Changing specialty mid-residency (surgery to PM&R)

[surg2phys]

I am in the middle of a surgical residency and it has been going great by all accounts. I've been selected for national leadership positions, had multiple publications and national conference presentations, and been elected to AOA after the nomination by my PD. I love surgery, but as my family has grown, I've come to realize how much I struggle with missing things and not being around. I knew I would miss things when I chose to go into surgery, but what I didn't know is how much that would wear on me.

As a medical student, I often thought of PM&R. I enjoy the diversity of practice and there are certain areas I could really see myself enjoying. I'd also be able to see my family a lot more. The most terrifying thought is making the decision to try and get a PM&R position, being unable to do so, and then being stuck with nothing or having to go into a field I have no interest in doing. I've done some research on this but still have several questions, thus I'd sincerely appreciate any general advice and some of the nuts and bolts of how switching would work. It seems like PM&R has become more competitive than it was when I applied--would this switch be realistically possible? How can I strengthen my application to make myself competitive?

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[DrMetal]

I am in the middle of a surgical residency and it has been going great by all accounts. I've been selected for national leadership positions, had multiple publications and national conference presentations, and been elected to AOA after the nomination by my PD. I love surgery, but as my family has grown, I've come to realize how much I struggle with missing things and not being around. I knew I would miss things when I chose to go into surgery, but what I didn't know is how much that would wear on me.

As a medical student, I often thought of PM&R. I enjoy the diversity of practice and there are certain areas I could really see myself enjoying. I'd also be able to see my family a lot more. The most terrifying thought is making the decision to try and get a PM&R position, being unable to do so, and then being stuck with nothing or having to go into a field I have no interest in doing. I've done some research on this but still have several questions, thus I'd sincerely appreciate any general advice and some of the nuts and bolts of how switching would work. It seems like PM&R has become more competitive than it was when I applied--would this switch be realistically possible? How can I strengthen my application to make myself competitive?

Don't do it. PMR is mostly "nothing-burger" medicine, dealing with chronic pain, work comp, and mostly psychosomatic symptoms (that nobody wants to admit are psychosomatic . . .nobody wants to tell the patient the truth, that's its 'all in their head'). Some of it can be interesting, when you're dealing with patients that have actual injuries and trauma (as we do a lot in the military). But most of PMR is crap. Sorry.

Surgery by contrast if very tangible, to cut is to cure. (I'm not a surgeon, I'm an internist).

What year are you? Residency sucks, no matter the specialty. But life as an Attending is much better, you call the shots in your life. You can work as much or as little as you want. If you're at least 50% done, don't quit, push forward.

 

[RangerBob]

Don't do it. PMR is mostly "nothing-burger" medicine, dealing with chronic pain, work comp, and mostly psychosomatic symptoms (that nobody wants to admit are psychosomatic . . .nobody wants to tell the patient the truth, that's its 'all in their head'). Some of it can be interesting, when you're dealing with patients that have actual injuries and trauma (as we do a lot in the military). But most of PMR is crap. Sorry.

Surgery by contrast if very tangible, to cut is to cure. (I'm not a surgeon, I'm an internist).

What year are you? Residency sucks, no matter the specialty. But life as an Attending is much better, you call the shots in your life. You can work as much or as little as you want. If you're at least 50% done, don't quit, push forward.

I think it depends a lot on what the OP wants to do, but the vast majority of my patients in residency (or my inpatient rehab patients now) are nothing like what you’re describing. The vast majority we see tangibly benefit from our treatment and they are very thankful and appreciative of what you do.

The population you describe is only a small subset of PM&R patients (really just pain clinic—and a subset at that). It’s like you’re saying all psychiatrists do is treat violent schizophrenic patients. Some do—but most don’t.

I agree surgery is very tangible—and often that is what attracts people to surgery.

PM&R will generally have a much better lifestyle. I see my family all the time. But as an attending , OP would have better control of their hours and could likely find a part-time job. If they’re in the middle of surgical residency already, that could be the better option if they live surgery. Realistically switching to PM&R could take a year given the match process, and then they have three more yes area of residency to complete.

With that said OP—if you were competitive enough for a surgical residency you’re likely competitive enough to snag a PM&R position. A handful of R2 positions come available each year which would let you go straight into PM&R as a 2nd year resident, but most positions will be advanced positions through the Match, which means you’re applying for positions that are a year out (since applicants are applying for both internship and advanced PM&R positions at the same time)

 

[DrMetal]

The vast majority we see tangibly benefit from our treatment and they are very thankful and appreciative of what you do.

