Patients in PM&R practice

[Leukocyte]

Hello,

I was just wondering...how is the avarage PM&R patient like? I mean:

-Are most patients, on avarage, older or younger?

-Are the majority of the patients seen in PM&R pain patients? If not, what medical condition do you see the most? (for example for IM/FM it is HTN and DM)

-How long does a typical out-patient clinic visit last ?

-Do PM&R docs follow patients long-term or short-term? When are patients discharged from the care of the PM&R doc?

-What are most PM&R consults from PCPs about?

Thanks.

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[pmrthoughts]

http://www.aapmr.org/career/students/Pages/default.aspx

http://c.ymcdn.com/sites/www.physiatry.org/resource/resmgr/introtorehab.pdf

probably a good introduction.

 

[Jitter Bug]

The nice thing about PM&R is it a very broad specialty, as broad as family practice I think and you can choose your niche. Pediatric PM&R sees newborns to age 18. Adult PM&R sees 18+

Inpatient: general rehab: the acute hospital feeds your practice: strokes, SCI, TBI, etc etc. All ages, all levels of function. You can keep them long term or stabilize their care and return to the PCP's with a plan in place.

Outpatient PM&R you have healthier patients and higher functioning ones. You market to attract the niche you want. You can seek MSK, spine, or general with a mix of allcomers.

Most PM&R docs will choose to stay general and are usually affiliated with a hospital acute rehab unit to feed the practice. A smaller group will subspecialize and see only MSK/spine, or other subspecialties like TBI, sports, pain.

There are very few outpatient referrals to PM&R. Usually involve patients with multiple medical conditions all affecting mobility and function that need a complex plan. Inpatient referrals are quite varied.

Honestly in this field you can choose the type of patients you want to see.

 

[lobelsteve]

The nice thing about PM&R is it a very broad specialty, as broad as family practice I think and you can choose your niche. Pediatric PM&R sees newborns to age 18. Adult PM&R sees 18+

Inpatient: general rehab: the acute hospital feeds your practice: strokes, SCI, TBI, etc etc. All ages, all levels of function. You can keep them long term or stabilize their care and return to the PCP's with a plan in place.

Outpatient PM&R you have healthier patients and higher functioning ones. You market to attract the niche you want. You can seek MSK, spine, or general with a mix of allcomers.

Most PM&R docs will choose to stay general and are usually affiliated with a hospital acute rehab unit to feed the practice. A smaller group will subspecialize and see only MSK/spine, or other subspecialties like TBI, sports, pain.

There are very few outpatient referrals to PM&R. Usually involve patients with multiple medical conditions all affecting mobility and function that need a complex plan. Inpatient referrals are quite varied.

Honestly in this field you can choose the type of patients you want to see.

Outpatient pmr referrals are common. Nonoperative ortho. Back pain. Exercise counseling. Etc. Some of us make a living doing this with no inpatient work.

 

[RUOkie]

Most PM&R docs will choose to stay general and are usually affiliated with a hospital acute rehab unit to feed the practice. A smaller group will subspecialize and see only MSK/spine, or other subspecialties like TBI, sports, pain.

I don't know where you are getting your info from, but the most recent practice survey shows that >50% of physiatrists are referring to themselves as PRIMARILY outpatient MSK practices. And that number is growing each year. That is why there is such a push to change training programs to reflect what the majority of us do on a daily basis.

 

[SSdoc33]

Outpatient pmr referrals are common. Nonoperative ortho. Back pain. Exercise counseling. Etc. Some of us make a living doing this with no inpatient work.

you are pain, you are not PM&R.

 

[Gauss]

Outpatient PM&R you have healthier patients and higher functioning ones. You market to attract the niche you want. You can seek MSK, spine, or general with a mix of allcomers.

I wouldn't hang this out there to med students as in the near future we will see a sea change due to ACA. I went into this for the chance to develop a niche but those opportunities are disappearing

 

[Jitter Bug]

I don't know where you are getting your info from, but the most recent practice survey shows that >50% of physiatrists are referring to themselves as PRIMARILY outpatient MSK practices. And that number is growing each year. That is why there is such a push to change training programs to reflect what the majority of us do on a daily basis.

I am commenting on the distribution in my city. The distribution of general vs MSK may be very different in your city/region.

