PM&R = Feel like sort of 2nd class?

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gasping81

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Hey guys/gals,

Do you feel that being in PM&R makes you feel like a 2nd class person ? Meaning that you really don't have your own patients or that you rely too much on others to establish your work routine on a daily basis (ex: ortho docs, IM docs). Overall, what do you feel is your level of independence? How do hospitals/facilities treat you?

Merry Xmas to all!
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IMHO:

Inpatient academic centers make residents feel like turds because they typically have no spines and take the LCD of patients. They are used to getting run over by ICU patients, patients without a dispo, and patients whose sole rehab criteria is a cheaper bed to park somebody.

In the outpt world, many Physies have taken a back seat to the Ortho and joined the Ortho groups with an offer of future partnership only to be a narcotic manager and a 3 ESI (go light on the steroid) on way to the fusion.

Others have set up their own shops and enjoy community respect, patient respect, and wind up telling their surgeons what needs to be done on the patient. :cool:

It's who you are, not what residency you did.
 
Only if you let yourself feel that way. We tend do deal more with the specialists with the biggest egos and the most arrogance - ortho and neurosurg. Many of them treat everyone as inferiors. In academics, in my experience, PM&R gets less respect. In private practice you earn it or lose it the same as anyone else - by treating patients and them reporting back to their PCP or referring doc.
 
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Gasping,

You meet diagnostic criteria for Physiatric Low Esteem And Suffering Experience (PLEASE). I believe that you are in the earliest stages and there may be help for you.

The first thing that you need to know is that the disease is endemic to most university PM&R training programs where most attending physiatrists are colonized with PLEASE. In fact, the PLEASE vector has been cultured from the nares and rectal mucosa of most tenured academic physiatrists who finished their residency prior to 1991.

The causes of PLEASE are well known and have been previously elucidated in other threads:

http://forums.studentdoctor.net/showthread.php?t=561597

PLEASE is a chronic relapsing condition that waxes and wanes over time. Your journey towards putting PLEASE into long-term remission starts with an accurate diagnosis.

PLEASE usually strikes physiatrists during their second year of post-graduate training. Symptoms may come on insidiously or begin precipitously. In the early stages, victims generally report feelings of malaise, confusion, hopelessness, impending sense of doom, restlessness, fear of the unknown, and an aching sense of regret.

As PLEASE progressses, physiatrists may lose their sense of orientation, medical judgement, historical context, and time. Recent scientific evidence suggests that once infected, the PLEASE vector resides in the ventromedial thalamus and frontal lobes of the brain. Thus, fulminant PLEASE often manifests with delusions of grandeur, an exaggerated sense of entitlement, anti-social behavior, self-preoccupation, and complete disregard for the feelings of others.

In recent years, we begun to understand more about PLEASE's mechanism of transmission. Epidemiological studies clearly demonstrate a higher incidence of PLEASE in large academic and multi-specialty group practices. Thus, epidemiologists believe that cannibalism may play a role: It's long been known that physiatrists eat their young.

My own experience with PLEASE started during my second year of residency. I was making my rounds as a dutiful, busy, eager beaver on the consult service racking up RVU's for my attending. At the time, I knew little about PLEASE. I had only heard stories and urban legends about the scourge and its effects on others.

Then, one day just before lunch, I was dispatched by my attending to the bowels of some surgical ward with a PM&R consult that read, "Please eval for compression stockings." Then, just like that, it took hold of me. I stared at the consult form for 15 minutes trying to make out the words and attach meaning to them.

My medical career flashed before my eyes...just mere months prior I was pushing amiodarone, running codes, putting in chest tubes, titrating drips in the ICU, suturing up crackheads and prostitutes in the ED...now, I was ordering up stockings for patients....Oh, PLEASE...

It hit me hard. Some who have conquered PLEASE (and it can be conquered) say that their affliction was like a blessing of sorts. It's as if someone peals back the veil and reveals the soft ugly underbelly of our modern health care system. Others compare it to seeing the face of God.

