PM&R backup vs solo

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keyathome

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Hey guys,
Just a confused third year student hoping to get some advice on my next course of action. I've been pretty set on trying to match derm with PM&R as backup but recently have begun debating this vs just applying PM&R. My step 1 is 240s, low tier med school without home derm, with home PM&R, mediocre third year grades, with research year and derm pubs. If I try for derm with PM&R I would only be able to do one home rotation in PM&R likely with no aways before eras submission. PDs in PM&R will also be able to see my derm aways and question my commitment? Otherwise if I forget about derm and focus PM&R I will be able to do more aways in PM&R, and put a focus on getting some PM&R research in.

However, will focusing on PM&R necessarily lead me to a better PM&R residency match? I am not really interested in academics but definitely want to match pain fellowship through PM&R and preferably live in a large city with a PM&R residency. Will the focus in derm prevent me from achieving this? Really confused and uncertain, any advice is appreciated!

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what kind of doctor do you want to be?
 
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You haven't made any indication that you even like PM&R. It seems like you are set on Derm but are concerned about your own competitiveness. If you ditch Derm for PM&R for that reason, you will end up regretting it. If you have your heart set on Derm...do what it takes to get Derm...and considering another specialty as a back-up just in case. Have a good back-up and something that you are passionate about. If PM&R just sounds like an obtainable residency that satisfies your requirement of a good lifestyle with decent pay...look elsewhere. That is the type of person who ends up burning out in PM&R.
 
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ssdoc- good question. So I would say that I am more interested in derm than PM&R but part of the reason is that I have had more exposure to derm. I have only shadowed PM&R in an outpatient clinic for a day. To be honest, it was pretty boring on initial impression- lots of arthritis and bursitis with paperwork but it was also a nonprocedural day. I can see myself doing it as U/S or CT guided pain injections sounds fun and I've heard there are cool advancements like stem cell injections and prosthetics. And in the end, I'm into a low acuity less stressful environment with good hours which PM&R provides.
J4pac- i think for some med students, knowing their passions come easy and others are ok with ending up in multiple specialties. I'd fit into the second category and haven't really been drooling in any of my rotations. The only rotation I've kinda enjoyed was psych- I enjoyed just talking to depressed patients and am drawn to psychology topics, I feel like I can relate to the depressed and manic patients. However, I just don't know if I can deal with mental health patients all the time, especially if they start splitting or get hostile. If I apply derm with backup I was also planning to do a 2 week rotation in psych 4th year just to compare it directly to a month of PM&R. So I guess my backup for derm can be either PM&R or psych and if I give up on derm I can explore these 2 options more thoroughly?
 
ssdoc- good question. So I would say that I am more interested in derm than PM&R but part of the reason is that I have had more exposure to derm. I have only shadowed PM&R in an outpatient clinic for a day. To be honest, it was pretty boring on initial impression- lots of arthritis and bursitis with paperwork but it was also a nonprocedural day. I can see myself doing it as U/S or CT guided pain injections sounds fun and I've heard there are cool advancements like stem cell injections and prosthetics. And in the end, I'm into a low acuity less stressful environment with good hours which PM&R provides.
J4pac- i think for some med students, knowing their passions come easy and others are ok with ending up in multiple specialties. I'd fit into the second category and haven't really been drooling in any of my rotations. The only rotation I've kinda enjoyed was psych- I enjoyed just talking to depressed patients and am drawn to psychology topics, I feel like I can relate to the depressed and manic patients. However, I just don't know if I can deal with mental health patients all the time, especially if they start splitting or get hostile. If I apply derm with backup I was also planning to do a 2 week rotation in psych 4th year just to compare it directly to a month of PM&R. So I guess my backup for derm can be either PM&R or psych and if I give up on derm I can explore these 2 options more thoroughly?

You need a much better reason to pursue PM&R. You sound like a very common applicant that likes the idea of the lifestyle and money without having a clue of what the job actually entails. PM&R has a very high burnout rate...the money’s ok, not great...the job entails tons of psych. You need much better exposure to the field. As it stands, I’d say you would be at high risk of changing specialties in residency or burning out.
 
I have only shadowed PM&R in an outpatient clinic for a day. To be honest, it was pretty boring on initial impression - lots of arthritis and bursitis with paperwork but it was also a nonprocedural day.

