Is interest in Pain enough for justify PMR

Discussion in 'PM&R' started by WaterAvatar, Dec 25, 2008.

  1. WaterAvatar

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    If one's only real goal/interest is Interventional Pain Medicine, yet they would like a more medicine/holistic approach than the anesthesia-route... is that enough reason to go into PMR? (keeping in mind that there are so many other aspects of PMR that may not interest you).
     
  2. axm397

    axm397 SDN Moderator
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    If there are a lot of aspects of PMR that not only does not interest you but you do not like, then you will be miserable in a PM&R residency. Statistically, you have a better chance of landing an interventional pain fellowship via anesthesiology. PM&R residency will teach you a different body of knowledge than anesthesiology but if procedures/interventions are what interest you the most - anesthesiology is probably better for you. 3-4 years is a long time to suffer through rotations you do not enjoy.
     
  3. lobelsteve

    lobelsteve SDN Lifetime Donor
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    It was for me.

    THe negatives of PMR were less than the negatives for Anes (only as far as residency goes).

    Now, access for PMR to pain fellowships has changed and for the next few years you need to think Gas to Pain.

    Five years from now it will all be changed...
     
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  4. PMR 4 MSK

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    If you only want to stick needles in people, go for IR. In PM&R, we talk to pts, see what their deficits and complaints are, formulate a treatment plan, including meds, PT/OT, injections and other treatments. In IR, people send you pts to inject, no follow-up, no decision making. Just pure needle-jockey happiness. You'd likely be miserable in PM&R.
     
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  5. drusso

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    Opinions on this topic are riddled with biases and stereotypes. I tend to agree with PMR4MSK that, in general, physiatry training better offers better foundational experiences for pain than other base specialties. I tend to agree with Steve that in the intermediate term, Gas training might be more politically expedient route to go.

    You have to do rotations in all related specialties and find your right fit. I liked Gas but not enough to train in it for 4 years years, ditto for neurology; I was too afraid of the dark to do Rads...
     
  6. oreosandsake

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    Lobelsteve,

    Can you please elaborate on this?

    thank you.





    btw, Happy New Year everyone!
     
  7. Ludicolo

    Ludicolo Fib Hunter
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    I believe he is speculating about the establishment of ACGME accredited Pain residency programs. A move who’s time has come. But until then…

    One bit of practical advice: even if interest in pain is your sole focus in pursuing PM&R (or anesthesia for that matter), I wouldn’t advertise this too strongly during the interview circuit. Not everyone you interview with will be that interested in pain. And you don’t want to appear too close-minded to the other aspects of PM&R or anesthesia.
     
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  8. rehab_sports_dr

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    I may just be getting curmudgeonly, but I feel like if you are only interested in pain, that PM&R is the wrong field for you

    I would also do a self-check to make sure you are really only interested in pain. I definitely have met medical students who thought they were just interested in pain, but that was in part an exposure issue. I am narcissistic enough to think that if a medical student who doesn't want to follow a career path exactly like mine, it's only because they haven't been sufficiently exposed to sports medicine, osteoarthritis management, and other aspects of musculoskeletal care.

    I also have seen medical students who like pain because they like doing pain procedures, but they really like the other aspects of pain. I certainly see lots of these people out in practice- they are the ones who do 20 procedures on their patients and then dump them on me when they've made their money off of them.

    I think for any medical student who is trying to figure out what they want to do, I would think about what are the things they would enjoy outside of their main scope of practice. For example, would you rather see a concussion patient or a trigeminal neuralgia patient? Would you rather see a patient with patellofemoral syndrome, or a patient with complex regional pain syndrome? Would you rather deal with sharing inpatient rehab call with your colleagues, or would you rather have to deal with late night calls about narcotic renewals?

    One of my partners has anasthesia based pain fellowship training, and I know she would give very different answers to these questions than I would. She's an amazing pain doc, and frankly does a better job with complex pain patients than I do. On the other hand, I enjoy the complex referrals from the sports orthopods for musculoskeletal conditions that need another pair of eyes, and I don't think my partner would want those.

