this is really sad trend

[Butterfly23]

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Musculoskeletal Ultrasound as a Motivator for Selecting a Physical Medicine and Rehabilitation Residency Program in the United States: A Multicenter Survey Study - PubMed

This study aimed to determine the influence of musculoskeletal ultrasound (MSKUS) curriculum on applicants during the residency-selection process. A survey of 666 applicants for the Johns Hopkins University, Mayo Clinic, and Harvard/Spaulding Rehabilitation Physical Medicine and Rehabilitation...

pubmed.ncbi.nlm.nih.gov

It is very sad that future PM&R applicants are looking at Ultrasound training as tool to rank programs. Where is our field going??
i am not discrediting ultrasound and I do use the ultrasound.

In the real world, good luck utilizing ultrasound as diagnostic tool for MSK. depending on the settings you practice, some clinicians will laugh PM&R utilizing Ultrasound. The reimbursement is low for using ultrasound and there are so many courses out there that you can catch up using ultrasound if you did not learn much in residency.

In the real world, no matter how good you are with injection, there are patients who want to get injections fast and walk away and some patients get scared when doctors bring gigantic GE machine in front of them.

I honestly want to say that ultrasound is becoming academic dildo with unachievable dreams. ultrasound for facet injections ultrasound for SI joint injection what is the point????

Ultrasound is great but what are these young milenials thinking??

 

[TheGreatestTrochanter]

Username doesn't check out...

 

[j4pac]

I’d rather have the skillset and not use it than not have the skillset. It’s part of being prepared for what the future may hold.

And I do use it quite regularly...and my patients don’t fear it...?

 

[Slowpoke]

People are interested in learning ultrasound. Let them be. You do you.

 

[cowboydoc]

Most students don’t understand the first thing about the finance of medicine. This is a major issue. Thinking US is a key to their training despite garbage reimbursement is a side effect thereof. They don’t know what they don’t know. Many academics are fairly out of touch with the rest of medicine. This combo leads to spending a lot of time in training focused on things of little consequence and neglecting things that would be highly valuable once in practice.

 

[j4pac]

Most students don’t understand the first thing about the finance of medicine. This is a major issue. Thinking US is a key to their training despite garbage reimbursement is a side effect thereof. They don’t know what they don’t know. Many academics are fairly out of touch with the rest of medicine. This combo leads to spending a lot of time in training focused on things of little consequence and neglecting things that would be highly valuable once in practice.

Who doesn’t teach MSK US these days? It’s a basic PM&R competency.

 

[sloh]

Most students don’t understand the first thing about the finance of medicine. This is a major issue. Thinking US is a key to their training despite garbage reimbursement is a side effect thereof. They don’t know what they don’t know. Many academics are fairly out of touch with the rest of medicine. This combo leads to spending a lot of time in training focused on things of little consequence and neglecting things that would be highly valuable once in practice.

So true. I'll also add that the highest paying jobs in PM&R (>400-500k/yr) aren't in outpatient clinics with ultrasound shenanigans.

 

[Slowpoke]

So true. I'll also add that the highest paying jobs in PM&R (>400-500k/yr) aren't in outpatient clinics with ultrasound shenanigans.

The highest paid jobs are likely needle for pill mills. That's not good medicine, in my opinion. If one is solely driven by money, PM&R ain't the right field.

The field needs visionaries if it is to survive into the future with lowering reimbursements for acute rehabilitation settings and poor/minimal evidence for a lot of what we do.

 

[sloh]

The highest paid jobs are likely needle for pill mills. That's not good medicine, in my opinion. If one is solely driven by money, PM&R ain't the right field.

No I wasn't referring to pain. I was referring to PM&R and non-outpatient jobs generally pay better. Our bread and butter.

 

[sloh]

The highest paid jobs are likely needle for pill mills. That's not good medicine, in my opinion. If one is solely driven by money, PM&R ain't the right field.

