Serious Consideration

[keepsmiling10]

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I am a PM&R resident and am having tremendous doubts about my career in the field. Although I highly admire much of what physiatrists do, there are some things that just seem to be missing for me.

- I really enjoy working up acute problems and I think that physiatrists can do this here and there but it is A) not their role/focus and B) not what they're good at
- I feel like much of what I do is putting in orders that other people are asking me to put in all the time (nurses, PT's, OT's, SLP's, dieticians)
- I think the therapists do an awesome job helping people to get better on the acute rehab side of things, but I don't really feel like the physicians are really all that helpful/involved (except to put in orders...see above)
- I have tried but I simply don't get excited about wounds, contractures, bowel/bladder, pain or spasticity
- I DO really enjoy the MSK part of PM&R but I don't think that training is exclusive to PM&R (fellowships can be done in other fields) and I feel like most of the time, the person is referred to PT anyways
- I enjoy being in a normal hospital and being part of their system rather than a separate stand-alone institution

I am just having a hard time justifying to myself or others why PM&R is worth it for me and meanwhile I have found other specialties to be somewhat more stimulating (albeit they have their negatives too). Thus, I'm trying to figure out if I am getting a skewed view of PM&R or if there is more to it that I haven't yet been able to grasp.

I'd love to hear what other people in PM&R think about this.
Of note, I do think PM&R is a wonderful specialty for many people. This post is in no way intended to put it down. I am just trying to determine if it is appropriate for me.
Thanks!

 

[eljefe]

I think the majority of us have experienced most of what you mentioned--especially on the inpatient floors. It took me until almost the end of residency until I finally understood what physiatry is all about and how we think. Our skill set overlies many other medical and allied health specialities--but is truly unique. Unfortunately, it takes a while to develop this skill set and see your role in patient care, but when it does it is like a light bulb getting turned on.

 

[SSdoc33]

I am a PM&R resident and am having tremendous doubts about my career in the field. Although I highly admire much of what physiatrists do, there are some things that just seem to be missing for me.

- I really enjoy working up acute problems and I think that physiatrists can do this here and there but it is A) not their role/focus and B) not what they're good at
- I feel like much of what I do is putting in orders that other people are asking me to put in all the time (nurses, PT's, OT's, SLP's, dieticians)
- I think the therapists do an awesome job helping people to get better on the acute rehab side of things, but I don't really feel like the physicians are really all that helpful/involved (except to put in orders...see above)
- I have tried but I simply don't get excited about wounds, contractures, bowel/bladder, pain or spasticity
- I DO really enjoy the MSK part of PM&R but I don't think that training is exclusive to PM&R (fellowships can be done in other fields) and I feel like most of the time, the person is referred to PT anyways
- I enjoy being in a normal hospital and being part of their system rather than a separate stand-alone institution

I am just having a hard time justifying to myself or others why PM&R is worth it for me and meanwhile I have found other specialties to be somewhat more stimulating (albeit they have their negatives too). Thus, I'm trying to figure out if I am getting a skewed view of PM&R or if there is more to it that I haven't yet been able to grasp.

I'd love to hear what other people in PM&R think about this.
Of note, I do think PM&R is a wonderful specialty for many people. This post is in no way intended to put it down. I am just trying to determine if it is appropriate for me.
Thanks!

if you want to work in a hospital, with a team, on the wards, and dont like inpatient rehabilitation, then find a different specialty. i share your sentiments

however, most PM&R grads go into outpatient musculoskeletal medicine (i think it is something like 70%). this is the "physical medicine" side of things. you do work up acute problems. you get paid decently. you have good hours.

if you can spend some time with a physiatrist outside of academia and outside of a hospital, then make up your mind.

personally, if i was forced to do exclusively inpatient rehab, i would probably quit.

 

[RUOkie]

- I really enjoy working up acute problems and I think that physiatrists can do this here and there but it is A) not their role/focus and B) not what they're good at
That is exactly what I do. I am the "go to person" in my community for working up neuromuscular disease. If someone has new onset of joint/axial pain, or numbness/tingling, they get sent to me. It took time to prove myself, but it is where I am now. I do second opinions for neuromuscular disease (including EMG) for the neurologists as well.
- I feel like much of what I do is putting in orders that other people are asking me to put in all the time (nurses, PT's, OT's, SLP's, dieticians)
Incorrect. I am TELLING the others what to do.
- I think the therapists do an awesome job helping people to get better on the acute rehab side of things, but I don't really feel like the physicians are really all that helpful/involved (except to put in orders...see above)
Get more experience and that will change
- I have tried but I simply don't get excited about wounds, contractures, bowel/bladder, pain or spasticity
Nor do I, except for the spasticity part. For the Botox.
- I DO really enjoy the MSK part of PM&R but I don't think that training is exclusive to PM&R (fellowships can be done in other fields) and I feel like most of the time, the person is referred to PT anyways
If you get a good background in biomechanics, you will have good MSK abilities. I did my training at Baylor Houston in the '90s when it was 80%inpt. We got great biomechanics, and as a result I am a good MSK doc. At the AAPMR ultrasound course, a lot of the table trainers are Baylor grads (which still has the reputation of heavy inpt)
- I enjoy being in a normal hospital and being part of their system rather than a separate stand-alone institution
I hate being in the hospital, but do it for political reasons.
!

see above, and good luck.