    So, in my typically long-winded fashion, I would think about what it is about pain you find appealing.
     
  9. Disciple

    Disciple Senior Member
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    Why?

    Let's say a medical student talks to an Anesthesia, Neurology and Psychiatry faculty, and they all say the same things about their specialties.



    Now what?


    There is a shortage of pain specialists in this country and no pain residency as of yet, yes?


    For a medical student interested in "pain management", I think a practical way of looking at things would be:

    -Do you like Orthopedic Medicine/procedures?-------PM&R

    -Do you like procedures, phys/pharmacology, regional blocks/catheters-------Anesthesia

    -Are you cerebral? Are you fascinated by neural-------Neurology
    pain pathways and the neurobiology of pain?

    -Do you like talking to your patients for 45 minutes at-------Psychiatry
    a time? Do you like getting into your patient's heads,
    focusing on the stress, depression and anxiety their pain is causing?

    -Do you want to do procedures only?-------Interventional Rads
     
    #9 Disciple, Jan 4, 2009
    Last edited: Jan 4, 2009
  10. drusso

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    I think that the real subtext to this discussion is the following: Some people misguidedly associate an "interest in pain" with wanting to make a lot of money. More than most specialties, physiatrists are quite neurotic when it comes to economic issues. To appear overly interested and motivated in pain medicine might be received as being "too Greedy," "too Agressive," or "too Coastal" by some PM&R programs.

    So, just try to be "vanilla" on the interview trail about all your interests...
     
  11. ampaphb

    ampaphb Interventional Spine
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    Does that mean Pittsburgh, Michigan, Baylor, Colorado, LSU, RIC, Wash U, Fortin, etc. are all outliers? (Gulf of Mexico and the Great Lakes notwithstanding)
     
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  12. rehab_sports_dr

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    > I think that the real subtext to this discussion is the following: Some people misguidedly associate an "interest in pain" with wanting to make a lot of money.

    Perhaps. I don't think it's misguided, though

    I think an appropriate parallel is the impact of marketing to physicians by device manufacturers and pharma. Most physicians feel that they are above being impacted by outside influences, but the data is pretty unequivocal- we are influenced. It's just a basic principle of economics- people respond to incentives, and this is true of medical students as much as any other cohort.

    I also don't think it's an accident that shifts in choice of fields for medical students follows pretty closely with lifestyle, of which income is a large component.

    Within PM&R, the practice patterns have shifted from inpatient --> electrodiagnostics --> interventional spine in a pattern that is consistent with financial forces that made each of these domains appealing.

    Beyond these very reasonable suspicions, I have heard many medical students and residents voice that the reason they chose to pursue pain procedures is because of financial factors.

    For myself, it's something I have to think about very hard. There are times that a patient is referred to me with the goal of doing an epidural, but I don't think it's in the patients best interest. To do what I think is the right thing flies right in the face of all my incentives- doing the epidural will take less time than trying to explain why I think an alternative pathway is easier, and I'll get paid less for doing it.

    Anyway, I don't think it is at all unreasonable to think that at least some subset of the medical students who are interested in pain are really interested in making lots of money.

    I think a strong parallel here is dermatology. I am sure there are some medical students who very passionate about medical dermatology. That doesn't explain why there are many people who bust their butt, take extra years off to do research, and fight tooth and nail to get into derm residencies. Of course lifestyle and finances are influencing the decision.

    Don't get me wrong- there are many very good pain physicians out there, and I admire people who do pain for the right reasons. I've fully supported my residents who are interested in pain fellowships, trying to give the best possible education and guidance to meet all their goals.

    It's a heck of a lot more fun to train residents and medical students who are primarily motivated by a desire to help patients.
     
  13. Ludicolo

    Ludicolo Fib Hunter
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    It ain’t about the money. I personally could care less what people make after graduation, so long as they earn their keep at a high quality and with integrity. I’m in academia – almost all of my graduates make more than I do. I applaud them for that. For better or for worse, when you graduate, you represent your institution, so we want you to succeed. Because success breeds success.

