Is The Rehab Field Doomed To Failure?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
R

RehabRes

New Member
10+ Year Member
15+ Year Member
Joined
Aug 30, 2007
Messages
2
Reaction score
0
I'm a new PGY 2 on the West coast who has become somewhat let down by my newly chosen field and am curious about other's opinions.

First off, I'm having a difficult time understanding exactly what we do. If the patients are supposed to be stable when they come to our floor, then what exactly is the point of the physiatrist? The therpatist do ALL of the therapy. If the patients are not stable, then an internal medicine doc can easily handle the patients. They are far better at managing medical issues then we are. Post CVA, TBI, and SCI patients are not much different from floor patients. It appears to me that if the physiatrist were not there, there would be no remarkable difference in quality of care.

As for outpatient clinics, it seems like it is mostly filled with hot air, smoke and mirrors. Again, it's the therapists who handle the therapy and they know it much better than we do. We mainly reassure the patient to continue with rehab. On the other hand, the medical part that we handle can be better managed by any primary care doc. Botox can easily be injected by a neurologist, EMG's can be better completed by a neurologist since they have a better understanding of the nervous system. Non surgical orthopedics and sports medicine can easily be managed by orthopods and PCP's. Without a pain fellowship, which are mostly anesthesia based anyway, I can't see how the field can last. And these continue to become increasingly more difficult to obtain. I know that there is definitely a need for rehab, but probably not a physiatrist. Many hospitals don't even have rehab units and do just fine. That can easily become the trend. Let's not kid ourselves, we don't add much for the therapists. There is NO specialty that we specialize in. All of our patient's concerns can easily be managed by others. Plus, it seems that we only get patients that no one else wants. How can you survive that way?

Also, our research is dismal at best.

I apologize for sounding so bleak but I may end up quitting the field. Is anyone else going through this? Are you guys being honest? I hope someone can shed some light.
Members don't see this ad.
 
I'm a fourth year medical student in the middle of my second away elective in PM&R and I'm having the exact same doubts. I am in love with the IDEA of PM&R but I can't figure out what exactly we "do," especially in an in-patient setting.

And I don't mean the type of patients we treat, or how to define their pathologies, I mean, what exactly does a Physiatrist do on a day to day basis? Rounds consist of a heart and lung exam and a wound check on each patient, with a few questions about bowel habits and swallowing ability. If there's a serious problem, you can call a medicine consult. I find it hard to believe that a very well experienced OT or PT or PA couldn't handle the in-patient role of the "Physiatrist."

On the other hand, the outpatient clinics seem to make more sense to me. Sure, orthopedists CAN do what we're doing, but they don't. Their interest is "surgery or no surgery," whereas PM&R can find a precise diagnosis, and the method by which a PT/OT treats a patient with a skeletal disorder is significantly different than if the real problem is reactive myofascial pain disguised as skeletal pain. A neurosurgeon probably could do as complete a neurological exam as a neurologist, but I never saw that happen.

Again, I'm only a fourth year medical student and I don't know much at all about this field I'm about to apply for, but I am quite disenchanted with in-patient physiatry and it's need for existence. I'm even a little worried about the out-patient stuff secondary to the points well illustrated in the ops post. Hopefully, some of the long practicing physiatrists and residents that frequent this board will be kind enough to add their (honest) 2 cents.

Thanks.
 
my opinion - I think physiatrists are supposed to be like coaches. We want to get the patient back to the home setting from the hospital setting and our role is to remove obstacles to therapy (spasticity, pain, infections, etc.) and communicate with team members, families, and patients to help get the patient as functional as possible with the best quality of life as possible. My PD gives a lecture every year about the "physiatric exam" and physiatric approach to patients. We are so conditioned from our intern year to see a patient, come up with a differential diagnosis, do a work up to figure out the most correct diagnosis, then treat. In rehab, the diagnoses are usually already identified. Our goal is to know the various impairments and disabilities that come with specific diagnoses and coordinate their care while "treating" issues that come up during their rehab course. Many times, family members and patients have never had conversations about prognosis, how they will function once they are discharged from a healthcare setting, and what kind of help/modification they will need. We help with that.

You also say that post stroke, SCI, and TBI patients are not that different from floor patients. I have to disagree. When stroke or TBI patients are on the floor - if they are severe injuries/insults - they are usually sedated with a sitter and they don't get out of bed. We have to get those people out of bed and in therapy while dealing with their agitation, impulsivity, sleep-wake cycle disturbance, and other issues. Also, how many internists know about autonomic dysreflexia, how to deal with neurogenic bowel and bladder, and other issues specific to SCI patients?

In the outpatient setting, we are more within the conventional medicine model of diagnosing and treating. We are experts in neuromuscular problems and anatomy. I have to disagree that neurologist know the nervous system better. Neurologists have to do a fellowship in order to perform EMG/NCS. We do not. We can botox the right muscles for function because we know gait and kinesiology. We also understand ADL function and stuff like muscle synergy, etc. Sure, anyone can look at a spastic limb, assess the spasticity and botox it - but it doesn't mean it's the right thing to do. Many patients use their tone to function (transfers, etc.) so you wouldn't want to botox those muscles. Orthopods are looking to operate. We are non-surgical and want to exhaust conservative options before sending them to the surgeons. I think we do a very thorough history and physical exam and we try to understand where the pain/dysfunction is coming from and we also ask about function/quality of life more. What are the patients' goals and how realistic are they? And we also need to look for red flags and contraindications to therapy before we can send them to therapists.


