Caring in the time of COVID-19

by Chris Ha, DO and Josh Romero, MD

Photo from Aaron Lieber/Freestyle Releasing per LA Times. https://www.latimes.com/entertainment/movies/la-et-mn-mini-bethany-hamilton-unstoppable-review-20190711-story.html

Movement is produced by the synchronization of 3 systems in our body: skeletal, muscular, and nervous. The nervous system acts as a conductor to integrate the ambiance of our surroundings and communicate via organized signals with the musical groups in our body including muscles and bones to produce a coordinated motion. If one of the elements in these three systems is not functioning properly, it will lead to impairments in the chain of motion. So what happens when one of the links in the chain is missing? Well, we may make the rest of the chain stronger. This is a lesson that athletes with amputations who have excelled in their sport have taught us, such as surfer Bethany Hamilton, through competing in sports as complex as surfing. This sport has unique challenges, requiring precise orchestration of motion that combines endurance, strength, power, stability, balance, and coordination. While many might think that missing a link in the chain of motion would be a fatal flaw for this sport, surfers like Bethany have gone above and beyond what we ever thought imaginable. In order to understand how to make the rest of the chain stronger, it is important to understand the kinetic chain and how this has been applied to the sport of surfing to bypass the missing links in the chain and allow optimal performance.

The knowledge of how our body is interconnected to produce movement as a unit is as important to a surfer as their connection to the ocean by reading the waves. The kinetic chain, a concept established in engineering by Franz Reuleaux, has been adapted to understand movement in linked systems such as the human body. In a system of overlapping rigid segments linked into a chain via pin joints, movement produced at one segment will affect movement in other segments. Therefore, a force applied to one segment will be transferred to adjacent segments and produce predictable patterns of movement at all the joints in the chain. Applying this concept to the human body, bones act as rigid overlapping segments that are linked at joints. In this way our foot, leg, thigh, pelvis, spine, ribs, arms, forearms, hands, skull are neatly connected into a chain by joints at the ankle, knee, hip, ribs, cervical, shoulder, elbow, and wrist. The kinetic chain principle helps to understand how movement in our body transfers force to adjacent segments in a chain reaction producing predictable patterns of movement. Based on this concept, human movements have been classified in two groups: closed and open kinetic chains, depending on whether the most distal segment is met by sufficient resistance or not. A kinetic chain is closed when the most terminal segment in the chain meets resistance considerable enough to restrain it from moving freely. This fixation markedly affects movement in other segments. In contrast, a kinetic chain is open when the terminal segment of the link is free to move in space. This allows for better isolation of the terminal joint during movement.

Most movements in exercise possess elements of both open and closed kinetic chains. However, most exercises can be classified as open or closed chain based on the characteristics at the specific joint targeted by the exercise. In surfing, the definition of closed kinetic chain raises an interesting question. As the feet are in continuity with the free moving surfboard, over freely moving water, this could potentially make surfing an open kinetic chain exercise. However, Kibbler has recently defined closed kinetic chain as a sequential combination of joint motions in which the distal segment of the kinetic chain meets considerable resistance, but does not have to be fixed. This clarifies that surfing is a closed kinetic chain exercise as the feet, which act as the terminal segment, are met by sufficient resistance from the surfboard to restrain them from moving freely. Muscles are therefore activated in a chain from distal to proximal as force is transferred upward from force generators including the lower limbs and trunk, towards mobile distal segments including the arms. Body segments along the chain must have optimal flexibility, strength, proprioception, and endurance to enhance and harmonize mobility and stability to surf successfully. In order to catch waves, surfers must perform the following cycle of events: paddle out, duck dive to push the board under crashing waves, paddle for a wave, push to stand, ride the wave, and perform maneuvers on the wave. Additionally, surfers must simultaneously interact with external forces including gravity, buoyant force keeping the board afloat, shear forces with the board, and torsional forces of their desired movements.

Understanding the kinetic chain in surfing can advance rehabilitation of surfers after an amputation. Particularly in upper extremity amputees, the following issues must be addressed: kinetic chain alterations, weight imbalances, challenges to duck diving, paddling, pushing to stand, and balance. Rehabilitation programs should focus on maximizing the kinetic chain by improving flexibility of joints and soft tissues, strengthening muscles of the lower limbs and core, and improving muscle endurance. Flexibility of the involved joints and soft tissues including the residual limb should be targeted first through muscle reeducation and soft tissue mobility. Failing to address inflexibilities of both upper and lower extremities early leads to limitations in mobility and hinders progression. Early stages should also focus on residual limb care to optimize mobility and functionality. This includes: positioning to prevent muscle and tissue shortening by extending the residual limb as much as possible, compression bandages to reduce swelling and aid circulation, appropriate skin care, desensitizing the skin by accustoming it to textures, and catching any phantom limb pain or sensitivity issues early to initiate any pharmacologic treatment or therapeutic modalities.

