Residency Program: the training program

Throughout the three-year residency program, residents are supervised by a staff of teaching clinicians. As the resident progresses he/she is given increasing clinical responsibilities and is expected to participate in the teaching activities for junior residents and medical students.

Most of the teaching occurs around individual patient encounters in the clinics and on the wards. In addition, there are clinical teaching rounds, conferences, and lectures on all services. The PM&R department also conducts regular teaching rounds, seminars, and a journal club.

The program is fully integrated in that residents are assigned to rotations at LLUMC, Jerry L. Pettis Memorial Veterans Medical Center, and Kaiser Hospital. The assignments are made by the residency program committee, which takes into account the level of training, the needs of that resident, the wishes and career objectives of the resident, and the balance of assignments between the three institutions. Some activities may be offered at all three. Each of the clinical experiences is designed to facilitate rational planning of each resident's clinical assignments. Although a major core experience is common to all residents, there is some flexibility in assigning specific rotations.

Yearly rotations:

1. PGY1 -- Internship

During the first year, residents complete a preliminary year of training in internal medicine. The most important PM&R objective for first-year residents is to develop proficient clinical skills. By the end of the first year, residents should be able to demonstrate competence in history-taking, physical examination, and establishing a management plan. Knowledge of general internal medicine should be adequate for subsequent management of clinical problems frequently encountered with patients in a PM&R setting. The clinical assignments and evaluations during this year are the responsibility of the residency program in internal medicine.

2. PGY2 -- First year PM&R

During the first year of PM&R training, residents have primary responsibilities on the PM&R inpatient services. Similar experiences are offered both at LLUMC and the VA Medical Center, with residents spending approximately equal time at the two hospitals. Residents gain in-depth experience of rehabilitation medicine on the wards, and are delegated increasing responsibility for patient care. They participate in all clinical activities such as daily rounds, weekly team conferences, family conferences, and program development meetings.

Residents are expected to gain experience and competence in working within the rehabilitation model of patient care. Residents should acquire understanding of psychosocial issues and develop good interpersonal skills in working with patients, families, and other team members. Residents are expected to carry out consultations on other inpatient services and to evaluate new and follow-up patients in outpatient clinics.

Another important objective for the first year is to develop clinical skills in the examination of the locomotor system. Residents should be able to investigate and manage patients with locomotor diseases and disabilities.

At LLUMC, the residents have specific assignments to program-based special services. Each resident spends a rotation on the spinal cord injury service (attending: Scott Strum, MD), the traumatic brain injury service (attending: Dr. Scott Strum), and the stroke service (attending: Dr. Brandstater). There are specific clinical skills and knowledge objectives for each of these rotations. The inpatient service at the VA Medical Center complements those at LLUMC in that the patients generally represent a broader cross-section of PM&R diagnoses, with numerous orthopaedic and musculoskeletal conditions represented (e.g. post-reconstructive surgery, amputation, chronic pain, and multiple sclerosis).

3. PGY3 -- Second year PM&R

During the second year of PM&R training, residents gain in-depth experience in diagnostic electromyography. The balance of the year is spent at the VA Medical Center.

a) EMG: EMG training is given in a six-month block. During this time, the resident customarily attends eight half-day EMG diagnostic clinics per week, with the PM&R and neurology attending. Normally, the resident would see approximately 20 patients per week, or well over 400 patients for the six-month period. All of these patients are seen with an attending present. During the last four months of the rotation, the resident actually performs many studies, always under the direct supervision of the attending. There is a reasonable volume of intraoperative monitoring and SEPs.

Dr. Brandstater is responsible for the formal didactic teaching program in EMG and neuromuscular diseases. The resident follows a directed reading program, and participates in two weekly neuromuscular disease seminars at which clinical, EMG, and basic science topics are taught in a planned curriculum. Formal case conferences are also held weekly.

b) VA Medical Center: The resident has rotations on the PM&R consultation service and in the outpatient clinics. Because of the pattern of referrals and admissions, residents gain valuable experience in management of patients with chronic pain syndromes and a range of musculoskeletal disorders.

