Before
medical school, I thought it would be a good idea to gain experience
in the medical setting as a volunteer for a local convalescent
hospital. There, I met an elderly gentleman who had suffered a
stroke leaving his left side paralyzed and his right face expressionless.
He told me how much he admired and enjoyed working with his PM&R
doctor. His good experience with the physiatrist was not only based
on physical results and improvement but also the emotional support
and encouragement his doctor provided. The emphasis on improving
function, maximizing potential, and adapting and adjusting to hardship
is what draws me to physiatry. During medical school, I had difficulty
finding an advisor to support me and steer me toward more exposure
to rehab medicine. Many doctors/faculty tried to discourage me
from pursuing physiatry because they thought it was "not academic
enough", "just physical therapy", and "not promising in the job
market". This troubled me a great deal at first, but I later realized
that a surprising number of M.D.'s just do not understand the challenging
and multi-faceted role of a PM&R specialist. I did a 2-week rotation
in an acute rehabilitation ward at Cedars-Sinai Hospital during
what should have been spring break, and loved it. Talking to the
residents and attendings convinced me that physiatry was a great
field for many reasons: 1. It is still growing and evolving - it
is a relatively new specialty (since 1947), 2. Great lifestyle
- hours are amenable to family/social life, and salaries are competitive,
3. Patient diversity - all ages and diagnoses ranging from the
esoteric genetic neurological disorders to traumatic injuries,
4. Meaningful doctor-patient interactions - strong emphasis on
teamwork, trust, and continuity, 5. Opportunity to further specialize
- fellowships are offered in sports medicine, pain management,
traumatic brain injury, spinal cord injury, and electrodiagnostics.
How
did you prepare yourself for application to your chosen specialty?
I arranged
a 2-week elective at the first opportunity - spring break. This
gave me enough time to experience the field, think about the other
career options, and decide upon the type of residency program to
apply to before the crucial summer months. Two weeks on an acute
rehab ward is adequate time to see a wide array of common rehab
admissions: CVA's, s/p hip replacements, s/p neurosurgery, amputees,
end-stage cancer, and chronic pain syndromes. I later did an outpatient
medicine sub-I and participated in a musculoskeletal clinic once
a week and gained experience in joint injections and evaluating
neuromusculoskeletal complaints. This exposure to both inpatient
and outpatient rehab medicine gave me a good feel for the field.
I researched PM&R on the internet and found some articles which
encouraged me to supplement the clinical years with rotations in
orthopedics, rheumatology, neurology, geriatrics, dermatology,
and other fields which are integrated in physiatry. Research was
not emphasized, but I imagine experience in neurology, biomechanics,
orthopedics, or pain management would be helpful. Talking to residents
and faculty about your desire to pursue PM&R early on in the rotations
also helps open doors. They often introduced me to important people
(program directors, clinical attendings, etc) because they knew
I was interested in applying someday. Remembering names, keeping
in touch with friendly faces, and staying sincere and honest were
helpful in establishing relationships.
Who
wrote your letters of recommendation for your application?
PM&R
specialists must be familiar with both surgery and medicine to
communicate effectively with referring doctors and deal competently
with their patients' diverse health problems. Therefore letters
of recommendation from either core rotation would be weighed heavily.
However, a letter from a physiatrist who supervised your injection
technique or helped you examine a knee would be a good ally if
he/she were willing to strongly support you on paper. There are
a limited number of PM&R residency programs and a letter from within
the circle of academic attendings would be valuable. My letters
were: 1 Internal Medicine Chair's letter, 1 internal medicine,
1 family med, 1 physiatry, and 1 surgery chair. Depending upon
the program to which I was applying, I would send a combination
of 4/5 letters plus the Dean's letter. It ultimately does not matter
much what specialty is writing your letter as long as the letter-writer
knows you well, thinks highly of you, and can communicate effectively
on your behalf.
Which
programs did you apply to and why?
PM&R
is a residency which may start in either the PGY-1 or PGY-2 years,
depending upon the program. The PGY-1 year may be in preliminary
medicine, preliminary surgery, or a transitional year. I chose
to apply to the following prelim medicine/transitional year programs
(in rank order): Scripps Mercy Hospital, San Diego - transitional,
UCSD - prelim med, Santa Barbara Cottage Hospital - prelim med,
UCLA/San Fernando Valley Program - prelim med, St. Mary's, Long
Beach - prelim med, UCI, UCLA.
I applied to the following PM&R programs: UCLA/West LA VA Greater Los Angeles
Program, UC Irvine, Loma Linda, Stanford, U. of Washington, Baylor, Houston
Note: The Rehabilitation Institute of Chicago (RIC) is ranked #1 in the
nation, but location is an important factor to consider in ranking/applying
for residency. On the above list, U. of Washington and Baylor outrank the
California programs, but my desire to stay in California far outweighed
any possible benefit that could be derived from training at the other more
distinguished but more distant institutions.
What
kinds of questions did programs tend to ask you?
