Allergy vs PM&R

[pathanon]

Hey everyone,
I'm considering going into one of the aforementioned fields.In allergy I just love almost all the science behind it;in pm&r I'm primarily interested in msk,emg,Botox,sports med(I'm really into sports myself).So which one would you recommend in terms of:

• easy-ness of setting up a p.p
• Patient population(I've heard pain patients in pm&r are "difficult" compared to allergy ones)
• Lifestyle during and post residency

My concerns:Even though PM&R sounds great on paper I'm afraid I'll struggle financially as rehab patients don't self refer and you have to rely on whatever Ortho/Neuro sends your way.I've also heard mixed things about allergy how pcp,ent, pneumo,peds like to play allergists.

In your experience what kind of personalities does allergy vs PM&r attract?

Thank you for stopping by!

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[Grogu21]

How much do you like IM? Would you be willing to risk the possibility of Allergy not happening for whatever reason, and you end up as a PCP or hospitalist?

 

[pathanon]

How much do you like IM? Would you be willing to risk the possibility of Allergy not happening for whatever reason, and you end up as a PCP or hospitalist?

I know where you're getting at with this.It will definitely be a very tough pill to swallow(no offense to PCP's)

 

[mszzeta]

I know where you're getting at with this.It will definitely be a very tough pill to swallow(no offense to PCP's)

I am not sure how difficult it is to match Allergy (definitively easier than cardiology). But if you do have difficulty, you could do "primary care sports medicine fellowship" which will have a lot of overlap of MSK medicine with PMR

 

[NewYorkDoctors]

a lot of PCPs out there are doing skin allergy testing..... they take a course... they buy the testing supplies... they bill for the CPT codes...
if they get sued that's a whole other story... but PCPs can do allergy skin testing. just like how PCPs can do exercise stress ECGs and sigmoidoscopies (no really.. they can... they just don't do it anymore unless you're in the boonies due to low reimbursement and not having enough volume to make it worthwhile)

But back to the OP's question, consider PM&R as it is just overall easier to get into. of course if you are motivated (and have no geographical limitations - this is huge) to make connections and do some scholarly activity residency, then you can get into allergy without too much issue.

 

[sloh]

a lot of PCPs out there are doing skin allergy testing..... they take a course... they buy the testing supplies... they bill for the CPT codes...
if they get sued that's a whole other story... but PCPs can do allergy skin testing. just like how PCPs can do exercise stress ECGs and sigmoidoscopies (no really.. they can... they just don't do it anymore unless you're in the boonies due to low reimbursement and not having enough volume to make it worthwhile)

But back to the OP's question, consider PM&R as it is just overall easier to get into. of course if you are motivated (and have no geographical limitations - this is huge) to make connections and do some scholarly activity residency, then you can get into allergy without too much issue.

Do you think they are doing it to an extent that it would significantly impact allergy job prospects in desirable metros?

 

[NewYorkDoctors]

Do you think they are doing it to an extent that it would significantly impact allergy job prospects in desirable metros?

im not quite sure. ultimately these PMDs are just doing it to generate extra revenue. I do not begrudge them for doing that. Don't hate the player, hate the game. I mean ENTs also can do this (though they have formal residency training for this) and I doubt that is impacting what A&I providers do. At the end of the day isnt the A&I provider's big bread and butter desensitization shots? That cannot be replaced.

 

[DrRedstone]

im not quite sure. ultimately these PMDs are just doing it to generate extra revenue. I do not begrudge them for doing that. Don't hate the player, hate the game. I mean ENTs also can do this (though they have formal residency training for this) and I doubt that is impacting what A&I providers do. At the end of the day isnt the A&I provider's big bread and butter desensitization shots? That cannot be replaced.

Allergy shots are desensitization shots if I understand what you are trying to say. But AI does a lot more than just that. They definitely have the definitive training on understanding why they should do allergy shots. But the field is also responsible for asthma therapy for both adults and children (especially allergic and eosinophilic asthma and the biologic therapies for any phenotype), atopic dermatitis, mast cell disorders, drug allergy (including delabeling testing for antibiotics, chemotherapy, etc) , immunodeficiencies, vaccine development, and a lot of other things that I'm sure I haven't come across yet.

My recommendation for the OP is to apply for the Chrysalis Project or SPARK (AAAAI or ACAAI conference, respectively) to get a better idea of allergy as a specialty. Allergy is super cool.