That's just my 2cents I'm sure others will have more to say. Hope this helps.
 
Members don't see this ad :)
Rehabres,

I apologize for the length of this reply but your concerns hit me very personally. I have to tell you that I had the same feelings as a PGY2. I felt that I had been lied to and deceived about the specialty. I look back and realize how little I actually knew about my own field at that time. It's not that I did not know the types of patients and conditions we treated. I just did not have the experience to realize how much of that work is specific to only PMR. I have to agree with everything axm has said. While it is true that other specialties could do portions of what we do (maybe even as well as we do it), there is no other specialty that does ALL that we do as well as we do it.
PMR is ALL about FUNCTION. I have noticed that "function" has become a major buzzword in medicine and many specialties pay lip service to it. However, no matter what they claim, only PMR actually practices with that goal (functional improvment) as their focus. By utilizing our knowledge of gait, biomechanics, kinesiology, and anatomy, we are better able to assess dysfunction and make the appropriate changes in treatment to improve function. I realize that what I am writing sounds egocentric but I have had so many experiences to back up this assertion. Your concern, though, seems to be -what does that mean? It is next to impossible to clearly and succinctly define what we do without describing the patients and conditions we treat.
As for inpatient, I don't know what exposure you've had, but here at Frazier Rehab and Neuroscience (U of Louisville), we are encouraged to manage most, if not all, medical problems as an inpatient. I have no problem consulting other specialties if necessary but I feel very comfortable handling these problems. And there are many problems that occur on the rehab wards that are better handled by PMR (from my experience) such as spasticity/tone/spasms, autonomic dysreflexia (SCI), dysautonomia (TBI, MS, etc), hypothalamic storm, neurogenic bowel/bladder, TBI agitation/somlolence, as well as many others. On top of all that, there have been plenty of times I have diagnosed cervical myelopathy, missed fractures, sprains, strains, infections (pulm, urinary, skin, gi, etc) and started treatment. I have discovered that most patients have multiple un-diagnosed problems and I challenge myself on every patient to find them. We have a unique vantage-point to look over the whole field and see exactly what has been done and what is left to be done in the care of the patient. I now feel that I completely underestimated our specialty initially in my PGY2 year. And by the way, when I started residency, I expected to hate inpatient. Now, I love the complexity of the patients and the teamwork with the therapists, nurses, etc.
As for doing therapy, I never wanted to do therapy. But any PMR doc had better understand the various therapies performed and know which therapies should and should not be used on their patients based on medical stability/needs . Because in the end, it is your name as the Physician. Any thing goes wrong and it is on your head. If you write "PT to eval and treat", you are not practicing as a real PMR doc. Too often, we let others dictate to us what is best for our patients. As a rule, most PMR docs are laid-back and somewhat passive. It does not have to be this way. In PMR, we have to know (not perform) about all the therapies , modalities (indications and contraindications), medications, interventions (tone/spasticity, joint, bursa, spinal), wheelchairs, orthotics/prosthetics. PMR is not only about medicine. It's also about the holistic approach to the patient, his/her function, and his/her quality of life now and ten years from now.
As for Neurology knowing more about neuroanatomy, they MAY have a better grasp on the brain but PMR has a better understanding of spinal and peripheral neuroanatomy (my apologies to any Neurology lurkers). Here at Frazier, we do 8 months of EMG's on top of the weekly resident clinic EMG's.
We also are the primary MD for all SCI's. We are consulted upon admission to the acute care hospital.
Also, I can not begin to tell you how many times I've been told how much more thorough our (PMR) H&P's & consults are. I was speaking with one of the Anesthesiology Pain Attendings last week and he could not stop praising the PMR residents and their neurological and msk exam skills.
As for research, the field is wide open. The opportunities are there. This has not been the most academic of specialties in the past. But that is changing. Here, we have extensive SCI research ongoing right now with Dr. Susan Harkema and Dr. Scott Whittemore. We have ongoing research in pulm rehab with Dr. Judah Skolnick. It is truly exciting for me to be a part of this.
I hope that you have not completely given up on PMR. The field has an exciting future. Those who say otherwise do not really understand the breadth and depth of the field. I realize that the field IS changing and the focus is moving more to outpatient but the opportunities will always be there for whatever you choose to do within the field.
Having said all of the above (and I do apologize again for its length but it is a very familiar concern), you have to do what you feel is best for you in the end. Good luck.

Brian T.
PGY4 UofLouisville PMR
 
You're going through the natural stages of accepting the physiatry specialty: Anger, denial, regret, acceptance, and celebration.

At one time or another, every PM&R resident feels or felt your way. The trick is understanding that PM&R is wider than it is deep. It's sort of like being a "generalist-specialist."

I jokingly refer to physiatry as the Sienfeld of Medical Specialties---it's sort of the specialty about nothing. There's a lot of "humpty-dumpty medicine" in physiatry...all the King's horses and all the King's men couldn't put humpty together again so they got a PM&R consult.

Once you get a little more breadth you'll realize that physiatrists *DO* a lot of very useful things and they make a substantial contribution to patient care---it's just not a disease-model specialty.
 