 

[PMR 4 MSK]

I'm guessing you've been stuck for a while on inpt wards, babysitting CVAs, amps and "deconditioned" pt. That is not particularly stimulating medicine for many of us.

If you have not done your outpt rotations, particularly MSK, you've only experienced part of the field.

It sounds like you are someone who will do much better with a pain fellowship - you'll do acute pain inpt and outpt, chronic pain, procedures, etc. You will do a lot more than babysit patients and write "PT: Eval and Tx."

 

[Jitter Bug]

In residency they force feed you the idea of academic physiatry, hospital based and that may not be your thing. Some people don't want to run a team of nurses, PT/OT/SLP, case managers, dieticians, etc. I didn't want to be a manager of health care team, I wanted to be a doctor to my patient. That's the only relationship I really give a f&$3 about. I respect good inpatient docs who can motivate and coordinate a care team and keep the patient taken care of and the family happy. I'ts just not my skill set. Maybe it's not yours either.

Get some exposure to PM&R practices outside the hospital before you make your decisions about whether to stay or go. Good Luck.

 

[101N]

I am a PM&R resident and am having tremendous doubts about my career in the field. Although I highly admire much of what physiatrists do, there are some things that just seem to be missing for me.

- I really enjoy working up acute problems and I think that physiatrists can do this here and there but it is A) not their role/focus and B) not what they're good at
- I feel like much of what I do is putting in orders that other people are asking me to put in all the time (nurses, PT's, OT's, SLP's, dieticians)
- I think the therapists do an awesome job helping people to get better on the acute rehab side of things, but I don't really feel like the physicians are really all that helpful/involved (except to put in orders...see above)
- I have tried but I simply don't get excited about wounds, contractures, bowel/bladder, pain or spasticity
- I DO really enjoy the MSK part of PM&R but I don't think that training is exclusive to PM&R (fellowships can be done in other fields) and I feel like most of the time, the person is referred to PT anyways
- I enjoy being in a normal hospital and being part of their system rather than a separate stand-alone institution

I am just having a hard time justifying to myself or others why PM&R is worth it for me and meanwhile I have found other specialties to be somewhat more stimulating (albeit they have their negatives too). Thus, I'm trying to figure out if I am getting a skewed view of PM&R or if there is more to it that I haven't yet been able to grasp.

I'd love to hear what other people in PM&R think about this.
Of note, I do think PM&R is a wonderful specialty for many people. This post is in no way intended to put it down. I am just trying to determine if it is appropriate for me.
Thanks!

I thought a lot of what I did during residency was like watching the grass grow, boring, bull s*it. When I graduated I went out and got a generic PM&R job - in an area that I though I wanted to live in -and my bosses - ortho's - told me I was going to do a fellowship. I was hapless and said sure. The fellowship - spine/pain - opened my eyes to what we can do and now I LOVE my career.

Over the years I've come to appreciate what "watching the grass grow" taught me. Whether or not you realize it now, you have good training for later on in your career. Our specialty is the like the clean-up crew. We are the folks that come out and clean the stands after the big event - surgery, trauma, bad luck etc - has ended, but not the way folks had hoped for. More often than not we are humble as we don't fix anything, we teach folks to adapt to hand they are dealt. In this day and age, that's very useful knowledge.

Don't give up yet. It wasn't until after my fellowship that I became interested in Physiatry.

 

[deleted185747]

I think the majority of us have experienced most of what you mentioned--especially on the inpatient floors. It took me until almost the end of residency until I finally understood what physiatry is all about and how we think. Our skill set overlies many other medical and allied health specialities--but is truly unique. Unfortunately, it takes a while to develop this skill set and see your role in patient care, but when it does it is like a light bulb getting turned on.

👍
+1

 

[padresp]

I am a PGY-2 at a large program. I saw a lot of the PGY-2's when I was an intern. I would say that 10% actually enjoyed that year; it was a lot of work, they constantly felt overwhelmed, they didn't feel like they ever "learned" anything worthwhile, the subject matter was usually boring, and they felt like an intern all over again. A lot of this year's PGY-2 class feels the same. However, last year's PGY-2 class is much happier this year, and they all feel it was worth it. The PGY-4s - even moreso.