I don't doubt the patients in PMR are appreciative. They love the attention they're getting, for mostly psychosomatic complaints that their regular doctors wont address. But most of the treatments in PMR are placebo, and only further fuel their somatization. It's a vicious cycle that no one wants to admit.

These of course are first world problems.

How many "PMR" referrals do we think happen in Mozambique, or Nigeria? Not many. When your patients are bleeding out of their eyeballs with malaria, fulminant HIV and HCV, you have much bigger fish to fry.

Be the doctor that fries bigger fish.

 

[RangerBob]

I don't doubt the patients in PMR are appreciative. They love the attention they're getting, for mostly psychosomatic complaints that their regular doctors wont address. But most of the treatments in PMR are placebo, and only further fuel their somatization. It's a vicious cycle that no one wants to admit.

These of course are first world problems.

How many "PMR" referrals do we think happen in Mozambique, or Nigeria? Not many. When your patients are bleeding out of their eyeballs with malaria, fulminant HIV and HCV, you have much bigger fish to fry.

Be the doctor that fries bigger fish.

I had no desire to be the doctor that "fries bigger fish." If that's your priority you can do more good going into public health/civil engineering and ensuring safe drinking water access, sanitation, etc. They will have far more impact than any physician can.

A physiatrist is like a psychiatrist in some ways. We're typically not saving lives. We're focused more on quality of life/optimization of independence (psychological for psych, physical for PM&R). It fits well with many personalities.

I've met PM&R physicians from non-Western countries. They still see amputations, spinal cord injuries, TBIs, etc, in their countries--typically many more than we see. They're busy and could use more physiatrist colleagues.

Our patients are not mostly psychosomatic. I'm not sure why you think that. Some are, but certainly not most. Have you done a PM&R rotation/worked with physiatrists? Do you really think our treatments are mostly placebo? PT/OT/SLP don't work? Because that's typically our first treatment for everything--therapy. Medication/modalities don't work for phantom pain? Or general OA? Spasticity? Neuromodulation after stroke?

I agree that many psychosomatic patients will get referred to PM&R pain/MSK clinics because no one else knows what to do and so they refer to PM&R pain clinics as a last resort. Despite this being a small proportion of PM&R patients (though a higher proportion of pain clinic patients), there are still things we can do for these patients. You probably know as well as I do that a chronic pain patients usually need a physiatrist, along with a psychiatrist, psychologist, PT/OT, and a host of others. But few payors want to actually pay for that kind of comprehensive treatment.

 

[DrMetal]

I had no desire to be the doctor that "fries bigger fish."

Well, at least you're honest.

Our patients are not mostly psychosomatic. I'm not sure why you think that.

It's a theory, perpetuated by one of your own: the late, great Dr. John E Sarno , Professor of Rehabilitation Medicine at NYU, who wrote several books about the matter. My particular favorite: Amazon product

You probably know as well as I do that a chronic pain patients usually need a physiatrist, along with a psychiatrist, psychologist, PT/OT, and a host of others.

Of course. And despite all these resources, they still don't seem to get better. Fact is, they need none of this. In the absence of real medical or surgical pathology, what they really need is a healthy dose of reassurance. Of course, we're too scared to tell them that, and so we refer to PM&R.

[wait a second: by my own logic, I just argued that we do need PM&R. I take it all back. OP, @surg2phys , go for it! If you're conscience doesn't weigh on you too much, go for it! ]

 

[RangerBob]

Well, at least you're honest.



It's a theory, perpetuated by one of your own: the late, great Dr. John E Sarno , Professor of Rehabilitation Medicine at NYU, who wrote several books about the matter. My particular favorite: Amazon product



Of course. And despite all these resources, they still don't seem to get better. Fact is, they need none of this. In the absence of real medical or surgical pathology, what they really need is a healthy dose of reassurance. Of course, we're too scared to tell them that, and so we refer to PM&R.

[wait a second: by my own logic, I just argued that we do need PM&R. I take it all back. OP, @surg2phys , go for it! If you're conscience doesn't weigh on you too much, go for it! ]

I agree with you that some patients clearly fit your (and Dr. Sarno's) description. But again, this is just a small subset of our patient population.

On the inpatient unit I've had zero patients who fit that description (at their primary diagnosis/reason for being on the rehab unit) since I started a few years ago.

Regardless, we're veering off original topic. It sounds like we both agree OP may be best off staying in general surgery if they enjoy surgery more than PM&R, since as an attending they can much more easily set their hours.

