An Interview with Dr. Alyssa Cole
Unmasking Rehab Medicine During COVID - Narratives & Portraits
Dr. Alyssa Cole is a physical medicine and rehabilitation physician, having recently finished her PM&R residency training in Philadelphia. She is now specializing in cancer rehabilitation as the city’s first cancer rehabilitation fellow physician. Back in medical school, Dr. Cole learned about the field after completing a preceptorship at a rehabilitation hospital. “As an osteopathic physician I have a strong understanding of anatomy, the musculoskeletal system, and the nervous system. Rehabilitation allows me to combine these interests in order to help patients regain their quality of life.” Initially, she did not know about the field of physical medicine and rehabilitation. She told her family how she wished she could be the physician overseeing the medical management of patients in therapy. It was that moment when her father turned to her and said, “you’re talking about physiatry.” It turned out that before she was born, her father was a research assistant for a physiatrist and so, in a way, Dr. Cole thought, “maybe it was embedded in my DNA... meant to be.”
Continuing to explore the field through elective rotations, Dr. Cole enjoyed seeing the progression and continuity of care as patients made their way through rehabilitation. Dr. Cole remembered meeting a stroke patient who had difficulty standing, but after a month of comprehensive therapy, was able to walk across the room and hug her children. “Knowing that I could be the cheerleader for her, and also having been a cheerleader, I felt like [PM&R] was the best of both worlds.” Dr. Cole described PM&R as “a hidden gem that not many people know about... it’s a field devoted to improving the functionality and quality of life of patients with a focus on neurological and musculoskeletal conditions.”
Dr. Cole explained how through PM&R you can either practice general physiatry or pursue more specialized interests such as sports medicine, pain, spinal cord injury, traumatic brain injury, cancer rehabilitation and palliative care. She said that sometimes when people hear ‘PM&R’ or ‘physiatry’ they think psychiatry or pediatrics, which is why it is important to bring awareness to the field, and educate the public about what these doctors offer patients.
Amidst the pandemic, outside of the hospital, Dr. Cole limited her normal activities to socially distance, arranged for groceries to be delivered, and canceled travel plans to visit family. In the beginning of the pandemic, she was on her EMG (electromyography) rotation, but due to administrative changes and restrictions on outpatient clinics, she was instead placed on reserve in case other physicians became ill. This meant that she served as backup both for her PM&R residency as well as for the internal medicine residents.
During this time, Dr. Cole was also moonlighting at a suburban rehabilitation hospital, where she had the opportunity to take on more attending-level responsibilities. Here she managed all of the rehabilitation patients, in addition to twenty patients recently added to a unit dedicated to COVID. “These were extra shifts I was taking on that I didn’t need to as part of my residency training, but I knew the hospital needed the help,” said Dr. Cole. She worked there a few times a month always in 24-hour shifts.
Thinking back to the height of the pandemic, Dr. Cole reflected on how “the stress of everything was difficult to manage. I remember walking in to the hospital one day and as I looked down I saw there were chalk drawings and messages all over the ground in front of the entrance. They said ‘Thank you,’ ‘Heroes work here,’ ‘We appreciate you,’ ‘You’re saving lives,’ and it just made me cry.” She remembered at the time being surrounded by a group of other employees, nurses and therapists, and she said, “We just all started bawling because it was just such a powerful message to read. And it meant a lot. This is what you do for your job every day and you never think of yourself as a hero.” Dr. Cole said she is so appreciative of her colleagues, the nurses she works with, the therapists, the environmental services team, the aides, and the technicians, explaining, “It takes a village.”