 

[bronx43]

Allergy shots are desensitization shots if I understand what you are trying to say. But AI does a lot more than just that. They definitely have the definitive training on understanding why they should do allergy shots. But the field is also responsible for asthma therapy for both adults and children (especially allergic and eosinophilic asthma and the biologic therapies for any phenotype), atopic dermatitis, mast cell disorders, drug allergy (including delabeling testing for antibiotics, chemotherapy, etc) , immunodeficiencies, vaccine development, and a lot of other things that I'm sure I haven't come across yet.

My recommendation for the OP is to apply for the Chrysalis Project or SPARK (AAAAI or ACAAI conference, respectively) to get a better idea of allergy as a specialty. Allergy is super cool.

The vast majority of their job is allergic rhinitis. Pulmonary can treat asthma. Dermatologists treat eczema (not a whole lot to do). Immunodeficiencies are really rare, and it’s basically just ivig. Clinical allergists have zero input into vaccine development which are mostly done by phds.
bread and butter is mostly just testing and shots. Not sure what you mean by “why” do allergy shots. It’s honestly not that complex…

 

[hotsaws]

Pretty different fields. Not sure what your level of training is currently but this should be considered as well. On avg, it's going to be easier to match into PM&R than allergy. Allergy is relatively competitive and not particularly accepting of IMGs or DOs (vs say cardiology which is considered competitive but has a wide range of actualy competitiveness because matching to community hospital X is much different than Duke). Not trying to get into that whole debate but essentially it's not like its just a walk in the park. First you're going to need to do a residency in IM, peds, or med-peds and you're almost certainly going to have to do some research and be a good resident throughout that whole time. I don't know a ton about PM&R but you've pretty much got one match and it's not known to be competitive (unless you do a fellowship, then another match).

Do not go into a field because you "like the science behind it." Do it because you like the clinical practice. The science behind neuro is pretty cool but I'm not sure you could pay me enough money to actually see bread and butter neuro referrals all day. Most of us do not practice that much immunology and most A/I fellows go on to be clinicians, not researchers.

No idea what it's like to set up a PP in PM&R. In A/I, it's definitely possible. Pretty much every metro area I know of has a handful of young and old docs that practice solo or with maybe another doc (usually a few midlevels). I don't know that starting any business is "easy." You've got to have risk tolerance, finances, willingness to work your tail off, etc. but I'd say the barrier to entry for opening an A/I practice is quite easier than alot of other fields.

The patient population has to be one of the most appealing aspects of A/I. I work in the suburbs and pretty much treat your average healthy person. I do see a very small amount of adult medicaid (like less than 3-4 pts a week, by design) and I see a decent amount of pediatric medicaid (maybe half of my new pediatric patients). My patients are quite healthy and high functioning, not a lot of comorbid disease, most can and do easily follow treatment plans, and are not too high maintenance. I also can actually help most of the patients I see and make a substantial improvement in their QOL. Not alot of fields get this and not so sure you will see much of this in PM&R but I don't know alot about the day to day of it.

Lifestyle of an IM resident kinda sucks. Peds is pretty similar. Add the necessary research and a** kissing to get a fellowship and it only gets worse. Lifestyle of an A/I fellow is better in terms of hours but worse in terms of the amount of research and academic garbage you will need to do.

Personalities in all fields vary but there is definitely sort of a tribe to each one. Academics vs PP is pretty different personality wise as well. Academic A/I docs can be nerdy (and quite smug) but if you just looked at the headshots and bios of the docs in my practice, you could easily think you're looking at an ortho group. Probably like attracts like.

I'd encourage you to do some rotations and pay particular attention to how happy the docs are. Try and see some private practice in each field too, even if it's just shadowing.

Make sure you're ok treating the bread and butter of each field. Like if all I did was treat allergic rhinitis and asthma all day, I'd be perfectly content.

 

[Drrrrrr. Celty]

You're comparing the nerdiest of the IM subspecialties to the least nerdy of what still can be considered a non-surgical specialty.

Allergy is more competitive than Rheum, but less competitive than Hem/Onc and Cardiology. It's not an easy field to land into. But most people also aren't aiming for it because it is so frankly niche.

And that's the point. Most people aren't going into it because of the PP lifestyle. Rheum, Endo, Hem/Onc all have comparable PP lifestyle, though AI and Hem/Onc make more money than Rheum and Endo on average. People go into AI because they're pretty into the science and diseases. And I want to say a lot of AI ppl have PhDs and or stay in academics. Likely a far higher proportion than any of the former 3.

PMR by comparison isn't a medicine specialty. It's an intersection between neurology, orthopedics, trauma, and some primary care.

 

[dozitgetchahi]

You're comparing the nerdiest of the IM subspecialties to the least nerdy of what still can be considered a non-surgical specialty.

