4th Year Medical Student: Questions about PM&R

[Socoli]

Hi everyone,

I'm strongly considering applying to PM&R, however, I've got some questions about the field that no one has been able to answer as I've mainly had inpatient exposure. I was hoping that some of you can help me out and provide some insight. If not, no worries. Thanks everyone

1. What do you think the future of outpatient care, specifically MSK, will look like?

A little while ago I was at a pain clinic where one doctor sees 60 patients daily. Honestly, it looks exhausting as 90% of the time they’re looking at their computer screen and not even talking to the patient. It’s disheartening because it feels like these doctors are experiencing indentured servitude to these insurance companies, which leads me to my next question.

2. How can I avoid being a “slave” to insurance companies? Is there any way a possible cash-based model in the outpatient world would be possible?

3. Regarding entrepreneurship, how realistic is it, time-wise and with Stark's law, to be an entrepreneur in this field if you’re doing either inpatient or outpatient?

4. Possibly a redundant question but how does your training location make you more or less better suited as a physiatrist? I only ask because each program has the same requirements for ACGME approval. So I was curious as to why some residencies are outpatient focused whereas some are inpatient focused.

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[j4pac]

Hi everyone,

I'm strongly considering applying to PM&R, however, I've got some questions about the field that no one has been able to answer as I've mainly had inpatient exposure. I was hoping that some of you can help me out and provide some insight. If not, no worries. Thanks everyone

1. What do you think the future of outpatient care, specifically MSK, will look like?

A little while ago I was at a pain clinic where one doctor sees 60 patients daily. Honestly, it looks exhausting as 90% of the time they’re looking at their computer screen and not even talking to the patient. It’s disheartening because it feels like these doctors are experiencing indentured servitude to these insurance companies, which leads me to my next question.

2. How can I avoid being a “slave” to insurance companies? Is there any way a possible cash-based model in the outpatient world would be possible?

3. Regarding entrepreneurship, how realistic is it, time-wise and with Stark's law, to be an entrepreneur in this field if you’re doing either inpatient or outpatient?

4. Possibly a redundant question but how does your training location make you more or less better suited as a physiatrist? I only ask because each program has the same requirements for ACGME approval. So I was curious as to why some residencies are outpatient focused whereas some are inpatient focused.

1. Not every pain management doctor sees 60 patients a day. Obviously, the more patients you see, the more you make. They aren’t indentured servants…they are choosing to make more money.

2. Cash pay practices are very challenging as a physician. You have to market yourself in a way that makes people willing to come out of pocket. Regen is en vogue. I know some that have been able to setup housecall type services. I’ve seen some tele health companies that only take cash but the legitimacy is always a bit sketchy. You could do medispa and Botox for reasons other than spasticity. Truth is that I have enough expertise with Botox that I could probably set up a cash pay Botox practice if I wanted to (which I don’t).

3. You can be an entrepreneur…and just like any small business there is considerable risk-reward. I’ve known a few that have setup their own practices that are doing well. Lots of potential in the SNF realm as an independent contractor these days.

4. The residency is often a reflection of the department on the whole. For example, Mayo Rochester is essentially the birthplace of EMG and MSK ultrasound. So of course the outpatient exposure will be exceptional. Meanwhile, Kessler has one of the strongest inpatient rehab hospitals in a country, especially at SCI…so of course that will be a strength. Every place tries to be balanced, but you can only work with what you’re given.

 

[Slowpoke]

Hi everyone,

I'm strongly considering applying to PM&R, however, I've got some questions about the field that no one has been able to answer as I've mainly had inpatient exposure. I was hoping that some of you can help me out and provide some insight. If not, no worries. Thanks everyone

1. What do you think the future of outpatient care, specifically MSK, will look like?

A little while ago I was at a pain clinic where one doctor sees 60 patients daily. Honestly, it looks exhausting as 90% of the time they’re looking at their computer screen and not even talking to the patient. It’s disheartening because it feels like these doctors are experiencing indentured servitude to these insurance companies, which leads me to my next question.

2. How can I avoid being a “slave” to insurance companies? Is there any way a possible cash-based model in the outpatient world would be possible?

3. Regarding entrepreneurship, how realistic is it, time-wise and with Stark's law, to be an entrepreneur in this field if you’re doing either inpatient or outpatient?

