As you noted, PM&R encompasses a little bit of everything. Graduates can go into fields as different as Pediatric Rehabilitation, Traumatic Brain Injury, or Interventional Pain. I heard recently that over 50% of PM&R residents now wind up going into Pain Medicine. I never considered Psychiatry so I think a reply about Psychiatry is best left from our Psychiatry colleagues. I can tell you why I was interested in PM&R, but only from the perspective of someone doing Interventional Pain:
1. Procedures - Botox/Phenol injections, Epidural Steroid Injections, Facet Injections, joint injections,
IDET, vertebroplasty,
percutaneous discectomies, etc. Some of these procedures will require an additional year of fellowship, but it's only another year.
2. MSK Medicine - I find it very satisfying to be good at the MSK exam and I like the patient population. We also learn a lot about imaging and EDX studies and this makes us a very well-rounded MSK/Orthopaedic/Spine specialist and can aid in the diagnosis.
3.
NCS/EMG - This is really part of the procedures section, but I think it deserves it's own section. Learning to do these studies during residency is a unique aspect of our residency training. We are required to do 200 studies prior to graduation and you wouldn't necessarily have to do a fellowship unless you want to do more advanced studies. You wouldn't need a fellowship if you wanted to do radiculopathies, carpal tunnel, ulnar, peroneal, polyneuropathies, etc. Many consider these studies to be an extension of your physical exam. These studies also answer a lot of important questions for spine surgeons, hand surgeons, PCPs, etc.
4. Imaging Studies - We are trained to order the appropriate imaging studies for patients. I think that working in a Spine Center (with Surgeons and Physiatrists), rotating through MSK Radiology, spending time on the inpatient Neurology service, and rotating through Pain/Orthopaedic/MSK clinics has made me very comfortable with reading films. I am in no way suggesting that we can substitue for a Radiologist's report, but
learning about imaging can help with determining what's clinically relevant from the report. Also, depending on which setting you are in (community hospital with a general radiologist without MSK/Neuroradiology training) they might miss small things that are only relevant for the pain physician (small HIZ on T2 axials at L3-L4 in a patient with axial back pain, mild R L2 foraminal narrowing on T1 sagittal views in a patient with anterior thigh pain and a + femoral stretch test, mild facet arthropathy in a patient with pain on extension of the spine, etc). Finally, it's not uncommon for a patient to bring in films from another institution without a report or to see a patient with an acute radiculopathy, but the films haven't been read and the patient is in severe pain.
5. Fellowships - The opportunity to pursue fellowship training in a number of areas such as Interventional Pain, Spine, Sports, TBI, SCI, Pediatrics, etc. The pain population can be a challenging group to work with, but also very satisfying when you are the one who can help with the pain. You will see cancer patients, athletes with acute radiculopathies, worker's comp, psych patients, scoliosis, knee pains, shoulder pains, drug-seekers, etc. Some patients are obviously more satisfying to treat than others.
🙂
I think another satisfying part of what we do is to
help patients avoid surgery. We are experts in maximizing function through procedures, medications, orthotics, prescribing appropriate rehab programs/exercises, etc. We work well with surgeons because we can do the workup EMGs, X-rays, diagnostic SNRBs, discography, etc.) and try conservative treatment (PT, medications, TPIs, ESIs,
MBBs, joint injections, IDET, 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 confirm 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. With additional training such as the ones
described here, we can also offer minimally invasive surgeries such as spinal cord stimulators, peripheral nerve stimulators, intrathecal pumps, etc.
I pulled a few job listings so you could see where a Physiatrist might work.
AAPM&R Website said:
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.