I was viscerally affected. I stumbled in the hall. I felt nauseated and confused, but I saw the consult as directed. I ordered the Jobst stockings (20mm Hg). Our institution billed the patient's insurance $320.00; my attending met his RVU productivity target for the day...

There is no known cure for PLEASE. The best treatment may be prevention. You can live and thrive with PLEASE by putting the following 7 habits into daily practice:

1) Question everything anyone tries to teach you.

2) Challenge authority.

3) Talk the talk; and walk the walk. That is, believe and practice the principles of rehabilitation.

4) Don't be a doormat.

5) Don't be a doorknob.

6) Don't be a tool.

7) Don't let others define what you do, lest you become their little b*tch.

PLEASE is a silent killer of physicians. Left unchecked it will rob you of your sense of self-worth, medical professionalism, and humanity. You will become consumed with antiquated ideas and nostolgic thinking. You will perseverate over trivial medical decision-making. You will begin talking in strange, almost incoherent vocabulary substituting bonafide medical terminology with politically correct Rehabby language...

Don't let this happen to you. Remember, you are a doctor. You know more and are smarter than the therapists you direct. You are actually smarter than most of the other doctors in the hospital when it comes to functional neuroanatomy, musculoskeletal medicine, and disability. Start practicing the 7 habits immediately. Find support among your classmates, SDN, and those who have escaped the scourge of PLEASE.

Please...
 
:laugh:

That's great!


drusso,

you should publish your list of SDN acronyms and distribute each fall to all PM&R PGY-2s.
 
drusso said:
Gasping,

You meet diagnostic criteria for Physiatric Low Esteem And Suffering Experience (PLEASE). I believe that you are in the earliest stages and there may be help for you.....................
Click to expand...

Thanks I guess for the really long reply. I'm actually in gasland, which does have a bit of what you describe as feeling undervalued or replaceable based on your PGY-2 story. If you really mean what you are saying, I do feel what you felt: doing more internist aka stereotypical doctor things as an intern, but that stuff has kind of passed (less for me than you I guess).

So I'm stuck between the idea of going on with this, which is long days 6-6 and lot of being compromised at times by surgical service, versus maybe switching over to something like PMR. I have done pain clinics in the past, which I thought was pretty cool, and I see that there are many aspects of PMR in that.

So wondering if there are program that would even take me at this point.
 
Drusso--I need a consult for a foley b/c I just wet myself. Best thing I have read in over a year! Now that I know my diagnosis, I can treat it with your recommendations.
 
PLEASE - that is F'in hilarious! You gotta get that in one of the journals or magazines.
 
To get serious for maybe for a moment,

Any one of you leave anesthesia to join PMR? I remember a while ago lurking around this forum somebody did mention it. Forgot who though. I would love to know the process, and how they felt about the transition eespecially what did they like compared to their previous position? Thanks to all.
 
DRusso, the single most most politically correct, politically adept, inoffenive consiliator I have ever met advocating ampaphb's standard brand of rablerousing, thorn in their side, squeeky wheel irritant approach (i.e. challenging authority)? Holy *&$#, Batman, he11 must have frozen over when I wasn't looking!
 
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ampaphb said:
DRusso, the single most most politically correct, politically adept, inoffenive consiliator I have ever met advocating ampaphb's standard brand of rablerousing, thorn in their side, squeeky wheel irritant approach (i.e. challenging authority)? Holy *&$#, Batman, he11 must have frozen over when I wasn't looking!
Click to expand...


Didn't Don Quixote eventually regain sanity and renounce chivalry? :laugh:
 
gasping81 said:
Hey guys/gals,

Do you feel that being in PM&R makes you feel like a 2nd class PERSON?

Merry Xmas to all!
Click to expand...


absolutely not. i let my cynicism and attitude make me feel like a second class person. second class doctor?..... maybe a bit.....
 
Yknow.. any uncertainty really stems from poor exposure to PMR in medical school. For example, I can clearly picture how a cardiologist or orthopedic surgeon treats a patient, but PMR therapeutic modalities are still a blur. I know what you can do through Interventional Pain medicine but how about the core of Musculoskeletal PMR. Is it only recommending physical therapy, Giving you some pain pills, or telling you to stretch more.

