IM vs PM&R

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Can the sdn community help list pros and cons of each? I am at a cross-roads right now and can't decide which one to go into.

Some personal info: Lifestyle and happiness is the most important to me. If I were to go into IM, I would for sure do fellowship (not sure what right now). I am not trying to live inside LA, SF, NYC or any other big city. Ideally, I would like to live in suburbs an hour away from a mid-sized city. I wouldn't ever want to do academic medicine so if I did IM->subspecialty, I would for sure work in outpatient group practice or the like. I am not opposed to doing inpatient PM&R (considering doing both inpatient and outpatient actually).

My step1 score is very mediocre (230), honored medicine and family med, HP peds and psych, Pass in ObGyn and surgery.

IM Pros:
- feels good to know a solid amount about everything
- do fellowship and I'm pretty much guaranteed a job with good pay, since location is not that important to me as I stated above

IM Cons:
- residency is hard. life after residency is hard.
- hours are long and all the medicine attendings I've been with seem very stressed.

PM&R Pros:
- residency is easy. life after residency is easy. (at least what I've heard...)
- option to do pain fellowship and work solely outpatient. or can do a mix of inpatient + outpatient (more $?)

PM&R Cons:
- don't get much respect from people in medicine (not that I really care..)
- I feel like I would forget all my medicine knowledge and be really specialized; i.e. forget how to manage someone with pneumonia (not that I would need this in PM&R..)

Thoughts?

 

[sloop]

Sounds like you want to do PM&R but are somewhat concerned about getting less respect than a medicine subspecialist, but at the same time don't really care about this. Doesn't seem like much of a question to me. I think deep down you have your answer.

 

[WheezyBaby]

Some personal info: Lifestyle and happiness is the most important to me.

Stopped reading, question answered

 

[DetectiveAlonzo]

You're looking for EM.

 

[Syndicate]

Can anyone comment on the job opportunities for PM&R? What setting, inpatient/outpatient/both, is it hard to find a job?


Sent from my iPad using SDN mobile

 

[tkim]

You're looking for EM.

EM is not a lifestyle specialty.

 

[cyanide12345678]

You're looking for EM.

EM resident here. EM is definitely not a lifestyle residency. ED physicians work hard. One ED shift is quite a bit of stress. I'm on my PICU month. It's ridiculous how amazing the life of these peds intensivists is at my hospital. Census of 3-5 patients usually. Work 6 days a month. 24 hour shifts where they just round in the morning and then go home and answer questions and put in orders over the phone for the residents and nursing staff. Now compare that to a normal ED shift where as an intern I'm seeing about 12-14 patients in a 10 hour shift. By the end of residency, I'll be seeing 20 patients in a 10 hour shift. That's 20 H&Ps. Nope, EM is definitely not a "lifestyle" field. It's a great gig, the salary after residency is great, the work is interesting and not boring. But there are better lifestyle gigs out there. Also IM hospitalist life sucks in comparison to Peds hospitalist in my experience at my hospital. The difference is ridiculous. Our ED easily admits 10-20 patients to the hospitalist service over night after capping the internal medicine teaching teams. While maybe we'll admit 1 or 2 kids the whole day to the Peds hospitalist. No wonder the pediatricians are significantly happier and have better work life balance than their adult counter parts.

 

[WheezyBaby]

EM resident here. EM is definitely not a lifestyle residency. ED physicians work hard. One ED shift is quite a bit of stress. I'm on my PICU month. It's ridiculous how amazing the life of these peds intensivists is at my hospital. Census of 3-5 patients usually. Work 6 days a month. 24 hour shifts where they just round in the morning and then go home and answer questions and put in orders over the phone for the residents and nursing staff. Now compare that to a normal ED shift where as an intern I'm seeing about 12-14 patients in a 10 hour shift. By the end of residency, I'll be seeing 20 patients in a 10 hour shift. That's 20 H&Ps. Nope, EM is definitely not a "lifestyle" field. It's a great gig, the salary after residency is great, the work is interesting and not boring. But there are better lifestyle gigs out there. Also IM hospitalist life sucks in comparison to Peds hospitalist in my experience at my hospital. The difference is ridiculous. Our ED easily admits 10-20 patients to the hospitalist service over night after capping the internal medicine teaching teams. While maybe we'll admit 1 or 2 kids the whole day to the Peds hospitalist. No wonder the pediatricians are significantly happier and have better work life balance than their adult counter parts.

