I think the physiatrist that I had lunch with had no clue what he was in for when he decided to leave the academic medical center to open shop out in the community. Academic medical centers are dominated by internists and surgeons; and when he went out into the community to interact with FP's who train in unopposed community programs, he didn't understand what he was talking about.
The difference between FM and IM is that FM has a MSK curriculum built into the training. We do that in several ways. We dedicate a minimum of 2 months or 200 hours to ortho and sports medicine, not to mention neurology, and we spend an incredibly large amount of time in the ambulatory setting in our continuity clinics where MSK problems are likely to present. MSK is the #3 largest bank of questions asked on our board certification and ITE, behind cardio & pulmonary. It is more important than GI in the eyes of the test makers. In FM, at least we have structure.
Internists don't have that, at least from when I was a med student comparing curricula. Internists have zero time devoted to MSK and spend a minimal amount of time in the ambulatory setting, unless you're on the primary care track. With the exception of rheumatology (and arguably neurology), a majority of their training focuses on organ systems in the thorax/abdomen.
Dumping happens for many reasons, but one of which is lack of training. Of course, PM&R is going to get the IM dump because IM docs aren't trained in matters MSK. FP's who don't pay attention during their rotations or their patient encounters are proned to dump as well when they don't understand what's going on and what to do. The failure isn't primary care's awareness of what PM&R is or what it does... the failure is in MSK training during medical education and in primary care residency education.
If you look at your medical school curriculum, when was the last time you had MSK training? 1st year anatomy? 1st/2nd year physical diagnosis class? Even osteopathic students turn their backs to MSK training because they're dying to be like allopathic students. The rest of the medical school curriculum is somehow related to internal medicine and surgery. Medical schools dump MSK training to orthopedists. So, if a student who was interested in primary care, who recognizes early that MSK is a large component of primary care, they have to compete with the gunners vying for an orthopedic match for an elective spot. So, basically, that's not going to happen. At my medical school, you got the ortho elective if you have a "particular interest" in orthopedics (hidden language for you are doing an audition elective). The worse ignorance comes when people say, "well, if you're so interested in orthopedics, why don't you become an orthopod?" What? I'm interested in orthopedics in the context of primary care. I don't care what nail you prefer for that tibia.
It's very well known how dismal MSK education is in our medical school system. It's been published many times in academic medical education journals.
BUT, here's your opportunity... If PM&R wants to be relevant, it needs to participate in all 4 years of medical school education AND all 3 years of primary care residency training. It needs to get it's clinical faculty involved early in anatomy dissection. It needs to take medical students interested in primary care medicine and teach them MSK exam, diagnosis, and management. It needs to offer itself to the training of primary care residents at managing ambulatory issues.
You start with education, and education fosters relationships. You can use that PM&R-primary care relationship as a gateway to show primary care all the other things that PM&R doctors are good at.
Unfortunately, the academic medical center isn't about relationships. It's about roles. And doctors who practice there try to define relationships by defining roles; in turn, they try to control relationships by controling roles (i.e. automatic consults, privileging). So when a PM&R doc shows up at my door step and tells me what I'm not good/trained at and tries to tell me what he's better at, I'm going to show him the curb. It's like an absent parent coming back into someone's life many years later, trying to dictate how patients should flow through the medical system. They were never a part of my medical education. What makes them think they can walk in and get my referrals? I mean, did you really think that 5 minutes of burger and fries will change that? You can't have a healthy relationship if one person is trying to control how that relationship goes. Everyone who's been on bad 1st dates would know about that.
I think PM&R can have a strong role and partnership with primary care, but I think they're trying too hard to pick up procedural scraps from neurology and orthopedics as a specialist on one hand, and on the other hand they try to displace primary care in the realm of MSK as a generalist on the other. The reality in community medicine is that PM&R doctors are a "nice to have" but not a "need to have", despite what they think. Many communities do not have PM&R docs, and people get over it. Do you think I would be sending you a Percocet addict if I knew what is causing his pain and can fix it for him? Of course not, I'd take care of it myself, bam bam, and move on. I am asking for your help because you are a specialist, so start acting like one, put your training to use, and step up to the challenge of taking care of difficult patients. Don't tell me that you don't want to see chronic pain patients.
If you want to have an impact, the time is now. The focus is on primary care, yet again; and rather than trying to define what a primary care doctor's boundaries are by trying to tell me what I can or cannot do, partner up, teach, mentor, and serve as my consultant, my back up. Get involved in medical education and embrace the education of a medical student who is interested in primary care as much as you would a medical student interested in PM&R. Referrals will naturally follow.
