basic questions about PM&R

[zer0el]

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hey all, i'm a first year med student who's trying to find out more about PM&R. this specialty isn't really discussed much among my peers, so i thought maybe you guys can help. i've got some basic questions to get me started.

1. PM&R's description sounds great (helping people improve their quality of life). however, do you ever find it slow or boring since you see patients over the course of several weeks, months, etc. as opposed to the quicker pace of IM or surgery.

2. how did you decide that PM&R was for you? i know that it's still early for me at this point, but i'm also interested in ortho and IM.

3. how competitive is it to match? i'm in a CA med school and would like to stay in state for residency. are AOA and 240+ common?

4. what are some negative aspects of PM&R?

thank you for your time!

 

[Stinky Tofu]

1. Physical Medicine & Rehabilitation is actually a pretty broad field. When most medical students think of PM&R they often just think of the inpatient rehabilitation aspects of the specialty. The day-to-day aspects of inpatient rehabilitation is definitely a slower pace than surgery or the ICU. However, proper initial management of the patient can have a huge effect on their functional recovery. The Physical Medicine aspects of the specialty (whether it be inpatient or outpatient) can involve a lot of procedures which can have a quicker impact on the patient. These procedure include trigger points, joint injections, EMGs, IDETs, SNRB, Radiofrequency rhizotomies, Botox, Phenol, Epidurals, facet injections, etc. A few of the residents in my year actually prefer the pace of inpatient rehabilitation. Personally, I am more interested in Interventional Physiatry and want an outpatient practice in the future.

2. I think I was fortunate because I met a lot of Physiatrists during medical school while I was doing other rotations.

3. In general, PM&R isn't that competitive. You don't have to be AOA with 240+. As with other specialties, the top programs are pretty competitive. Also, I've heard that this year's match will be much more competitve than previous years. Speaking of CA schools, the CA students that have rotated at our program have all said that there are many more students applying this year. With regards to the programs in CA, they are probably moderately competitive when compared to other PM&R programs. This is mainly because of the few spots available and the location. Stanford and UCLA are probably the most competitive ones in CA.

4. Within the field itself, I haven't found a whole lot of negatives. The negatives that I think the field suffers from in general is lack of understanding with regards to the role of the Physiatrist.

 

[drusso]

I agree with Stinky. A big plus for me is that PM&R is a specialty with a "controllable lifestyle." You can do so many different things with it ranging from running an inpatient rehabilitation unit and being a neurorehabilitation specialist to working in a multispecialty orthopedic group and being the conservative care specialist.

Lack of visability is probably the biggest negative. The joke among my resident colleagues is when seeing consults on some of the med-surg floors other residents from other services will ask, "Oh what service are you with?" Replying "PM&R..." some times gets you a blank stare and a retort along the lines of, "What does the 'N' stand for?" The AAPM&R is trying to address this issue, but the specialty is a small one.

 

[zer0el]

thank you all for your great responses. whenever i talk about PM&R with others, i get the impression that they think it's all about physical therapy. i've seen some terms floating around such as EMG and other procedures done in an outpatient setting. are outpatient procedures what ultimately separate a physiatrist from a PT? 4 years of med school + 4 years of residency is a long time to be doing what a PT does... thanks for clarifying.

 

[Stinky Tofu]

PM&R is not just about physical therapy and outpatient procedures. You can start by looking at some of the stickies in the PM&R forum to get an idea of the things Physiatrists do.

The role of the Physiatrist in the inpatient setting can be very different from their role in an outpatient setting. If your mother or grandmother was transferred to an acute rehabilitation facility following a stroke or spinal cord injury, would you want her to just be seen by a physical therapist? What if she suddenly became short of breath and desats? Is this a PE, CHF, or aspiration PNA? Could a physical therapist make these decisions and manage the problem? Many of the patients in a rehab facility also have a long list of co-morbidities. You'll commonly find patients with DM, HTN, renal failure, etc. It's the role of the physician to manage these medical problems and do the work-up if necessary. None of these things can be done by a PT. On an inpatient rehab service, you'll find a lot of patients who develop spasticity that will limit their progress in therapy. Those patients might need a Botox or Phenol injection which would need to be done by a physician. What would happen if a patient who is s/p subdural hematoma evacuation began to seize during physical therapy? These are the types of situations that separate a Physiatrist from a physical therapist.

In the oupatient setting, many patients do frequently get referred to physical therapy. However, there's more to LBP, shoulder pain, hip pain, etc. than just physical therapy. Ultimately it's the physician who needs to diagnose the problems. A physician will need to answer whether it is a C8 radiculopathy, ulnar neuropathy, or rotator cuff tear. Will the patient need a joint injection, spinal injection, or electromyography? What if the patient needs pain medications or muscle relaxants? What if a patient with LBP begins to complain that he's develop some saddle anethesia and some bowel incontinence?

These are just a few examples of things that Physiatrists deal with that therapists would not. Ultimately, we are the physicians and the ones who will need to manage every aspect of the patient's care from diagnosis to imaging, labs, procedures, physical therapy, occupational therapy, or medications.

 

[tempperson]

This is a good question since I've asked this myself. Right now I'm just a clinical med student, not set on anything, but leaning towards PMR.

From what I hear, board scores are not that important now but maybe it will be later. Taking a cynical/practical view of things, one has to ask why is it not that many people are interested in this field. The hours are generally good, and the job descriptions sounds great (at least it appeals to me).

I talked this over with a couple fellow med students and this is what we concluded (of course we are only med students not residents in the field):

1) extremely low visibility, even within the medical profession. My school used to require a rotation through PMR but now its dropped. most med students have no idea what PMR people do, and it doesn't help that its so broad. It can range from doing procedures all day to general pmr work in which you manage pts all day.

2) the salary is not high. I don't know where salary.com got their figures from, but I think they are high. I have spoke toa few pm&r docs, and the ones who do general pm&r are getting $125-150 starting, with very little increase each year. This is better than medicine generally, but it would pale incomparison to other specialties like radiology or derm (which require a comparable amount of time training). Of course if you are more procedure oriented than you get paid much more, but you have to like doing that type of stuff. I like PMR b/c of the taking care of ppl aspect and so doing EMG's all day may not be an option.

3) the work of PMR is not 'prestigious' in certain peoples eyes. this is probably one of the dumber reasons people don't even try it, but its true. At my school, lots of people are striving for neurosurgery, orthopedics, rads, etc. They generally frown upon family medicine, psych, and other specialties that aren't as prestigious.

 

[drusso]

Originally posted by tempperson


3) the work of PMR is not 'prestigious' in certain peoples eyes. this is probably one of the dumber reasons people don't even try it, but its true. At my school, lots of people are striving for neurosurgery, orthopedics, rads, etc. They generally frown upon family medicine, psych, and other specialties that aren't as prestigious.

I guess it's all about who you want to impress---your subspecialty colleagues or the patient who actually demands your services.

Another question you might consider is who do you personally find more impressive: 1) An arrogant surgeon who is very technically skilled but doesn't return phone calls, treats OR and ancillary staff like slaves, and doesn't really know the first thing about his patients personal lives or social situation; or 2) a dedicated family physician who is readily available, collegial, and knowledgable about his patients' medical history, allergies, and social situation.