Money aside, our focus as a field on ultrasound isn't the best for patients either. Often times, diagnostic ultrasound does not change management especially for insidious onset pain where history and physical give you all the information you need to manage the patient appropriately. This is usually going to be reassurance with progressive exercise/rehab/activity.

For acute traumatic injuries or red flags, you're going to get an MRI and sometimes EMG/NCS anyways.

What exactly are we injecting under ultrasound? PRP and Stem cells where the evidence is weak and bordering on grifting? Steroids where the deleterious effects on connective tissue are unequivocal at this point?

These posts are from the anesthesia forums on pain but it relates to PM&R as well because we do see a lot of chronic pain patients, just not usually as bad as the ones seen in pain. And we are somewhat guilty ourselves with our ultrasound procedures.

Senate proposal to add 1000 new pain residency positions

https://www.aamc.org/advocacy-policy/washington-highlights/opioid-workforce-act-2021-introduced-senate This bill was recently introduced in the senate aiming to add 1,000 new Medicare-supported positions in the areas of pain and addiction medicine. Given that there are currently less than 350...

forums.studentdoctor.net

"We have the best technology, best research, best drugs compared to any time previously. We still have the so called "epidemic of pain" which has in large part lead to the opioid epidemic.

The cure for the opioid epidemic is NOT in interventional procedures. The answer is in addictions management, something the fellowship trained guys got a month of training in. Many fellows just pop their head in, say hi then leave to the fluoro suite.

A far more reasonable answer is place all that money and training spots in addictions management and psychiatry. That will make real changes. Open up prescribing of Suboxone, that will make a difference.

The pain market is already saturated and too many of the new grads just wanna be needle jockeys.

The promise that interventional pain management will cut down on opioid use in patients is marketing. There is poor quality data that our interventions decrease daily morphine equivalent dose. Industry funded and low n values. It's so far a false bill of goods.

I would argue that if they actually do use this money to fund non multidisciplinary "Spine fellowships" and more grads as they currently practice, it will exacerbate the problem not improve it."

"Oh great -

Even more pain physicians who get trained into thinking the answer to chronic pain is by somehow blocking a nociceptive input peripherally (which has and will continue to completely fail miserably).

I wonder if in my lifetime, we will ever listen to the data and change our ways."

 

[cowboydoc]

Who doesn’t teach MSK US these days? It’s a basic PM&R competency.

Agree, but it shouldn’t be a primary driver of most residency programs IMO.

 

[Slowpoke]

Money aside, our focus as a field on ultrasound isn't the best for patients either. Often times, diagnostic ultrasound does not change management especially for insidious onset pain where history and physical give you all the information you need to manage the patient appropriately. This is usually going to be reassurance with progressive exercise/rehab/activity.

For acute traumatic injuries or red flags, you're going to get an MRI and sometimes EMG/NCS anyways.

What exactly are we injecting under ultrasound? PRP and Stem cells where the evidence is weak and bordering on grifting? Steroids where the deleterious effects on connective tissue are unequivocal at this point?

In my usual day to day, as a resident, ultrasound is utilized more for guidance and less for diagnostic purposes. The attendings who use it for more than that are sports and often helping to guide surgical planning for compressed nerves. Do I have periodic sessions on identifying structures on ultrasound? Yes.

In my opinion, ultrasound resolution will continue to improve and with it, come more utility. I think it is important to keep a foot in the technology than to shun it as a waste of time. The reality is that the structured ultrasound time hardly impedes on my learning of rehabilitation concepts. In fact, it is the medicine-light work as a resident on the inpatient acute rehab unit that impedes my learning of rehabilitation concepts in the therapy gym...

 

[sloh]

In my usual day to day, as a resident, ultrasound is utilized more for guidance and less for diagnostic purposes.

Yes you can use it for guidance for CTS and dequervain's but for many of the other injections, there is no evidence that injecting improves outcomes. First. Do no harm.

The attendings who use it for more than that are sports and often helping to guide surgical planning for compressed nerves.

Wrt ultrasound to guide surgical planning for compressed nerves, what exactly are you referring to? If it's CTS, history, physical exam, and EMG/NCS are all the surgeon needs.

