Am I in the right speciality?

[Baron Samedi]

Like others have said, my issue with PM&R is that we have become so focused on MSK that we have forgotten how to be doctors. We spend 45 minutes doing a comprehensive (but ultimately inconsequential) foot and ankle ultrasound on a 25 year old with 2/10 ankle pain but get IM consults for hypertension.

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[drusso]

Like others have said, my issue with PM&R is that we have become so focused on MSK that we have forgotten how to be doctors. We spend 45 minutes doing a comprehensive (but ultimately inconsequential) foot and ankle ultrasound on a 25 year old with 2/10 ankle pain but get IM consults for hypertension.

Not inconsequential if you're tee-ing them up for a PRP injection. So much to look at and think through biomechanically & fuctionally.

How's it different from a flock of neurologists waxing philosophical about the localization of a stroke and MRI findings for 45 minutes...and then prescribing an aspirin?

 

[Baron Samedi]

Not inconsequential if you're tee-ing them up for a PRP injection. So much to look at and think through biomechanically & fuctionally.

I guess. Its just not for me. I have zero interest in sports med but PM&R has moved so heavily in that direction. Almost all my referrals are for chronic musculoskeletal pain. I can't remember the last time I saw an amputee, neuromuscular disorder, spinal cord injury, palliative, or stroke patient in outpatient. We have basically become ortho PAs.

The amount of times I've heard physiatrists refer to our own specialty as "ortho with a lifestyle" makes me feel ill.

 

[drusso]

I guess. Its just not for me. I have zero interest in sports med but PM&R has moved so heavily in that direction. Almost all my referrals are for chronic musculoskeletal pain. I can't remember the last time I saw an amputee, neuromuscular disorder, spinal cord injury, palliative, or stroke patient in outpatient. We have basically become ortho PAs.

The amount of times I've heard physiatrists refer to our own specialty as "ortho with a lifestyle" makes me feel ill.

It's how you set it up. I split my time between urban and rural location. In the urban location I'm strictly Interventional pain. In my rural location I do (and did) it all: Medical director of a rehab unit, I see the SCI's, spasticity, TBI's, etc. I do all the contested disability evals, back up the occ med doctors, EMG's, etc. The rural neurologists have no interest in migraine, spasticity, etc. I work with the local oncologist on cancer rehab. For a while I even did rounds on the weekends at a SNF. Wound care is huge.

YOU choose your scope of practice, not your specialty.

 

[j4pac]

I guess. Its just not for me. I have zero interest in sports med but PM&R has moved so heavily in that direction. Almost all my referrals are for chronic musculoskeletal pain. I can't remember the last time I saw an amputee, neuromuscular disorder, spinal cord injury, palliative, or stroke patient in outpatient. We have basically become ortho PAs.

The amount of times I've heard physiatrists refer to our own specialty as "ortho with a lifestyle" makes me feel ill.

I’d say my biggest gripe about PM&R is that we are essentially 100% reliant on referrals. We get what we get referred. There aren’t many patients that even know what a PM&R physician does...there are even fewer actively pursuing us.

Referrals can be a heavy Neuro rehab population, but you must have a diverse referral source that understands what you want to see and respects you enough to not just be their dumping ground for chronic pain. I see quite a bit of chronic pain but my referral sources know that if I get a patient that expects me to be nothing more than a dope guy...I’m either not seeing them or I’m going to respectfully get rid of them. So far it hasn’t been a big probably, albeit I work apart of a group practice, so I think that there’s a better chance of common respect in my setup. Chronic pain/MSK is a big need. I really do think that we do MSK/pain/sports exceptional well. I wouldn’t advise anyone to go into PM&R if they weren’t interested in MSK/Ortho/Sports. If you hate that side of it...you should really do Neuro.

 

[Baron Samedi]

YOU choose your scope of practice, not your specialty.

Not exactly(military medicine), but for many that is probably true. My civilian practice will look much different than my active duty one.

There is little doubt, though, that many residencies are moving strongly towards becoming ortho-lite. OP's experience is not a unique one. Many of my colleagues who trained elsewhere had similar experiences.

 

[Baron Samedi]

I’d say my biggest gripe about PM&R is that we are essentially 100% reliant on referrals. We get what we get referred. There aren’t many patients that even know what a PM&R physician does...there are even fewer actively pursuing us.

