medicine and Rehabilitation
History taking in physical medicine and rehabilitation can vary significantly depending upon the setting. In the outpatient setting, the expectation may be a focused evaluation, especially in the established patient, whereas a comprehensive assessment is the norm for inpatients. Regardless of the setting, however, there are significant differences between history taking in physiatry and other fields. The following are some key points to guide your history:
Patience will be required when eliciting history from patients with cognitive impairment or speech difficulties. Knowledgeable family members, friends, and caregivers are important sources of information in these cases.
The review of systems should be complete. In particular, students should inquire about history of cardiopulmonary disease since the rehabilitation plan that is developed must take into account cardiopulmonary limitations.
Although you will have inquired about support systems with patients in other specialties, you will often have to probe deeper in physiatry. A strong understanding of your patient's support system will help you determine how much assistance your patient will need following discharge. You can then make the appropriate arrangements to allow for smooth transitions in care.
Inquire about the home environment. Does the patient live at home or an apartment? What floor? Are there stairs or will the patient use an elevator? How many steps need to be climbed? Are there handrails? Is the home wheelchair accessible? Are there grab bars in the shower?
A thorough occupational history will allow your team to determine if the patient can fully return to his previous level of functioning at work. Many questions will need to be answered. What can be done to return the patient to work? Does the patient's workplace need environmental modification? Are assistive devices necessary at the workplace? If the patient will not be able to return to work, what type of vocational rehabilitation can be offered?
Review How To Perform Musculoskeletal and Neurologic Exams
The PM&R rotation will provide you with rich opportunities to become more comfortable and confident in your ability to perform a musculoskeletal physical exam. Although you were introduced to the musculoskeletal exam during your physical diagnosis course, you may have had few opportunities to build upon this initial experience in other rotations. The evidence indicates that many students graduate from medical school lacking confidence in thir skills. National performance on the USMLE Step 2 CS exam indicates that musculoskeletal physcial exam performance tends to be poorer than exam performance in other areas.
An excellent article "History and Examination in the Assessment of Musculoskeletal Problems" focusing on the nuts and bolts of the musculoskeletal evaluation was published in Nature Clinical Practice Rheumatology. Another recommended resource is the Adult Physiatric History and Examination Introduction and Overview. The following video clip provides additional information.
Bates Guide to Physical Examination & History Taking: Musculoskeletal System
The neurologic exam is also of obvious importance to the practice of physiatry. A review of neurological history taking and examination is recommended prior to the rotation. I recently described ways to sharpen your clinical skills in these important areas in the post "How To Succeed In Your Neurology Rotation: Tips For Medical Students."
Demonstrate Your Ability To Collaborate With An Interdisciplinary Team
Although the physiatrist is the team leader ultimately responsible for establishing goals for the patient, he or she will also rely on the expertise of a diverse group of team members. Care delivered to physical medicine and rehabilitation patients involves an interdisciplinary approach. "The team approach, using multiple medical and therapeutic modalities, is key to our patients' success," writes the Department of Physical Medicine and Rehabilitation at Stanford University.
During your rotation, you'll have opportunities to work closely with a diverse group of healthcare professionals including, rehabilitation nurses, physical therapists, occupational therapists, recreational therapists, speech-language pathologists, social workers, dieticians, and psychologists. Work hard to form strong relationships with these team members. There's much you can learn from them, and your patients will most certainly benefit. This is also an opportunity to show your attending that you are a team-oriented student.
Periodically, the team will meet to review the patient's progress. Is the patient making progress towards his or her goals? Are there any social or psychological issues that need to be addressed? This will be an opportunity for you to update the team, and share concerns. The multiple perspectives of team members will allow the attending physiatrist to revise goals as needed. The way in which you interact and collaborate will be a major part of the impression you make during the rotation. Remember that interpersonal skills are the most important factor used by residency programs to make rank-order list decisions.
“We are trained to work with physical therapists, occupational therapists, psychologists and speech therapists, using their skills in addition to our own clinical acumen and hands-on skills to guide patients through the rehabilitation process,” says Dr. Leonard B. Kamen, Clinical Director of the MossRehab Center, a part of the Einstein Healthcare Network.
Understand How The Patient's Condition Has Affected All Spheres Of His Life
As you evaluate patients, your focus will be on improving quality of life and developing a plan for maximum independence. To accomplish these goals, you must understand how the condition or disease process has affected all spheres of the patient's life. In assessing loss of function from injury and illness, you'll be discussing sensitive and delicate issues such as bathing, grooming, bowel/bladder control, and sexual function. You'll inquire about the disability's impact at home, work, or school, and how that has changed over time. As you explore the patient's social support system, you'll learn about important relationships in the patient's life, and how these relationships have changed with the illness.
These can be difficult conversations, and you may encounter a wide range of emotions. By demonstrating care and sensitivity in your conversations, your patients will reveal crucial information that will allow you to develop a plan that meets each individual's needs. “In rehab medicine, we are helping people in the darkest moments of their lives in many cases,” says Dr. Christina Richardson. “We are there for some of the lowest of the lows and the highest of the highs. It takes a special person to be part of that process.”
An excellent discussion of the psychosocial issues affecting rehabilitation can be found at the University of Pittsburgh Medical Center website.
Dr. Samir Desai is the author of The Successful Match 2017 and the co-host of the Success in Medicine podcast.