Rehabilitation Residency Research Articles

Poster 158: Teaching Residents in rehabilitation to communicate bad news to their patients.

Objective: To determine if an educational program can improve a physical medicine and rehabilitation resident’s ability to deliver bad news to patients. Design: Preeducation and posteducation assessment of residents’ communication ability with a standardized patient. Setting: Clinical skills center. Participants: 10 rehabilitation residents (PGY-2 to PGY-4). Intervention: Preeducation experience with a standardized patient with a simulated C6 complete spinal cord injury followed by a 1-hour educational lecture using the American Medical Association’s (AMA) Education for Physicians on End-of-Life Care (EPEC) program on communicating bad news to patients. This was followed by a posteducation experience with the original standardized patient. The person monitoring the session then provided feedback to the resident before a novel standardized patient, who simulated a mother of a patient who had been in a persistent vegetative state for over a year. The monitor and the standardized patient used a standardized checklist to assess the resident’s performance. Main Outcome Measures: Monitor checklist of 8 items: score 1 if done and 0 if not done (max=8, min=0). Standardized patient checklist of 7 items rated on a Likert scale: excellent, 5; very good, 4; good, 3; fair, 2; poor, 1 (max=35, min=7). Results: Monitor checklist: the preeducation mean was 2.9 (95% confidence interval [CI], 1.81–3.99); the posteducation mean was 5.4 (95% CI, 4.377–6.423); and the novel case mean was 5.9 (95% CI, 5.044–6.756) (multivariate test [Hotelling trace], P=.002). Standardized patient checklist: the preeducation mean was 31.4 (95% CI, 29.609–33.191); the posteducation mean was 34.2 (95% CI, 33.636–34.764); and the novel case mean was 27.9 (95% CI, 25.577–30.223) (multivariate test [Hotelling trace], P=.001). Resident survey (5-point scale): worthwhile educational experience was 4.9; I will use what I learned in the future was 4.7; and I would participate again if not compensated was 4.4. Conclusions: A 1-hour lecture on delivering bad news to patients using the AMA’s EPEC program produced a significant change in resident behavior in interaction with a standardized patient. Residents felt that it was a worthwhile educational experience that would help them in their future practice.

Assessing Clinical Competence in Physical Medicine & Rehabilitation Residency Programs

Evaluation of resident clinical competence is a complex task. A multimodal approach is necessary to capture all of the dimensions of competence. Recent guidelines from the Accreditation Council for Graduate Medical Education delineate six general competencies that physicians should posses. Application of these guidelines presents challenges to residency program directors in defining educational experiences and evaluation methods. We surveyed 81 physical medicine and rehabilitation program directors regarding assessment tools used in their programs. Seventy-five percent responded. The most frequently used assessment tools included: In-training self-assessment examinations, faculty evaluations, direct observation, and conference participation. Program directors assigned the highest values to direct observation, faculty evaluations, self-assessment examinations, and oral examinations. Of the general competencies, more than 90% of program directors believed they did an adequate job rating dimensions of patient care, medical knowledge, professionalism, and communication skills. Approximately one-third, however, thought they did a less than fair job rating practice-based learning and improvement and systems-based practice. The majority of programs reported that they were able to identify a resident with difficulties during the first year of training, 44% within the first 6 months. Program directors reported that their residents spend a significant amount of their time with nurses and therapists during their inpatient rotations; however, this was not reflected in their evaluation practices, in which only one-fourth of programs reported the use of nurses and therapists in evaluating residents. Survey results indicate that physical medicine and rehabilitation program directors apply a variety of assessment tools in evaluating resident clinical competence. Although perceptions about the relative value of these tools vary, most programs report a high value to direct observation of residents by faculty. Of the six general competencies, program directors struggle the most with their evaluation of practice-based learning and improvement and systems-based practice.

Pilot study of a 360-degree assessment instrument for physical medicine & rehabilitation residency programs.

