Please weigh-in on your prediction(s) for the future of PM&R

[MSKMed]

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A few questions for all PM&R residents and attendings,



Given the current economic landscape and uncertainty about the future of health care:



1) How do you feel PM&R will be affected?


2) What direction do you feel the profession will take (or what in your opinion is the best move for PM&R) in the future?


and 3) What strategies or action steps do you feel are required of the profession in order to protect its clinical, political and economic interests?

There is concern that other fields may encroach on the patient population commonly seen by physiatrists such as: orthopedic surgeons, neurosurgeons, neurologists and anesthesiologists for interventional procedures (Spinal injections, intra-discal electrothermal annuloplasty (IDET), flouro-guided facet injections, nerve blocks, discograms, etc.), and primary care sports physicians for non-interventional procedures (TrP injections, PRP etc..) and prescription of braces, orthotics, physical rehabilitation regimes etc.. Do you acknowledge this? And if so, how do you feel that the PM&R profession may protect its interests in this regard?


From the perspective of inpatient rehabilitation, my (limited) understanding is that the physiatrist acts as the Quarterback of the rehabilitation team, directing the course of care of patients under his/her service and collaborating with other professionals such as PTs, OTs, SLPs, RNs, SWs, etc… This area of physiatry seems fairly insulated to me without an obvious threat of encroachment by another field of medicine. Is this point of view accurate?


I know it is difficult to forecast the future given the various external forces that may affect the field and medicine as a whole. Just wanted to get some perspective from practicing physicians/residents as I am very interested in this field and would like to learn more about some of the difficulties faced by PM&R docs and what everyone feels the future direction of the profession should/will be.


Thanks in advance.

 

[PMR 4 MSK]

A few questions for all PM&R residents and attendings,



Given the current economic landscape and uncertainty about the future of health care:



1) How do you feel PM&R will be affected?


2) What direction do you feel the profession will take (or what in your opinion is the best move for PM&R) in the future?


and 3) What strategies or action steps do you feel are required of the profession in order to protect its clinical, political and economic interests?

There is concern that other fields may encroach on the patient population commonly seen by physiatrists such as: orthopedic surgeons, neurosurgeons, neurologists and anesthesiologists for interventional procedures (Spinal injections, intra-discal electrothermal annuloplasty (IDET), flouro-guided facet injections, nerve blocks, discograms, etc.), and primary care sports physicians for non-interventional procedures (TrP injections, PRP etc..) and prescription of braces, orthotics, physical rehabilitation regimes etc.. Do you acknowledge this? And if so, how do you feel that the PM&R profession may protect its interests in this regard?


From the perspective of inpatient rehabilitation, my (limited) understanding is that the physiatrist acts as the Quarterback of the rehabilitation team, directing the course of care of patients under his/her service and collaborating with other professionals such as PTs, OTs, SLPs, RNs, SWs, etc… This area of physiatry seems fairly insulated to me without an obvious threat of encroachment by another field of medicine. Is this point of view accurate?


I know it is difficult to forecast the future given the various external forces that may affect the field and medicine as a whole. Just wanted to get some perspective from practicing physicians/residents as I am very interested in this field and would like to learn more about some of the difficulties faced by PM&R docs and what everyone feels the future direction of the profession should/will be.


Thanks in advance.

1) Negatively - less money, more responsibility, more liability, less protection, more paperwork

2) PM&R will continue to stagnate as the old gaurd continues to hold on to their ideals of inpt rehab being the bigger part of what Physiatrists due, in stark contrast to the desires of the majority of it's members. The demise of PASSOR was designed to castrate the outpt docs from gaining a foothold in the politics of the field, and instead assign it to "interest groups" and, in fact, dividing the fields seemingly arbitrarily, but again, they were divided in order to keep the power out of the hands of those who could use it, to be kept by those who want it.

3) The only thing we can protect is what no one else wants to do - inpt rehab. Everything else is stuff we mostly took from other fields, so it's no suprise others encroach on us.

