help convince me

[freddydpt]

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Hi,

So I'm curious about PM&R... I'm a PT and I already know I enjoy working in an outpatient atmosphere with MSK injuries. I also know that I really didn't like working with neuro patients as much because of the slow to nill recovery (and the IP setting was a little depressing). How much of PM&R graduate training is dedicated to each training. I know I could eventually control my patient population, but I would hate to go through years and years of training with a patient population I didn't enjoy working with. I'm interested in PM&R more so than family medicine sports because of the procedures and quite honestly the debt that I've built up along the years of graduate school.

Any advice? Thanks!

 

[drusso]

Hi,

So I'm curious about PM&R... I'm a PT and I already know I enjoy working in an outpatient atmosphere with MSK injuries. I also know that I really didn't like working with neuro patients as much because of the slow to nill recovery (and the IP setting was a little depressing). How much of PM&R graduate training is dedicated to each training. I know I could eventually control my patient population, but I would hate to go through years and years of training with a patient population I didn't enjoy working with. I'm interested in PM&R more so than family medicine sports because of the procedures and quite honestly the debt that I've built up along the years of graduate school.

Any advice? Thanks!

You won't get around doing a significant amount of inpatient rehab in your training. Most residents don't enjoy inpatient rehab, some do, but I think that it is an important part of the training. With your background in PT you might be well ahead of the curve in your experience and thinking, but most people (especially young healthy medical students and residents) underestimate what people *CAN* do following a devastating neurological injury or illness. It's hard to sign those disability papers for a 42 year old woman with nonmalignant chronic pain and fibromyalgia when you've seen people with tetraplegia go through a successful course of rehabilitation and retrain in another field.

So, yes, inpatient is a drag, but it does have its rewards. I don't think that it is where the future of the field is (until we have some significant basic science breakthroughs in stem cell research and neuro-regenerative therapies) but I do think it's the foundation.

 

[paz5559]

You won't get around doing a significant amount of inpatient rehab in your training. Most residents don't enjoy inpatient rehab, some do, but I think that it is an important part of the training. With your background in PT you might be well ahead of the curve in your experience and thinking, but most people (especially young healthy medical students and residents) underestimate what people *CAN* do following a devastating neurological injury or illness. It's hard to sign those disability papers for a 42 year old woman with nonmalignant chronic pain and fibromyalgia when you've seen people with tetraplegia go through a successful course of rehabilitation and retrain in another field.

So, yes, inpatient is a drag, but it does have its rewards. I don't think that it is where the future of the field is (until we have some significant basic science breakthroughs in stem cell research and neuro-regenerative therapies) but I do think it's the foundation.

Does that mean you are not in favor of a dedicated pain residency?

 

[drusso]

Does that mean you are not in favor of a dedicated pain residency?

I go back and forth on the topic. I know that there is a big push to establish pain medicine as its own distinct field but I'm unconvinced. I see the advantages for both patients and practitioners to having a dedicated field of practice called pain medicine, but I see the advantages for the field as a whole of keeping it more multidisciplinary/subspecialty in nature. I don't think that the field is quite "there" yet.

It's kind of like those campaigns you see small cities promote to "Keep Austin Weird" or what not. I think that we might become too homogenized and like echo chamber if pain became its own primary specialty. I'm sentimental about keeping it a subspecialty accessible to a variety individuals with experiences in other domains.

 

[freddydpt]

I actually worked with a couple of chronic pain patients during my PT education and I actually enjoyed it! How long is a pain fellowship after PM&R? How competitive is it to get?
Thanks again!

 

[Disciple]

Hi,

How much of PM&R graduate training is dedicated to each training.

Any advice? Thanks!

Your inpt load will probably be somewhere between 12 and 24 months out of 36, depending on which program you enter.

So, if you're looking for more outpt training, pick one of the more progressive programs.

 

[Disciple]

I go back and forth on the topic. I know that there is a big push to establish pain medicine as its own distinct field but I'm unconvinced. I see the advantages for both patients and practitioners to having a dedicated field of practice called pain medicine, but I see the advantages for the field as a whole of keeping it more multidisciplinary/subspecialty in nature. I don't think that the field is quite "there" yet.

It's kind of like those campaigns you see small cities promote to "Keep Austin Weird" or what not. I think that we might become too homogenized and like echo chamber if pain became its own primary specialty. I'm sentimental about keeping it a subspecialty accessible to a variety individuals with experiences in other domains.