    It’s about having too narrow a focus entering residency. No offense to the MS-4’s, but most of you guys/gals don’t have the experience yet to fully commit to any subspecialty of PM&R. When candidates state that they do, it comes off as being either extremely arrogant, or extremely naïve. How many people changed their minds about a specialty during medical school?

    Certainly, we are/were all drawn to PM&R for one reason or another, and it’s fine to talk about what attracted you to the field initially. Personally, I wanted to do sports medicine starting off. I’m an academic EMG doc now. Our field as many have said is ridiculously broad - you don’t know what you ultimately will end up doing.

    Case in point, the other week I interviewed someone with a strong interest in peds rehab. A bit too strong IMHO. I would bring up our program's SCI exposure or our burn exposure or our EMG exposure, the candidate would ask what percentage of patients were peds patients. While I admire the singular determination - and there were no other "red flags" - I know that this person will not do well at our program. If you’re that narrow minded, you will have a difficult time working with a lot of your attendings and colleagues. You need to at the very least tolerate the non-peds, or non-pain aspects of any specialty residency, in order to survive, much less thrive.
     
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  14. SSdoc33

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    agreed, and very well stated. however.....

    there is SO much PM&R that i have little or no interest in (ie: the "R") part. i could spend literally all of my time trying to focus on a narrow aspect of outpt physiatry and still spend a career honing my skills. the beauty of a specialist is that you can be just that -- an expert in your particular field. IMHO, you simply cant be (or at least most of the mortals out there) a jack of all the PM&R trades. i find nothing wrong with a particular desire and a focus. it is a means to an end. i had to tolerate a lot of PM&R that i really didnt like, and i bet a lot of us out there had to do the same. while i was smart enough not to let that show too much going through the process, i knew that i would rather not practice medicine than practice most of what i had to do as a resident.
     
  15. Disciple

    Disciple Senior Member
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    And many of these applicants get accepted to Derm residency, become good Dermatologists, help alot of patients, and make positive contributions to their specialty.

    Why should we descriminate against otherwise good applicants because we perceive during an interview that lifestyle and financial factors may be impacting (to a certain degree) their choice of specialty?
     
  16. Disciple

    Disciple Senior Member
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    I think we need to give special consideration to the unique situation surrounding "Pain Medicine".

    As much as it should probably be its own specialty, for the time being it remains a subspecialty.

    I see nothing wrong with a medical student being proactive, taking the time to look into a field carefully and being decisive early-on with their career choice. Surgical specialties seem to encourage this.

    When pain residencies are eventually developed, we can leave all the "Why Pain Medicine?" interview questions to the Pain Medicine faculty.

    But for the time being, instead of saying "Not in my specialty, your intentions are not pure, go take up a spot in Anesthesia or somewhere else", I think we should use the current situation as an opportunity to instill (willingly, not by force-feeding) Physiatric philosophy and skill sets into future Pain Medicine specialists. Thus, when pain residencies come into existence, we will have greater influence within the field. As many of you know, our specialty did somewhat of a poor job representing our interests in Pain Medicine and in maintaining our fellowships, and it makes me cringe every time I receive progress notes from PM&R pain specialists who do poor MSK exams, no longer do EMGs because they're too busy injecting, or seem to be focused more on narcotics and esoteric procedures than coming up with a good anatomic diagnosis and rehab plan.

    In addition, I don't think it's all that common to have good medical students, who then become PM&R residents, who can't push through core rotations, even rotations they don't like. Afterall, good medical students who go on to Cardiology and GI have to push through 3 years of inpt medicine, Plastic Surgery fellows had to spend 5 years taking out gallbladders and draining abcesses and Anesthesia residents have to take OB call and work in the SICU.

    Which brings me to my second point, surrounding the whole specialty/subspecialty debate and the attitude of our field towards increasing the degree of expertise of our new graduates.

    In IM (a specialty arguably just as broad as PM&R), you have some programs known for putting out primary care docs, some known for sending people on to Cards, GI, Nephrology, Rheum, etc, and even some with hospitalist tracts.

