Future of Physiatry

[klumpke]

Hi Everybody! I apologize in advance if a thread like this has been floated around recently but I just wanted to get your thoughts on the future of PM&R as a field.

I saw a recent article from Doximity (link at bottom) that referenced PM&R salary outpacing inflation with all of the other hot surgical specialties which is promising! What're your thoughts on the future of compensation, job market availability, and if inpatient vs outpatient will become more prominent?

Thanks again everybody, I love reading your interesting takes on these things!!

In the Race Against Inflation, Half of Medical Specialties Are Left Behind

Inflation outpaced physician salary growth for nearly half of all medical specialties over the past five years, according to surveys of more than 1...

www.doximity.com

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[Iamnew2]

Hi Everybody! I apologize in advance if a thread like this has been floated around recently but I just wanted to get your thoughts on the future of PM&R as a field.

I saw a recent article from Doximity (link at bottom) that referenced PM&R salary outpacing inflation with all of the other hot surgical specialties which is promising! What're your thoughts on the future of compensation, job market availability, and if inpatient vs outpatient will become more prominent?

Thanks again everybody, I love reading your interesting takes on these things!!

In the Race Against Inflation, Half of Medical Specialties Are Left Behind

Inflation outpaced physician salary growth for nearly half of all medical specialties over the past five years, according to surveys of more than 1...

www.doximity.com

PM&R is highly variable as a field - outpatient is competitive particularly in large cities, and mostly has to be done via an Orthopedic group which tends to not be great and has numerous pitfalls that have been discussed in the past, vs via Pain management/Interventional type set up which tends to go via Anesthesia/Ortho/NSG - this is a mixed bag, some good places some not so good paces. Some places are salary/employed, and you are at the mercy of what the group wants to pay you.

Lots of jobs in inpatient at this time, inpt was for a long time not viewed as desirable which left a lot of need out there - this in return has allowed for many openings, and with a contractor type set up, a very nice living, and a door into administrative type positions for those out there who are interested in them. Lots of older/baby boomer type individuals so lots of potential patietns. Multiple other areas of expansion in addition to outpatient MSK/pain, including regen, expert witness/catastrophic injury type things as nature of the field, SNF, some people do concierge type stuff, etc. I think we have a reasonably good future

 

[DMBandFan86]

That is a 5 year period. No one is beating inflation right now over the last 2 years. I know I am not.

Physician pay goes up because we have to see more people generally. It also helps that it is easier to bill outpatients visits as a level 4 now.

Medicare physician Reimbursement doesn’t keep up with inflation. Nor costs of care.

It also doesn’t help that NPs are willing to take a lot less money to work in healthcare and some people don’t see the big difference between mid level and physician care.

Overall, I think just like everywhere in healthcare that numbers will slowly go down after the baby boomer generation. But you have a while until that happens.

 

[Dr. Ice]

I think outpatient pain is dead in the water. Way too much saturation not enough spines. Reimbursement cuts, inflation, etc. As many of my quirky inpatient attendings postulated in the past, as they saw all their residents salivate over pain, the pendulum is swinging back to inpatient. The hay day of pain docs in ascs killing it are few and far between now (geographic and state law specific). I actually thought about taking a part time gig seeing pretzels in the nursing homes and depending on how it pans out might just give up pain completely for writing the same notes day in and day out about stair navigation and disposition for 400k a year

 

[sloh]

The future for pain and MSK do not look bright.

 

[Iamnew2]

I think outpatient pain is dead in the water. Way too much saturation not enough spines. Reimbursement cuts, inflation, etc. As many of my quirky inpatient attendings postulated in the past, as they saw all their residents salivate over pain, the pendulum is swinging back to inpatient. The hay day of pain docs in ascs killing it are few and far between now (geographic and state law specific). I actually thought about taking a part time gig seeing pretzels in the nursing homes and depending on how it pans out might just give up pain completely for writing the same notes day in and day out about stair navigation and disposition for 400k a year

you like seeing pretzels in the nursing home eh? I prefer patients!

 

[DMBandFan86]

I wouldn’t say outpatient or pain is dead. It is saturated. You also have to compete with ortho, neuro, sports. There are still jobs out there for outpatient (EMG, Botox, MSK, diagnostic U/S, non-interventional pain) depending on the region and how good you are. PRP, prolo, manipulation also can help build a practice.

Overall I think people use EMG less than they did in the past and I don’t see many EMG jobs advertised or people wanting to do EMG for a living.

