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what are the pros and cons of a career of pm&r? i hear alot of the postives, but obviously this specialty isnt for everyone.
appeal of physical medicine and rehabilitation
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True. This board mostly concentrate on the positive side of the specialty. And again, you are exactly correct, this is a specialty not for everybody. Let me give you what I know about PM&R and I welcome response that disagree with my viewpoint.
PM&R is a great specialty for people who enjoy team approach in patient care, who loves to spend time interacting with therapists, speech pathologists, neuropsychologists, case managers, nurses, social worker, etc. Though, the specialty is promoting itself more and more as musculoskeletal specialists, and most graduates these days will move on to work in outpatient settings, concentrating on musculoskeletal, spine, sports and pain medicine. There are a lot of options, you don't work very hard and can make a decent living, well as least compare to primary care fields. No real emergencies, some practice settings will have no call and no weekends required.
On the other hand, some people will say PM&R physicians are not "real" doctors. They usually don't know enough about medicine to deal with complex medical problems. Some attendings will want their patient to be transfer out of their service for minor, easily correctable problems like dehydration, or will consider their patients ready to crash when they have a fever. This is their mind set. Everybody needs to have primariky no medical problems. They may know what the therapists do, but they have practically no role in hands on care. Some may not even know how to do the exercises. In short, you are the team leader, you over see how the team function and make sure everybody do their work correctly and coordinate the rehab process. In the outpatient settings, you see mostly musculoskeletal conditions like back pain, neck pain, shoulder pain. From time to time you will do a few steroid injections here and there. But most of the time, you are responsible to manage these condition conservatively and send the patient to therapies, get proper equipments like canes, scooters, walkers, splints, etc. You do however can be consider a specialist to perform EMG/nerve conduction studies. Since nobody assume you to be able to handle medical issues, nobody really bothers you.
Students should be careful that this is not a typical field of medicine, you may not feel like a physician at times. And the time that you spent dealing with direct patient care is minimal compare to your medical colleagues in other fields(at least in the inpatient settings).
People sometimes refer this as a best kept secret in medicine, or saying that it represents plenty of money and relaxation. Relaxation may be, but most medical and surgical specialists should still make more money than Physiatrists unless you become a pain and spine specialist. PM&R is still not a widely accepted field, not only in U.S., but worldwide. Some of the elite institutions has no PM&R department or would not recognize this as an individual specialty, but a division of Orthopedics.
PM&R is a great specialty for people who enjoy team approach in patient care, who loves to spend time interacting with therapists, speech pathologists, neuropsychologists, case managers, nurses, social worker, etc. Though, the specialty is promoting itself more and more as musculoskeletal specialists, and most graduates these days will move on to work in outpatient settings, concentrating on musculoskeletal, spine, sports and pain medicine. There are a lot of options, you don't work very hard and can make a decent living, well as least compare to primary care fields. No real emergencies, some practice settings will have no call and no weekends required.
On the other hand, some people will say PM&R physicians are not "real" doctors. They usually don't know enough about medicine to deal with complex medical problems. Some attendings will want their patient to be transfer out of their service for minor, easily correctable problems like dehydration, or will consider their patients ready to crash when they have a fever. This is their mind set. Everybody needs to have primariky no medical problems. They may know what the therapists do, but they have practically no role in hands on care. Some may not even know how to do the exercises. In short, you are the team leader, you over see how the team function and make sure everybody do their work correctly and coordinate the rehab process. In the outpatient settings, you see mostly musculoskeletal conditions like back pain, neck pain, shoulder pain. From time to time you will do a few steroid injections here and there. But most of the time, you are responsible to manage these condition conservatively and send the patient to therapies, get proper equipments like canes, scooters, walkers, splints, etc. You do however can be consider a specialist to perform EMG/nerve conduction studies. Since nobody assume you to be able to handle medical issues, nobody really bothers you.
Students should be careful that this is not a typical field of medicine, you may not feel like a physician at times. And the time that you spent dealing with direct patient care is minimal compare to your medical colleagues in other fields(at least in the inpatient settings).
People sometimes refer this as a best kept secret in medicine, or saying that it represents plenty of money and relaxation. Relaxation may be, but most medical and surgical specialists should still make more money than Physiatrists unless you become a pain and spine specialist. PM&R is still not a widely accepted field, not only in U.S., but worldwide. Some of the elite institutions has no PM&R department or would not recognize this as an individual specialty, but a division of Orthopedics.
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Hmm, interesting...I'll respond.
Okay, so far so good...
What does it mean to be a "real doctor?" Are pathologists real doctors? How about radiologists? Psychiatrists? I think that people confuse doing some interventional procedure with "real doctoring." It may pay well and be fun to stick a tube in an orifice, but certainly doctoring takes on many forms.
I think that this is an overstatement. Certainly physiatrists are no worse at punting patients to the internist than are orthopedic surgeons! I know orthopods who consult pulmonology if the patient coughs twice. Patients need to be medically stable in order to receive maximum benefit from rehabilitation. More importantly, hospitals lose money when patients are getting general medical care on rehabilitation units. They don't get reimbursed for things the same way they would if the patient were on a general medical floor being treated for a "medical issue." That being said, most physiatrists are comfortable with bread and butter general medicine work-ups and will get the ball rolling before calling the consultant.
Now think about it: Radiologists don't physically position patients the table an x-ray table or put patients in the CT scanner. Pulmonologists don't actually give albuterol nebulizer treatments, physically perform spirometry, or do percussion therapy to mobilize secretions; cardiologists rarely actually physically put the EKG leads on the patient to obtain a 12 lead EKG, and the list goes on and on. All of these tasks are adequately performed by well trained technicians and "allied health professionals." Physiatrists *PRESCRIBE* therapy. So could any doctor. Physiatrists could also order EKGs, spirometry, 3 views of the ankle, or breathing treatments. Does the fact that they don't actually physically do these things make them less of a doctor? Physiatrists steer the ship. They medically monitor and assess patients undergoing intensive rehabilitation. You need to have someone with sound medical judgment making these decisions---shouldn't it be a comprehensively trained physician who has specialized in rehabilitation medicine?