Referrals can be a heavy Neuro rehab population, but you must have a diverse referral source that understands what you want to see and respects you enough to not just be their dumping ground for chronic pain. I see quite a bit of chronic pain but my referral sources know that if I get a patient that expects me to be nothing more than a dope guy...I’m either not seeing them or I’m going to respectfully get rid of them. So far it hasn’t been a big probably, albeit I work apart of a group practice, so I think that there’s a better chance of common respect in my setup. Chronic pain/MSK is a big need. I really do think that we do MSK/pain/sports exceptional well. I wouldn’t advise anyone to go into PM&R if they weren’t interested in MSK/Ortho/Sports. If you hate that side of it...you should really do Neuro.

This is so true. The quality and makeup of your patient panel is linked to the quality and makeup of your referral source.

The referrals I typically get are:
- 30 year old, shoulder clicks sometimes for last 5 years please eval and treat
- 40 year old, BMI 35 with bilateral knee pain and normal imaging, no previous therapy, please eval and treat
- 21 year old, low back pain but only after standing for >1hr or sitting in the car for >3 hours, please eval and treat
- 50 year old 1 month post knee-arthroscope and meniscus debridement but still has some pain, please eval and treat

And the classic:
- 40 year old, has been in ED/admitted too many times demanding opioids for nonexistant pain condition, please eval and treat

Some flavor of those general scenarios makes up ~75% of the referrals I get. Occasionally, I do get the patients with real pathology who benefit from my help but they are far outnumbered by the others.

 

[90sportsfan]

I am a M3, and PM&R has definitely piqued my interest. Although a few things mentioned in this thread worry me.

I could care less that the general public has no idea what PM&R or a Physiatrist is, from a social/prestige factor when you mention it at a party, lol; but I do wonder what the impact of this is on something important like referrals or how patients being completely unaware of the specialty impacts practice business (i.e. generating patients)? I honestly can't think of another specialty that is as unknown as PM&R, and from a referral/business perspective, this is a little worrisome to me.

My second question is somewhat related to the first point; I don't mean this to be disrespectful, but it's hard for me (with admittedly limited knowledge) to immediately identify the bread and butter aspect of the specialty that is completely unique to PM&R. It seems like Ortho, Neuro, Rheum, Primary Care Sports Medicine, and Physical Therapists all do things that Physiatrists do. With almost every other specialty you can immediately describe their unique niche in specialty medicine, but with PM&R, it seems like several other specialists and health providers (i.e. PTs) do aspects of PM&R.

It's just hard to tell what the unique procedure/patient/condition is that PM&R handles, like you can with almost every other specialty. This also goes back to how this impacts referrals and patient volume.

It seems like such an interesting specialty, but for me, these are some major points of concerns, which make me hesitant in pursing it.

 

[Butterfly23]

I am a M3, and PM&R has definitely piqued my interest. Although a few things mentioned in this thread worry me.

I could care less that the general public has no idea what PM&R or a Physiatrist is, from a social/prestige factor when you mention it at a party, lol; but I do wonder what the impact of this is on something important like referrals or how patients being completely unaware of the specialty impacts practice business (i.e. generating patients)? I honestly can't think of another specialty that is as unknown as PM&R, and from a referral/business perspective, this is a little worrisome to me.

My second question is somewhat related to the first point; I don't mean this to be disrespectful, but it's hard for me (with admittedly limited knowledge) to immediately identify the bread and butter aspect of the specialty that is completely unique to PM&R. It seems like Ortho, Neuro, Rheum, Primary Care Sports Medicine, and Physical Therapists all do things that Physiatrists do. With almost every other specialty you can immediately describe their unique niche in specialty medicine, but with PM&R, it seems like several other specialists and health providers (i.e. PTs) do aspects of PM&R.

It's just hard to tell what the unique procedure/patient/condition is that PM&R handles, like you can with almost every other specialty. This also goes back to how this impacts referrals and patient volume.

It seems like such an interesting specialty, but for me, these are some major points of concerns, which make me hesitant in pursing it.

Plus covid 19 pandemics going on, I will be hesitant to pursue as medical students. Pm&r is basically the speciality that plays the role of integration of different disciplines and the pmr job is to lead them. These therapists can practice therapies under PMR presence. Without PM&R, i see so many resources getting wasted and a lot of therapists will pursue the Bs sessions performing sham therapies(heating pad sessions)
However, when we millenials graduate from residencies, many graduates want to go to subspecialty that looks like hands on and many want to feel like they are actually doing stuff and want to feel important. Therefore, pain fellowship tends to be popular.
If you want to feel like the major player in the health care, do not go into PM&R.