HAHAHA. :laugh: love the "humpty-dumpty" drusso.

and bry22, that was an awesome post. even as someone who's very confident and happy with pm&r it's great hearing such a positive and inspirational post. thanks man.

i forget the original poster's name but i gotta tell you, i went thru that same questioning of my chosen profession when i got into chiropractic. i've always loved outpt msk medicine and kept thinking throughout my chiro training that "it's gonna click any day now and i'm gonna realize what it is i can do with this knowledge"...but it never came. i was always felt disappointed with what i could do as a chiro, but now find PMR to have all those missing aspects of msk medicine. hang in there for the rest of your pgy2 year and see if it "clicks" for you. but if it doesn't, get out. there's nothing worse then not loving your career. it may just not be for you. good luck.
 
I happened to be checking out this forum for a friend on aways. I am in a different field. As a DO, there is also very little research out there to prove osteopathic techniques, but the patients still keep coming. As the rates of obesity increase in America, you will have more and more people with chronic pain issues, heart attacks, and strokes. There are many studies that show how beneficial rehab is for MI and stroke. You will always have patients lining up at your doors, even if the research isn't there.
 
Thank you axm397, bry22, drusso, and dc2md. What you all have said is truly inspirational and I can feel the passion you have for the field in your words. I am and have been rotating at various rehab facilities over the last year as a medical student and I could not agree more with your opinions. Unfortunately there are still people within and out of PMR who doubt the future of rehab or are confused about the roles of rehab medicine. I believe I was one of them until I got to work with people who have passion for the field. rehab is such a dynamic field and like any other field you get what you put into it. And rehab is not just about function, its about the whole person. I feel like in my limited experience rehab doctors care more about the persons enviroment, social, mental, functional and medical well being than anyone else. I strongly believe that the role of a physiatrist can not be filled by anyone else and this field will get more and more essential as time goes on.
 
C'mon guys . . . as if I wasn't already almost too excited to function thinking about starting my PGY-2 in rehab medicine. 10 months . . . [sigh].
 
/\
/ | \
|
|


I didnt know Stiffler was a physiatrist!??!??!!
 
SSdoc33 said:
/\
/ | \
|
|


I didnt know Stiffler was a physiatrist!??!??!!
Click to expand...

I must know you . . . that was my nickname in college but haven't been called that in years.
 
RehabRes said:
Are you guys being honest?
Click to expand...
You know what? I'm tired of all this whiny crap. No, we are all a bunch of liars, who delude ourselves. Go ahead, quit the field. More work for those of us who feel what we do is worthwhile.

I have patients thank me for what I do every day, and I sleep just fine with the thought that I have helped someone, regardless whether you are having a crisis of confidence or not.

As for the dismal quality of research, interventional spine research is actually of a quite reasonable quality, and is getting better as the field grows and the funding is increased
 
Members don't see this ad :)
ampaphb said:
You know what? I'm tired of all this whiny crap. No, we are all a bunch of liars, who delude ourselves. Go ahead, quit the field. More work for those of us who feel what we do is worthwhile.

I have patients thank me for what I do every day, and I sleep just fine with the thought that I have helped someone, regardless whether you are having a crisis of confidence or not.

As for the dismal quality of research, interventional spine research is actually of a quite reasonable quality, and is getting better as the field grows and the funding is increased
Click to expand...

Nobody is accusing anyone of being a liar. I can't speak for the OP, but I can promise you that my concern is chiefly based on the fact that every PM&R resident and attending I've asked (and I've asked plenty) about what they do respond by telling me the type of patients that they see rather than telling me what they actually DO on a day to day basis.

This thread has been so helpful to me (and I hope to other MSIV's and other residents who are struggling with this question) because people have given concrete examples of things that they did (i.e. dealing with spasticity, being a "generalist-specialist" was a great explanation by drusso, in my opinion). I appreciate that you're upset by the constant questioning, but I think it might have been more constructive to offer some of your own examples of what you really do on a day to day basis.

From what I gather, the job of the physiatrist is to act as a GP for a specific subset of patients, i.e. those on an acute rehabilitation service. I never would have claimed to understand that without this thread's existence. Hopefully, I'm not wrong. Hopefully, that doesn't upset you, even more hopefully, you don't see this response as "whiny crap" for you to be "tired of."
 
A specialty with members who constantly need to explain what they do after 60 years of existence and with the clear inability to keep or develop subspecialty accredited programs is obviously doomed to failure.
 
paindefender said:
A specialty with members who constantly need to explain what they do after 60 years of existence and with the clear inability to keep or develop subspecialty accredited programs is obviously doomed to failure.
Click to expand...


And thats the truth! Its interesting that so many more of the "top" fellowship applicants are applying to anesthesia based pain programs. Obviously they realize the instability of the PM&R "pain/spine" or "sports/spine" fellowships. I guess you can consider this as further proof that the field may in fact be "doomed to failure." My advice to you prospective residency applicants...apply to anesthesia...if you are looking at all to do any kind of procedure-based pain management. You will wind up wanting to do the same thing that your anesthesia counterparts are obviously more qualified for at the end of a PM&R residency training program. You also will not have to go through all the pointless low maintenance inpatient and SCI/TBI which you wont end up using in the real world anyway. Im just throwing this out there. Im sure there are other current PM&R PGY4s out there who concur with me, but who will never admit it on a public forum like this one.
 