In my opinion, ultrasound resolution will continue to improve and with it, come more utility. I think it is important to keep a foot in the technology than to shun it as a waste of time. The reality is that the structured ultrasound time hardly impedes on my learning of rehabilitation concepts. In fact, it is the medicine-light work as a resident on the inpatient acute rehab unit that impedes my learning of rehabilitation concepts in the therapy gym...

There are big "ifs." For the large majority of patients seen in a typical outpatient PM&R MSK clinic, they will benefit much more from lifestyle interventions. Simple and not as glamorous or sexy as tech gadgets.

 

[Butterfly23]

Back in residency, we were doing academic dildo workshop to find lateral femoral cutaneous nerve block under ultrasound lol what is the point of this ? It is so sad when people sign up for these types of workshop in aapmr conferences?? I was there ! Lol

 

[The kitchen sink]

Most students don’t understand the first thing about the finance of medicine. This is a major issue. Thinking US is a key to their training despite garbage reimbursement is a side effect thereof. They don’t know what they don’t know. Many academics are fairly out of touch with the rest of medicine. This combo leads to spending a lot of time in training focused on things of little consequence and neglecting things that would be highly valuable once in practice.

I’m literally replying to repost your post.
This, this and this. Read it. Please.

 

[j4pac]

Agree, but it shouldn’t be a primary driver of most residency programs IMO.

Yes you can use it for guidance for CTS and dequervain's but for many of the other injections, there is no evidence that injecting improves outcomes. First. Do no harm.


Wrt ultrasound to guide surgical planning for compressed nerves, what exactly are you referring to? If it's CTS, history, physical exam, and EMG/NCS are all the surgeon needs.

There are big "ifs." For the large majority of patients seen in a typical outpatient PM&R MSK clinic, they will benefit much more from lifestyle interventions. Simple and not as glamorous or sexy as tech gadgets.

Lol if our patients were willing to comply with lifestyle modification...few of us would even be in business. But reality is that very few of our patients are willing to do what it takes to get better. So we are left with these passive treatment modalities to try to help them. Frankly, I feel you can’t have enough of these gimmicky gadgets. I need literally every trick in my bag to help my patients. I’m very well trained in ultrasound and I’m glad it was a part of my training.

Was it one of my top 3 reasons for going to residency? It wasn’t. But it did help me learn anatomy, and I do think that it gives me some skills that can potentially help patients. Not to mention...you don’t go to residency to learn everything you need to know. You go to residency to develop a baseline level of competency so that you are capable of adapting to what the future may hold. Right now, ultrasound isn’t a financial boom and efficacy is debatable (but let’s be real...efficacy will always be difficult to prove with our patient population, and many out there doing ultrasound have no idea what they’re doing). But that doesn’t necessarily mean that it’ll always be that way...having a broad skillset and knowledge base is very important for being adaptable.

 

[Bostonspine]

Musculoskeletal Ultrasound as a Motivator for Selecting a Physical Medicine and Rehabilitation Residency Program in the United States: A Multicenter Survey Study - PubMed

This study aimed to determine the influence of musculoskeletal ultrasound (MSKUS) curriculum on applicants during the residency-selection process. A survey of 666 applicants for the Johns Hopkins University, Mayo Clinic, and Harvard/Spaulding Rehabilitation Physical Medicine and Rehabilitation...

pubmed.ncbi.nlm.nih.gov

It is very sad that future PM&R applicants are looking at Ultrasound training as tool to rank programs. Where is our field going??
i am not discrediting ultrasound and I do use the ultrasound.

In the real world, good luck utilizing ultrasound as diagnostic tool for MSK. depending on the settings you practice, some clinicians will laugh PM&R utilizing Ultrasound. The reimbursement is low for using ultrasound and there are so many courses out there that you can catch up using ultrasound if you did not learn much in residency.

In the real world, no matter how good you are with injection, there are patients who want to get injections fast and walk away and some patients get scared when doctors bring gigantic GE machine in front of them.

