I think that PM+R is tremendously intellectually stimulating for 2 reasons:
1. The breadth of the differential
2. The breadth of diagnostic options
3. The breadth of the treatment options
Expanding:
1. The breadth of the differential- because of the breadth of our training, we have to consider more options than just one part of the body. A common example is a patient presenting with a foot drop.
This has an incredibly broad differential that we have to consider- working proximally to distally, it could be something central like a stroke or multiple sclerosis, it could be something in the spinal cord like a myelopathy or motor neuron disease, it could be something in the verterbral canal like a radiculopathy, it could be something in the proximal thigh like a lumbosacral plexopathy, it could be something in the peripheral nervous system, like a peripheral neuropathy or a peroneal entrapment neuropathy. And if it is a peroneal entrapment neuropathy, it could be at many different locations (at the sciatic notch, the popliteal fossa, the fibular head, the anterior leg compartment).
Other specialties may look at something like a foot drop and consider only the central phenomena or the peripheral phenomena, but PM+R often has to think deeper into a broader differential.
2. Breadth of diagnostic options- PM+R is unique in how many different diagnostic options we use. For example, an internist diagnosing a foot drop may be limited to the physical exam (which they aren't trained to do as thoroughly as PM+R), and perhaps an MRI of the brain. Physiatrists are trained to do EMGs, nerve conduction studies, selective nerve root blocks, dynamic ultrasound, in addition to an incredibly detailed examination. This breadth of options is very exciting, and makes the potential work-up more complex and interesting than for many other specialties.
3. Breadth of treatment options- this is where I feel PM+R especially shines. Think of how many times internists (or other specialties) are faced with an impairment and then don't know what to do about it. PM+R has by far the broadest array of treatment options of any specialty. For example, for a foot drop, we are as well versed in the potentially valuable medications as anybody (including neuropathic meds like Neurotin, TCAs, anti-seizure meds, corticosteroids), trained for localized steroid injections as indicated, have excellent training in orthoses as well alternatives to orthoses like Unna boots. Nobody has a better understanding of the indications and specifics of therapy prescriptions, and nobody is better trained in understanding how these impairments affect someone's functional life.
So, as to whether PM+R is a thinking specialty- absolutely. If you like to spend time thinking about the differential diagnosis, having the skill set for actually making the diagnosis, and then have the skill and training to actually improve a patients function, then PM+R is enormously intellectually satisfying.
