Do you need a fellowship?

[JBM16BYU]

Hi everyone! I have some questions that I hope generate a discussion. Hopefully, this helps current PM&R residents and medical students considering PM&R.
1) For a PM&R resident, do you need a fellowship?
2) What can you do without a fellowship?
3) What must you do a fellowship in order to do?

My personal feeling is that unless you want to be uber subspecialized in a particular patient population (ex. athletes, chronic pain, brain injury, SCI, kids), want to cover professional/Olympic teams (sports), or want to do spinal injections (pain/interventional spine), a fellowship is likely not needed. Thoughts?

---

Members don't see this ad.

 

[RangerBob]

Hi everyone! I have some questions that I hope generate a discussion. Hopefully, this helps current PM&R residents and medical students considering PM&R.
1) For a PM&R resident, do you need a fellowship?
2) What can you do without a fellowship?
3) What must you do a fellowship in order to do?

My personal feeling is that unless you want to be uber subspecialized in a particular patient population (ex. athletes, chronic pain, brain injury, SCI, kids), want to cover professional/Olympic teams (sports), or want to do spinal injections (pain/interventional spine), a fellowship is likely not needed. Thoughts?

Fellowships are rarely needed in PM&R. You can pretty much do whatever you want without the fellowship, but the following jobs (off the top of my head) will be harder to get without the fellowship:

- Interventional pain
- A true sports practice
- Medical director of SCI unit (VA or academic)
- Most VA SCI units will want/require SCI board certification
- Peds PM&R (most programs don't have sufficient peds training, but there's such a shortage of interested applicants many jobs will waive fellowship requirements)
- Moving forward I expect it'll be harder to become medical director of an academic TBI unit without board certification as well

I'm sure there are others. But you can get almost any community-based job you want without fellowship. Whether you can find a malpractice provider to insure you to do interventional pain without the fellowship is another matter though.

 

[TheGreatestTrochanter]

This will also depend on the market you are looking at, and what type of job you want. The residency program you are in may influence this some as well. In a competitive market someone with a fellowship will likely always be selected in place of you for a job. For gen rehab inpatient or outpatient you should be fine. I've seen some postings for "non-interventional spine" PM&R doctors (basically what PAs are doing at many spine clinics), should be fine.

I would reach out to people in your desired market to survey the landscape and see if fellowship is a waste of time, or if you will be kicking yourself for not doing it because you can't do the job you want in the place you want down the road.

 

[DMBandFan86]

Sports med or pain fellowships are obviously the most popular. If you want to do either of those for a career then a fellowship is a great idea. There are some guys doing interventional spine without a fellowship, but malpractice-wise and training-wise I would discourage it. A non accredited spine fellowship is also another option. But since both are 1 year, I’d recommend acgme fellowship and getting board certified. Most physiatrists do MSK, but if you want more training in U/S and procedures like tenex then sports is a good idea. You do have to consider rising job saturation and NP creep.

If you want to do research and spend your career mostly taking care of SCI or TBI then that is the main reason to do those fellowships. I find that a sole TBI or SCI clinic is overwhelming personally and I don’t know how people do it. I do see people getting fellowship trained in these and then doing general PMR and I always wonder why. I can take care of TBI and SCI patients just fine from just residency training. Won’t give you more income to do the fellowship necessarily.

Cancer fellowships are out there. They are relatively new. Again are best for people who want to do research and do a career as cancer rehab director. I think your PMR residency is just fine for being able to take care of cancer patients and their complications.

NMM fellowships help get you into mostly academic centers and linked into neurology to take care and evaluate very hard to diagnose conditions with usually little treatments options. Patient cases are lower, but very complex and time consuming. Most people went into neurology in the first place to do this sort of thing.

EMG fellowships are great if you want to be the best in EMG. I don’t think we get enough EMG in residency if you want to do that for a a career and want to be proficient and skilled in the top % of docs. EMG can be quite challenging with complex cases and this will help you and prepare for EMG boards. Very few people doing these fellowships. Won’t make you any more money necessarily, but may help develop a skilled practice. People will also send you all the hard stuff that they can’t figure out.

 

[JBM16BYU]

Sports med or pain fellowships are obviously the most popular. If you want to do either of those for a career then a fellowship is a great idea. There are some guys doing interventional spine without a fellowship, but malpractice-wise and training-wise I would discourage it. A non accredited spine fellowship is also another option. But since both are 1 year, I’d recommend acgme fellowship and getting board certified. Most physiatrists do MSK, but if you want more training in U/S and procedures like tenex then sports is a good idea. You do have to consider rising job saturation and NP creep.