 

[TheGreatestTrochanter]

I think the approach of PM&R is valuable for the way the health care system is headed right now, and in the right setting is beneficial to any group. I think we need to really push residency and fellowship training in cancer rehab and palliative care. Sports, pain, and spine medicine are needed and high-demand specialties and provide expertise that is needed across the country. EMGs are also in high demand, most the systems I am familiar with are 3-4 months out to get an EMG. Good MSK training when seeing patients for EMGs has led to me diagnosing many chronic problems that were missed by PCPs and then sent them for EMGs because they weren't sure what else to do.

I think the biggest problems of PMR right now: We need to do a better job at staking our ground and letting everyone know what we do. Many settings that have a strong PMR program know what they can bring but this is not the national standard.
I think this is slowly changing, but PMR is the "lifestyle" specialty that is the easiest to get into with regards to board scores. Still competitive especially for a top program. I've met a lot of lousy PMR attendings and residents that complain about their hard 40-50 hour workweek, meanwhile other specialties are running circles around us with work ethic. Hard to get credibility if you are not available and not continuing to learn. I want a good lifestyle as well, but we can do better. The places that have a strong PMR presence surprisingly have attending docs who work hard, get involved, and are continually learning and expanding their skillset.

In other words, you can certainly get a skill set to be appreciated and valuable in any system with a PM&R training, especially if you had a fellowship. If we keep yielding and ceding ground for others to do our work as discussed, we would become less-valuable.

 

[sloh]

The truth is our “unique” contribution in the outpatient MSK setting is ultrasound and fluoro procedures (that is unless we start emphasizing progressive loading, nutrition, lifestyle interventions). The evidence is mounting that many of these procedures don’t really work—not to mention the deleterious effects steroids have on bone and connective tissue. Many see regen med as grifting (and they aren’t really wrong tbh). It seems when PM&R does get referrals, it’s often to appease the patient they were able to be seen by a specialist and truly tried everything (even if the referring physician anticipates the procedure will do nothing). Med students aren’t dumb and EBM (the importance of randomized controlled trials) is increasingly emphasized in the med school curriculum.

 

[drusso]

The truth is our “unique” contribution in the outpatient MSK setting is ultrasound and fluoro procedures (that is unless we start emphasizing progressive loading, nutrition, lifestyle interventions). The evidence is mounting that many of these procedures don’t really work—not to mention the deleterious effects steroids have on bone and connective tissue. Many see regen med as grifting (and they aren’t really wrong tbh). It seems when PM&R does get referrals, it’s often to appease the patient they were able to be seen by a specialist and truly tried everything (even if the referring physician anticipates the procedure will do nothing). Med students aren’t dumb and EBM (the importance of randomized controlled trials) is increasingly emphasized in the med school curriculum.

My mentor in medical school once told me, "Specialize in something they'll never find a cure for..."

The future is of PM&R is bright I've got to wear shades!

 

[RangerBob]

My mentor in medical school once told me, "Specialize in something they'll never find a cure for..."

The future is of PM&R is bright I've got to wear shades!

My staff and I all tell patients we'd all love to be out of a job. Unfortunately stroke/SCI/TBI/amputations/hip fractures aren't going away, and if anything will likely become more common as more of us live into old age. And with all the boomers aging right now, I think the next 20 years are looking very busy.

The same goes for the bread and butter of outpatient rehab. Chronic/acute MSK pain, entrapment neuropathies, spine/sports/chronic pain aren't going away either, in addition to the traditional outpt rehab stuff like amputee/stroke/SCI/spasticity.

If you're not tied to an academic center it takes more effort to educate the providers in your region about what you can offer, but I find the PM&R docs who are good at what they do, even if it's just one thing like EMG or MSK, have their clinic scheduled full for months ahead.

I agree our future is very bright. Where I live in Coastal CA, we have significant need for both outpt and inpt rehab docs. I felt even in the big cities I lived in there was generally a shortage of us, but I could see how it'd be harder to break into those markets.