    At the subspecialty focused programs, I highly doubt they look down on medical students committed early on to a particular subspecialty, knowing that the groundwork for matching into Cards, GI, etc. generally begins during intern year or early on in PGY-2.

    Everyone has their own motivations for going into medicine, picking a particular specialty, etc. and I think if we show tolerance towards those differences, our specialty will be unified and benefit in the long-run.
     
    #16 Disciple, Jan 4, 2009
    Last edited: Jan 4, 2009
  17. drusso

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    I don't argue that broad-based, comprehensive training is important and should be valued.

    However, all things being equal, I think that there are substantial differences between how a field like Internal Medicine and PM&R would regard a given applicant's aspirations for specialization.

    I think that a categorical internal medicine applicant who shows up for their internal medicine interview with a zealous passion for understanding the phenotypic expression of polycystic kidney disease and a single-minded quest to secure *THE BEST* internal medicine training possible in order to obtain a nephrology fellowship would be viewed more positively by their department than a categorical physiatry applicant with a zealous passion for understanding the histochemical basis of lumbar degenerative disc disease and a single-minded quest to secure *THE BEST* interventional spine or pain training possible...I think that one applicant would be viewed as "serious" and the other might be viewed as "opportunistic."

    Despite all the professional issues endemic to general internal medicine, that field still embraces *THE VALUE* of sub-specialists in a manner that physiatry has yet to demonstrate. I think that physiatry is still very ambivalently attached to the idea of subspecialization and this is evident by strong feelings about PASSOR reintegration issues, membership councils, etc.

    I think that PM&R applicants should be aware that physiatric sub-specialization is controversial to some people and modify their interview behavior accordingly.
     
  18. Disciple

    Disciple Senior Member
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    Yes,

    exactly.


    So, if we are to reference the original question,

    If one's only real goal/interest is Interventional Pain Medicine, yet they would like a more medicine/holistic approach than the anesthesia-route... is that enough reason to go into PMR? (keeping in mind that there are so many other aspects of PMR that may not interest you).


    The answer the yes.


    Just don't tell anybody about it until the time is right.;)
     
  19. ampaphb

    ampaphb Interventional Spine
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    I don't think the ambivalence is toward sub-specialization in general - quite honestly, if you express an interest at the get go toward EMG, SCI, or TBI, the programs will be enamoured with your focus, and smitten by any evidence of indepth knowldge you might possess. Should you have a similar focus toward pain, however ...
     
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  20. drusso

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    ...then you might be called a "needle-jockey," "pokey-pony," or "pill-pusher." :D
     
  21. DrMarchMadness

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    True, but 3 years of OR is a long time to suffer if you want to only do Pain. I hated the OR.
     
  22. drusso

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    True. But three years on a rehab unit is a long time if you hate disabled people! (I don't, but I'm just saying...)
     
  23. DrMarchMadness

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    Hardly anyone gets into pain from Psychiatry.
    PM & R in my opinion, has better anatomical/functional anatomy and MSK training. You spend most of your time in Anesth in the OR. I know, I was a resident.
    However, the perception is that it is much easier to get into Pain from Anesthesiology. Me, I couldn't take 3 years of OR just to do pain since I didn't end up liking the other aspects of anesth. You will get great epidural/spinal, regional block training (depending on your residency, that is). But, you can get that from a Pain fellowship anyway. I truly think it is harder to get into Pain from Psych and even Neuro.
     
    #23 DrMarchMadness, Jan 6, 2009
    Last edited: Jan 6, 2009
  24. DrMarchMadness

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    I agree. Personally, I like working with people, and didn't get enough of that in anesthesiology. It's funny, but if medical students would just know themselves better (myself included in the past), they would avoid choosing the wrong specialty for the wrong reasons. But, that would solve a lot of problems wouldn't it?
     
  25. rehab_sports_dr

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    > Hardly anyone gets into pain from Psychiatry.

