- Email: [email protected]
Poster 51 lead toxicity in a patient with retained bullets: A case report and literature review. Linda R. Ladesich, MD (Univ Kansas, Kansas City, KS); Dana McKinney, MD; George Varghese, MD, e-mail: [email protected]
E20
2004 Academy Annual Assembly Abstracts
for a maximum of 4 injections. For patients who had more than 90% pain reduction, the injections were terminated and gabapentin was titrated off. For the gabapentin patients, the medication was increased until they reached a tolerable pain level. Main Outcome Measure: VAS. Results: The mean VAS for the TF group at day 1 and 1, 2, 3, 4, and 12wk were 7.42, 5.25, 3.25, 1.83, 1.33, and 1.25 and for the gabapentin group it was 8.45, 6, 4.81, 3, 2.45, and 2, respectively. In the TF group, 3 patients were cured at 2wk and 3 at 3wk. 5 patients were cured at 12wk. Mean number of injections was 3.08. 1 patient in the gabapentin group was completely cured at 12wk. The average daily gabapentin dose at 12wk for the TF group was 1191.67mg and for the gabapentin group it was 2109.09mg. Conclusions: Gabapentin is an excellent medication for postherpetic neuralgia. Combining gabapentin with transforaminal epidural injections led to a dramatic reduction of VAS scores, a reduction of gabapentin doses, and a chance for an early cure. This is the first case series reporting the use of transforaminal epidural steroids as an adjunctive treatment for patients with postherpetic neuralgia. Key Words: Neuralgia; Rehabilitation; Steroids. Poster 50 Design and Validation of an ICD-9 Crosswalk Identifying Secondary Conditions in People With Disabilities. Leighton Chan, MD, MPH (Univ Washington, Seattle, WA); Anne Shumway-Cook, PhD; Kathryn Yorkston, PhD; Marcia Ciol, PhD; Elizabeth Kanny, PhD; Jeanne Hoffman, PhD, e-mail: [email protected]. Disclosure: L. Chan, None; A. Shumway-Cook, None; K. Yorkston, None; M. Ciol, None; E. Kanny, None; J. Hoffman, None. Objective: To design and validate a methodology identifying secondary conditions in people with disabilities using the International Classification of Disease (ICD-9) codes. Design: Secondary conditions were identified through a literature search and a survey of Washington State physiatrists. These conditions were then translated into ICD-9 codes. This ICD-9 crosswalk was then validated against a national sample of Medicare patients with no, mild, moderate, severe, or profound mobility disability. Setting: National survey. Participants: 26 Washington State physiatrists and 9731 participants of the 1999 Medicare Current Beneficiary Survey (MCBS). Intervention: Not applicable. Main Outcome Measures: Identification and classification of secondary conditions into 4 categories: medical, psychosocial, musculoskeletal, and oral motor. The relationship between the prevalence of secondary conditions (identified through billing data) and the presence of mobility disability. Results: Our literature search and survey of physiatrists identified 58 secondary conditions including depression, decubitus ulcers, deconditioning, and chronic pain. 48.1% of the MCBS patients had no mobility disability; 33.9% had mild disability, 11.9% had moderate disability, 4.5% had severe disability, and 1.6% had profound mobility disability. We found a significant relationship between increasing disability and being treated for a secondary condition (Cochran-Armitage test for trend⫽–13.4, P⬍.0001). This relationship existed for all categories of secondary conditions: medical (Cochran-Armitage⫽⫺13.3, P⬍.0001), psychosocial (Cochran-Armitage⫽⫺6.1, P⬍.0001), musculoskeletal (Cochran-Armitage⫽⫺14.3, P⬍.0001), and oral motor (Cochran-Armitage⫽⫺15.4, P⬍.0001). Conclusions: Our ICD-9 crosswalk was able to identify secondary conditions in Medicare patients with mobility disability. This methodology will be very useful for health services researchers interested in studying the impact of secondary conditions. Key Words: Disability evaluation; Medicare; Rehabilitation. Poster 51 Lead Toxicity in a Patient With Retained Bullets: A Case Report and Literature Review. Linda R. Ladesich, MD (Univ Kansas, Kansas City, KS); Dana McKinney, MD; George Varghese, MD, e-mail: [email protected]. Disclosure: L.R. Ladesich, None; D. McKinney, None; G. Varghese, None. Setting: Tertiary care hospital. Patient: 48-yo woman with chronic lead toxicity due to retained bullets. Case Description: The patient had a history of several hospitalizations for diffuse