D
deleted1082647
Last edited by a moderator:
- Joined
- Jul 21, 2016
- Messages
- 108
- Reaction score
- 232
Have you thought about just sticking it out through PM&R residency and then doing a palliative fellowship afterward? You could focus on communication and connecting with patients and leave MSK behind you. Might be a nice middle ground if switching completely isn't in the cards
- Joined
- Sep 15, 2008
- Messages
- 1,778
- Reaction score
- 114
The parts of PM&R that attracted to you into the field sound less robust of an exposure in your program. Unfortunately, PM&R is such a broad field that many of us end up slugging through parts of the training. For instance, I dread inpatient rehabilitation and have considered quitting/switching myself. Thankfully, there are parts of PM&R that are enjoyable to me -- as such I decided to stick to it. Have you had any Neuro rehab-based rotations yet?
- Joined
- Jul 28, 2014
- Messages
- 179
- Reaction score
- 57
I would stick it out. My program is opposite of yours and very focused on neurorehab/inpatient. There were times where I considered switching specialties as well, particularly during rotations like SCI and peds. The job market is also way stronger for inpatient as opposed to outpatient msk/sports so as long as you graduate residency you will be fine.
- Joined
- Aug 22, 2005
- Messages
- 3,041
- Reaction score
- 3,242
If you hate MSK...I’d switch to Psych. Certainly, not everyone practices heavy MSK after residency but just about all of our patients have MSK issues.
- Joined
- Feb 24, 2010
- Messages
- 3,032
- Reaction score
- 6,173
If you stick with PM&R, you might want to do an elective with Cleveland or Mayo in their Chronic Pain Rehab programs. Heavy psych element. Could be just the blend to maximize your PM&R background and Psychiatry interests. Cleveland has a Pain Management fellowship and they are probably still looking for folks to stick around and run the chronic pain rehab program, as most pain folks, even the Psychiatry folks aren't wanting to do it.
- Joined
- Sep 16, 2012
- Messages
- 2,212
- Reaction score
- 3,241
I was in your shoes. I was set on psych as a med student and then found out about PM&R. I really enjoyed the interdisciplinary/team aspect or rehab. I do like some MSK, but I really disliked sports, interventional pain, and EMG. Basically what I really liked was inpatient, and the more counseling-heavy MSK stuff (chronic pain clinics, and VA MSK where appointments are longer and there’s time for counseling). I hate, hated my 15 min per patient sports clinic.
I thought about switching to psych. A few times actually-mostly in my PGY3 (outpatient-heavy) year. Most PM&R residents dislike inpatient and debate switching in their PGY2 year if it’s all/mostly inpatient, as many still are. I was one of the oddballs that liked inpatient.
Here’s what I can tell you honestly: I’ll probably always wonder “what if” I’d gone into psych. But I also still wonder if I bought the right car or right house. Like you, I found psych concepts much easier to learn. But that doesn’t mean it was the better specialty for me. When I really sat down and thought about it, I found myself smiling more on my inpatient rehab rotations than any psych rotation—seeing my recovering brain injury patients make remarkable gains, helping SCI patients cope/adjust to their disability. There’s plenty of space for counseling in PM&R.
When I thought about it more, I realized I had zero interest in the really heavy stuff (schizophrenia, mania, etc) that would let me work in a team (ie, inpatient) environment, and I thought I’d be lonely and bored running an outpatient clinic. I can’t imagine spending most/all of my workday just talking with patients and no colleagues. The few outpatient team-focused psych gigs just sounded too disjointed. Maybe addiction psych could be interesting, but literally every addiction psych doc I worked with was burnt out and jaded and that told me to run the other way. That and enjoying my brain injury and SCI rotations are what flipped me from psych to rehab. I just didn’t see a happy future for me in psych, and I saw onE in rehab.
I talk to my RNs, therapists, managers, etc all the time on our rehab unit. It’s really not just about the pathology—it’s the environment I enjoy. I really don’t care about patient pathology-I care more about the patient themselves and the people I work with-that’s what makes my day fun. That’s why I don’t get bored with my 300th stroke rehab patient either.
With all that said, you’re talking about the rest of your life. If psych is really where you’re going to be the happiest, then switch now and don’t look back. But really reflect deeply on where you want to be in five years and what will make you happy. PM&R is a great and broad field and there’s plenty of space for you if MSK isn’t your thing. There are also lots of great (and not-so-great) things about psych, so reflect on whether you really see yourself happier there.
I thought about switching to psych. A few times actually-mostly in my PGY3 (outpatient-heavy) year. Most PM&R residents dislike inpatient and debate switching in their PGY2 year if it’s all/mostly inpatient, as many still are. I was one of the oddballs that liked inpatient.
