Confused MSIV- Please help me!

[PhillDOc]

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Hi all,

I posted here a while back asking for some advice on how to choose between PM&R and Internal Medicine....I received some decent feedback and felt more comfortable pursuing medicine in my 4th year schedule.....FAST FORWARD TO NOW....

I'm currently in the middle of my medicine sub-I and I'm really confused again....I'm literally being treated like an intern and feel overwhelmed every second of every day. I'm in my first month of 4th year and feel like I've gone from msIII to intern over a weekend....anyway, it's not the new workload that's really getting to me, but the day to day medicine itself. I'm just not sure if I'm interested in doing this for 3 years every day. If i went into medicine i would definitely do a fellowship, but i haven't had the chance to explore most specialties in medicine so at this point I don't even really know if or what I would do!

I honored a PM&R rotation late in my third year and got inpatient and outpatient (mostly pain) experience. I didn't LOVE the inpatient part, but i think i did like it better than the daily life in medicine.

I'm so confused and the thought of reworking (if even possible at this point) my whole 4th year schedule is daunting. I just don't know what to do. Additionally, I even had the thought to apply to both, but several places I'm very interested in would be on my list for both medicine and pm&r. Please help!

My biggest concerns about pm&r is that I want to make good money (250K+) and I'm also still not entirely clear on the breadth of PM&R after residency. I did enjoy pain, but have been told that not only will reimbursement fall (possibly to a point that the year fellowship might not be worth it), but that in the future only ACGME fellowships will be recognized for billing and certain hospital privileges. With these possibilities, I'm not sure if medicine is "safer" in the long run. Can anyone give me a better or more accurate idea of the potential earnings of physiatrists in either mixed practices or non-pain? I've searched all over sdn and have found wildly varying numbers, most of which arenfrom 3+ years back....ANY input or help is appreciated. Thank you!

 

[AndyDufrane]

I would consider the day to day nature of the field over money, you have to like what you are doing on a daily basis,

 

[RUOkie]

Hi all,
<snip>
My biggest concerns about pm&r is that I want to make good money (250K+) and I'm also still not entirely clear on the breadth of PM&R after residency. I did enjoy pain, but have been told that not only will reimbursement fall (possibly to a point that the year fellowship might not be worth it), but that in the future only ACGME fellowships will be recognized for billing and certain hospital privileges. With these possibilities, I'm not sure if medicine is "safer" in the long run. Can anyone give me a better or more accurate idea of the potential earnings of physiatrists in either mixed practices or non-pain? I've searched all over sdn and have found wildly varying numbers, most of which arenfrom 3+ years back....ANY input or help is appreciated. Thank you!

Firstly, I agree with AndyDufrane. Like what you do,and the $ will follow. If you can't live on $200k/yr, you have a problem.

Secondly, both IM subspecialties and PM&R's reimbursement parellell each other. Both are E&M and office procedure based (except Interventional Cardiology and GI). So what happens to us will happen to them.

As you said, the figures posted are 3 yrs old. Well I still have not done my taxes for 2011, so my final figures are not there yet, but my income has been pretty stable for the past 4 yrs. (+/- 30K). AND I have no idea what will happen over the next 10 yrs. I could make 50%more, or 50 % less.

 

[theserbatron]

as someone who just went through the match, and having discussed this very issue with a few classmates who were interested in another field -- often not related at all -- and PM&R as well, one thing you will have to consider is the types of patients you will take care of.

in IM, you will be doing A LOT of medical management. A LOT. as you know from your current rotation, you'll be doing a lot of admissions, and the bread and butter medicine diagnoses that come through the floors. you'll be optimizing patients medically for discharge or surgery for a large chunk of your residency, until you sort out what fellowship you might want to do.

pm&r patients aren't that... on the inpatient side you'll be doing medical management + working/coordinating to return maximum level of function. this is an aspect of practice and interaction with patients that you don't get on the IM side. nevermind how different outpatient PM&R and internal medicine is...

i would avoid applying to both IM and PM&R programs at the same institutions, if you choose to go that route. someone will get wind at some point and this is a horror waiting to happen. good luck! if you need any more advice, feel free to PM me.

 

[Lanvin]

I had a hard time deciding between IM and PM&R also. It was so close of a decision that I almost cancelled my PM&R away rotation last minute just to save money (thereby choosing IM and no visiting student rotations).

I didn't have ANY PM&R rotations until mid-August (except 2 half days during our Neurology rotation). You should have plenty of time to adjust your schedule as needed.

I don't think there is a problem applying to both IM and PM&R, but I'm not sure that you'll even need to. Consider getting a few more weeks of PM&R (maybe even an away rotation if you can) on your schedule before you need to submit ERAS. See how things go. If you end up deciding IM come September, the few weeks of PM&R would not have hurt your application.

 

[PMR 4 MSK]

So which IM fellowships are you looking at - rheum, GI, heme/onc, etc?

All IM subspecialties are as different from one another as PM&R is from IM.

You don't want to be an IM generalist, that much is clear. They work too hard for too little money and the field is being taken over by mid-levels anyway.

So what kind of patients do you see yourself enjoying treating the most?

Would you rather treat a herniated disk or a spinal schwannoma?

A belly pain or a wrist pain?

Would you rather go into pulmonary and be a critical care specialist, or rheumatology and treat little old ladies with OA and osteoporosis?