I can see myself doing it as U/S or CT guided pain injections sounds fun and I've heard there are cool advancements like stem cell injections and prosthetics.

1. Well boring as a first impression doesn't sound good. When I was a med student and rotated in something "boring" I would push that specialty down my list of potential options. Overall, PM&R is a specialty that primarily deals with disability. So if you find long-term care of disabling conditions (such as OA) to be boring then I would say this doesn't sound like the right specialty for you. BTW, just wait until you watch NCS/EMG's for a day as a med student--I'd imagine that you would fall asleep.

2. CT guided procedures are done by interventional radiologists. I don't know of any PM&R physicians that work next to a CT scanner. U/S injections can be learned in many specialties besides PM&R such as Rheum, FM, IM, etc. Also, pain management isn't always just interventional procedures (which mainly uses fluoroscopy guidance) and you can also enter that field from an anesthesia residency.

Overall I think you are very confused about what PM&R is. If you love MSK and neurology then it might be a specialty for you. Also, inpatient rehab is where most residents get burned out. So be prepared to spend about 35-50% of a PM&R residency in the inpatient setting and taking call.

Now if you had said that you like dermatology for facial botox procedures, and as a back up want to do botox injections for chronic migraine or cervical dystonia then I would tell you to look into neurology as a specialty.
 
You need a much better reason to pursue PM&R. You sound like a very common applicant that likes the idea of the lifestyle and money without having a clue of what the job actually entails. PM&R has a very high burnout rate...the money’s ok, not great...the job entails tons of psych. You need much better exposure to the field. As it stands, I’d say you would be at high risk of changing specialties in residency or burning out.
I'm interested in why you consider PM&R to have a very high burnout rate, DMB mentioned inpatient rehab, can someone expand on this? I am mainly interested in lifestyle, I don't care as much about the pay. Obviously the work itself has to be at least somewhat interesting to me, can you please elaborate on why you say PM&R entails a lot of psych. That would be good since I am interested in patients with depression and therapy for common depression and to be able to do that in PM&R would be great. The argument of interest vs lifestyle has no definitive answer and has pretty good points on both sides but I'm on the side of lifestyle. At this point in time, while I have had some cool experiences in third year, once it passes 5pm, I'm pretty much burned out and I'd rather spend the time doing what I enjoy outside of work. And I'm not about that weekend work life. At least from what I have heard, most PM&R residencies are pretty chill, what are the hours like in a typical PM&R residency from year 1 to 3? How much call is there and what does that usually entail? I can't imagine I'll burn out more in PM&R than in say IM or surgery. Other specialties I've considered include anesthesia and rads but they are lower on the list than derm, psych, and PM&R- anesthesia seemed a little too boring with little patient interaction and rads has little patient interaction as well. One reason I enjoy patient interaction is because I've always enjoyed teaching such as tutoring other students in college and I think that would translate well to teaching patient's about their disease process.
 
1. Well boring as a first impression doesn't sound good. When I was a med student and rotated in something "boring" I would push that specialty down my list of potential options. Overall, PM&R is a specialty that primarily deals with disability. So if you find long-term care of disabling conditions (such as OA) to be boring then I would say this doesn't sound like the right specialty for you. BTW, just wait until you watch NCS/EMG's for a day as a med student--I'd imagine that you would fall asleep.

2. CT guided procedures are done by interventional radiologists. I don't know of any PM&R physicians that work next to a CT scanner. U/S injections can be learned in many specialties besides PM&R such as Rheum, FM, IM, etc. Also, pain management isn't always just interventional procedures (which mainly uses fluoroscopy guidance) and you can also enter that field from an anesthesia residency.

Overall I think you are very confused about what PM&R is. If you love MSK and neurology then it might be a specialty for you. Also, inpatient rehab is where most residents get burned out. So be prepared to spend about 35-50% of a PM&R residency in the inpatient setting and taking call.

Now if you had said that you like dermatology for facial botox procedures, and as a back up want to do botox injections for chronic migraine or cervical dystonia then I would tell you to look into neurology as a specialty.