Here’s what I can tell you honestly: I’ll probably always wonder “what if” I’d gone into psych. But I also still wonder if I bought the right car or right house. Like you, I found psych concepts much easier to learn. But that doesn’t mean it was the better specialty for me. When I really sat down and thought about it, I found myself smiling more on my inpatient rehab rotations than any psych rotation—seeing my recovering brain injury patients make remarkable gains, helping SCI patients cope/adjust to their disability. There’s plenty of space for counseling in PM&R.
When I thought about it more, I realized I had zero interest in the really heavy stuff (schizophrenia, mania, etc) that would let me work in a team (ie, inpatient) environment, and I thought I’d be lonely and bored running an outpatient clinic. I can’t imagine spending most/all of my workday just talking with patients and no colleagues. The few outpatient team-focused psych gigs just sounded too disjointed. Maybe addiction psych could be interesting, but literally every addiction psych doc I worked with was burnt out and jaded and that told me to run the other way. That and enjoying my brain injury and SCI rotations are what flipped me from psych to rehab. I just didn’t see a happy future for me in psych, and I saw onE in rehab.
I talk to my RNs, therapists, managers, etc all the time on our rehab unit. It’s really not just about the pathology—it’s the environment I enjoy. I really don’t care about patient pathology-I care more about the patient themselves and the people I work with-that’s what makes my day fun. That’s why I don’t get bored with my 300th stroke rehab patient either.
With all that said, you’re talking about the rest of your life. If psych is really where you’re going to be the happiest, then switch now and don’t look back. But really reflect deeply on where you want to be in five years and what will make you happy. PM&R is a great and broad field and there’s plenty of space for you if MSK isn’t your thing. There are also lots of great (and not-so-great) things about psych, so reflect on whether you really see yourself happier there.
Your post kind of confuses me. How can you assess function without knowledge of MSK? Plus, MSK and neuro are intimately tied together. I get it. You're at the beginning, maybe you haven't' seen enough. It sounds like you have a LOT of doubt in your head even before stepping into residency. Sounds like you are partial to psychiatry and feel a sense of buyers remorse. If you truly experienced enough MSK, and decide you don't like it. That'd be a good enough reason to switch because PM&R has A LOT of MSK.
- Joined
- Mar 31, 2008
- Messages
- 1,381
- Reaction score
- 2,034
FWIW, I went into PM&R residency absolutely enamored with MSK and not liking inpatient rehab very much. I now find the day-to-day practice of outpatient MSK a drag, compensation/hr is not that great; and I really enjoy inpatient/subacute rehab. I see much more visible progress with IPR patients. A lot of what I saw in outpatient MSK when I used to work that job was a consequence of many patients just not being able to "adult."
PMRDO2015
New Member
- Joined
- Oct 8, 2019
- Messages
- 2
- Reaction score
- 0
I had a good friend who transitioned from PM&R to Psychiatry after her PGY2 year. She was so happy that she did. She was interested in PMR for chronic pain, but has found the Psych route much more up her alley and fulfilling. I think, in the end, I think you would be a wonderful chronic pain management provider, so much of it is psych-based. But after reading your post, you sound like you have your mind made up, you just need some reassurance. I say make the switch. My friend is so happy that she did. And in the grand scheme of things, it is just a year extra!
Good luck!
Good luck!
- Joined
- Aug 14, 2006
- Messages
- 123
- Reaction score
- 48
What kind of function do you want to optimize? If it's primarily mental, then sure, go Psych. If it's a combination physical and mental, you should stick it out. You don't have to touch an EMG machine or a syringe after residency if you don't want to. As Eurycea mentioned, a Palliative Care fellowship seems up your alley.
Can you speak to this little more? I kinda like the MSK side of things but find some of it boring on a day to day basis but always thought that MSK and pain is significantly higher in salary compared to general physiatry or inpatient
- Joined
- Jan 2, 2016
- Messages
- 2,105
- Reaction score
- 2,079
One person’s opinion. Your perspective is closer to my reality (and preference). There are probably areas where outpt. MSK is saturated and not as lucrative. I make a lot more than my partners doing inpt and outpt. Traditional rehab, and don’t work much more.
Pmr.attendingdoc
PMR doc
- Joined
- Nov 18, 2020
- Messages
- 10
- Reaction score
- 13
I am a board certified Physiatrist and fellowship trained in interventional pain. I have a different complaint than all of you. I feel that the role of a physiatrist is constantly getting diminished. The new model of inpatient rehab is to get a hospitalist to run the unit and the physiatrist as a consultant. On admission the hospitalist places standing orders for rehab related issues and so when you do a consult all you are doing is recommending to continue those. How much contribution can you have with just managing bowel, bladder, sleep and pain?