complaints including severe peripheral neuropathy, abdominal pain, seizures with resulting encephalopathy, dysarthria, cognitive deficits, ataxia, and fine motor dysfunction. She was initially thought to have acute intermittent porphyria because there was some crossover in laboratory testing. However, a heavy metal screen was positive for severe lead toxicity, with a blood lead level (BLL) of 111.1/dL (BLL ⬍3/dL is mean, ⬎25/dL is elevated). After a thorough evaluation for the etiology, it was determined that the toxicity was most likely due to retained bullets from gunshot wounds 30y ago. Assessment/Results: The patient underwent thoracotomy to remove 1 bullet. The other bullet was inoperable due to its location in the cervical spine. She underwent chelation treatment with calcium edetic acid and succimer with a gradual decrease in lead levels to 31.8/dL. However, she continued to have difficulties with neuropathy, fine motor function, dysarthria cognition, and generalized pain. The patient refused further chelation due to side effects. Discussion: A review of the literature yields multiple case reports of lead toxicity from gunshot wounds. However, current reported incidence of lead toxicity in adults reflects only occupational exposure. While occupational history remains an important aspect of the physiatric patient interview, a significant number of physiatric patients have had gunshot wounds. Conclusions: We propose that, in patients with generalized neurologic complaints, this history also include previous trauma including potential gunshot wounds. Furthermore, as is supported in the literature, patients whose bullets are known to reside in a fluid-filled cavity or bony structure should be periodically screened for BLL. Key Words: Lead; Rehabilitation.
Poster 52 Organ Transplant Versus Other Debilitated Patients’ Inpatient Rehabilitation Functional Outcomes and Payment Recovery. Ellen Lin, MD (Univ Texas Health Sci Ctr, San Antonio, San Antonio, TX); John C. King, MD; Kathleen Sotello, e-mail: [email protected]. Disclosure: E. Lin, None; J.C. King, None; K. Sotello, None. Objective: To study the demographics, functional outcomes, and payment recovery of all postorgan transplantation patients admitted to a rehabilitation unit compared with an age-matched control group of other surgically and medically debilitated patients over a 2-y period. Design: Retrospective chart review. Setting: Inpatient rehabilitation unit of a tertiary care hospital. Participants: Postorgan transplant patients and other medically and surgically debilitated cohort. Inter-
Arch Phys Med Rehabil Vol 85, September 2004
ventions: Inpatient rehabilitation. Main Outcome Measures: Length of stay (LOS), FIM efficiency, and FIM reimbursement efficiency. Results: The posttransplant group (n⫽46) was 63.0% white and the debilitated group (n⫽84) was 51.2% white (P⬎.15). The mean LOS for the transplant patients versus the control patients was 10.4⫾5.2d versus 12.1⫾6.8d, respectively; the difference was not statistically significant (P⬎.10). The mean federal prospective payments (FPPs) for posttransplant and nontransplant debilitated patients were $9327⫾$3453 and $11,388⫾$4136, respectively (P⬍.01), which was statistically significant. The mean total FIM change for the transplant versus control patients was 19.1⫾16.0 and 22.5⫾18.2, respectively (P⬎.25). FIM efficiencies in the posttransplant and debilitated patients were 2.0⫾2.0 and 2.2⫾2.0 respectively (P⬎.60). FIM reimbursement efficiencies for the transplant versus control patients were 1.8⫾1.9 and 1.9⫾2.0, respectively (P⬎.9). LOS on the rehabilitation unit was approximately 1.6d fewer for the posttransplant patients compared with the debilitated cohort (P⬎.10). FPPs were $2061 lower (P⬍.010) for the organ transplant patients, with FIM cost efficiency .158 less (P⬎.90). After acute rehabilitation stay, 37 (80.4%) of the postorgan transplant patients were discharged to the community compared with 62 (73.8%) of the debilitated patients. Conclusions: The postorgan transplant patients, composed of significantly more men who generated lower FPP reimbursements, had similar race distributions, similar LOS, similar FIM efficiencies, and FIM reimbursement efficiencies and were just as likely to return to the community as other debilitated patients from inpatient rehabilitation. Key Words: Costs and cost analysis; Outcome assessment (health care); Organ transplantation; Rehabilitation.