The next priority is the strengthening of the lower limbs and core muscles to aid balance and strength. Proper activation of the lower limbs is crucial to generate power and create a stable base of support that will allow dynamic stability so both arm and residual limb can direct the resultant energy during cuts and turns on the wave by facilitating scapular motion. Proper core muscle activation also aids balance and posture as the loss of weight on the amputated side can lead to imbalance and poor posture. When establishing balance on the board, the arms spread out instinctively to spread mass away from our feet that act as the pivot point. This increases the body’s moment of inertia or resistance to rotational forces so that more torque would be required to rotate the surfer making it more difficult to fall from the board. Therefore, optimizing core and lower extremity activation, mobility, strength, and proprioception are essential to surfers with an upper extremity amputation. Closed kinetic chain exercises should start early after the amputation to provide a stable axially loaded static setting to the residual limb in a more controlled environment, work at specific snapshots of the range of motion, and unload the rotator cuff muscles by activating inhibited muscles emphasizing normal activation patterns to reestablish proximal stability and control in the links of the kinetic chain such as the pelvis and trunk. This will not only help maneuvering on the board, but also in pushing to stand and duck diving under waves which are both closed chain motions initiated by the legs and core. Once the normal activation pattern has been restored, more challenging isolated open kinetic chain exercises should be implemented. This should be done later in the program due to their increased demand on the soft tissues. These open chain exercises will help the unaffected arm in developing power and endurance to be able to withstand paddling with one arm.

While it may seem that the amputee population has a disability, a much better description for this population is that they are adaptive. They have changed the mindset that certain activities are not possible with a missing limb. Further, they have adapted the equipment to bolster performance, the possibilities in their sport, the way we approach rehabilitation, and their body to reach heights that no one thought imaginable. In summary, these athletes are enabling what once seemed impossible by adapting our mindset and approach to sports.

Claudia Jimenez is a PGY-1 at the Department of Physical Medicine and Rehabilitation at University of Puerto Rico School of Medicine. You can follow her on Instagram @pm_and_art.

1. Karandikar, N., & Vargas, O. O. O. (2011). Kinetic Chains: A Review of the Concept and Its Clinical Applications. Pm&r, 3(8), 739–745. doi: 10.1016/j.pmrj.2011.02.021
2. Sciascia, A., & Cromwell, R. (2012). Kinetic Chain Rehabilitation: A Theoretical Framework. Rehabilitation Research and Practice, 2012, 1–9. doi: 10.1155/2012/853037
3. Information for upper limb amputees and their families. (n.d.). Retrieved April 19, 2020, from https://www.ottobockus.com/prosthetics/info-for-new-amputees/information-for-upper-limb-amputees-and-their-families/
4. Clark , M. A., Lucett, S., & Corn, R. J. (2008). Basic Exercise Science . In NASM essentials of personal fitness training (3rd ed.). Philadelphia , PA: Wolters Kluwer Health/​Lippincott Williams &​ Wilkins.
5. Airaksinen, Lisa. The Role of Core Stability in Surfing According to a Delphi Panel. Bachelor’s Thesis. Mikkeli University of Applied Sciences, Finland. https://core.ac.uk/download/pdf/38093862.pdf

Social Media Use in Rehabilitation Medicine

by Kathy Plavnik, DO

Social media has become a growing hot topic in the medical community. Whether it is Facebook, Instagram, YouTube, Twitter, or the new Tik Tok, these are platforms where physicians are beginning to share both their personal journey in medicine and educating the population on medical topics related to their fields. Although the online community is an easy way to share information to thousands of individuals with just one click, there are many risks associated with social media use as a medical professional including breaching patient trust and confidentiality. In response to the increased use of the internet, the American College of Physicians (ACP) has published guidelines with detailed information for medical professionals (1). This article will review the advantages and disadvantages of social media use as it relates to rehabilitation physicians.