To perform a pilot test on a new format for multidisciplinary assessment of resident physicians' professionalism and clinical performance in acute inpatient rehabilitation settings. In this pilot study, a 26-item ratings instrument was developed for use by therapists, nurses, social workers, case managers, and psychologists to rate inpatient residents. A total of 421 ratings forms were returned over four academic years. Alpha reliability coefficient for instrumentation sample was 0.99. chi2 and analysis of variance procedures examined item mean differences. Significant differences (P <or= 0.05) were found based on resident sex (17 items) and rotation setting (20 items). No significant differences were found based on rater profession; mean ratings by profession ranged from 6.67 (physical therapists) to 7.46 (case managers). Psychometric properties of this new ratings format are encouraging. The tool was a useful way to provide formative feedback to residents regarding professionalism and performance. Residency program directors can use this approach to fulfill Accreditation Council for Graduate Medical Education mandates to use a variety of assessment methods regarding resident education. However, potential sex bias and other issues affecting performance ratings should be considered in interpreting results and warrant further study.

Residents' teaching of anatomy in the laboratory: enhancement of student learning.

Objective: This pilot project examined the use of physical medicine and rehabilitation (PM&R) residents as teachers in gross anatomy (GA) and in introducing clinical correlation of the cadaver at an appropriate level for first-year students. Description: Integrating the basic medical sciences with one another and with clinical material in the first year is a challenging process. Basic sciences faculty typically lack formal clinical training, and clinical lectures presented by senior clinicians are often too advanced for first-year students, resulting in high levels of student dissatisfaction. Gross anatomy is taught primarily in a small group, and active dissection provides an excellent avenue to teach clinical correlation. The PM&R residency program lists teaching undergraduates as a required component of their training. Furthermore, this discipline emphasizes neuromuscular and musculoskeletal aspects, making it well suited for GA needs. The PM&R residents joined a small dissection group and taught in a clinical oriented, interactive style. Their near-peer status allowed for a more informal learning atmosphere. In this setting, the residents were able to quickly assess the level of student knowledge and comprehension, and to modify their teaching accordingly. The cadaver provided a valuable tool, permitting the visual demonstration of muscle, nerve, and plexus. The residents were able to demonstrate how nerve injury or impingement could occur, and how the related symptoms were typically presented. They also demonstrated how various muscle groups function on a joint, and how injury to muscle, tendon, or ligament affected range of motion and mobility. Students were taught how to test for nerve injuries, and to perform a basic clinical evaluation. Simultaneously, the students were exposed to rehabilitation approaches. Interested students were taught advanced material in rehabilitation. At the end of the semester, a survey using Likert-scaled items (1 = ineffective, 5 = highly effective) was distributed to the students to assess the residents' teaching and effectiveness in making the material understandable. They were encouraged to provide additional narrative comments. Discussion: The questionnaire focused on three constructs: (1) student learning: student understanding of the anatomy in a clinical context further reinforced by clinical examples, demonstration and explanation (mean rating 4.37), clinical relevance of musculoskeletal structures and nerve injuries and their clinical manifestations (mean 4.65); (2) residents as teachers: effectiveness of residents' ability to link clinical situations to basic anatomy (mean 4.51), residents enthusiasm, role model impact, and high professional standard (mean 4.64), and their ability to communicate knowledge at an appropriate level (mean 4.5); (3) impact of the residents' teaching and interacting on student interest and awareness of PM&R as a specialty (mean 3.94). The residents reported benefiting from this teaching experience as well. They were able to review the cadaver to enhance their own learning, and student interaction reinforced their knowledge. This type of resident teaching program provides a useful model for increasing clinical correlation in undergraduate medical education at an appropriate level.

Development of a musculoskeletal examination skills course for a physical medicine and rehabilitation residency program.

This article describes the development of a musculoskeletal physical examination skills course for a physical medicine and rehabilitation residency training program. Course objectives, structure, and modification over time based on experience and resident feedback are discussed. The current course design is adaptable to meet the needs and resources of most residency programs.

Resident research education in physical medicine and rehabilitation: a practical approach.

The Accreditation Council for Graduate Medical Education includes training in research as a required component of physical medicine and rehabilitation residency programs. Unfortunately, there is a lack of practical information on how to meet this requirement. In this paper, information is provided for individuals involved in resident education on how to teach residents about research.