Poster 53 Medicare Patients With Mobility Disability and Satisfaction With Health Care: 1992, 1996, and 2000. Leighton Chan, MD, MPH (Univ Washington, Seattle, WA); Anne Shumway-Cook, PhD; Kathryn Yorkston, PhD; Marcia Ciol, PhD; Elizabeth Kanny, PhD; Jeanne Hoffman, PhD, e-mail: [email protected]. Disclosure: L. Chan, None; A. Shumway-Cook, None; K. Yorkston, None; M. Ciol, None; E. Kanny, None; J. Hoffman, None. Objectives: To examine the effect of mobility disability on satisfaction with care and to determine if these attitudes have changed over time. Design: Data analyzed from Medicare Current Beneficiary Surveys (MCBS) performed in 1992, 1996, and 2000. Patients were separated into 5 categories: no, mild, moderate, severe, and profound mobility disability. Setting: The MCBS is an annual, nationally representative survey of all Medicare beneficiaries. With the weights applied, results may be generalized to the entire Medicare population (41 million people). Participants: 40,986 surveys were performed, 10,576 in 1992, 15,674 in 1996, and 14,736 in 2000. Interventions: Not applicable. Main Outcome Measures: Proportion of patients who were dissatisfied with their medical care. Other domains assessed included: availability of care, the ease of getting care, costs, physician’s level of concern, availability of specialists, and the ease of obtaining answers over the phone. Results: Between 4% and 5% of all patients were dissatisfied with their medical care. Increasing disability was associated with an increasing dissatisfaction. This relationship was significant and existed in all 3 surveys: 1992 (Cochran-Armitage test for trend⫽⫺486.3, P⬍.0001), 1996 (Cochran-Armitage⫽⫺373.2, P⬍.0001), and 2000 (Cochran-Armitage⫽⫺475.5, P⬍.0001). In addition, there was little variation in the proportion of dissatisfied patients in each disability category between the 3 surveys. For instance, 6% to 7% of those with moderate mobility disability and 7% to 8% with severe mobility disability were dissatisfied with their overall care in 1992, 1996, and 2000. Other domains where patients expressed a high level of dissatisfaction included the ease of getting care, costs, and the availability of specialists. Conclusions: Medicare patients with mobility disability are more dissatisfied with their health care than their able-bodied counterparts. These findings have been consistent over nearly a decade, suggesting that more aggressive approaches are needed to improve this situation. Key Words: Disability evaluation; Medicare; Personal satisfaction; Rehabilitation.
Poster 54 Morbidity and Outcomes Conference: A Rehabilitation Version of Morbidity and Mortality Conference. Renu K. Debroy, MD (Univ Kansas Med Ctr, Kansas City, KS); Ivy Garcia, MD; George Varghese, MD, e-mail: [email protected]. Disclosure: R.K. Debroy, None; I. Garcia, None; G. Varghese, None. Setting: University residency program in a tertiary care center. Program: Monthly resident didactics. Program Description: 2 residents each month presented 1 to 3 cases, each with unexpected outcomes in a clinical setting. These were discussed in an open forum between residents and staff during 1-h sessions of “morbidity and outcomes” (M&O) conferences. Discussion: Many surgical and medicine specialties hold M&O conferences as venues for discussion of unexpected or adverse outcomes to improve patient care and as a forum for education. This same concept was applied in a rehabilitation setting. Each resident was asked to present a case in which there was an unexpected or adverse outcome, including what went wrong, what could have been done differently, and what we would do if the situation were to occur in the future. The presentation was followed by a brief medical didactic review and then an open discussion was held between faculty and residents. Selected cases addressed the following issues: prolonged length of stay, transfer to acute units, adverse reactions to medicines, falls, wound infections, misdiagnoses, disposition issues, and medical issues. Conclusions: The Residency Review Committee requires addressing education and proficiency in 6 competencies: patient care, medical knowledge, interpersonal communication skills, professionalism, system- based practice, and practice-based learning. Regular incorporation of the last 2 competencies can sometimes be difficult. We have found the M&O conference to be an excellent way to address them. Some of the topics discussed have included discharge planning, admission process, working with outside agencies and insurers, support services, community services, and relating with acute hospital services and physicians. The M&O conference has been a valuable tool for facilitating open discussions and education of actual and potential unexpected outcomes and management of these issues on the rehabilitation unit. Key Words: Graduate medical education; Rehabilitation.
