For the first time, I'm really worried about entering this field.

[pinkeclipse]

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This is old, but is anyone else worried?! I'm a 3rd year who is gun-ho about entering the field of PM&R even after always being told not to (like I'm too smart; it's too boring; it's not intellectually stimulating, etc). I've never wavered in my decision. But after reading this, I'm worried! What's going on here? I've always felt like PM&R was a specialty made just for me. I love it, but am I delusional since I've never actually practiced in the field?????

This is the

Residency Training Outcomes by Specialty in 2007 for New York:
A Summary of Responses to the 2007 New York Resident Exit Survey
Here's a link to it. It's the second report/presentation: http://chws.albany.edu/index.php?nys_exit

Ophthalmology, pediatrics–general, physical medicine and rehabilitation, pathology, pediatric
subspecialties, geriatrics, and hematology/oncology were experiencing the weakest relative
demand.

The highest percentages of graduates having difficulty finding a satisfactory practice position were in physical medicine and rehabilitation (59%), geriatrics (56%), hematology/oncology (42%), and pediatric subspecialties (38%). Conversely, otolaryngology (0%), pulmonary disease (0%), gastroenterology (4%), and ophthalmology (11%) had the fewest respondents reporting difficulty.

Graduates of pathology (+.26), pediatric subspecialties (+0.37), and physical medicine and
rehabilitation (+0.44), were the least optimistic in their views of the regional job market.

Graduates of pathology (+1.00), otolaryngology (+1.20), and physical medicine and
rehabilitation (+1.24) gave the least positive assessments of the national job market.

Sixteen percent (16%) of respondents reported having to change their plans due to limited job
opportunities, approximately the same as in 2005 (14%).

Urology (0%), otolaryngology (0%), pulmonary disease (0%), orthopedics (4%), and
dermatology (6%) had the fewest graduates having to change plans in 2007. Graduates of
physical medicine and rehabilitation (35%), geriatrics (31%), pediatric subspecialties (31%),
child and adolescent psychiatry (29%), and pathology (28%) were the most likely to have to
change plans.

Well, at least for once PM&R is not mentioned with something negative here.

Pathology (+12%), internal medicine-general (+10%), physical medicine and rehabilitation
(+7%), and internal medicine and pediatrics (combined) (+7%) were the specialties showing
the greatest average annual increases in job offers. Conversely, neurology (-15%),
otolaryngology (-13%), urology (-8%), and anesthesiology-general (-6%) saw the largest
decreases in job offers.

The respondents that had the least positive views of the regional job market were those in
pathology (0.26), pediatric subspecialties (0.37), physical medicine and rehabilitation (0.44),
and ophthalmology (0.67).

The respondents that had the least positive views of the regional job market over the last two
years were those in pathology (0.25), physical medicine and rehabilitation (0.37), and
pediatrics subspecialties (0.39).

The job market for ophthalmology (23.0), pediatrics-general (22.0), physical medicine and
rehabilitation (22.0), pathology (21.5), pediatric subspecialties (20.0), geriatrics (18.5), and
hematology/oncology (18.0) appears to be bleak relative to other specialties.

So have we discussed this before? Maybe I missed it. But PM&R usually had the highest numbers in each of these stats. I mean how could it have been consistently in the bottom of the barrel? This makes me sad. 🙁

Maybe the fact that this is only limited to NY makes a differences. But it's still worrisome as I'm from NY.

 

[MSKalltheway]

The first thing I noticed about that survey is that, as you pointed out, its back a$$wards from any other survey I've seen. PM&R docs are generally the most satisfied and the happiest docs I've ever seen, on paper and in person. Those that are unhappy with the field, well, I can see why this is so through certain personality traits or experiences.

In terms of demand, it brings me to what we learned in our biostats/"how to read a study" courses. There's an old adage that goes something like "stats are full of lies and damn lies". One thing about NY and PM&R that I've noticed (I grew up on Long Island) is that its one of the few areas of the country that is saturated with PM&R. If anywhere in the US has a large concentration of physiatrists, I'm not surprised its there. Being down here in Maryland and seeing what opportunities there are in Rehab is crazy, I'm so tempted to settle here just because I wouldnt rally have any sports/spine competition here, maybe = successful practice. That may change in 7yrs when I'm done, but as of now the supply/demand curve looks quite nice around here, even for PM&R in general.

My general criticism about the study is that you have to remember that NY is a different place and has a different breed of people in it than other sections of the country. Docs of all specialties are pretty much super-saturated there since its such a desirable place to be. I think if you looked into it elsewhere, you would most likely get different results.

Also, it seems from the docs on the board that before demand increases for the field, more people (and the medical community at large) needs a better idea of what PM&R does. I think after some educating, demand will increase on its own. Little demand could stem from little knowledge...I'm finding myself explaining PM&R to ATTENDING physicians when they ask me what my specialty choice is.