Carpal tunnel syndrome in the presence of wrist flexion and absence of repetitive movements

Rajeswari Kumara,∗, Maria Stella M. Gaerlanb and Teri Burgessc Dept. of Physical Medicine and Rehabilitation, VA Greater Los Angles Health Care System, Los Angeles, CA, USA UCLA Multicampus Physical Medicine and Rehabilitation Residency Program and VA Greater Los Angeles Health Care System, Los Angeles, CA, USA Occupational Therapy Dept. VA Greater Los Angeles Health Care System, Los Angeles, CA, USA

Continuing medical education: interests of former and current residents of a physical medicine and rehabilitation residency program.

To plan targeted, relevant continuing medical educational activities, a study was undertaken to assess demographic data, practice patterns, and current continuing medical educational needs of former graduates of the physical medicine and rehabilitation program. A survey was sent to the 168 physicians who had completed a physical medicine and rehabilitation residency program from 1961 to 1995 and to the 34 then current residents in the program. Questions were asked regarding gender, year of completion of residency, certification, fellowships, current employment situation, size of practice community, work time distribution, and busiest areas of clinical practice. In addition, from a list of 47 topics plus "other," the respondents indicated in which topics they had a current strong interest in continuing their education. They also responded to questions about their most important considerations when deliberating about attending an educational activity, the amount of notice required regarding an upcoming course, and the preferred duration of educational activities. The response rate of former residents was 56% and of then current residents was 100%. Topics of interest to greater than half of the respondents, in descending order, were musculoskeletal/soft tissue disorders, therapeutic injections/nerve blocks, industrial medicine, back and neck pain rehabilitation, and sports-related disorders. There were significant differences on some topics based on gender, year of residency completion, academic affiliation, private practice, and ratings of residency training in that topic. The most important consideration when deciding whether to attend an educational activity was, by far, interest in topic, followed by provision of continuing medical educational credits. There are among physiatrists several differences in educational interests that challenge continuing medical education planners to determine efficient, effective ways to deliver continuing medical education to meet these needs within the financial and time constraints imposed by today's clinical practice.

Removal of bedrails on a short-term nursing home rehabilitation unit.

Our goal was to determine whether bedrails could be removed safely on a geriatric rehabilitation unit. Staff attended in-services about bedrails, assessment, and possible alternatives. Residents in the study group were assessed by an interdisciplinary team, following which a determination was made about the use of bedrails or alternatives. Eighty percent of residents in the study group were free of bedrails, which suggests that bedrails can be safely removed from most short-stay nursing home rehabilitation residents.

Acupuncture Education and Integration in the Physical Medicine and Rehabilitation Residency

Acupuncture is a growing field of interest to patients, medical students, and physicians. This article outlines the educational efforts and requirements to teach and practice acupuncture in the United States. A rationale for integrating acupuncture into physical medicine and rehabilitation residency programs is included. This article provides a structure for determining the type of education goals and plans most suited to a particular residency.

Further experience in development of an objective structured clinical examination for physical medicine and rehabilitation residents.

Since the last report, two additional objective structured clinical examinations (PGY-2, PGY-3, and PGY-4, as well as incoming PGY-2) have been administered. As a result, our curriculum has been modified to strengthen physical examination skills, including specific workshops. Interrater reliability of evaluators has been tested for the first time to verify reliability, and refinements have been made in the standardized checklist grading system. The interrater grading of history-taking had good reliability (0.73-0.96), as did neurological and spine physical examination (0.84-0.88). The interrater grading reliability of small and large joint examination was more problematic (0.46-0.62) because of examiners' inability to have full visibility, evaluator's fatigue, and confusing evaluation scoring descriptions. We now use a two-point grading scale (correct or incorrect) for history but continue a three-point scale (correct, partially correct, or incorrect) for physical examination. The examination schedule is being modified to add more encounters, give time for trainee feedback, and further refinement of grading expectations for a more efficient and reliable scoring system.

Mentorship in physical medicine and rehabilitation residencies.

