Program Structure

The main objective of the PM&R residency program is to provide trainees with clinical skills necessary to acquire competencies in clinical practice of rehabilitation medicine. Every effort is made to keep the program flexible and to provide the most effective way of clinical and academic training based on the unique talents of each resident. Our program takes into consideration special clinical, academic and research interests of each resident and helps to channel their career growth and development.

We believe that our PM&R Residency Program will prepare residents well for a career in either private practice or academic medicine, as well as Board Certification in Physical Medicine and Rehabilitation.

Training Options

Our program offers two training tracks: 4-year categorical and 3-year advanced tracks. The program is approved for a total of 16 resident positions, two at PGY-1 level, and 14 distributed between PGY-2 –PGY-4 levels.

  • Categorical Track: This 48-month track integrates 12 months of basic clinical rotations (PGY-1) and 36 months (PGY-2 – PGY-4) of PM&R training.
  • Advanced Track: Residents who join the program on the advanced track complete 36 months of PM&R training. The prerequisite for this track is a completion of 12 months of basic clinical training, such as a transitional year or internship; these must be accredited by ACGME, Royal College of Physicians, or AOA.


Training Structure

PGY-1 Internship

This year includes 12 months of basic clinical rotations usually include 6 months of internal medicine and 6 months of selective clinical rotations including neurology, neuromuscular, rheumatology, radiology, and brain injury rehabilitation.

The Hospitalist Division of the Department of Internal Medicine at Washington University supervises the core medicine rotations at Barnes-Jewish Hospital. Other clinical rotations of the PGY-1 year are supervised by the faculty from the divisions of the Internal Medicine, Neurology, and Radiology.

PGY-1 Categorical Schedule

  • Internal Medicine: 6 months 
  • Neurology: 2 months 
  • Neuromuscle: 1 month
  • Rheumatology: 1 month
  • Radiology: 1 month
  • Neurorehabilitation: 1 month

Total: 12 months 

PGY-2 PM&R

The emphasis of training during the PGY-2 year is on direct inpatient care of patients with complications of major neurological diseases needing specialized multidisciplinary rehabilitative care. The year is divided into block rotations on the inpatient services at TRISL – Stroke, BI, Spinal Cord Injury.

Additional rotations may include VA, O&P, Pediatrics, and MSK.

PGY-3 PM&R

During the PGY-3 year, residents continue with several blocks of inpatient Neurorehabilitation rotations and progress to rehabilitation consults at Barnes-Jewish Hospital.

Other rotations include pediatrics, specialty rehabilitation clinics, MSK, pain, VA, and elective rotations.

PGY-4 PM&R

The emphasis of the PGY-4 year is on electrodiagnostic training, more advanced MSK training, rehabilitation consults and specialized rehabilitation clinics.

PGY-2 – PGY-4 Advanced PM&R Training Schedule 

  • Spinal Cord Injury: 5 months 
  • Brain Injury: 4 months 
  • Stroke: 4 months 
  • Pediatric Rehab: 2 months 
  • Musculoskeletal (MSK), Pain Medicine: 5 months 
  • Orthotics and Prosthetics (O&P): 1 month
  • Electrodiagnostics: 2-3 months 
  • Consult: 2-3 months 
  • Veteran Affairs (VA): 3 months 
  • Specialty Rehab Clinics: 3 months 
  • Electives: 3-4 months 

Total: 36 months


Rotations 

PGY-1 Rotations

Our interns who match the categorical positions will experience a well-rounded and academically rigorous year. Interns will rotate in internal medicine with the Washington University Hospitalist service at Barnes-Jewish Hospital for half of the year. Here interns will gain competency in managing complex medical patients and gain confidence in their medical decision making. Interns will also rotate with neurology, rheumatology, radiology, neuromuscular medicine and PM&R during their intern year. Altogether this experience will provide interns the knowledge and the tools they need to transition seamlessly into their training in PM&R.

PM&R Rotations

Our PM&R rotations are broken down into inpatient and outpatient experiences. Typically, residents will spend a healthy portion of their PGY-2 year mastering the fundamentals of inpatient rehabilitation medicine. There is also ample time directed towards electives during the PGY-2 year in order for residents to gain early exposure in areas of potential sub specialization that they may be interested in pursuing. As residents progress to the PGY-3 and PGY-4 years, increasing flexibility is provided for the resident to round out their physiatry skills and begin to focus on their areas of interest. Opportunities to engage in leadership activities including the education of medical students is available throughout the various rotations.

