MS3 very interested in Pain

[Fabio001]

Hi there, I'm looking for some advice regarding my future.

I'm a 3rd year medical student at a US medical school (lower tier, MD) with a blossoming interest in pain medicine. I recently got my Step 1 scores back and it's much higher than I expected (240+). So now I'm trying to figure out what would be the best path for me: Anesthesia residency vs. PM&R vs. Neurology.

I envision my end-game as fulfilling the role of the only pain management specialist within a small community (80,000-150,000), and I see myself being a referral source for virtually all the orthopedists, oncologists, primaries, etc… within that community. In this role I would provide chronic pain management as well as some interventional care (ideally like one or two mornings a week in the OR).

So, in a nutshell, I'm concerned about whether I would be best served through PM&R training, or the more conventional route through anesthesia. So far, my experience with both fields has been limited to what I've heard and read. From these boards, there seems to be an arguable consensus that anesthesia matches more easily to pain, but that PM&R will more often than not better prepare someone for private practice. With my step 1 where it's at, I feel that I have a good shot at matching into a great program in either field, so that's not an issue.

My thoughts on Anesthesia residency:
Pros:
I want to match into a great fellowship and most are anesthesia based
I love strong medicine and find analgesics and anesthesia fascinating
I feel that the extra training with procedures and needles will be invaluable in my practice
While building my practice I have a potential source of high income working OR part-time
Cons:
I'm doing surgery right now and am not loving the idea of spending all day every day in the OR for 4 years of residency (though I'm sure I could do it without becoming suicidal)

My thoughts on PM&R:
Pros:
More time learning to manage and care for my own patients
More time spent in the clinic (which is where I envision most of my career taking place)
Cons:
Less money and no reliable high-income cash source to fall back on (is this true?)
From what I understand about the scope of practice of PM&R, off the cuff it sounds less interesting to me than anesthesia

Any advice is greatly appreciated - what to look for in programs, other things to consider, corrections to any assumption I have made, etc... 🙂


--- Also posted in Anesthesiology and Pain ---

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[RangerBob]

Full disclosure--I'm a intern who matched into PM&R and did lots of rotations in PM&R, including pain. No experience through anesthesia, but some experience with IR.

From talking with other physicians and my experience, my honest opinion is PM&R trained pain physicians make better pain physicians (obviously I'm very biased here). You learn much more about the pathophysiology behind pain. You're essentially trained as a neuro-ortho-musculoskeletal specialist. You'll get training in orthopedic, general, cancer & neuro rehab, sports medicine, EMGs (think peripheral neurology), etc. etc. Especially on inpatient rehab, you'll also learn a lot about the psychosocial aspects that factor into a patient's disease/pain. (Some physicians don't want to deal with them, but you have to learn to deal with it to be a pain physician, and to be a good one you have to understand them). PM&R physicians will also know much more about PT (I'm not sure if anesthesiologists learn anything about PT and physical modalities), and physiatrists know and usually write on the prescription pad exactly what they want the physical therapist to work on, rather than the "evaluate and treat" that every other physician does. (And the really good PM&R physicians will teach the exercises to motivated patients).

I agree you are a much more competitive for a pain fellowship through anesthesia, but if you're interested in clinic, PM&R is great because you could still practice general outpatient musculoskeletal rehab, sports, EMGs, etc. on the side. If you want to really treat and understand the source of the pain, I just think PM&R does a better job--and I think they better learn when not to inject.

I do think you'll be more comfortable with procedures through anesthesia, but you'll get lots of experience with peripheral injections in general musculoskeletal PM&R clinics. Both specialties should have you rotating through pain and interventional pain clinics, though sometimes PM&R programs don't have a lot of elective time. Not too sure about anesthesia.

I definitely agree anesthesia will earn you much more money, probably even after a pain fellowship, compared to a physiatrist who completed a pain fellowship (though they still make a ton of money! At least to me...). But I also think reimbursement for interventional pain is likely to fall... Just a hunch--I have no evidence to support that other than lots of overused procedures are seeing cuts.

With all that said, honestly, if the description of PM&R doesn't appeal to you, then maybe it's not the right path. Remember, you're going to be a generalist first, specialist second. Assume that it's possible you might change your mind about sub-specialization (lots of people do) and go with the residency that you find more interesting and would be more willing to do/practice generally. If you can't stand the OR, ask yourself if you really want to tolerate 4 years of it. Either way, I think it's worthwhile to shadow a physiatrist for a few days--they're usually really likeable people, so at the very least it'll probably be enjoyable, even if you opt not to pursue it as an option.

Your Step 1 score is fantastic--the odds are you'd get interviews at top PM&R programs if you did apply, assuming you have strong clinical grades. You could rank programs with PM&R fellowships highest (UCLA has two spots per year, I believe). You always have the best shot at getting a fellowship in-house. (Or if you come from a place like Mayo, UW, RIC, Kessler, etc...)

Lastly, try to keep an open mind throughout third year. If you rotate through and really love neurology, then maybe that's the field for you. I loved some rotations I thought I'd hate--I actually really enjoyed OB and surgery. I completely changed my mind about what specialty to pursue (more than once!). Fortunately your Step 1 score should keep a lot of doors open, so do your best in your clinical years to get great grades and after you gain more experience, hopefully the light will shine on you and you'll go into PM&R... I mean..., wherever you're meant to be 🙂

 

[DrMattOglesby]

I met with a anesthesia-trained pain attending and he told me that he uses very little of what he learned in his Anesthesia residency. He said if an applicant knows that they want to do pain medicine, he wouldn't recommend an anesthesia residency to get to it. The training just isn't built for that type of practice. However, he went on to say that PM&R would be a great route to pain medicine. Though the applicant should be careful in selecting which PM&R program in which they train because he has noted some PM&R pain medicine fellows he has trained were weak in their procedural skills compared to other PM&R pain med fellows that came from certain programs (Mayo and Columbia were used as examples of providing strong training).
Last point he made: if you go into Anesthesiology and work with neurosurg and ortho surgeons, there is a possibility that you could not receive as much respect from them because they may hold to the OR mentality of bossing around anesthesiologists. PM&R docs may not get mistreated as much in private practice because they are classically viewed as working independently from the surgeons anyway.

 

[Fabio001]

Thank you both so much for your feedback and advice! The most epic pain medicine doc that we see at my hospital is a private practice physiatrist who has a morning or two in the OR per week. I definitely will get in touch with him!

A couple more questions: Is it realistic for a PM&R trained pain medicine doc to expect to get paid as much as anesthesia trained pain doc -- I appreciate that many of them will be billing for the same stuff, but with salaried positions will the anesthesiologist always have more bargaining power? This is probably my biggest concern as I'll be graduating with a good few hundred thousand dollars in loan debt Also, what can I expect from a typical PM&R residency in respect to pain training - do all residents rotate through pain? Are the residencies with larger blocks of the curriculum dedicated to pain the same ones that put out graduates who are better at procedures? What are these programs? Also, what are the programs that I should really look at - not just the most well known, but those that are well known for their pain training and in-house pain residencies (or does the whole 'avoid places with fellows' mantra apply to PM&R pain like it does in surgery)?