Patient Education

Social media has become a source of patient access to medical resources when provided by educated professionals. Medical centers and hospital organizations have started utilizing the power of social media to spread information about health and wellbeing in their local areas. For example, Mayo Clinic has established a Center for Social Media dedicated to establishing an online presence on multiple platforms (Facebook, Twitter, and YouTube) and providing health professional-based podcasts and blog posts (2). The hope is that the more physicians utilize social media to distribute evidence-based information, the more they can counter inaccurate information distributed online. In one study by Workewych et al, 7483 Twitter tweets related to traumatic brain injuries in sports were collected and analyzed. In order of popularity, the tweets consisted of subjective opinions (26%), instances of injury (22%), education (21%), policy and rules (16%), and medical (15%) (3). In addition, the study found misinformation regarding return to play, which can be countered by physical medicine and rehabilitation physicians sharing their knowledge and expertise on the social media platform.

Community

Patients may use social media to connect with others affected by similar conditions and build a community of support for one another. For example, the hashtag #StrokeSurvivor has 165,000 public posts of individuals sharing their journeys from stroke to recovery. This allows individuals suffering through similar obstacles to share with one another and provide support during one of the most vulnerable times in their life. Physiatrists help improve patient functional recovery and enhance their quality of life by participating in ADLs and iADLs, which can include social media use. In a study by Brunner et al., rehabilitation professionals agreed that encouraging patients to return to their pre-injury use of social media has benefits including reduced social isolation however harbors the risk of vulnerability (4). Social media has the potential to provide patients and physicians with a community of familiarity and comfort with appropriate use.

Marketing

Social media engagement can help to build a successful practice if used efficiently. According to a study done in 2011, hospitals use social media to target a general audience, provide content about the organization, announce news and events, further public relations and promote health (5). As many patients search for a provider online before scheduling an appointment, social media can be beneficial for physicians who are able to market themselves online to a large audience (6).

Confidentiality

When choosing to utilize social media, all healthcare professionals should use extreme caution while posting pictures or stories to ensure that there is absolutely no personal health information (PHI) anywhere. In addition, physicians should avoid sharing personal opinions that have not been proven by science or on controversial topics that may negatively impact others. A national survey of state medical boards indicated that the most common violations include inappropriate patient communication online, use of the Internet for inappropriate practice, and online misrepresentation of credentials (7). Most of these violations were reported by patients, their families, or other physicians in the community. Physicians must understand that sharing events even without explicit patient identifiers, such as “today we saw a patient that fell onto the train track and had to have their leg amputated” can still lead to a breach of confidentiality. If someone’s friend fell onto the train track that day and knows the hospital where they are working, the connection can be made and their personal information would be exposed. Violating the HIPPA Act and failing to adhere to institutional policies can lead to the loss of both a job and a medical license.

Conclusion

While social media has a vast array of potential benefits for both physicians and patients, rehabilitation health care providers must be cautious in avoiding breaches of confidentiality while utilizing social media in their practice.

1. Farnan JM, Snyder Sulmasy L, Worster BK, Chaudhry HJ, Rhyne JA, Arora VM (2013) American College of Physicians Ethics, Professionalism and Human Rights Committee; American College of Physicians Council of Associates; Federation of State Medical Boards Special Committee on Ethics and Professionalism*. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med 158(8):620–627
2. George DR, Rovniak LS, Kraschnewski JL. Dangers and opportunities for social media in medicine. Clin Obstet Gynecol. 2013 Sep;56(3):453–462
3. Workewych AM, Ciuffetelli MM, Jing R, Zhang S, Topolovec-Vranic J, Cusimano MD. Twitter and traumatic brain injury: A content and sentiment analysis of tweets pertaining to sport-related brain injury. SAGE Open Med 2017 Aug;5:2050312117720057
4. Brunner M, Togher L, Palmer S, Dann S, Hemsley B. Rehabilitation Professionals’ Views on Social Media Use in Traumatic Brain Injury Rehabilitation: Gatekeepers to Participation. Disabil Rehabil. 2019 Nov 7:1-10. doi: 10.1080/09638288.2019.1685604.
5. Thaker SI, Nowacki AS, Mehta NB, Edwards AR. How U.S. Hospitals Use Social Media. Ann of Intern Med. 2011;154:707–8
6. Bernstein KI, Promislow S, Carr R, et al. Information needs and preferences of recently diagnosed patients with inflammatory bowel disease. Inflamm Bowel Dis. 2011; 17:590-8
7. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;307(11):1141–1142.
8. Photo by Cristian Dina from Pexels

Kathy Plavnik, DO is a PGY-4 in PM&R and Chief Resident at NYU Rusk Rehabilitation.