Personally I see no reason for the entire residency to be tossed on its a%^ because some of us don't do inpatient anymore. I would rather learn to do the whole spectrum of PM&R then have the choice to carve my niche later. I think medicine is too fragmented as it is.

 

[RUOkie]

I am commenting on the distribution in my city. The distribution of general vs MSK may be very different in your city/region.

Personally I see no reason for the entire residency to be tossed on its a%^ because some of us don't do inpatient anymore. I would rather learn to do the whole spectrum of PM&R then have the choice to carve my niche later. I think medicine is too fragmented as it is.

I am not commenting on "My region". My comments were based on the data from the most recent AAPMR practice survey, and from the residency program directors surveys of where new grads are going post residency. And nobody is suggesting getting rid of inpatient rehab training. The proposals are just to mandate formalized MSK training in lieu of the vague "outpatient" training in the current RRC rules.

 

[Disciple]

Most PM&R docs will choose to stay general and are usually affiliated with a hospital acute rehab unit to feed the practice. A smaller group will subspecialize and see only MSK/spine, or other subspecialties like TBI, sports, pain.

There are very few outpatient referrals to PM&R.

Uh, what!?

Are you kidding me?

 

[PMR2008]

I am a solo outpatient MSK/Sports and Regenerative medicine specialist so my responses are going to be very different from a 'General PM&R" specialist who also does inpatient/subacute rehab.

Hello,

I was just wondering...how is the avarage PM&R patient like? I mean:

-Are most patients, on avarage, older or younger?
On average my patients are between the age of 30 and 50. I do see high school and younger athletes and patients over 60 as well.

-Are the majority of the patients seen in PM&R pain patients? If not, what medical condition do you see the most? (for example for IM/FM it is HTN and DM)
Most patients have chronic MSK/Nerve related injuries. I am not seeing any chronic pain and do not prescribe any opiates. The patient population I am attracting do not want any opiates anyway so that helps

-How long does a typical out-patient clinic visit last ?
Typical clinic visits are 45 minutes to 60 minutes for new evaluations and 30-45 minutes for followup. I could speed up if I want to but I want to distinguish myself from other local MSK doctors. I spend a lot of time teaching using models and technology etc

-Do PM&R docs follow patients long-term or short-term? When are patients discharged from the care of the PM&R doc?
I am avoiding seeing patients long term. If there is a new issue they are more than welcome to see me. Usually my aim is to see them short term, get them healthy so they don't need to come back.

-What are most PM&R consults from PCPs about?
The local PCPs/Chiros/Rheum/Ortho docs know that I will see the patients who are NOT interested in surgery and are open to regenerative medicine. But at this point most of my referrals are from word of mouth which is how I like it.

Thanks.

 

[Jitter Bug]

Wow you guys are really splitting hairs. There are very few GENERAL rehab outpatient consults.

when is the last time you sent an outpatient TBI referral clinic to clinic? Or outpatient stroke referral? These folks are usually caught through the hospital.

 

[RUOkie]

Wow you guys are really splitting hairs. There are very few GENERAL rehab outpatient consults.

when is the last time you sent an outpatient TBI referral clinic to clinic? Or outpatient stroke referral? These folks are usually caught through the hospital.

you are right, which is why we need to ensure that our "outpatient" training is actually MSK. Many Inpt heavy programs are using their follow up stroke/TBI/SCI clinics as their "outpatient" training. This is NOT sufficient for the true generalist, since most of their referrals will me MSK.

And saying that, I am a primarily MSK, and do little to no inpt currently. I've seen 3 CVA new patients in the past week.

 

[Disciple]

you are right, which is why we need to ensure that our "outpatient" training is actually MSK. Many Inpt heavy programs are using their follow up stroke/TBI/SCI clinics as their "outpatient" training.

There is a great deal of inertia in doing that, as the last several years have demonstrated.

We probably need to sponsor out own MSK/Spine fellowships, similar to how Ortho sponsors theirs.

We had that going, for a little while, when PASSOR was around.

 

[RUOkie]

There is a great deal of inertia in doing that, as the last several years have demonstrated.

We probably need to sponsor out own MSK/Spine fellowships, similar to how Ortho sponsors theirs.

We had that going, for a little while, when PASSOR was around.

personally I want to see this as basic skills from residency instead of more fellowships.

 

[Disciple]

personally I want to see this as basic skills from residency instead of more fellowships.

That is a viable option as well. However, Academic Physiatry was not interested.

