scope of PM&R

[Dr. G]

Im a 4th year student, recently applied to a bunch of rehab programs, and I am currently scheduling interviews. I had a rather interesting conversation today with a physitrist who has been in practice for 25 years. With out mentioning his name, he was the medical director at the columbia/cornell program for a number of years as well as director of the BTU at JFK. He basically spent an hour telling me all the reasons I SHOULD NOT do PM&R. He told me that its a dead field and that no one consults rehab physicians anymore. He also stated that many of the big name programs will hire recent grads from residency programs and then fire them after a few years. He stated that unless I was willing to constantly travel and look for work, I would be out of a job by the time I was 35-40. He made some interesting points, and I wasnt really in any position to disagree with a physician in practice for so many years, especially given his credentials. Does anyone have any take on this? Does what he say have any validity? Is the prospect for physiatry really as bad as he says? Any input would be great...

thank you,

a concerned med student

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[Ligament]

I have no idea where this guy gets the job *in*security thing from. I'd say PM&R is as secure a specialty as most others.

As far as consults...I'm up to my ears in spinal cord injury consults every day. It is possible that this fellow trained so long ago that he no longer has the skills that pay the bills, namely EMG and interventional spine procedures. He may have had minimal to no training in these. Or maybe he did.

Furthermore, I'd be hesitant to take career/business advice from ANY academic physician. What do they know about the job market in the real world?

as far as being out of a job by 35-40...can't fathom what he is talking about.

There was a time in the 70's and 80's where rehab docs could pull down 500k/year doing just inpatient rehab. This is no longer the case and he may be bitter about it, as is every physician in every specialty.

Anyway, I'd be interested to hear what the others on this forum think, as these comments from this Dr. are off the wall to me.

Best, ligament

 

[Dr. G]

thanks for the reassurance. I think what shook me is that he seemed to have a lot of experience and credentials in rehab. I figured well, "thing guy must know what he is talking about." He brought up the point about how many hospitals dont consult rehab physicians. He even went so far as to question whether or not I, in my notes, ever suggested a rehab consult. To be honest, I actually never did. In the hospital I was at doing my medicine rotation, we were always taught to write "consult PT/OT", but never physiatry. I guess you could kinda say, that I almost felt a little guilty and foolish that I wanted to go into a field where I myself never considered suggesting a rehab consult on patients. I guess no one can really know in what direction medicine is going, and Im still going to pursue rehab. I do think its a great field regardless of what this physician says. His words did however, provide some food for thought, and if nothing else, an idea to start a thread!!

thanks...

 

[Nikiforos]

Dr. G, I would pay close attention to what the physiatrist with 25 years of experience told you. Physiatry is definitely not for everybody, though it may be for you. It has very strong appeal to DO's and IMG's --for obvious reasons. It is very easy to get into a residency.

The stats in the September issue of JAMA dealing with medical education show that it has one of the highest, if not the highest, percentage of DO's (16%) and IMG's of any residency. Even psychiatry had a slightly higher percentage of American medical grads.

Inpatient rehab is a lot like FP but with a different name. There is a lot of coordinating of care. Much of it is custodial care, not medical care.

 

[jeeva]

Nikiforos,

I'm sure you're not purposely trying to bash on our specialty, but I think some of your opinions may be a little misguided.

It has very strong appeal to DO's and IMG's --for obvious reasons. It is very easy to get into a residency

I don't think it's necessarily fair to say that a specialty is easier to match into simply because it has a higher percentage of DO's/IMG's. You really have no way of knowing what every applicant's motivation for choosing the specialty are. Personally, I'd argue that DO's have more "obvious" reasons for choosing PM&R: Manual medicine is an excellent modality to use in the care of some patients in rehabilitation medicine. It's a skill I wish I had and look forward to learing more about from my osteopathic peers during residency.

Inpatient rehab is a lot like FP but with a different name. There is a lot of coordinating of care. Much of it is custodial care, not medical care.