Lol, suffice to say your peds ICU / hospitalist experience doesn't exactly mirror mine

 

[RangerBob]

There's nothing wrong with wanting a nice lifestyle, but you want to make sure you like the field. PM&R is a great field, and there are plenty of jobs out there (inpatient, outpatient, and inpatient/outpatient). Between PM&R and IM, PM&R definitely has the better lifestyle. I had six weekend calls this year--the rest of my weekends have been golden weekends. In our PGY2 and 3 years we do closer to 14-16 or so weekend calls, so we still have the majority of weekends off. There are a few really heavy PM&R residency programs, so it's not universal to have a nice lifestyle in residency, but it's pretty common.

I sort of understand your concern about worrying you'll forget basic medicine, but I don't think you need to worry. Some rehab units hire a physiatrist to do just the rehab management and a hospitalist does the medical management, but many units the physiatrist is still managing the medical problems. I'm still a resident, but I'm not consulting anyone for management of a pneumonia, chest pain work-up, etc. I do that myself. Most of my attendings feel the same. If it gets really complicated then we consult, but we're quite comfortable with the basics. The attendings that just do outpatient and cover inpatient on a few weekends a year aren't typically comfortable with medicine, so unless they have a resident on with them they will typically consult for even the simple medical stuff.

When we get into specialized populations, like spinal cord injury, medicine starts consulting us for management. So if medicine is important to you there are plenty of ways to use it in PM&R. If you do just outpatient PM&R then yeah, you'll probably lose it (like you would if you did psych, derm, path, etc.). On the other hand, in outpatient PM&R you need to know a crazy amount of MSK/peripheral nervous system anatomy, so it's not like there's a huge void of knowledge.

As for the respect, I feel we get plenty from the services that refer to us because they know what we can offer patients. I've never felt disrespected/not respected by others--the bigger issue is there are plenty of people who just don't know what we do. But instead of feeling bad we're not as sexy as neurosurgery or cerebral as nephrology, I just think about how much I love what I do and how much I'm helping my patients (and how I actually have time to see my wife).

 

[msrbutch]

Can the sdn community help list pros and cons of each? I am at a cross-roads right now and can't decide which one to go into.

Some personal info: Lifestyle and happiness is the most important to me. If I were to go into IM, I would for sure do fellowship (not sure what right now). I am not trying to live inside LA, SF, NYC or any other big city. Ideally, I would like to live in suburbs an hour away from a mid-sized city. I wouldn't ever want to do academic medicine so if I did IM->subspecialty, I would for sure work in outpatient group practice or the like. I am not opposed to doing inpatient PM&R (considering doing both inpatient and outpatient actually).

My step1 score is very mediocre (230), honored medicine and family med, HP peds and psych, Pass in ObGyn and surgery.

IM Pros:
- feels good to know a solid amount about everything
- do fellowship and I'm pretty much guaranteed a job with good pay, since location is not that important to me as I stated above

IM Cons:
- residency is hard. life after residency is hard.
- hours are long and all the medicine attendings I've been with seem very stressed.

PM&R Pros:
- residency is easy. life after residency is easy. (at least what I've heard...)
- option to do pain fellowship and work solely outpatient. or can do a mix of inpatient + outpatient (more $?)

PM&R Cons:
- don't get much respect from people in medicine (not that I really care..)
- I feel like I would forget all my medicine knowledge and be really specialized; i.e. forget how to manage someone with pneumonia (not that I would need this in PM&R..)

Thoughts?

PMR residency is not easy. That is a common misconception. It is challenging, but in different ways than IM. Of course it does vary with what program you go to. I went to Baylor in Houston and I personally found it difficult managing ventilators at night at TIRR and it was heart wrenching seeing patients with complete tetraplegia and severe brain injury. Do not go into something because you think it might be easy.


The lack of respect for PMR from other providers does not make sense to me. The really good PMR docs have huge knowledge base and are brilliant people and do back breaking hard work.
Its just a very different world knowledge wise than IM. I think people don't understand what a physiatrist does exactly. Perhaps that is the problem.

 

[DetectiveAlonzo]

PMR residency is not easy. That is a common misconception. It is challenging, but in different ways than IM. Of course it does vary with what program you go to. I went to Baylor in Houston and I personally found it difficult managing ventilators at night at TIRR and it was heart wrenching seeing patients with complete tetraplegia and severe brain injury. Do not go into something because you think it might be easy.

