PM&R is an ILL-DEFINED specialty. Although it has been around for more than 50 years, many leading hospitals don't have physiatrists on staff. If they do have them, they are there almost as an afterthought. Physiatrists are like relief pitchers put into the game when you are either 20 runs ahead or 20 runs behind. For the most part, physiatrists are tolerated, not respected by other physicians.
PM&R can be basically divided into inpatient and outpatient physiatry. Inpatient physiatry is NOT a growth area. This seems a little paradoxical given the aging population. However, the healthcare system is placing major emphasis on getting people out of hospitals as quickly as possible or keeping them out of hospitals altogether. The American Academy of PM&R has done a 180 degree turn in the past 5 or 6 years. In 1995 or 1996, the Academy commissioned a study (I think it was by the Lewin group) to look into the future of PM&R. The study concluded that the musculoskeletal area was NOT a growth area. However, in the past year or two, an update to that study says that muculoskeletal medicine IS the future of PM&R and that inpatient physiatry will shrink. Visit the Academy website at <a href="http://www.aapmr.org." target="_blank">www.aapmr.org.</a> Apparently, even the Academy doesn't know what its future is.
My gut feeling is that INPATIENT physiatry is dead. For a long time rehab hospitals had DRG exempt status. This has shielded them from some of the financial pressures general hospitals have been facing. This will soon change as Medicare alters the way that it looks at inpatient rehabilitation. Lengths of stay will probably get shorter. There has been speculation that rehab hospitals will be penalized financially if a patient is not discharged home but instead is discharged to an extended stay facility (nursing home). This will be done to hopefully stem the abuse by for-profit rehab hospital chains in admitting patients who are not appropriate for acute inpatient rehab. Some of these for-profit chains have their nonphysician administrators (often a speech therapist or physical therapist) make the medical decision as to who is an appropriate patient to admit to their rehab hospital. A PHYSIATRIST HAS NEVER SEEN THESE PATIENTS FOR AN INPATIENT CONSULT TO DETERMINE APPROPRIATENESS! It is a bad position for an ethical physician to be in.
Inpatient rehab can be classified as: 1) ACUTE- the patient can tolerate AND benefit (?require) from 3 hours of therapies per day. This is the MOST COSTLY inpatient rehab ~$1200 or more PER DAY. 2) SUBACUTE- less intense therapies, often in a skilled nursing facility at a cost ~$400 to $600 per day. 3) NURSING HOME- limited therapies and the least costly at ~$1200 PER WEEK.
It is easy to see why 3rd party payers prefer to send total knee and total hip patients to subacute facilities or nursing homes where they can get physical therapy only-NO PHYSIATRIST REQUIRED!
The elder statesmen and stateswomen who comprise the American Board of PM&R as well as the "leadership" of the American Academy of PM&R have been agonizingly slow to recognize the changes sweeping American medicine and to take corrective action. They remind me of the tired, old men of the former Soviet politburo who would vote as one even as their country was going down in flames.
Outpatient physiatry has some potential. BUT, YOU'VE GOT TO LOVE BACK PAIN. Physiatrists will often say they do "musculoskeletal" medicine. This USUALLY means low back pain and neck pain with a fair amount of "fibromyalgia." These are the bread and butter conditions of outpatient PM&R. Sports medicine is RARELY a big part of any physicians practice including orthopedic surgeons. It sounds glamorous but it is not the real world. As part of my training, I worked with an orthopedic surgeon for a major league baseball team. Contrary to popular belief, his practice was NOT mostly sports-related injuries. Sports medicine can be a PART of your practice but don't expect it to pay your bills.
A big challenge for OUTPATIENT physiatrists is WHERE they get their patients. Most people with muculoskeletal complaints see their primary care physician (internist or family practice) first. Almost always, if a consult is needed, they will be referred to orthopedic surgeons or rheumatologists, NOT TO PHYSIATRISTS.
Some physiatrists get around this by going to work for orthopedic surgeons. Do you know of any other physician specialtist who goes to work FOR another physician of a different specialty? Cardiologists don't generally work FOR cardiovascular surgeons. Many physiatrists apparently don't mind being ancillary help for orthopedic surgeons as long as the pay is good (and the pay is VERY good.) You get to do what the surgeons HATE to do,i.e. screen tons of back patients (many of whom are total crocks or crooks trying to cash in on secondary gain.) You also get to "manage" patients with failed back syndrome - they are the bane of every spine surgeon. Oh boy! Yipee! No wonder the orthopods "love" physiatrists. They let their "esteemed" physiatric serfs deal with workmen's comp claims, motor vehicle accident claims, etc. There was a physiatrist in MA whose practice was called THE MOTOR VEHICLE ACCIDENT CENTER - I'm not kidding. Another physiatric group told me that they get a significant number of referrals from personal injury lawyers. Physiatry has more than its share of sleazy characters.
If you like thinking and being challenged, consider neurology or rheumatology. If lifestyle during residency and practice is MOST important to you, then PM&R may be a consideration BUT I strongly suggest doing outpatient. Speak to as many physicians as possible not only in PM&R but in other specialties. Don't ask friends - they may not want to hurt your feelings or steer you too strongly. Spend time in several PM&R practices AWAY from the distorted view of academic medical centers. Follow physiatrists as they do nursing home rounds, hold team meetings, hold family conferences, see their 10th workmen's comp patient of the day,etc.
Above all, gather lots of information from as many sources as possible. Look at the classifieds in the back of ARCHIVES OF PM&R (a throwaway journal with articles written mostly by PT's and OT's.) Call some of the recruiters listed in the back of the journal. Learn to read between the lines. One recruiter told me bluntly that the jury is still out as to whether or not physiatrists and orthopods in the same practice will be a long term stable option. Check it out.
GOOD LUCK WHATEVER YOU DECIDE!