Need a Plan B.

 

[ampaphb]

I am a solo outpatient MSK/Sports and Regenerative medicine specialist so my responses are going to be very different from a 'General PM&R" specialist who also does inpatient/subacute rehab.

I was good until i got to this response.

WTF is "regenerative medicine"? Anti-aging? HGH? Stem-cells?

 

[PMR2008]

PRP and Stem Cell. It is the future whether you like it or not. The studies are sparse and poor at the moment but things will change within a few years just like everything else in medicine.

 

[lobelsteve]

PRP and Stem Cell. It is the future whether you like it or not. The studies are sparse and poor at the moment but things will change within a few years just like everything else in medicine.

Or the studies will prove it useless. Or the side effects will be severe though rare. Or vBulletin the cost will make it never available.

There are no sure things in treatment other than ice heat and exercise.

 

[PMR2008]

Or the studies will prove it useless. Or the side effects will be severe though rare. Or vBulletin the cost will make it never available.

There are no sure things in treatment other than ice heat and exercise.

I don't think any thing I say will change your or ampaphb's mind. Just like your generation has not been able to change the mindset of those before you. There is value in thinking outside the box and exploring new and safer treatments for patients as long as we keep ethics ahead of profits.

 

[RUOkie]

I don't think any thing I say will change your or ampaphb's mind. Just like your generation has not been able to change the mindset of those before you. There is value in thinking outside the box and exploring new and safer treatments for patients as long as we keep ethics ahead of profits.

you are right about that. BUT, in my short 20 yrs of medical practice, I've already seen the "next great thing" come and go so many times that it makes you cynical. Especially when we are dealing with non-dangerous, painful conditions.

 

[PMR2008]

you are right about that. BUT, in my short 20 yrs of medical practice, I've already seen the "next great thing" come and go so many times that it makes you cynical. Especially when we are dealing with non-dangerous, painful conditions.

I agree with your assessment. It is important to keep an open mind about these things and always try to use evidence based medicine first and foremost. Many physicians still don't think acupuncture or chiropractic care has any role in MSK care but there is relatively strong evidence to support its use for acute low back pain. What do you do with a patient who had tried therapy, medications, modalities and does not want to consider surgery or opioids? I disagree with physicians who think that Prolo/PRP/Stem cell should be the first treatment offered and that it cures every MSK condition but it certainly has a role for a selected group of patients.

 

[SSdoc33]

I don't think any thing I say will change your or ampaphb's mind. Just like your generation has not been able to change the mindset of those before you. There is value in thinking outside the box and exploring new and safer treatments for patients as long as we keep ethics ahead of profits.

Yeah, YOUR generation. Why don't you just retire already? What was your unit in WWII, anyway?

 

[PMR2008]

Yeah, YOUR generation. Why don't you just retire already? What was your unit in WWII, anyway?

If you don't think there is a generation gap in PM&R than you are oblivious. There was a generation which believed that physiatrist only belong in the hospital setting. Than a generation that believed in the merits of interventional spine and now a generation which is more comfortable with ultrasound, alternative medicine and PRP. Maybe it is the group of physiatrist I hang out but talking to recently graduated fellows, residents and current residents the interest in these new potential treatments is very high.

 

[ampaphb]

PRP and Stem Cell. It is the future whether you like it or not. The studies are sparse and poor at the moment but things will change within a few years just like everything else in medicine.

The same way IDETs studies made it part of the future? Nucleoplasty? Disctrode?

Without an EBM basis, payers wont cover unproven technologies, and only the rare patient will pay out of pocket when medicare or insurance says no.

 

[101N]

I don't think any thing I say will change your or ampaphb's mind. Just like your generation has not been able to change the mindset of those before you. There is value in thinking outside the box and exploring new and safer treatments for patients as long as we keep ethics ahead of profits.

Why don't we start an evidence-based discussion about PRP or "Regenerative medicine"? Start a new thread with that title, I'm sure you will get a spirited response

 

[RUOkie]

The same way IDETs studies made it part of the future? Nucleoplasty? Disctrode?

Without an EBM basis, payers wont cover unproven technologies, and only the rare patient will pay out of pocket when medicare or insurance says no.

you should have seen Chris Centeno's talk at AAPMR on putting stem cells in discs. Holy crap.