This has been from my recent experience at a rehab facility. I felt that there was not much contribution as all the therapists were doing their job, the hospitalist was managing the medical issues and all I did was writing notes. I felt like I was not much of a physician but just a note writer. But that is also how I felt during residency too. We are so scared of managing medical issues that even for small things we consult a hospitalist. At some point in time, Medicare will definitely consider us a redundant specialty. As for pain management most jobs are opioid refills with some procedures. There is a lot of money but no job satisfaction. I sometimes feel like a professional drug dealer.
I definitely feel like I bought the wrong car or house.
This has been from my recent experience at a rehab facility. I felt that there was not much contribution as all the therapists were doing their job, the hospitalist was managing the medical issues and all I did was writing notes. I felt like I was not much of a physician but just a note writer. But that is also how I felt during residency too. We are so scared of managing medical issues that even for small things we consult a hospitalist. At some point in time, Medicare will definitely consider us a redundant specialty. As for pain management most jobs are opioid refills with some procedures. There is a lot of money but no job satisfaction. I sometimes feel like a professional drug dealer.
I definitely feel like I bought the wrong car or house.
- Joined
- Sep 16, 2012
- Messages
- 2,212
- Reaction score
- 3,241
That model is becoming more common as inpatient physiatrists are increasingly hard to find (and provide coverage for) and patients become increasingly medically complex, necessitating an internist anyway. But you are correct down the line CMS may wonder why we are needed.
It’s actually really hard to teach an internist to think like a rehab doc. It takes long enough to get them to think like a rehab internist as opposed to an acute care internist. But as patients become increasingly medically complex, many units are better off with an internist rather than a physiatrist which can’t manage those complex patients. The internist may not provide optimal screening/rehab care/dispo planning, but other members of the team can do it well enough and the internist can keep the patient alive.
We have a nice system where we’re at. Rehab is primary. Internists are consulted in every patient and see them as needed-typically every few days on average. More if they’re really complex/sick, less if healthy. They don’t provide much weekend support so I have to take point on more medical needs over the weekend, unless it’s a heavy need in which case the cross-cover internists will step in.
I used to be jealous of the systems where rehab was a consultant, but I think I’d wonder what am I doing as a consultant on my own unit. We’re not doing ourselves any favors.
Fortubately (or unfortunately) the area I live in is hard to recruit physiatrists and internists to, so I don’t think I’ll be out of a job anytime. But I could see Medicare saying they’ll only cover only so many MD visits per day. Still, they did sort of create the problem by limiting who can come to rehab in the first place and essentially requiring thy be more medically complex.
- Joined
- Jul 21, 2016
- Messages
- 108
- Reaction score
- 232
This is what's frustrating to me. When inpt rehab stays were longer and patients were more stable, the utility of a physiatrist is obvious- but if inpt rehabs are just being turned into glorified medicine step-down units with more therapy presence, inpatient physiatry is getting squeezed from the inside out. I really hope there's still a model for PM&R-as-primary inpatient rehab when I'm out in practice
- Joined
- Sep 16, 2012
- Messages
- 2,212
- Reaction score
- 3,241
The need for us is still. I think the bigger issue is there just aren’t as many physiatrists that want to do inpatient, yet demand is growing. When you’re the only rehab doc for the unit it’s tough to take vacation, have weekends off, etc. Having medicine be primary helps with this, which I’m sure is part of why it’s done, but obviously this pushes us more to the periphery. You wouldn’t ask a psychiatrist to be a consultant on a psych unit-I’m not sure why rehab would be a consultant on a rehab unit. A co-management model with rehab as primary makes more sense to me.
- Joined
- Jul 7, 2007
- Messages
- 133
- Reaction score
- 46
I was wondering what kind of patients MSK physiatrists get who are not in academia. I ended up with so many obese patients, smokers and medical comorbidties who could not get surgeries. In my real world, orthopedists never wanted to operate on patients with knee OA with BMI above 35 and I had a lot of obese patients with ACL and PCL tear on the top of OAs who cannot get arthroscopic sx and too obese for knee replacement and I was asked to inject on their knees.
These patients became so much drag for me. I ended up leaving after one yr and never want to go back to MSK world ever again.
I may sound very pessimistic but we PM&R have been obsessed with MSK Ultrasound. MSK Ultrasound is great but it takes your time and reimbursement is horrible. so you see the tear of supraspinatus but ortho will still order MRIs. It does not add that much on RVUs. You may diagnose intersection syndrome on wrist and find the intersection on wrist extensors and inject with using Ultrasound but at the end is this really worth it???
I really want to advise people who are in training not to pursue your career based on liking of certain procedures. I strongly advise choosing fellowships after considering whole picture. Especially, PM&R we are not surgeons and our procedures we do will be very very repetitious and time consuming
These patients became so much drag for me. I ended up leaving after one yr and never want to go back to MSK world ever again.