Interview with a Women’s Health Physiatrist

by Debbie Lee, MD

Rising awareness of gender disparity in medicine has created a growing interest to develop or enhance training in women’s health at both undergraduate and graduate medical education levels across all medical specialties, including in Physical Medicine and Rehabilitation (PM&R). In a recent survey study to assess prevalence of musculoskeletal women’s health curricula as well as women’s health physiatrists at ACGME-accredited PM&R residency programs, the authors highlight an unfortunate mismatch between the prevalence of formalized women’s health education (11%) versus physiatrists providing women’s health care (66%) in the 55 programs that responded1. Even for those residents who train at programs with formal education, there are varying levels of exposure throughout training and there is currently no PM&R fellowship for women’s health for those who wish to further their knowledge in this subspecialty.

I was fortunate to interview Dr. Sarah Hwang, the Director of Women’s Health Rehabilitation at Shirley Ryan Abilitylab, to discuss her experiences pursuing women’s health physiatry as a career.

What attracted you to women's health over general physiatry or other subspecialties within PM&R?

I really enjoy working with women and empowering women. As a medical student, I was initially drawn to obstetrics and gynecology. Then I spent a month with a physiatrist and found that the focus on function and quality of life aligned with the way I wanted to practice medicine. Being a woman and a mom myself, I feel like I can relate to a lot of my patients. I am passionate about helping my patients regain their function and improve their quality of life.

Did you have formal women's health education during residency, and how did you develop your skills during training?

As a resident I was exposed to women’s health early – with lectures, physical exam skills sessions and continuity clinic with a women’s health rehabilitation (WHR) physician. As soon as I learned about WHR, I knew that this was the patient population that I wanted to work with. I used my continuity clinics and elective time to work with the WHR physiatrists and physical therapists to develop my skills. As an attending, I quickly established a relationship with the other WHR physiatrists throughout the country (all of whom had also trained with my mentor, Dr. Colleen Fitzgerald). This network has served as a great resource and a way to continue to advance my knowledge.

What did you do early in your career that enabled you to recruit and define your patient population?

When applying and interviewing for my first job, I was clear that I wanted to practice WHR. Out of residency, I joined the faculty at University of Missouri (Mizzou). During my interview, I met with the chief of the urogynecology division. I discussed my passion for treating women with pelvic pain and he invited me to join their clinic one day per week. Once I started the job, I networked with obstetrician-gynecologists, urologists, gastroenterologists – each time explaining what services I offered and how I could help their patients. When I was hired at Mizzou, there were no women’s health physical therapists, so I also met with the director of physical therapy and explained that I wanted to build a women’s health rehabilitation program, which wasn’t possible without women’s health physical therapists. He helped to identify two current therapists that expressed an interest in WHR. Once we had the personnel needed to form our team, the networking helped to grow our patient population. Our stand alone WHR clinic opened about 3 years after joining the group at Mizzou. This space also allowed us to host exercises classes and community lectures which were another effective way to grow our practice.

What does your current practice look like?

I treat pelvic pain, pelvic floor dysfunction, urinary frequency/urgency, urinary incontinence, constipation, bowel incontinence, coccydynia, postpartum injuries and pain during pregnancy. I have WHR colleagues that also treat osteoporosis. My practice is mostly outpatient but I also do inpatient consults at both at the rehabilitation hospital (mostly seeing pelvic pain, coccydynia or incontinence) and at Northwestern Prentice Women’s Hospital (where I see postpartum patients with musculoskeletal or nervous system injuries). In my clinic, I also perform trigger point and botox injections to the pelvic floor muscles.

What advice would you give to residents considering a PM&R women's health practice?

Find a mentor that practices WHR – try to work with them. If you don’t have a local physiatrist that treats this patient population, try to spend some clinic time with urogynecologist or gynecologist that treats chronic pelvic pain. Consider doing a lecture for your co-residents on a WHR topic.

1 Bennis, Stacey, and Monica Rho. "Musculoskeletal Women's Health Education in Physiatry: A Mismatch in Residency Education and Clinical Practice." PM&R (2019).

Debbie Lee is a PM&R resident at Shirley Ryan Abilitylab/McGaw Medical Center of Northwestern University.

