PM&R vs Ortho

[2nd year]

I'm nearing the end of my second year and I'm still up in the air as to what I want to do. Musculoskeletal medicine is definitely where my interests lie and I would like to do at least some procedures. I'm trying to decide between Ortho and PM&R. Just curious as to what people in the Ortho. community think of PM&R becoming more involved in treating non-operative orthopedic ailments. Certainly, the lifestyle in PM&R seems a little more reasonable, but is the lifestyle in orthopedics really that bad. I know the residency is tough, but then what? Any insight would be appreciated. Thanks.

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[dry dre]

I'm nearing the end of my second year and I'm still up in the air as to what I want to do. Musculoskeletal medicine is definitely where my interests lie and I would like to do at least some procedures. I'm trying to decide between Ortho and PM&R. Just curious as to what people in the Ortho. community think of PM&R becoming more involved in treating non-operative orthopedic ailments. Certainly, the lifestyle in PM&R seems a little more reasonable, but is the lifestyle in orthopedics really that bad. I know the residency is tough, but then what? Any insight would be appreciated. Thanks.

Good questions. When the day comes that a PM&R doc gets all gung-ho and starts edging in on someone else's turf, call a news conference and then ask the ortho guys what they think.

Seriously, the lifestyle of any doc is dependent on the wishes of the individual. If you want to make big money, you need to work a lot of hours in ortho or PM&R. Of course, a "part-time" orthopod will likely take home more than a part-time PMR doc. Certainly, you make more money doing procedures, but in a world of diminishing reimbursements, I'd have to assume (big assumption) that less complicated/technically difficult procedures will suffer more than surgical procedures (surgery may be cut deeper, but 'procedures' may not be worth the hassle to the non-specialist). At the same time, depending on the community in which you practice, if there was a turf war, ortho will likely win out insofar as A) ortho tends to be well organized politically B) mechanical consults go to ortho to begin with and C) ortho generally employs midlevels in their offices that can clean-up/perform simple procedures that the attendings don't care to take part in.

When if comes to choosing a specialty, never let the residency profile scare you away...unless you have very extenuating circumstances that would prohibit you from, for instance, spending 5 years in a particular location and so on. Don't forget, there's a lot of musculoskeletal in primary care as well...you can go FP and do a sports med fellowship and tailor a practice to athletics....I would personally do this instead of the PM&R route for the motivation reasons that I take from your post.

 

[2nd year]

Thanks for your response. Just curious as to why you think doing a sports med. fellowship via Fam. Med. would be a better route than PM&R? There are many sports/spine fellowships for PM&R that are well established and apparently accredidation by ACGME or ABMS is already being sought by those in power. Are the mid-level people working in Ortho. practices generally PAs/NPs or are they FM/sports or even PM&R docs? Thanks again.

 

[dry dre]

Frankly, I know little about PMR but am familiar with FP.

When I was referring to 'midlevels' working in an ortho office, I was referring to PAs and NPs. There probably are comprehensive sports/ortho clinics out there that may have any combination of specialists under the same roof (theoretically I suppose you could have athletic trainers, PTs, PMR, pain people). I just don't know....I was referring to average/smaller ortho practices.

I guess I'm biased towards FP instead of PMR. I like the the patient populations in FP (and ortho); when I think of PMR I think of smart but BORING physicians dealing with the kinds of problems I neither know about nor want to know about. The rehab floor was always the place I hated to have to go to consults on...for whatever reason. It's like the rehab floor is the magnet for problems that just won't go away.

Generally speaking, I'd say that PT is more complimentary to the ortho mission than PMR, but again, I may be missing something big here. Someday I'll have to look into that PMR thing...

 

[Stinky Tofu]

I disagree with the notion that FP followed by Sports Medicine is a better option for your interests. I think what this shows is a lack of understanding in terms of what Physiatrists do and what we learn during residency. While we are doing a better job now educating people about what we do, clearly there is still work to be done.

