Overlapping Fields

[JSW1123]

Hi all,

I am an MS3 currently thinking about multiple fields, among them neurology and PM&R. I have been reading a lot about PM&R and been in touch with several PM&R docs to try to understand more about what is done in practice. I think part of my problem in understanding the field properly is that it overlaps with so many fields that it is hard for me to understand what they do differently than a non-PM&R doc.

The main difference that gets mentioned constantly is that PM&R focuses on "the whole person" and "function," but the specifics of that often seem to consist of various physical therapies that often ends up sounding to me like you are a rehab coordinator. But I'm sure that there is a lot more to it than that!

To give a specific example to make it concrete--I am interested in outpatient neuro much more than inpatient, specifically I find neuromuscular diseases interesting. So what would I do differently if I was a neurologist vs PM&R doctor? Don't both want to preserve functionality/slow disease progression/etc.?

Another part of what I don't understand is that I have seen references to the large range of outpatient practices in PM&R, even to the point of it being said that it could resemble a neuro outpatient practice or an ortho outpatient practice etc. That really surprises me. The implication is that if you specifically like these sorts of things then you may as well go the PM&R route (as the residency sounds easier than ortho/neuro/etc. Can that be? It seems strange to me...so again, I think I am just missing the boat on PM&R.

I know I've covered a few different questions here. In short: What does PM&R do differently than other apparently overlapping fields in practice? Would/Could it really be very similar to the outpatient versions of orhto/neuro/etc.?

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[Slowpoke]

This is an incredibly deep and insightful question. I applaud the effort! AND kudos to you for fully exploring your options prior to committing.

Stroke
Neuro: The reason you had the stroke was because of x, y, z from these tests we ordered. Take these pills to prevent another stroke. You'll need rehab.
PM&R: You can't move your arm or your leg? Here's what we can do to give you the best shot at getting movement back in your extremities and getting you back to your prior level of function > acute rehabilitation
or
PM&R: You had a stroke and unfortunately, it seems like you weren't set up for rehabilitation services, you've now got some spasticity. I can inject botox to specific muscle groups to help facilitate the recovery of x, y, z function
+

Spine
Neurosurg/Ortho: Your back pain is likely from this mild-moderate spinal canal stenosis, we don't recommend surgery at this time. See a physical therapist.
PM&R: You have mild-moderate spinal canal stenosis. What sort of activities are you finding difficult to do/what limitations do you currently have? Here's what we can do to slow the progression of disease, and give you the best chance of returning to your prior activity > PT +/- meds; PT +/- epidural

Spinal Cord Injury (SCI)
Trauma surgery: you were involved in a motor vehicle accident, we were able to resuscitate you, but unfortuntaely you've sustained a spinal cord injury. you'll need lots of rehab
PM&R: We're going to admit you to acute SCI rehabilitation, we're going to be by your side to help, we work with a team of individuals whose main goal is to help you recover from this traumatic event, we're responsible for establishing your prognosis, managing any complications that arise during your rehabilitation and recommend medications. We'll continue to care for you even after discharge from acute rehabilitation to care for you throughout the rest of your life.

Sorry, it is getting late here and I have to wake up for my shift tomorrow, but if you found this help, I can potentially write more at later time. LOL.

 

[JBM16BYU]

I think the above answer gives a great start. If I may, I’m going to add to it.

PM&R does add great variety. From an inpatient standpoint, you do kind of feel like a rehab coordinator sometimes, because you essentially oversee all of the medical needs to ensure that none of them get in the way of their PT, OT, SLP, rehab psychology, recreational therapy, etc. for example, a patient who just underwent brain surgery, or had a spinal cord injury or a stroke May have difficulty with bowel and bladder management, which may lead to incontinence or constipation, either of which get in the way of their therapies, so it’s up to you to come up with a plan to maximize this management. You are there for any medical issues that arise on the unit, such as new seizures after surgery, repeat head bleeds, falls, blood clots and pulmonary emboli, and pain management. The patients need therapy to improve after their traumatic event, your job is to ensure that nothing medical gets in the way.

From an outpatient standpoint, it varies highly, like you mention. This is an oversimplification, but specialities like neurology, neurosurgery, orthopedics and rheumatology diagnose and May offer some medicinal management of a disease; but PM&R’s job is to help you manage the rest of your life with the diseases. Your outpatient practice could function as a non-surgical orthopedics practice, referring people to PT, diagnosing hip/knee/shoulder pain. Other things you can add are musculoskeletal ultrasound guided injections into joints, MSK ultrasound diagnostics. In a spine clinic, you may be able to offer fluoroscopic guided axial spine injections, prescribing orthotics if a patient develops foot drop from chronic radiculopathy, spasticity management for myelopathy in the spine, plus bowel and bladder management. All of those neurological diseases that get diagnosed, from MS to ALS to brain tumors to transverse myelitis, even things such as carpal tunnel syndrome, May need bracing, spasticity managment, pain management, managing baclofen pumps, etc. PM&R helps people continue to manage their life, despite the disease or injury. There is some diagnostics in PM&R, for example training in EMG is built into PM&R residency and you need 200 before graduating, but oftentimes you simply manage the things that are diagnosed elsewhere and help the patients continue to live life.