I think things will be different over time. I actually discussed with a classmate the possibility of trying to start a dept at my school once I have enough experience under my belt. Hell if I'm gonna want that kind of responsibility and deal with pissing off that many egos, but sometimes I just cant tame my ambitious side 🙂

I think as with any specialty, if you are smart about things you'll find yourself to be in a good position. There are always exceptions, but I see a lot of good things in the future with this specialty that I cant see with others.

 

[WaterAvatar]

So for those of us that want to practice in NY? this is bad news eh?

 

[topwise]

I've heard NY is really saturated and it's very hard to find jobs there. But not so much in other areas in the country.

Being down here in Maryland and seeing what opportunities there are in Rehab is crazy, I'm so tempted to settle here just because I wouldnt rally have any sports/spine competition here, maybe = successful practice. That may change in 7yrs when I'm done, but as of now the supply/demand curve looks quite nice around here, even for PM&R in general.

Really? I was thinking about Maryland as one of the places i wouldn't mind living. What opportunities are there?

 

[PMR 4 MSK]

I know in New York and in most of New England there is the pervasive thought the USA is made up of a few states on the upper east coast, The South, California, and the flatlands in-between. I lived near there many years ago. I also know many people from there couldn't imagine life outside of there, nor are they sure if there really is life outside of there.

However, everywhere else, PM&R appears to be doing quite well. There are so many directions you can go in within the field. There are job opportunities all over. Some areas, mainly the large cities, are saturated. The rest are wide open and expanding.

Look at the job board on AAPMR.org, look at all the ads at the back of the red journal, peruse internet job boards. One I just looked at claimed 323 PM&R jobs listed.

Everything in life like this is controlled by supply and demand. NY is apparently in huge demand and has an over supply of PM&R docs. That = crap to choose from. The more open you can be to other locales, the better your opportunities will be.

 

[WaterAvatar]

do you think the same stats go for PMR-Pain docs?

 

[Ludicolo]

do you think the same stats go for PMR-Pain docs?

According to the first zip file, pain management seems to have quite a relatively better demand compared to most of the other specialties. Not clear how this is divided between anesthesia-pain and PM&R-pain. Important to note though that this has nothing to do with absolute demand.

Yeah – it’s tough in NY. NYC in particular. Ultra-competitive and certainly not for everyone. I think the students/residents who have spent their entire scholastic life in NY seem to be the most disenchanted, realizing that they may have to move somewhere else...like New Jersey😱. Those NYers who left to go to school or residency out of state may have a different perspective, because as others have alluded to, the prospects are actually pretty good in other areas of the country. Even so, a lot of native NYers practicing out of state seem like they are always looking to come back.

Those wanting to eventually practice here need to be on their game during training, with a definite back up plan. Or two. Or three. Keep your eyes and ears open as far as opportunities go. Network as much as you can. Know what you're good at and market yourself. Gotta hustle – which can be somewhat challenging for the typical “laid-back” physiatrist.

 

[LTS6776]

I'm a New Yorker as well although I did my residency in Chicago. The job market is much better elsewhere, even other places on the East Coast. Private practice jobs in Manhattan might not offer you everything you are looking for, and I've been told they come with outlandish non-compete clauses. NJ and CT might offer you better opportunities while allowing you to commute from NY. I graduated just about a week ago and my classmates and I were very happy with the positions we are entering! You should whatever specialty you feel is the best fit for you. There will be a good job for you out there if you look for it.

 

[MSKalltheway]

I was thinking about Maryland as one of the places i wouldn't mind living. What opportunities are there?

To be honest, I'm unsure of how many jobs are out there in private practice, whether it be with ortho/neurosurg groups or other physiatrists, I assume you'll be able to get your hands on the info easier than I could. I do know that when I have done my searches for docs in the area, if you cant count the number of docs on fingers and toes, the true # is not very much more than that (at least when considering those who are in the private world).

I'm kind of ambitious and want to start my own practice from scratch (at least for now, that may change) so it seems doing so around here could be a consideration since there really isn't a lot of competition in the private sector. I *think* there is only one practice that serves where I live in the 'burbs, and these three docs are the only ones that are around for quite a few miles--could be up to a 20 mile radius if I truly had full access to all the info of who is around.

As for academics, I had the head of ortho sports med at my school light his eyes up with $$$ when I told him I was interested in PM&R sports. He was quick to say "I would LOVE to have PM&R in my practice...that way I don't have to worry about another ortho guy taking my cases!" So it seems that academic jobs may not be so difficult either, esp at my institution as we only have 4-5 PM&R staff--one interventional spine in ortho and the others in neuro (with our own Rehab hospital and no dept, go figure). So if academics is your thing, I'm sure you may be able to come across something in Baltimore, esp if you know how to handle needles. This is only conjecture on my part, so take that with a grain of salt.