2004 Academy Annual Assembly Abstracts
for a maximum of 4 injections. For patients who had more than 90% pain reduction, the injections were terminated and gabapentin was titrated off. For the gabapentin patients, the medication was increased until they reached a tolerable pain level. Main Outcome Measure: VAS. Results: The mean VAS for the TF group at day 1 and 1, 2, 3, 4, and 12wk were 7.42, 5.25, 3.25, 1.83, 1.33, and 1.25 and for the gabapentin group it was 8.45, 6, 4.81, 3, 2.45, and 2, respectively. In the TF group, 3 patients were cured at 2wk and 3 at 3wk. 5 patients were cured at 12wk. Mean number of injections was 3.08. 1 patient in the gabapentin group was completely cured at 12wk. The average daily gabapentin dose at 12wk for the TF group was 1191.67mg and for the gabapentin group it was 2109.09mg. Conclusions: Gabapentin is an excellent medication for postherpetic neuralgia. Combining gabapentin with transforaminal epidural injections led to a dramatic reduction of VAS scores, a reduction of gabapentin doses, and a chance for an early cure. This is the first case series reporting the use of transforaminal epidural steroids as an adjunctive treatment for patients with postherpetic neuralgia. Key Words: Neuralgia; Rehabilitation; Steroids. Poster 50 Design and Validation of an ICD-9 Crosswalk Identifying Secondary Conditions in People With Disabilities. Leighton Chan, MD, MPH (Univ Washington, Seattle, WA); Anne Shumway-Cook, PhD; Kathryn Yorkston, PhD; Marcia Ciol, PhD; Elizabeth Kanny, PhD; Jeanne Hoffman, PhD, e-mail: [email protected]. Disclosure: L. Chan, None; A. Shumway-Cook, None; K. Yorkston, None; M. Ciol, None; E. Kanny, None; J. Hoffman, None. Objective: To design and validate a methodology identifying secondary conditions in people with disabilities using the International Classification of Disease (ICD-9) codes. Design: Secondary conditions were identified through a literature search and a survey of Washington State physiatrists. These conditions were then translated into ICD-9 codes. This ICD-9 crosswalk was then validated against a national sample of Medicare patients with no, mild, moderate, severe, or profound mobility disability. Setting: National survey. Participants: 26 Washington State physiatrists and 9731 participants of the 1999 Medicare Current Beneficiary Survey (MCBS). Intervention: Not applicable. Main Outcome Measures: Identification and classification of secondary conditions into 4 categories: medical, psychosocial, musculoskeletal, and oral motor. The relationship between the prevalence of secondary conditions (identified through billing data) and the presence of mobility disability. Results: Our literature search and survey of physiatrists identified 58 secondary conditions including depression, decubitus ulcers, deconditioning, and chronic pain. 48.1% of the MCBS patients had no mobility disability; 33.9% had mild disability, 11.9% had moderate disability, 4.5% had severe disability, and 1.6% had profound mobility disability. We found a significant relationship between increasing disability and being treated for a secondary condition (Cochran-Armitage test for trend⫽–13.4, P⬍.0001). This relationship existed for all categories of secondary conditions: medical (Cochran-Armitage⫽⫺13.3, P⬍.0001), psychosocial (Cochran-Armitage⫽⫺6.1, P⬍.0001), musculoskeletal (Cochran-Armitage⫽⫺14.3, P⬍.0001), and oral motor (Cochran-Armitage⫽⫺15.4, P⬍.0001). Conclusions: Our ICD-9 crosswalk was able to identify secondary conditions in Medicare patients with mobility disability. This methodology will be very useful for health services researchers interested in studying the impact of secondary conditions. Key Words: Disability evaluation; Medicare; Rehabilitation. Poster 51 Lead Toxicity in a Patient With Retained Bullets: A Case Report and Literature Review. Linda R. Ladesich, MD (Univ Kansas, Kansas City, KS); Dana McKinney, MD; George Varghese, MD, e-mail: [email protected]. Disclosure: L.R. Ladesich, None; D. McKinney, None; G. Varghese, None. Setting: Tertiary care hospital. Patient: 48-yo woman with chronic lead toxicity due to retained bullets. Case Description: The patient had a history of several hospitalizations for diffuse complaints including severe peripheral neuropathy, abdominal pain, seizures with resulting encephalopathy, dysarthria, cognitive