PM&R vs Ortho vs neuro + more

[scm]

hey all, being that I think I already know why I'm really interested in/excited about PM&R, I try to listen to negative things people have to say about it just to get a balanced view, this isn't hard considering the enviroment here at school. anyway, I guess I'm curious how people with more exposure to the field would have to say about these issues.

-I'm sure this has come up before...:a few people have pointed out to me that if someone needed help with a musculoskeletal problem, the most qualified person would be an Orthopod, and similarly for a neuro problem, a Neurologist would be most well-trained and suited for making a diagnosis and so forth, as such, Rehab doc is essentially redundant in these areas, and lacks a specific purpose/identity (these being a conglomeration of various assertions made to me). Diagnosis and treatment of neuromuscular type stuff is something that really interests me, and hence, my interest in PM&R, but really why would someone chose a physiatrist in an outpatient setting, initially, over either of the above specialists? what does PM&R have to offer that they don't? (generally speaking)

-sure, PM&R docs are great at managing Rehab...my main expsure has been outpatient so far, and a couple of days of not so great inpatient. i've been talking to some 3rd yr friends who roatated through rehab recently, these being open-minded, caring, thoughtful students, and it's really interesting that both independantly said that after their rotation in inpatient rehab they felt like these docs werent "doing real medicine. they both said this word for word...has anyone encountered this assertion before? i tried to understand what they meant, obviously they didn't have a great experience. im guessing their traditional view of medicine involves curative type things and this is where they had a problem, but I guess I'm still wrestling with the issue of potentially feeling like I'm not _doing_ much if I do inpatient rehab with competent PTs and OTs around...but I think I like the idea of helping people in a hosoital setting much more than a 9-5 office type setting...

-to discourage me further, numerous other people mentioned rehab docs they knew who just do admissions in nursing homes.

still looking for inspirational/excited people where I'm at....

thanks for any insight/input
scm

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[drusso]

I'll try to respond to your questions on a point-by-point basis...

Originally posted by scm

-I'm sure this has come up before...:a few people have pointed out to me that if someone needed help with a musculoskeletal problem, the most qualified person would be an Orthopod, and similarly for a neuro problem, a Neurologist would be most well-trained and suited for making a diagnosis and so forth.

I really think that this depends on the type of injury. Sure, if a patient has an acute fracture or needs an operation, then the most qualified physician is an orthopod. But most orthopods are not the greatest at managing non-operative musculoskeletal injuries (nor do they enjoy doing so), thus a huge void is left unfilled. And, what about patients who can't have an operation secondary to advanced age, medical complications, etc? Do you just write these people off, or can rehabilitative modalities help? And, it is these types of injuries (nonoperative, chronic musculoskeletal injuries) that most primary care physicians feel most ill-equiped to treat. Let me dredge up some data.....

Educational deficiencies in musculoskeletal medicine.
Freedman KB, Bernstein J.
University of Pennsylvania School of Medicine, Philadelphia, 19104, USA.

CONCLUSIONS: According to the standard suggested by the program directors of internal medicine residency departments, a large majority of the examinees once again failed to demonstrate basic competency in musculoskeletal medicine on the examination. It is therefore reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.

Confidence of graduating family practice residents in their management of musculoskeletal conditions.

Matheny JM, Brinker MR, Elliott MN, Blake R, Rowane MP.

Department of Orthopedic Surgery, Saint Lukes Medical Center, Cleveland, Ohio, USA.

...In conclusion, family practice residents show relatively low confidence in the management of musculoskeletal conditions and receive minimal exposure to all aspects of fracture care. Confidence can be improved with greater exposure to the musculoskeletal sciences--such as a rotation of 8 weeks or more on an orthopedic surgery service.

Furthermore, it's not clear that operative management of musculoskeletal problems is always the best solution anyway. Recently, a NEJM study suggested that knee arthoscopy (orthopod's bread and butter procedure) may be no better than placebo for osteoarthritis of the knee.

A controlled trial of arthroscopic surgery for osteoarthritis of the knee.

Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP.
Houston Veterans Affairs Medical Center, Baylor College of Medicine, Houston, TX 77030, USA.