 

[Bostonspine]

The truth is our “unique” contribution in the outpatient MSK setting is ultrasound and fluoro procedures (that is unless we start emphasizing progressive loading, nutrition, lifestyle interventions). The evidence is mounting that many of these procedures don’t really work—not to mention the deleterious effects steroids have on bone and connective tissue. Many see regen med as grifting (and they aren’t really wrong tbh). It seems when PM&R does get referrals, it’s often to appease the patient they were able to be seen by a specialist and truly tried everything (even if the referring physician anticipates the procedure will do nothing). Med students aren’t dumb and EBM (the importance of randomized controlled trials) is increasingly emphasized in the med school curriculum.

I would be careful reading New England journal of nothing ever work... quality of life is what we specialize in and there is a growing demand to help people play with there grand kids, get back on the slopes return To the gym and do one more 10k. The total package is the selling pint we provide true functional medicine... our problem is we are the best kept secrets people wonder around blindly at there Chiro/yoga/Pilates/acupuncture/functional medicine doctor by vitamins, devices, massages and other thing when they need you and me to diagnose the problem and lay out a treatment plan

 

[sloh]

I would be careful reading New England journal of nothing ever work... quality of life is what we specialize in and there is a growing demand to help people play with there grand kids, get back on the slopes return To the gym and do one more 10k. The total package is the selling pint we provide true functional medicine... our problem is we are the best kept secrets people wonder around blindly at there Chiro/yoga/Pilates/acupuncture/functional medicine doctor by vitamins, devices, massages and other thing when they need you and me to diagnose the problem and lay out a treatment plan

So what’s your “total package” that distinguishes us from chiropractors and acupuncturists? The appeal to authority (our MD/DO degrees and training) isn’t sufficient.

Vinay Prasad, MD, on 'Medical Reversal'

'Not every reversal puts money in doctors' pockets'

www.medpagetoday.com

“One of the other things I think about that comes to mind rather quickly is the use of steroid injection for spinal stenosis, so epidural steroid injection. Now a couple years ago, there was an outbreak of fungal meningitis in compounding pharmacies, and people rightly faulted the compounding pharmacies for failing to follow proper hygienic policies. But one of the things that was under-discussed was the fact, "Well, why are we doing so many epidural steroid injections?" We were doing it because we thought that it would decrease pain over the course of weeks to perhaps even months in patients, and there were a lot of uncontrolled studies and anecdotal reports that that was true. But there are also well done sham-controlled studies showing that that benefit is, in fact, probably nothing more than a placebo effect.”

 

[drusso]

So what’s your “total package” that distinguishes us from chiropractors and acupuncturists? The appeal to authority (our MD/DO degrees and training) isn’t sufficient.

Vinay Prasad, MD, on 'Medical Reversal'

'Not every reversal puts money in doctors' pockets'

www.medpagetoday.com

“One of the other things I think about that comes to mind rather quickly is the use of steroid injection for spinal stenosis, so epidural steroid injection. Now a couple years ago, there was an outbreak of fungal meningitis in compounding pharmacies, and people rightly faulted the compounding pharmacies for failing to follow proper hygienic policies. But one of the things that was under-discussed was the fact, "Well, why are we doing so many epidural steroid injections?" We were doing it because we thought that it would decrease pain over the course of weeks to perhaps even months in patients, and there were a lot of uncontrolled studies and anecdotal reports that that was true. But there are also well done sham-controlled studies showing that that benefit is, in fact, probably nothing more than a placebo effect.”

This is a great book.

 

[Bostonspine]

So what’s your “total package” that distinguishes us from chiropractors and acupuncturists? The appeal to authority (our MD/DO degrees and training) isn’t sufficient.

Vinay Prasad, MD, on 'Medical Reversal'

'Not every reversal puts money in doctors' pockets'

www.medpagetoday.com

“One of the other things I think about that comes to mind rather quickly is the use of steroid injection for spinal stenosis, so epidural steroid injection. Now a couple years ago, there was an outbreak of fungal meningitis in compounding pharmacies, and people rightly faulted the compounding pharmacies for failing to follow proper hygienic policies. But one of the things that was under-discussed was the fact, "Well, why are we doing so many epidural steroid injections?" We were doing it because we thought that it would decrease pain over the course of weeks to perhaps even months in patients, and there were a lot of uncontrolled studies and anecdotal reports that that was true. But there are also well done sham-controlled studies showing that that benefit is, in fact, probably nothing more than a placebo effect.”

