Reputation/rank of PM&R among other specialties

I've been surfing through the other forums here on SDN, specifically, Radiology, Derm, and Surgery, and I have to ask: where does PM&R rank among all the specialities of medicine? Don't get me wrong, I know this is what i want to do with my life (I'm an MS3) because musculoskeletal and neuological aspects of medicine are what interest me the most, and before I knew PM&R existed I was despondent because I did not find a single speciality which I could see myself really enjoying the rest of my life. But I am curious about this. I have heard all the rumors and half truths: that Rehab is for those with bad Boards Scores, those people who are lazy, that it's a field where you get no respect. Of course, this comes from those who get 2nd hand information and don't really care enough to check if it's true. I realize that PM&R is "below" the 3 specialties I listed, but for those who are practicing, what sorts of changes have you seen within the medical community over the past 5-10 years?

Depends on you definition of "rank" -

Reputation - the field may be the butt of jokes, but I feel we laugh last - if you were to calculate how much we make on an hourly basis, especially when you're doing EMG's, we rank much higher than most non-surgical fields. If you go mainly outpatient, there's no call. Even with inpatient work, call is from home, even in most residencies.

Prestige - pretty low, mainly because most docs have no clue what we do, if they even know we exist. For those who primarily work in hospitals, PM&R is seen as a dumping ground for no longer sick patients who need a baby-sitter. However, once they get to know you and see what you can do for patients, individual prstige can ge good.

Money - we make more than primary care, on average, and as above, much more per hour.

I work 8 am - 5 pm. I take off whenever I want. I do well financially. I have worked on building my practice so 90%+ of the patients I see are those I want to see, not those that no one else wants. Hence PM&R standing for "Pleasure, Money and Relaxation" can have truth to it.

PM&R's awareness is growing. As other docs realize what we do and what we can do, our field's reputation grows. We'll never be on par with surgeons, cardiologists and similar high-profile fields, and we'll always have to explain to everyone else - patients, docs, family, friends, what it is we do.

When I was in med school and intership, people talked about taking the "radi-holiday" and "derma-holiday", knowing they were cush rotations. No one even thought about taking a PM&R rotation. Our residency tends to be much easier than many fields, and we're plagued by a lack of awareness and understanding of our field. We all bitch about it and try to come with solutions. As long as you are contect to know what you do and that you'll have to explain it to others a lot, you can do very well.

The one area where everyone agrees we rank high - Lifestyle!

It sounds like the perception of PM&R being a lower prestige field continues to exist, even among practitioners...interesting. What I meant by rank was, among all the specialties, where would PM&R rank overall in terms of the total package, the prestige, rank, pay, lifestyle, all put together like was mentioned. It was interesting to see one of the radiology posters (I think ApacheIndian was their name) ranking "surgical subspecialities" in the middle of the pack. Though they diddnt specifically mention PM&R, it would fall under that sort of title. They also ranked IM, FP, and Psych at the bottom of the barrel, so to speak. Now, in the end chest thumping and bashing other specialties is a sign of arrogance/insecurity. Does the mixed nature of PM&R, meaning that boards scores are not the be-all/end-all, that the "total package" and personality are considered far more than would be in Derm or Rads, eliminate or downsize this sort of discussion?

I think PMR4MSK already covered it, but my perception is that people don't consider PMR highly because (que the broken record) they simply do not know the scope of a physiatrist.

Sure, the average board scores for PMR are lower, however that is largely due to the fact that it is such an unknown field. Most medical schools don't even have PMR rotations. When people don't know about it, they obviously won't apply to it, thus leaving spots open for those with lower board scores or for people to scramble in. I don't think this is the case any more as there is a gradual increase in awareness of PMR (at a snails-pace) which is attracting higher caliber candidates.

The field is so vast (Spinal Cord Inury, TBI, Musculoskeletal/Sports Injury, Pain Medicine, P/O) that I find the possibility to carve you're own niche very reachable.

Even after I heard about the field, I never really grasped what it was fully until I did a rotation. Try to get a global impression of it at your home program (this includes most of the facets of PMR I mentioned above). And also remember that medicine is always evolving and this is not different for PMR. Try to get a sense of what technologies are being developed that will perhaps shape the different facets of PMR (easier said than done.. I know). For example (I may be wrong), but I sense more MSK ultrasound diagnosis/procedures for those interested in sports/spine.

PMR is not without it's own faults and future obstacles, but you picked a bright field. Just look at how angry people are on the other forums!!! haha.. you won't find that aggression here, for the most part.