I dunno, I don't think boring is all that bad. Are PM&R docs supposed to be that interested in a slew of patients in an outpatient clinical setting that are all coming in with typical bursitis or arthritis? It's also possible that because I never studied or rotated in PM&R that the finer details of the diagnostic process in PM&R is unknown to me, so I couldn't appreciate it.
I liked learning the anatomy and the MSK system. I also liked learning neuroscience. Didn't really like the actual clinical practice of neurology though- many patients were comatose and correlating focal deficits to a specific area of the patient's brain didn't really have the charm it had when I was studying it.
 
Well first of all if you want to do PM&R you will have to do an internship. So your PGY-1 year is doing IM. Typical hospital hours, 80 hours per week, etc.

The rest of your years will depend on what program you go in to. PGY-2 to PGY-3 is mostly inpatient with some outpatient rotations. Inpatient rotations in stroke, traumatic brain injury, spinal cord injury, oncology rehab, general rehab. Inpatient rotations are busy and you do a lot of internal medicine. Hours are probably typical of 7-5:30 plus call (so after 5 pm you will still be working all night at home). Outpatient rotations are a large mix since PM&R is a broad field: TBI, spinal cord, spasticity clinic, EMG/NCS, MSK, pain management and interventional spine, general rehab, WC clinics, hospital consults, sports medicine, etc. On TBI you will see patients as low as a rancho II level (you can look that up), so that will be a problem if you didn't like 'comatose patients' before.

Burnout rates are probably more in inpatient rehab setting as I said before. You will field a lot pages in PM&R since you also have PT, OT, SLP and TR paging you as well as nursing. There is a lot of additional paper work in inpatient rehab and a lot of equipment that has to be ordered for patients. It is also very high flow and there is quite a bit of call. Patients are also sicker now a days then they used to be in IPR. On call you will be coving 30 - 50 patients which makes things quite busy. Most of the work is internal medicine based and day-to-day rounding.

If you want lifestyle then PM&R is not always the best option. Many PM&R physicians work the same hours as IM docs. If you want lifestyle then psychiatry would be a better option. You can also look into rheumatology, however you would have to make it through a 3 year IM residency before getting to fellowship.

PM&R can have some psychiatry in it, but not like a psychiatrist practice would be like. Many of are patients are debilitated and very depressed. Sometime suicidal. We prescribe many antidepressants and neurological medications, however we are also limited by our scope of practice and comfort level to take care of complex psych issues.

Overall from what you are saying I would not recommend PM&R as a field for you. I don't think you will like it and you will find the lifestyle is not always as chill as you think it will be. If you are still thinking PM&R then do a 4-week rotation somewhere where you get inpatient exposure and also get the chance to see some EMGs and consults. That should give you a decent idea.
 
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I'm interested in why you consider PM&R to have a very high burnout rate, DMB mentioned inpatient rehab, can someone expand on this? I am mainly interested in lifestyle, I don't care as much about the pay. Obviously the work itself has to be at least somewhat interesting to me, can you please elaborate on why you say PM&R entails a lot of psych. That would be good since I am interested in patients with depression and therapy for common depression and to be able to do that in PM&R would be great. The argument of interest vs lifestyle has no definitive answer and has pretty good points on both sides but I'm on the side of lifestyle. At this point in time, while I have had some cool experiences in third year, once it passes 5pm, I'm pretty much burned out and I'd rather spend the time doing what I enjoy outside of work. And I'm not about that weekend work life. At least from what I have heard, most PM&R residencies are pretty chill, what are the hours like in a typical PM&R residency from year 1 to 3? How much call is there and what does that usually entail? I can't imagine I'll burn out more in PM&R than in say IM or surgery. Other specialties I've considered include anesthesia and rads but they are lower on the list than derm, psych, and PM&R- anesthesia seemed a little too boring with little patient interaction and rads has little patient interaction as well. One reason I enjoy patient interaction is because I've always enjoyed teaching such as tutoring other students in college and I think that would translate well to teaching patient's about their disease process.

The data behind PM&R burnout is rather misleading. It's rare for PM&R to show up in most specialty comparison reports (especially salary) because we're such a small specialty and the response pool is likely to be small. So I don't think the data is accurate. Some inpatient doctors get burnt out because they're the sole inpatient provider and may have minimal or no help covering the unit/call. However, in my experience (ie., anecdotal, but across multiple academic, VA, and community hospitals/programs) burnout seems higher in the outpatient (particularly pain) population. I've met a total of one sort of burnt-out inpatient provider, and he was retirement age. The rest loved what they do, and had great lives.