While you're at it, you may as well take my analysis of [doc] in MD with a grain of salt as I haven't had the chance to hook up with anyone in the private world and talk about who is around that isn't listed. That and since I'm only starting 3rd year on Tuesday, I guess that grain is kind of tiny now 🙂. Called the local practice to talk to them once, but never got a response back...I may just have to show up one day. But it seems to me that a physiatrist could create quite a demand in the area if all the cards are played right, esp since those that are around are clustered in Annapolis, Bethesda, one of those towns in PG county, and a few docs in the rural west. Theres still tons of the state left untouched!

 

[Dr. Ice]

take it from someone who has completed his residency training in NY and who has heard about job opportunities in NY/NJ. IT SUCKS!!!! There is way too much competition and the salaries are def not comparable with the rest of the country... even if you do interventional. I know someone who just completed a one year accredited PM&R spine fellowship and who is now only making $180 base in jersey.

Part of the reason NY grads are "disenchanted" is because of the influence of disheartened attendings (I have encountered my fair share), and the overall sub-par training that we recieve in NY. Way too much inpatient...not enough exposure to procedures, etc. If you are hard pressed to stay in NY...you better marry rich, or hope to win the lottery, because your salary probably wont even be able to support the eventual $6/gallon for gas that we will all be facing...

As for me...Im probably gonna end up practicing in Billings, Montana, where I will have to take my chances with ex-klan members and cow tipping for fun...

 

[pinkeclipse]

Wow ok. So NY sucks for PM&R.

I really hope this isn't the same at other places. Had I not stumbled on that survey, I never would have known. Very depressing. It's almost like my attendings and peers swaying me against it were right?

 

[Dr. Ice]

they were

 

[pinkeclipse]

take it from someone who has completed his residency training in NY and who has heard about job opportunities in NY/NJ. IT SUCKS!!!! There is way too much competition and the salaries are def not comparable with the rest of the country... even if you do interventional. I know someone who just completed a one year accredited PM&R spine fellowship and who is now only making $180 base in jersey.

Part of the reason NY grads are "disenchanted" is because of the influence of disheartened attendings (I have encountered my fair share), and the overall sub-par training that we recieve in NY. Way too much inpatient...not enough exposure to procedures, etc. If you are hard pressed to stay in NY...you better marry rich, or hope to win the lottery, because your salary probably wont even be able to support the eventual $6/gallon for gas that we will all be facing...

As for me...Im probably gonna end up practicing in Billings, Montana, where I will have to take my chances with ex-klan members and cow tipping for fun...

No wonder when I tell people from back home (NY) what I'm going into, I get a "are you crazy?" look.

So are you gonna do a fellowship or just going straight into practice?

 

[pinkeclipse]

they were

Anesthesia is starting to look good now. 🙁

 

[MSKalltheway]

No wonder when I tell people from back home (NY) what I'm going into, I get a "are you crazy?" look.

I mean you can also see it this way--the same is true for many other specialties in NY. Thats just because it's NY, not because its PM&R. You'll find that the other specialty forums her on SDN echo this. You could easily expect to find the same in any primary care specialty. Honestly I'd bet most things without cosmetic procedures will get you less bang for your buck there than other parts of the country.

Physicians just dont have it the same as other professions. The more saturated the area is, the less you'll make. Physicians are the only ones that are different. I was talking to my mom this weekend (a nurse in NY for many years) and she said nurses get paid WAY more there than if you were to move out to the middle of nowhere. You wont find this with physicians, since docs get paid differently than everyone else.

I would just pick the specialty you like and worry less about the pay scale, you'll make it work if you're responsible with what you get.

Honestly, I dont even want to move back to NY; I can get cheaper living elsewhere!

 

[Dr. Ice]

fellowship...not that it makes a difference.

Go into anesthesia...its much better. Plus theres not that much mental stimulation involved in checking the PT box which is basically what we do.

Oh yeah, and some of us do "intervention" which really hasnt proven to be beneficial at all according to recent articles in the Archives of PM&R.

 

[PMR 4 MSK]

Oh yeah, and some of us do "intervention" which really hasnt proven to be beneficial at all according to recent articles in the Archives of PM&R.

But it pays the bills and keeps the patients amused for a while...

 

[bedrock]

It's a known fact that reimbursement has dropped significantly for inpatient rehab and that inpatient jobs are limited in certain parts of the country (although there quite a few options remain outside of major coastal cities).

No one knows for sure how long providers will continue to be reimbursed for interventional procedures and at what rates. I would worry if that's all you hope to do for 30 years.

The one area of PM&R that still has tremendous growth is outpatient MSK care. The wave of baby boomers trying to stay active will keep everyone busy for the next 25 years, whether it be in your own MSK practice or with an orthopedic/NS group, as surgeons only want to be in the OR and they love physiatrists to take care of their non-surgical patients. Orthopedists are becoming overwhelmed with increased MSK needs of the baby boomer generation, orthopods/neurosurgeons are in short supply, and physiatrists can fill that gap satisfying everyone, surgeon, physiatrist, patient.

