Dr. Bharathi Swaminathan is a physical medicine and neurodiagnostic physician. Join us to her about her journey from OB/GYN in India to Physiatry and Electromyography (EMG) in the U.S.
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[01:38] Interest in Electromyography and Physiatry
Dr. Swaminathan did her medical training in India so she had no idea what PM&R is. Working as an OB/GYN, she loves doing procedures and delivering babies. She recalls having a little internal competition doing C-sections under 20 minutes.
When she moved to the U.S., she had to take the USMLE and looking into a procedure-oriented specialty to get into. She looked into anesthesia and her classmate in medical school talked to her about PM&R, telling her how it’s a great mix of procedures and clinical care.
In her PGY-1 preliminary year, she was doing a preliminary surgery wanting to go into anesthesia. One of her PGY-2 residents also just got matched into PM&R at a university and he was raving all about it. So she decided to apply to both anesthesia and PM&R.
After her first interview, she got a callback and offered her a pre-match. She didn’t go into any other interviews and now the rest is history.
During her PGY-2 residency training year, she had the opportunity to rotate in the EMG lab. Her EMG lab director was Dr. Jay Liveson who wrote books on clinical EMG peripheral neurology. His unique approach to patient care got her interested in this subspecialty. And so, Dr. Swaminathan hasn’t even considered EMG as a career option until she met him. She’s grateful for his encouragement to learn more about this and now, she’s happy to have returned the favor by training others.
[04:27] Academic Knowledge + Technical Skills'EMG is a highly specialized field so you have to have solid background knowledge in your anatomy, neuroanatomy, neurophysiology, and pathology.”Click To Tweet
Dr. Swaminathan explains that aside from solid academic knowledge, you have to have clinical skills and put all this together when you perform the procedure. For instance, during the winter months, the hands are really cold. So if you do the procedure and when the patient’s hand is really cold, you may get a false positive carpal tunnel.
Hence, there are so many technical variables that you need to problem-solve. It needs dynamic decision making and you need to use all the tools in your toolbox to come up with an accurate diagnosis.
First, you need to make sure the patient is comfortable and able to tolerate the test so you could gather quality data for interpretation.
Dr. Swaminathan expresses her admiration for Dr. Jay Liveson’s uncanny ability to put patients to ease. He would put the needle in the patient where he would make it a fun experience for them – not only for the patient but also for the trainees. And so, she thought she could also do it and be good at it too.
[07:10] Common Myths or Misconceptions Around Electromyography
According to Dr. Swaminathan, not a lot of people know about EMG. The other misconception is a lot of them think it’s primarily done by neurologists. So they would be surprised to see a PM&R doctor doing it. They have a four-year training residency program. And ”
As opposed to neurology, it depends on the program. In some programs, you may get some exposure. In others, it’s optional. In their facility, they have four PM&R doctors, all of them do EMGs. They also have four neuro doctors, but only one does EMG.
Dr. Swaminathan explains that in PM&R, they are more attuned to a patient-centered approach. So some of their neuro colleagues send all the difficult patients to them.
Either way, they approach each patient by taking a new history. They would do an independent musculoskeletal exam. Then they decide between the trainee, the resident, and the fellow, on what test is appropriate and they customize the tools to get the maximum benefit.
[11:46] Types of Patients: Who Comes to a PM&R Physician or Neurologist for an EMG?
As PM&R physicians, they treat a wide variety of medical conditions, from a patient with brain injury or after stroke in an acute setting to a patient with spinal cord injury or musculoskeletal or peripheral nervous system. For instance, if a patient had any new onset paresthesia, numbness, tingling, or chronic neck back pain, they want to rule out and diagnose the etiology of their current problems.
They also see patients with myopathy, motor neuron disease, radiculopathy, neuromuscular junction disorder, and polyneuropathy.
Dr. Swaminathan shares her experience with some patients working at an Amazon facility. Because the nature of their work involves repetitive movement, they were diagnosed with overused tendons resulting to tendinitis, which they even joke of as Amazon tendinitis. And so, it’s not carpal tunnel syndrome.
And this is where physiatry training can help because a lot of the patients may have musculoskeletal issues with a few neurologic symptoms. So the EMG helps tease out and confirm your diagnosis, and either prove or disprove your theory.“The EMG helps tease out and confirm your diagnosis, and either prove or disprove your theory.”Click To Tweet
Ultimately, being a PM&R doc or a physiatrist, anatomy must be a strength of yours. You have to be able to carry a solid knowledge of anatomy to help you with the diagnosis.
Dr. Swaminathan reveals that most medical schools don’t have a PM&R department or they don’t have too much awareness or special interest groups. As the chair of the PM&R department at Chicago Medical School, the first thing they did was they started a 10-week PM&R elective course. It was widely received with 40 students who enrolled and they’re trying to increase awareness of specialty.
[16:44] Typical Day
Dr. Swaminathan wears multiple hats. As the chief of PM&R, she has administrative time built into her schedule. Monday mornings, she sees migraine patients for Botox injections.