If you want to do research and spend your career mostly taking care of SCI or TBI then that is the main reason to do those fellowships. I find that a sole TBI or SCI clinic is overwhelming personally and I don’t know how people do it. I do see people getting fellowship trained in these and then doing general PMR and I always wonder why. I can take care of TBI and SCI patients just fine from just residency training. Won’t give you more income to do the fellowship necessarily.

Cancer fellowships are out there. They are relatively new. Again are best for people who want to do research and do a career as cancer rehab director. I think your PMR residency is just fine for being able to take care of cancer patients and their complications.

NMM fellowships help get you into mostly academic centers and linked into neurology to take care and evaluate very hard to diagnose conditions with usually little treatments options. Patient cases are lower, but very complex and time consuming. Most people went into neurology in the first place to do this sort of thing.

EMG fellowships are great if you want to be the best in EMG. I don’t think we get enough EMG in residency if you want to do that for a a career and want to be proficient and skilled in the top % of docs. EMG can be quite challenging with complex cases and this will help you and prepare for EMG boards. Very few people doing these fellowships. Won’t make you any more money necessarily, but may help develop a skilled practice. People will also send you all the hard stuff that they can’t figure out.

Thank you for this. I do not believe EMG fellowships are really offered anymore anywhere. From what I understand, Clinical Neurophysiology fellowships kind of replaced them, and since PM&R cannot sit for the Clinical Neurophysiology boards, these fellowships are 99% of the time for Neurology only.

I believe that, from a PM&R residency, each resident should be competent at and be able to perform EMG/NCS, ultrasound-guided injections, botulinum toxin injections, trigger point injections, and baclofen-pump refills. I understand the sentiment of only doing spine injections after a fellowship specifically geared towards those procedures. The above-mentioned procedures, though, should be our bread and butter, right? I mean, we spend 4 years in a residency program, we should have bread and butter hands-on skills once we leave, even without a fellowship, correct?

 

[DMBandFan86]

Youre right the aanem only lists 2 fellowships listed that support PM&R for EMG. I always thought they were mostly unaccredited fellowships anyways.

But anyways, my point was for high level electromyogrophers it is a good option. If you want to dedicate your practice to EMG and be the best. Yes, bread and butter is done during residency (myopathy, neuropathy, radiculopathy, etc). But that doesn’t mean you are ready for everything that could be possible from EMG and making very complex diagnosis.

 

[Momentum70]

Market determines a lot I have found. For instance in a place like Los Angeles, Houston, New york city, etc their may be a lot of specialists and subspecialists. However in smaller markets like the one I practice then non fellowship trained people will often do most of the work. To give you some examples some places including mine have neurology and pmr in the same department. None of the physicians here are EMG fellowship trained, but neither is anyone in town and the group does a lot of them. There is no movement disorder fellowship trained neurologist but a couple of them do it. Nobody is pmr peds, but obviously have to cover peds so people do it. The closest "big city" is 2 hours away and many people either dont want to or dont have the means to travel that far for something like botox injections for spasticity for MRCP kids. I tend to take a lot of cancer patients, mainly because they tend to be medically complex and nobody else wants to do it.

 

[j4pac]

Do you NEED a fellowship? No. Not many PM&R docs on street corners begging for change.

If you’re picky…a fellowship can help open certain doors for you. If you want to stick needles into peoples spines, it makes sense to do a fellowship. If you insist on doing high level Sports coverage (Division 1 or Professional), a Sports fellowship could make sense. If you only want to work in an academic setting…a fellowship could help in that regard.

But if you are flexible, want to do appendicular injections (with or without ultrasound), Botox, EMG, or pretty much anything else not listed above…you can be a generalist.

I did General…I do everything I want to do. I also work in academics. I do ultrasound, I could do EMG, I do Botox, I could do pumps refills. I do a mix of inpatient consults and outpatient. I really do think that Spine is the only fellowship that would add an additional skillset that I couldn’t get credentialed for in most practices. I could set up shop a stick needles into needles spines in many community settings, but have little interest to do so in spite of the current reimbursement. Granted, I did residency at Mayo which increases my comfort level procedurally…but it comes down to credentialing, and a generalist is able to get credentialed for just about anything.