PGY2 at X-roads RE: choosing future career path

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Hello, I'm currently pgy2 finishing the inpt yr, and like most other pgy2s, I'm trying to figure out which career path I want to commit myself to.

I enjoy doing spine / MSK / sports, and also possibly want to retain skills in EMG and bread/butter inpatient issues.

I enjoy procedures and get much satisfaction when patients get relief and improvement in symptoms & function from treatment, or pain controlled enough for patients to function. I want to be able to manage majority of spine issues (less interested in Pain-specific procedures). I also want to be able to incorporate ultrasound for axial / peripheral MSK dz management with a strong level of expertise.

I feel that doing a sports/spine fellowship will be something I would love doing, but I haven't seen or heard from anyone who actually practices the entire breadth of what they learn in fellowship (from few instances of what I heard, most ppl just end up doing spine?)

Having a high job satisfaction from being able to do a good management is probably the single most important thing to me.

I love PM&R and I'm extremely happy in being trained to become a physiatrist, but I my main concern is, by wanting to do so many different things, am I setting myself up to be a PM&R jack of all trades & master of none, which will result in less job satisfaction from not being able to manage a lot of the cases?

Or is it a realistic goal for me to want to develop very solid expertise in so many different aspects of PM&R (sports,spine,EMG, some inpt), and be able to at least handle >80-90% of cases? (I'm thinking of doing sports & spine, but perhaps I would want to do sports only, or spine only? I'm not sure what I should do....)

To those who're still reading, thank you for hearing my dilemma, and any feedback is greatly appreciated

I am that guy. It is easier to do that type of practice in rural/semirural areas. I've been at this for 15 yrs and consider myself a pretty good doctor. (no fellowship here, but my first job was a very well paid 3 yr unofficial fellowship) I know my limits and refer to others when I reach them (for example, I do NO TBI and very little spinal cord)

Versatility is good, as long as you are good at all the things you do. You will likely find that over time, your interests in PM&R narrow. You may decide you don't want to treat kids, or brain injuries, or whatever. Some things are best left to those who do it a lot, like spinal cord injury. Some require fellowship, like much of pain management. No one does it all. Some do a lot, some just a little.

a lot of things are up in the air with our outpatient future - spine, US, EMG. As said above you gotta have versatility for the unpredictable future.
What will happen, regardless of whether we like it or not, is all insurances will mandate everyone with back pain go to PM&R first. That is inevitable and already occurring

Originally Posted by Gauss

What will happen, regardless of whether we like it or not, is all insurances will mandate everyone with back pain go to PM&R first. That is inevitable and already occurring

The largest IPA in my region (major metropolitan area), also the one taking the most cost cutting measures as of late, instituted this policy about 18 months ago.

Not surprisingly, they have concurrently become very restrictive regarding utilization of interventional pain procedures, imaging, etc.

Good for Physiatry on the surface, but has been shunting alot of patients to certain Physiatrists with little spine or MSK skill.

When this becomes the norm with most insurers, maybe we want to revisit the idea of a Spine/MSK CAQ.

Originally Posted by Disciple

The largest IPA in my region (major metropolitan area), also the one taking the most cost cutting measures as of late, instituted this policy about 18 months ago.

Not surprisingly, they have concurrently become very restrictive regarding utilization of interventional pain procedures, imaging, etc.

Good for Physiatry on the surface, but has been shunting alot of patients to certain Physiatrists with little spine or MSK skill.

the shunting is a tidal wave, everyone with back pain is coming. Imagine every medicaid patient with back pain being referred to you now. That is happening.
I order PT - they approve 1 session. MRI? Why with only 1 session of PT? Meds are restricted, so everyone is on vicosomaxanax. Gabapentin? Prior auth. Interventions? You better have superior pt selection skills otherwise they'll use injections as a way to get more meds.

Thank you all for your inputs. It seems like the reoccurring theme is remaining versatile, which is my top priority at this stage in training, with the focus on being excellent spine/MSK doc.

Originally Posted by RUOkie

I am that guy. It is easier to do that type of practice in rural/semirural areas. I've been at this for 15 yrs and consider myself a pretty good doctor. (no fellowship here, but my first job was a very well paid 3 yr unofficial fellowship) I know my limits and refer to others when I reach them (for example, I do NO TBI and very little spinal cord)

RUOkie, that's awesome for you to have had that kind of opportunity right out of residency. If I had to guess, that sounds like a multi-PM&R doc group in private setting, with some docs with specialized training, which is a group with whom I would love to work with and learn a little bit along the way as well, although I'm not sure about how easily those chances may come by by the time I'm done with training. Nonetheless, metropolitan/suburban/rural isn't a major priority for me, so I find that encouraging.

Originally Posted by PhysMedDoc

RUOkie, that's awesome for you to have had that kind of opportunity right out of residency. If I had to guess, that sounds like a multi-PM&R doc group in private setting, with some docs with specialized training, which is a group with whom I would love to work with and learn a little bit along the way as well, although I'm not sure about how easily those chances may come by by the time I'm done with training. Nonetheless, metropolitan/suburban/rural isn't a major priority for me, so I find that encouraging.

You are correct. I was in a 14 doc PM&R group of whom 1/2 were interventionalists, and ALL did MSK and a lot of work comp. The interventionalists were willing to train anybody in anything, provided you were willing to take the time out of your own day to do it. They forced nobody into anything (except seeing a lot of patients).

What I would suggest then is to find a job with an ortho group or a practice like I was in for a few years. Look at it as if you are continuing your training (but don't tell them!) and then once you feel confident, move to a semirural area (OK, Neb, the Dakotas, Arkansas, TX--you get the picture) where you can do it all.

Originally Posted by Gauss

the shunting is a tidal wave, everyone with back pain is coming. Imagine every medicaid patient with back pain being referred to you now. That is happening.
I order PT - they approve 1 session. MRI? Why with only 1 session of PT? Meds are restricted, so everyone is on vicosomaxanax. Gabapentin? Prior auth. Interventions? You better have superior pt selection skills otherwise they'll use injections as a way to get more meds.

Who says you have to accept Medicaid?

For any Physiatrist who considers themself a "spine", "spine & sports" or "musculoskeletal" doc, this is exactly what you want.

It gets around the problem of coming up with creative ways to get referals for MSK patients, e.g. "I do comprehensive pain management", "I'll take over opioid prescriptions", etc.

The reason why alot of Physiatrists join Ortho groups is to have easy access to MSK and spine patients, without significant opioid management, sifting through referrals for chronic pelvic pain, fibromyalgia, etc. The trade off? You will never become a full partner, at least not on the level of the surgeons or founding members of the group.

With patients shunted to Physiatrists, this solves one of our major problems (as a specialty). The Neurosurg or spine groups will now be bringing bagels to your office to get referrals. If these types of policies are expanded to hips/knees, etc., now entire multispecialty surgical groups will be getting referrals from you. If Physiatry continues to increase its presence in Sports Medicine, even more referrals to whatever group you choose.

Pain practices will be asking for patients who have plateau'd, to take over long term managment with continuing injections, implants, etc. If you are a "PM&R/Pain" doc, you no longer have to worry so much about taking over opioid prescriptions to keep the primary care referrals coming.