Perhaps you haven't done an inpatient rehab rotation, but there certainly is quite a lot of "medical care" going on. Just because a patient has survived the acute phase of their stroke/brain injury/spinal cord emergency, etc. does not mean they stop having medical issues. Believe it or not, these patients still can develop chest pain, respiratory distress, fevers, etc. etc., just like many other inpatients--issues that need to be worked up (and not just by consulting internal medicine or a specialist). In addition, these particular patients often have medical issues that general internists don't regularly deal with anyway, like spasticity, bladder management, and chronic pain control. Yes, there is a lot of coordination with other professionals in the care of the pateint: PT, OT, speech, social services all play a big role, but it's your job as the physiatrist to bring everything together to ensure the complete care of the patient.

If you feel this work is too custodial in nature, perhaps inpatient rehab is not for you (now, there are plenty of discussions on outpatient PM&R in other threads on this forum).

 

[jeeva]

I'd also like to add that while it may be true that PM&R is historically a relatively easy match, it has recently grown more competitive. As more medical students become exposed to what physiatry truly entails, I think that trend will continue. In fact, word on the street (and by street, I mean these forums) is that the volume and quality of this year's applicant pool may make it the most difficult match this field has seen in quite some time.

 

[bbbmd]

Jeeva... Nice job... I look forward to meeting you next year!!!

It seems that there really IS a lot of ignorance or mis-information out there about PHYSIATRY. The AAPM&R is well aware of this and has been doing a lot of promotionals (via print media, television) in the last few years. It is suprising that some PM&R docs out there are not satisfied with their career choice? PM&R has one of the highest job satisfaction rates of all the medical specialties!!!

Clarification of a few things: PM&R is not a PRIMARY CARE SPECIALTY!!! Just like Rads, Ophtho, Derm, we do not deal with "complicated" medical issues. (I personally do not want to). We are trained to recognize any medical issues and treat accordingly on the rehab/sci/tbi units and only consult other services when the need arises. Remember, like rads, ophtho, derm, we too have a year of medicine, surgery or a transitional year under our belts and feel very confident handling medical issues that arise. We have the extra training to recognize and correct issues that would hinder rehabilitation therapies!!! Spasticity, Pain, Urogenic bowel and bladder, TBI issues, Polytrauma and the many patients with ALL these problems... Physiatrists are the EXPERTS in getting these people FUNCTIONAL once again, not an FP doc, not the internist, not the surgeon, not the urologist and not the PT (PhD, MPT, BSPT)!!! Like an FP doc, we are holistic, something we are proud of, but have a focused and "SPECIALIZED" role in the care of the patient.

A few years back there was a push for PM&R to take on the "PRIMARY CARE" role of patients with disabilities (SCI)... There was some contraversy about this and I believe the consensus now is that we are not taking on this role (unless you are working in the VA system). We are now educating FP docs and IM docs on the SCI issues for these patients. We would act as a consult service for the primary care team and address their questions about these chronic SCI patients admitted for acute medical problems. Of course, the new injuries would be treated primarily by the Physiatrist.

Like most (but not all) specialties, competitiveness is cyclical. As one of my attendings said, about a decade ago PM&R was EXTREMELY competitive to match into and there were amazing applicants. Then there was a low for a few years... Presently PM&R is a HOT field again and as per my program directors the applicants this year and last have been exceptional to the point that they will not interview as many applicants and be even more SELECTIVE this year. Im interested in the outcome of the upcoming match!!!

Dr. Niki... I do respect your opinion, but do not agree with your interpretation of what us physiatrists do. I wonder if their is a study out there about the rehabilitation OUTCOME of a TBI or SCI patient who was managed by an FP or IM doc alone??? Probably wouldnt be ethical from the patient's standpoint??? (Im not bashing FP/IM.... I think you guys do a great job- just wanted to make a point!). I did a year of medicine and never learned about the problems I encounter with these patients now!!!!