4. Possibly a redundant question but how does your training location make you more or less better suited as a physiatrist? I only ask because each program has the same requirements for ACGME approval. So I was curious as to why some residencies are outpatient focused whereas some are inpatient focused.

1. People will always have degenerative joints. Outpatient MSK care will remain. Innovations continue to be in the pipeline -- newer biologics, higher def ultrasounds, regenerative stuff etc. Also, you can choose how much you want to work as an attending. The doctor who decides to see 60 patients a day is a doctor who is trying to make $$$ and if they looked miserable, they're doing it to themselves.

2. Insurance companies are the payer. You'll likely need to appease the payor to get your $. This is the same across the board for every field except maybe heavy out of pocket practices (medical boutiques, derm/plastics etc.) and large HMO groups who are the insurance company and the provider (eg Kaiser Permenante)

3. Defer to another person

4. Pick the program that is a best fit for you. Based off of what you wrote, an outpatient MSK heavy exposure with a strong name (think ivy league) for marketing purposes as an entrepreneur.

 

[RangerBob]

60 patients a day? Ouch...

Looking at the computer while seeing patients is often an unfortunate reality in outpt medicine in any specialty, particularly if you don't want to be working on notes until midnight.

That alone would be reason enough for me to work at the VA (which I enjoy), as the patient visits are long enough you could look your patient in the eyes while you talk to them and after they leave type of a brief note before the next patient's scheduled appointment. We usually saw 8 patients per half day if they were follow-ups, so 16/day.

Working at the VA solves the work-life balance issue and "slave to insurance company" issues.

It does substitute "slave to government bureaucracy" as a new issue though. But at least the government bureaucracy actually cares about its patients unlike the insurance companies, so I always felt it was easier to put up with because of that

 

[DMBandFan86]

There is no rule that you have to see 60 patients per day. Which is largely unattainable even for pain docs, unless you have residents/mid levels/scribes.

Sounds like a seasoned doc that you shadowed. Probably makes over 1 million a year. But really interventional pain is fairly straightforward, either inject or not. The patients can draw their pain on a map and you can determine where to inject. Many are not waisting their time with hard to deal patients or complex medication management. If you want to see 60 patients per day there is no time for chitchat.

But pain is not MSK. General outpatient PMR MSK can be quite different. Just depends how you set your practice up.

Yes you can do cash based. But no one is going to pay cash to you unless you have a great reputation or offer something insurance won’t pay for. Especially just coming out of training. But I’m not a slave to insurance companies. They offer you a payment for service, and the more people you see the more you make. That’s the same concept of taking cash. You need to take location into strong consideration if opening a cash business.

I don’t understand your question about Stark laws.

Training programs just evolve overtime by the facilities and faculty they have. I trained at a heavy inpatient program and developed basically no functional U/S skills and our sports doc was a piece of work. But we had a great pain program. But I like inpatient and had strong interest in pain. Just interview, talk to residents and decide where you want to go. For most, it is a natural process to find where you want to go most.

 

[PhyzPhyz]

There is no rule that you have to see 60 patients per day. Which is largely unattainable even for pain docs, unless you have residents/mid levels/scribes.

Sounds like a seasoned doc that you shadowed. Probably makes over 1 million a year. But really interventional pain is fairly straightforward, either inject or not. The patients can draw their pain on a map and you can determine where to inject. Many are not waisting their time with hard to deal patients or complex medication management. If you want to see 60 patients per day there is no time for chitchat.

But pain is not MSK. General outpatient PMR MSK can be quite different. Just depends how you set your practice up.

Yes you can do cash based. But no one is going to pay cash to you unless you have a great reputation or offer something insurance won’t pay for. Especially just coming out of training. But I’m not a slave to insurance companies. They offer you a payment for service, and the more people you see the more you make. That’s the same concept of taking cash. You need to take location into strong consideration if opening a cash business.

I don’t understand your question about Stark laws.

Training programs just evolve overtime by the facilities and faculty they have. I trained at a heavy inpatient program and developed basically no functional U/S skills and our sports doc was a piece of work. But we had a great pain program. But I like inpatient and had strong interest in pain. Just interview, talk to residents and decide where you want to go. For most, it is a natural process to find where you want to go most.

Did you do a fellowship?

 

[DMBandFan86]

No I did not.