Look: In the hospital setting, primarily what physiatrists do is direct resources. It's a little known fact that inpatient rehabilitation is the second most expensive (and *THE* most labor-intensive) area of the hospital. Only the ICU costs more on a per day basis. At my institution, comprehensive inpatient rehabilitaiton costs $3K per day (not including physician fees). Not everyone requires the same level of medical intervention and rehabilitation for their disability. It's up to the physiatrist to decide what they in fact do need. But, if you want to see where the "PM&R Magic" happens, it is more in the outpatient venue.
In the hospital, we function as the primary medical service for patients with devasting neurological injuries and impairments---yes, that means that we do a lot of babysitting. We handle all the "crap" that no one wants to do (or that general medicine is too freaked out to do) but that these patients need in order to maximize their functional outcome. We watch for neurological decline and complications. We treat pain. We deal with the whole "adjustment to disability" issue. In short, physiatrists manage disability. Do you need to be physiatrist to babysit disabled people? Probably not. Do you need to be an anesthesiologist to do a MAC for a breast biopsy or hernia repair? Ditto.
After a patient acquires new cervical tetraplegia and has their spine stabilized, the neurosurgeons really have nothing left to offer. I'm not slamming neurosurgeons, but that's the reality. The neurologists are completely unintersted in the situation---there is nothing left to diagnose. Assuming that there are no associated secondary injuries, other hospital services have nothing to contribute. But, this person is still severely disabled, not "whole," still requires medical resources and care, and is not ready to go home by any stretch of the imagination. So, they need rehabilitation and they need long-term follow-up:
1) Equipment
2) Education
3) Re-training
4) Therapy
5) Home modification
6) Long term bowel and bladder management
7) Usually medico-legal issues out the whazzoo
Rehabilitation is a different model of care than traditional "curative" medicine so it takes a little getting used to in order to understand what physiatrists "do." It's the epitome of "humpty-dumpty medicine" where after all the king's horses and all the king's men couldn't put humpty back together again, someone got a PM&R consult...Or, put another way, it's not so much about saving lives (although any PM&R resident can relate numerous stories of codes, acute strokes, "missed" aortic dissections, tension pnuemos, etc on the rehab unit) as it is about saving futures.
All of which gives physiatrists a unique perspective about managing and treating painful conditions. It's hard to believe that some pain doc would certify a 45 year old woman with fibromyalgia as "completely disabled" when in any given day in your spinal cord injury clinic you see dozens of quads and para becoming productive members of society despite significant hurdles. Rent Murderball and see rehab in action.