Real Medicine is the distinction... I’m not advocating for steroid but rather the ability of a physiatrist to look at a patients deficits form a differential diagnosis and develop a treatment plan... we can debate what that plan Should be or consusist of but we can all agree it not 30 sessions for biweekly adjustments or IV Vitamins and hormone replacement

 

[Butterfly23]

Real Medicine is the distinction... I’m not advocating for steroid but rather the ability of a physiatrist to look at a patients deficits form a differential diagnosis and develop a treatment plan... we can debate what that plan Should be or consusist of but we can all agree it not 30 sessions for biweekly adjustments or IV Vitamins and hormone replacement

I agree with you. But in my limited scope of real world, people come to the clinics to receive injections hoping it works and how many people really listen to do therapies and do home exercises?!?!
How many employers will hire PM&Rs without interventional skills ?!?!

going back to SLoH's comments, it does not have to be scientific and it does not have randomized studies that need to tell you that ESI for spinal stenosis is not efficacious. People with spinal stenosis have degenerative processes that have been developed over many years. Expecting that ESI will break the pain cycle that is developed from many years of degenerative cycles is just crazy to me.

 

[Bostonspine]

I agree with you. But in my limited scope of real world, people come to the clinics to receive injections hoping it works and how many people really listen to do therapies and do home exercises?!?!
How many employers will hire PM&Rs without interventional skills ?!?!

going back to SLoH's comments, it does not have to be scientific and it does not have randomized studies that need to tell you that ESI for spinal stenosis is not efficacious. People with spinal stenosis have degenerative processes that have been developed over many years. Expecting that ESI will break the pain cycle that is developed from many years of degenerative cycles is just crazy to me.

For outpatient MSK probably none but my point is none of those are hiring chiropractors either often we feel entitled to patients but at it’s core medicine is a business even if you start off seeing undesirable patients you can grow your practice into what you want... our ortho colleagues will take call at hospitals in BFE to pay the bills while building his total joint practice but all we see is the total joint practice. Do a spine or pain fellowship to pay the bill the morph it into MSK over 5 yrs. do subacute while you grow your outpatient practice...

 

[avalon10]

This is so true. The quality and makeup of your patient panel is linked to the quality and makeup of your referral source.

The referrals I typically get are:
- 30 year old, shoulder clicks sometimes for last 5 years please eval and treat
- 40 year old, BMI 35 with bilateral knee pain and normal imaging, no previous therapy, please eval and treat
- 21 year old, low back pain but only after standing for >1hr or sitting in the car for >3 hours, please eval and treat
- 50 year old 1 month post knee-arthroscope and meniscus debridement but still has some pain, please eval and treat

And the classic:
- 40 year old, has been in ED/admitted too many times demanding opioids for nonexistant pain condition, please eval and treat

Some flavor of those general scenarios makes up ~75% of the referrals I get. Occasionally, I do get the patients with real pathology who benefit from my help but they are far outnumbered by the others.

That sounds horrible. I would be leaving that job if that were me.

 

[avalon10]

I agree with you. But in my limited scope of real world, people come to the clinics to receive injections hoping it works and how many people really listen to do therapies and do home exercises?!?!
How many employers will hire PM&Rs without interventional skills ?!?!

going back to SLoH's comments, it does not have to be scientific and it does not have randomized studies that need to tell you that ESI for spinal stenosis is not efficacious. People with spinal stenosis have degenerative processes that have been developed over many years. Expecting that ESI will break the pain cycle that is developed from many years of degenerative cycles is just crazy to me.

It's just crazy to me to go to surgery without trying ESIs first.

 

[PMR2008]

This is so true. The quality and makeup of your patient panel is linked to the quality and makeup of your referral source.

The referrals I typically get are:
- 30 year old, shoulder clicks sometimes for last 5 years please eval and treat
- 40 year old, BMI 35 with bilateral knee pain and normal imaging, no previous therapy, please eval and treat
- 21 year old, low back pain but only after standing for >1hr or sitting in the car for >3 hours, please eval and treat
- 50 year old 1 month post knee-arthroscope and meniscus debridement but still has some pain, please eval and treat

And the classic:
- 40 year old, has been in ED/admitted too many times demanding opioids for nonexistant pain condition, please eval and treat

Some flavor of those general scenarios makes up ~75% of the referrals I get. Occasionally, I do get the patients with real pathology who benefit from my help but they are far outnumbered by the others.

I guess it is a matter of prospective but that is what my typical patient referral looks like. And I don't mind it.