Personally I really enjoy inpatient. I think it's more rewarding, more fun, and more relaxed. I did not get paged much in residency compared to intern year--it was great, the nurses and therapists just came over to the office to talk to us/ask us questions. I loved it--I hate my pager. Some days got busy with admits/consults, but I never felt in over my head, and I'm not the most efficient guy. I made an effort to enjoy being at work and chat with people during the day, whether with a co-resident, attending, nurse, therapist, or patient. Inpatient rehab is a very fun and exciting place to be. VA inpatient rehab, in particular, is the least stressful (unless dispo issues stress you out...) in my mind.

I felt I had a lot more control over my schedule on inpatient as well--you can decide how to structure your day. Granted, in residency, things like when your attending wants to round will give you less control, but in my mind it was still much better control (and for me less stressful) than seeing a whole day of patients scheduled in clinic. Plus outpatient attendings are much busier than they appear to be--they're working behind the scenes all the time to call patients about results of imaging/labs from the orders that we place. We just don't see that behind the scenes type of stuff. Still, many outpatient community physiatrists don't take call, so that's sure nice...

Ultimately, as others said above, it really comes down to doing what you want to do. If you spoke with every PM&R resident in the country, I'm willing to bet most would say they like outpatient rehab more and find it more enjoyable. The different areas of PM&R, like the different medical specialties, come with their own pros and cons, and it's all about personal fit. I would never consider going into a field of medicine that I didn't enjoy. What is interesting is the things you think matter in medical school change. Back then, I didn't think FM would be a good choice because I didn't want to deal mostly with HTN, DM, etc. And I didn't like peds because the well-child checks were kind of boring. But I find most of my enjoyment comes from talking with the other members of the rehab team, getting to know my patients, and following them over time. That's a big reason why I chose PM&R, and I'd chose it again, but in hindsight I could actually see myself happy in FM following the same patient for years and years and doing "boring" stuff like just adjusting BP meds. And if I could do ONLY well-child checks, well that would actually be a real blast, seeing those kiddos grow up.

To be honest, a lot of the exposure we get to different specialties in med school doesn't help all that much in making a truly informed decision. Fields like FM, peds, and psych are generally rewarding for the long-term relationships you build with patients, and you really can't get a good feel for that in medical school. Many people choose more "exciting" specialties like EM (highest rate of burnout), partly because they like the schedule, but then realize once they have a family that same schedule is the thing they hate. You really have to think hard about what really matters to you, and try to think about what will matter to you in 10 years. Medicine is too much work to be miserable.

I would encourage the OP not to apply to PM&R unless it's something they are excited about. I think if one is neutral about all specialties, then I think psych is the best choice. Great lifestyle, with the option to open up your own solo practice and do your own scheduling (all you need to do is rent a room in an office building--there's really minimal overhead), you can schedule yourself to work as much or little as you want (easier to do part-time with the lower overhead, assuming you are ok with a lower salary), and there are opportunities everywhere. I thought heavily about psych, but I wanted to do addiction psych and saw myself getting burnt out and cynical real fast, whereas in PM&R I saw myself remaining optimistic and hopeful, and happy, so it was an easy choice for me.
 
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I'm interested in why you consider PM&R to have a very high burnout rate, DMB mentioned inpatient rehab, can someone expand on this? I am mainly interested in lifestyle, I don't care as much about the pay. Obviously the work itself has to be at least somewhat interesting to me, can you please elaborate on why you say PM&R entails a lot of psych. That would be good since I am interested in patients with depression and therapy for common depression and to be able to do that in PM&R would be great. The argument of interest vs lifestyle has no definitive answer and has pretty good points on both sides but I'm on the side of lifestyle. At this point in time, while I have had some cool experiences in third year, once it passes 5pm, I'm pretty much burned out and I'd rather spend the time doing what I enjoy outside of work. And I'm not about that weekend work life. At least from what I have heard, most PM&R residencies are pretty chill, what are the hours like in a typical PM&R residency from year 1 to 3? How much call is there and what does that usually entail? I can't imagine I'll burn out more in PM&R than in say IM or surgery. Other specialties I've considered include anesthesia and rads but they are lower on the list than derm, psych, and PM&R- anesthesia seemed a little too boring with little patient interaction and rads has little patient interaction as well. One reason I enjoy patient interaction is because I've always enjoyed teaching such as tutoring other students in college and I think that would translate well to teaching patient's about their disease process.