deficits, ataxia, and fine motor dysfunction. She was initially thought to have acute intermittent porphyria because there was some crossover in laboratory testing. However, a heavy metal screen was positive for severe lead toxicity, with a blood lead level (BLL) of 111.1/dL (BLL ⬍3/dL is mean, ⬎25/dL is elevated). After a thorough evaluation for the etiology, it was determined that the toxicity was most likely due to retained bullets from gunshot wounds 30y ago. Assessment/Results: The patient underwent thoracotomy to remove 1 bullet. The other bullet was inoperable due to its location in the cervical spine. She underwent chelation treatment with calcium edetic acid and succimer with a gradual decrease in lead levels to 31.8/dL. However, she continued to have difficulties with neuropathy, fine motor function, dysarthria cognition, and generalized pain. The patient refused further chelation due to side effects. Discussion: A review of the literature yields multiple case reports of lead toxicity from gunshot wounds. However, current reported incidence of lead toxicity in adults reflects only occupational exposure. While occupational history remains an important aspect of the physiatric patient interview, a significant number of physiatric patients have had gunshot wounds. Conclusions: We propose that, in patients with generalized neurologic complaints, this history also include previous trauma including potential gunshot wounds. Furthermore, as is supported in the literature, patients whose bullets are known to reside in a fluid-filled cavity or bony structure should be periodically screened for BLL. Key Words: Lead; Rehabilitation.
Poster 52 Organ Transplant Versus Other Debilitated Patients’ Inpatient Rehabilitation Functional Outcomes and Payment Recovery. Ellen Lin, MD (Univ Texas Health Sci Ctr, San Antonio, San Antonio, TX); John C. King, MD; Kathleen Sotello, e-mail: [email protected]. Disclosure: E. Lin, None; J.C. King, None; K. Sotello, None. Objective: To study the demographics, functional outcomes, and payment recovery of all postorgan transplantation patients admitted to a rehabilitation unit compared with an age-matched control group of other surgically and medically debilitated patients over a 2-y period. Design: Retrospective chart review. Setting: Inpatient rehabilitation unit of a tertiary care hospital. Participants: Postorgan transplant patients and other medically and surgically debilitated cohort. Inter-
Arch Phys Med Rehabil Vol 85, September 2004
ventions: Inpatient rehabilitation. Main Outcome Measures: Length of stay (LOS), FIM efficiency, and FIM reimbursement efficiency. Results: The posttransplant group (n⫽46) was 63.0% white and the debilitated group (n⫽84) was 51.2% white (P⬎.15). The mean LOS for the transplant patients versus the control patients was 10.4⫾5.2d versus 12.1⫾6.8d, respectively; the difference was not statistically significant (P⬎.10). The mean federal prospective payments (FPPs) for posttransplant and nontransplant debilitated patients were $9327⫾$3453 and $11,388⫾$4136, respectively (P⬍.01), which was statistically significant. The mean total FIM change for the transplant versus control patients was 19.1⫾16.0 and 22.5⫾18.2, respectively (P⬎.25). FIM efficiencies in the posttransplant and debilitated patients were 2.0⫾2.0 and 2.2⫾2.0 respectively (P⬎.60). FIM reimbursement efficiencies for the transplant versus control patients were 1.8⫾1.9 and 1.9⫾2.0, respectively (P⬎.9). LOS on the rehabilitation unit was approximately 1.6d fewer for the posttransplant patients compared with the debilitated cohort (P⬎.10). FPPs were $2061 lower (P⬍.010) for the organ transplant patients, with FIM cost efficiency .158 less (P⬎.90). After acute rehabilitation stay, 37 (80.4%) of the postorgan transplant patients were discharged to the community compared with 62 (73.8%) of the debilitated patients. Conclusions: The postorgan transplant patients, composed of significantly more men who generated lower FPP reimbursements, had similar race distributions, similar LOS, similar FIM efficiencies, and FIM reimbursement efficiencies and were just as likely to return to the community as other debilitated patients from inpatient rehabilitation. Key Words: Costs and cost analysis; Outcome assessment (health care); Organ transplantation; Rehabilitation.