- 30 year old, shoulder clicks sometimes for last 5 years please eval and treat

Ultrasound the shoulder, maybe it is bicep tendon subluxation, impingement, labral tear. Might need diagnostic injection. If diagnosis is confirmed do steroid injection versus regen based on patient preference. return to therapy with new instructions. If not improved send to ortho.

- 40 year old, BMI 35 with bilateral knee pain and normal imaging, no previous therapy, please eval and treat
Discuss weight loss strategies. Diagnose issue. Maybe it is a meniscus tear. Review imaging and if no MRI rule out quad or patellar tendonitis. Maybe knee needs to be aspirated and might need steroid vs viscosupplementation vs regen med. Start therapy. Might need topical ointments, orthotics, knee brace?

- 21 year old, low back pain but only after standing for >1hr or sitting in the car for >3 hours, please eval and treat

Review hx. Maybe previous injury in sports. Auto immune? if just muscular than might need rehab, home exercise program?


I really don't need to go through your list and what I stated above is overly simplified. the point is that as Physiatrist we have the tools to diagnose the underlying issue and optimize care. it does not always have to be injections or 'PT eval'. Most patients want the diagnosis and treatment plan. But all that requires spending time with the patient and using your training.

 

[avalon10]

I guess you're right. I shouldn't have said "horrible".
It depends on interests, practice, style, etc. I only do spine, and I only want to do spine, so I don't see any of that other stuff. But I understand that a lot of people do like it and interests vary a lot.

 

[PMR2008]

I am a M3, and PM&R has definitely piqued my interest. Although a few things mentioned in this thread worry me.

I could care less that the general public has no idea what PM&R or a Physiatrist is, from a social/prestige factor when you mention it at a party, lol; but I do wonder what the impact of this is on something important like referrals or how patients being completely unaware of the specialty impacts practice business (i.e. generating patients)? I honestly can't think of another specialty that is as unknown as PM&R, and from a referral/business perspective, this is a little worrisome to me.

My second question is somewhat related to the first point; I don't mean this to be disrespectful, but it's hard for me (with admittedly limited knowledge) to immediately identify the bread and butter aspect of the specialty that is completely unique to PM&R. It seems like Ortho, Neuro, Rheum, Primary Care Sports Medicine, and Physical Therapists all do things that Physiatrists do. With almost every other specialty you can immediately describe their unique niche in specialty medicine, but with PM&R, it seems like several other specialists and health providers (i.e. PTs) do aspects of PM&R.

It's just hard to tell what the unique procedure/patient/condition is that PM&R handles, like you can with almost every other specialty. This also goes back to how this impacts referrals and patient volume.

It seems like such an interesting specialty, but for me, these are some major points of concerns, which make me hesitant in pursing it.

There is nothing that we do as Physiatrist that is unique to us. But being able to have a knowledge overlap between Ortho, Neuro, Rheum, Primary Care Sports Medicine, and Physical Therapists is a big plus in my opinion. Yes we are jack of all trades and master of none but that is what the payors are looking for. The primary care sports med doc in an ortho group can not do EMGs. Neuro can not manage sports injuries. Ortho does not want to manage rheum issues. But we can do all of the above.

 

[Baron Samedi]

I guess it is a matter of prospective but that is what my typical patient referral looks like. And I don't mind it.


- 30 year old, shoulder clicks sometimes for last 5 years please eval and treat

Ultrasound the shoulder, maybe it is bicep tendon subluxation, impingement, labral tear. Might need diagnostic injection. If diagnosis is confirmed do steroid injection versus regen based on patient preference. return to therapy with new instructions. If not improved send to ortho.

- 40 year old, BMI 35 with bilateral knee pain and normal imaging, no previous therapy, please eval and treat
Discuss weight loss strategies. Diagnose issue. Maybe it is a meniscus tear. Review imaging and if no MRI rule out quad or patellar tendonitis. Maybe knee needs to be aspirated and might need steroid vs viscosupplementation vs regen med. Start therapy. Might need topical ointments, orthotics, knee brace?

- 21 year old, low back pain but only after standing for >1hr or sitting in the car for >3 hours, please eval and treat

Review hx. Maybe previous injury in sports. Auto immune? if just muscular than might need rehab, home exercise program?


I really don't need to go through your list and what I stated above is overly simplified. the point is that as Physiatrist we have the tools to diagnose the underlying issue and optimize care. it does not always have to be injections or 'PT eval'. Most patients want the diagnosis and treatment plan. But all that requires spending time with the patient and using your training.