I know that sounds very naive, but I just want some clear cut examples of modalities. I can't find this on websites (all they say is that we work to restore function... but how!??). What can PMR do that chiropractors don't (I'm not glorifying chiros at all... in fact I think they do a lot of harm sometimes... and some good other times). I'm only speaking of Musculoskeletal PMR.. not spinal cord injury or traumatic brain injury.

don't mean to sound like I'm playing down the field at all. I just want answers that I don't seem to be getting from any informative website.
 
First off. DRusso outdid himself. Probably the best post in the history of this board

Second, as for other docs not having a clear idea what we do- yeah, this is an ongoing issue

IMO, one of the reasons so many PMR docs are moving into Pain (beyond money) is that other referring docs know what Pain is. When I refer to myself as Sports & Spine rehabilitation or MSK rehabilitation, often times other docs don't really know what I am talking about. They usually get the idea after I handle some tough cases effectively, but it's a harder sell.

This gets to a related issue that has been much discussed on these boards- the dramatic heterogeneity in practice patterns amongst physiatrists. Even if I were to look at my practice patterns within a very narrow scope (e.g., Sports and Spine physiatrists who trained at Kessler or RIC), there would still be a wide range of practice patterns that would make it very hard to know exactly what you are getting.

For this specific problem- heterogeneity of practice patterns- I think there are two distinct issues:
1. Lack of adherence to evidence-based standards. At least part of what is going on is that some physiatrists are simply inadequately trained
2. The scope of the field is legitimately really wide, so we need to stay on message on what it is we do

I had one attending who did a really good job addressing point #2. her rule of thumb was that on every patient encounter, even simple consults that are mainly addressing disposition, or a routine office encounter for something like rotator cuff tendonopathy or carpal tunnel syndrome, always do at least 1 thing that would be above and beyond what your referring physician would have thought of.

I think this gets to the heart of the matter- PM&R will become a field that is respected by other specialties when it is apparent that we are doing things above what physican extender could do.

Time to raise our game
 
rehab_sports_dr said:
I think this gets to the heart of the matter- PM&R will become a field that is respected by other specialties when it is apparent that we are doing things above what physican extender could do.

Time to raise our game
Click to expand...

Besides EMGs... what else can they do besides the physician extender... I"m talking treatment modalities
 
WaterAvatar said:
Besides EMGs... what else can they do besides the physician extender... I"m talking treatment modalities
Click to expand...

Salvage lives.

Some of us put wires where others can't comprehend and hook them up to batteries in people's butt's (SCS/PNS Robot Factory). Some of us can make clinical patho-anatomical correlations that allow an exceptionally more efficient means of treating common low back pain with a single poke and a multimodal approach.

And yes, others write eval and treat on Rx's to PT and try acupuncture and repeated trigger points. But only because they are stupid and/or lazy.
 
WaterAvatar said:
Besides EMGs... what else can they do besides the physician extender... I"m talking treatment modalities
Click to expand...
Effectively diagnose the problem as something besides "lumbago" for a start. Physiatry excels at diagnosis of MSK disorders. PCPs, let alone their extenders mostly do not have the training or the desire to treat these problems. Then we select the most advantageous treatment. If it were so easy anyone could do it, they would, but they don't and often can't.
 
WaterAvatar said:
Yknow.. any uncertainty really stems from poor exposure to PMR in medical school.
Click to expand...

It goes beyond poor exposure to medical school. It's a lot more structural and basic (literally) than that. As medical students we get little to no exposure in the basic sciences of the realm of physical medicine: namely kinesiology. What we learn in medical school really sets the stage for the way we see the human body. And, unfortunately, we tend to get trapped into believing that only what we learn about--only the domains of biology considered important enough to be taught to us--are important for understanding the human body in health and disease.

We don't respect physical medicine because we don't understand it. We learn so little about MSK and the functions of the moving physical body that we think there's very little to know.

I think if PM&R is going to gain the respect that it deserves--and I think in this day when MSK complaints are some of the most common reasons for loss in productivity, quality of life, disability, and healthcare costs it's hard to argue that this are doesn't need to be emphasized--the changes have to come a lot earlier in our education.