 

[Ludicolo]

Dr. Ice

You're obviously not satisfied with your "sub-par" residency training. Congratulations on your fellowship nonetheless. You may want to warn those about to interview in PM&R about your specific program's deficiencies, but I'm not sure if you want to generalize your findings to all NY programs, or all attendings.

As for "checking the PT box" - you know that's not what we do.

 

[Disciple]

The one area of PM&R that still has tremendous growth is outpatient MSK care. The wave of baby boomers trying to stay active will keep everyone busy for the next 25 years, whether it be in your own MSK practice or with an orthopedic/NS group, as surgeons only want to be in the OR and they love physiatrists to take care of their non-surgical patients. Orthopedists are becoming overwhelmed with increased MSK needs of the baby boomer generation, orthopods/neurosurgeons are in short supply, and physiatrists can fill that gap satisfying everyone, surgeon, physiatrist, patient.

Breaking away from surgeons and standing on our own two feet is the next milestone for musculoskeletal Physiatry.

 

[Dr. Ice]

How long do you think its gonna take Barack and Hiliary to realize that our specialty can basically be done away with??

I give it 2-3 months tops

 

[ampaphb]

Oh yeah, and some of us do "intervention" which really hasnt proven to be beneficial at all according to recent articles in the Archives of PM&R.

Could you provide a citation for the article you make reference to?

 

[ampaphb]

take it from someone who has completed his residency training in NY and who has heard about job opportunities in NY/NJ. IT SUCKS!!!! There is way too much competition and the salaries are def not comparable with the rest of the country... even if you do interventional. I know someone who just completed a one year accredited PM&R spine fellowship and who is now only making $180 base in jersey.

You are absolutely right - BASE salaries are generally lower in NY. But I know NO employed interventionist who relies on their base salary, so long as they have a productivity bonus, after the first 6 months of practice. Interventional pain management specialists make between $250 and $400,000 within the first year or two, even in the Tri-State area.

 

[SSdoc33]

How long do you think its gonna take Barack and Hiliary to realize that our specialty can basically be done away with??

I give it 2-3 months tops

You know something I don't?

As far as your other comments about PMR in NYC area, I have to begrudgingly agree with you. opportunities are scarce, reimbursement relatively poor, training not that great (with the exception of Kessler). i guess you actually have to be GOOD at what you do to make it in the area -- wow, what a shocking realization.

I can understand your disillusionment. However, there is clearly a place for physiatry, and we can be very valuable. that is, again, if you are any good.

 

[Dr. Ice]

Could you provide a citation for the article you make reference to?

I believe there was some article in the June addition which studied the use of ESIs for lumbar stenosis and the roundabout conclusion was that ESIs used in these patients did not decrease the need for opiod analgesics....ie...useless. I do recognize, however, the psychological component in treating these patients (addiction, psedo addiction, whatever)...but still...

Granted, it has long been debated that spinal stenosis in the absense of true radicular symptoms is generally not considered an indication for ESIs. However, people do use them to treat these patients, and it has proven (according to the article) once again, the useless nature of the intervention.

But, as stated..."it pays the bills...." at least for now

 

[Dr. Ice]

You know something I don't?

As far as your other comments about PMR in NYC area, I have to begrudgingly agree with you. opportunities are scarce, reimbursement relatively poor, training not that great (with the exception of Kessler). i guess you actually have to be GOOD at what you do to make it in the area -- wow, what a shocking realization.

I can understand your disillusionment. However, there is clearly a place for physiatry, and we can be very valuable. that is, again, if you are any good.

Kind of difficult to be "good" at what you do without the proper training...no??

 

[Gauss]

I believe there was some article in the June addition which studied the use of ESIs for lumbar stenosis and the roundabout conclusion was that ESIs used in these patients did not decrease the need for opiod analgesics....ie...useless. I do recognize, however, the psychological component in treating these patients (addiction, psedo addiction, whatever)...but still...

That article has major faults: inclusion criteria had acute and chronic LBP spanning from radic to stenosis to "other", possibly even failed back surgery or who knows what. It's not an article worth referencing

 

[ampaphb]

That article has major faults: inclusion criteria had acute and chronic LBP spanning from radic to stenosis to "other", possibly even failed back surgery or who knows what. It's not an article worth referencing

Arch Phys Med Rehabil. 2008 Jun;89(6):1011-5.
The relationship between repeated epidural steroid injections and subsequent opioid use and lumbar surgery.
Friedly J, Nishio I, Bishop MJ, Maynard C.

OBJECTIVES: To evaluate whether the use of epidural steroid injections (ESIs) is associated with decreased subsequent opioid use in patients in the Department of Veteran's Affairs (VA) and to determine whether treatment with multiple injections are associated with decreased opioid use and lumbar surgery after ESIs.

DESIGN: VA patients undergoing ESIs during the study period for specific low back pain (LBP) diagnoses were identified, and lumbar surgery and opioid use were examined for 6 months before and after

ESI. SETTING: National VA administrative data.