    Is that true? I don't know the numbers

    My first exposure and interest in pain was from a Psychiatrist, Rollin Gallagher, who is now the editor in chief for Pain Medicine. Maybe I have a skewed perspective, but I was under the impression that there are a lot of pain physicians who are primarily psychiatry based

    There has been some cross talk on this thread (some of which I am largely responsible), with different people talking about different topics that are similar, but not quite the same thing

    There appears to be some confounding of "Pain Medicine" and "Fluoroscopically guided spine procedures." There is obviously overlap, but they are not the same thing. I do fluoro guided injections, but don't consider myself a pain physician. I know many tremendous pain physicians (Norm Harden comes to mind) who never do spine injections.

    I am assuming the quoted comment above is noting that few people with a psychiatry background eventually do fluoro guided spine injections
     
  26. rehab_sports_dr

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    > But for the time being, instead of saying “Not in my specialty, your intentions are not pure, go take up a spot in Anesthesia or somewhere else”

    I have probably been the most outspoken person on this forum on this "pure blood" intention, and probably deserve the criticism for being too dogmatic. I think everyone here has raised some great points, and you're all right- PMR needs to be more open minded about pain medicine. We can best influence the debate of how to treat pain patients as insiders.
     
  27. Disciple

    Disciple Senior Member
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    :laugh:

    I was thinking, "if you hate being on a rehab unit"

    but,

    OK
     
  28. lobelsteve

    lobelsteve SDN Lifetime Donor
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    I actually loved being on the rehab unit. Typically 3 admissions, 3 discharges, 2 family conference, one team conference, and rounds on 15 patients (stable) 2x in a day. It was like a vacation (or detention). I could lift weights, play basketball (both on the rehab floor), free lunch (ST eval, needs swallow study, NPO- free lunch for me), and still be home at 3:30 most days.

    Sure, watching people go from FIM of 2 to FIM of 3 not exciting, but admit to DC scores going from D to mod-I in an SCI (spinal shock/contusion), or hemorrhagic CVA patient made me proud to be watching the therapists do all that hard work with the patients. Actually, I think all I did was the paperwork, sprinkled encouragement and enthusiasm, and stole their lunch. Oh, and yeah, wrote an admission cookbook to make sure the b/b, DVT, skin, wound, GI, anticoag, prealb/nutrition, SW/placement, equipment eval, was all done automatically so I could walk around Ghent for some frsh air most days.
     
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  29. drusso

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    This is a pretty good thumb-nail sketch of it. I always thought of myself as sort of a cruise-ship director...
     
  30. lobelsteve

    lobelsteve SDN Lifetime Donor
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    Is that why they gave you the nickname Julie?
     
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  31. drusso

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    Gosh, DP talks you into the crimper just once and you get a rep...
     
  32. lobelsteve

    lobelsteve SDN Lifetime Donor
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    He's metro...

    http://www.folica.com/Sexy_Hair_Curve_d3542.html

    Officially endorsed by DP.
    Nevada Spine is not responsible for the personal hair products of its physicians and other staff members.
     
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  33. Disciple

    Disciple Senior Member
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    I've only found 1 good Pain Psychiatrist in my community. I don't think he's fellowship trained though I've found him to be very knowledgable.

    I send him alot patients, usually those who require long-term opiates and have a significant Psychiatric disorder i.e. Bipolar D/O, multiple suicide attempts, etc.

    I think the reason we talk about pain and interventional procedures as being one and the same is that our specialty (Physiatry) has yet to make a firm statement regarding these procedures and has not yet created any regulatory mechanism for Interventional Physiatrists. You can see this a little bit with the new membership councils (MSK & Sports vs. Pain "Rehabilitation"--no real mention of which council an interventionalist should be a part of, no real unified body to represent this aspect of Physiatry)

    Pain Medicine does embrace these procedures and provides certification and regulation to a certain degree.

    If this ever changes in the Physiatry world, I think you'll start to see the lines more clearly demarcated.

    I think IR is a good example. They certify their own fellows and do many of the same procedures as Interventional Pain physicians, up through cervical discography and vertebroplasty, yet I doubt you'd hear confusion in any Rads departments about what it is they do in IR vs. Pain Medicine.
     

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