During one of her 24-hour shifts, Dr. Cole recalls getting paged about a patient who spiked a low-grade temperature. “All of us suddenly start thinking COVID,” said Dr. Cole, knowing the patient had been on a floor where another individual had tested positive for COVID. After donning the proper PPE and examining the patient, Dr. Cole remained concerned. While the patient did not have any other symptoms, no cough, no shortness of breath, her temperature remained elevated with no obvious source. In addition to ruling out common causes of fevers like a urinary tract infection, Dr. Cole sent for a COVID test. “I would rather be safe than sorry. Whenever you order something you have to ask yourself how is this going to change my management, and so by ordering it, if it came back positive then we would know if we needed to isolate the patient in the cohorted COVID unit, keep her more closely monitored, or obtain a chest x-ray. If she came back negative, then we would feel more comfortable where she was and look for other sources of infection.”
Around one o’clock in the morning, Dr. Cole received a call and found out that her patient tested positive. The patient had been progressing well in therapy and was otherwise medically stable such that she was supposed to be discharged a few days later. However, with this new diagnosis, plans changed. When the patient asked Dr. Cole if she was going to die, Dr. Cole reassured the patient, telling her that luckily, they had caught the virus early and they would monitor her closely in the COVID unit. “Hearing your patient say that to you and also recognizing this is a new disease [where] there isn’t enough evidence-based medicine...is just a jarring sensation and emotionally taxing. Sometimes the best thing you can do for your patients is to just be there to listen to them and help them through their concerns.”
In cases where patients with COVID were medically stable, Dr. Cole said that they might be admitted to a rehabilitation facility as was the case where she worked, as opposed to an acute care hospital. This helped to free up space in the main hospitals for patients with higher acuity medical issues. However, patients who were in more critical condition due to COVID would instead go to the acute care hospital, where they could be managed in the intensive care unit (ICU) if necessary, with some requiring intubation. She said that once these patients have recovered, they will need rehabilitation for deconditioning as well as other issues such as critical illness neuropathy, dysphagia, and malnutrition.
“Everyone focuses on the statistics of COVID and the mortality rate, but nobody focuses on how once people have recovered, though it wasn’t fatal for them, they now have long-lasting effects,” said Dr. Cole. “Yes, they survived, but at what cost to their bodies? Many of them will likely need intensive physical, occupational, and speech therapy to regain their strength and endurance. If there is any specialty that is going to be in high demand, and that we need more doctors for, it is physical medicine and rehabilitation. These are the doctors that will get these patients functioning again, to get them back to their quality of life, and back into their homes and the community.” She noted that some patients who were previously healthy, have been in a hospital bed for months. This increased length of stay can lead to muscle atrophy, pressure ulcers, kidney damage, lung damage and other medical complications whether from the virus or overall hospital course.
Dr. Cole also saw how insurance protocols and policy changed in response to the pandemic. “It was almost like the focus shifted to saving the patient, forget about the paperwork, forget about the insurance coverage.” Especially for rehabilitation medicine, Dr. Cole said that, “Things changed drastically and rapidly to get patients who were no longer required to be in the acute care hospital into rehab, where before they needed to jump through all of these hurdles to qualify for acute comprehensive rehab.” She noted that in particular, Medicare changed a lot of its requirements to accommodate for the influx of patients. Dr. Cole hopes that this approach to patient care will continue beyond the pandemic to benefit patients, especially as it relates to preventative medicine. She discussed how the lack of preventative care reimbursement impacts so many fields in medicine, including PM&R. “The most frustrating part is that [insurance companies] wait until it becomes an acute issue to provide coverage. Had they covered it months ago when it would have been a preventative measure, [patients] could have avoided these astronomical healthcare expenses, operations, interventions, medications, and diagnostic testing.”
As her PM&R residency has ended, Dr. Cole says she’s excited for what’s ahead — she is now in her second month of fellowship in cancer rehabilitation and has already learned so much. She explained, “Last week I high-fived a patient in clinic who survived cancer and COVID. It is the most rewarding population to work with because they have a new lease on life, they are so appreciative of your help and receptive to your recommendations.”
R. Mayeda is a second year MD candidate at the Lewis Katz School of Medicine at Temple University in Philadelphia, Pennsylvania.