At our program, we are required to do 3-4 months of EMGs, 3 months at the Spine Center working with Spine Surgeons and Spine Physiatrists, 2 months of MSK medicine, a Pain Management rotation, 2 months of Neurology, 2 months of Spinal Cord Injury, and two months of Amputee. Additionally, many residents do a MSK Radiology rotation, a Neuroradiology rotation, Sports Medicine rotations, Interventional Spine rotations, etc. In terms of procedural experience, you can read this thread. I think we clearly get training that's more relevant to someone who is interested in MSK medicine and in doing procedures. Additionally, if you do a fellowship, you can also do surgical procedures such as spinal cord stimulators, intrathecal pumps, and peripheral nerve stimulators.

At least at the institutions I've worked at, Physiatrists and Surgeons work well together. Our services are highly valued by the surgeons and we refer lots of patients to each other. Also, we can do the workup (MRI, CT, EMGs, X-rays, diagnostic SNRBs, discography, etc.) and try conservative treatment (PT, medications, TPIs, ESIs, MBBs, joint injections, etc.) first. If these measures don't work, we refer them to the surgeon and they are happy to get these patients because they can schedule surgery for them fairly quickly. Most surgeons will want to cofirm the source of the pain generator and make sure that it isn't amenable to conservative treatment before performing surgery. Additionally, we see lots of patient after surgery to prescribe an appropriate rehabilitation program, monitor progress, or because they have FBSS and they aren't surgical candidates.

 

[dry dre]

I disagree with the notion that FP followed by Sports Medicine is a better option for your interests. I think what this shows is a lack of understanding in terms of what Physiatrists do and what we learn during residency. While we are doing a better job now educating people about what we do, clearly there is still work to be done.

That stuff isn't for me (simply personal preference, not to be judgemental).

I suppose when I said that the OP's interests would be better suited in FP/Sports, I was reflecting my own interests. I like the sports/general side of ortho, particualrly the patient interactions...I don't like to deal with chronic bain pain etc... I liken general ortho somewhat to sports med, that is to say working with athletes/individuals with injuries that aren't going to be a long, drawn-out affairs...

After reading Tofu's excellent response, I think it a fair generalization that someone interested in ortho spine might find an interest in PMR. I also think it fair to say that many/most ortho guys try to avoid chronic pain management problems whenever possible (who doesn't? PMR and anest, God bless them). It's often said that this is why ortho-spine guys earn what they do....no one else wants to deal with those type of problems.

 

[Stinky Tofu]

Spine is just one aspect of what a Physiatrist might do in a MSK practice. There are many things that Physiatrists treat that do not involve a long-drawn-out relationship with no end in sight. Also, as specialists, you might get referrals from Orthopods, Neurosurgeons, or PCPs to just do an epidural, EMG, knee injection, etc. In these instances, you do the procedure and then you are pretty much done.

Sports Medicine is also an area that Physiatrists fit nicely into. Unless you want to do primary care, I think the training in a PM&R residency is more relevant to the diagnosis and treatment of athletic injuries. There's an old thread in the PM&R forum that dealt with the differences between a physiatrist and a primary care physician. One of our graduates a few years ago was recruited to join the Steadman-Hawkins Clinic and he didn't do a fellowship. I think this illustrates how much better a PM&R residency by itself prepares you for both MSK and Sports Medicine when compared to a primary care residency. I pulled a few job listings to show how Physiatrists might fit into a Sports Medicine/Orthopaedic practice.

1. CT - Seeking a fellowship trained physiatrist to join our comprehensive musculoskeletal center Located one hour from New York City and two and one half hours from Vermont ski country with a reputation for excellence in patient care, our group covers professional Athletes including Division 1 college athletes as well as many local high schools. The primary emphasis of this position would be spinal intervention, pain management and electrodiagnosis. Experience in intraoperative spinal cord monitoring would confer advantage. Comprehensive salary and benefit package including profit sharing and 401K.

2. NY - Excellent opportunity for a Board Certified/Board Qualified physiatrist to join a progressive five member private practice orthopaedic group with sub-specialty interest in spine, sports medicine, adult reconstructive, total joint arthroplasty, and metabolic bone disease. Experience in muscle testing, electrodiagnostic testing, and injection treatments (epidural blocks, etc.) required. The position is primarily outpatient with in-patient acute rehabilitation available.

