stimulating differentials

[icebreakers]

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the one thing that I DO like about medicine, is that at times coming up with a differential is both stimulating and exciting.


is there much stimulation and excitment in the field of pm&r, in coming up with differentials...and just the learning that goes along with the field?....

for example, some would argue (myself included) that in surgery, it seems like the intellectual stimulation is for the most part absent, and is replaced by very precise procedural activities (which many people find exciting too)..

is pm&r , also one of the fields where intellectual stimulation is given up? I hope not. but please be honest ..as I'm really nitpicking away at what this field consists of...so i can better make a decision to go in it or not

 

[cyanocobalamin]

the one thing that I DO like about medicine, is that at times coming up with a differential is both stimulating and exciting.


is there much stimulation and excitment in the field of pm&r, in coming up with differentials...and just the learning that goes along with the field?....

for example, some would argue (myself included) that in surgery, it seems like the intellectual stimulation is for the most part absent, and is replaced by very precise procedural activities (which many people find exciting too)..

is pm&r , also one of the fields where intellectual stimulation is given up? I hope not. but please be honest ..as I'm really nitpicking away at what this field consists of...so i can better make a decision to go in it or not

I would say that there is less detective work in some regards from what I've seen than a more general field. Inpatients usually have a diagnosis attached to them when they are d/ced from acute care - e.g. left MCA ischemic CVA with expressive aphasia and right hemiparesis. There might be more detective work in outpatient areas like electro-diagnostics EMG/NCS.

But it is very different from the endless iterations of for and against that a typical internal medicine resident may go through from what I've seen. But that is true of many specialties, in general.

But then again, in general pediatrics e.g., how many times does one diagnose AOM or asthma? And how intellectually stimulating is that arguing the factors for and against? (Well, Miss Daisy has been pulling on her ear for the last 3 days, which tends to point for.....)

 

[daphilster78]

I had to step in to answer this one b/c this is one issue I dealt with before deciding PM&R over IM.

Most inpatient as cyano mentioned have already been seen by at least one provider. TBI, SCI pt have had neurosurg work on them and transfer them to you, same with many ortho patients. However, problems crop up on the floor, such as a patient develops a fever but has negative pan-cx's, or a patient suffers acute onset of HA or weakness. All these scenarios require a PM&R doc to actively think of good ddx, even if they end up getting a consultant in ID or neurology in the cases I described in the end. The potential for ddx is there and almost as wide as general medicine, but the need to actively think like this occurs on a smaller percentage of patients whereas just about every new medicine admit requires this thought process.

Outpatient rehab usu involves identifying which muscles, bones, tendons, joints, nerves are causing pain or limitation in movement. This is diagnostic work that involves a very experienced physical examiner and imaging, as wells as possible emg or diagnostic injections. It is not the same breadth as a general medicine differential that involves cards, pulm, heme-onc, rheum, GI, AI, etc, etc... but try it yourself and see it. Many ppl including myself think its lots of fun. The MSK is not a straightforward exam of doing neer's test and anterior drawer test and blah blah test. You have to really think about what's causing the pathology. I think its much trickier than the neuro exam where you are looking for specific findings in CN, reflexes, cerebellar, etc. Both MSK and neuro are an integral part of outpatient MSK physiatry.

 

[icebreakers]

thanks daphilster78(sp?)...

thats the kind of answer i'm looking for. so are you a practicing physiatrist? or physiatrist in training?

with the differences from gen medicine aside, do you find this field intellectually stimulating...you really have to think to help your patients? even though you are not required to come up with ddx as freq as in med?

 

[rehab_sports_dr]

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.