I may sound very pessimistic but we PM&R have been obsessed with MSK Ultrasound. MSK Ultrasound is great but it takes your time and reimbursement is horrible. so you see the tear of supraspinatus but ortho will still order MRIs. It does not add that much on RVUs. You may diagnose intersection syndrome on wrist and find the intersection on wrist extensors and inject with using Ultrasound but at the end is this really worth it???
I really want to advise people who are in training not to pursue your career based on liking of certain procedures. I strongly advise choosing fellowships after considering whole picture. Especially, PM&R we are not surgeons and our procedures we do will be very very repetitious and time consuming
- Joined
- Mar 31, 2008
- Messages
- 1,381
- Reaction score
- 2,034
This post should be stickied. Very good post. Many of the "glamorous" injections are nothing more than placebo as well, and the long term negative effects of steroids is well appreciated in the literature now. Residency focuses so much on ultrasound...but does all this ultrasound actually change management in a meaningfully positive way? Often times, no.
Regen med borders on snake oil.
- Joined
- Feb 24, 2010
- Messages
- 3,032
- Reaction score
- 6,173
*You have medicine as the primary on a Psych unit so that they do the admissions during the middle of the night with basic orders. Then the next day Consult Psych to flip over the management. Great way to reduce call burden for Psych, and keep IM busy, and knock out their initial H&P they'd do anyways.
- Joined
- Sep 16, 2012
- Messages
- 2,212
- Reaction score
- 3,241
Really? Medicine is primary? On a psych unit?
I get the patient needing to be seen soon, but it should be the psychiatrist’s job to do the H&P since their on a psych unit. IM has no business managing acute psych patients’ psych meds/needs, in my opinion. The psychiatrist on call should be at least putting in the admit orders/med rec and then see the patient in the AM depending on law/regulations/medical stability. Or come in the middle of the night if it was an emergent transfer, though most psych unit will limit the hours they take admits.
The last psych unit I had much exposure to the psychiatrists had essentially delegated everything to midlevels. The psychiatrist did the initial eval but after that all visits were the NP. I thought that was quite sad. It seems inpatient psych just doesn’t appeal to new psychiatrists, not unlike our own specialty.
I am also pain trained/boarded and recently decided to give it up. The legal drug dealer component was definitely a factor as well as pushing procedures that realistically offer very little benefit. I had 2 awful job experiences where I was expected to manage opiates on 99% of patients despite the jobs being touted as procedurally focused positions, often times extremely high MMEs. There were many other issues but that's a whole other story. Pain is fraught with fraud, although I think a lot of medicine is, but it's especially true in the pain world. I've looked a lot of inpatient jobs, but the issue with a lot of them, especially the independent contractor model, is that it becomes extremely difficult to take time off. I personally know a few physicians in these models that took zero vacation last year. They used COVID-19 as a excuse but I know the main reason was they had no coverage. I don't know about you all, but I couldn't live like that. I'll take less money at the end of the day for more peace of mind/quality of life. I'd be more inclined to take more a consulting based position, but you are right about losing ground. I'm not sure what the future of PM&R is but one could definitely be worried in some sense. I think a lot of other specialties can do what we do on the inpatient side. Maybe not as well but can do it regardless. Thus why some units are run by neurologists, etc. Justifying your existence or purpose, only means some one else is questioning it. I often times question it myself. I think the more variety you can do/offer is best at the end of the day for marketing purposes as well as for combating burnout. The problem realistically with this specialty is that we don't really "own" a particular skill set. You can say we "own" rehab....but we don't.
Mid-level creep is happening in every specialty as you all are well aware. Just a matter of time for PM&R especially as less people go into the inpatient world.
- Joined
- Mar 31, 2008
- Messages
- 1,381
- Reaction score
- 2,034
Totally agree, I feel like job security especially on the coasts/metros will be more of an issue in the coming years. It's hard for me to honestly recommend our specialty to med students tbh.
- Joined
- Sep 16, 2012
- Messages
- 2,212
- Reaction score
- 3,241
Lots of doom and gloom here. I think it’s all about finding the right job-there are lousy ones out there and wonderful ones. There are lots of happy physiatrists even here on SDN.
I really enjoy inpatient. I know I offer a lot more than just an internist or neurologist would. And the people I work with are great. I’m lucky to not be alone, so my partner and I can take turns covering for each other and take lots of time off if we want it. I like what I do, I get paid extremely well, I can take lots of time off.
Our specialty certainly has some hurdles, but so does every other specialty out there.
I really enjoy inpatient. I know I offer a lot more than just an internist or neurologist would. And the people I work with are great. I’m lucky to not be alone, so my partner and I can take turns covering for each other and take lots of time off if we want it. I like what I do, I get paid extremely well, I can take lots of time off.