Disability in Film: An Interview with Dr. Glendaliz Bosques

by Jason Edwards, DO

Media can have tremendous influence on all aspects of human life. The ways in which society at large perceives disability is no exception. While the media’s depictions can have a significant positive impact on societal norms, misrepresentation, unfortunately, can lead to reinforcement of negative stereotypes and spread misinformation. These are some of the reasons why Disability in Film, an extracurricular event at The University of Texas Health Science Center at Houston / McGovern Medical School and Baylor College of Medicine, was started. The program involves PM&R trainees and an attending moderator watching a film that portrays someone with a disability. Following the film there is an in-depth discussion assessing how disability is portrayed and contrasting that with the unique realities of the patients we serve. Today I am joined by Glendaliz Bosques, MD, Associate Professor of Physical Medicine and Rehabilitation at McGovern Medical School, Chief of Pediatric Rehabilitation Medicine at University of Texas Health Science Center at Houston and Director of Pediatric Rehabilitation at Shriners Hospitals for Children – Houston.

Dr. Bosques, thank you for joining us. Tell us about how you became interested in Disability in Film and your experience with this activity.

I have always been interested in finding non-conventional ways to discuss important topics. When I was in medical school, we would play parts and try our best to be actors in order to practice challenging topics, such as how to break bad news, or dealing with a patient with a new life altering diagnosis. However, we were medical students and horrible actors. Sometimes it was difficult to learn from the situation, because it didn’t feel real or honest. As a young faculty member, I wanted to find something that would be able to connect to our core as learners and thought about how touching and deep some movies may be. This gave me the idea of integrating videos and films into medical education with my trainees. I started doing it informally during my first faculty position at Hopkins, as part of the Chronic Disease and Disability Curriculum there. I was the director of the Kennedy Krieger Institute site as part of a required rotation for medical students. It was there that I thought for the first time about compiling a list of films, videos, books and other media that provided portrayal of people with disabilities. Most of the students would watch a movie, instead of reading a book. It takes longer to read a book, especially as a busy medical student. That is why when I came to UTHealth and McGovern Medical School, I restructured the rotation. As I was reading the reflections that the medical students completed as part of their required activities during their rotation, I thought it would be a good idea to have a similar exercise with the residents. Find a way to discuss topics and connect, outside of the confines of our daily clinical practice.

Can you share some of the success stories you have experienced with this initiative?

Personally, I truly enjoy being able to open my house and share some of my time with my trainees. I think part of why we go into medicine is our drive to connect with people, mostly our patients. There is a big concern in the healthcare environment in regards to burn out. We have demanding jobs, feel loss of control of our environment and end up documenting and spending more time with a computer screen than with our patients. Some of the research has shown that despite being stressed, most of us can more readily cope if we feel that we have a larger meaning, are able to connect and have a sense of community. As an educator, I strongly feel that we need to connect with our learners. This allows me the opportunity to have more casual conversations. From a resident standpoint, I think they appreciate the fact that we can sometimes discuss other factors that are not the “pure medical/clinical” ones, that we typically discuss at bedside. We actually may delve into psychosocial factors that sometimes are difficult to address at bedside.

What are some of the challenges that have come with this initiative?

I think the most important challenge that we need to discuss is that we need to make sure that we are also acutely aware of our own biases. Most of us in medicine and even in rehab see disability through the eyes of an able body person. The challenge is to try our best to not insert ableist narrative into these conversations. The challenge is to expose our own vulnerabilities. As we discuss these topics, everyone needs to be ready to come into the experience with an open mind and ready to learn from others and listen. The challenge is understanding that our learning should not stop there. We should continue to expand our knowledge on the issues that touch our patients lives, to be better rehab physicians, to be better advocates, to be better humans who value inclusivity.

Disability in Film uses moving image as an unconventional tool for education. Tell us how this, as well as other unconventional tools, are important for resident education.

We are so used to sitting in a room to learn with someone providing digested information in the form of a lecture. Pedagogical evidence shows us that lectures are not great for active learning. We need to think and find relationships and associations in order to learn better. It is so much easier to just put a presentation together. It is harder as an instructor to find new ways to keep your learners engaged, to support their higher cognitive processes. We all can open a book and read about a topic, but I think in rehab it is even more important to go beyond bedside topics. We pride ourselves in being holistic physicians, and this goes beyond the clinic. We need to discuss how life happens to allow us to anticipate other needs that may be important to our patients. That is how we impact long-term outcomes.