I've talked to some senior Anesthesiologists doing Pain medicine recently and 3/5 told me they would have considered going into PMR and doing either Pain or Sports/Spine if they could do it again. They were well-informed physicians of course. 😀

one thing i've noticed through my years of school, and now internship, is that people in medicine love to bash other areas of medicine. as you walk through the hospital on your rotations just listen to the types of things people say.

"medicine does all thinking and no doing"
"surgeons don't think, they just cut"
"can't believe those idiots in the er made us admit this guy"
"cardiology is so simple, blood goes in, blood goes out."

and so and so on. name any specialty, and i guarantee i've heard people bash it. if you listened to all that, you'd drop out of medicine altogether.

bottom line, pick something that you're going to be happy doing every day for the rest of your life. if that happens to be PMandR for you, then i'm sure you'll become a successful and respected physician.

philaPMR said:

one thing i've noticed through my years of school, and now internship, is that people in medicine love to bash other areas of medicine. as you walk through the hospital on your rotations just listen to the types of things people say.

"medicine does all thinking and no doing"
"surgeons don't think, they just cut"
"can't believe those idiots in the er made us admit this guy"
"cardiology is so simple, blood goes in, blood goes out."

and so and so on. name any specialty, and i guarantee i've heard people bash it. if you listened to all that, you'd drop out of medicine altogether.

bottom line, pick something that you're going to be happy doing every day for the rest of your life. if that happens to be PMandR for you, then i'm sure you'll become a successful and respected physician.

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Wisdom beyond his or her years. 👍

Don't come into this field if you need respect from other docs. However, when patients see you out in the community they often come over to tell you how much better they're functioning. The nice thing is our patents are more motivated. Folks usually don't care if they have HTN but many care if they can't perform ADL's.

No, I am not in need of the undying awe of other doctors. I just wanted to know how perceptions have changed toward PM&R, or even if they had at all. It's those ADL's that attract me to the field, because science wise it's what interests me the most, and it also allows me to make a difference which I will always want to learn more about for my knowledge and for my patients' benefit.

I break down the conversation into components- awareness and prestige

From an awareness standpoint, PM&R is low. We are not a small specialty- I think in the latest issue of the Physiatrist, it said we ranked #13 of 24 specialties in size, which would classify us as a mid-sized field.

However, in polling other specialists as to what a physiatrist does, the awareness is clearly pretty low. One recent poll, for example, showed that many primary care physicans are only aware of the inpatient scope of our practice. I interpret this to mean that they know physiatrists will take patients from their inpatient services into an acute rehab facility, but beyond that, are unaware of what we do.

Similarly, there are many physiatrists that are known on a national level, but they are not necessarily known as physiatrists. For example, I regularly pay attention when I hear mention of physiatrists in the media, and whether they mention they are a physiatrist. Oftentimes, that is not the case. The Wall Street Journal has referenced physiatrists over a dozen times in the past few years, but in none of the articles did they refer to the physician as a physiatrist. They would often use terms like "orthopedic specialist" or "sports medicine physician." There is a popular radio show in the NY area that is hosted by a physiatrist, but only occasionally notes that the physician is a physiatrist (BTW, I am by no means calling this doctor out. This is true of many specialtisits- Dr Dean Edell has a very popular radio show, and only rarely mentions that he is an opthalmologist by training).

This appears to be changing, though. For example, or XM Radio's ReachMD channel, they recently had an interview with Dr. Richard Harvey from RIC. He represented himself extraordinarily well, and mentioned clearly that he was a physiatrist. It made me very proud as a physiatrist to hear him mention this, and it was clear the radio host came away impressed. He should have- Dr. Harvey is an impressive guy.

Similarly, the AAPM&R has made this a stated initiative- to make people aware that what we do is physiatry, so that our field gets credited for our good deeds.

Ok, so that addresses the question of awareness, but what about prestige?

From a prestige standpoint, I would say PM&R is lacking. While it is certainly true that for many years PM&R attracted some sub-par physicians, I think the prestige is on some level associated with the lack of awareness. When physiatrists do a good job, the credit is often attributed to other fields, but when we do a poor job, other physicians may then become aware of who we are.

I also think there are some structural issues. For historical reasons, PM&R has not often exerted their influence on other fields, and have been somewhat subservient to other specialties. That is changing, however. For example, many spine centers are realizing the benefit of having a physiatrist as not an employee, but rather as a medical director. Physiatrists are starting to chair associations where they have only minority representation (e.g., the North American Spine Society).

There is also the issue of publication. While physiatrists certainly do publish in premier journals with a high impact factor like JAMA, NEJM, and MSSE, they still do not do so to the extent of some other fields. Much of that has to do with industry support- we simply do not use expensive patented medications and DMEs to the extent of some other industries, so there are fewer physiatrists who have independent and dependable funding sources.