The same goes for neurology. Neurologists, far and away, are the best at managing acute CNS disorders. But, what about dealing with the day-to-day realities of living with a chronic, debilitating neurologic disease such as MS, ALS, or others? What does the neurologist have to offer? Many physiatrists specialize in treating neurodegenerative disorders (both acutely and chronically) and, for example in MS, physiatrists can be very useful. Relatedly, most neurologists are not trained to deal with musculoskeletal disorders and musculoskeletal and neurologic disordes often blend into each other---hence NEUROMUSCULOSKELETAL MEDICINE! It all depends upon your interests in physiatry and how you market yourself to primary care physicians.

I seriously considered neurology as a specialty because the overlap in patient population is substantial. But, given the low salaries of neurologists, the lack of procedural training (you will get more experience in joint injections and spinal therapeutics as a physiatrist than as a neurologist), and the decline of neurology as a specialty in recent years (just look at the numbers of FMGs entering into neurology residencies!), I opted for PM&R. Neurology is a fascinating field that is very academic and on the verge of making huge contributions (it already has made a number of contributions) to medicine. I just wanted more musculoskeletal training, more procedural training, and clicked better with the personalities attracted to physiatry. Moreover, many neurologists are getting interested in rehabilitation and there are even neurology fellowships for neurologists in "neurorehabilitation."

Kraft GH.
Rehabilitation still the only way to improve function in multiple sclerosis.
Lancet. 1999 Dec 11;354(9195):2016-7. No abstract available.

Kraft GH.
J Spinal Cord Med 1998 Apr;21(2):117-20 Rehabilitation principles for patients with multiple sclerosis.

O'Hara L, Cadbury H, DeSouza L, Ide L.

Physical rehabilitation has a positive effect on disability in multiple sclerosis patients. Neurology. 2000 Mar 28;54(6):1396-7. No abstract available

Interesting BMJ article on "neurorehabilitation."

Another interesting BMJ paper on rehabilitative medicine

Originally posted by scm
- i've been talking to some 3rd yr friends who roatated through rehab recently, these being open-minded, caring, thoughtful students, and it's really interesting that both independantly said that after their rotation in inpatient rehab they felt like these docs werent "doing real medicine. they both said this word for word...has anyone encountered this assertion before? i tried to understand what they meant, obviously they didn't have a great experience. im guessing their traditional view of medicine involves curative type things and this is where they had a problem, but I guess I'm still wrestling with the issue of potentially feeling like I'm not _doing_ much if I do inpatient rehab with competent PTs and OTs around...but I think I like the idea of helping people in a hospital setting much more than a 9-5 office type setting...

I think you're right. What does it mean to be doing, "real medicine?" Are psychiatrists doing "real medicine?" How about pathologists? Would they say the same thing if you were going into diagnostic radiology? Does doing "real medicine" only entail surgery or interventional procedures? So much of western medicine is geared towards, "doing something." Rehabilitation is a different phase of healing that requires a slightly different approach to thinking about medicine. PM&R is not a specialty for everyone. I've always maintained that if you're a "Johnny-on-th-spot" type of person you're likely to be frustrated with the pace of rehab medicine. If you're uncomfortable tolerating ambiguity you're likely to be frustrated in rehab because rehab patients' problems are complex, multifocal, often degenerative, and not clearly organ-system specific.

Still, I think that the future of PM&R is great. It started out as a specialty that evolved between the boundaries of neurology, orthopedics, rheumatology, and general internal medicine. Advances in functional restoration, artificial limb technology, pain management, spinal therapeutics, coupled with gathering momentum for the utility of an "aggressively conservative" approach to patient care holds substantial promise for PM&R as a specialty. It's a young field (only formally established in 1938) so it does a require a pioneer mentality and maybe a leap of faith. I think that you're asking all the right questions...

Another interesting BMJ paper on rehabilitative medicine

Multidisciplinary rehabilitation for chronic low back pain: systematic review

BMJ 2001;322:1511-1516 ( 23 June )

Insurance case managers' perception of quality in back pain programs: a focus study group.

Haig AJ, Rich DM, Hadwin K, Davis LP, Theissen M.

Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor 48108, USA.