PARTICIPANTS: U.S. veterans (retrospective data analysis).

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: Opioid use and lumbar surgery after ESIs.

RESULTS: During the 2-year study period, 13,741 different VA patients underwent an ESI for LBP. The majority of patients were using opioids before their ESIs (64%), as were the majority after their ESIs (67%). Of patients not on opioids before the ESIs, 38% were prescribed opioids afterward, whereas only 16% of people on opioids before the ESIs stopped using opioids afterward. Patients who received more than 3 injections were more likely than patients receiving fewer injections to start taking opioids after ESIs (19% vs 13%, P<.001) and to undergo lumbar surgery after ESIs (8.7% vs 6.3%, P=.003).

CONCLUSIONS: Opioid use did not decrease in the 6 months after ESIs. In this population, patients who received multiple injections were more likely to start taking opioids and to undergo lumbar surgery within the 6 months after treatment with ESIs. These findings are concerning because our data suggest that ESIs are not reducing opioid use in this VA population.

 

[ampaphb]

Arch Phys Med Rehabil. 2008 Jun;89(6):1011-5.
The relationship between repeated epidural steroid injections and subsequent opioid use and lumbar surgery.
Friedly J, Nishio I, Bishop MJ, Maynard C.

OBJECTIVES: To evaluate whether the use of epidural steroid injections (ESIs) is associated with decreased subsequent opioid use in patients in the Department of Veteran's Affairs (VA) and to determine whether treatment with multiple injections are associated with decreased opioid use and lumbar surgery after ESIs.

DESIGN: VA patients undergoing ESIs during the study period for specific low back pain (LBP) diagnoses were identified, and lumbar surgery and opioid use were examined for 6 months before and after

ESI. SETTING: National VA administrative data.

PARTICIPANTS: U.S. veterans (retrospective data analysis).

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: Opioid use and lumbar surgery after ESIs.

RESULTS: During the 2-year study period, 13,741 different VA patients underwent an ESI for LBP. The majority of patients were using opioids before their ESIs (64%), as were the majority after their ESIs (67%). Of patients not on opioids before the ESIs, 38% were prescribed opioids afterward, whereas only 16% of people on opioids before the ESIs stopped using opioids afterward. Patients who received more than 3 injections were more likely than patients receiving fewer injections to start taking opioids after ESIs (19% vs 13%, P<.001) and to undergo lumbar surgery after ESIs (8.7% vs 6.3%, P=.003).

CONCLUSIONS: Opioid use did not decrease in the 6 months after ESIs. In this population, patients who received multiple injections were more likely to start taking opioids and to undergo lumbar surgery within the 6 months after treatment with ESIs. These findings are concerning because our data suggest that ESIs are not reducing opioid use in this VA population.

No no, it's much better than that -

1) It doesn't make clear, and therefore I am assuming, these were both blind and fluoroscopically guided epidurals

2) It doesn't distinguish between transforaminal, interlaminar, or caudal procedures

3) It compares >3 vs 3 or less, within a 2 year period, but does not discuss whether these were done in a series, or over time. One series of three which then needed an additional injection is thus lumped in the same category as patients that had one injection every six months

4) 35% of patients who were not on opioids pre-procedure received opioid prescriptions after - were these short term, post-procedure prescriptions, or were they chronic opioid users - they do not distinguish.

5) They measured those who d/c'd their opioid use, but did not look at whether opioid use was decreased, even if not discontinued.

6) If a patient got better after one or two injections, you would expect them to stop using opioids, right? You would expect that THEY would be the ones more likely to not need surgery, right? Not these guys - they expect that, if you needed more than three injections, you should reduce your opioid use, and so were surprised when that population was more likely to go onto surgery.

Admittedly, if you didn't get better after either one or a series of three injections, you would also probably need opiods or surgery, but to me, that just belies the basic problem of the premise of the study - the assumptions they made, definitions they used, and methods they chose to employ to answer their questions, were imprecise (I am being kind).

What is really interesting is that, despite what a mess this paper is, it was published. Now each time you get turned down for an ESI, this is yet another horrendously flawed study that is going to be included in ACOEM, ODG, etc, and you are going to have to take time to explain to the medical director of the insurance carrier why they should not pay attention to "peer reviewed literature". Better still, some genius is going to include this nonsense in a meta-analysis, and tell you that 30 out of 42 published articles on ESI's show they don't work (I am making those numbers up).

You can thank the Dr. Friedly, The PM&R Department at The University of Washington, the Archives, and the Academy for adding to both of those particular headaches.

 

[Ludicolo]

I was going to pick apart the above article, but ampaphb beat me to it. Can we all agree that the study was useless, and it’s not going to change our practice in any way, shape, or form?