If thats what you're interested in, then great. I get the impression that OP is not. PM&R is advertised as this diverse field that treats people with rare and interesting pathologies. That aspect of it has become less and less true over time and instead we are treating chronic nonoperative MSK pain. Probably not what OP is looking for, nor what I was looking for. I can only stand telling people they need to lose weight and strengthen their quads/core/rotator cuff so many times a day before I feel like I'm losing my mind.

 

[Baron Samedi]

There is nothing that we do as Physiatrist that is unique to us. But being able to have a knowledge overlap between Ortho, Neuro, Rheum, Primary Care Sports Medicine, and Physical Therapists is a big plus in my opinion. Yes we are jack of all trades and master of none but that is what the payors are looking for. The primary care sports med doc in an ortho group can not do EMGs. Neuro can not manage sports injuries. Ortho does not want to manage rheum issues. But we can do all of the above.

Another way of putting it is that we have situated ourselves as the docs to see when your PCM can't/won't treat an issue but you're not quite sick or injured enough to see the real experts on it.

How many of us are actually treating rheumatologic disorders? I have never prescribed a DMARD and doubt most physiatrists have.

 

[runfastnow]

Another way of putting it is that we have situated ourselves as the docs to see when your PCM can't/won't treat an issue but you're not quite sick or injured enough to see the real experts on it.

How many of us are actually treating rheumatologic disorders? I have never prescribed a DMARD and doubt most physiatrists have.

This is a very accurate way to state it.

I do all of our practice's US injections, non-op spine, EMGs, PRPs, etc.

If there is a bucket-handle tear meniscus or radiculopathy with huge disc that doesn't respond to TFESI then I send them on to the surgeon. I am happy with the set up and the surgeons are happy to have people ready to go to OR since they know I've done all non-op appropriately. They are equally happy that I can do US guided injections and handle all the PRP stuff for them.

Sure there are a few scenarios it's annoying to not be able to do a knee/shoulder scope for someone. However, being able to do all the non-op (appropriately) for someone and then push them on to the surgeon if they want is fine for me. Also, the massively bad complications that come with a surgical specialty I am glad to avoid.

 

[Bostonspine]

This is a very accurate way to state it.

I do all of our practice's US injections, non-op spine, EMGs, PRPs, etc.

If there is a bucket-handle tear meniscus or radiculopathy with huge disc that doesn't respond to TFESI then I send them on to the surgeon. I am happy with the set up and the surgeons are happy to have people ready to go to OR since they know I've done all non-op appropriately. They are equally happy that I can do US guided injections and handle all the PRP stuff for them.

Sure there are a few scenarios it's annoying to not be able to do a knee/shoulder scope for someone. However, being able to do all the non-op (appropriately) for someone and then push them on to the surgeon if they want is fine for me. Also, the massively bad complications that come with a surgical specialty I am glad to avoid.

Entrance into an ortho practice is one model you can also serve as the ex hit to a primary care group. Acting as the gate keeper for MSK especially spine is a big money saver for practices with risk contract and capitation

 

[Butterfly23]

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

well I am glad that some or many folks out there can advertise and collect the populations they want to treat. Hmm, it will be very hard to refuse the referals in many settings I am familiar with though. Anyway, I said adios to MSK world.

 

[Butterfly23]

This is the typical example of ultrasound abuse that does not change the outcome.
65 yo male with trigger finger went to msk PM&R practice and that MSK PM&R ultrasound guru guy blocked the median nerve using fancy ultrasound and waited longer and then got thumb trigger finger shot with ultrasound, and he kept triggering. MSK ultrasound guru physician was advertising how he can use 30 guage needle and make the procedure painless

so he got annoyed and went to the hand surgeon he knows personally and he did in few seconds and his triggering went away

This is drastic example but it happens a lot.

 

[Bostonspine]

well I am glad that some or many folks out there can advertise and collect the populations they want to treat. Hmm, it will be very hard to refuse the referals in many settings I am familiar with though. Anyway, I said adios to MSK world.

So I didn’t say anything about refusing referrals when you start you have to see whatever pays the bill but as you become more know you can morph you practice to Mirrror your interest. This apply to a TBI fellowship trained doctor doing general rehab and getting to know every trauma surgeon neurologist and neurosurgeon to increase referrals. MSK requires you to compete or collaborate ortho, Rheum, Sports and build relationships with PT, PCP and Chiro.