I honestly want to say that ultrasound is becoming academic dildo with unachievable dreams. ultrasound for facet injections ultrasound for SI joint injection what is the point????

Ultrasound is great but what are these young milenials thinking??

Wait you do hip injections without guidance… also there are a lot of handheld ultrasound you can carry in with you or you can walk the patient t to a designated procedure room. I actually see more ultrasound injections in private practice where the global reimbursement can be significant for commercial insurance. Also if they are finishing medical school they probably aren’t millennials. Our ortho group (18 surgeons) have a pain doc and PM&R guy that does 14 plus injection under u/s per day. The reimbursement I. Our hrs are on par with basic spine procedure

 

[Slowpoke]

Yes you can use it for guidance for CTS and dequervain's but for many of the other injections, there is no evidence that injecting improves outcomes. First. Do no harm.

I don't need a double blinded randomized controlled trial to tell me that by being able to visualize my target and where I am distributing medication improves outcome.

 

[sloh]

I don't need a double blinded randomized controlled trial to tell me that by being able to visualize my target and where I am distributing medication improves outcome.

You need a sham controlled trial to show the procedure works in the first place. Especially for Are you still a resident? Lol.

Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial - PubMed

Arthritis Research UK, the National Institute for Health Research Biomedical Research Centre, and the Royal College of Surgeons (England).

pubmed.ncbi.nlm.nih.gov

Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial - PubMed

NIHR Imperial Biomedical Research Centre, Foundation for Circulatory Health, Imperial College Healthcare Charity, Philips Volcano, NIHR Barts Biomedical Research Centre.

pubmed.ncbi.nlm.nih.gov

Vinay Prasad, MD, on 'Medical Reversal'

'Not every reversal puts money in doctors' pockets'

www.medpagetoday.com

"One of the other things I think about that comes to mind rather quickly is the use of steroid injection for spinal stenosis, so epidural steroid injection. Now a couple years ago, there was an outbreak of fungal meningitis in compounding pharmacies, and people rightly faulted the compounding pharmacies for failing to follow proper hygienic policies. But one of the things that was under-discussed was the fact, "Well, why are we doing so many epidural steroid injections?" We were doing it because we thought that it would decrease pain over the course of weeks to perhaps even months in patients, and there were a lot of uncontrolled studies and anecdotal reports that that was true. But there are also well done sham-controlled studies showing that that benefit is, in fact, probably nothing more than a placebo effect."

The Case for Being a Medical Conservative - PubMed

The Case for Being a Medical Conservative

pubmed.ncbi.nlm.nih.gov

"When genuine benefit exists for an intervention, it easily withstands critical appraisal. No one debates the value of antibiotics for bacterial infection, percutaneous coronary intervention for acute myocardial infarction, or repair of femoral head fractures."

People are interested in learning ultrasound. Let them be. You do you.

This also isn't the most important point of medical training. The point of medical training is to train future clinicians/physicians in diagnostic and management approaches that actually benefit patients. If it doesn't, to go on teaching things that are nothing but placebo makes us no different than naturopaths.

 

[Slowpoke]

You need a sham controlled trial to show the procedure works in the first place. Are you still a resident? Lol.

no need for ad hominems, tbh.

My comment from above still stands. I'm not talking about establishing efficacy for certain injections. I'm talking about how ultrasound facilitates improved outcomes by allowing you to visualize your target and medication distribution.

 

[sloh]

no need for ad hominems, tbh.

My comment from above still stands. I'm not talking about establishing efficacy for certain injections. I'm talking about how ultrasound facilitates improved outcomes by allowing you to visualize your target and medication distribution.

Cart before the horse.