So now I’m torn Dr. Ice. You are bitter. I get that. You mock your residency and the specialty of PM&R - your specialty - and use this article as “evidence” that the field of PM&R is suspect. I have to admit that your inability to critically analyze such an article does in fact support your argument that your residency program was weak. And embarassingly enough, the fact that this study was published in the Archives (our specialty's "premiere" journal) - not your conclusion that ESIs are not helpful - lends further fuel to your argument that our field is not up to par compared to other specialties.

Fine – your program sucks. Nothing you can do about it now, except perhaps warn others about your experience. But are you going to move on, or are you going to continue to bash your residency and the field of PM&R? Are you going to apply yourself in your fellowship and make the most of your situation? Or if you don’t succeed there, will you go on to bash your fellowship?

If you don't believe in what you're doing, if you’re not satisfied with the field, if you don't think you can advance the field - then get out. PM&R can ill-afford another bad physiatrist.

 

[Dr. Ice]

I was going to pick apart the above article, but ampaphb beat me to it. Can we all agree that the study was useless, and it’s not going to change our practice in any way, shape, or form?

So now I’m torn Dr. Ice. You are bitter. I get that. You mock your residency and the specialty of PM&R - your specialty - and use this article as “evidence” that the field of PM&R is suspect. I have to admit that your inability to critically analyze such an article does in fact support your argument that your residency program was weak. And embarassingly enough, the fact that this study was published in the Archives (our specialty's "premiere" journal) - not your conclusion that ESIs are not helpful - lends further fuel to your argument that our field is not up to par compared to other specialties.

Fine – your program sucks. Nothing you can do about it now, except perhaps warn others about your experience. But are you going to move on, or are you going to continue to bash your residency and the field of PM&R? Are you going to apply yourself in your fellowship and make the most of your situation? Or if you don’t succeed there, will you go on to bash your fellowship?

If you don't believe in what you're doing, if you’re not satisfied with the field, if you don't think you can advance the field - then get out. PM&R can ill-afford another bad physiatrist.

You are probably right. I think Im gonna work for a pharmaceutical company.

 

[lobelsteve]

You are probably right. I think Im gonna work for a pharmaceutical company.

You've got people skills!!

Charassma...😀

 

[Disciple]

You can thank the Dr. Friedly, The PM&R Department at The University of Washington, the Archives, and the Academy for adding to both of those particular headaches.

Doesn't really promote the whole unity thing does it?

Any inklings that the new Academy journal will be any better?

 

[ampaphb]

Doesn't really promote the whole unity thing does it?

Any inklings that the new Academy journal will be any better?

I know Dr. Massagli has responded to this board in the past - maybe she, or Dr. Weinstein, can comment.

 

[ShrikeMD]

Doesn't really promote the whole unity thing does it?

Any inklings that the new Academy journal will be any better?

I think the new journal will be better than the Archives, but that is only a guess. (It shouldn't be full of articles from PT departments with DPT candidates who need to send their research project summaries somewhere.)

I think my MSK/pain/spine colleagues will likely be happier with a greater proportion of articles oriented toward their interests. Being a neurorehab doc, I don't think it will do much for me, but the Archives didn't either. Even though it had a much higher proportion of neurorehab oriented articles, a number of these were psychosocial stuff that has more peripheral relevance to the clinical work that neurorehab physicians perform on a daily basis.

I am also curious regarding the proportion of research vs review vs case reports in the new journal. Our field, whether MSK or Neurorehab, could improve upon its clinical research base. I suppose I could try and support the new journal by submitting a manuscript, but lately I have been having fun with some cool articles that I will want to send to a journal with the greatest dissemination/visibility potential. A big factor regarding submission of potentially important work to any journal involves the "user friendliness" of the journal: quick review of submissions (I can take rejection, just don't make me wait 6 months for it), quick turnaround to print (isn't it ridiculous to be invited to submit a review article, only to wait 14-18 months after submission to see it in print? In some fields of medicine, the review article would almost be outdated at time of publication. OK, I exaggerate a bit, but hopefully you get the point), and reasonable reviewers (review the study you were asked to review, not the study you WISHED you were asked to review-->there are plenty of worthwhile contributions that aren't 1000-subject multicenter DBRCTs). In my experience, Archives generally did poorly in all three categories.

 

[ShrikeMD]

No no, it's much better than that -

1) It doesn't make clear, and therefore I am assuming, these were both blind and fluoroscopically guided epidurals

2) It doesn't distinguish between transforaminal, interlaminar, or caudal procedures

3) It compares >3 vs 3 or less, within a 2 year period, but does not discuss whether these were done in a series, or over time. One series of three which then needed an additional injection is thus lumped in the same category as patients that had one injection every six months

4) 35% of patients who were not on opioids pre-procedure received opioid prescriptions after - were these short term, post-procedure prescriptions, or were they chronic opioid users - they do not distinguish.

5) They measured those who d/c'd their opioid use, but did not look at whether opioid use was decreased, even if not discontinued.

6) If a patient got better after one or two injections, you would expect them to stop using opioids, right? You would expect that THEY would be the ones more likely to not need surgery, right? Not these guys - they expect that, if you needed more than three injections, you should reduce your opioid use, and so were surprised when that population was more likely to go onto surgery.