Give it some time, especially if you're more of the outpatient or MSK type. Just from what I've seen, you'll be glad you finished this year and things will get better.

 

[nleeds24]

and my bosses - ortho's - told me I was going to do a fellowship. I was hapless and said sure. The fellowship - spine/pain - opened my eyes to what we can do and now I LOVE my career.

Wow I can't remember ever hearing of someone doing a fellowship because their bosses forced them to. Those surgeons did you a HUUUGGGEEE favor. It wasn't until I did a fellowship that I actually began to think I would get over the time wasting experience of residency.

 

[PMR 4 MSK]

I am a PGY-2 at a large program. I saw a lot of the PGY-2's when I was an intern. I would say that 10% actually enjoyed that year; it was a lot of work, they constantly felt overwhelmed, they didn't feel like they ever "learned" anything worthwhile, the subject matter was usually boring, and they felt like an intern all over again. A lot of this year's PGY-2 class feels the same. However, last year's PGY-2 class is much happier this year, and they all feel it was worth it. The PGY-4s - even moreso.

Give it some time, especially if you're more of the outpatient or MSK type. Just from what I've seen, you'll be glad you finished this year and things will get better.

If anything feels boring, it's because you've done it a hundred times. While it gets repetetive, once you become an attending, you'll find one day you'll be glad to have been through it. Alternatively, just doing board exams, written or oral, you'll do better because of it. The point of this training is to make it so you know what to do at all times.

Rehab, by its nature, is slow.Patients are not as sick as those on IM or surdery wards. Many rounds,admits and discharges become routine. It's certainly not for everyone, but will form the base/foundation of you medical career. The principles you learn will help you in many of your everyday decisions for the rest of your life.

You can also put things in perspective. If you had gone into a surgical field, you would have gotten to the hospital several hours earlier, worked several hours later, had a lot more in-house call, more weekends, all for the same pay. Most nights you get to go home to your family, or apartment and relax, work-out, watch TV, etc. Many other residents go home to sleep, so they can get up early the next day and work like a dog until they get to come home and sleep again.

On my SCI rotation, we had an occasional urology resident. It was our toughest rotation. It was their easiest.

 

[keepsmiling10]

Thank you for all of your thoughts and suggestions!

I have given it several months and I am still finding myself in a similar bind. I know that many of you mentioned you didn't become fully interested in physiatry until your fellowship or attending status, but I just don't see residency as a time to waste. We put a great deal of work and numerous hours into our days and I don't think it should be routine / tedious for several years! Even my intern year was stimulating and felt very worthwhile. I also feel as though I truly am not learning much at all (despite working 12 hour days most days!). Although the lifestyle is probably better as an attending, I have definitely not found it to be better as a resident (In addition, I'm unlikely to choose my career mostly based on lifestyle).

I actually am very interested in inpatient general medicine but did not enjoy my general rotation much (I didn't enjoy digging through 300 pages of Acute Care notes). I am also interested in Sports medicine, but again, I feel as though I may be able to get this through another venue.

Ideally, I would want to do some combination of inpatient & lifestyle medicine where I deal with prevention, sports medicine, and alternative therapies (including helpful devices like P/O). However, I have not been excited by SCI, Stroke, TBI. I also can't imagine going through 3 years of training feeling as though my daily work is just work and I'm not really learning much.

I'm not sure what the best solution is.
Any thoughts? Thanks!

 

[PMR 4 MSK]

Thank you for all of your thoughts and suggestions!

I have given it several months and I am still finding myself in a similar bind. I know that many of you mentioned you didn't become fully interested in physiatry until your fellowship or attending status, but I just don't see residency as a time to waste. We put a great deal of work and numerous hours into our days and I don't think it should be routine / tedious for several years! Even my intern year was stimulating and felt very worthwhile. I also feel as though I truly am not learning much at all (despite working 12 hour days most days!). Although the lifestyle is probably better as an attending, I have definitely not found it to be better as a resident (In addition, I'm unlikely to choose my career mostly based on lifestyle).

I actually am very interested in inpatient general medicine but did not enjoy my general rotation much (I didn't enjoy digging through 300 pages of Acute Care notes). I am also interested in Sports medicine, but again, I feel as though I may be able to get this through another venue.

Ideally, I would want to do some combination of inpatient & lifestyle medicine where I deal with prevention, sports medicine, and alternative therapies (including helpful devices like P/O). However, I have not been excited by SCI, Stroke, TBI. I also can't imagine going through 3 years of training feeling as though my daily work is just work and I'm not really learning much.