OBJECTIVES: Insurance case managers commonly interact with physiatrists and rehabilitation programs. They influence referrals and patients' decision making. This study was designed to determine which factors affect case managers' perception of back pain program quality. DESIGN: Repeated focus group interview in a neutral facility in an urban Midwestern United States community. Subjects were two groups (n = 12 and 11) of insurance case managers employed by case management firms (large and small), insurers, and self-insured employers. Outcome measures included group and individual responses to a pre-scripted interview and were collected on tape, transcribed, and interpreted by two different persons: the independent expert interviewer and a pain psychologist. RESULTS: There was substantial agreement between the two interpreters. Both groups overwhelmingly chose physiatrists over other specialists. They emphasized timeliness, communication, functionally oriented programs, concrete program goals and time frames, physician knowledge of the legal aspects of disability, and rapid communication of patient noncompliance. CONCLUSIONS: Rehabilitation programs may strive to meet many of these qualities but, in doing so, should be aware that the legal and ethical roles of case managers differ from that of clinicians.

Originally posted by scm

-to discourage me further, numerous other people mentioned rehab docs they knew who just do admissions in nursing homes.

still looking for inspirational/excited people where I'm at....

thanks for any insight/input
scm

This would drive me crazy too. I'd rather stick a fork in my eye than be a "nursing home doctor." But, ask yourself how many general internists or geriatricians are doing exactly the same thing??

 

[Neurogirl]

While I agree with some of the above info, I must disagree with several points. First of all, stating that neurologists do not receive training in musculoskeletal disorders is simply not true and to imply that we do not treat neuromuscular complaints is laughable! A complete examination and evaluation of the peripheral nervous system and muscles is part of EVERY patient visit. Secondly, we are VERY involved in the day to day needs of patients with debilitating illnesses. In fact, we often end up fighting with the rehab docs about providing services. It usually falls to US to insist that the patients continue to receive assistance and some type of rehab. Also, I'm not sure what is meant by the question, "what do neurologists have to offer?". What specifically (other than pt/ot), do physiatrists do for these conditions that we don't? We are the ones who provide disease specific treatments and pain management (for some proceedures, we refer to anesthesiology...some we do ourselves). Our physiatrists are never involved (or interested) in those aspects of care. Are there some new treatments I'm unaware of?

Regarding the "decline of neurology as a specialty", the above info is somewhat outdated. Competition is actually increasing and it is becoming increasingly difficult for FMGs to secure positions in even mid tier programs. This new trend has been ongoing for at least 3-4 years and is expected to continue. Why the change? Demand and therefore salaries are on the rise. Prospects for all grads are good, but US born grads can write their own ticket. I'm only a PGY-2 and I've already been approached by three different groups. Salary info has been posted elsewhere, so I won't regurgitate the numbers, but I can tell you that we do very well and no one is complaining about income. The exception is academic medicine where salaries are pretty low (but that is the case in all areas of medicine).

I'm not trying to dump on PM&R, but the physiatrists I know do not have the type of practice described above. It doesn't mean it couldn't happen, but it would be difficult. Most primary care physicians and orthopods refer their neuro patients to neurologists...not physiatrists (if for no other reason than CYA).

 

[Stinky T]

I'm sure the training of Neurologists and Physiatrists differ depending on where you are. At the Harvard affiliated hospitals, Neurologists receive far less musculoskeletal training than Physiatrists. In fact, one of the attendings that we rotate with as a PGY-2 is a former Neurologist (who also completed a Cerebral Vascular Disease Fellowship after his Neuro residency) at HMS. After practicing several years as a Neurologist, he went back and did a PM&R residency at Harvard. After completing the PM&R residency, he now does occupational & musculoskeletal medicine. I'm sure that different Neuro residencies may give you more exposure, but the fact is that it will almost always be less than what is covered in a PM&R residency.

With regards to managment of CVA patients, we get lots of Internists and Neurologists that send us their CVA patients. There is often the feeling that on the Neuro service it is often "diagnose and adios". We spend two months as a Neuro resident at MGH and we get a ton of CVAs (amongst other things) from the Neuro departments so this impression is from these experiences. Don't get me wrong, we have the utmost respect for the incredible Neurologists (with many diseases or signs named after them) that we work with, but it seems that their interests lies more in the diagnosis rather than with the recovery.