Interventional still has jobs available but usually not in the best cities. NP takeover hasn’t helped. In my opinion, a lot of the procedures don’t work well or don’t last long or the effectiveness wears off over time despite repeated treatments. Still a lot of room for improvement and advancement in technology.

I agree inpatient is a good career if you like that sort of thing. A lot of residents don’t like inpatient or taking call. But if you don’t mind it and are efficient than it can be very rewarding. Just keep the NPs away. I do fear Medicare removing the rehab physician necessity in the future from inpatient requirements and NPs coming in.

Usually jobs available for SCI or brain injury fellowship trained docs. So if you want to limit yourself to mostly that population then you probably have good job security.

 

[Iamnew2]

I wouldn’t say outpatient or pain is dead. It is saturated. You also have to compete with ortho, neuro, sports. There are still jobs out there for outpatient (EMG, Botox, MSK, diagnostic U/S, non-interventional pain) depending on the region and how good you are. PRP, prolo, manipulation also can help build a practice.

Overall I think people use EMG less than they did in the past and I don’t see many EMG jobs advertised or people wanting to do EMG for a living.

Interventional still has jobs available but usually not in the best cities. NP takeover hasn’t helped. In my opinion, a lot of the procedures don’t work well or don’t last long or the effectiveness wears off over time despite repeated treatments. Still a lot of room for improvement and advancement in technology.

I agree inpatient is a good career if you like that sort of thing. A lot of residents don’t like inpatient or taking call. But if you don’t mind it and are efficient than it can be very rewarding. Just keep the NPs away. I do fear Medicare removing the rehab physician necessity in the future from inpatient requirements and NPs coming in.

Usually jobs available for SCI or brain injury fellowship trained docs. So if you want to limit yourself to mostly that population then you probably have good job security.

I would agree with the EMG comment. I don't know too many EMG'ers out there, between the time consumption that they require in terms of completion, particularly for more involved issues, reimbursement cuts, and the fact that most people don't like doing them, fewer and fewer people do them these days.

 

[Bostonspine]

I think outpatient pain is dead in the water. Way too much saturation not enough spines. Reimbursement cuts, inflation, etc. As many of my quirky inpatient attendings postulated in the past, as they saw all their residents salivate over pain, the pendulum is swinging back to inpatient. The hay day of pain docs in ascs killing it are few and far between now (geographic and state law specific). I actually thought about taking a part time gig seeing pretzels in the nursing homes and depending on how it pans out might just give up pain completely for writing the same notes day in and day out about stair navigation and disposition for 400k a year

I don’t know if you practice in a rural area but in Boston most of the people seeing pretzels aren’t making $400k and the SNF guys making that are seeing high volume. When I did the math it was easier for me to do more pain/MSK because I’m actually good at that vs re learning rehab. There is value in doing what you like.

 

[Dr. Ice]

you like seeing pretzels in the nursing home eh? I prefer patients!

Pain patients are basically pretzels that haven’t taken pretzel form yet…ok I’m gonna stop now. One would think after 12 years of practice I’m misanthropic..🤷🏽‍♂️

 

[RangerBob]

I don’t know if you practice in a rural area but in Boston most of the people seeing pretzels aren’t making $400k and the SNF guys making that are seeing high volume. When I did the math it was easier for me to do more pain/MSK because I’m actually good at that vs re learning rehab. There is value in doing what you like.

I wouldn't think it'd be that hard to make $400k in Boston. The SF docs I know (independent contractors) are easily able to make $400k with a fairly comfortable workday if they're receiving some sort of director stipend and have a reasonable patient census. In my discussions with them, they're making 15-20% more per patient than I do since Medicare reimburses them better than me in a more rural (but cheaper COL) area.

I certainly agree there is value in doing what you like. The biggest risk to financial independence/retirement is burnout. I would burnout quickly if I had to do outpatient and am thankful people like you enjoy it, just as I'm sure you're thankful people like me are running inpatient units!

Back to the OP's original question--unfortunately as mentioned above, Medicare reimbursement (and thus likely private reimbursement) doesn't keep pace with inflation. I (and I'm sure many others) are hoping to see some bill introduced to increase physician reimbursement as there hasn't been this significant of inflation since the 70's, back when Medicare rates were still increasing/adjustable. Hospital reimbursement does go up with inflation, but for some reason ours doesn't.

Still, I doubt there's much hope, but at some point the lack of tying physician reimbursement rates to inflation will mean the only ones that make anything decent are hospital/health-system employed docs, who are subsidized by systems that get increasing facility reimbursements.