 

[MSKMed]

Thank you for your candid and insightful response. Knowing this, and given your experience in the field, what advice would you offer someone who wishes to pursue a career in medicine with a focus on sports medicine and industrial rehabilitation, along with opportunities in occ med consulting?



From what I understand, PM&R seems to be the best specialty to prepare one for such opportunities. Would you agree? Or would advise one to consider another specialty? And if so, which one?

 

[Feed Me]

1) Negatively - less money, more responsibility, more liability, less protection, more paperwork

2) PM&R will continue to stagnate as the old gaurd continues to hold on to their ideals of inpt rehab being the bigger part of what Physiatrists due, in stark contrast to the desires of the majority of it's members. The demise of PASSOR was designed to castrate the outpt docs from gaining a foothold in the politics of the field, and instead assign it to "interest groups" and, in fact, dividing the fields seemingly arbitrarily, but again, they were divided in order to keep the power out of the hands of those who could use it, to be kept by those who want it.

3) The only thing we can protect is what no one else wants to do - inpt rehab. Everything else is stuff we mostly took from other fields, so it's no suprise others encroach on us.

Thank you for this honest response. Number 1 seems like it could be said for every specialty in medicine, correct? If not, I'd like to get your thoughts on what one would give the most resistance to these changes coming.

Your last two points paint a contradictory picture which makes me a little nervous. Do you feel that as the younger generations of PM&R doctors grow into the profession and take leadership roles, this old guard line of thinking will fade and the field can actively pursue more of a stronghold on these out pt practices? Also, as the specialty becomes more and more competitive every year (and matching more AMGs with better overall accolades), will this affect the the field positively by garnering more interest and a better reputation?

 

[RUOkie]

Thank you for this honest response. Number 1 seems like it could be said for every specialty in medicine, correct? If not, I'd like to get your thoughts on what one would give the most resistance to these changes coming.

Your last two points paint a contradictory picture which makes me a little nervous. Do you feel that as the younger generations of PM&R doctors grow into the profession and take leadership roles, this old guard line of thinking will fade and the field can actively pursue more of a stronghold on these out pt practices? Also, as the specialty becomes more and more competitive every year (and matching more AMGs with better overall accolades), will this affect the the field positively by garnering more interest and a better reputation?

The field has a positive reputation now. Getting harder working/smarter physicians will only help more.

I disagree with PMR4MSk about what the demise of PASSOR did for the field. Since then, we are seeing far better MSK educational offerings by AAPMR. I think that bringing PASSOR back into AAPMR, has encouraged the MSK medicine academics to be more involved in the overall Academy instead of just PASSOR.

I see tremendous upside to the field of PM&R EXCEPT general inpt rehab. We do things more cost effectively, with less complicaitons than other fields.

 

[RUOkie]

You see, I am not afraid of encroachment. I am a good doctor, so other good doctors send me patients. I have encroached more on what other doctors do in my community than vice versa. That has become a double edged sword, now they send me things I don't like taking care of, since I have done a good job.

The governmental regulations scare me a lot more. But all docs are affected by that.

 

[Phillyborn]

I disagree with PMR4MSk about what the demise of PASSOR did for the field. Since then, we are seeing far better MSK educational offerings by AAPMR. I think that bringing PASSOR back into AAPMR, has encouraged the MSK medicine academics to be more involved in the overall Academy instead of just PASSOR..

Good point RUOkie. The highlighted speakers for the 2012 Annual conference look pretty heavily tipped in terms of outpatient MSK interests.

http://www.aapmr.org/assembly/program/Pages/highlighted-speakers.aspx

 

[PMR 4 MSK]

Thank you for this honest response. Number 1 seems like it could be said for every specialty in medicine, correct? If not, I'd like to get your thoughts on what one would give the most resistance to these changes coming.

Your last two points paint a contradictory picture which makes me a little nervous. Do you feel that as the younger generations of PM&R doctors grow into the profession and take leadership roles, this old guard line of thinking will fade and the field can actively pursue more of a stronghold on these out pt practices? Also, as the specialty becomes more and more competitive every year (and matching more AMGs with better overall accolades), will this affect the the field positively by garnering more interest and a better reputation?