Our specialty certainly has some hurdles, but so does every other specialty out there.
- Joined
- Aug 17, 2007
- Messages
- 926
- Reaction score
- 563
Agree with your sentiments. I am pain trained. Almost all the jobs I applied for were heavy into opiate management. So I took the brave step and started my own non narcotic practice. 8 years in and I have zero regrets. I have been able to add a lot of skills over the years including med legal. I am an expert witness, IME certified, Life care planning certified etc. I also work as a billing/compliance expert. None of the above are full time jobs but they keep things interesting and most importantly I get to see the extent of the fraud in the medical system. It is all over. Specially pain and Chiro. Therapy is not far behind as well has ortho spine. Independent consultant in the IRF setting is difficult specially if you can not coverage/locum. One of my close friend who works in a less than desirable state has not taken time off for 2 years. But his goal is to make a lot of money and than leave.
I am still optimistic about our specialty. Probably more now that I was coming out of training. I know I am the best at managing non surgical care. This has been reaffirmed by attorneys, patients, referring providers, insurance companies. Variety and having unique skills is paramount for longevity and survival. Mid level creep is real and not going anywhere and we will have to fight for jobs with them.
- Joined
- Jul 7, 2007
- Messages
- 133
- Reaction score
- 46
Academics knee OA rehab: PT + home exercise+ tylenol----> steroid injection-+PT or b.s jelly called synvisc----> geniculate block----> opiod
Real world knee OA rehab: shot shot shot pill pill pilll and glorious procedure burn the geniculate nerve / therapy DOES NOT DO SHXX too obese for surgery
Real world knee OA rehab: shot shot shot pill pill pilll and glorious procedure burn the geniculate nerve / therapy DOES NOT DO SHXX too obese for surgery
- Joined
- Jul 7, 2007
- Messages
- 133
- Reaction score
- 46
I wish I got to appreciate the inpatient rehab more. The thing is training/residencies did not provide good experience and i know my friend who did residency at one of big three in manhattan and she was asked to ask consults to ID even though urine culture came back with antibiotic sensitivity. I was forced to call Gi for pinworms and they called me idiots. This is my point. The PM&R world got huge blow on our face few yrs ago when CMS determined that it can be any other specialties to run inpatient rehab. This is what i think huge problems CMS saw. CMS prolbalble saw too many consults getting generated
So i think many residents pursue pain and sports medicine to feel more like experts. I understand pursuing pain fellowship but sports medicine just to hold on to ultrasound
- Joined
- Aug 22, 2005
- Messages
- 3,041
- Reaction score
- 3,242
Tell us how you really feel. Seems like you are holding back a little bit! 😂
- Joined
- Jul 7, 2007
- Messages
- 133
- Reaction score
- 46
haha gotta watch out what you say nowadays
- Joined
- Nov 21, 1998
- Messages
- 12,568
- Reaction score
- 6,967
Snake oil, my ass...
Am J Sports Med
. 2021 Jan;49(1):249-260.
doi: 10.1177/0363546520909397. Epub 2020 Apr 17.
Platelet-Rich Plasma Versus Hyaluronic Acid for Knee Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Controlled Trials
John W Belk 1, Matthew J Kraeutler 2, Darby A Houck 1, Jesse A Goodrich 1, Jason L Dragoo 1, Eric C McCarty 1Affiliations expand
- PMID: 32302218
- DOI: 10.1177/0363546520909397
Abstract
Background: Platelet-rich plasma (PRP) and hyaluronic acid (HA) are 2 nonoperative treatment options for knee osteoarthritis (OA) that are supposed to provide symptomatic relief and help delay surgical intervention.Purpose: To systematically review the literature to compare the efficacy and safety of PRP and HA injections for the treatment of knee OA.
Study design: Meta-analysis of level 1 studies.
Methods: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify level 1 studies that compared the clinical efficacy of PRP and HA injections for knee OA. The search phrase used was platelet-rich plasma hyaluronic acid knee osteoarthritis randomized. Patients were assessed via the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and Subjective International Knee Documentation Committee (IKDC) scale. A subanalysis was also performed to isolate results from patients who received leukocyte-poor and leukocyte-rich PRP.
Results: A total of 18 studies (all level 1) met inclusion criteria, including 811 patients undergoing intra-articular injection with PRP (mean age, 57.6 years) and 797 patients with HA (mean age, 59.3 years). The mean follow-up was 11.1 months for both groups. Mean improvement was significantly higher in the PRP group (44.7%) than the HA group (12.6%) for WOMAC total scores (P < .01). Of 11 studies based on the VAS, 6 reported PRP patients to have significantly less pain at latest follow-up when compared with HA patients (P < .05). Of 6 studies based on the Subjective IKDC outcome score, 3 reported PRP patients to have significantly better scores at latest follow-up when compared with HA patients (P < .05). Finally, leukocyte-poor PRP was associated with significantly better Subjective IKDC scores versus leukocyte-rich PRP (P < .05).