Mentorship is considered by many authorities as being possibly the most important developmental tool for the progression of a professional in training. In recent years, progressively increasing support of mentoring programs has been documented, especially in business, academia, and overall career development. Despite its recognized importance, there is a paucity of literature examining the needs of physicians in residency training programs in regard to mentorship. A 21-item questionnaire was sent to all physical medicine and rehabilitation (PM&R) residents in training in United States residency programs in May of 1993. The objectives of this survey were 3-fold: to assess interest in mentorship among PM&R residents, to determine the effect of preresidency mentorship on candidates choosing PM&R as a specialty, and to identify the factors that establish a successful mentorship in PM&R residency. A response rate of 36.2% (406/1123) was obtained. Analysis of the results indicated that 97.3% (390/401) of the respondents were interested in mentorship programs during PM&R residency; however, only 28.1% (114/406) had a mentor at the time of the survey. Before residency, 35.4% (143/404) of the respondents had a mentor, and of those, 75.9% (107/141) indicated that mentorship had a positive effect on their decision to choose PM&R as a specialty. Regarding the current mentorship, respondents benefited the most in the categories of increased knowledge of PM&R, 72.8% (83/114), and improved clinical skills, 65.8% (75/114). The least satisfaction was with the mentor's assistance with a research project, 46% (52/113), and with the effect of mentorship on the resident's visibility and reputation, 38.6% (44/114). Overall resident satisfaction with mentorship was significantly higher (P < 0.0001) in mentorships formed by free choice compared with those that were formally assigned by the residency program. Success of mentorship significantly correlated (P < 0.0001) with frequency of communication between mentor and protégé, while gender and ethnicity had no effect.

Development of an objective structured clinical examination (OSCE) for physical medicine and rehabilitation residents.

Clinical competency is poorly measured by knowledge-based written examinations. A five-station, four-interstation objective structured clinical examination (OSCE) has been developed in consultation with the National Board of Medical Examiners as a pilot study to standardize assessment methods that serve to evaluate the clinical competency of senior physical medicine and rehabilitation residents. Various stations demonstrating musculoskeletal and neurologic conditions commonly encountered in physiatric practice were included, incorporating the use of standardized patients into the OSCE format. This is a descriptive study of individual stations-evaluated history-taking, physical examination, and communication skills, whereas the interstations measured the residents' ability to write therapy and prosthetic/orthotic prescriptions, as well as interpret x-ray and electrodiagnostic data. The OSCE program development including case background, principal tasks, time allotment, evaluation objectives, performance criteria, therapeutic plan, standardized patients case descriptions, and assessment checklists as well as the training procedure is discussed. Additionally, cost analysis and scheduling issues are reviewed. This information should aid other training programs or consortiums in developing similar clinical evaluation tools.

Medical school achievements as predictors of performance in a physical medicine and rehabilitation residency.

To determine whether medical school achievement is related to or predictive of performance in a physical medicine and rehabilitation (PM&R) residency, performance on PM&R board examinations, and entry into academic PM&R practice. In 1994-1995, data were extracted from the files of 205 former residents who trained for at least six months from 1959 to 1991 in the PM&R program at the University of Washington. Associations between medical school and residency and post-residency variables were sought using chi-square analyses, analysis of variance, and linear and logistic regression. Clinical residency performance was predicted by clerkship honors grades (p = .0001). Probation was predicted by failing a basic science course (p = .0001). Written board performance was related to Alpha Omega Alpha status (p = .04). Failing written boards on the first attempt was predicted by failing a basic science course (p = .05). Entry into an academic PM&R practice was predicted by an interest in such a practice in the personal statement of the residency application (p = .002) and by writing a thesis in medical school (p = .03). Because medical school achievements were related to performance during and shortly after residency training in PM&R, they can be used as partial predictors of success.

Sports medicine in physical medicine and rehabilitation residency programs

Because sports medicine is a rapidly expanding field within many specialties, it is important to gauge how active physiatrists have become in this arena. A nationwide survey of program directors and chief residents of physical medicine and rehabilitation residency programs was conducted to determine such prevalence. For the purposes of this study, sports medicine was defined as the routine care of athletes involved in organized sporting activities at any level of competition. Questionnaires were mailed to program directors and chief residents with response rates of 79.7% each. Overall, correlation of the answers between groups was high. The level of interest of residents was rated at 46%. Data was also obtained regarding research, clinical rotations, lectures, fellowships, association with academic departments of other specialties, and affiliations with professional sports medicine organizations. The actual level of educational opportunities available was much lower than might be expected given the high level of interest expressed. It is reasonable to conclude that more opportunities should exist for education in sports medicine.