Dr. Ice said:
And thats the truth! Its interesting that so many more of the "top" fellowship applicants are applying to anesthesia based pain programs. Obviously they realize the instability of the PM&R "pain/spine" or "sports/spine" fellowships. I guess you can consider this as further proof that the field may in fact be "doomed to failure." My advice to you prospective residency applicants...apply to anesthesia...if you are looking at all to do any kind of procedure-based pain management. You will wind up wanting to do the same thing that your anesthesia counterparts are obviously more qualified for at the end of a PM&R residency training program. You also will not have to go through all the pointless low maintenance inpatient and SCI/TBI which you wont end up using in the real world anyway. Im just throwing this out there. Im sure there are other current PM&R PGY4s out there who concur with me, but who will never admit it on a public forum like this one.
Click to expand...

Prospective residents need to take any advice here with a grain of salt. It's well accepted that to really make money in pain management you need to buy into a facility. Lining up 50 ESIs/day without having to do pharmacological management, that ship has sailed. ASC reimbursements will be cut by 3-9% next year despite the efforts of ASIPP. Remember that it is expensive to buy into an ASC and that it takes several years to make your money back. Hmmm... just when everybody is predicting reimbursements will go through the floor. So, what if you go into anesthesia just to become a pain doc and this situation has come to pass. So, you decided to go back to the OR but realize that the situation with CRNAs has become extremely unfavorable? What if on top of that you don't like OR anesthesia. What if at that point universal health care has taken hold and cost-effective practice is in demand, but unfortunately, you don't have any MSK skills to fall back on?
 
For those becoming disillusioned with inpt rehab, you're right, most of what you do as a resident could probably be handled just fine by an internist with a little rehab CME.
On the other hand, there are many Physiatrists whose knowledge of practical rehab medicine goes far beyond what you will learn from the pocketpedia or Cuccurrullo. Unfortunately, PM&R residency training supports a model that is heavy on scut-work with teaching here and there. Those who really want to become experts do so through experience and self-education. One solution would be to make general inpt rehab as much of a subspecialty focus as Sports, pain, etc. Inpt Physiatrists would take on a supervisory role to midlevels, concerning themselves with particularly complex patients. Obviously, residency training would have to change to reflect this. Which would be cheaper, one medical director and some mid-levels or one medical director and 5 new-grad Physiatrists all paid 130-150K each? In the former approach, fewer positions would be available, but the value of each Physiatrist would be that much greater.

Regarding the outpt setting, sure, Anesthesiologists can do injections, Radiologists can read spine films, Surgeons can inject joints and Neurologists can do EMGs. As a Physiatrist, you should be able to do all these things (in addition to sifting through all possible diagnoses), and sometimes, a one-stop shop is what's best for the patient. Have you seen what happens to some patients with MSK injuries/chronic degenerative conditions? They get run through 3-5 specialists, are given 5 different diagnoses (what they really get is the complete differential, with each specialist picking his/her pet diagnosis as the patient's definitive diagnosis), get unnecessary diagnostic injections, get PT on an exercise bike (at some Occ-Med clinics), have 90 minute EMGs, etc. The timing of their treatment is all off and they end up with permanent disability, a chronic pain syndrome and never return to work.

As a Physiatrist your special knowledge is functional anatomy, whether of the brain, musculoskeletal system, etc. Ever wonder why all the PM&R spine guys are into ISIS and NASS, sometimes even more than PASSOR? What about APS? Not so much.

Surgeons will surgically correct structural lesions and physical therapists will find all kinds of secondary somatic dysfunction. What if the patient has shown no improvement? Does that mean it's time for opiates by default? Who is supposed to put it all together? You'd probably have to talk to someone like Ben Kibler to find a surgeon who is as "into" global biomechanics as the leading MSK Physiatrists.

With the emphasis on conserving healthcare dollars these days, Physiatrists could be the preferred choice for intial management of acute and sub-acute musculoskeletal injuries and degenerative conditions. I believe we are still the preferred choice in the inpt setting, but we need to re-affirm our role and again justify our existence, and the best way to do this is to demonstrate superior outcomes to Medicare and insurers, or at the very least, cost-effectiveness.

The fact that PM&R became an ABMS specialty some 60 years ago affirms our expertise in caring for those will disabilities. This got a lost somewhere along the way. In the past 15 years, the value of Physiatry in caring for those with non-surgical orthopedic conditions has been accepted. The next step is to become recognized as preferred providers.
 
A lot of people say that these message boards are not the greatest thing because there is a lot of misinformation on them. unfortunately, the last few posts have been full of a bunch of garbage. be careful not to disguise your opinions as facts, everyone.

ok, first of all, savealife, physiatrists are DEFINITELY NOT general practitioners for a specific subset of patients. in fact, that probably happens only a miniscule amount with SCI patients in an academic setting. any physiatrist who is practicing as a general practitioner is selling him/herself short and doing the specialty a disservice.

paindefender, you stated "with the clear inability to keep or develop subspecialty accredited programs". that is just simply untrue. PMR has lost a few of it ACGME accredited pain programs, but have developed new ACGME accredited fellowships in sports and neuromuscular medicine
and also have fellowships in peds, TBI, and SCI.