Admittedly, if you didn't get better after either one or a series of three injections, you would also probably need opiods or surgery, but to me, that just belies the basic problem of the premise of the study - the assumptions they made, definitions they used, and methods they chose to employ to answer their questions, were imprecise (I am being kind).

What is really interesting is that, despite what a mess this paper is, it was published. Now each time you get turned down for an ESI, this is yet another horrendously flawed study that is going to be included in ACOEM, ODG, etc, and you are going to have to take time to explain to the medical director of the insurance carrier why they should not pay attention to "peer reviewed literature". Better still, some genius is going to include this nonsense in a meta-analysis, and tell you that 30 out of 42 published articles on ESI's show they don't work (I am making those numbers up).

You can thank the Dr. Friedly, The PM&R Department at The University of Washington, the Archives, and the Academy for adding to both of those particular headaches.

Reviewer failures abound-in both "directions". Manuscripts that ought to be published are rejected, flawed studies that ought to be rejected are published. (The archives doesn't have a monopoly on this issue, unfortunately.)

Conversations with insurance carrier medical directors typically aren't difficult because we are asking them to ignore peer-reviewed literature. Rather, the challenge involves their tendency to selectively choose the literature that supports their denials, while ignoring literature that supports the indication for the treatment in question. Depending upon the (lack) integrity of the medical director, almost any piece of literature (or lack thereof) can provide justification for a claims denial.

I am not defending the publication of poorly-conducted/interpreted research. I merely am resigned to the fact that ill-informed ad-hoc reviewers are found in most journals, and therefore we are stuck with these problems for the foreseeable future.

 

[ampaphb]

Reviewer failures abound-in both "directions". Manuscripts that ought to be published are rejected, flawed studies that ought to be rejected are published. (The archives doesn't have a monopoly on this issue, unfortunately.)

Conversations with insurance carrier medical directors typically aren't difficult because we are asking them to ignore peer-reviewed literature. Rather, the challenge involves their tendency to selectively choose the literature that supports their denials, while ignoring literature that supports the indication for the treatment in question. Depending upon the (lack) integrity of the medical director, almost any piece of literature (or lack thereof) can provide justification for a claims denial.

I am not defending the publication of poorly-conducted/interpreted research. I merely am resigned to the fact that ill-informed ad-hoc reviewers are found in most journals, and therefore we are stuck with these problems for the foreseeable future.

Generally I have found that, if I can get to a peer-review or a medical director, they tend to be reasonable. The exception lies in those companies that apply ACOEM guidelines. My concern, therefore, is that poorly designed studies with indefensible hypotheses like the Friedly article, or indefensibly overbroad conclusions like last year's American Academy of Neurology article (Neurology, 2007 Mar 6;68(10):723-9) will be incorporated in subsequent "guidelines", the same way equally bad articles have been in the past.

 

[ShrikeMD]

Generally I have found that, if I can get to a peer-review or a medical director, they tend to be reasonable. The exception lies in those companies that apply ACOEM guidelines. My concern, therefore, is that poorly designed studies with indefensible hypotheses like the Friedly article, or indefensibly overbroad conclusions like last year's American Academy of Neurology article (Neurology, 2007 Mar 6;68(10):723-9) will be incorporated in subsequent "guidelines", the same way equally bad articles have been in the past.

Speaking of the aforementioned AAN guidelines, do you know if they were reviewed or submitted for review by anyone from the AAPMR? Occasionally, the Therapeutics and Technology Assessment Subcommittee of the AAN will request a review of an upcoming publication from an organization with interest in the topic (e.g. the recent TTAS-AAN review of botulinum neurotoxin therapy in spasticity was reviewed by the AAPMR prior to publication).

Even if this wasn't done, one could still write a letter to the editor, or if you really have a lot of time & motivation, form a scholarly committee that reinterprets or refutes the conclusions of the guidelines in question. There is precedent for this. (Example: An important catalyst for development of the guidelines of the definitions & criteria for Minimally Conscious State [Neurology 2002; 58: 349-53] was the publication of The Multisociety Task Force Report on PVS [N Engl J Med 1994; 320: 1499-508, also 1572-9], which did NOT include physiatry/neurorehab participation.)

 

[Disciple]

Generally I have found that, if I can get to a peer-review or a medical director, they tend to be reasonable.

Really?

I've found it to get tougher as you go up the administrative chain.

Had one medical director tell me he wasn't going to approve a stim trial for chronic radic (corresponding MRI and EMG findings) due to the small chance that the radic could've been due to the patient's Type II DM.

Maybe it's because it was a work comp case.

 

[TRAMD]

take it from someone who has completed his residency training in NY and who has heard about job opportunities in NY/NJ. IT SUCKS!!!! There is way too much competition and the salaries are def not comparable with the rest of the country... even if you do interventional. I know someone who just completed a one year accredited PM&R spine fellowship and who is now only making $180 base in jersey.