Well, again, physiatrists are conservative care specialists. This why they are highly sought after by multispecialty surgery groups who would rather have a physiatrist on board and perhaps a whole physical therapy/out patient rehabilitation facility than continually refer out these services and lose money. It's kind of the same reason why surgeons own outpatient surgery centers.
Physiatrists don't operate. If operating is important for you, then physiatry is not your kind of specialty. Most physiatrists in musculoskeletal medicine do much more than a few steriod injections---they comprehensively and nonoperative manage musculoskeletal conditions using therapeutic exercise, physical therapy, physical agents and modalities, manual medicine, drugs, assistive devices, athletic training, and mind-body approaches.
Well, again, let's think about it: Minimal call, above average compensation relative to primary care, specialty status and reimbursement, few emergencies, interesting and complex patient care issues (ever try to take care of a patient with a spinal cord injury or brain injury?), potential for subspecialty certification in pain, electrodiagnosis, sports, spinal cord injury, neurorehabilitation, or occupational medicine. Sure beats getting paid almost nada to work-up the COPDers at the hospital or having to see 30 patients per day as a doc-in-box. Physiatrists doing straight inpatient PM&R make about $140-160K. Add to that an outpatient practice, medical director stipends, medicolegal work, and it can be significantly more.
PM&R is an accepted field and one of the recognized 31 ABMS specialties in medicine! At some universities it's a division of orthopedics and at some places it's a free standing department. Hell, ortho is still a division of surgery at some medical schools and general surgeons will the first to remind you that up until the early 1900s fracture management was the sole responsibility of the general surgeon and orthopods did nothing but braces. So, I don't see where the academic affiliation of a field within an institution has anything to do with its how recognized it is.
PM&R is an evolving field. It's history traces back to the Mayo Clinic and NYU's Rusk Institute and Frank Krusen's and Howard Rusk's pioneering idea that there ought to be physicians specially trained in the application and appointment of physical agents of healing and the process of rehabilitation. The specialty flourished in the VA system and in the care of war wounded veterans. Now, the field continues to evolve in the direction of conservative care and functional restoration of individuals with impairments caused by diseases and injuries.
I do think that it is one of the best kept secrets in medicine and the field is now attracting a cadre of bright and enthusiastic young physicians. In the late 1960s, you couldn't give away a radiology spot, ortho was considered a specialty for jocks only (strong as an ox and half as smart), and any well trained internist would have laughed at the idea of doing a cardiology fellowship---I mean as far as cardiac meds there was nitroglycerin, hydralazine, and propranolol---that's it. Medicine is constantly evolving and changing. With the aging baby-boomers, advances in our understanding of pain and neuroplasticity; insights from latest studies in bioengineering, material sciences, and artificial limb technology; coupled with a demand for more "holistically" oriented patient care, I argue that the future for physiatry is indeed bright.
---------------------
"You don't get fine china by putting clay in the sun. You have to put the clay through the white heat of the kiln if you want to make porcelain. Heat breaks some pieces. Life breaks some people. Disability breaks some people. But once the clay goes through the white-hot fire and comes out whole, it can never be clay again; once a person overcomes a disability through his own courage, determination and hard work, he has a depth of spirit you and I know little about.
Rehabilitation is one branch of medicine in which the patient has more power than the doctor in setting the limits and possibilities. The doctor can tell the patient what to do, but only the patient himself can decide how much he's going to do. In making these decision, patients are constantly teaching us doctors new things about rehabilitation by proving that they can do more than we had presumed possible. "
?XHoward A. Rusk, M.D., 1948
"Rehabilitation is to be a master word in medicine."
?XWilliam Mayo, M.D., 1925
Okay, so far so good...
What does it mean to be a "real doctor?" Are pathologists real doctors? How about radiologists? Psychiatrists? I think that people confuse doing some interventional procedure with "real doctoring." It may pay well and be fun to stick a tube in an orifice, but certainly doctoring takes on many forms.
I think that this is an overstatement. Certainly physiatrists are no worse at punting patients to the internist than are orthopedic surgeons! I know orthopods who consult pulmonology if the patient coughs twice. Patients need to be medically stable in order to receive maximum benefit from rehabilitation. More importantly, hospitals lose money when patients are getting general medical care on rehabilitation units. They don't get reimbursed for things the same way they would if the patient were on a general medical floor being treated for a "medical issue." That being said, most physiatrists are comfortable with bread and butter general medicine work-ups and will get the ball rolling before calling the consultant.
Now think about it: Radiologists don't physically position patients the table an x-ray table or put patients in the CT scanner. Pulmonologists don't actually give albuterol nebulizer treatments, physically perform spirometry, or do percussion therapy to mobilize secretions; cardiologists rarely actually physically put the EKG leads on the patient to obtain a 12 lead EKG, and the list goes on and on. All of these tasks are adequately performed by well trained technicians and "allied health professionals." Physiatrists *PRESCRIBE* therapy. So could any doctor. Physiatrists could also order EKGs, spirometry, 3 views of the ankle, or breathing treatments. Does the fact that they don't actually physically do these things make them less of a doctor? Physiatrists steer the ship. They medically monitor and assess patients undergoing intensive rehabilitation. You need to have someone with sound medical judgment making these decisions---shouldn't it be a comprehensively trained physician who has specialized in rehabilitation medicine?