Inpatient Rotations

Core Inpatient Rehabilitation rotations are located exclusively at The Rehabilitation Institute of St. Louis (TRISL). TRISL is a free standing 96-bed comprehensive rehabilitation facility located on the Washington University Medical Campus. A multitude of inpatient and outpatient programs are available at TRISL. These programs form a solid teaching base for the training of residents and medical students. Patient referral sources to TRISL are mainly from Barnes-Jewish Hospital and other community and regional hospitals of BJC Health Care System. Comprehensive Rehabilitation Services are structured programmatically and comprise the following programs: Stroke Rehabilitation, Traumatic Brain Injury, Spine and Spinal Cord Injury, Amputee and General Rehabilitation.

Stroke (CVA) Rehabilitation and Brain Injury (BI) Training

Residents are involved in the management of all aspects of the medical and rehabilitation care of stroke patients of various etiologies, and brain injury patients both traumatic and non-traumatic in the inpatient setting. Residents are actively involved in leading the rehabilitation team including rehabilitation nurses, case management, respiratory therapy, speech therapy, physical therapy, and occupational therapy. Residents are exposed to neuro-psychological testing and evidence-based aphasia programs.

Spinal Cord Injury (SCI) Training

Residents are responsible for the management of a wide range of traumatic and non-traumatic spinal cord injury patients in this inpatient setting. Multiple sclerosis, transverse myelitis, tumors, post-surgical degenerative spine diseases, scoliosis, failed back syndrome are among some of the spine associated issues that residents will encounter on this service. Residents acquire the clinical skills to provide specific medical and rehabilitative care and will learn to manage complications relating to spinal cord injury.

General Rehabilitation Training

On this service, senior residents will manage patients in their transition from the acute care hospital to the home environment. Diagnoses seen on this unit include general deconditioning secondary to multiple medical co-morbidities, complicated knee and hip joint replacements, fractures, polytrauma, LVADs, transplants (kidney, heart, liver) and post COVID-19. Residents are involved in the management of all aspects of the patient’s medical and rehabilitation care and participate in weekly conferences with the rehabilitation team. Senior residents on this service will take on a role as mentor and will help in providing education for the junior residents that are concomitantly on the other inpatient services.

Amputee Training

Residents will gain exposure to patients with amputations and co-existing medical conditions. Residents will be responsible for managing the entire continuum of care for their amputee patients to include pre-prosthetic acute inpatient program and prosthetic gait training rehabilitation. With this, residents will be responsible for overseeing all aspects of the patient’s medical and rehabilitation care. Clinical skills acquired during this experience include wound care, pain management, gait analysis and prosthetic prescription.

Outpatient Rotations

Specialty Rehabilitation Clinics Rotation

Specialty Rehabilitation Clinics are held at the Center for Advanced Medicine on the Washington University Medical Campus. Residents participate in Stroke, Brain Injury, Spinal Cord, Spasticity and Amputee Clinics. These are all continuity clinics where residents acquire clinical skills and knowledge in long-term rehabilitation management of a wide range of neurological conditions, pain management, amputee care, evaluation and management of spasticity to include Botulinum toxin therapy and Intrathecal Pump management.

Musculoskeletal (MSK) Rotation

Residents have an extensive exposure to acute and chronic musculoskeletal conditions and pain syndromes through a variety of clinics in the outpatient setting. During this rotation, residents work with physiatric faculty in the Department of Orthopedic Surgery. Residents acquire skills in various interventional spine procedures, MSK ultrasound, joint and trigger point injections, as well as EMGs. Residents may also rotate with private practice musculoskeletal/sports medicine physicians where they are exposed to Independent Medical Evaluations (IME) and worker’s compensation.

Pain Management Rotation

Residents rotate in the Pain Management Center within the Department of Anesthesiology. This clinic offers diverse training in both medical management and interventional procedures as well as working in a multidisciplinary team. Residents will be exposed to a high volume of fluoroscopic and ultrasound guided interventional pain techniques including epidurals, various nerve blocks, neuraxial blocks, joint injections, neurolytic procedures, radiofrequency lesioning, and spinal cord stimulator trail and permanent placement.