Dr. Ice, do you have any concrete evidence that the "top" applicants are applying to anesthesia, or is that just something you came up with yourself. a top "pain" applicant may be applying to anesthesia programs, but there is so much overlap with the sports/spine field that no one can make the claim that you did. pain / spine and sports / spine are not unstable. thats as far as the advice of "aplying to anesthesia

A few years ago, as was well documented in other threads, the AAPMR leadership decided to support more of the "interventional spine" angle than the ""pain" angle. news to everyone out there: people are still going to have back pain!! the pain / spine and sports / spine fellowships are not unstable. the passor programs have been there for ages and most are well-rooted. a few have lost their pain accreditation, but unstable? nope. as far as your advice to encourage applicants to apply for anesthesia? they should apply to whatever residency they like better. anesthesia is not purely pain medicine, just like PMR is not purely pain medicine. what you say is pointless time on the TBI/SCI ward, i would call pointless time in the OR while the patient is asleep.

what does a physiatrist do? 70% of recent graduates go into outpatient musculoskeletal medicine. that includes some non-operative orthopedics, pain management, interventional spine, EMG, and sports. the view of the field gets skewed by inpatient-heavy academic training centers. very simple.
 
Lost "a few" pain pain programs?? All of them with a couple of exceptions will dissappear after 2008. Sports accredited programs?? None of the PM&R fellowships is ACGME accredited. May want to try family practice if you want to become board certified is sports medicine. Neuromuscular Medicine, I see the neurologists taking over the control of the fellowships (remember, one fellowship by institution).
 
paindefender said:
Lost "a few" pain pain programs?? All of them with a couple of exceptions will dissappear after 2008.
Click to expand...
Remind me again, how many of the orthopaedic fellowships are accredited? Let me give you a hint - NONE of them. Accreditation is a nice extra, but is is hardly the be all and end all of what makes a fellowship excellent.

If you want to practice pain, by all means, go do inpatient acute pain, cancer pain, peds pain, etc, etc, etc in an accredited program.

If, on the other hand, you want to do what you will be doing in the real world, and oh by the way, not just be a technician, able to perform whatever the surgeon asked you to do, but rather evaluate the patient yourself, determine what is appropriate, and potentially think for yourself, rather than just travelling down the pre-determined algorythym, you might want to chose to develop those skills at the top notch, but unaccredited programs like Slipman's, Furman's, Prather's, RIC, UW, Windsor's, Colorado, Utah, Gerracci's, etc, etc, etc.

Baylor, MCV, UTSW, Rochester, UCLA ... the list is getting bigger, not smaller, from what I can tell. So unless you know something the rest of us don't, none of PM&R-based fellowships are going anywhere.
 
paindefender said:
A specialty with members who constantly need to explain what they do after 60 years of existence and with the clear inability to keep or develop subspecialty accredited programs is obviously doomed to failure.
Click to expand...

One of the things that I like about PM&R is that the residency itself sets you up well for a career (which seems to be increasingly uncommon in medicine), without the need to do fellowships/research/etc. In Surgery and other specialties, many people are finishing as PGY-9's in their middle/old age, after which I guess they have about 10-15 years of actual practice time left. I just don't see the value in that.

Unless you want to do Interventional Spine/Pain Management, there's no real need to do a fellowship in PM&R, and I see that as a good thing. :thumbup:
 
ok, first of all, savealife, physiatrists are DEFINITELY NOT general practitioners for a specific subset of patients. in fact, that probably happens only a miniscule amount with SCI patients in an academic setting. any physiatrist who is practicing as a general practitioner is selling him/herself short and doing the specialty a disservice.
Click to expand...


OK... so what is the difference in your opinion? I did not mean to state this as a fact, I meant to state it as the opinion of a fourth year medical student who has been on two separate month long rotations and found this to be the case (neither rotation did I do SCI by the way). I am DYING to have a real, clear-cut answer that proves this information wrong.

Thank you for your response.

and amphpb, I apologize for the inconsistency, though my next sentence in my post did say, "I can't speak for the OP..." either way, I wasn't questioning you as a liar, I am just a student starved for information in a field where, even after two month long rotations, I am hard pressed to find much at all.
 
Jay Smith, one of the smartest guys I have ever met in the field, spoke at the Annual Assembly resident's lunch a few years ago, defining what a physiatrist is (actually, the discussion was how he describes to his mother what it is we do).

His definitions suggested that we see the big picture, and have a broader scope.

Ultimately, he defined physiatrists as:
Experts in the comprehensive provision and orchestration of neuromusculskelletal medicine
​
 
Paindefender,

You appear to be either purposely "pushing buttons" or are ill-informed. Maybe a little of both? Are you a PMR-trained pain doc who never really liked anything about PMR or are you an anesthesiology-trained pain doc that is bitter because PMR docs are increasingly "invading your territory (pain)"? You seem bent on stating your opinions as facts seemingly to dissuade others from going into PMR.

"A specialty with members who constantly need to explain what they do after 60 years of existence and with the clear inability to keep or develop subspecialty accredited programs is obviously doomed to failure."