Is this a model that is sustainable and replicable, and for anyone interested in establishing a similar program, what advice do you have?

I do think it is sustainable and replicable. I think it is important to have learners who are open and willing to have honest and respectful conversations about topics that sometimes are difficult to tackle. I encourage the faculty (or the moderator) to try not to structure it too much. I prefer to follow the lead of the learners in terms of the topics to discuss after the movie. There should be a list of options for films, and I would not pick the same one all the time. As a moderator, we also need to ready ourselves to be open, vulnerable and eager to learn as well. I highly recommend having a session at least twice a year, because it is also fun!

Jason Edwards, DO is the Brain Injury Medicine Fellow at McGaw Medical Center at Northwestern University/Shirley Ryan AbilityLab and the 2019-2020 Fellow Representative for the Resident Fellow Council of AAP.

Disparities in Rehabilitation Medicine

by Soojin Kim, MD

Nelson Mandela, past president of South America, once said, “Health cannot be a question of income; it is a fundamental human right.” Being a medical school student myself, I hear the question ‘Is healthcare right or privilege?’ a lot. Truth be told, I do not have a clear answer to this question. However, I do believe it is unfortunate that patients come out with different health outcomes because of disparities. I witnessed this type of events numerous times, but the most memorable and impactful event took place on the third day of spinal cord injury (SCI) rotation during the medical student summer clinical externship.

It was just a regular day like always. Dr. Kirksey, Dr. Hutts, and I were making our regular rounds, meeting and talking with patients. As we were walking towards our next patient room, we heard someone speaking from that very room. “Don’t put your arms around me. While you are at it, bring the blanket just up to my thighs. Hand that document to doctors when they come in, will you George?” As we entered the room, we were greeted by an elderly gentleman, surrounded by his family members, a nurse, and an occupational therapist. Despite being at a hospital for 2 weeks, the elderly patient looked as if he just came out from a business meeting. His face was well-groomed, looked well younger than his actual age, and it was clear for everyone to see that the impairment of his lower extremities, which could have permanently damaged him, did not break him one bit. Another thing that was very noticeable was his demanding demeanor. Being a wealthy businessman himself, it seemed as if he knew exactly what he wanted and made sure everybody in the room knew that as well. Making sure they get all the information that the patient wanted, his family members asked the doctors information regards to optimal care, home health options, follow-up appointments, different physicians, wheelchair selections, and other ancillary healthcare services. With immediate medical management following SCI, he and his family members taking ownership of the patient’s own health and deciding the best rehabilitation process, the elderly patient seemed to be able to regain the similar quality of life he had prior to the injury.

That very afternoon, a young man in his 30s showed up in front of Dr. Kirksey and I at the outpatient SCI clinic by an ambulance with his parents. As soon as we entered the room to examine this patient, a stench of urine greeted us. This young patient had fallen from a ladder 18 months ago and was bedridden since then, without any medical assistance. Unlike the elderly patient that was just discharged this morning, this young patient seemed as if he had not taken a shower for weeks and was in a diaper. The reason why we were able to tell that he was wearing a diaper was because he was hardly covered with any clothing, which exposed his scrawny body and contractured limbs. When we asked him a question, he was barely able to make eye-contact, mumbled a few words, and lacked facial expression or emotions. This was his first doctor’s visit since the accident and the only reason his parents brought him in was because they themselves were getting too old and taking care of their son had become too overbearing for them, physically, emotionally, and financially. Already spent hundreds of dollars on ambulance fee alone, patient’s parents asked Dr. Kirksey about inpatient care at UAB, in the hopes of his son improving from his current state. When they were told about the high cost of the medical fee for other subacute facilities and that the timeframe for a possible recovery from SCI is about one year, but the patient does not have much room for improvement because of late response post-accident, the room was filled with silence and looks of devastation.

Different types of disparities are present everywhere, whether that be racial, financial, or medical. Sadly, these disparities hugely impact patient outcomes.

Photo by Alexandre Aaraiva Carniato from Pexels

Soojin Kim is a resident at the University of Alabama in PM&R.