What
drew you to physiatry? How did you hear about PM&R? What do you
think about a physiatrist playing a more primary care role? What
type of prelim year are you applying to and why? What would you
do if a nurse informed you that one of your rehab patients was
in cardiopulmonary arrest? What is your greatest strength? What
are three of your weaknesses? What are three words to describe
yourself? How would a friend describe you? What rotations have
you done in medical school and why did you pick them?
What
would you have done differently in applying?
I believe
that I performed enough research on the field, talked to enough
residents and physiatrists, self-analyzed to the core, and applied
to an appropriate number of programs to feel very comfortable about
the match process and results. If I had let the negative, though
ignorant, remarks from others discourage me from looking deeper
into physiatry, I know I would have regretted it.
What
was the most difficult part of the application process?
Overcoming
the misperceptions and lack of familiarity with the field of physiatry
among doctors, colleagues, and faculty was most difficult. My course
advisors and mentors did not fully understand the entire role and
capacities of a physiatrist. Friends often made the mistake of
assuming it was "Physical Therapy" or did not know that one could
pursue fellowship training in sports medicine or spinal cord injury
after PM&R residency. Instead of discussing the field or trying
to better explore what it means to me, several advisors discouraged
me from going into a specialty they completely misunderstood! When
I recovered from the disappointment and shock that faculty members
could be so wrong about a field, I found it easy to commit whole-heartedly
to PM&R. If you care a lot about what others or peers think of
you, PM&R may not be as elevating in status as surgery or ophthalmology.
But patients will think the world of you if you do your job wellÌ..and
that's what counts.
What
should I look for on my interview and tour day?
How
much teaching is provided by faculty? By coursework? By senior
residents? By clinical experience? Are the residents happy with:
Call schedules? Patient loads? Range of experiences? Clinical attendings?
Didactic teaching? Amount of driving? Balance in the program? --
cardiac rehab, pediatric rehab, burn units, neuro rehab, etc. Exposure
to various environments? -- county vs. Private vs VA setting Size
of program? # of residents? Shrinking? Growing? Employment opportunities?
Unemployment rate of graduates? Where do graduates go? Reputation
of program within region? Stability of program? New faculty? Retiring
faculty? Program changes? Is the surrounding city suitable to live
in for three years? Facility? Ancillary services? Modern equipment?
Nice clinics?
What
questions should I ask of residents, faculty, and program directors?
What
kinds of things do residents complain/rave about each year? How
easily to graduates find jobs? Do you help them find employment?
What is the program's strength? Do residents have difficulty reaching
the required number of EMG's? Is research a part of the program?
Have any residents transferred out of the program in the last five
years and why? Do the other specialties work well with the PM&R
department? What do you think of the other programs to which I
am applying? Where did you train? How is it similar/different from
this program?
How
did you form your rank list?
I had
strong family ties and loved ones in Southern California, so location
was most important in making my ranklist. After interviewing in
Seattle, Los Angeles, and Irvine, I decided the program in Los
Angeles was most well-balanced, stable, and compatible with a sane
lifestyle. My final ranklist was short because I listed only the
programs I was willing to attend: 1. UCLA/VA Greater Los Angeles
Multicampus Program 2. UC Irvine 3. U. of Washington U. of Washington
gave me the impression that it worked the residents too hard on
the wards in addition to demanding participation in a very rigid
classroom-type curriculum. The damp climate was not appealing to
me. They are ranked very high nationally, and they don't hesitate
to tell you that. I did not appreciate the program director's comment, "If
you want a good PM&R training, you have to leave California." Irvine
has a very good reputation in California, but the senior faculty
members who helped build that reputation have been rapidly retiring.
The Irvine program hired a brand new residency director this year
who seems very committed and is enthusiastic about research, but
the program seems too unstable at this time. Stanford has a good
overall name, but in the PM&R world, they are very weak. Loma Linda
has a very prominent physiatrist as the director, but requires
residents to do the PGY-1 year there. UC Davis is supposedly a
good program, but the program size is dwindling to 1-2 residents
per year. Baylor in Houston has a great reputation academically,
but a disgruntled resident left their program and joined the UCLA/West
LA VA program last year. She disclosed that many residents are
unhappy in the Houston program because there are too many sites
to rotate through, and attendings abuse residents by making them
do inpatient wards at every opportunity rather than allowing them
outpatient clinic experience which is less time-consuming for the
attendings.
What
other advice can you give seniors applying in your specialty?
oLook
into it for yourself. Don't ask others to explain it to you or wait
for others to encourage you to pursue it - in all likelihood, that
will never happen. If you read about rehab medicine or experience
it firsthand, you will instantly appreciate that PM&R is about quality
of life for patients. Encouraging the discouraged and enabling the
disabled is what physiatrists do better than most other physicians.
However, you will not find happy endings all the time. There are
no quick fix surgeries or potent medical cures for most of the complex
disabilities you deal with in PM&R. The best advice is to be true
to your personality - ask yourself if you are the type of person
who can deal with slow progress? No progress? Sad outcomes? Depressed
or difficult patients? Are you patient? Optimistic and enthusiastic?
If you like to be the doctor who sweeps into the ER to save the day
or deliver the healthy baby to make all the relatives smile, could
you be satisfied with a 10 degree improvement in range of motion
of a frozen shoulder?