3. **** Healthcare is seeking a Physiatrist or Anesthesiologist with a pain fellowship to develop a comprehensive outpatient spine and pain management program. The provider will work primarily with the neurosurgeons and orthopedic surgeons to establish a non-operative spine, sports and postoperative program. Candidates will practice a full spectrum of physiatry including clinical diagnosis, invasive procedures and epidural pain management. **** Healthcare is a teaching hospital, affiliated with Columbia University, serving an 8-county region in Upstate New York, with active neurosurgical and orthopedic programs as well as practices in 22 regional health centers.

4. **** Orthopaedics & Sports Medicine, five respected and innovative surgeons with spine program serving population base of 350,000 offer excellent practice opportunity. Candidates must be board eligible. Community has excellent hospitals, including an in-patient rehabilitation hospital. We offer generous salary, outstanding benefits and partnership opportunity.

5. **** Health Care is seeking 1 BC/BQ musculoskeletal physiatrist to join 2 other physiatrists in a thriving multi-specialty group. The primary focus is outpatient musculoskeletal physical medicine. Patient mix includes shoulders, knees, spine, sports, arthritis & EMGs. Flouroscopy available for epidurals and other procedures. Referral sources are primary care and orthopedics. Department includes 2 orthopedic surgeons, 1 podiatrist and 2 physiatrists, and it is adjacent to a full service radiology department.

 

[GuP]

this is an excellent thread and it sure taught me a buncha new stuff about PMRs...i was wondering what kind of physicians do sports team prefer i.e. the doctor for giants or jets or nets etc etc...do the sports teams go for an ortho guy or PMR or someone with a sports med fellowship? which guy would have the best chance of being hired?

 

[mysophobe]

I might be missing something, but I would think that they would prefer an ortho guy because A) they are more familiar with ortho guys than PM&R guys, and B) an ortho guy can do surgery and therefore is able to take care of a wider range of injuries without referring to someone else.

Just my thoughts. I may be wrong.

 

[GuP]

I might be missing something, but I would think that they would prefer an ortho guy because A) they are more familiar with ortho guys than PM&R guys, and B) an ortho guy can do surgery and therefore is able to take care of a wider range of injuries without referring to someone else.

Just my thoughts. I may be wrong.

same thing i was thinking but i just wanted to confirm with someone in the field and maybe someone who knows first-hand

 

[dry dre]

this is an excellent thread and it sure taught me a buncha new stuff about PMRs...i was wondering what kind of physicians do sports team prefer i.e. the doctor for giants or jets or nets etc etc...do the sports teams go for an ortho guy or PMR or someone with a sports med fellowship? which guy would have the best chance of being hired?

There's no getting around the fact that pods do the comprehensive physical workup for injured athletes. After workup/treatment, care falls to someone else.

A number of "team physicians" pay for the advertising privilige, to the tune of millions of dollars for the right to say "team physicians of the Dallas Cowboys" (and so forth). This practice is very common.

I'm still ignorant in most aspects of team care (frankly don't have an interest in it any more). If I wanted to learn more, I would simply contact a group that deals with pro athletes. There is something to be said about athletic trainers in this mix that shouldn't be ignored. In college I spent a little time thinking about being a trainer. These people are degreed professionals who, on that level, know there stuff, particularly when it comes to the dynamics of training athletes in the field. I would suspect that trainers do much of the hands-on work that is being intimated here.

In short, if you want to be associated with the pros, if you have the motivation and willingness to move for a position, you likely will get hooked up somewhere from your respective background (FP, ortho, rehab, IM, etc).

 

[GuP]

thanks for the insight dry dre

 

[dobonedoc]

When it comes to big name team sports, the Orthopod is the BMOC. Everyone else is support staff.

I'd love to see the day when some Division I athete is sent to the PM&R guy after an injury to be evaluated. Doesn't happen that way. Instead, the surgeon gets the first look, and makes a treatment plan. If it is not a surgical problem, then the PM&R staff can manage the care.

FP with Sports med training seem to be involved in the primary care aspect of athletes. Injuries and MSK problems go directly to the Orthopedist. Derm issues, nutrition, and general medical issues are better suited for the primary care doc who happens to know a bit more about the special needs of athletes.