Medical specialties with the highest burnout rates

Look at the top 3 specialties...EM, Urology, and PM&R. All three are perceived "better lifestyle" specialties. Urology is a grind through residency...but many applicants pursue Urology because there eventually could be a high pay to work ratio in practice. People that are drawn to a medical specialty because of lifestyle often realize that they made a mistake. Even in EM, PM&R, and Urology, you are still a physician and put in lots of work. It's not a typical average American day job...and if you aren't enjoying what you are doing...it's still going to suck. Finding a job that you enjoy and find rewarding is how you make it as a physician.

PM&R is a great specialty for people who love MSK and want to help patient's make the most out of their situation in life. But our typical patient has chronic pain, depression, anxiety, and quite honestly many are hopeless. Working with that time of patient day in day out can be a grind. In the outpatient setting...we see tons of failed Ortho and Neurosurgical procedures and the patients are left in chronic pain and even more hopeless. We also see patients on disability who have a financial incentive to NOT improve.

I love PM&R because I love the challenge of treating those types of patients. I'm probably in the minor, but I like chronic pain and I like trying to break the chain of learned hopelessness. I find it very rewarding. I suppose I could burnout eventually...but I think that I have the mindset that is sustainable. If I didn't love the field, I could definitely see how people can burn out in the field.


Apparently I was typing as RangerBob posted his post. He's spot on about outpatient being the place where people burn out. It is pretty rare to find an inpatient doc that is burned out unless they are overworked. But I also think that inpatient docs are typically the ones who love the field and don't mind the extra hours. Outpatient tends to attract more residents who are looking for the great lifestyle...and in spite of the better lifestyle...they still burn out at a higher rate.
 
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63.3% burn out rate in PM&R. 45% burn out in all physicians. lol what question did they ask in their survey? Can't be that many physicians burnt out, hating their jobs, showing up and just going through the motions.
 

There is a large confounding element in this survey and that is a lot of those people in those fields were probably attracted to them because of the hours. You see fields like EM, FM, dermatology, radiology and other non-surgical fields more at the top versus fields like neurosurgery and general surgery which are at the bottom (even though those these fields put in insane hours). The only reason why psychiatry even has a low burn out rate is because they have far more control of their hours. If they weren't compensated as well and had to see more patients, those numbers would rise drastically.

Not to say that PM&R doesn't have a fair amount of burn out, but unfortunately it is crowded by people who want an 8-5 job in medicine.
 
Medical specialties with the highest burnout rates

I love PM&R because I love the challenge of treating those types of patients. I'm probably in the minor, but I like chronic pain and I like trying to break the chain of learned hopelessness. I find it very rewarding. I suppose I could burnout eventually...but I think that I have the mindset that is sustainable. If I didn't love the field, I could definitely see how people can burn out in the field.

These are the pain docs that don't seem to burn out--it suggests you actually like chronic pain patients. My favorite pain doc had the same mindset. It's surprising how many people go into a certain specialty or subspecialty and don't actually enjoy the patients they work with.

The physicians I most see burning out go into a field for the glory, money, or hours. The importance of all three of these things changes over our lives. Which is why I think geriatricians rank at the highest for satisfaction with their lives--who goes into geriatrics for fame or money? But we all know students who applied to competitive specialties in part for the prestige or the money. Within PM&R, the money is generally in interventions, so I think compared to SCI and TBI, interventional pain/spine just draw more people that aren't as passionate about the field itself. No one does a TBI or SCI fellowship unless they really like the field/population. It's all about selection bias.

The other side of the burnout coin I see are physicians who really enjoy what they do and feel pressured to work inhumane hours and overextend themselves. Particularly once a family comes into the picture, even the most noble physician needs some time away from their work.

Personally, if I went into EM or rads I'd be beyond burnt out by now. That EM schedule just made me miserable in med school and intern year, and a 4 hr day in the radiology reading room wore me out more than 14 hrs in the ICU. I have a med student right now going into surgery who was quite honest he would find inpatient PM&R way too dull, slow, and depressing. It's all about finding the right fit.
 
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