As stated earlier in the thread, PMR is not defined by one system or disease unlike most other specialties. And therefore, it's very difficult to define in one sentence. The "need to explain" what we do is merely a product of : 1) our specialty being based on function and quality of life (which begs further explanation), 2) small numbers and 3) lack of PR. It is certainly not based on need. We treat an extremely small percentage of people compared with most other inpatient-based physicians. Those patients who do eventually make it to inpt rehab may or may not even remember who you are. Many times, we introduce ourselves as "Dr. ------" but never explain that we are PMR specialists. And if they do remember you, it is as a "TBI doc" or a "SCI doc" or some other single-disease specialist. The other problem is that we, as a specialty, have never really attempted to educate the public on our specialty (until recently). However, I have explained the specialty to literally hundreds, if not thousands, of people (friends, family, patients, patients' families, colleagues, and strangers). And after each of those discussions (without fail), they tell me they wished they had known about the specialty earlier because of some medical problem that would have been better addressed by PMR in a "one-stop shop" rather than being bounced around to multiple specialists. To be clear, I am not making the claim that PMR is any better (or worse) than any other specialty. I am only stating that the need for PMR is definitely there but the PR/advertising/public education is not. We deal with a broad variety of diseases/illnesses/etc (on inpatient and outpatient settings) that otherwise may require multiple specialists.

As for your assertions that we can not maintain ACGME-accredited fellowship programs (specifically Pain, Sports, Neuromuscular), that simply is not true. I will concede that our RRC screwed us by agreeing to the "one program per sponsoring institution" guideline for Pain fellowships. There were bound to be some closures. However, I know of at least 2 and maybe 3 PMR programs in the process of applying for new Pain ACGME-accreditation. Also, it won't matter nearly as much in the future as Pain continues to become more "multidisciplinary" at academic centers. As for Sports programs, come on... The approval for accreditation was only given in Sept (?), 2006. Many programs are in the process of applying for accreditation. The same can be said for Neuromuscular. You may be right about the Neuromuscular programs, though, simply because of the residents' lack of interest. Most PMR residents don't feel the need to do a fellowship for EMG's since, during residency, we already get significantly more than the required number to sit for the Boards. And most residents are not interested enough in neuromuscular diseases to perform an extra year of training.

Also, you stated "remember, one fellowship by institution". Someone please correct me if I am wrong but I believe that the "one program per institution" rule was an agreement specific to PAIN between the RRC's of Anesth, PMR, Neuro, and Psych. This would then not apply to the other fellowship programs.

Paindefender, I hope I am wrong about your motives here. It is extremely difficult to determine motives on these forums. Hopefully, I misunderstood the "tone" of your replies. Or maybe you are just playing devil's advocate. If that is the case, I apologize. If not, then I don't. ;)

And for those of you who believe that anesthesiology training will better prepare you for pain --- I could not disagree more. Except for the political connection to the Anesthesiology Depts that run many of the pain programs (I do agree that this is a significant advantage at this time), there is no other advantage. I have heard that they are better with the needle. maybe, maybe not. To be sure, they are better initially with epidurals, IV's and intubations. However, we have plenty of training with needles performing specific localization of muscles for EMG's and botox, as well as the numerous peripheral joint injections and the many spinal/SIJ injections performed on the multiple months spent in the interventional spine or pain clinics. Certainly, our exposure to the above, our extensive experience with inpatient and outpatient pain medication management (majority of patients with pain control issues), our treatment of patients with disease of the facets, SIJ and spine, as well as our knowledge of the MSK and neurological systems, the specific therapies, the modalities, the electrodiagnostics, and imaging interpretation prepare us better for the multidisciplinary Pain Model. To be completely open, I am in the process of applying for pain fellowships myself. During this application/interview process, I have continuously had these assertions confirmed to me by many pain attendings (most of them anesth-trained).
I agree with the above-poster that PMR training prepares you well for either a broad-based practice or a specialized "niche" practice even without a fellowship. This is PMR's appeal to me. I also believe that it prepares you well for subspecialization in pain, sports and neuromuscular with an excellent foundation of knowledge and experience if that is your desire.
Not to mention, you can totally eradicate "immobilization syndrome".:D

Brian T.
PGY4, UofLouisville PMR
"Savin' lives, stampin' out disease... one immobilization syndrome at a time.":rolleyes:
 
  • Like
Reactions: 1 user
The problem with the whole "pain" thing is that for the vast majority of injecting Physiatrists, it's a misnomer. The only PM&R private practicioner that comes to mind that does the entire scope of out-pt pain management is Rob Windsor. I'm sure there are others, but he's the only one I can think of at the moment. Well, maybe Frank Falco and a few others. As far as the entire scope of in and outpt pain management, I can't think of a single person. Were the ABPMR to certify procedural training (separate from the "pain" certification), I'm pretty sure the vast majority of future Interventional Physiatrists wouldn't be rushing to Anesthesia programs.

Regarding EMGs, Physiatrists are no better or worse than our Neurology colleagues. If given a good history and access to a patient's imaging studies, I can usually do a uni/bilateral EMG for radic while screening for peripheral nerve entrapment in 20-30 minutes, just as I'm sure that many Neurologists can do a study for Guillan Barre while screening for AMAN/AMSAN variants much more quickly and efficiently than I.
 
Can we close this thread...sounds like a premed Md v Do thread now?


Disciple said:
The problem with the whole "pain" thing is that for the vast majority of injecting Physiatrists, it's a misnomer. The only PM&R private practicioner that comes to mind that does the entire scope of out-pt pain management is Rob Windsor. I'm sure there are others, but he's the only one I can think of at the moment. Well, maybe Frank Falco and a few others. As far as the entire scope of in and outpt pain management, I can't think of a single person. Were the ABPMR to certify procedural training (separate from the "pain" certification), I'm pretty sure the vast majority of future Interventional Physiatrists wouldn't be rushing to Anesthesia programs.