I think it depends on whether one thinks pain = spine. I think most good musculoskeletal Physiatrists would say no. Personally I tend to think of pain medicine as treatment of a symptom, requiring a multidisciplinary approach (interventional, psyche, neuro, etc.) and musculoskeletal medicine as being orthopaedic in nature, with a structural/anatomic/kinesiologic approach often being effective.

If one believes that pain medicine should be standardized, and that all practicioners be lumped under this umbrella, then what is a musculoskeletal Physiatrist other than a "pain" doc with an incomplete skill set, who treats a select population of patients? I am skeptical that the emerging model of multidisciplinary pain medicine training or even a proposed standardized pain residency curriculum could produce pain docs with MSK skills equivalent to those that will emerge in the next ten years out of Physiatric training.

So I think there should be standardized training in "pain" medicine, but also a separate subspeciality encompassing musculoskeletal medicine (whatever it may be called), both with legitimacy. As Physiatrists, we should promote what we do as different from "pain" docs, not necessarily superior.

 

[drusso]

So I think there should be standardized training in "pain" medicine, but also a separate subspeciality encompassing musculoskeletal medicine (whatever it may be called), both with legitimacy. As Physiatrists, we should promote what we do as different from "pain" docs, not necessarily superior.

I agree with you in principle, but in practice there are many conditions that pain physicians manage that MSK/spine physiatrists (even those with significant interventional skills and training) would have little interest in managing: Acute post-op pain, malignant cancer pain, pediatric pain, CRPS, etc. Some pain physicians view interventional MSK/spine physiatrists as "cherry pickers" who only want to deal with the straightforward stuff. I don't agree and can't articulate their views beyond that, but just so you know there are other opinions on the topic.

Without a doubt, a typical physiatric outpatient practice involves a significant amount of pain management and general physiatric training is excellent in preparation for managing a variety of painful conditions. Still, general physiatric training does not adequately prepare most residency graduates to COMPREHENSIVELY manage these conditions...i.e. diagnose, intervene, and longitudinally manage patients with complex pain conditions. If you want to combine expert diagnostic skills with expert procedural skills in your practice, that training is only available at the fellowship level for either PM&R, neurology, or anesthesiology graduates.

 

[Disciple]

Yeah,

The "cherry picker" label is the favorite handed out by many interventional pain docs.

I realize many PMR MSK/Spine docs don't treat cancer/Peds/CRPS etc. well or don't want to, but then again many pain docs don't handle Musculoskeletal Medicine or Complex Spinal Disorders very well, and I don't think any multidisciplinary pain fellowship or even pain residency can give that level of skill, just as no PM&R residency or MSK/Spine fellowship for that matter will train someone in blind thoracic epidurals, regional blocks or pump/stim implants.

Have you met anyone that can do "everything" with skill and expertise?

Neither have I.

As of 2006 anyway.

So in my opinion, this entire scope of practice cannot and should not be lumped under one classification. I know these issues are political, but in the best future interests of our specialty (now referring to PM&R not "Pain"), I strongly believe we should have our own subspecialty (Musculoskeletal, Non-surgical Orthopaedic, or whatever we need to call it to get it done) and take a "separate/different but valid" type of stance. As long as we let ourselves become labeled as similar in practice and skill set to other specialties, there will always be the argument of who's background is more appropriate or suitable, and as you know, we will probably always be the smaller specialty.

The reason I bring these issues up is that with the way careers typically develop, it will be you, I and the residency class of '00-'10 discussing these issues in 2016 at PASSOR, NASS or whatever our representative musculoskeletal forum may be at that time.

 

[Disciple]

You won't get around doing a significant amount of inpatient rehab in your training. Most residents don't enjoy inpatient rehab, some do, but I think that it is an important part of the training. So, yes, inpatient is a drag, but it does have its rewards. I don't think that it is where the future of the field is (until we have some significant basic science breakthroughs in stem cell research and neuro-regenerative therapies) but I do think it's the foundation.

This is unfortunate,

I think if inpt training wasn't so similar to a 2nd intern year at many institutions, many residents would be much more interested in this aspect of Physiatry and would get more out of their training (more time to interact with the rehab team and address "rehab" issues).

IM is also a primary service but PGY-2s and 3s get to take a more supervisory role.

Perhaps there needs to be a greater role for mid-levels in inpt rehab e.g. in the community setting, one Physiatrist overseeing a unit with NP's or PA's doing daily rounds and discharges. The Physiatrist could directly manage the more complex patients.

In addition to increased resident interest in inpt rehab, I think more graduating residents would be interested in the high volume inpt jobs often offered right out of residency if this model were in place.

I know that rehab departments typically have smaller budgets than other departments, but if inpt rehab is to live on and fluorish, we may need a change in the typical inpt practice model.