Conclusion: Patients undergoing treatment for knee OA with PRP can be expected to experience improved clinical outcomes when compared with HA. Additionally, leukocyte-poor PRP may be a superior line of treatment for knee OA over leukocyte-rich PRP, although further studies are needed that directly compare leukocyte content in PRP injections for treatment of knee OA.
Keywords: hyaluronic acid; knee; osteoarthritis; platelet-rich plasma.
- Joined
- Mar 31, 2008
- Messages
- 1,381
- Reaction score
- 2,034
SAGE Journals: Your gateway to world-class research journals
Subscription and open access journals from SAGE Publishing, the world's leading independent academic publisher.
"PRP injections within interstitial supraspinatus tears did not improve tendon healing or clinical scores compared with saline injections and were associated with more adverse events."
- Joined
- Jan 27, 2010
- Messages
- 431
- Reaction score
- 408
I'm sorry to hear so many unhappy physiatrists out there. I love my job.
I work in a private practice multi-specialty ortho clinic and do all of our EMGs, spine injections/RFs, ultrasound, and non-op sports medicine. Sure there are some opiate and disability seekers out there, but what speciality doesn't have a sub-section of patients that are difficult or annoying to deal with? I'd rather try to work through MSK/spine issues with patients in hopes of keeping them active than be a nephrologist dealing with dialysis or endo with poorly compliant diabetic patients.
I agree that inpatient PM&R needs to step up and be comfortable with inpatient IM problems. My residency prepared me for that, and while it has been a few years, would feel comfortable with more scenarios that have been presented here.
I'd be happy to PM with any young or in training physiatrists out there feeling the specialty isn't "worth it", etc.
I work in a private practice multi-specialty ortho clinic and do all of our EMGs, spine injections/RFs, ultrasound, and non-op sports medicine. Sure there are some opiate and disability seekers out there, but what speciality doesn't have a sub-section of patients that are difficult or annoying to deal with? I'd rather try to work through MSK/spine issues with patients in hopes of keeping them active than be a nephrologist dealing with dialysis or endo with poorly compliant diabetic patients.
I agree that inpatient PM&R needs to step up and be comfortable with inpatient IM problems. My residency prepared me for that, and while it has been a few years, would feel comfortable with more scenarios that have been presented here.
I'd be happy to PM with any young or in training physiatrists out there feeling the specialty isn't "worth it", etc.
- Joined
- Nov 21, 1998
- Messages
- 12,568
- Reaction score
- 6,967
SAGE Journals: Your gateway to world-class research journals
Subscription and open access journals from SAGE Publishing, the world's leading independent academic publisher.journals.sagepub.com
"PRP injections within interstitial supraspinatus tears did not improve tendon healing or clinical scores compared with saline injections and were associated with more adverse events."
View attachment 329580
Dispute this!
Attachments
- Joined
- Jul 28, 2014
- Messages
- 179
- Reaction score
- 57
What type of fellowship did you do?
- Joined
- Aug 17, 2007
- Messages
- 926
- Reaction score
- 563
Thank you. We need more people like you. The vast majority of Physiatrist I know love what they do.
- Joined
- Jan 27, 2010
- Messages
- 431
- Reaction score
- 408
I did a ACGME PM&R sports fellowship. We did ultrasound, lumbar spine injections, and minimal PRP injections (institution was very conservative about regenerative stuff). I've added a few skills to what I did in fellowship in regards to spine procedures through SIS, but all additive to the base I had in fellowship.
In my opinion PM&R needs to step up on both ends of our typical spectrum of work:
- Inpatient needs to step up and be comfortable doing IRF inpatient medicine (BP, diabetes, etc.) without consulting IM on everything. After all, we all do the equivalent of about 2.5 years of inpatient work between intern year and PGY2-4.
- Outpatient needs to be comfortable doing more than just one thing - i.e. you can't just do ultrasound and expect to survive (or be successful). You need AT LEAST two skill sets between US, EMG, spine, regenerative medicine (I'm becoming less of a skeptic, but still not completely convinced), amputee, spasticity/Botox, etc.
There will always be academic jobs and random opportunities that you can carve out doing 100% niche things like amputee, disorders or consciousness, etc. but you can't expect that will be you or only see these diagnoses. Unless you add value through being as good as IM on inpatient or procedural skills as an outpatient there are other specialties that WILL eat into EVERYTHING we do.