So, what does this all mean for the burgeoning physiatrist in medical school who is deciding what they want to do with the rest of their life? It's not a great field for ego gratification, and you will have to be explaining to friends, family members, physician colleagues, and patients what exactly you do.

But..... I see this as a great opportunity. For example, today I was doing some spinal injections at a local facility that is also used by other spine specialists from other specialties. Since I was training my resident, we were working at a slower pace and I had more time to talk to the nurses and radiology techs about what we do. I think they came away impressed about how physiatrists take a more comprehensive approach to the spine and that we are "not just about the needle." I happen to love educational opportunities like that, so if that is something you enjoy, then being a physiatrist is a great opportunity.

PMR 4 MSK said:

Depends on you definition of "rank" -

Reputation - the field may be the butt of jokes, but I feel we laugh last - if you were to calculate how much we make on an hourly basis, especially when you're doing EMG's, we rank much higher than most non-surgical fields. If you go mainly outpatient, there's no call. Even with inpatient work, call is from home, even in most residencies.

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Right on. I am pretty smug about my finding the perfect specialty.

Listen, I WANT PM&R to remain under the radar. I don't want it to be perceived as prestigious. This specialty is SWEET and I don't want no competition!

More physiatrists means less business for me. More physiatrists means more competition for jobs and less bargaining power when negotiating contracts.

Ligament said:

Listen, I WANT PM&R to remain under the radar. I don't want it to be perceived as prestigious. This specialty is SWEET and I don't want no competition!

More physiatrists means less business for me. More physiatrists means more competition for jobs and less bargaining power when negotiating contracts.

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It's our little secret.

Let me ask you all then: with the continued general lack of awareness for PM&R, how do you feel about the candidates that come into the field? Would you prefer more people who come in, who could be better doctors but might be in the field for the wrong reasons (lifestyle)? Or do you like the lower amount of candidates, who might come in because of interest/statistics preventing them from going into their true field of choice? Or is that stuff usually weeded out by interviews?

SportsMed09 said:

Let me ask you all then: with the continued general lack of awareness for PM&R, how do you feel about the candidates that come into the field? Would you prefer more people who come in, who could be better doctors but might be in the field for the wrong reasons (lifestyle)? Or do you like the lower amount of candidates, who might come in because of interest/statistics preventing them from going into their true field of choice? Or is that stuff usually weeded out by interviews?

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I am not sure if I understand your second choice. Are you lumping together people that enter because of a true interest for PM&R and those that just couldn't become orthopedic surgeons or dermatologists? If you are not including those that are just interested in PM&R then are you saying that people only enter PM&R for lifestyle or as a back-up to more competitive specialties?

I would say that if you got into med school, made it through med school and matched at a residency then you will most likely (not always) be a good doc. If you are not interested in a specialty then it is unlikely that lifestyle alone will keep you in that specialty.

I like the way it is now. I don't want PM&R to become another dermatology.

What we need is a good mixture.

PM&R has always been able to attract (without much effort) touchy feely types who are good with patients/families.

However, you need some driven academics (dare I say gunners) thrown in to help advance the the field scientifically and politically. So, we need to make an effort to appeal to them as well. Unfortunately, that is often most effectively accomplished through expectations of lifestyle, prestige, earning potential, etc.



We want to move forward, not back to the way things were.

Can you elaborate a little more on the way things were and the way you would like to see the field head in the future?

Disciple said:

What we need is a good mixture.

PM&R has always been able to attract (without much effort) touchy feely types who are good with patients/families.

However, you need some driven academics (dare I say gunners) thrown in to help advance the the field scientifically and politically. So, we need to make an effort to appeal to them as well. Unfortunately, that is often most effectively accomplished through expectations of lifestyle, prestige, earning potential, etc.



We want to move forward, not back to the way things were.

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👍 Good stuff.

I'm also curious as to what is meant by "the way things were". We med students (and maybe some residents) wouldn't mind a history lesson.

Since its inception, Physiatry has toiled along in obscurity, albeit while helping a lot of patients along the way. The personality types typically suited for, and effective in this line of work were not those that tend to be involved in the politics of medicine and those that perhaps have a less aggressive, er, assertive personality. In those times physicians from other medical specialties who could recognize the services of Physiatrists were likely Internists, Neurologists and Orthopedic/Neurosurgeons, and only as these services related to the inpatient setting. Nobody knew what a Physiatrist was (still a problem) and outpt services were basically for f/u care from the inpt service.