Just my 2 cents. Probably not worth even that since I'm actually headed into psychiatry. *shrug*
 
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WaterAvatar said:
Besides EMGs... what else can they do besides the physician extender... I"m talking treatment modalities
Click to expand...

Alot of the value of a musculoskeletal Physiatrist is in his/her diagnostic abilities.

Finding the underlying cause (there are usually several, many of which do not have concrete findings) of musculoskeletal pain can be very difficult, especially with non-specific entities such as low back or neck pain.

Without a correct and comprehensive diagnosis, patients often get cookie-cutter treatment, don't improve, start using alot of narcotics, become depressed, then angry, file for disability, etc.

So, the Physiatrists responsibility is to come up with the right diagnosis (hopefully in an efficient and expedient manner) leading to the right treatment.

As far as what treatment the Physiatrist directly, it is usually procedures or medication, and in some instances manipulation, acupuncture, etc.
 
lobelsteve said:
Archives would publish it, but it needs to come from a PT or PhD and it needs worthless stats and measures. GBB- God Bless Basford
Click to expand...

Maybe the new journal will take it... maybe.
 
Disciple said:
Alot of the value of a musculoskeletal Physiatrist is in his/her diagnostic abilities.

Finding the underlying cause (there are usually several, many of which do not have concrete findings) of musculoskeletal pain can be very difficult, especially with non-specific entities such as low back or neck pain.

Without a correct and comprehensive diagnosis, patients often get cookie-cutter treatment, don't improve, start using alot of narcotics, become depressed, then angry, file for disability, etc.

So, the Physiatrists responsibility is to come up with the right diagnosis (hopefully in an efficient and expedient manner) leading to the right treatment.

As far as what treatment the Physiatrist directly, it is usually procedures or medication, and in some instances manipulation, acupuncture, etc.
Click to expand...

This sounds very exciting! There seems to be no limit to this field.
 
I don't mean to use 2nd class as a means of saying rehab docs are less important. I actually was quite aware of their consultant role as an intern. Plenty of patients who developed strokes and thus needed immediate intervention to have the best recovery possible versus the neurologists who were let's see what comes back working.

But, I am not aware of the politics and social interaction at the attending level. What is your role in the hospital or outpatient setting? What you like about it and don't that you don't tell your medical students? Also, how intense is the specialty? I won't judge based on my novice observation. Do people find themselves really stressed out at many times? Or not? Is the specialty conducive to family life and friends?

To be honest, I don't really care if the money is there or not (meaning 150-175K is fine but wouldn't complain about 400K either) but I like most others of this generation value my time away from the profession. And I like working with people who are nice and not always tense making me act not myself.
 
unhappy people will complain regardless of specialty or situation. Physiatrists tend to have nice lives outside of work - I have met Physiatrists who fly planes, show dogs, play music, act, etc. If you search the forum, there have been discussions on physiatrists who were on the survivor show, american gladiator, etc. I think our field gives us the opportunity to do that.

Most of the complaining probably happens in the Academic setting - mostly because the payment structure is different and because there are different political issues in Academia vs private practice. People are unhappy because they feel like they work hard and don't get paid enough - medicare fee cuts usually cause us to grumble and personality conflicts between physicians (both intra and inter specialty relationships) also can make us unhappy. As a new attending, some are treated like glorified residents - doing a lot of coverage and going to locations no one else wants to go.

In private practice - its usually politics also - referring docs, intra-office conflicts, if it's multi-specialty - there may be situations where we get treated differently in a bad way (especially if its some kind of surgery-PM&R combo).