The field has a positive reputation now. Getting harder working/smarter physicians will only help more.

I disagree with PMR4MSk about what the demise of PASSOR did for the field. Since then, we are seeing far better MSK educational offerings by AAPMR. I think that bringing PASSOR back into AAPMR, has encouraged the MSK medicine academics to be more involved in the overall Academy instead of just PASSOR.

I see tremendous upside to the field of PM&R EXCEPT general inpt rehab. We do things more cost effectively, with less complicaitons than other fields.

It's a matter of the MSK docs not giving a crap what the old guard wants and pushing new material through. Those who want it need to seek it out. AAPM&R recently started offering it's MSK US courses, which are fantastic, but US is destined to be executed in the next year or two by CMS.

The demise of Passor was designed to hurt MSK, but it is re-emerging.

Progressive programs are training docs in outpt medicine much more. Older programs stick to 24+ months out of 36 as inpt rehab. They want residents to run the wards so they can bill more and pay less. There are programs that are trying to survive by utilizing residents as a cash source.

Programs that offer more outpt training will rise in the rankings. It will be the young, incoming residents who will drive that. Older programs will lose their standings as top programs if they don't train people to compete in today's medical marketplace.

And the last two points I had were contradictory. Even many/most Physiatrists don't want to do inpt rehab any longer. Since no one else is moving into it, it is our for now, if only by default. Try finding a non-physiatrist to cover your solo rehab floor for a week while you go on vacation. I found it to be like trying to sell ice to Eskimos.

 

[phoenix0610]

I don't post very often but I couldn't sit idly by on this one any more. As one of the younger members of the field I've always been baffled by the continuous "inpatient" vs "outpatient", MSK vs neurorehab, old guard vs new guard, us vs them, etc etc etc ad nauseam debate. Why do we continue to do this??? Every specialty has their factions but it doesn't seem nearly as bad as PM&R and quite frankly the field can't afford it--we're just not that cool. I love inpatient rehab--I like taking care of sicker patients, interacting with families sometimes for weeks and weeks on end, and derive a morbid pleasure from being the ringleader of the circus known as the "multidisciplinary team" lol. I enjoy MSK/pain issues well enough but it's just not what gets me going--again, the acutity is not high enough for me so I often get frustrated working with these patients and their "problems" when I think of my vented quad back on the unit. Yet there are some people on this forum who think it's just the most awful thing ever, and only the lazy and uninitiated continue to do inpatient rehab. It's just different strokes for different folks--why can't we support and lift each other up (there by lifting the specialty up) instead of constantly tearing people down? I'm done ranting, and will go back to lurking status now...smdh😕

 

[deleted185747]

My take on the future:

All Doctors will be responsible for overseeing midlevels more than direct patient care; we are already setup for this and are ahead of the curve.

Cost containment will become an even higher priority for all Doctors. Back pain is very expensive and its management will likely change (less MRIs and less injections)

Family med and Ortho don't want to manage CLBP; so there is no turf battle there

Inpt rehab saves money in the long run and will be kept in play by the payers.

Conservative measures will be pursued for a longer period of time in pursuit of cost containment; We are great at conservative care/therapy/injections/modalities.

 

[PMR 4 MSK]

I don't post very often but I couldn't sit idly by on this one any more. As one of the younger members of the field I've always been baffled by the continuous "inpatient" vs "outpatient", MSK vs neurorehab, old guard vs new guard, us vs them, etc etc etc ad nauseam debate. Why do we continue to do this??? Every specialty has their factions but it doesn't seem nearly as bad as PM&R and quite frankly the field can't afford it--we're just not that cool. I love inpatient rehab--I like taking care of sicker patients, interacting with families sometimes for weeks and weeks on end, and derive a morbid pleasure from being the ringleader of the circus known as the "multidisciplinary team" lol. I enjoy MSK/pain issues well enough but it's just not what gets me going--again, the acutity is not high enough for me so I often get frustrated working with these patients and their "problems" when I think of my vented quad back on the unit. Yet there are some people on this forum who think it's just the most awful thing ever, and only the lazy and uninitiated continue to do inpatient rehab. It's just different strokes for different folks--why can't we support and lift each other up (there by lifting the specialty up) instead of constantly tearing people down? I'm done ranting, and will go back to lurking status now...smdh😕

You are quite correct, and it's good to see people who still like inpt rehab standing up for it. Part of the problem might be that the inpt guys tend to be more of the Type-B personalities, while the pain/MSK guys are much more Type-A, and therefore more vocal.