Well, again, physiatrists are conservative care specialists. This why they are highly sought after by multispecialty surgery groups who would rather have a physiatrist on board and perhaps a whole physical therapy/out patient rehabilitation facility than continually refer out these services and lose money. It's kind of the same reason why surgeons own outpatient surgery centers.
Physiatrists don't operate. If operating is important for you, then physiatry is not your kind of specialty. Most physiatrists in musculoskeletal medicine do much more than a few steriod injections---they comprehensively and nonoperative manage musculoskeletal conditions using therapeutic exercise, physical therapy, physical agents and modalities, manual medicine, drugs, assistive devices, athletic training, and mind-body approaches.
Well, again, let's think about it: Minimal call, above average compensation relative to primary care, specialty status and reimbursement, few emergencies, interesting and complex patient care issues (ever try to take care of a patient with a spinal cord injury or brain injury?), potential for subspecialty certification in pain, electrodiagnosis, sports, spinal cord injury, neurorehabilitation, or occupational medicine. Sure beats getting paid almost nada to work-up the COPDers at the hospital or having to see 30 patients per day as a doc-in-box. Physiatrists doing straight inpatient PM&R make about $140-160K. Add to that an outpatient practice, medical director stipends, medicolegal work, and it can be significantly more.
PM&R is an accepted field and one of the recognized 31 ABMS specialties in medicine! At some universities it's a division of orthopedics and at some places it's a free standing department. Hell, ortho is still a division of surgery at some medical schools and general surgeons will the first to remind you that up until the early 1900s fracture management was the sole responsibility of the general surgeon and orthopods did nothing but braces. So, I don't see where the academic affiliation of a field within an institution has anything to do with its how recognized it is.
PM&R is an evolving field. It's history traces back to the Mayo Clinic and NYU's Rusk Institute and Frank Krusen's and Howard Rusk's pioneering idea that there ought to be physicians specially trained in the application and appointment of physical agents of healing and the process of rehabilitation. The specialty flourished in the VA system and in the care of war wounded veterans. Now, the field continues to evolve in the direction of conservative care and functional restoration of individuals with impairments caused by diseases and injuries.
I do think that it is one of the best kept secrets in medicine and the field is now attracting a cadre of bright and enthusiastic young physicians. In the late 1960s, you couldn't give away a radiology spot, ortho was considered a specialty for jocks only (strong as an ox and half as smart), and any well trained internist would have laughed at the idea of doing a cardiology fellowship---I mean as far as cardiac meds there was nitroglycerin, hydralazine, and propranolol---that's it. Medicine is constantly evolving and changing. With the aging baby-boomers, advances in our understanding of pain and neuroplasticity; insights from latest studies in bioengineering, material sciences, and artificial limb technology; coupled with a demand for more "holistically" oriented patient care, I argue that the future for physiatry is indeed bright.
---------------------
"You don't get fine china by putting clay in the sun. You have to put the clay through the white heat of the kiln if you want to make porcelain. Heat breaks some pieces. Life breaks some people. Disability breaks some people. But once the clay goes through the white-hot fire and comes out whole, it can never be clay again; once a person overcomes a disability through his own courage, determination and hard work, he has a depth of spirit you and I know little about.
Rehabilitation is one branch of medicine in which the patient has more power than the doctor in setting the limits and possibilities. The doctor can tell the patient what to do, but only the patient himself can decide how much he's going to do. In making these decision, patients are constantly teaching us doctors new things about rehabilitation by proving that they can do more than we had presumed possible. "
?XHoward A. Rusk, M.D., 1948
"Rehabilitation is to be a master word in medicine."
?XWilliam Mayo, M.D., 1925
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howdy, something to add here, from my own experiences and conversations with classmates. I think the potential for creativity and/or flexibility in this field might be greater than others-and of course this is one of the many things that attracted me to it.
For instance, I've had discussions with classmates regarding various classes from MS2. There seemed to be this polarization, some people loved psych precisely because there is still so much not yet known, and so many ways to approach problems, whereas others hated it for this same reason. The latter were more likely to have enjoyed cardio, since in a lot of the situations things are pretty clear cut, this is the diagnosis, this is what can happen, this is how we treat it, etc etc, there is a lot less , well, fuzziness. I would venture to say that PM&R is a lot more like psych in some ways, or at least has the potential for more situations as described above(though not always the case of course). Pain and disability are complex, there often are no clear cut solutions, and there are a variety of modalities that might be attempted while ascertaining the patient's goals. I think some people(as mentioned above), tend to get frustrated at this sorta , for lack of a better articulation, potentially "fuzzy" kinda situation, whereas others are inspired to tackle it. This is not to say that the former arent interested in "complex" situations, but rather , more well-defined situations, if that makes any sense.. anyone?
In regard to the prescribing p/t stuff, i'm not sure how it's different than any other type of doc prescribing anything else(i.e. meds). The difference may be that improvement might take awhile and be more long-term, some people are frustrated by incremental improvement. If you want instant gratification, PM&R probably isn't right for you. Granted some of this was mentioned above..as well as the procedure stuff, I know plenty of psyiatrists, who do mostly musculoskeltal stuff, who actually spend a good deal of their time with trigger point injections, botox, EMGs and so on, along with all the other ortho-related stuff they do(and no they didnt do a pain fellowship), so i wouldnt say its an occasional steroid injection once in awhile, but granted this is in a major city with an affiliation with a major teaching institution, which brings in more varied and complicated cases......
there really are so many options in PM&R it's probably just as appropriate to talk about the pros and cons of those roles...While I think I'd really enjoy work in spinal cord injury and traumatic brain injury from what I've seen so far-you obviously dont get to make a diagnosis(granted, you can figure what's happening subsequently). One of the most fun parts of medicine so far, for me has been learning to generate a diagnosis(even a "fuzzy" one, heh), and perhaps this is one reason why I might chose outpatient musculoskeletal stuff vs. inpatient...but who knows..