Physicians tend to be really bad about looking down on other specialties. I'm sure many of us heard physicians knocking other specialties as we went through med school. It doesn't stop after med school either. I don't mind because I see it as jealousy that I get to take home call as others have to take OR/ER call. I have met many physiatrists who out-earn/out-collect their surgical partners and their surgical partners don't like that. I personally think it's better to have people knock you and be jealous of you rather than being the person everyone else feels sorry for :laugh:

I think if you carefully choose your work environment and your peers, you will be happy. Referring docs and your partners don't really care what specialty you are as long as you take care of their patients and in the case of your partners, you hold your own in terms of covering your overhead and contributing to the group. If you go to the AAPM&R you'll see that the majority of Physiatrists tend to be fun, laid back people with great personalities. We tend to be team players and humble but confident. The unhappy people are people who shouldn't have gone into the specialty or felt like they didn't have a choice. PM&R will not give you much fame and glory but I knew that going in.

not sure if that's the type of answer you were looking for?
 
OP asked about life outside of work so I answered that question. I didn't mean that PM&R gives us the opportunity to become gladiators and go on survivor... although reading back, it certainly sounds like I meant that.

My plan is to include those photos of Venus in any presentation I do for med students to get the best and the brightest :laugh:
 
axm397 said:
OP asked about life outside of work so I answered that question. I didn't mean that PM&R gives us the opportunity to become gladiators and go on survivor... although reading back, it certainly sounds like I meant that.
Click to expand...

That's OK, maybe we can promote ourselves as the fun-loving goofballs of medicine.:D
 
Bluemirage said:
Haha...you beat me to it. I was just about to post this same link with Dr. Ramos as a way to "sell" PM&R.
Click to expand...

Pilot study,

maybe after the match one the UC Irvine residents on this board can post how male candidates who interviewed with Dr. Ramos ranked the program versus those who didn't. :laugh:
 
gasping81 said:
To get serious for maybe for a moment,

Any one of you leave anesthesia to join PMR? I remember a while ago lurking around this forum somebody did mention it. Forgot who though. I would love to know the process, and how they felt about the transition eespecially what did they like compared to their previous position? Thanks to all.
Click to expand...
Yes, let me give you the best advice I could ever give anyone. The grass is not greener, each specialty has its advantages/disadvantages. I recommend you stay in anesthesiology. Why? It has nothing to do with PM & R, but how hard it can be to switch specialties. It is very hard, and you will be asked a million times why you left your other specialty, and they will think that you will leave theirs. Medicine is not very friendly toward people switching specialties. That is the real truth, I have lived it.

Having said all of that, if you WANT to be in PM & R, like I did, and not just looking for a way out of Anesthesiology, then do some research. Find out as much about PM & R as you can before you leave anesthesiology. DO NOT leave anesthesiology before you acquire a PM & R position if that is what you truly want. That makes it pretty hard to go to enough interviews, etc. I know. Ask yourself what you don't like about Anesthesiology. If it is the surgeons or perceived status of the job as a resident, don't let that make you leave the field. Ask yourself if you truly like doing anesthesiology. If you do, stay in it, no matter how bad your residency program is, and how bad the surgeons, attendings are, etc. PM & R has its problems as do most other fields, and there really is no perfect specialty. Make sure you really know what PM & R is like. It would drive me crazy on the interview trail when I would interview alongside people that were using it as a backup in case they didn't match into ortho, and didn't know anything about PM & R. Those are the people that end up matching PM & R and end up unhappy.
Do the specialty you truly like and what you see yourself doing everyday of your life until you retire. I wouldn't base my decision on money either. I left behind the potential Anesthesiology money because although I like money, I also wanted to enjoy what I did every day. Anesthesiology was not a good fit for me for many reasons, but it is a very good field for those out there that like it. Same goes for FP, Psychiatry, etc. Don't let other physicians perception of your field determine what specialty you enter. I find physicians to be some of the most insecure people (including myself to some extent, lol) that I know.
Look at the people that you like to be around. What specialties are they in? I found I fit in with PM & R people best, and not anesthesiology people. I really don't fit in with doctors much at all, but definitely PM & R the most. Think back to when you were on the interview trail as well. Did you fit in with those people you were interviewing alongside?
In closing, I want to reiterate that leaving a specialty is a pain in the *****, and you really really should proceed with much introspection. Good luck to you. This is just my opinion everyone, so don't flame me. I am glad I am in PM & R, but switching truly is a pain, and you really need to be sure you WANT to do PM & R for the right reasons.
 
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