Poster 53 Medicare Patients With Mobility Disability and Satisfaction With Health Care: 1992, 1996, and 2000. Leighton Chan, MD, MPH (Univ Washington, Seattle, WA); Anne Shumway-Cook, PhD; Kathryn Yorkston, PhD; Marcia Ciol, PhD; Elizabeth Kanny, PhD; Jeanne Hoffman, PhD, e-mail: [email protected]. Disclosure: L. Chan, None; A. Shumway-Cook, None; K. Yorkston, None; M. Ciol, None; E. Kanny, None; J. Hoffman, None. Objectives: To examine the effect of mobility disability on satisfaction with care and to determine if these attitudes have changed over time. Design: Data analyzed from Medicare Current Beneficiary Surveys (MCBS) performed in 1992, 1996, and 2000. Patients were separated into 5 categories: no, mild, moderate, severe, and profound mobility disability. Setting: The MCBS is an annual, nationally representative survey of all Medicare beneficiaries. With the weights applied, results may be generalized to the entire Medicare population (41 million people). Participants: 40,986 surveys were performed, 10,576 in 1992, 15,674 in 1996, and 14,736 in 2000. Interventions: Not applicable. Main Outcome Measures: Proportion of patients who were dissatisfied with their medical care. Other domains assessed included: availability of care, the ease of getting care, costs, physician’s level of concern, availability of specialists, and the ease of obtaining answers over the phone. Results: Between 4% and 5% of all patients were dissatisfied with their medical care. Increasing disability was associated with an increasing dissatisfaction. This relationship was significant and existed in all 3 surveys: 1992 (Cochran-Armitage test for trend⫽⫺486.3, P⬍.0001), 1996 (Cochran-Armitage⫽⫺373.2, P⬍.0001), and 2000 (Cochran-Armitage⫽⫺475.5, P⬍.0001). In addition, there was little variation in the proportion of dissatisfied patients in each disability category between the 3 surveys. For instance, 6% to 7% of those with moderate mobility disability and 7% to 8% with severe mobility disability were dissatisfied with their overall care in 1992, 1996, and 2000. Other domains where patients expressed a high level of dissatisfaction included the ease of getting care, costs, and the availability of specialists. Conclusions: Medicare patients with mobility disability are more dissatisfied with their health care than their able-bodied counterparts. These findings have been consistent over nearly a decade, suggesting that more aggressive approaches are needed to improve this situation. Key Words: Disability evaluation; Medicare; Personal satisfaction; Rehabilitation.
Poster 54 Morbidity and Outcomes Conference: A Rehabilitation Version of Morbidity and Mortality Conference. Renu K. Debroy, MD (Univ Kansas Med Ctr, Kansas City, KS); Ivy Garcia, MD; George Varghese, MD, e-mail: [email protected]. Disclosure: R.K. Debroy, None; I. Garcia, None; G. Varghese, None. Setting: University residency program in a tertiary care center. Program: Monthly resident didactics. Program Description: 2 residents each month presented 1 to 3 cases, each with unexpected outcomes in a clinical setting. These were discussed in an open forum between residents and staff during 1-h sessions of “morbidity and outcomes” (M&O) conferences. Discussion: Many surgical and medicine specialties hold M&O conferences as venues for discussion of unexpected or adverse outcomes to improve patient care and as a forum for education. This same concept was applied in a rehabilitation setting. Each resident was asked to present a case in which there was an unexpected or adverse outcome, including what went wrong, what could have been done differently, and what we would do if the situation were to occur in the future. The presentation was followed by a brief medical didactic review and then an open discussion was held between faculty and residents. Selected cases addressed the following issues: prolonged length of stay, transfer to acute units, adverse reactions to medicines, falls, wound infections, misdiagnoses, disposition issues, and medical issues. Conclusions: The Residency Review Committee requires addressing education and proficiency in 6 competencies: patient care, medical knowledge, interpersonal communication skills, professionalism, system- based practice, and practice-based learning. Regular incorporation of the last 2 competencies can sometimes be difficult. We have found the M&O conference to be an excellent way to address them. Some of the topics discussed have included discharge planning, admission process, working with outside agencies and insurers, support services, community services, and relating with acute hospital services and physicians. The M&O conference has been a valuable tool for facilitating open discussions and education of actual and potential unexpected outcomes and management of these issues on the rehabilitation unit. Key Words: Graduate medical education; Rehabilitation.