ok
any comments/confirmations/arguments appreciated.
scm
For instance, I've had discussions with classmates regarding various classes from MS2. There seemed to be this polarization, some people loved psych precisely because there is still so much not yet known, and so many ways to approach problems, whereas others hated it for this same reason. The latter were more likely to have enjoyed cardio, since in a lot of the situations things are pretty clear cut, this is the diagnosis, this is what can happen, this is how we treat it, etc etc, there is a lot less , well, fuzziness. I would venture to say that PM&R is a lot more like psych in some ways, or at least has the potential for more situations as described above(though not always the case of course). Pain and disability are complex, there often are no clear cut solutions, and there are a variety of modalities that might be attempted while ascertaining the patient's goals. I think some people(as mentioned above), tend to get frustrated at this sorta , for lack of a better articulation, potentially "fuzzy" kinda situation, whereas others are inspired to tackle it. This is not to say that the former arent interested in "complex" situations, but rather , more well-defined situations, if that makes any sense.. anyone?
In regard to the prescribing p/t stuff, i'm not sure how it's different than any other type of doc prescribing anything else(i.e. meds). The difference may be that improvement might take awhile and be more long-term, some people are frustrated by incremental improvement. If you want instant gratification, PM&R probably isn't right for you. Granted some of this was mentioned above..as well as the procedure stuff, I know plenty of psyiatrists, who do mostly musculoskeltal stuff, who actually spend a good deal of their time with trigger point injections, botox, EMGs and so on, along with all the other ortho-related stuff they do(and no they didnt do a pain fellowship), so i wouldnt say its an occasional steroid injection once in awhile, but granted this is in a major city with an affiliation with a major teaching institution, which brings in more varied and complicated cases......
there really are so many options in PM&R it's probably just as appropriate to talk about the pros and cons of those roles...While I think I'd really enjoy work in spinal cord injury and traumatic brain injury from what I've seen so far-you obviously dont get to make a diagnosis(granted, you can figure what's happening subsequently). One of the most fun parts of medicine so far, for me has been learning to generate a diagnosis(even a "fuzzy" one, heh), and perhaps this is one reason why I might chose outpatient musculoskeletal stuff vs. inpatient...but who knows..
ok
any comments/confirmations/arguments appreciated.
scm
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oops, forgot to add, as far as a con is concerned.....
i''ve always been interested in working with the underserved (i.e. homeless, uninsured, doctors w/out borders etc etc) and have done so quite a bit in school. Initially I was interested in EM and FP, I had had exposure to both, and in that capacity I think it would be a lot easier to do the aforementioned type of stuff. I'm not sure what kinda opportunities there are for physiatrists in this regard, I've asked around, and have gotten assurences but no concrete, well, examples of people involved in things. Obviously if a physiatrist showed up in some developing country and was like "hey how can I help", it would kinda be unclear in what capacity + how that would work out. Of course this doc would be well, less potentially useful in a general sense, but perhaps there are specific charitable organizations/programs where they might be of help....this is one of the main things kinda bugging me about PM&R.
...artificial limbs and such are one way i could see them being of great help...some people on here sent me some contacts who might know of such things(thanks!), and i've still got to e-mail a few of them....
take care
scm
i''ve always been interested in working with the underserved (i.e. homeless, uninsured, doctors w/out borders etc etc) and have done so quite a bit in school. Initially I was interested in EM and FP, I had had exposure to both, and in that capacity I think it would be a lot easier to do the aforementioned type of stuff. I'm not sure what kinda opportunities there are for physiatrists in this regard, I've asked around, and have gotten assurences but no concrete, well, examples of people involved in things. Obviously if a physiatrist showed up in some developing country and was like "hey how can I help", it would kinda be unclear in what capacity + how that would work out. Of course this doc would be well, less potentially useful in a general sense, but perhaps there are specific charitable organizations/programs where they might be of help....this is one of the main things kinda bugging me about PM&R.
...artificial limbs and such are one way i could see them being of great help...some people on here sent me some contacts who might know of such things(thanks!), and i've still got to e-mail a few of them....
take care
scm
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I have been reading a lot about the pros and cons of PM&R and I can definitely see why there is all the hype.
However, there is still one issue that bugs me about the specialty... RESPECT! Physiatrist get no respect from other physicians. In general (I'm not talking about individual experiences), other specialties seem to frown upon PM&R docs. I've heard things from Physical Therapist doctors to Poor man version of Orthopods.
What do you guys think about this issue? Is it just my institution (I am in a top 10 school) and the aggrogance around here or is this a common problem? Even among my class, I think I am the only one contemplating a career in PM&R.
However, there is still one issue that bugs me about the specialty... RESPECT! Physiatrist get no respect from other physicians. In general (I'm not talking about individual experiences), other specialties seem to frown upon PM&R docs. I've heard things from Physical Therapist doctors to Poor man version of Orthopods.
What do you guys think about this issue? Is it just my institution (I am in a top 10 school) and the aggrogance around here or is this a common problem? Even among my class, I think I am the only one contemplating a career in PM&R.