Try to look at each of the IM specialties and see how you would feel treating each of those patient groups. E.g. I could never do heme/onc. Cancer is too depressing for me. GI could be cool, but all those patients with vague abdominal complaints gives me indigestion thinking about it.

Rheumatology is nice, mostly outpt, but they get the crazy fibros along with really, really sick patients, and the drugs they give can kill.

Then look at PM&R. It sounds like inpt rehab is not you thing. That's cool. Could you see yourself treating complex chronic pain patients, or does the thought make you want to slit your own throat with a dull knife?

Do you like sports medicine - young, well-insured, motivated patients, but a lot of time away from the family covering games.

How about doing diagnostic work like EMGs and nerve blocks, and letting others do most of the work up and treatment?

How about peds rehab - kiddies with CP, SCI, MD, etc?

Take a breather and do some contemplation on what aspects of medicine excite you. What brought you to medical school and how has that changed in the past few years?

And if you bring up money as a deciding factor, you will be unhappy in life.

 

[PhillDOc]

Thank you all very much for your responses and help. The sad part was (is) that I didn't LOVE anything in my third year....i toyed with anesthesia, neuro, and medicine before exploring pm&r....Part of my difficulty deciding is that I really don't know what kind of patients i'm most happy treating and what I find most fun. Additionally, at this point, the two most interesting sub-specialties of medicine to me are cards, GI, and heme/onc...along with every other medicine resident....

I'm trying to be practical about this so i've decided to work on a PS for PM&R and attempt to schedule another rotation within the next couple of months (although, due to being so late i've already been shot down by 2 places). I will move ahead with essentally applying to both and see if my thoughts sort themselves out at the conclusion of my sub-i month or during my next pm&r rotation...that's really the best i can do right now. Did anyone else not really LOVE anything they did?! I feel somewhat ashamed and discouraged about this. Thanks again to all.

 

[RUOkie]

<snip>
Did anyone else not really LOVE anything they did?! I feel somewhat ashamed and discouraged about this. Thanks again to all.

While my training was in the dark ages (we submitted our residency apps ON PAPER!), I did not love any of my rotations. In fact, much of my early decision making was based upon what I hated least.

What ultimately made my decision was some good mentors. The Physiatrists I encountered were just good doctors, and seemed to look at the entire person as opposed to an organ system. They even took social situation into account! How novel. I was also very interested in sports med/exercise physiology/neurophysiology from college, but did not like the operating room. So I fell into PM&R, entered residnecy without being sure.

 

[Jitter Bug]

Don't depair. In medicine there is a field for every personality type. You can totally avoid awake human beings, totally avoid doing procedures, totally avoid prescribing pills, avoid the hospital, avoid the clinic, etc.

I think PMR MSK's comment about thinking about what made you go to medical school is a good place to start. Different people get different satisfaction from the job. And it may help to do an opposite match: start with all fields, and start eliminating ones that you think suck. Then keep crossing things off your list until you only have 3 or 4 left. Those you then start considering, decide if they match your personality and interests.

 

[Makaio]

What about choosing between Ortho and PM&R?
I'm a lousy candidate for ortho but can get PM&R. I know if I give it my all I can stand a shot at ortho. But I also wonder about the consequences of the 2 (potentially) different lifestyles...anybody else make this decision?
I would suspect that most PM&R docs like ortho a lot, but either: 1) didnt like the OR, 2) didn't like the lifestyle, or 3) weren't competitive for the field.
So what do most do in my shoes?

 

[Gauss]

Ortho is shifting to a predominantly OR based practice. Meaning surgery nearly all week and office staffed by PA's or NP's. Call exists but again they are operating while midlevels cover the floors and ER consults. You would think this would open up office based MSK to other areas: sports, PM&R, rheum. But that is an ongoing debate.
So you have to be a surgeon, enjoy the OR, to do ortho.

 

[PMR 4 MSK]

What about choosing between Ortho and PM&R?
I'm a lousy candidate for ortho but can get PM&R. I know if I give it my all I can stand a shot at ortho. But I also wonder about the consequences of the 2 (potentially) different lifestyles...anybody else make this decision?
I would suspect that most PM&R docs like ortho a lot, but either: 1) didnt like the OR, 2) didn't like the lifestyle, or 3) weren't competitive for the field.
So what do most do in my shoes?

1 - If you don't like the OR, you're not a surgeon. Surgeons can't understand this in general. Why would anyone not love being in surgery, in total command of someone's life or livelihood? Cutting, bolting, screwing, sewing, etc. It just doesn't work for many of us. The surgeons then just condescendingly say "You're just not good enough to be a surgeon!" Nope, just not the right mindset.

2 - Correct - ortho comes with it's own unique lifestyle. 80+ hour weeks. Very high pressure. Very high rewards for many.

3 - in some cases, this is true, but today's competitve PM&R candidate could easily qualify for most ortho residencies. Yes, our averages are lower, but that's the applicant pool and the effect of those not competitve for other fields.

And for those reading, and thinking, "Yeah, but the money in ortho is better", not so fast there! A good pain doc can easily make better than the 50th % for ortho. Many orthopods are in small groups or solo, with high overhead and poor business skills.

My group has looked at taking over a few ortho groups in the past few years. Each one had overhead in the 60 - 80% range. Ours is < 20%. That's is a huge amount of take-home pay being lost.