Physical Medicine and Rehabilitation

Physical Medicine and Rehabilitation Educational Goals & Objectives

Physical medicine and rehabilitation physicians, or Physiatrists, are specialists in the nonsurgical treatment of acute and chronic disorders of the musculoskeletal system, brain, and spinal cord. Physiatrists also diagnose and treat pain by creating a comprehensive rehabilitation program to restore maximum function lost through injury, illness or disabling conditions. The treatment plan typically involves a medical team that may include physical therapists, occupational therapists, speech-language pathologists, and other specialists.

These conditions may be congenital, reflect overuse or trauma, or be a result of aging or systemic disease. The Physical Medicine and Rehabilitation physician at Community Memorial Hospital will help the resident become familiar with clinically applicable principles of basic science, anatomy, pathology, and biomechanics, with an emphasis on the clinical care of patients with musculoskeletal disorders. The goal of this elective rotation is to provide exposure to a broad base of physiatric learning and to encourage critical thinking, such that learners can provide compassionate care at the forefront of medical knowledge.

Since residents may take this elective at any point in their training, emphasis will be on providing an overview of diagnostic and treatment principles. As the resident demonstrates practical competence with this foundation, Faculty will focus on teaching more advanced skills as well as allowing progressive autonomy in application of these principles to clinical care. Clinical experience will be supplemented by our ongoing OMT curriculum as well as core and elective rotations in pain management, neurology, radiology, rheumatology, sports medicine and other rotations.

Faculty will facilitate learning in the 6 core competencies as follows:

Patient Care and Procedural Skills

I. All residents must be able to provide compassionate, culturally-sensitive, and appropriate care for patients with musculoskeletal disorders, from pediatrics through geriatrics.

II. Residents will demonstrate the ability to take a pertinent history and perform a systematic physical exam with emphasis on the musculoskeletal and neurologic exams, including:

• Joint, muscular, and neuropathic symptoms
• Systemic symptoms, such as fatigue, fever, poor sleep, sweats, or weight loss
• Occupational history, and history of repetitive use
• History of antecedent events, such as trauma and exercise or sports injury
• Family or personal history of autoimmune disease
• History of drug and alcohol use

III. Residents will recognize the contribution of comorbidities and medication compliance to a patient’s symptoms as well as learn to

• Differentiate inflammatory from mechanical joint pain
• Identify the mechanism of injury in trauma and sports injuries
• Independently obtain details for patients with a complex medical history

IV. Learners should be able to characterize the following physical exam findings:

• Abnormal posture or gait, foot drop
• Baker’s cyst, bunion, ganglion
• Clubbing
• Dislocation, fracture
• Dupuytren’s contracture, epicondylitis and tendonitis/tendonopathies
• Joint abnormalities, including arthritis, crepitus, instability, effusion, limited range of motion and flexibility, pain, patellofemoral problems, and subluxation
• Kyphosis, scoliosis
• Labral tear, rotator cuff disease, subacromial impingement
• ligamentous and meniscal injuries
• Muscle atrophy; hip muscle flexibility and gluteus medius weakness
• Peripheral nerve compression at the carpal, cubital, and radial tunnels

V. Residents will understand the appropriate use of Rehabilitation services and understand the appropriate questions to ask when consulting the Physiatrist.

VI. Through the course of their rotation, residents may have the opportunity to become skilled in the technical performance of the following procedures:

• Diagnostic musculoskeletal ultrasound
• Complex bursal, joint and peritendinous aspirations/injections, and injections of trigger finger, carpal tunnel, and base of thumb arthritis

Medical Knowledge

I. Residents will develop an approach to the evaluation and treatment of the following presenting conditions:

• Amputations, spasticity management, and other conditions affecting mobility
• Back and neck pain, acute and chronic
• Joint disorders, overuse syndromes, rheumatologic conditions, strains and sprains
• Neuromuscular disorders, nerve injuries, spinal cord injuries, stroke, traumatic brain injuries

II. Residents will explore the basic pathophysiology, clinical presentation, and treatment of more common conditions, such as Baker’s cyst, bursitis, carpal tunnel syndrome, costochondritis, ganglion cyst, hallux valgus, labral and meniscal tears, plantar fasciitis, Morton’s neuroma, osteoarthritis, osteoporosis and vertebral compression fracture, rotator cuff tear, scoliosis, tendonitis, and trigger finger.