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i've heard that occasionally too, the respect thing, but not nearly as much as in reference to FP for instance, or Psych, or especially EM. To some degree, I think it really depends where you are at specifically(institutions with an entire rehab freestanding hospital for instance), and in terms of region (this is especially true in reference to FP, it probably one of the most respected in certain places).
this kinda thing really isn't important to me, i didnt go into medicine for respect or prestige,and it seems kinda silly to make a decision with that in mind...so I haven't asked around about it. whenever i goto an "interest group" meeting at my school, someone from every specialty always bashes other specialties etc etc and says why they are better and more qualified to deal with so and so etc etc, with the exception of meetings for FP, Peds, and PM&R. heh. that type of thing always seemed to me more about people feeling insecure about themselves, but i dunno....
granted not many people from my school go into PM&R either, but I wouldn't say this is because of the respect issue. I think partially its due to lack of exposure, it's not a required rotation at most schools so many people never check it out, of course there are other things that are not appealing about it, that I've mentioned above....
i really should go study.
scm
this kinda thing really isn't important to me, i didnt go into medicine for respect or prestige,and it seems kinda silly to make a decision with that in mind...so I haven't asked around about it. whenever i goto an "interest group" meeting at my school, someone from every specialty always bashes other specialties etc etc and says why they are better and more qualified to deal with so and so etc etc, with the exception of meetings for FP, Peds, and PM&R. heh. that type of thing always seemed to me more about people feeling insecure about themselves, but i dunno....
granted not many people from my school go into PM&R either, but I wouldn't say this is because of the respect issue. I think partially its due to lack of exposure, it's not a required rotation at most schools so many people never check it out, of course there are other things that are not appealing about it, that I've mentioned above....
i really should go study.
scm
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I am glad I generated some interesting discussions. After all, this board should consist both the positives and negatives. And the future physicians should make decisions about their specialty primarily because of their interests and dedication to the field. Since PM&R is a relatively unknown field to most, I want to try to give you the other side of the story.
David, as the moderator, certainly has done his homework and I can tell he is dedicated, but to most, you are still seraching and exploring the field. So here are some more things that you should know.
1) PM&R is not a specialty about respect. If you care about respect and glory, you should stick with the traditional medical fields like medicine and surgery(yes even psychiatry and neurology), where you can make direct impact in saving lives. I am at a top university/hospital in the nation. Our students don't do PM&R. I only knew less than a handful who did in the last 5-6 years. And our PM&R department did try to evolve out of the shadow of Orthopedics, but failed(David, you just haven't seen enough!). Many foreign countries have no such specialty and most of the general public has no idea who physiatrists are. In fact, many physicians don't understand what physiatrists do.
2) PM&R doctors, in GENERAL lack basic medical knowledge. The residency requires 1 year of preliminary medicine, surgery, transitional year, etc. It particularly bothers me that people who prepare to do PM&R want to spend their preliminary year in the easiest program where they practically don't want to do anything. I as a surgeon, at one time, bailed out a PM&R resident AND the attending when they were treating a patient with Lasix for CHF and shortness of breath. I came and immediately order an EKG, cardiac enzymes, and the results, you should know...... I always tell my medical students, ones clinical skills and knowledge directly proportional to the time they spend in the hospital and the patients they have seen.
3) PM&R prescribes therapies and modalities for musculoskeletal conditions. Well, this is not rocket science. You can't compare others who precribe medicine because there are many different medical conditions with hundreds of drugs to choose from, you have to consider the side effects profile. In PM&R, you almost can go no wrong to offer physical therapies to all those who come through your door for musculoskeletal conditions. On top of it, therapies may not help musculoskeletal illness, it is however, a way to start.
4) There is still controversies about what's the value of inpatient rehab. All patients, given time, will get better one way or the other. In fact, in 1900, PM&R probably don't even exist. Inpatient rehab is a place to make people work-out and motivate them to keep mobile, learn about compensation techniques. There are criterias to get admitted to rehab and not everybody that needs rehab is eligible.
5) I disagree PM&R is attracting a cadre of bright young physicians. However, I think more and more PM&R applicants are above average students, which is encouraging. Nevertheless, PM&R is still a haven for IM, surgery drop-outs, surgery and surgical subspecialties rejects, as well as a hot pursuit for many FMGs. You still hear PM&R residents whine and complaints about working too hard(8-5pm?? or even leave in early afternoons!), refuse to come in to see patients or follow-up labs or studies they ordered after-hours. My perception is these are really a lazy bunch!
In conclusion, keep an open-mind. PM&R may surprise some poeple in a negative way. You need to have an idea about this field and should do some research. Yet, I think the specialty will continue to grow and generates increasing interests, but it will remain an easy match at least for the next few yeras.
David, as the moderator, certainly has done his homework and I can tell he is dedicated, but to most, you are still seraching and exploring the field. So here are some more things that you should know.
1) PM&R is not a specialty about respect. If you care about respect and glory, you should stick with the traditional medical fields like medicine and surgery(yes even psychiatry and neurology), where you can make direct impact in saving lives. I am at a top university/hospital in the nation. Our students don't do PM&R. I only knew less than a handful who did in the last 5-6 years. And our PM&R department did try to evolve out of the shadow of Orthopedics, but failed(David, you just haven't seen enough!). Many foreign countries have no such specialty and most of the general public has no idea who physiatrists are. In fact, many physicians don't understand what physiatrists do.
2) PM&R doctors, in GENERAL lack basic medical knowledge. The residency requires 1 year of preliminary medicine, surgery, transitional year, etc. It particularly bothers me that people who prepare to do PM&R want to spend their preliminary year in the easiest program where they practically don't want to do anything. I as a surgeon, at one time, bailed out a PM&R resident AND the attending when they were treating a patient with Lasix for CHF and shortness of breath. I came and immediately order an EKG, cardiac enzymes, and the results, you should know...... I always tell my medical students, ones clinical skills and knowledge directly proportional to the time they spend in the hospital and the patients they have seen.
3) PM&R prescribes therapies and modalities for musculoskeletal conditions. Well, this is not rocket science. You can't compare others who precribe medicine because there are many different medical conditions with hundreds of drugs to choose from, you have to consider the side effects profile. In PM&R, you almost can go no wrong to offer physical therapies to all those who come through your door for musculoskeletal conditions. On top of it, therapies may not help musculoskeletal illness, it is however, a way to start.