I enjoyed inpt rehab except for the night and weekend calls, and politics destroyed it for me.

I sometimes think sometime in the future, PM&R will have a great schizm, and people will go into either PM or R, not both.

 

[Gauss]

there has to be some changes for the outpatient MSK tract. It is idioitic to have 2 separate fellowships for the biggest growth potential of our field - MSK and spine. Some form of integrated MSK ACGME accreditation that isn't pure pain or pure sports because in reality it's all mixed together.

 

[scifiMD]

I don't post very often but I couldn't sit idly by on this one any more. As one of the younger members of the field I've always been baffled by the continuous "inpatient" vs "outpatient", MSK vs neurorehab, old guard vs new guard, us vs them, etc etc etc ad nauseam debate. Why do we continue to do this??? Every specialty has their factions but it doesn't seem nearly as bad as PM&R and quite frankly the field can't afford it--we're just not that cool. I love inpatient rehab--I like taking care of sicker patients, interacting with families sometimes for weeks and weeks on end, and derive a morbid pleasure from being the ringleader of the circus known as the "multidisciplinary team" lol. I enjoy MSK/pain issues well enough but it's just not what gets me going--again, the acutity is not high enough for me so I often get frustrated working with these patients and their "problems" when I think of my vented quad back on the unit. Yet there are some people on this forum who think it's just the most awful thing ever, and only the lazy and uninitiated continue to do inpatient rehab. It's just different strokes for different folks--why can't we support and lift each other up (there by lifting the specialty up) instead of constantly tearing people down? I'm done ranting, and will go back to lurking status now...smdh😕

Speaking as an "inpatient rehab" doc, I think a lot more of the followers and posters on this site are skewed to outpatient MSK/sports/spine/pain. Is it because the inpatient docs are more of the "lurkers" or are we "type B"? (as an aside, no one has ever said I was type B in my life) Mayhaps they are working in the private sector (as there are tons of inpatient rehab jobs out there), so they don't follow what the student docs are doing. Or they are actually catching up on their paperwork as opposed to procrastinating like myself. All I can say is that I'm glad that there are young residents out there that like inpatient because there are lots of positions out there to fill

 

[fozzy40]

I don't post very often but I couldn't sit idly by on this one any more. As one of the younger members of the field I've always been baffled by the continuous "inpatient" vs "outpatient", MSK vs neurorehab, old guard vs new guard, us vs them, etc etc etc ad nauseam debate. Why do we continue to do this??? Every specialty has their factions but it doesn't seem nearly as bad as PM&R and quite frankly the field can't afford it--we're just not that cool. I love inpatient rehab--I like taking care of sicker patients, interacting with families sometimes for weeks and weeks on end, and derive a morbid pleasure from being the ringleader of the circus known as the "multidisciplinary team" lol. I enjoy MSK/pain issues well enough but it's just not what gets me going--again, the acutity is not high enough for me so I often get frustrated working with these patients and their "problems" when I think of my vented quad back on the unit. Yet there are some people on this forum who think it's just the most awful thing ever, and only the lazy and uninitiated continue to do inpatient rehab. It's just different strokes for different folks--why can't we support and lift each other up (there by lifting the specialty up) instead of constantly tearing people down? I'm done ranting, and will go back to lurking status now...smdh😕

Finally🙂 👍

 

[Aegis]

So, heres a random thought. Are there international opportunites with PM&R? I'm asking both from the perspective of US physiatrists doing international work, either paid or NGO based? As well as what is the job market like overseas if one wanted to pick up and move?