At this point the odds of OP starting PM&R residency for this coming July are very low since all those positions are likely filled. PM&R is an advanced specialty requiring a prelim year (which gen surg would give credit for), so those who apply in the 2024 Match next year are actually applying for PM&R positions that start in 2025 or for categorical positions starting in 2024 (meaning OP would repeat intern year). There are usually at least handful of advanced positions that become available through the Match, so OP would be able to apply for at least some advanced positions that started in July 2024, but again, most would start 2025. So OP may not finish PM&R residency until 2028, which is what OP needs to consider when debating if they really watch to switch out of gen surg.

Realistically, PM&R residencies are among the "easiest" hour-wise, typically second to psych. Normal PGY2 hours are all but the busiest/most competitive programs are usually around 60hrs/week (up to 70-80 if on call that weekend). I was usually out around 5-6 during the week and by noon on weekends when I was on call. PGY3-4 are closer to 50hrs/week. So most PM&R programs will offer a much better lifestyle in residency than gen surg. Competitive programs like UW, Spaulding, RIC, Mayo, will have longer hours, as will the more malignant programs out there.

OP, if you really enjoy surgery more and would prefer to work 40hrs/week as a general surgeon than 40hrs/week as a physiatrist, I think it's worthwhile to talk to your gen surg mentors about how feasible it is to work part-time as a general surgeon.

 

[j4pac]

Don't do it. PMR is mostly "nothing-burger" medicine, dealing with chronic pain, work comp, and mostly psychosomatic symptoms (that nobody wants to admit are psychosomatic . . .nobody wants to tell the patient the truth, that's its 'all in their head'). Some of it can be interesting, when you're dealing with patients that have actual injuries and trauma (as we do a lot in the military). But most of PMR is crap. Sorry.

Surgery by contrast if very tangible, to cut is to cure. (I'm not a surgeon, I'm an internist).

What year are you? Residency sucks, no matter the specialty. But life as an Attending is much better, you call the shots in your life. You can work as much or as little as you want. If you're at least 50% done, don't quit, push forward.

I practice PM&R and love it. I would quit medicine if I was a surgeon. Everyone is different

 

[DrMetal]

I practice PM&R and love it.

I don't doubt you love it. In the military, we're fortunate enough to have patients (active duty service members) who do actually need PM&R, as per real injuries sustained in battle. And when they're done---or, if they don't have real injuries, if they're chronic pain seeking malingers---we can readily discharge them from care and order them back to full duty.

The civilian world is a much nastier beast, where lawyers and insurance companies rule the land. Good luck slaying those dragons.

I would quit medicine if I was a surgeon.

No you wouldn't. You'd get into the rhythm of it, set up your practice however you want, work as much as you want, and develop a bad whiskey habit like the rest of us.

When did we become so scared of doing the hard and important things?

 

[LucidSplash]

I’m a surgeon and while I like it, for the life of me I don’t understand the need for a given specialty to piss in the cheerios of another specialty, especially surgeons who feel the need to tell practicing PM&R docs or any other specialty that they’d want to keep doing surgery if they were surgeons. I also don’t know where we as surgeons get off telling someone what another specialty is “really like” because we read a book about it once.

It’s perfectly fine to say you would find a different job if you had to be a specialty you don’t enjoy. Just like it’s fine for me to like surgery even though others don’t. There are several specialties where I would leave medicine if I had to do those.

But that’s the beauty of own occupation disability insurance.

 

[j4pac]

I don't doubt you love it. In the military, we're fortunate enough to have patients (active duty service members) who do actually need PM&R, as per real injuries sustained in battle. And when they're done---or, if they don't have real injuries, if they're chronic pain seeking malingers---we can readily discharge them from care and order them back to full duty.

The civilian world is a much nastier beast, where lawyers and insurance companies rule the land. Good luck slaying those dragons.



No you wouldn't. You'd get into the rhythm of it, set up your practice however you want, work as much as you want, and develop a bad whiskey habit like the rest of us.

When did we become so scared of doing the hard and important things?

No…I would quit. Pretty confident I know myself better than you.

I’m a civilian PM&R doctor, and I think your characteristics of my patient type are inaccurate. I care for neurological disease patients. I don’t practice pain management…I honestly can’t remember the last time I even prescribed an opiate. I previously did primary care where I saw far more secondary gain. patients with neurological diseases are usually very grateful for care and have little incentive to game the system. Your description of PM&R is one that I would expect from someone that really doesn’t have much experience with my field…it’s way to generalized and simplistic.