 

[drusso]

Another way of putting it is that we have situated ourselves as the docs to see when your PCM can't/won't treat an issue but you're not quite sick or injured enough to see the real experts on it.

How many of us are actually treating rheumatologic disorders? I have never prescribed a DMARD and doubt most physiatrists have.

I think that's the whole point: We fill a gap in the continuum of care...

 

[Butterfly23]

This is a very accurate way to state it.

I do all of our practice's US injections, non-op spine, EMGs, PRPs, etc.

If there is a bucket-handle tear meniscus or radiculopathy with huge disc that doesn't respond to TFESI then I send them on to the surgeon. I am happy with the set up and the surgeons are happy to have people ready to go to OR since they know I've done all non-op appropriately. They are equally happy that I can do US guided injections and handle all the PRP stuff for them.

Sure there are a few scenarios it's annoying to not be able to do a knee/shoulder scope for someone. However, being able to do all the non-op (appropriately) for someone and then push them on to the surgeon if they want is fine for me. Also, the massively bad complications that come with a surgical specialty I am glad to avoid.

That is great!. But in many situations, patients are not happy if surgeries get delayed with steroid injections. I used to get annoyed when ortho guys use intraarticular hip injections as diagnostic tools before hip arthroplasty while patients get annoyed that they have to wait for three months for surgeries. gate keeper role in ortho practice is just another ball game and I trully got fed up with that roles. when people with traumatic rotator cuff tear come to you and lets say you are in ortho practice, do not ever inject!!! ortho guys can get mad at you and they will blame injectors for delaying their surgeries as we all know sports/arthroscopic surgeons are in very competitive markets

 

[Bostonspine]

That is great!. But in many situations, patients are not happy if surgeries get delayed with steroid injections. I used to get annoyed when ortho guys use intraarticular hip injections as diagnostic tools before hip arthroplasty while patients get annoyed that they have to wait for three months for surgeries. gate keeper role in ortho practice is just another ball game and I trully got fed up with that roles. when people with traumatic rotator cuff tear come to you and lets say you are in ortho practice, do not ever inject!!! ortho guys can get mad at you and they will blame injectors for delaying their surgeries as we all know sports/arthroscopic surgeons are in very competitive markets

All good advice diagnostic injections can be anesthetic only... dirty secret is some of these joint guys are booked out three months. Also no excuse for fully torn RTC in someone under 65

 

[MavFab]

This is the typical example of ultrasound abuse that does not change the outcome.
65 yo male with trigger finger went to msk PM&R practice and that MSK PM&R ultrasound guru guy blocked the median nerve using fancy ultrasound and waited longer and then got thumb trigger finger shot with ultrasound, and he kept triggering. MSK ultrasound guru physician was advertising how he can use 30 guage needle and make the procedure painless

so he got annoyed and went to the hand surgeon he knows personally and he did in few seconds and his triggering went away

This is drastic example but it happens a lot.

Don't some MSK people fix the trigger finger themselves?

 

[runfastnow]

That is great!. But in many situations, patients are not happy if surgeries get delayed with steroid injections. I used to get annoyed when ortho guys use intraarticular hip injections as diagnostic tools before hip arthroplasty while patients get annoyed that they have to wait for three months for surgeries. gate keeper role in ortho practice is just another ball game and I trully got fed up with that roles. when people with traumatic rotator cuff tear come to you and lets say you are in ortho practice, do not ever inject!!! ortho guys can get mad at you and they will blame injectors for delaying their surgeries as we all know sports/arthroscopic surgeons are in very competitive markets

Of course - that's why I counsel my patients on appropriate options and if they want surgery then they come back and get signed up for one or I transfer to the surgeon's schedule the same day if that is the right decision. I'm satisfied with what I do, patients and student-athletes are happy with how I and our practice takes care of them, and I can sleep satisfied at night that I do the right thing for patients.

I post to help medical students, residents, etc. see there are people who are happy and satisfied doing PM&R MSK/sports/spine. If people aren't happy with the role I play or feel PM&R MSK is a waste that is fine by me. I know I won't change your thoughts via an internet forum. Academic medicine, inpatient rehab, EMG clinic, other specialties, etc. may be for these people - which are themselves important roles in the healthcare system.

 

[j4pac]

Don't some MSK people fix the trigger finger themselves?

Yes. Absolutely no need for someone to go straight to surgery for trigger finger.