 

[PMR2008]

Great discussion. Agree with the above posts. @JSW1123 name some diagnosis and I will tell you how we treat patients from the Physiatry prospective.

 

[JSW1123]

Thanks for all the responses, @PMR2008, @JBM16BYU, and @Slowpoke!

Stroke
Neuro: The reason you had the stroke was because of x, y, z from these tests we ordered. Take these pills to prevent another stroke. You'll need rehab.
PM&R: You can't move your arm or your leg? Here's what we can do to give you the best shot at getting movement back in your extremities and getting you back to your prior level of function > acute rehabilitation
or
PM&R: You had a stroke and unfortunately, it seems like you weren't set up for rehabilitation services, you've now got some spasticity. I can inject botox to specific muscle groups to help facilitate the recovery of x, y, z function
+
.....

It sounds like neuro is really just diagnostic, then? I have heard it is very "diagnose and adios," but I'd also heard that that has changed a lot recently...but I guess you are saying in practice not much has changed?

Would definitely appreciate any more examples and clarifications that come to mind! These were really great and instructive.

....
From an outpatient standpoint, it varies highly, like you mention. This is an oversimplification, but specialities like neurology, neurosurgery, orthopedics and rheumatology diagnose and May offer some medicinal management of a disease; but PM&R’s job is to help you manage the rest of your life with the diseases. Your outpatient practice could function as a non-surgical orthopedics practice, referring people to PT, diagnosing hip/knee/shoulder pain. Other things you can add are musculoskeletal ultrasound guided injections into joints, MSK ultrasound diagnostics. In a spine clinic, you may be able to offer fluoroscopic guided axial spine injections, prescribing orthotics if a patient develops foot drop from chronic radiculopathy, spasticity management for myelopathy in the spine, plus bowel and bladder management. All of those neurological diseases that get diagnosed, from MS to ALS to brain tumors to transverse myelitis, even things such as carpal tunnel syndrome, May need bracing, spasticity managment, pain management, managing baclofen pumps, etc. PM&R helps people continue to manage their life, despite the disease or injury. There is some diagnostics in PM&R, for example training in EMG is built into PM&R residency and you need 200 before graduating, but oftentimes you simply manage the things that are diagnosed elsewhere and help the patients continue to live life.

That last line of this stands out to me, as I do like the puzzle of diagnosis (especially utilizing physical exam, which is a big neuro thing, from what I understand, but in general I do like the puzzle too). Do you feel like, overall this is lacking in the field? Would you tell someone who enjoys that skill that this is a serious tradeoff to consider?

Great discussion. Agree with the above posts. @JSW1123 name some diagnosis and I will tell you how we treat patients from the Physiatry prospective.

I guess, as I'm interested in outpt neuro types of things (although if you have any other choice examples, I would love to hear them too!), I would say things like Parkinson's, MS, myasthenia gravis, neurogenic bladder, various brain injuries, strokes...I know that was a bunch of things, but really, any of those would be revealing to me I think.

Thank you all so much for your answers thus far!

 

[90sportsfan]

Hi all,

I am an MS3 currently thinking about multiple fields, among them neurology and PM&R. I have been reading a lot about PM&R and been in touch with several PM&R docs to try to understand more about what is done in practice. I think part of my problem in understanding the field properly is that it overlaps with so many fields that it is hard for me to understand what they do differently than a non-PM&R doc.

The main difference that gets mentioned constantly is that PM&R focuses on "the whole person" and "function," but the specifics of that often seem to consist of various physical therapies that often ends up sounding to me like you are a rehab coordinator. But I'm sure that there is a lot more to it than that!

To give a specific example to make it concrete--I am interested in outpatient neuro much more than inpatient, specifically I find neuromuscular diseases interesting. So what would I do differently if I was a neurologist vs PM&R doctor? Don't both want to preserve functionality/slow disease progression/etc.?

Another part of what I don't understand is that I have seen references to the large range of outpatient practices in PM&R, even to the point of it being said that it could resemble a neuro outpatient practice or an ortho outpatient practice etc. That really surprises me. The implication is that if you specifically like these sorts of things then you may as well go the PM&R route (as the residency sounds easier than ortho/neuro/etc. Can that be? It seems strange to me...so again, I think I am just missing the boat on PM&R.