Part of the reason NY grads are "disenchanted" is because of the influence of disheartened attendings (I have encountered my fair share), and the overall sub-par training that we recieve in NY. Way too much inpatient...not enough exposure to procedures, etc. If you are hard pressed to stay in NY...you better marry rich, or hope to win the lottery, because your salary probably wont even be able to support the eventual $6/gallon for gas that we will all be facing...

As for me...Im probably gonna end up practicing in Billings, Montana, where I will have to take my chances with ex-klan members and cow tipping for fun...

Montana isn't in the south.

 

[Pyroclast]

Montana isn't in the south.

Neither are a lot of KKK members. The Klan's big boom, which from around 1915-WWII, was started in Indiana. It dominated the state and pretty much ran Indianapolis for years, as well as being hugely influential in many other Northern and Western states, including Michigan and Oregon. The KKK was not even remotely isolated to the South. There are idiots everywhere, including violent racist ones.

 

[TRAMD]

Neither are a lot of KKK members. The Klan's big boom, which from around 1915-WWII, was started in Indiana. It dominated the state and pretty much ran Indianapolis for years, as well as being hugely influential in many other Northern and Western states, including Michigan and Oregon. The KKK was not even remotely isolated to the South. There are idiots everywhere, including violent racist ones.

Thanks for the history lesson in response to my joke. It was my VERY roundabout way of saying that I think Montana would be a great place to live.

I am also pretty sure we were talking about Montana NOW, not in the 1920s. You would be hard pressed to find a KKK member (or ex-member) anywhere in the entire Northwest quadrant of the country. The same cannot be said for the South and "Midwest". When I say "Midwest" I am talking about the states just south of the Great Lakes. I place "Midwest" in quotes because I believe that thinking of this area as the midwest, while common, is one of the stupidest things I have ever heard. The Midwest to me is Utah, Colorado, Wyoming and the surrounding area, not hundreds-of-miles-east-of-the-Mississippi Indiana.

I am not sure who the KKK would hate in Montana . . . other white people?

 

[Gauss]

Wiki is your friend:
"The Midwestern United States (or Midwest or Middle West or The Heartland) is an informal name for a group of north-central states of the United States of America, usually including Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Ohio, Nebraska, North Dakota, South Dakota and Wisconsin."

http://en.wikipedia.org/wiki/Midwest

 

[ampaphb]

Thanks for the history lesson in response to my joke. It was my VERY roundabout way of saying that I think Montana would be a great place to live.

I am also pretty sure we were talking about Montana NOW, not in the 1920s. You would be hard pressed to find a KKK member (or ex-member) anywhere in the entire Northwest quadrant of the country. The same cannot be said for the South and "Midwest". When I say "Midwest" I am talking about the states just south of the Great Lakes. I place "Midwest" in quotes because I believe that thinking of this area as the midwest, while common, is one of the stupidest things I have ever heard. The Midwest to me is Utah, Colorado, Wyoming and the surrounding area, not hundreds-of-miles-east-of-the-Mississippi Indiana.

I am not sure who the KKK would hate in Montana . . . other white people?

http://www.mtstandard.com/articles/2006/04/01/newsbutte_top/newsbutte_top.txt

 

[Xardas]

Thanks for the history lesson in response to my joke. It was my VERY roundabout way of saying that I think Montana would be a great place to live.

I am also pretty sure we were talking about Montana NOW, not in the 1920s. You would be hard pressed to find a KKK member (or ex-member) anywhere in the entire Northwest quadrant of the country. The same cannot be said for the South and "Midwest". When I say "Midwest" I am talking about the states just south of the Great Lakes. I place "Midwest" in quotes because I believe that thinking of this area as the midwest, while common, is one of the stupidest things I have ever heard. The Midwest to me is Utah, Colorado, Wyoming and the surrounding area, not hundreds-of-miles-east-of-the-Mississippi Indiana.

I am not sure who the KKK would hate in Montana . . . other white people?

You may be surprised at the number of minorities in states that do not necessarily hold larger cosmopolitan cities, and you should also realize there are truly ignorant idiots anywhere you go in the world.

The KKK is a bit of a caricature of its former self, but ugly racism still exists albeit not in the form of sheet wearing gatherers. Racism is probably more dangerous when it exists in people who look ordinary but harbor ill intent anyways.

 

[Pyroclast]

http://www.mtstandard.com/articles/2006/04/01/newsbutte_top/newsbutte_top.txt

Yikes. I'd forgotten that a lot of those separatists living up in Montana are separating themselves from minorities, among other things. Like sanity.

Sorry for inadvertently hijacking the thread. It was a bit of kneejerk sensitivity to cracks and stereotypes about the South, being from an arguably southern state myself.

And I'm sure Montana would be a perfectly lovely place to live, aside from all the elderly racists.

Now let's please all stop talking about racism and get back to discussing PM&R.