I'm not sure what the best solution is.
Any thoughts? Thanks!

Residency sucks and is not what daily life is like as an attending. You not subservient. Consider sports fellowship.

I can't see why you'd want to do inpt work if you didn't like any of it - just don't do it.

For many PM&R residents now, residency is a springboard to their fellowship, which will define their career. Unfortunately, residency directors have not caught on to this.

 

[webtek]

I cannot agree any more with what the poster above said. Especially the last sentence.

I am in my 4th year of residency and cannot wait for my fellowship to start. I was lucky enough to have strong MSK and sports in residency, but outside of that I feel fellowship is where I will get the most training in what I hope to do for the rest of my life. Residency is not easy, maybe a bit easier in PM&R than a surgical specialty. Especially in PM&R where there are so many topics to cover.

My advice is figure out what excites you the most in this general field of ours and pursue that, either through fellowship training or the right job. Good luck.

 

[axm397]

You do realize that you can't really do inpatient AND preventive/alternative AND sports all for the same patient population, right? If you want to do a little inpatient rehab in addition to an outpatient practice, that would work. There are lots of Physiatrists who practice preventive/alternative/sports medicine. You can google - or go to the aapm&r phyzforum and ask if anyone practices that type of Physiatry close to your location. I think you should find a good private practice Physiatrist that does what you describe - and see if you like their practice - if so, stick with it. If not, switch. You just have to be careful with the grass is greener mindset and make sure that if you are going to switch, you are absolutely sure about your choice. I know a resident who switched from IM to PM&R to Neurology back to PM&R. That was a lot of wasted time and energy and it made him look pretty unattractive to fellowships and future employers.

 

[specepic]

You can be happy in PM&R but it is up to you to find the avenues. You most likely have RUS (rehab unit syndrome), or P2S (PGY-2 syndrome). It will get better. Switching res. now is a bad idea. If you like acute inpt, I know plenty of PMR who get involved on trauma services, ICUs etc, as the acute rehab consultant and advisor and you can check labs, chest XRs, and all that other **** I'm glad I stopped doing after PGY-2. Being a res can suck. Stick it out and find a sub-spec that is a good match.

 

[Jitter Bug]

Two points:

1. It's not enough to hate your residency. You need to know if there is an alternative residency out there you could actually switch into (not something no-one will have slots for like derm or ENT) AND would that residency be better to train you for the career you want later?

2. Can't stress enough getting the perspective of PM&R docs in actual practice outside yuor residency. Find a private guy who works at a small neighborhood hospital, or does outpatient practice and a few procedures. It's a vastly different world, and one we think you may like.

 

[lobelsteve]

Two points:

1. It's not enough to hate your residency. You need to know if there is an alternative residency out there you could actually switch into (not something no-one will have slots for like derm or ENT) AND would that residency be better to train you for the career you want later?

2. Can't stress enough getting the perspective of PM&R docs in actual practice outside yuor residency. Find a private guy who works at a small neighborhood hospital, or does outpatient practice and a few procedures. It's a vastly different world, and one we think you may like.

Well said.

If you hate your residency- shut up and focus on what you want to do when you graduate and put in your time. Count the days. But do not complain or try and change the system. Find a goal and a mentor nearby who does what you want to do and keep in touch. PMR has 100's of docs who love to mentor. PM your location and goals and the secret network can find you a doc who does PMR and made it work for them doing inpt, outpt, PMR/PCP, pain, peds, research, SCI, TBI, etc ,etc. Residency is 3 years of base training so you can have cocktail conversation with friends at academy meetings and pass tests. Fellowship and practice is where horizons are broadened and you cannot believe what you thought you knew only 2 years prior.

[YOUTUBE]http://www.youtube.com/watch?v=eiRGRvE_Wqg[/YOUTUBE]

 

[PhysiatristDoc]

No one has said so thus far, but it sounds like you would have been happier in Family Practice with a Sports Medicine fellowship. The only difference between those guys and PM&R is they don't get EMG training, and FP has more job opportunities, and much more flexibility. Some sports fellowships are teaching some interventional spine and ultrasound at this time. I'm sorry to say that PM&R is not the supposed goldmine that some seem to think for all in the field, only a handful are doing very well. This holds true even more so if you are tied to a specific geographic location. There are some with long established practices, or who are good hustlers, who are making 500K+ but most of us work very hard to make 200K.

If you like acute hospital care and musculoskeletal issues, FP+sports is another option for you. You will be done in the same number of years if you can find a PGY2 spot willing to give you credit for you 'time' to date, and you will have the advantage of being a primary care physician (yes, that is a HUGE advantage) when you are done.