Regarding EMGs, Physiatrists are no better or worse than our Neurology colleagues. If given a good history and access to a patient's imaging studies, I can usually do a uni/bilateral EMG for radic while screening for peripheral nerve entrapment in 20-30 minutes, just as I'm sure that many Neurologists can do a study for Guillan Barre while screening for AMAN/AMSAN variants much more quickly and efficiently than I.
Click to expand...
 
drusso said:
...I'm hoping for another lecture on how to pronounce "fizz-e-at-rist." :laugh:
Click to expand...
Yah, making the name of our specialty unpronouncable is certain to make us more easily identified by the general population.

My other oldie but goodie is the limb/extremity distinction (now remember kiddies, only hands and feet are extremities)
 
Is it wrong that I abandon this convention and still say Fizz-eye-uh-trist? I just like it better and my dictionary shows both pronunciations.
 
"what the heck do a physiatrist really do? HONESTLY, what do I really do that cannot be better managed by internists with a little of bit of extra training on rehab?"[/QUOTE]

NOTHING
 
paindefender said:
"what the heck do a physiatrist really do? HONESTLY, what do I really do that cannot be better managed by internists with a little of bit of extra training on rehab?"
Click to expand...

NOTHING[/QUOTE]

You could probably say the same thing about Dermatologists. 95% of what they do (hand out propecia for hair loss, steroid creams for rashes, and cut out warts) could easily be done by a PCP. Why don't they do it? I don't know. :sleep:
 
Llenroc said:
NOTHING
Click to expand...

You could probably say the same thing about Dermatologists. 95% of what they do (hand out propecia for hair loss, steroid creams for rashes, and cut out warts) could easily be done by a PCP. Why don't they do it? I don't know. :sleep:[/QUOTE]

Most patients prefer to go to dermatogists for those problems. I don't hear patients asking for a physiatrist when they need rehab.
 
paindefender said:
Most patients prefer to go to dermatogists for those problems. I don't hear patients asking for a physiatrist when they need rehab.
Click to expand...

Well if other people are ordering rehab. for patients, then that's great. Honestly, most Physiatrists don't want to see cases like that. But if they are inpatient, whose going to supervise the rehab.? Also, there's a lot that physiatrists do that doesn't involve prescribing X amount of PT/OT for patients.

Personally, I think you're doomed to failure, just because you're a dumb shiat. I've never seen someone before with an axe to grind against Physiatrists.
 
stgeorge said:
a physiatrist will go around and see pts quickly, often missing important medical issues. in fact, often she'll miss even ulcers, which take only half a minute to check out, because of the "volume" of patients. many physiatrists do harm by being lazy and neglectful because most of inpatient rehab patients cannot move on their own. it's very sad.
Click to expand...

It's very sad that you obviously have a very limited understanding of PM&R and what a physiatrist does. I have not seen many physiatrists "rounding quickly". Most of my inpatient rehab rounds have been more on the "excruciatingly slow, long, and thorough" side.:laugh:

And when you say "most inpatient rehab patients cannot move on their own" - what do you mean? Patients have to be able to tolerate 3 hours of therapy to be in acute inpatient rehab - if they are not moving around, what are they doing? I have actually seen more pressure ulcers develop during acute hospital stay when people are sedated and mostly lying in bed than in rehab when they are out of bed and getting therapy. When you accuse a majority of a specialty of being "lazy and neglectful", it's not only offensive, it actually reflects on your character. We have enough people trying to attack us, pretend to be us, sue us, and pay us less - do we really need a med student accusing us of being "lazy and neglectful" and "causing harm"?

stgeorge said:
a physiatrist will earn more than a hundred thou, which will put him in upper middle class.
Click to expand...

most physicians earn more than "a hundred thou" - so what's the point?

stgeorge said:
a physiatrist will probably have enough time to spend with family and friends.
Click to expand...

is that a bad thing? :hardy:
 
To all the critics of our field, who are residents and who are medical students? How many rotations in the field have you done?
 
stgeorge, when you were agreeing with "rehabres", you automatically assumed that that post was from a male. yet, when disparaging a physiatrist, you automatically gave her a feminine role. whats going on? it is very clear that you have very poorly defined / inappropriate gender roles. your assignment of a negative role to a woman is an obvious sign of misogyny. however, your assignment of a positive role to a man could easily be a sign of.... well... you figure it out. not that there's anything wrong with that.....

plus, your posts are ridiculous and clearly trolling.
 
Just some random thoughts - I'm not even sure who they are directed towards:

To the I hate PM&R guy - Why is this so emotional for you? I never thought one physician could feel such negative feelings toward an entire specialty. Live and let live, just calm down, geez. Do you believe there is an entire specialty predicated on charging patients to make quick rounds, miss diagnoses, and add nothing of value? Who is taking care of the TBIs, spinal cords, and amputees coming back from Iraq? Yup, physiatrists. Oh, but they aren't important, I am sure just a few CME hours would cover the physiology of a spinal cord injury, just a few hours more for the TBIs, and what are amputations other than short limbs? I know I am not going to change your mind, so I have to give you a hard time, sorry.

To the unsure PM&R resident -read your personal statement again I am sure there was some reference as to why you wanted to do the specialty. Otherwise, you can always switch, I'm sure your still young.