 

[mistafab]

Back to OP.

Best of luck. People exiting surg is not super uncommon. Just make sure you’re right about this before you try to jump. Compare the end of surg (attending life) to the end of pmr, and make sure it isn’t a grass is greener thing.

Would you be happy if you got the exact job you wanted as a surgeon? What would that look like? Make sure you are not interested in the end goal, rather than just burnt to a crisp from the residency. Good luck!

 

[hardworkDream]

It sounds like your are crushing your residency and doing great. I'm making the assumption that the biggest reason you are thinking of switching is based on your work/life balance aka to spend more time with your growing family. I know nothing of PM&R but I would recommend you consider options in general surgery if that's the case. One example is breast surgery. I don't know if you have experience with dedicated breast practices but it is one of the best lifestyle out there. something to consider. Surg CCM (+/- trauma) does shift work. You can also do a palliative fellowship.

All 3 of these are just 1 year fellowships (breast is non-acgme).

If your heart is set on pm&r, go for it. If you don't want to do surgery anymore, make the switch.

But you chose surgery during medical school for a reason. And you also got through 3 years of Surgery Residency with great success. if it's purely a lifestyle decision, there are options. Also consider that the system/group/partners, regardless of specialty, will play a large role in terms of lifestyle as well.

PM&R may still be the best choice for you, but just some thoughts to think over.

 

[Dr.LeoSpaceman]

I'd also be able to see my family a lot more.

Coming from a surgeon, you'll also likely be able to see your family a lot more once you finish surgical residency and hit practice. Maybe not as much as if you were in PM&R, but certainly much more than when you're in residency.

I won't make any comment about the merits of either specialty, but I will simply caution you to think deeply about the decision and avoid one that potentially places outsized emphasis on short-term gain. This is a different discussion of you either weren't satisfied or weren't doing well in surgical residency.

 

[Kissmyabjj]

Don't do it. PMR is mostly "nothing-burger" medicine, dealing with chronic pain, work comp, and mostly psychosomatic symptoms (that nobody wants to admit are psychosomatic . . .nobody wants to tell the patient the truth, that's its 'all in their head'). Some of it can be interesting, when you're dealing with patients that have actual injuries and trauma (as we do a lot in the military). But most of PMR is crap. Sorry.

Surgery by contrast if very tangible, to cut is to cure. (I'm not a surgeon, I'm an internist).

What year are you? Residency sucks, no matter the specialty. But life as an Attending is much better, you call the shots in your life. You can work as much or as little as you want. If you're at least 50% done, don't quit, push forward.

I’ve cleaned up a lot of crap left over or totally missed by many surgeons. Just off the top of my head:

1) Cervical myelopathy: saw an orthopedic spine surgeon the day before my evaluation, who just whiffed on this. I sent her urgently to a different surgeon who did a 3-level ACSD 2 weeks later
2) Cervical myelopathy: missed by orthopedic and trauma surgery while hospitalized for polytrauma 2/2 bicycle accident. Sent to neurosurgery for 3 level ACDF.
3) Unstable degenerative valgus knee OA: seen by orthopedic surgeon 1 week before I saw her. He recommended steroid injections, but never evaluated her standing to see that her gait was totally unstable. Sent her to a different surgeon.

I could go on and on. The fact you have so little respect for PM&R makes me think you may have been bailed out by one of us without even knowing it.

 

[j4pac]

I’ve cleaned up a lot of crap left over or totally missed by many surgeons. Just off the top of my head:

1) Cervical myelopathy: saw an orthopedic spine surgeon the day before my evaluation, who just whiffed on this. I sent her urgently to a different surgeon who did a 3-level ACSD 2 weeks later
2) Cervical myelopathy: missed by orthopedic and trauma surgery while hospitalized for polytrauma 2/2 bicycle accident. Sent to neurosurgery for 3 level ACDF.
3) Unstable degenerative valgus knee OA: seen by orthopedic surgeon 1 week before I saw her. He recommended steroid injections, but never evaluated her standing to see that her gait was totally unstable. Sent her to a different surgeon.

I could go on and on. The fact you have so little respect for PM&R makes me think you may have been bailed out by one of us without even knowing it.

I’ve gotten quite a few conference trips to present on Neuro cases missed by Ortho, Neurosurgery, and sadly Neurology. UMN vs LMN is one of the most important concepts in medicine…and yet it is missed…frequently.