4. PGY4 -- Third year PM&R

a) Pediatric Rehabilitation: The Loma Linda University Children's Hospital, with approximately 250 beds, provides services in all of the pediatric sub specialties including trauma, orthopaedics, neurosurgery, child neurology, rheumatology, oncology, etc. Attendings in these specialties refer patients to the pediatric rehabilitation service which provides consultation, and when appropriate primary management on the inpatient pediatric rehabilitation unit under the direction of Murray Brandstater, MD.

Residents maintain a busy service, with a small inpatient service. Special pediatric rehabilitation clinics are incorporated into the resident's experience, including spasticity and spina bifida, home ventilator clinic.

b) PM&R outpatient departments: Nine months of the final year of training is spent in the outpatient departments at LLUMC and Kaiser Hospital. Patients are seen under the supervision of PM&R attendings at both locations, and the predominant experience is with patients presenting with various musculoskeletal problems, including spinal disorders. Residents develop expertise in the management of patients with myofascial pain. The Loma Linda Center for Pain Management operates out of the PM&R clinic, and residents interact closely with the attendings and fellows on the pain service.

See rehabilitation.

Structured teaching

The department offers a structured didactic teaching program for all residents. The components of the teaching schedule are as follows:

1. Seminars in basic and clinical science of PM&R

Two seminars are held weekly, over a two-year repeating cycle, and cover the broad content of the specialty of PM&R. The topics generally follow the learning objectives of the Self-Assessment Program published by the American Academy of Physical Medicine and Rehabilitation (AAPM&R). The specific topics are developed in advance and assigned to faculty, who give most of the presentations. Each resident is responsible for a seminar presentation about once every six weeks. Selected topics are presented by faculty.

2. Resident Lecture Series

Resident lecture series are held monthly, and are presented by PM&R residents on important topics of current interest.

3. Research seminar

These are held monthly and are given by faculty, residents, or guests. Topics cover research methodology and frequently involves current departmental research activities.

4. Journal Club

The most recent issues of the Archives of PM&R and American Journal of PM&R are systematically reviewed. In addition, core and current articles are brought for discussion by residents and faculty. Each year an introduction is given on how to read journal articles critically. The session is held once a month.

5. Case presentation

Once a week, semi-formal clinical teaching takes place around clinical problems encountered with patients on the ward. A case is presented and discussion is led by a faculty member.

6. Lectures

Lectures are given weekly by faculty in other departments at Loma Linda University, PM&R department faculty, and occasionally by residents. These sessions cover topics of special interest or importance that are not covered otherwise in the seminar series. A typical series of lectures includes: skeletal radiology, neuroimaging, cardiac rehabilitation, sports medicine, neuropsychology, medical administration, etc.

7. Neuromuscular disease/EMG seminars

The didactic teaching program in EMG is directed by Dr. Brandstater. Two seminars are held weekly, one on clinical neuromuscular diseases and one on EMG. They are directed primarily to the residents on the EMG service, although all residents attend when possible. The presentation is made by a resident who has completed in-depth review of an assigned topic, interspersed with formal presentations by Dr. Brandstater. The topics cover clinical neuromuscular diseases and diagnostic electromyography, and are given over a 6-month cycle.

8. Neurogenic urology rounds

Case presentation and discussion of patient management issues by the consulting urologist are held monthly. Faculty and residents attend.

9. Anatomy

A special arrangement has been established by which the residents in PM&R have an in-depth experience in anatomy. All residents in the second year of PM&R training serve as laboratory assistants in the department of anatomy for the gross musculoskeletal component of the anatomy course given to undergraduate medical students. The residents will join two orthopaedic residents in doing some dissection, supervising students on cadaver work, and leading seminar discussions. They will also attend all lectures by the anatomy faculty. The commitment is for one-half day per week for four months.

10. Neuroscience

Residents in PGY-3 and 4 participate in the medical student teaching program in neuroscience. They serve as group discussion leaders in small group problem-based learning. These sessions provide a valuable review of clinical neurosciences for the residents.

Research

The department is committed to an active research program. Each resident is expected to participate in and complete a research project by the end of his/her residency program.

All residents attend journal club and receive an initial orientation to critical appraisal of scientific literature and an introduction to study design.

Each June all senior residents are required to present a research seminar on a topic of his/her choice. This task involves write-up, with references, as well as a verbal presentation.

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