I ****ing hate when people say that such-and-such residency is "easy". Bench players talking like starters.

 

[zeppelinpage4]

Can the sdn community help list pros and cons of each? I am at a cross-roads right now and can't decide which one to go into.

Some personal info: Lifestyle and happiness is the most important to me. If I were to go into IM, I would for sure do fellowship (not sure what right now). I am not trying to live inside LA, SF, NYC or any other big city. Ideally, I would like to live in suburbs an hour away from a mid-sized city. I wouldn't ever want to do academic medicine so if I did IM->subspecialty, I would for sure work in outpatient group practice or the like. I am not opposed to doing inpatient PM&R (considering doing both inpatient and outpatient actually).

My step1 score is very mediocre (230), honored medicine and family med, HP peds and psych, Pass in ObGyn and surgery.

IM Pros:
- feels good to know a solid amount about everything
- do fellowship and I'm pretty much guaranteed a job with good pay, since location is not that important to me as I stated above

IM Cons:
- residency is hard. life after residency is hard.
- hours are long and all the medicine attendings I've been with seem very stressed.

PM&R Pros:
- residency is easy. life after residency is easy. (at least what I've heard...)
- option to do pain fellowship and work solely outpatient. or can do a mix of inpatient + outpatient (more $?)

PM&R Cons:
- don't get much respect from people in medicine (not that I really care..)
- I feel like I would forget all my medicine knowledge and be really specialized; i.e. forget how to manage someone with pneumonia (not that I would need this in PM&R..)

Thoughts?

The cons for IM are legit, and if you want good lifestyle and dislike academic medicine, I feel like you're putting yourself through 5 years of misery before you finish fellowship and find an outpatient practice setting you like.

The cons for PM&R don't seem like problems to me. Most of us will forget a lot of what we learned in med school. You're going to get better at your specialized area and get rusty in other areas to some degree in almost any specialty. The only exception to this is Family Med which is about knowing a little bit about everything.

And you said you don't care about how much respect your field gets. And truthfully, you should never let that be a deciding factor in your decision anyways, as you need to follow your heart and not what others make you feel.

Truth be told, I don't know that much about IM or PM&R (applied peds), but just from reading your post, it looks like PM&R is the better choice for you.

One more thing to consider is, lifestyle aside, do you enjoy the field of PM&R and find the practice interesting? I was looking at PM&R briefly, but realized that I couldn't stand learning about musculoskeletal, neuro, and limb anatomy. The field just wasn't interesting to me.

But, two friends of mine who applied PM&R had really compelling reasons for applying and you could tell they really enjoyed the field itself.

 

[IslandStyle808]

PMR residency is not easy. That is a common misconception. It is challenging, but in different ways than IM. Of course it does vary with what program you go to. I went to Baylor in Houston and I personally found it difficult managing ventilators at night at TIRR and it was heart wrenching seeing patients with complete tetraplegia and severe brain injury. Do not go into something because you think it might be easy.


The lack of respect for PMR from other providers does not make sense to me. The really good PMR docs have huge knowledge base and are brilliant people and do back breaking hard work.
Its just a very different world knowledge wise than IM. I think people don't understand what a physiatrist does exactly. Perhaps that is the problem.

I have read Baylor's PM&R residency program is especially hard. Was it mostly in-patient or do you get a fair mix of in-patient and out-patient?

 

[Durty-Trixxx]

EM resident here. EM is definitely not a lifestyle residency. ED physicians work hard. One ED shift is quite a bit of stress.

I'm amazed at how many people still think ED is cush. I almost never see an ED attending over the age of 55 and there's good reasons for that.

 

[ekmf27050]

-the bigger issue is there are plenty of people who just don't know what we do

As an ortho surgery pt, I stumbled over to PMR not really knowing what they did, and I literally fell in love. I don't know how I made it without physiatrists all this time. Once I combined ortho surgery + physiatry I was able to fully recover from some complex stuff. Plus, my sports med physiatrist made a tough dx that literally saved my leg- so I went from not knowing what PMR was to having lots of love for it

 

[Butterfly23]

PMR is very diverse field and the treatment plans can be very idiosyncratic between practioners. for example, ankle foot orthosis has so many different designs and depending on who you talk to, people will choose different options. For example, adductor muscle spasticity with hip dysplasia, some will choose to do botox and i will not do botox and do alcohol block instead because I believe botox does not do jack shxx.
overall, idiosyncracy is what I love about PMR. for Me IM is too much of text book based and i just cannot stand reading algorithm from the harrison. IM treatments plans can be different from each attending. But, PMR presents with much more challenges due to idiosyncracy. my PT prescriptions are very different for medial pain due to plicae syndrome vs knee osteoarthritis. i also think ober test is BS for iliotibial band syndrome.

