PMR vs Neuro

[lobelsteve]

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As a PMR/Pain doc (100% pain at this time), I do a fair amount of consult work reviewing charts for disability. Basically, I am an independent reviewer who cares not if a patient is disabled, malingering, or other. I get paid to review a PDF file 30-1000 pages long of medical records, and fill out a DOC file answering a few questions (1-7) regarding restrictions/limitations, cognitive side effects from meds, diagnoses, impairments, ability to work 40 hrs per week, is treatment appropriate, what is future treatment and prognosis.

It is like doing puzzles for me and I think it's fun. Plus it pays.

I get a call from a Neurologist who is reviewing a chart of patient I had seen last year 3 times and he asks me the questions I typically ask. We get talking about the company I review for and the company he reviews for. He is surprised at how little my hourly rate is and how fast I can turn a 500 page case around.

I got the impression of some type of superiority and a complete lack of understanding of what disability is when he finishes lauding over me.

PMR: you either can or you can't do it. Not us, the patient.
Neuro: life is a rheostat, maybe today, but maybe tomorrow, good days and bad days....

PMR: cut and dry, the documentation supports the impairments, there is concordance between history, exam, imaging/testing, and treatment.
Neuro: after spending 20 hours thinking about it, we're still not sure and want more testing and an IME, and FCE, redo all imaging.

Maybe it was just this one guy and his attitude. I work less hours and double or triple his take home. I enjoy my time with my patients and helping them achieve functional goals. I think he just orders more tests and dabbles in medication trials.

Rant off. PM&R ftw. 👍👍

 

[PMR 4 MSK]

I'll temper this by saying I started med school 20 years ago this year.

When trying out Neuro and PM&R as a student, I found Neuro to be more of cognitive exercising. The referrals were mostly to ask "Why?"

Why does this patient have a visual field deficit?
Why does this kid's left arm not work?
Why did this patient have a stroke?
Why is this teenager failing school?

There was also the "What?" and "Where?"

What caused this stroke? What is the location of the stroke?

For most of the patients we saw, there was no treatment, except ineffective medications or a referral to neurosurgery. Neurologists were mostly diagnosticians. They were the MRI before it became mainstream.

I found it to be tedious. I fell asleep several times while my attendings were doing their literally 30 min + neurologic exams. It was obvious Neuro was not for me.

I fell in love with PM&R in my first week doing it. There were treatment plans, goals, hope and thanks. It was functional and not as academic. It made sense to me, it is what clicked in my brain - this is what I was meant to do.

I refer to neurology a few times a month. It almost never goes the other way. I could not tell you the last time I had a referral from Neuro. I refer out questionable diagnoses or things I don't treat - Parkinson's is a common one for me to refer out for. I've seen quite a number of undiagnosed cases.

I have found few neurologists outside of academia who do a good EMG. But the community standard is always to send EMGs to neuro.

Between traditional turf wars and more recent economic pressures, I agree the Neurology field has always held itself in higher regard than PM&R. You could probably say that about any field toward PM&R, however.

 

[Llenroc]

It's hilarious how hard Neurology residents compete to get into EMG fellowships, so they can have a billable procedure.

 

[SSdoc33]

the treatments are better in neuro than they used to be. but still not very great. i cant tell you how many spine patients i get that have languished with a neurologist for months before they could find someone (myself - a physiatrist) who could help them. this is not befoer they have tried countless neuropathic pain meds and always have had an EMG claiming a multilevel radiculopathy.

how many of us had that 70-something neurologist, typically wearing a bow-tie, who could tell you what the MRI showed by doing a neuro exam? i thought that was pretty cool. again, more of an academic pursuit than anything b/c once the diagnosis is made, then you refer out to someone who can do somethign about it

 

[oreosandsake]

I fell in love with PM&R in my first week doing it. There were treatment plans, goals, hope and thanks.

🙂

 

[surftheiop]

Something I was wondering about, mostly just for fun seeing as its all complete conjecture-

But in my crystal ball it seems like in the next couple decades (like 30 years from now) stem cells or some other sort of neuro-regenerative treatment are going to make some the current untreatable neurological diseases/injuries treatable or even curable.

So in that fantasy land would it be the neurosurgeons, neurologists or PM&R who would get to have the fun with the sweet new regenerative therapies?

 

[Llenroc]

They've been doing research on stem-cells since the 1970's, with limited success. In the early 2000's, a lot of wild promises regarding stem cells were made. This included many people in the PM&R field. The view regarding stem cells is a lot more reserved now as a result of that.

Either way, if stem cells become a viable cure (which I personally don't see happening any time soon), then I see no reason why the current model would change: surgeries/implantations are done by neurosurgeons, subsequently the patients come to a rehabilitation hospital (and/or do outpatient therapy) to maximize their gains. A PM&R doctor then would follow the course of their functional gains.

 

[drusso]

PM&R vs Neuro debates always remind me of the duet between Annie Oakley and Frank Butler from the muscial "Annie Get Your Gun."

In this rendition, PM&R is played by Annie. Enjoy.

http://www.youtube.com/watch?v=tfHBPusZg6E