The establishment of non-operative orthopedic care in Physiatry in the 90's began to attract a different type of Physiatrist to the field, and many of the pioneers of this movement have played a large part in the growing influence of the field you are now witnessing. There has been steady growth, but as you've seen, if not fed by an inpt service, outpt referrals still flow through Ortho/Neurosurg/Neurology/Occ Med or go through "pain management" (a more recognizable classification to PCPs in the standard American medicine referral algorithm).

The most competitive specialties draw the best and the brightest for 4 main reasons, 1 of the 4 being genuine interest in the specialty. Does Physiatry need "the best and the brightest"? Of course we do, unless we want to go back to the pre-90s era. Medicine gets tougher and more competitive every day, and now is not the time to be inactive about the issues. A small specialty made primarily of "passive" personalities is not going to have a loud voice. Does that mean we should abandon the values that have shaped the specialty for the past 50+ years? Of course not. I agree with what's been stated above. The holistic approach and focus on functional anatomy is what separates Physiatrists from being Physicians with superficial training in a bunch of different specialties. At the same time, we need to put political correctness aside, to a certain degree, for the continued growth/advancement of the specialty. We need to accept and come to terms with reasons 1-3. There is no need to apologize for the fact that we are compensated relatively well and have good lifestyles. Plenty of Money and Relaxation may be a joke, but on whom?

This has been mentioned previously, but in a recent issue of "the Physiatrist" (AAPMR newsletter), Dr. Braddom makes it a point that we should shoot for a goal of matching 50% AOA medical students within the next ten years. We all know what it would take to accomplish that. Why set a goal like that if we're not ready to do what's necessary to reach it? Unless his statement was a joke as well.

Physiatry has been gaining momentum for some 15 years. I see no reason to stop now.

IMO, we can certainly continue to move the specialty forward without abandoning the tenets on which the specialty was founded.

"All things in moderation" and "Honesty" are the best policies here.

Disciple said:

Since its inception, Physiatry has toiled along in obscurity, albeit while helping a lot of patients along the way. The personality types typically suited for, and effective in this line of work were not those that tend to be involved in the politics of medicine and those that perhaps have a less aggressive, er, assertive personality. In those times physicians from other medical specialties who could recognize the services of Physiatrists were likely Internists, Neurologists and Orthopedic/Neurosurgeons, and only as these services related to the inpatient setting. Nobody knew what a Physiatrist was (still a problem) and outpt services were basically for f/u care from the inpt service.

The establishment of non-operative orthopedic care in Physiatry in the 90's began to attract a different type of Physiatrist to the field, and many of the pioneers of this movement have played a large part in the growing influence of the field you are now witnessing. There has been steady growth, but as you've seen, if not fed by an inpt service, outpt referrals still flow through Ortho/Neurosurg/Neurology/Occ Med or go through "pain management" (a more recognizable classification to PCPs in the standard American medicine referral algorithm).

The most competitive specialties draw the best and the brightest for 4 main reasons, 1 of the 4 being genuine interest in the specialty. Does Physiatry need "the best and the brightest"? Of course we do, unless we want to go back to the pre-90s era. Medicine gets tougher and more competitive every day, and now is not the time to be inactive about the issues. A small specialty made primarily of "passive" personalities is not going to have a loud voice. Does that mean we should abandon the values that have shaped the specialty for the past 50+ years? Of course not. I agree with what's been stated above. The holistic approach and focus on functional anatomy is what separates Physiatrists from being Physicians with superficial training in a bunch of different specialties. At the same time, we need to put political correctness aside, to a certain degree, for the continued growth/advancement of the specialty. We need to accept and come to terms with reasons 1-3. There is no need to apologize for the fact that we are compensated relatively well and have good lifestyles. Plenty or Money and Relaxation may be a joke, but on whom?

This has been mentioned previously, but in a recent issue of "the Physiatrist" (AAPMR newsletter), Dr. Braddom makes it a point that we should shoot for a goal of matching 50% AOA medical students within the next ten years. We all know what it would take to accomplish that. Why set a goal like that if we're not ready to do what's necessary to reach it? Unless his statement was a joke as well.

Physiatry has been gaining momentum for some 15 years. I see no reason to stop now.

IMO, we can certainly continue to move the specialty forward without abandoning the tenets on which the specialty was founded.

"All things in moderation" and "Honesty" are the best policies here.

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.

Who are those "pioneers" who brought about the non-operative ortho care into Physiatry?

Does even derm have 50% AOA?

I think in the article he listed Derm as #1 at 47%.

So, he was basically saying that we should try to surpass Derm.



Yeah,


like that's ever gonna happen.

SportsMed09 said:

Who are those "pioneers" who brought about the non-operative ortho care into Physiatry?

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Partial list

http://www.aapmr.org/passor/member/passcharter.htm