In General - God forbid someone you know might require real rehabilitation, say I don't know, a brother with brain cancer as in my situation. You might appreciate physiatry when they help someone learn to function in their new limitations (relearn to walk, drive, eat, bathe, you know - ADLs). It also helps the family. And no, a rehab trained internist would not be "okay" for my family, the issues are more complex than that and you should only want the best when it comes to, well, general lifelong function of the person. It is crucial to quality of life, something easily overlooked at discharge. Yes, even though it won't bother you that the patient can't care for themself, it will bother them and end up costing a lot of extra $$$. In closing, I can say PM&R is important, and I hope you never have to understand why.

Thank you for your time.
 
paindefender said:
Most patients prefer to go to dermatogists for those problems. I don't hear patients asking for a physiatrist when they need rehab.
Click to expand...

Those in the know most certainly do. Most of the general public doesn't know what a Physiatrist is.

I thought we had been over this.
 
stgeorge said:
at work, however, she'll forever wonder,,, "what the heck does a physiatrist really do? HONESTLY, what do I really do that cannot be better managed by internists with a little of bit of extra training on rehab?"
Click to expand...

The fact is that Physiatry has been around for 60+ years and is only expanding, not dying out. This is obvious and I don't think anyone in the know would dispute it.

I somewhat regret making the Physiatrist or internist with some CME comparison.

What do Physiatrists do? Neurologists, Orthopedists, Neurosurgeons, etc. seem to know, but we still have trouble explaining this to most physicians and the general public. Were I to need treatment for myself or my family for the following conditions and had the option of being cared for by any physician I so desired:

Rehab of uncomplicated joint replacement/Deconditioning (internist with some CME or midlevel under supervision of a Physiatrist would be fine)

Rehab of Stroke/TBI (if I wanted any kind of meaningful life afterward, Physiatrist at a center with a strong residency program, specifically, strong inpt component. Also, one with some years of experience)

Rehab of Spinal Cord Injury (someone like a Dr. Kirschblum)

Non-operative management of degenerative spondylosis or acute disc herniation (Curtis Slipman)

Labral/Rotator Cuff Tear threatening a high level pitching career (repair by Jim Andrews or Lewis Yocum)

-If the lesion was non-operative and I wanted to avoid re-injury the next season or a dip in my performance, or even for post-op rehab (RIC or Michael Geraci's practice)

-difficult to control cancer pain syndrome or CRPS (MD Anderson, Cleveland Clinic pain centers)
 
Disciple said:
Non-operative management of degenerative spondylosis or acute disc herniation (Curtis Slipman)
Click to expand...
Boy, there are about 100 people whose names I would recommend before letting someone I cared about be treated by that arrogant SOB, especially now that he appears to be going through a mid-life crisis. Paul Dreyfuss, Nik Bogduk, and Jerome Schofferman immediately come to mind as being far superior choices
Disciple said:
Cancer pain
Click to expand...
Memorial Sloan Kettering
Disciple said:
CRPS
Click to expand...
Giancarlo Barolat, Josh Praeger, Rick North
 
Just illustrating a point.


Those are all fine choices as well.
 
Hello, I am a long-time viewer and first time poster. This thread has finally compelled me to register and start responding to some of these unbelievable posts. I am a 4th year resident in PM+R and I too have had some of these questions early in my residency. I have decided against fellowship and feel comfortable in many aspects of general PM+R. What I have realized throughout my training is that, very generally speaking, there are two types of PM+R physicians out in the world. There are the ones that love the field and continue to read and learn as much as possible about all the various aspects (or more specific aspects) of PM+R, and are not lazy, and are not unhappy, and are not questioning what it is they do or what it is they know. Then there are the PM+R docs that dont love the field but see it more as a job to make a decent living without really having to do much at all. They dont read, they dont learn, they do quick rounds at midnight and write two notes at a time (to cover themselves for two days) :laugh:... and they write PT orders as eval and treat 2x per week for 6 weeks Dx: leg pain. This field of ours is so vast that if you take the time to learn about what it is we know and all the things we can do you wont get bored and you'll do very well for yourselves mentally and monetarily. Can you think of any field of medicine without some overlap? No, there isnt any. Maybe Pathology is the closest to it. Can orthopods do joint injections... sure, can Neurologist perform EMGs... sure with a fellowship..., can an IM doc take care of many of the issues on an acute rehab unit... of course. But who can do all of the above and more? There is only one.
 
  • Like
Reactions: 1 users
Myofascist said:
There are the ones that love the field and continue to read and learn as much as possible about all the various aspects (or more specific aspects) of PM+R, and are not lazy, and are not unhappy, and are not questioning what it is they do or what it is they know.
Click to expand...
Wait, what about the *****s like me who love what they do, but question it all the time?
 
You must log in or register to reply here.
Next unread thread

Similar threads

D
Inpatient Acute Rehab Salaries?
Replies
14
Views
2K
redfish1891
R
R
Inpatient rehab under a consultant model
Replies
2
Views
1K
Iamnew2
I
P
Rehab coverage with clinic
Replies
1
Views
894
DMBandFan86
DMBandFan86
P
Moonlighting covering call at local rehab facilities
Replies
0
Views
619
paper_plates
P
M
Acute rehab billing- help
Replies
9
Views
1K
PMR’s chill
P
Top