On the other hand, people (physicians) keep saying physician reimbursement will go down, but it seems to continue to go up. I'm not so sure we're working that much harder than our predecessors...

 

[Iamnew2]

Pain patients are basically pretzels that haven’t taken pretzel form yet…ok I’m gonna stop now. One would think after 12 years of practice I’m misanthropic..🤷🏽‍♂️

I got a kick out of that.

I wouldn't think it'd be that hard to make $400k in Boston. The SF docs I know (independent contractors) are easily able to make $400k with a fairly comfortable workday if they're receiving some sort of director stipend and have a reasonable patient census. In my discussions with them, they're making 15-20% more per patient than I do since Medicare reimburses them better than me in a more rural (but cheaper COL) area.

I certainly agree there is value in doing what you like. The biggest risk to financial independence/retirement is burnout. I would burnout quickly if I had to do outpatient and am thankful people like you enjoy it, just as I'm sure you're thankful people like me are running inpatient units!

Back to the OP's original question--unfortunately as mentioned above, Medicare reimbursement (and thus likely private reimbursement) doesn't keep pace with inflation. I (and I'm sure many others) are hoping to see some bill introduced to increase physician reimbursement as there hasn't been this significant of inflation since the 70's, back when Medicare rates were still increasing/adjustable. Hospital reimbursement does go up with inflation, but for some reason ours doesn't.

Still, I doubt there's much hope, but at some point the lack of tying physician reimbursement rates to inflation will mean the only ones that make anything decent are hospital/health-system employed docs, who are subsidized by systems that get increasing facility reimbursements.

On the other hand, people (physicians) keep saying physician reimbursement will go down, but it seems to continue to go up. I'm not so sure we're working that much harder than our predecessors...

you know after one of your former posts I came to the realization that that’s exactly right in terms of reimbursement depending on area- I think it’s significantly higher for higher cost of living areas. I’ve learned so much From this forum!

 

[DMBandFan86]

I'm not so sure we're working that much harder than our predecessors...

You mean the ones that didn't have to pay an arm and a leg for medical school. Or the ones that could scribble a crappy note on a piece of paper in a few seconds and get reimbursed.

I found an interesting article that compares cost of school and physician salary compared to inflation since 1970. Not saying it is the greatest article, but shows a nice concept of how things were a bit different back in the day.

Is It Better to Be a Doctor Now Than It Was 50 Years Ago? | Physician Sense

A lot has changed in medicine since 1970. This month, we're looking at how the financial picture for physicians differs from how it looked 50 years ago.

www.mdlinx.com

 

[klumpke]

So for someone just now entering the field, it sounds like (from a strictly financial/job prospect perspective) it would be best to stay in general rehab as opposed to doing any outpatient msk/sports/int pain? Anything else to consider that might be a good bet for the future of the field?

Again, you all are awesome this is so helpful when im thinking about the future.

 

[Iamnew2]

So for someone just now entering the field, it sounds like (from a strictly financial/job prospect perspective) it would be best to stay in general rehab as opposed to doing any outpatient msk/sports/int pain? Anything else to consider that might be a good bet for the future of the field?

Again, you all are awesome this is so helpful when im thinking about the future.

Not necessarily. It's not a good idea to "time" a specialty or time what might happen in the future - none of us can know what might happen in the future. I would say go into whatever you enjoy and are good at. The rest will eventually follow. Inpt rehab is not for everyone. Just like outpatient is not for everyone. Do what you enjoy.

 

[j4pac]

The concerns reinforce the importance of being flexible and having well rounded training. If you get too narrow in either your clinical focus or skillset, it may hurt you.

 

[RangerBob]

You mean the ones that didn't have to pay an arm and a leg for medical school. Or the ones that could scribble a crappy note on a piece of paper in a few seconds and get reimbursed.

I found an interesting article that compares cost of school and physician salary compared to inflation since 1970. Not saying it is the greatest article, but shows a nice concept of how things were a bit different back in the day.

Is It Better to Be a Doctor Now Than It Was 50 Years Ago? | Physician Sense

A lot has changed in medicine since 1970. This month, we're looking at how the financial picture for physicians differs from how it looked 50 years ago.

www.mdlinx.com

Ok, good point. I wish I could write a note that literally just read "Pain better with oxycodone. Wound looks good. Continue current plan."

I really wish I could pay 1970's prices (even adjusted for inflation) for med school