However, IM mistakes can kill patients but PMR mistakes are much lower risk. IM is more evidence based but PMR research is very lacking.

Also, remember PMR is not glorious field. You will have to do stuff that is not supposed to be regular MD jobs. why do i have to fight insurance company for broken wheelchair footrest plate? some of my colleagues say PMR is fillup gap specialty or dumbster specialty.
it will take many many years for PMR to be glorious. a lot of my friends are going into pain so they can feel like they are doing more from their direct hands.

so decide for yourself!

 

[DubVille]

My residency was very easy. Im not ashamed to admit it. Had 2 relatively intense rotations but otherwise was laid back. It gave me time to have a life and read about my interests in the field without any burnout. My fellowship is mostly 7:30-5 and honestly feels "harder" than residency.

Jobs are out there. You can get inpatient jobs almost anywhere (of course really desireable markets are tougher). Outpatient jobs typically will want interventional or regenerative med experience and are slightly harder to come by. Still a good market overall, but not like IM/FM where you can look at any city and have 15+ options. All residents and fellows got jobs in the areas they wanted but none were looking in NYC, SF, LA.
As noted above some residencies are much more intensive than others, but the great majority are far easier than any IM residency.
Residency is temporary, do what will make you happy. I dont regret my decision at all (yet).

 

[W19]

IM is the dumping ground in every hospital. If you equally like another specialty as you like IM, go for the other specialty.

By the way, What do PM&R docs do?

 

[LoGo]

IM is the dumping ground in every hospital. If you equally like another specialty as you like IM, go for the other specialty.

By the way, What do PM&R docs do?

I hear 90% of the job and 75% of the residency is dedicated to how to tactfully decline a consult or transfer of care from IM, neurology or surgery.

I jest, but aside from those who do non-op sports med (which I'm not sure why you'd do PMR then sports med over FM then sports med), I don't know much of what they do.

 

[ekmf27050]

IM is the dumping ground in every hospital. If you equally like another specialty as you like IM, go for the other specialty.

By the way, What do PM&R docs do?

• To maximize function, physiatrists use a variety of techniques including medications, injections, modalities, therapeutic exercise, prosthetics / orthotics, cognitive therapy and adaptive devices to treat patients of all ages.
• Physiatrists facilitate physiologic adaptation to disability to prevent complications or deterioration secondary to disabling conditions.
• Physiatrists may use musculoskeletal ultrasound and electrodiagnostics to help aid in the diagnosis of complex neurologic or musculoskeletal injuries.
• The goal of the physiatrist is to provide medical care to patients with pain, weakness, numbness, flaccidity, spasticity and loss of function so that they can maximize their physical, biological, psychological, social, and vocational potential

(What Does a Physiatrist Do)

In short- do you have a musculoskeletal problem, but you don't need cut open to fix it? Go see a physiatrist.

 

[Atom612]

Man, people really tend to hate on IM on this board. I've seen EM docs and FM docs defend their specialties, but haven't really seen that with IM. Aren't there any internists on here that actually like their jobs? I really like the "thought" of doing IM, but haven't been able to actually shadow any internists to see what it's like.

 

[NITRAS]

There is a lot of variety of IM jobs out there. Clinic, inpatient, mixed, in addition to non-clinical positions that are there. You can do lot of procedures and manage ICU's or not do any procedures and no ICU at all. I can genuinely say, I see a huge variety of patients at my hospital. I work at a large hospital with a closed ICU and good night coverage.

Sub-specialists and surgeons will always dump unwanted patients onto medicine services. I find it laughable how medicine sub-specialists seem to quickly forget basic medicine. They also tend to run hospitals and set hospital policy, which can get frustrating at times.

I make decent money, and I don't know of any specialty that I'm willing to spend 2 or 3 years to learn.

I have a lot of respect for PM&R. At my medical school, they had a couple good ones that can diagnose pain syndromes better than most. Personally, I would never go into a specialty that deals primarily with pain. But that is me.