Allergy is more competitive than Rheum, but less competitive than Hem/Onc and Cardiology. It's not an easy field to land into. But most people also aren't aiming for it because it is so frankly niche.

And that's the point. Most people aren't going into it because of the PP lifestyle. Rheum, Endo, Hem/Onc all have comparable PP lifestyle, though AI and Hem/Onc make more money than Rheum and Endo on average. People go into AI because they're pretty into the science and diseases. And I want to say a lot of AI ppl have PhDs and or stay in academics. Likely a far higher proportion than any of the former 3.

PMR by comparison isn't a medicine specialty. It's an intersection between neurology, orthopedics, trauma, and some primary care.

Not sure I agree with some of these impressions.

IMO, the “nerdiest” specialty in IM is probably renal. That’s the only specialty where I’ve ever seen docs bust out paper and literally start working equations in front of me as a resident lol.

After renal, rheum, heme/onc, and ID are about equally “nerdy” at that point IMO. I guess you could throw A/I in there too, but at least on the PP side I get the impression that a lot of those folks are very lifestyle focused (which I 100% agree with). Out of any of the specialties mentioned above, I would bet dollars to donuts that the one with the highest % of MD/PHDs and academicians is heme/onc.

My understanding is that A/I used to be a lot more competitive than it is now, but for various reasons it has become less so.

I agree that the only similarity between these fields and PMR is lifestyle. In terms of day to day practice, they probably have very little in common otherwise.

 

[hotsaws]

The majority of A/I fellows go into private practice, about 25% stay in academics (many of these are just clinical educator type positions). Not sure how that compares percentage wise to other fields. The academics are always trying to retain fellows. PP pays quite a bit more than academics and the lifestyle is generally better. Most A/I docs do not have PhDs, I'd say that's more common in the academic A/I docs that are primarily immunologists. I agree with what was said above that Heme/onc docs seem to be the more MD/PhD heavy crowd.

I might be defensive but I don't think most A/I docs are on the nerdy side. We are for sure the crowd that is more lifestyle oriented and don't want to deal with any hospital or primary care stuff. Like we want a "job" that allows us to have an involved family life, work out, play golf/sports, hang out on nights and weekends, have hobbies, etc. I'd say we're pretty similar to the crowd in derm. The actual practice of A/I is not as "nerdy" as people seem to think. Most of us do not treat that much immunodeficiency in day-to-day practice and its very niche to be managing the rare genetic diseases requiring BMT and all that -- pretty much done only at large children's hospitals. The approach to the management of most things we see is actually quite practical rather than nuanced.

 

[Immunogoblin E]

Do you think they are doing it to an extent that it would significantly impact allergy job prospects in desirable metros?

A good chunk of A/I is opening up diets that have been restricted by false positives from PCP skin prick or blood testing. More PCP testing may end up with more business for A/I clinics in the area.

A/I and PM&R definitely sound like the same flavor of chillness. Only lived one life (A/I) so can't fairly compare to PM&R. In this forum, it's "other" IM specialties so there will be a bit of A/I selection bias without too many PM&R people speaking up.

• easy-ness of setting up a p.p - Relatively easy to set up compared to other specialties because you don't really need to be associated with a hospital. You just need a clinic. You can do challenges, skin prick testing, immunotherapy, whatever really anywhere. 99.9% of the time, reactions can be managed in the office with epinephrine and 0.01% you can just send them to the ED via ambulance. I imagine more patients get sent to the ED via ambulance from a PCP's office than allergy offices.
• Patient population(I've heard pain patients in pm&r are "difficult" compared to allergy ones) - Allergy patients can vary. Some are looking for relief (and you can offer relief to them), others sometimes fall into a role of "I'm allergic to everything" and may require a bit more effort. Immunology patients are really interesting (most don't have an immune deficiency), and the one's with real immunodeficiencies can be all types of zebras. The immunology patients can take more thought, work and effort without procedures so not the area to make money. If you're taking care of someone with a complex 1 in a million combined immunodeficiency, you may end up in a somewhat PCP role because other specialties may look to you for guidance/help in management (particularly autoimmune manifestations). Most A/I don't see them "Big A, little I," even more rare in private practice.
• Lifestyle during and post residency - Fellowship lifestyle was so much better than residency. Attending lifestyle is ideal, no real reasons ever to go in at night, weekends/hospital call can vary dependent on sites (but should be less than other specialties). Patients feel better so satisfying. Relatively low stakes compared to other specialties. Academics have to deal with the whole academics thing (lower salary, teaching roles), but may have less patients per day.