AAP Medical Student Council Response to COVID19

by Nicole B. Katz, MS3

The 2020-2021 AAP Medical Student Council has been hard at work since its inauguration in February at ISPRM 2020. This year’s council is composed of 10 medical students representing nine medical schools from across the United States and advised by Dr. Ravi Kasi, Assistant Professor and Residency Program Director at Rush University Medical Center. Collectively, we have defined our mission to be to provide meaningful opportunities for premedical and medical students to explore the field of Physiatry. Furthermore, we aim to accomplish our mission by facilitating engaging activities, distributing valuable learning resources, coordinating mentorship connections, advocating for students, and fostering an international community of those who are passionate about physical medicine and rehabilitation.

After establishing our goals at ISPRM, our agenda quickly changed as the needs of the medical student community were drastically altered in the wake of COVID-19. From reorganized preclinical courses to suspended clinical rotations, medical students of all years have been greatly impacted by the orders to stay safe at home. Beyond wanting to provide physiatry-related learning opportunities, we hoped to help facilitate a sense of social closeness during this time of physical distancing. One of our endeavors includes partnering with A.T. Still University of Osteopathic Medicine to hold weekly zoom-based journal clubs. These hour-long sessions include two student-led article presentations and discussions enriched by residents, fellows, and attending physicians who graciously offer their expertise. In the coming months, the AAP MSC alone will organize this journal club; we are excited to provide this resource now as well as once standard medical education resumes. If interested in participating in an AAP MSC journal club, please email medstudent@physiatry.org.

Another virtual resource we are thrilled to be launching is the medical student didactics beginning in May 2020. As a supplement to AAP’s incredible webinar series, this lecture series is geared specifically towards medical students. Is there a lecture you were hoping to give to medical students on their PM&R rotation? We’d love to hear it! If you’re a physiatrist of any level of training (resident, fellow, or attending physician) and interested in lecturing, please consider completing this form (https://docs.google.com/forms/d/e/1FAIpQLSds4HP2WDnNCJAk3svQsaGYkEX3sVHyB-rnAr8QnWSWyiw5Vw/viewform).

In working to strengthen the physiatry medical student community further, we created a web-based international PM&R interest group for medical students at international medical schools wishing to connect with one another. If interested in joining, this group can be found on Facebook under the name “PM&R Virtual International Medical Student Interest Group.”

With the uncertainty surrounding what medical education will be in the coming months, the AAP MSC is humbled to be able to play a part in increasing both camaraderie and learning opportunities for medical students worldwide.

Nicole B. Katz, is an MS3 at the Lewis Katz School of Medicine at Temple University and Chair of AAP MSC. Follow her on Twitter @NicoleBKatz

Delayed Goals

by Captain J. Tyler Bates, DO

Long term goals and delayed gratification are a part of medicinal education, the path is long and requires many sacrifices. For some practicing medicine is fulfilling a lifelong dream, others discover their dream later in life. Regardless of when one finds the dream to become a doctor, they have years of work ahead requiring long hours of studying, sacrifice, and formal education. I myself decided to pursue medicine while in high school.

Around my junior year of college, I discovered that I wanted to pursue Physical Medicine and Rehabilitation (PM&R). There are a multitude of reasons why, but this is not the time for that. I was curious about other specialties and looked forward to discovering them but I was confident that PM&R was the right match for me. Though, I had another interest, aviation. Prior to pursuing medicine, my dream was to become a pilot. Multiple experiences pushed me to pursue medicine over aviation but I knew that I could mix both medicine and aviation by becoming a flight surgeon.

In the rush to accomplish my goals I largely disregarded my side interest in aerospace medicine. Number one reason for that was that it would increase the time it would take for me to become a physiatrist. Neither the U.S. Air Force or the U.S. Navy consistently authorize active duty physicians to specialize in PM&R. The Army has active duty physiatrists but only a small number. Another reason was money. I was aware of the Health Professions Scholarship Program (HPSP) which was offered by the Army, Navy, and Air Force. I had calculated the financial outlooks of both methods, taking the scholarship and owing four years military service in exchange for tuition and a living allowance as opposed to student loans. While the military route provided short term access to money and more comfortable living through medical school it did not make a significant difference in the long term. Between those points and others, I did not join the military for medical school.

Why am I in the Air Force now? Well, I was sitting in lecture one day and realized “I am going to graduate from med school, go somewhere for residency, graduate, practice, retire, and die.” I thought that sounded boring so I called the recruiter the next day. I wanted more adventure and service in my life.