I would agree with David in that many of the Neurologists I've worked with tend to focus more on the acute management of CNS disorders. Physiatrists tend to focus on the functional recovery (possibly involving botox/phenol/orthopedic injections, gait analysis, orthotic prescriptions, etc.) as well as the medical management and prevention of medical complications that often occur with a certain disease.

I think that PM&R and Neurology do overlap in such areas such as TBI, Stroke, SCI, etc. and we do get similar training in certain procedures. However, there are also profound differences in our training. We get much more exposure to musculoskeletal medicine (especially outpatient orthopedics) and interventional pain procedures. I'm not saying that these things aren't available to Neurology residents, but it certainly isn't a standard part of the Neuro curriculum. Also, it should be noted that many of the medical students who now go into PM&R have interests that are very much different than those who chose the field 10-15 years ago.

With regards to salaries, I can't say that I really have a lot of knowledge in this area. I will say that the Neuro residents I worked with in CA, painted a similar picture to the one by another Neuro resident on SDN about IL. The job offers for graduating Neuro residents were around $90,000 or less. I know this is just one example, but many of them were extremely unhappy because they wanted to remain in the Bay Area and there weren't many offers (even at $90,000).

 

[drusso]

Originally posted by Neurogirl
While I agree with some of the above info, I must disagree with several points. First of all, stating that neurologists do not receive training in musculoskeletal disorders is simply not true and to imply that we do not treat neuromuscular complaints is laughable! A complete examination and evaluation of the peripheral nervous system and muscles is part of EVERY patient visit. Secondly, we are VERY involved in the day to day needs of patients with debilitating illnesses. In fact, we often end up fighting with the rehab docs about providing services. It usually falls to US to insist that the patients continue to receive assistance and some type of rehab. Also, I'm not sure what is meant by the question, "what do neurologists have to offer?". What specifically (other than pt/ot), do physiatrists do for these conditions that we don't? We are the ones who provide disease specific treatments and pain management (for some proceedures, we refer to anesthesiology...some we do ourselves). Our physiatrists are never involved (or interested) in those aspects of care. Are there some new treatments I'm unaware of?

I think that its a difference in conceptualization and approach to treating chronic illness. Anyone can write pt/ot orders to "eval-and-treat" versus truly *PRESCRIBING* specific physical medicine modalities, exercise therapies, and other interventions. There's a whole host of modalities ranging from heat, cold, electricity, etc. Not to mention botox injections for spasticity, phenol injections (motor point blocks), trigger point injections, IDET, nerve blocks, the list goes on and on! Most of these modalities are more commonly encountered in a physical medicine specialty clinic than a neurology clinic (although I know a few neurologists who do them).

I agree with Stink about Neurologists being generally "hands-off" about managing patients---the old, "there's the lesion, there's the door." Neurogirl, I don't know where you're doing residency, but from this and previous posts it doesn't seem like your PM&R doctors are very progressive. I'm very curious if your institution is considered a leading center for rehabilitation medicine. You always seem to take the position that physiatrists are really doing a form of watered-down neurology (or nothing at all), that neurology is just as procedurally-oriented as physiatry (aside from spinal taps, most of the neurologists I've met never learned to do any procedures during their residency), and that there is some bias AGAINST physiatrists on the part of neurologists. Is this true?

 

[Neurogirl]

The above points are well taken. It appears that programs (both neuro and pm&r) vary widely in the types of training and exposure they offer. Perhaps I'm just fortunate to be in a program so progressive and "hands on". Regarding proceedures, in addition to EMG/NC, EEG, LPs, and nerve/muscle biopsies, we receive training in all the various injection techniques. From the posts in this forum, it does appear that our physiatry program is extremely antiquated. As I said, we are usually on our own when it comes to pain management and long term care. However, I view this as advantageous as it will serve me well in private practice.

Regarding salaries, I guess I won't be moving to CA anytime soon! HaHa! In the midwest, things are much different. Two of our senior residents have already signed their first employment contracts. One will start at $150,000, plus loan repayment (she didn't say how much). The other is starting at $140,000 with a production bonus that's guaranteed to provide another $30,000+. I'm surprised that salaries would vary so much, but I guess they do.

 

[drusso]

Off the subject a bit, but here's an interesting news story that some of the people posting might find interesting...See, all the neurologists and physiatrists can play nicely together in the real world!

Spine Care a Backbone for New Neurological Center

--dave