I am most familiar with my ortho colleagues and they are experiencing similar issues. Unless you are in a super high volume setting of joint replacement you have to expand your skillset. Gone are the days of ONLY doing knee scopes (unless you are in a hyper-academic setting) - you better add shoulder scopes, cartilage restoration, etc. to what you do.
- Joined
- Aug 17, 2007
- Messages
- 926
- Reaction score
- 563
Absolutely agree with you. You have to have multiple skill sets to survive. As you mentioned in the outpatient setting you have to have specific skills sets but have to be willing to adapt. I would argue that you need 3/5+1 skills sets. US, EMG, Spine/Fluoro, Regen med, med legal + admin.
IRF patients are complicated now and you need IM coverage but not for bread and butter issues. I am not sure how many years post fellowship you are but currently in the IRFs we cover as a group the patients have issues beyond the scope of PM&R. I am talking about cancer meds, complicated cardiac patients, post transplant, direct admit from ICU etc.
Every single Physiatrist needs to integrate into admin regardless of clinic, SNF, IRF or academic hospital setting. If you don't have a seat at the table others will decide our future.
IRF patients are complicated now and you need IM coverage but not for bread and butter issues. I am not sure how many years post fellowship you are but currently in the IRFs we cover as a group the patients have issues beyond the scope of PM&R. I am talking about cancer meds, complicated cardiac patients, post transplant, direct admit from ICU etc.
Every single Physiatrist needs to integrate into admin regardless of clinic, SNF, IRF or academic hospital setting. If you don't have a seat at the table others will decide our future.
- Joined
- Jan 27, 2010
- Messages
- 431
- Reaction score
- 408
Absolutely.
In residency we had LVADs, organ transplant, cancer rehab, etc. that absolutely need IM or the specific specialty involved (or we coordinated everything through multiple phone calls, notes, etc.).
But inpatient rehab consulting IM on “easy” CVAs, SCIs, multi traumas and the like is the fastest way to inpatient PM&R being taken over by hospitalist IM docs who want a different (easier?) case load but don’t understand the PM&R mindset and true rehab medicine.
- Joined
- Aug 17, 2007
- Messages
- 926
- Reaction score
- 563
Most residents have no idea that per Medicare any speciality can be considered a “rehab doc” in the IRF setting. In the future maybe NP/PA will be considered the “rehab provider”. Get involved with admin/advocacy or stop complaining.
- Joined
- Sep 16, 2012
- Messages
- 2,212
- Reaction score
- 3,241
True, but I find most hospitalists are happy to let us deal with the psychosocial/dispo issues, overseeing therapy (our primary reason for being there), pain management, etc.
I agree for bread and butter BP/DM, etc, if you don't know how to manage it you don't belong on inpatient rehab.
Logistically it gets tough though. Our internists didn't want to be on the hook to cover all rapid responses/chest pain issues unless they were consulting on everyone. And our patients are complicated now so we felt it was in their best interest to have hospitalists available 24/7. But it's the hospitalists' discretion how often to see patients (if they're not doing anything worthwhile they don't see the patient), and they only provide "urgent" coverage on weekends, so in the end I still provide half of the medical needs of my patients. As the patient's attending, the buck stops with me, so I'm logging into the chart of every patient daily, reviewing all labs/vitals daily, etc., just as I did in residency.
- Joined
- Aug 5, 2011
- Messages
- 528
- Reaction score
- 398
Lol why are people complaining that inpatient physiatrists don't do enough. This coming mostly from outpatient physiatrists that don't do inpatient?
I do plenty of internal medicine on IPR, but I am happy to say that I let the NP deal with diabetes. I look at every lab and vital sign every day. I make medical adjustments, recommend adjustments or change BP medications, anticoagulation, order thoracentesis, visceral imaging, IVF and antibiotics, etc all the time. I think you are just making a general assumption about the rest of us.
On inpatient service I get 2-4 days off per month and am on 24/7 call for director issues or admissions. I also do some outpatient. I believe I wouldn't survive without 24/7 IM consultation support to deal with overnight medical issues. Sorry I don't want to wake up at 2 am everynight about someones glucose being high and am happy to let IM handle it.
But I do understand and have worked with several PM&R doctors that only did bowel, bladder and pain. I think that is what you are referring to and that is a dying breed. I believe they will either retire or get replaced slowly by other providers. I think the hospital system I work in can see the extra value I add and wouldn't try to replace me. On the other hand, if you work for Encompass Health, they will probably replace the PM&R docs with NPs as soon as the medicare laws change in a few years.
I do plenty of internal medicine on IPR, but I am happy to say that I let the NP deal with diabetes. I look at every lab and vital sign every day. I make medical adjustments, recommend adjustments or change BP medications, anticoagulation, order thoracentesis, visceral imaging, IVF and antibiotics, etc all the time. I think you are just making a general assumption about the rest of us.
