PM&R: Primary vs. Consultant
When it comes to Physical Medicine and Rehabilitation, there are different models that a physician might be asked to work.
A majority of the locum positions I've held thus far have required me to be the primary attending physician. Many times, especially in a freestanding facility, I might be the only physician in the building at any given time. 😅This can be a daunting task, especially if you're rusty on your internal medicine skills. Completing a robust preliminary internship and residency program can be very helpful to strengthen both internal medicine skills as well as rehab leadership.
I have worked a few jobs, however, in which physical medicine and rehab acts as a consultant service. This is an incredible luxury, and I feel it truly utilizes the expertise and knowledge of a physiatrist. When PM&R is the consulting service, it typically means that internal medicine or family medicine is the primary physician, i.e., they do admissions, discharges, med recs, orders, and H&P/DC summaries. They also see the patient day-to-day for internal medicine-related problems, such as hypertension, diabetes, heart failure, etc. While I am learning a lot from my internal medicine collogues, it is a huge stress off my shoulders not doing the job of the internal medicine physician and the rehab doctor. This means I can focus my energy on rehabilitation, which translates to more time observing patients in the gym, working with therapists to come up with the right therapies, brainstorming ideas with case management about outpatient plans, and truly spending time getting to know the functional progress of the patient. It also allows me to spend more time thinking about what pharmaceutical interventions would benefit the patient because less of my time is spent working out internal medicine problems.
Another scenario that I have experienced as a Locum Tenens physician is being the primary attending with internal medicine consulted on every admission. I find this helpful as well because I can continue to focus on a rehab-heavy approach to patients, knowing I have the support and backup of a hospitalist who can comanage medical problems with me. One downside I have noticed to having internal medicine as a consult service when I am the primary is that some things can be under-communicated, which can be frustrating not knowing the full picture of a patient. This is your classic 'too many cooks in the kitchen' scenario, but is easily remedied by increasing communication with your colleague. I also like taking time out of the day to review our patient list together.
I find it most advantageous to work and chart in the same office as your hospitalist so that you can easily discuss patients back and forth. It becomes much more challenging when you and your internal medicine cohort are documenting from completely different locations. Working together also helps each physician build trust in the other and become a better team.
As a locum doc, we are in a constantly changing environment, which might mean a new hospitalist/PM&R team every week. Despite these challenges, I do appreciate having internal medicine available to comanage patients with me. It is easy to get comfortable doing everything on your own, so being flexible is paramount when going from job to job. Overall, I think there are pros and cons to each approach.
Let me know what your thoughts are in the comments below. Would you prefer to be the primary or a consult service as the rehab physician?"