4) There is still controversies about what's the value of inpatient rehab. All patients, given time, will get better one way or the other. In fact, in 1900, PM&R probably don't even exist. Inpatient rehab is a place to make people work-out and motivate them to keep mobile, learn about compensation techniques. There are criterias to get admitted to rehab and not everybody that needs rehab is eligible.
5) I disagree PM&R is attracting a cadre of bright young physicians. However, I think more and more PM&R applicants are above average students, which is encouraging. Nevertheless, PM&R is still a haven for IM, surgery drop-outs, surgery and surgical subspecialties rejects, as well as a hot pursuit for many FMGs. You still hear PM&R residents whine and complaints about working too hard(8-5pm?? or even leave in early afternoons!), refuse to come in to see patients or follow-up labs or studies they ordered after-hours. My perception is these are really a lazy bunch!
In conclusion, keep an open-mind. PM&R may surprise some poeple in a negative way. You need to have an idea about this field and should do some research. Yet, I think the specialty will continue to grow and generates increasing interests, but it will remain an easy match at least for the next few yeras.
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wow awesome.
you should stick with the traditional medical fields like medicine and surgery(yes even psychiatry and neurology), where you can make direct impact in saving lives.
ah i see. i would venture to say that in most instances IM people and many surgeons i met have absolutely no impact on saving lives. especially in an outpatient setting. if thats what important to you a-ok. i suppose PM&R is just concerned with helping people regain their lives.
I am at a top university/hospital in the nation. Our students don't do PM&R.
what does "do PM&R" mean?
I only knew less than a handful who did in the last 5-6 years.
thats interesting, I'm at a "top hospital" as well (according to US NEws BS), I think only maybe like 4-5 people out of a 100 went into surgery last year. i only know a few people who actually want to be surgeons. i think only 2-3 per yr go into FP...
In fact, many physicians don't understand what physiatrists do.
good point. i would venture to say, yourself included.
PM&R doctors, in GENERAL lack basic medical knowledge.
nice! all of them? amazing. lack of all basic medical knowledge?
The residency requires 1 year of preliminary medicine, surgery, transitional year, etc.
so would this assertion hold true for other specialties that require a prelim year? everyone lacks basic medical knowledge?
I as a surgeon, at one time, bailed out a PM&R resident AND the attending when they were treating a patient with Lasix for CHF and shortness of breath. I came and immediately order an EKG, cardiac enzymes, and the results, you should know
excellent generalization from one single experience. i guess you save lives.
PM&R prescribes therapies and modalities for musculoskeletal conditions. Well, this is not rocket science. You can't compare others who precribe medicine because there are many different medical conditions with hundreds of drugs to choose from, you have to consider the side effects profile.
what's rocket science? removing gallbladders all day? there aren't many different neuro/musculoskeletal conditions that require some expertise to manage as inpatient or outpatient?
There is still controversies about what's the value of inpatient rehab.
care to elaborate? cite some examples? studies? I don't know what Harvard is thinking, having an entire rehab hospital essentially. Is Harvard a "top hospital/university"?
All patients, given time, will get better one way or the other.
that statement seems really naive.
i'm not gonna touch it. i dont have time. anyone else?
In fact, in 1900, PM&R probably don't even exist.
really I'm not sure what difference this makes, most of what is medicine today didn't exist in 1900. it would help if you looked over your post/english after you write long msgs, all the grammar mistakes make it seem as though you really didn't think much about what you were writing.
Inpatient rehab is a place to make people work-out and motivate them to keep mobile, learn about compensation techniques. There are criterias to get admitted to rehab and not everybody that needs rehab is eligible.
sometimes. it seems as though you haven't had any exposure to what PM&R docs do on an outpatient basis, all along it seems as though all you are talking about is inpatient rehab no?
anyone else care to respond? to this? or anything above by anyone else... much thanks
scm
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I think the bottom line for any MS2 or MS3 is to get as much input/info from others as you want, but wait until you actually do a rotation in the field before making a decision as to what you want to go into "FOR THE REST OF YOUR CAREER". It isn't a decision that should be effected by what other's perception of you is, what your classmates think about your chosen field, etc. You should find something that YOU enjoy and YOU can see yourself doing for 30+ years. And you'll see a small taste of that during your 3rd year rotations.
I really don't have a problem with what Surgery said, because it's a good counterpoint/argument to those who promote PMR. I would like to add that there are also some regional biases that may be going on. Where I'm going to school, there are four residency programs in PMR within 100 miles, and all the major academic centers in the area have free-standing PMR departments (including a top-10 institution, UMich), so Surgery's viewpoints may not be representative of all other surgeons.
I think the only problem I DO have with what Surgery said was the idea that only PMR residents scout for easy transitional spots. MOST residents from EVERY residency that requires a transitional year do this. However, it probably isn't as good an idea for future PMRs, because, like Surgery points out, you WILL have sick patients on the inpt. rehab floor, and the medical call team may not always be available...
Just the viewpoints of a soon-to-be MS4 and PMR resident
I really don't have a problem with what Surgery said, because it's a good counterpoint/argument to those who promote PMR. I would like to add that there are also some regional biases that may be going on. Where I'm going to school, there are four residency programs in PMR within 100 miles, and all the major academic centers in the area have free-standing PMR departments (including a top-10 institution, UMich), so Surgery's viewpoints may not be representative of all other surgeons.
I think the only problem I DO have with what Surgery said was the idea that only PMR residents scout for easy transitional spots. MOST residents from EVERY residency that requires a transitional year do this. However, it probably isn't as good an idea for future PMRs, because, like Surgery points out, you WILL have sick patients on the inpt. rehab floor, and the medical call team may not always be available...
Just the viewpoints of a soon-to-be MS4 and PMR resident
I think it's true that PM&R docs get less respect sometimes. The problem is that we do so many things, ie. jack of all trades, master of none kind of thing.