Consult Rotation

Residents are involved in the rehabilitation consults at Barnes-Jewish Hospital. Emphasis of the consult is to provide parallel and ongoing rehabilitative assessment and recommendations for patients with neurological, musculoskeletal and medical conditions and disorders and associated disabilities. Residents actively engage with acute medical and surgical teams and well as rehabilitation team to discuss and initiate rehabilitation therapies and recommendations and facilitate transfer to TRISL or provide other recommendations for another level of rehabilitative care. This resident works under the supervision of the attending physician.

Orthotic and Prosthetic (O&P) Rotation

Residents attend clinics and production labs at the local orthotic & prosthetic companies: Prosthetic & Orthotic Design and Hanger. They have an opportunity to work with very experienced practitioners and do hands-on evaluation, casting and fitting of orthotics and prosthetics.

Electrodiagnostic (EDX) Rotation

Residents rotate through the Electrodiagnostic Lab of the Department of Neurology where approximately 3,000 studies are performed each year. Residents receive the extensive training in performing NCSs and EMG and attend weekly clinical neuroscience lecture series that cover mechanisms of neuromuscular diseases, nerve and muscle pathology and electrodiagnostic testing and interpretation. Additional EDX training takes place during MSK rotations and at the VA under the guidance of physiatric faculty. Over the course of the residency program, residents perform over 200 EDX studies under the direct guidance and supervision of AANEM Board Certified neurologists and physiatrists.

Pediatric Rehabilitation

Residents rotate at the Ranken Jordan (RJ) Pediatric Specialty Hospital, which provides a continuum of care and the intensive transitional care and living support and for medically complicated children and their families. Residents are involved in inpatient and outpatient care of children of all ages and are supervised by two experienced pediatric physiatrists.

Residents also rotate on the pediatric PM&R service at St. Louis Children’s hospital. There are opportunities to participate in several pediatric specialty clinics including neurorehabilitation, Muscular Dystrophy Clinic, and orthopedics. During this rotation residents gain clinical skills and knowledge in the diagnosis and rehabilitation management of a variety of pediatric conditions to include spinal cord and brain injury, cerebral palsy, spina bifida, scoliosis, hip dysplasia, and numerous other neuromuscular and musculoskeletal diseases.

VA Rotations

Residents rotate on the Extended Care Rehabilitation Service and the Spinal Cord Injury Service at the Jefferson Barracks division of the St. Louis VA System. They work under the guidance of several physiatrists and are involved in the evaluation and management of vide range of patients with neurological, polytrauma and MSK conditions in inpatient and outpatient settings. They learn about state, federal and community resources for long term care and support for veterans and their families.

Multidisciplinary Rounds (MDR)

Residents have the opportunity to customize this rotation based on their personal interests. Residents are encouraged to spend time during this rotation engaged in clinical opportunities that they feel would be beneficial to their individual growth and goals as a physiatrist. Residents have chosen to work with various forms of therapy (physical, occupational, speech) to gain better understanding of what role these clinicians play in the rehabilitation of patients. Other residents have chosen to work with various Washington University surgical teams who refer many of our rehabilitation patients to us. Some residents chose to gain experience with private practice physicians during this rotation. These are just a few examples, but there are many unique opportunities that residents can choose to participate in during the MDR elective.

Research

Residents who have a significant interest in research can utilize this dedicated time to focus on active or new research projects. Washington University provides endless opportunities with regards to research and this rotation allows residents the chance to contribute meaningful time to these endeavors.

 

Research + QI

PM&R Quality Improvement (QI)

The PM&R Quality Improvement curriculum was developed for the purpose of facilitating the learning process of in-depth quality improvement project design and implementation. Overall, the curriculum aims to foster a lifelong approach of actively seeking and adopting evidence-based best clinical practices.

Objectives
1. Promote a culture of patient safety and continuous quality improvement in healthcare

  • Implement safe, efficient, effective, and equitable solutions

2. Promote evidence based medicine skills

  • Identify institutional clinical issues / outcomes / protocols
  • Define the clinical question
  • Evaluate literature for potential solutions

3. Promote quantitative clinical improvement skills

  • Design a study to address the question
  • Implement the study
  • Analyze data
  • Refine the study in context of results

4. Promote national-level academic participation skills

  • Present the study at conferences
  • Publish the study in journals

Program Structure for QI projects

1. What qualifies as a QI project? A clinical question based upon clinical issues / outcomes /protocols that:

  • Directly impact patient care
  • Addressed by SMART (specific, measurable, achievable, relevant, timed) intervention
  • Expected to demonstrate measurable improvement