Oh... I almost forgot... DO's and IMGS...
"The wealth of knowledge and experience that IMGs and DOs bring to a program.... PRICELESS!!!"

Thats my two cents on INPATIENT PHYSIATRY.... But wait, we dont only do inpatient... OUTPATIENT stuff is even better!!!!! SPORTS MED, INTERVENTIONAL PAIN and SPINE, OCCUPATIONAL MED, WORKERS COMP, PERFORMING ARTS MED, SPACTICITY and AMPUTATION CLINICS.... Yup, we do it all!!!! Am I satisfied??? DEFINITELY....

 

[bbbmd]

NEUROGENIC BLADDER/BOWEL... NOT UROGENIC... hehe

 

[drusso]

Originally posted by Nikiforos

The stats in the September issue of JAMA dealing with medical education show that it has one of the highest, if not the highest, percentage of DO's (16%) and IMG's of any residency. Even psychiatry had a slightly higher percentage of American medical grads.

I think that DO's are attracted to the field in part because of the opportunities to do non-operative musculoskeletal medicine (spine, sports, occ med, performing arts, etc). This is sort of "right up our alley as DO's. Also, many of the PT's I work with are very skilled in basic osteopathic and manual medicine techniques and I sometimes grin to myself as I write these very wonderfully "osteopathic" PT orders---myofascial release to thoracolumbar fascia, Jone's strain counterstrain to iliopsoas muscle, muscle energy treatment to lumbar spine, etc.

I also agree with bbbmd that the field is on the upswing again. I've been told by my program director that we have one of the strongest applicant pools in years. Physiatry is not for everyone that is for sure. It's a different kind of health care, very patient-centered, with progress often measured in terms of months and sometimes years instead of days. There are few physiatric quick fixes. Still, seniors in my program say that demand is high for physiatrists--especially for those will internventional, EMG, or fellowship level musculoskeletal training. I could quote actual salary offers but it might upset the FP's and internists among us!

 

[drvlad2004]

Originally posted by Nikiforos
Inpatient rehab is a lot like FP but with a different name. There is a lot of coordinating of care. Much of it is custodial care, not medical care.

Through my rotations in PM&R, FP docs don't do nearly as close to physiatrist do in inpatient rehab. FP docs hardly have any musculoskeletal nor the neuro training to even compare with PM&R. I'd be horrified to see an FP working on a full time basis on the SCI or TBI units. Please do not make assumptions if you do not have hard facts. In terms of competitiveness of any field, everything happens in cycles, maybe except for FP and IM.

 

[bustbones26]

Mark my words! I am not a know it all, but mark my words!

I would bet every dollar that in the future, when there is an overgrowth of radiologists, dermatologists, and ER doctors that people will start to say

"Hey, I can go into PM&R, have a great lifestyle, and still bring home a six figure salary"

Then you will see a flooding of applicants, and with everything else, as the applications flood, so will the competitiveness of the specialty.

Some of you may think I am ignorant, but I can see it happneing in the field of PM&R.

Also, as far as the DO think goes, well, DO's do spend a lot more time learning neuromusculoskeletal medicine and manipulation than the MD's do. If you're a DO that uses OMT, then PM&R is a good specialty to go into.

 

[drusso]

Originally posted by bustbones26


Some of you may think I am ignorant, but I can see it happneing in the field of PM&R.

It's already started...these things are cyclical. Back in the early 1980's when inpatient rehab docs were making 200K+ the field was hot and applications skyrocketed. Then, medicare reforms kind of put the kabosh on the inpatient gravy train and applications fell. Now, with great opportunities in the outpatient sports/spine/occupational rehab areas the applications are picking up again.

 

[pwall]

Could somebody please help me nail down the path to interventional PM&R. Does this involve a pain fellowship or do some programs actually prepare you for this type of practice without fellowship training? Any help would be appreciated.