Would I have done it again? Probably.
Do I feel insecure about mysfelf as a doctor? Sometimes. Many other specialties do as well.
Have I been able to help people that have seen 3-4 other doctors? Every day.
Would I have done it again? Probably.
Do I feel insecure about mysfelf as a doctor? Sometimes. Many other specialties do as well.
Have I been able to help people that have seen 3-4 other doctors? Every day.
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Nice discussion.
As a person who has chosen this specialty and quite satisfied with the choice, I have some advise for all parties: you would never know about the other specialty unless you are in it. There are many knowlable surgeons and they?re any many stupid ones. There are plenty of excellent physiatrists and there are many awful ones as well. There are many high tech, acute level rehab facility, which handle complex medical patients, and there are rehab centers that deserve being closed since they simply suck. Generalizing in this case is just immature.
Currently at the place I work, we have physiatrists that income wise, they put surgeons and radiologists to shame. Talk about 500k. It is certainly possible if you are good, have the right qualifications, have a good personality, and well-trained. No calls, No stress, 9-5 job, minimal malpractice.
I believe this is a better deal compare to many hours standing and stressful lifestyle, with calls and critical patients and.... If someone gets excited with that, all powers to them but personally I like the 9-5 no call, clinic based, EMG and Spine interventions better.
Don?t forget, it is not late to convert. There is a light at the end of the tunnel. hehehehe
good luck to all of you.
rehabdoc
As a person who has chosen this specialty and quite satisfied with the choice, I have some advise for all parties: you would never know about the other specialty unless you are in it. There are many knowlable surgeons and they?re any many stupid ones. There are plenty of excellent physiatrists and there are many awful ones as well. There are many high tech, acute level rehab facility, which handle complex medical patients, and there are rehab centers that deserve being closed since they simply suck. Generalizing in this case is just immature.
Currently at the place I work, we have physiatrists that income wise, they put surgeons and radiologists to shame. Talk about 500k. It is certainly possible if you are good, have the right qualifications, have a good personality, and well-trained. No calls, No stress, 9-5 job, minimal malpractice.
I believe this is a better deal compare to many hours standing and stressful lifestyle, with calls and critical patients and.... If someone gets excited with that, all powers to them but personally I like the 9-5 no call, clinic based, EMG and Spine interventions better.
Don?t forget, it is not late to convert. There is a light at the end of the tunnel. hehehehe
good luck to all of you.
rehabdoc
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Let's get real here folks, PM&R salaries putting radiology salaries to shame? Not even close.
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i have to agree with alex. maybe a pm&r doc who has done a pain management fellowship make rake in $500,000 a yr.
but the average pm&r doc does not make anywhere close to that. radiology is a hot ticket right now, with salaries to match. its cool to be pro-pm&r, but its absurd to generalize that pm&r salaries are putting radiology salaries to shame.
rehabdoc, if that is the case at ur hospital, those pm&r docs are the luckiest docs i have ever heard of.
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I don't understand your values. As my grandmother used to say, "...they've got the same pants to be glad in," which is just a folksy way of saying, "So, what." So, because some people don't understand or have knowledge of what physiatrists do, and in turn don't respect the specialty, this should be a reason for not pursuing a medical career that has other very significant positive attributes including 1) above average compensation relative to primary care, 2) interesting and complex patient care issues, 3) subspecialty training and certification, 4) above average demand (I can post the data showing that the demand for physiatrists is increasing relative to other medical specialties primarily due to an aging population and improved survival of patients with chronic, debilitating diseases.)?
Physiatrists may not routinely save lives, but we save quality of life. This is comes at a huge benefit to patients. At the hospital where I work, PM&R is an integral component of full spectrum trauma care. Physiatrists see all acute spinal cord injuries, brain injuries, and multiple orthopedic trauma and begin planning a rehabilitation program from day one. In an incomplete spinal cord injuries, for example, aggressive rehabilitation can make the difference between preserving enough adductor or hip flexor power to allow a patient to lift a lower extremity 6 inches of the ground and tie his shoes. This, in turn, translates into functional gains that will eventually allow a patient to return work (or be vocationally retrained) as computer programmer or other upper-extremity dominant field despite having to use a wheelchair for mobility.
Glory? That's the knowledge that comes from knowing that someone can sustain a catastrophic injury such a spinal cord injury and return to society as a productive, high functioning human being who is still able to provide for his family and feel a sense of self-esteem in the world despite his disability.
Physicians respect fellow physicians not on the basis of their specialty, but on the basis of their competence, compassion, and efficiency. As a general surgeon, who do you respect more:
A) a family physician who promptly returns your call regarding a patient you seen in the ER for an emergency appendectomy and is able to give you an updated medicine list, list on-going chronic medical conditions, and a reminder that the patient had an "untoward" side effect to cephalosporins. (Better have the anesthesiologist hold that 1 gram of Ancef.)
**OR**
B) a neurosurgeon widely known to be disruptive and abusive in OR who refuses to come in and see a trauma patient in the ICU with altered mental status and a clinical picture worrisome for cerebral edema. After multiple attempts to reach him he finally returns your page and curtly instructs to just start mannitol and he'll have his PA see him in the morning.
Not surprising that few countries have a specialty such as PM&R when the USA leads the world in technologically sophisticated medicine, assistive technology, and biomechanical engineering. Yes, it's true that there are no physiatrists in Jakarta, but that doesn't mean that Indonesians wouldn't benefit from rehabilitation.
Finally, if you're going to make the ad hominem argument that I haven't "seen enough" perhaps you should know a little more about me: I graduated cum laude from UC Berkeley, worked in multiple sclerosis research at UCSF before medical school, graduated with three degrees including a DO, a MPH, and a MS in clinical research (as part of a K-30 NIH training program in complementary and alternative medicine); have authored 9 papers and 2 book chapters on manual medicine; and am pursuing a residency in PM&R at the Mayo Clinic (the country's oldest PM&R training program). I've been around a little...