I decided to delay my ultimate goal of practicing PM&R by joining the Air Force to become a flight surgeon. As I progressed through medical school and Air Force training, I found others that also loved PM&R but were unable to pursue that specialty in the military. There were other specialties as well that were not readily available in the military. They mentored me as I worked towards two different medical careers, one as a flight surgeon and the other as a physiatrist. The most important aspect that all echoed was to make the most of my active duty service and learn as much as possible. While something might not be directly related to my ultimate career goal it can help me learn to be a better doctor and that is the important part.

As a flight surgeon I am the primary care physician for pilots, student pilots, air traffic controllers, and aerospace physiologists. We are specialists of normal physiology in abnormal conditions. Additionally, I do annual occupational exams for firefighters, pre-employment physicals for civilian employees, and separation/retirement exams prior to people leaving the Air Force. Outside of the clinic I go with Public Health to ensure food safety and oversee safety in occupational shops on base. Oh, and I fly in the backseat of supersonic aircraft.

To be an Air Force flight surgeon one needs to complete a PGY-1 year and at least six weeks of Air Force flight surgeon training. Some are residency trained, usually family, internal, or emergency medicine trained. Many however, are General Medical Officers (GMOs) having completed an internship year without a full residency and board certification. GMOs are utilized in every branch of the military with the Navy having the most and Army having the least. In the Air Force the majority of GMOs are flight surgeons with a few in primary care clinics. The Army has GMOs as primary care doctors in multiple settings including as flight surgeons. The Navy though, has the most variety of GMO jobs including flight surgeons, dive medical officers, Marine Battalion Surgeons, and shipboard physicians.

Due to my plans to become a flight surgeon after completion of intern year I sought out unique training opportunities I might not have pursued if I planned to go straight through residency. During medical school I elected to pursue one of our rural medicine clinical tracks. I optimized my electives to gain knowledge in a broad base of medical knowledge and experiences. Additionally, my internship was a transitional year associated with a full spectrum unopposed family medicine residency in a rural area. I feel like these are all great life and educational experiences that I likely would have missed if I were focused only on getting into residency.

While these experiences may not be directly related to the field of Physical Medicine and Rehabilitation, I am learning so many things that are helping me to be a better doctor and well rounded leader. Some of the PM&R related tasks include reviewing fitness and duty restrictions for all military members, reviewing medical discharge. We work with teams of other medical professionals including optometrists and physical therapists.

Likewise, things I learned during my PM&R rotations are helping me at my job. One thing I always enjoyed about inpatient rehab were multidisciplinary meetings with Physical, Occupational, and Speech Therapists - along with nursing staff and social workers. It was great to all be together talking about the patient’s progress and needs. I have not encountered this in any other field of medicine except for flight medicine. We have weekly meetings to discuss everyone that is unable medically to do their duties. These meetings include a multidisciplinary team and the focus of helping the patient improve to return to their job, to get retrained into another career field, or medically discharged. The team ensures the ability of the Air Force to maintain a ready and healthy fighting force and the patient’s best interest. That takes a team.

Perhaps, the most obvious overlap PM&R and flight medicine is exposure, comfort, and knowledge with handling musculoskeletal (MSK) injuries. I serve a young healthy population that is frequently active and also driven to be the best. As such injuries frequently occur. Additionally, their job exposes their bodies to conditions not foreign to the body. Some have spent a career pulling Gs, where their body becomes up to 9 times its normal weight. While they’re pulling those Gs, they are constantly moving their heads looking for the enemy aircraft. Others fly continued non-stop flights that sometimes exceed 48 hours in duration. Most everyone, has back or other musculoskeletal pain. Many medications and modalities to help pain are dangerous in flight and having a functional focus and training helps to find common goals between what the pilot desires and what medical standards permit. While, I do not have all the answers for their pain I have a comfortable foundation in evaluation and diagnosis of MSK injuries and responsible imaging determination.

For those considering this career progression, there will be many who discourage you. This is not the normal path that people take. Many will discourage you from “pausing” the pursuit of further specialization in order to serve. Others will attempt to encourage you to find a replacement for PM&R and specialize in something else as to not have an intermission. Those are all valid options but if PM&R is your medical love and you have a desire to serve in the military, there is a way. It has been done before, mentors are out there. The most important part is to make the most of the time you have learning in school, internship, and during military service.

I will pursue PM&R because I love what the specialty offers but I am going to take advantage of my time as a flight surgeon. There are so many things to continue to learn that will help me be a better person, physician, and physiatrist and I get to fly in military jets while I doing it.