III. Residents will learn appropriate ordering of diagnostic testing including lab tests, imaging and EMG, and indications for appropriate use of durable medical equipment in maximizing patient mobility and function.

Practice-Based Learning and Improvement

I. All residents should be able to access current national guidelines to guide patient care (e.g. American Academy of Physical Medicine and Rehabilitation).

II. Residents should participate in case-based therapeutic decision-making and coordinate patient care as part of a larger team, including the primary care provider, physical and occupational therapists, and orthotics/prosthetics specialist to optimize patient care. PGY3s should take a leadership role.

III. All residents should respond with positive changes to feedback from members of the healthcare team.

Interpersonal and Communication Skills

I. All residents must demonstrate organized and articulate electronic and verbal communication skills that build rapport with patients and families, convey information to other health care professionals, and provide timely documentation in the chart.

II. Residents must also develop interpersonal skills that facilitate collaboration with patients and their families as well as other health professionals.

Professionalism

I. All residents must demonstrate strong commitment to carrying out professional responsibilities as reflected in their conduct, ethical behavior, attire, interactions with colleagues and community, and devotion to patient care.

II. Residents must educate patients and their families in a manner respectful of gender, age, culture, race, religion, disabilities, national origin, socioeconomic status, and sexual orientation on choices regarding their care.

III. Residents should be able to use time efficiently to see patients, chart information, and counsel patients and families on diagnostic and treatment decisions.

Systems-Based Practice

I. Residents must have a basic understanding that their diagnostic and treatment decisions involve cost and risk and affect quality of care.

II. Residents will become familiar with billing and coding Physiatry services and how this process affects reimbursement for the patient and the institution.

III. All residents must develop an understanding of insurance coverage and how it affects access to care

Teaching Methods

I. Supervised patient care in the inpatient and outpatient setting

• Residents will initially be directly observed with patients to facilitate the acquisition of excellent history taking and physical exam skills.
• As they become more proficient, they will interact independently with patients and present cases to faculty.
  • Initial emphasis will be on diagnosis and basic management.
  • When residents have mastered these skills or for those residents who have already met those Milestones, focus will be on medical decision-making and technical skills.
  • Residents will work with supervising physicians to finalize a care plan.

II. Conferences

• Specialty-specific didactics

III. Independent study

• While the hope is that the resident will see the majority of common conditions during their elective, the resident will be expected to pursue resources for independent study in addition to scheduled didactics
• Journal and Textbook reading TBD by Physiatry attending
• Online educational resources
  • American Academy of Physical Medicine and Rehabilitation - particularly clinical practice guidelines and Choosing Wisely campaign
  • Pain management and addiction:
    • Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury
• Up to Date
• Clinical Key

Evaluation

I. Faculty will provide verbal feedback during the rotation as well as an attending written evaluation of the resident at the end of the month based on rotation observations.

Schedule

I. Residents should contact the Physiatry attending the day prior to determine start time and location.

II. Residents should divide their time between hospital consultation, the nursing home, and the clinic as appropriate to achieve the above educational goals.

• Rotations are a “hands-on” learning experience. Residents will be involved in discussion of patient presentation, differential diagnosis, treatment, and patient follow up.
• Case-based learning is most effective. Nightly reading/study should be based on cases reviewed during the day.
• Residents may be asked to do focused literature searches or presentations during the course of the rotation.
• When doing consults, ensure the resident understands the question asked and provides a concise answer.

III. Call and weekend responsibilities TBD by the attending physician.