You cannot make that generalization. Do you know how often physiatrists "pick-up" general medical conditions that have been unaddressed during a patient's acute hospital stay? Very often. There are good and bad doctors (and surgeons) everywhere. I've seen surgeons medically mismanage patients. We all have horror stories. Whether or not there should be more general medical training a PM&R residency program is open to debate. To generalize that all physiatrists lack sufficient general medical knowledge is ridiculous.
Physiatry is a cognitive specialty. It's a problem solving specialty. If you think that it amounts to walking out into the waiting room and throwing canes and walkers at people you misunderstand what PM&R specialists do. The process of functional restoration and rehabilitation is not the same taking out a gallbladder. Again, referring to a previous post, disability is a complex biopsychosocial issue. Physiatrists are physicians trained to recognize and treat disability.
Laproscopes probably didn't exist around 1900 either. Does that mean that laproscopes are not valuable? The documented benefits of a comprehensive, medically-supervised, rehabilitation program for a variety of conditions is enormous. You will have to do the literature search yourself. People just don't "get better" from a spinal cord injury on their own. Nor stroke, nor brain injury, nor trauma. Time and time again, medically supervised rehabilitation programs have been shown to decrease disability, improve functional outcomes, increase independence, and promote healthier psychological adjustment to disability. Yes, it is true that there exists a large unmet need for intensive rehabilitation. That's because rehab is expensive, time and personnel intensive, and requires well-developed institutional resources and infrastructure to be maximally beneficial.
Okay, let's examine some of these slack-jawed, lazy, bottom of the barrell, rejects who make a home for themselves in this wasteland specialty called physiatry...
David Kilmer, MD
Gordon Matheson, MD, PhD
Mark Harrast, MD
Joel M. Press, MD
Andy Haig, MD
Daniel Dumitru, MD, PhD
John Whyte, MD, PhD
.Thomas C. Apostle, DO
...and the list goes on and on. These are all mid-career physiatrists on the cutting edge of rehabilitation research and practice. What a bunch of losers!
"...may surprise some people in a negative way." Hmm, sounds like my third-year surgery clerkship. What's wrong with a field being an easy match? Are radiologists really better doctors because thousands of students are climbing all over themselves to get a match? How about dermatologists? Competition does promote selectivity, but one has to always ask, "Exactly **WHAT** is being selected for in the process?" I encourage medical students to learn more about the field too---it's a small field and it doesn't adequately promote itself. I think that when most people understand what physiatrists do, and who we take care of, they regard us the same way as radiation or medical oncologists...sure they provide valuable medical services, but you sort of hope that you never find yourself in personal life circumstances such that you require their care
B
briandavis
Dear Thread Readers:
I read with utter disappointement the entire set of threads from the surgeon wholly discrediting the field of Physical Medicine and Rehabilitation. That is tantamount to saying that all Jell-O is bad or that all politicians are evil.
For those considering PM&R as a specialty - ignore what the surgeon has to say. My grades and board scores were very good and I was heavily recruited by Internal Medicine, Orthopedic Surgery and PM&R programs. Many of my colleagues have identical credentials. You do not NEED those marks to become a PM&R physician - because PM&R physicians need to talk to their patients. That isn't something that is learned from books.
PM&R is a specialty that is very broad, with ability to go in any direction you want to take it. Our training programs vary in caliber, as with any specialty. You will be respected as a physician by being a physician with caring, compassion and intellect. You must respect yourself before you can learn to respect others.
You will learn exactly what you need to learn to do Sports Medicine, Amputee, Head Injury, Stroke, or any other subspecialty area you chose if you go to a good program and study.
For those interested in PM&R - do yourself a favor and spend at least 2 weeks in a rotation to see what it's all about. Pick a program that's well-respected. See if I'm not telling you the truth.
Feel free to write me directly at [email protected]
I read with utter disappointement the entire set of threads from the surgeon wholly discrediting the field of Physical Medicine and Rehabilitation. That is tantamount to saying that all Jell-O is bad or that all politicians are evil.
For those considering PM&R as a specialty - ignore what the surgeon has to say. My grades and board scores were very good and I was heavily recruited by Internal Medicine, Orthopedic Surgery and PM&R programs. Many of my colleagues have identical credentials. You do not NEED those marks to become a PM&R physician - because PM&R physicians need to talk to their patients. That isn't something that is learned from books.
PM&R is a specialty that is very broad, with ability to go in any direction you want to take it. Our training programs vary in caliber, as with any specialty. You will be respected as a physician by being a physician with caring, compassion and intellect. You must respect yourself before you can learn to respect others.
You will learn exactly what you need to learn to do Sports Medicine, Amputee, Head Injury, Stroke, or any other subspecialty area you chose if you go to a good program and study.
For those interested in PM&R - do yourself a favor and spend at least 2 weeks in a rotation to see what it's all about. Pick a program that's well-respected. See if I'm not telling you the truth.
Feel free to write me directly at [email protected]
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Dear Dr. Davis,
It is nice to see you continue to check in on this forum as well as on POL.
We would like to see you be more active in these discussions, as there are few to no PM&R attending level physicians on the SDN PM&R forum.
Your comments are always well put and appreciated. Please feel welcome to become more involved time permitting.
All the best,
Ligament, PM&R resident
It is nice to see you continue to check in on this forum as well as on POL.
We would like to see you be more active in these discussions, as there are few to no PM&R attending level physicians on the SDN PM&R forum.
Your comments are always well put and appreciated. Please feel welcome to become more involved time permitting.
All the best,
Ligament, PM&R resident
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Welcome Dr. Davis, nice to have you aboard.
--David
--David
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