On inpatient service I get 2-4 days off per month and am on 24/7 call for director issues or admissions. I also do some outpatient. I believe I wouldn't survive without 24/7 IM consultation support to deal with overnight medical issues. Sorry I don't want to wake up at 2 am everynight about someones glucose being high and am happy to let IM handle it.
But I do understand and have worked with several PM&R doctors that only did bowel, bladder and pain. I think that is what you are referring to and that is a dying breed. I believe they will either retire or get replaced slowly by other providers. I think the hospital system I work in can see the extra value I add and wouldn't try to replace me. On the other hand, if you work for Encompass Health, they will probably replace the PM&R docs with NPs as soon as the medicare laws change in a few years.
Last edited:
- Joined
- Aug 5, 2011
- Messages
- 528
- Reaction score
- 398
I don't know if I agree. While I am comfortable dealing with "easy CVA's", I still like IM consultation.
Imagine getting an easy CVA patient with HTN. You don't consult IM and adjust BP medications for ongoing HTN (very common). You think you are comfortable doing so. Patient subsequently has another stroke and acute care neurology blames it on poorly-controlled HTN. Now if you end up getting sued, would you rather have had IM consulted (who specializes with HTN treatment and has board certification to treat the condition) or go in as PM&R where our specialty education and board exams have nothing to do about BP treatment. Maybe you can get away passing it on poor discharge planning from acute care?
From a liability standpoint many of these patients are more complex than I think you appreciate. I like my patients to get the best care possible and I feel like a comprehensive approach is best. I discuss their care with my consultants several times per day.
Last edited:
- Joined
- Jul 7, 2007
- Messages
- 133
- Reaction score
- 46
Hi I am back!!!!lol
I am asking if msk physiatrists in real world or even in academia have dealt with these populations such as BMI over 35 with knee OA and hemoglobin a1c 10 ish and acl tear on the top of that(primary care ordered mri and sent the referal) or cervical myelopthy patient with shoulder rotator cuff tears and knee OA(i aspirated 100 cc of synovial fluid). I am not sure how much regenerative medicine will help these populations and ortho colleagues will not provide TKR THR etc etc. THERE ARE folks out there walking with AVN of hip and unfortunately intraarticular inj of hip is only option because they cannot get surguries.
I am not saying i am very experienced but are we prepared for these populations?!?! They will keep coming back and you have to deal with patient satsfactions!!!! My previous practice consisted of a lot of these folks. I am not doing MSK anymore.
Residency training MSK may not prepare for this(myofascial and trigger point and itb band syndromes meh). I really want to know how msk highly trained folks out there dealing with these populations
I am asking if msk physiatrists in real world or even in academia have dealt with these populations such as BMI over 35 with knee OA and hemoglobin a1c 10 ish and acl tear on the top of that(primary care ordered mri and sent the referal) or cervical myelopthy patient with shoulder rotator cuff tears and knee OA(i aspirated 100 cc of synovial fluid). I am not sure how much regenerative medicine will help these populations and ortho colleagues will not provide TKR THR etc etc. THERE ARE folks out there walking with AVN of hip and unfortunately intraarticular inj of hip is only option because they cannot get surguries.
I am not saying i am very experienced but are we prepared for these populations?!?! They will keep coming back and you have to deal with patient satsfactions!!!! My previous practice consisted of a lot of these folks. I am not doing MSK anymore.
Residency training MSK may not prepare for this(myofascial and trigger point and itb band syndromes meh). I really want to know how msk highly trained folks out there dealing with these populations
- Joined
- Mar 31, 2008
- Messages
- 1,381
- Reaction score
- 2,034
Just ride the placebo train haha
- Joined
- Nov 21, 1998
- Messages
- 12,568
- Reaction score
- 6,967
Heat...ice...heat & ice....stretching, strengthening, & range of motion.
- Joined
- Mar 31, 2008
- Messages
- 1,381
- Reaction score
- 2,034
- Joined
- Jul 7, 2007
- Messages
- 133
- Reaction score
- 46
If i am not under the hippa restrictions, i could have collected the pictures of synovial fluids i collected daily and post on instagrams and i wanna see how many likes i will get from residents and medical students
- Joined
- Aug 22, 2005
- Messages
- 3,041
- Reaction score
- 3,242
When all else fails...psychology and OMT the crap out of it
- Joined
- Feb 22, 2016
- Messages
- 157
- Reaction score
- 104
I think you marketing need some adjustment you’re attracting a whole lot of what no one wants to see. MSK is competitive you need to clarify you message. Like what do you actually do. Help people with arthritis get better without surgery or help people in pain get back to the activities they love... present yourself as the solution to a clear problem for primary care or patients directly
- Joined
- Jul 7, 2007
- Messages
- 133
- Reaction score
- 46