I know I've covered a few different questions here. In short: What does PM&R do differently than other apparently overlapping fields in practice? Would/Could it really be very similar to the outpatient versions of orhto/neuro/etc.?

I am a medical student, and asked the exact same question a few months ago on this board and got some really helpful replies from PM&R docs on this board.

One place that PM&R is more involved in than Neuro on the outpatient side, would be Rehab. The thing that worried me is that PM&R is just not very well known by the general public, and I was wondering how that would impact patients. Almost nobody I know outside of medicine, knows what a "physiatrist" is, but as long as referring physicians do, you should be ok.

I ultimately am leading towards Radiology (although I still have Neuro on my radar). PM&R is third on my list, but I've pretty much narrowed it down to Radiology (most likely) and Neuro (which I still like very much).

 

[Musculo]

Hi, I’m sort of jumping in, but I’d love to hear if physiatrist is involved in home care right now. Theoretically, I think this next generation of older folks will fight being institutionalized for even short periods like rehab after a total knee and rehab/nursing home may shift away from facilities. Seems like PM&R would be the perfect specialty for this. Does PM&R currently have a role in this area and are there signs of major expansion in it? This thread has been extremely helpful, so thanks for all the replies!

 

[9732doc]

That last line of this stands out to me, as I do like the puzzle of diagnosis (especially utilizing physical exam, which is a big neuro thing, from what I understand, but in general I do like the puzzle too). Do you feel like, overall this is lacking in the field? Would you tell someone who enjoys that skill that this is a serious tradeoff to consider?

@JSW1123 Welcome to the PM&R forum. You're asking all the right questions and there are many good answers here.
PM&R is a broad field and that is in part why it is hard to give a general statement about what it does. In reality, it's a umbrella for multiple subfields.
The general features are though:

• Body system: Musculoskeletal and Nervous System focused
• Overall goal: Maximize functional ability. A PM&R doc said recently "Most specialties focus on adding years to life, but we focus on adding life to years." The specifics of that look different in each subfield.
• Environments: Inpatient or Outpatient. I'd say, in residency at least, there is a predominant interest in outpatient PM&R more than inpatient, but both have rewarding opportunities.
• Training path: Compared to Neurology, for the most part, PM&R residency training is more humane. Take that as you will.
• Balance of diagnosis vs. management (below):

Depends on subfield. For much of inpatient physiatry, we are tasked with doing things to mitigate the after-effects of someone's injuries and impairments. There is the opportunity to diagnose sequelae of those injuries. For example, in a new SCI, you might detect heterotopic ossification and intervene. Or you might identify a new mononeuropathy that resulted from the positioning the patient rests his arms on his wheelchair. So you can do diagnosis but over a longer term and not for the main issue.

But there are areas where you are the first set of eyes (or the best set of eyes). In MSK/sport medicine, I'd say the phyiastrist can be the primary diagnostician. People come in with chief complaint of a some kind of joint pain, it's your job to do all the things to figure out what it is. I'd say in the domain of MSK-related problems, PM&R is the most sophisticated and thorough. I'm really impressed how my MSK attendings bring to bear physical exam, ultrasound, diagnostic imaging to precisely say what the issue is. And then, you also have the ability to intervene with an injection, directed therapy, medicine or for some, even doing minimally-invasive procedures like carpal tunnel release (this is very new). Or, if warranted, you refer the patient to your orthopedic colleagues, knowing that they truly are in need of surgery, and not just prematurely getting a spine fusion because they saw an orthopod first. I think the MSK physiatrist really is the complete physician.

Many PM&R trained people go into pain medicine now, doing the same fellowship as anesthesia trained people. Pain medicine is also largely management but there is the opportunity to diagnose what the source of the pain is, in a way that is usually more in depth and targeted than most.

From a neuro standpoint, I'd say the area where you could be most like an outpatient neurologist is neuromuscular medicine. Neuromuscular medicine is one of the recognized subspecialties of PM&R and PM&R trained people can/do train in ACGME neuromuscular fellowships, alongside neurologists. If you like NM disease (neuropathies such as GBS, CIDP, myopathies, NMJ disease like MG) and want to operate as an outpatient NM specialist, you could be the the primary diagnostician for all the weird NM diseases. AND on top of that, you can bring to bear your physiatry knowledge/training and take part in not just the medical treatment but also direct the therapy and exercise, and if there is pain involved, you could treat the pain, rather than outsource to pain management.

For other neuro diseases like stroke, seizure, MS, neuro-ID, neuro-Onc etc. we won't be the first set of eyes in PM&R. So if that's what you like, you should consider neurology more.

Hope that helps. PM&R is an awesome field and has so much variety. It's good to be asking these questions now. You may be able to get what you want from it.