 

[ampaphb]

http://www.quackwatch.org/02ConsumerProtection/FDAActions/regenexx/overview.html

 

[ampaphb]

Many physicians still don't think acupuncture or chiropractic care has any role in MSK care ...

Acute spinal subdural hematoma with hemiplegia after acupuncture: a case report and review of the literature.
Park J, Ahn R, Son D, Kang B, Yang D.
Spine J. 2013 Oct 2. [Epub ahead of print]

PURPOSE: The purpose of this case report was to present the first case of subdural hematoma after acupuncture and the reasons for the risks of blind cervical acupuncture.

STUDY DESIGN: A case report and review of the previous literature are presented.

METHODS: A 69-year-old man complained of progressive weakness in the right upper and lower extremities 2 hours after acupuncture on the cervical spine and back. The diagnosis was delayed because of unilateral weakness, and the symptom was initially misinterpreted as a transient ischemic attack because of no sensory change and pain and normal findings of two brain magnetic resonance imaging (MRI).

RESULTS: Cervical MRI 36 hours after onset revealed acute hematoma from the C3-C5 level; hematoma showed an isointensity on T1-weighted image (WI) with the preservation of epidural fat and a hypointensity on T2WI. A decompressive surgery was scheduled to perform within 2 days after the cervical MRI scan because of a previous anticoagulation therapy, but the patient refused it. Finally, 9 days after the onset, surgical decompression and removal of hematoma were performed. Three months postoperatively, the patient had fully recovered demonstrating fine hand movement and good ability to walk up and down the stairs.

CONCLUSIONS: Our study indicates that it is essential to perform cervical MRI when a patient does not show an improvement in the neurologic deficit and has a negative brain MRI after acupuncture. In addition, blind acupuncture if not correctly practiced may be harmful to the cervical structures.

 

[PMR2008]

Acute spinal subdural hematoma with hemiplegia after acupuncture: a case report and review of the literature.
Park J, Ahn R, Son D, Kang B, Yang D.
Spine J. 2013 Oct 2. [Epub ahead of print]

PURPOSE: The purpose of this case report was to present the first case of subdural hematoma after acupuncture and the reasons for the risks of blind cervical acupuncture.

STUDY DESIGN: A case report and review of the previous literature are presented.

METHODS: A 69-year-old man complained of progressive weakness in the right upper and lower extremities 2 hours after acupuncture on the cervical spine and back. The diagnosis was delayed because of unilateral weakness, and the symptom was initially misinterpreted as a transient ischemic attack because of no sensory change and pain and normal findings of two brain magnetic resonance imaging (MRI).

RESULTS: Cervical MRI 36 hours after onset revealed acute hematoma from the C3-C5 level; hematoma showed an isointensity on T1-weighted image (WI) with the preservation of epidural fat and a hypointensity on T2WI. A decompressive surgery was scheduled to perform within 2 days after the cervical MRI scan because of a previous anticoagulation therapy, but the patient refused it. Finally, 9 days after the onset, surgical decompression and removal of hematoma were performed. Three months postoperatively, the patient had fully recovered demonstrating fine hand movement and good ability to walk up and down the stairs.

CONCLUSIONS: Our study indicates that it is essential to perform cervical MRI when a patient does not show an improvement in the neurologic deficit and has a negative brain MRI after acupuncture. In addition, blind acupuncture if not correctly practiced may be harmful to the cervical structures.

So one case report justifies never considering acupuncture? I don't perform acupuncture and don't plan on incorporating into my practice but I do see the potential benefit for a selected group of patients for low back pain. I have yet to refer someone for cervical pain.

 

[lobelsteve]

So one case report justifies never considering acupuncture? I don't perform acupuncture and don't plan on incorporating into my practice but I do see the potential benefit for a selected group of patients for low back pain. I have yet to refer someone for cervical pain.

Acupuncture is not based on physical sciences so as an MD you are might as well Rx rainbow unicorn tears as both are pure fantasy and have no pathoanatomic correlation.

 

[SSdoc33]

Acupuncture is not based on physical sciences so as an MD you are might as well Rx rainbow unicorn tears as both are pure fantasy and have no pathoanatomic correlation.

BC / BS doesnt cover rainbow unicorn tears. Only monochrome, which we all know can cause cancer.

 

[Gauss]

Rx rainbow unicorn tears as both are pure fantasy and have no pathoanatomic correlation.

preservative free?
brand only, I can't take that generic crap