2. What is the structure of a QI Project?
A QI project requires sequential progression through the steps defined below:

  • Description – clinical problem, outcomes, protocols
  • Analysis of associated factors and literature review
  • Define SMART goals
  • Planned Intervention
  • Planned Monitoring
  • Implementation and Post-intervention outcomes

3. What comprises a QI team?

  • Resident(s) – maximum of 3 per project
  • Faculty QI mentor(s)
  • Facility staff members, including Risk Management

4. What are the resident expectations for QI projects?

  • Complete at least one QI project
  • Present at the PM&R Resident Research & QI Lecture Series
    • Format – based upon the QI Program Form
    • Initial presentation – Define project
    • Subsequent presentations – Present results, modify project per results
  • Poster presentation opportunities include
    • Institutional – PSQI Symposium, Neurology Resident Day
    • National meetings
  • Complete WashU GME PSQI feedback forms

5. What are some of the additional resources available to residents for the project?

  • WashU GME PSQI Steering Committee
  • WashU PM&R Research and QI team

Research

Residents are encouraged to be involved in at least one research projection during their time at Washington University. During the initial years of residency, residents will identify faculty mentors based upon desired professional expertise within the field of rehabilitation medicine. The faculty mentors will guide the mentored resident through a structured program aimed at developing clinical and research expertise in the resident’s field of interest. The Research/QI Chief Resident and Mentorship Program Director will facilitate the program, including providing assistance for matching residents with mentors, identifying and developing additional resources as needed, coordinating and helping with presentation activities, and monitoring progress.

Typical Progress during Residency Years 1-4

PGY 1-2

  • Identify area of interest and Perform literature review

PGY 2-4

  • Present resident seminar, clinical case conference, and JC on related topics
  • Present research projects, if involved

PGY 3-4

  •  Submit clinical case conference to a national journal
  • Present clinical case/resident seminar at national conference
  • Present/publish original research, if involved

Rehab in Review (RIR)

Rehab in Review

Rehab in Review (RIR) is a monthly review journal published through Emory University and the Association of Academic Physiatry (AAP). The journal is comprised of physiatry-relevant publications selected from article summaries authored by PM&R residents from participating residency programs. Selection criteria relate to the relevance of the summary for physiatry and the authoring itself. RIR is distributed nation-wide to all PM&R residency programs.

Each PGY 1 submits 1 publication annually, and each PGY 2-4 resident submits 3 publications annually to the Rehab in Review (RIR) Regional Managing Editor, who in turn, helps residents with articles selection, editing, submitting to Rehab in Review. Involvement in this process keeps residents up to date on the most recent physiatric evidence based medicine.


Curriculum

Weekly Conference Schedule

Monday:
8-9am - Neuromuscular/EMG

Tuesday:
7:30-8:30am - Neuromuscular/EMG

Wednesday: 
7:30-9am - Spine and Sports Journal Club
12-1pm - Board Review

Thursday: 
7-8am - Critical Thinking
8-9am - Journal Club/Case Conference/Resident Seminar

Friday: 
7:30-8:30am - Core Didactics 
8:30-9:30am - Core Didactics 

Conference Descriptions

Neuromuscular/EMG Lecture Series
Lecture series given by neuromuscular disease specialists. Conferences cover electro-diagnostic topics that range from the basics of EMG/NCS to rarely seen neuromuscular diseases.

Spine and Sports Journal Club
This is a weekly journal club that is organized by the PM&R sports medicine fellow. Evidenced-based lectures are presented. Discussions typically focus on how the information presented can be used in clinical practice.

Board Review
Interactive format of reviewing high-yield, board relevant topics.

Critical Thinking Sessions
This is an attending-run, active-learning exercise. Attending physician will typically discuss a case or topic with a focus on resident participation, which is encouraged and expected.

Journal Club/Resident Seminar/Case Conference
The academic curriculum is organized into blocks. During each block of time, there are resident-led lectures, journal clubs and case conferences pertaining to the topic of that block.

Core Didactics
Faculty led didactic sessions that cover the breadth of PM&R. Block sections include: Stroke, Spinal Cord Injury, Brain Injury, Amputee, Musculoskeletal Injury, Pain Management, EMG, Pediatrics, Rheumatology and Orthotics and Prosthetics.

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