Then she comes down to their rehab clinic through battlefield acupuncture, which was developed by a flight surgeon in Air Force. During the Iraq-Afghan war, a lot of the soldiers were getting injured and didn’t have access to medications right away. They used gold semi-permanent needles (5 on each ear) put at specific points around the ears to help with chronic pain.
At least up to over 75% of patients get some kind of immediate relief. And so, if it works, they come every four weeks to repeat the procedure. Then she does EMG clinic on Monday afternoons.
And then spread throughout the week, she does meetings with the leadership team, EMG lab. She also has allotted didactic days with clinics, where they do a mini monograph, an in-depth review of each neuromuscular disease, like carpal tunnel syndrome, radiculopathy, and ALS.
Dr. Swaminathan says you can customize your practice based on your skill set and your interest. For instance, some of her residents who only love inpatient can choose to do primarily acute inpatient rehab. Or if you like primarily outpatient settings, you could do a sports medicine fellowship and just see musculoskeletal cases. By the time you get to PGY-4, you could choose which way you want to go.
[25:28] Taking Calls and Life Outside of the Hospital
Dr. Swaminathan doesn’t take any calls since their facility is more outpatient-based. But if you go to another facility, like in a tertiary care center, they do take calls because they have a huge service. They have a spinal cord injury unit and a traumatic brain injury unit. They also have more faculty members so they may take one call a month or something like that. That said, you don’t have to come in the middle of the night for a carpal tunnel.
EMG is more of an elective procedure, meaning you need to wait at least a minimum of three weeks to make sure the Wallerian degeneration happens. However, if you suspect any patient with Guillain-Barre syndrome, also known as acute inflammatory demyelinating polyneuropathy, that’s the only time they get consulted.
She explains to her trainees that if they get a call from the ER doc and ask them for an EMG. It means they want to rule out Guillain-Barre syndrome because you see time-dependent changes in their nerve conduction and the needle EMG portion.
In terms of having a life outside of the hospital, Dr. Swaminathan says it’s possible. You just need to be organized and get as much family support if you can.
[29:22] The Training Path
To do the fellowship, you have to be either trained in PM&R or neurology. These are the two specialties that can perform the EMG testing.
For PM&R residency, some places offer a categorical position which is a four-year program. Some only do the three-year program. The first year is like a PGY-1 where you do either preliminary medicine or preliminary surgery. Some had done family practice one year and decided to move into PM&R. So then it will be a three-year program and a total of four years.
After that, you could sub-specialize depending on your interest. For instance, if you don’t like doing procedures, you could be an inpatient medical unit medical director. Or you could be Medical Director for a traumatic brain injury unit or spinal cord injury unit.
If you are a medical director, you are primarily serving as their primary care and then you will consult as needed. Or if you are interested in pediatrics, you could do a pediatric fellowship. Most of their fellowships are only one year so it’s very easy for them if they need to sub-specialize.
[30:57] How to Be a Competitive Applicant
Dr. Swaminathan says they have an accredited fellowship offered through neurology. And if you think this is what you want to do, she encourages students to apply early because most places only have one or two fellows.
To be a competitive applicant, you need to show interest and that you really want to learn and you’re passionate about taking care of the patient. They treat each patient as a potential for discovery and they like to be challenged. Because a simple carpal tunnel referral could be something different.
[33:46] Message to Osteopathic Students and Future Primary Care Physicians
In their specialty, Dr. Swaminathan says they don’t really see any bias against DOs and that they value their background since their philosophy goes along well with the PM&R specialty. As a matter of fact, a lot of their academic leaders in PM&R are DOs.
Her message to future primary care physicians is that she wishes they knew the wide variety of patients they see. And so, hopefully, they could refer the patients to them sooner than later. The sooner they see them, they could make an accurate diagnosis and they won’t delay getting treatment or care.
They also see patients for a second opinion. They may start something, undergo surgery, and then turn out to be different. Hence, it would benefit everybody if they consult them sooner.
[35:53] The Most and Least Liked Things
Dr. Swaminathan likes the challenge each patient brings. Don’t forget about the patient, just keep them entertained. Try to put patients at ease because they truly appreciate that.
Right now, she couldn’t find anything that she likes the least about her specialty. Previously, report-writing was quite challenging for them. But with new technology, they now have auto-save features that make things easier for them.
[38:57] Major Future Changes Coming to Physiatry and Electromyography
Dr. Swaminathan thinks neuromuscular ultrasound is a new rapidly evolving field that can complement their EMG findings. So they’ve now added that as part of their curriculum in their training program. This is where the turf war between radiology and PM&R may get into, but she thinks it’s exciting nonetheless.
[40:11] Final Words of Wisdom
If she had to do it all over again, Dr. Swaminathan says she would still do physiatry and EMG. She loves the challenge and it’s an indispensable tool that gives us a good understanding of the peripheral nervous system. It’s an extension of a neuro exam.
Finally, she wishes to tell students who might be interested in this field to always be a physician and not a technician.“Approach each patient as a potential for discovery.”Click To Tweet
She believes technology can be a blessing, and a curse or a curse. So it’s very important not to be impatient or jaded. And she leaves us with this quote from William Osler, “Medicine is a science of uncertainty and the art of probability.” So you have to approach each patient as a potential for discovery.