Perceptions of gender discrimination in physical medicine and rehabilitation residency programs

Perceptions of gender discrimination in physical medicine and rehabilitation residency programs

Perceptions of gender discrimination in physical medicine and rehabilitation residency programs

Perceptions of gender discrimination in physical medicine and rehabilitation residency programs

Rehabilitation resident academic productivity. Report on 1993 graduates.

A survey was designed to explore the relationship among elective time (ET), residency research requirement (RR), mandatory research rotation (MR), and academic productivity for the 1993 graduating residency class. Sixty-seven of the 75 rehabilitation residency program directors listed in the 1993 Directory of Graduate Medical Education Programs responded (89% response rate). Data from 60 programs, representing 283 graduating residents, were analyzed (80% usable response rate). A resident was operationally defined as "active" if that individual submitted either articles (SART) for publication or abstracts (SABS) for oral/poster presentation during the training years; residents with accepted articles (AART) and/or abstracts (AABS) were defined as "productive." Odds ratios and chi 2 statistics were calculated for each study risk variable (ET, RR, MR) and the corresponding outcome variables (SART, SABS, AART, AABS). One hundred and fifty-nine residents (56%) submitted abstracts; 86 (30%) submitted articles; of these residents, 134 (47%) and 54 (19%) had their work accepted, respectively. Research was required by 26/60 (43%) programs. Research elective time was available in 41/60 (68%) programs; only 44/203 (22%) residents used this time for research. Residents who had research required had a 1.9 times greater likelihood of submitting both abstracts (P < 0.008) and articles (P < 0.014). No other study relationship was found to be significant. The study results suggest that implementing a research requirement in the residency training curriculum may lead to an increase in resident research activity.

Factors used by physical medicine and rehabilitation residency training directors to select their residents.

A 17-item questionnaire was designed to assess the relative importance of various factors to physical medicine and rehabilitation (PM&R) training directors when ranking PM&R resident applicants during the National Resident Match. The questionnaire was sent to all PM&R residency training directors. The recipients were asked to grade most selection factors based on a numerical scale: 1, unimportant; 2, some importance; 3, important; 4, very important; 5, critical. The specific factors addressed in the questionnaire were: academic criteria, letters of recommendation, individual applicant characteristics and aspects of the interview process. Twelve yes-or-no questions were also designed to determine the weight that residency training directors place on certain academic criteria. A response rate of 88% (66/75) was obtained. The most important academic criteria were grades in a PM&R clerkship in their facility (4.1 +/- 0.8), followed by grades in a PM&R clerkship in another facility (3.6 +/- 0.9). The most important letters of recommendation were from a PM&R faculty member in the respondent's department (4.0 +/- 0.8), followed by the dean's letter (3.7 +/- 1.0) and the PM&R chairman's letter (3.7 +/- 1.0). The three most important applicant characteristics evaluated during the interview were compatibility with the program (4.4 +/- 0.8), the ability to articulate thoughts (4.2 +/- 0.8) and the ability to work with the team (4.2 +/- 0.8). Most program directors used multiple criteria to complete their rank list, but the most important were based upon the interview (4.5 +/- 0.9), letters of recommendation (3.7 +/- 0.9), medical school transcript (3.6 +/- 0.8) and the dean's letter (3.6 +/- 1.1).(ABSTRACT TRUNCATED AT 250 WORDS)

Physical medicine and rehabilitation residents' educational needs assessment.

A study was done to determine how well residents in Physical Medicine and Rehabilitation (PM&R) believe their educational needs are being met in various clinical and didactic areas. Surveys were sent in April 1989 to the 814 persons on the 1989 American Academy of Physical Medicine and Rehabilitation resident physician registry. Residents were asked to rate how much experience they thought they were getting in their residency for each of 22 clinical and didactic topics such as stroke, spinal cord injury, head injury, prosthetics, chronic pain, sports medicine, pediatric rehabilitation, cardiopulmonary rehabilitation, electromyography, and physical modalities. In addition, they were asked to rate how much they believed they should be given with respect to these same topics. The response rate was 532 out of 814 (65%). Residents expected somewhat more than what they were getting overall; however, there were exaggerated discrepancies in a few specific areas. Residents believed they should be getting significantly more clinical and didactic experience in Industrial Medicine, Sports Medicine, Computer Applications, Therapeutic Injections, and Administration. The results should serve as guidelines for residency training and the study should serve as a model for future routine assessments.