 

[PMR2008]

I barely had exposure to u/s during residency. Got a decent amount in fellowship and since than I have mastered it. U/S is a tool. Just like physical exam, reading imaging, EMGs, interpreting history etc. A good tool improves the way you work. a great tool improves the way you think.
For me u/s is a quick easy way to confirm a suspicion. Tendonitis versus tear. Subluxation versus impingement, presence of effusion etc. What is important is to learn not just how to use u/s but when not to use it. If I can diagnose a non spine related issue quickly without using more advanced imaging than why not. I am saving the patient and health care system money. Sure u/s does not reimburse as well as it did a decade ago but if it good for the patient I will still do it.
I use u/s mostly for needle placement. Nothing beats accuracy. Now we can debate what we inject but in most cases I will do diagnostic blocks to confirm my suspicion. For those of us who have done this long enough we know how often patient will complain of knee pain and xray shows OA but the pain is referred from the spin or hip. How many patients end up getting epidurals when it is the SI that is causing pain. We also know that a lot of the typical exam maneuvers have low sensitivity and specificity.
U/s is a tool in the end of the day to make us better at what we should already know. finally in the 10 years as an attending and doing thousands of injections not one patient has complained about me using u/s. I am quick, I explain what I am seeing and the patients value being able to see the problem versus having them interpret their own imaging report.

 

[PMR2008]

Picking a residency program strictly based on ultrasound training is ridiculous. At the same time I am fairly certain that all the programs that have top notch u/s training are excellent in other areas as well.

 

[j4pac]

Picking a residency program strictly based on ultrasound training is ridiculous. At the same time I am fairly certain that all the programs that have top notch u/s training are excellent in other areas as well.

Exactly. Places like Mayo aren’t great because they do ultrasound. They are great because they have exceptional MSK training, and because they want to be the best at MSK, they teach you MSK ultrasound.

 

[Butterfly23]

Once again, i am not discrediting ultrasound and i need ultrasound when applicable for better outcomes. Not just for MsK, i use ultrasound to do alcohol nerve block for spasticity(obturator nerve and musculocutaneous nerve)

I am thinking about ultrasound being utilized for bs reasons

what are the chances that people will do office based ultrasound guided injection for SI joint and facet?!?

 

[Butterfly23]

No patients complained to me about using ultrasound
There are folks out there using ultrasound for no good reasons

what is the point of using ultrasound for trigger point injections??

what is the point of using ultrasound for lateral femoral cutaneous nerve and many of those patients are very obese and ultrasound is time consuming

why are these academic people making these fancy ultrasound workshops and claim their superiority while in the real world, it has no efficacy and most likely will not get reimbursed?!?

academic ultrasound is far from the real world. Oh. I even saw the academic people claiming to see DRG on ultrasound!!! It is great that u see but what are u gonna do with this ?

 

[Iamnew2]

In my usual day to day, as a resident, ultrasound is utilized more for guidance and less for diagnostic purposes. The attendings who use it for more than that are sports and often helping to guide surgical planning for compressed nerves. Do I have periodic sessions on identifying structures on ultrasound? Yes.

In my opinion, ultrasound resolution will continue to improve and with it, come more utility. I think it is important to keep a foot in the technology than to shun it as a waste of time. The reality is that the structured ultrasound time hardly impedes on my learning of rehabilitation concepts. In fact, it is the medicine-light work as a resident on the inpatient acute rehab unit that impedes my learning of rehabilitation concepts in the therapy gym...

Meh US is more for feeling fancy than anything else. Most injections don't need US and if you truly want to ensure adequate injection accuracy then use fluoro. Very few people truly are good at US. US is a difficult skill to learn and even for people who are good at it, it is unclear whether injections under US are truly accurate. Fluoro is really the way to go if you truly want accuracy. However for most outpatient non pain injections US is really not needed in prob over 90% of injections.
And inpt. reimbursement is not that low - I know in residency given lack of business or financial teaching it is thought that inpt. is a poorly paid area of PM&R - but that is quite incorrect. In the right setting inpt PM&R can make a significant deal of money, more so than pain procedures without the massive overheard that pain has.

 

[Iamnew2]

No patients complained to me about using ultrasound
There are folks out there using ultrasound for no good reasons

what is the point of using ultrasound for trigger point injections??

what is the point of using ultrasound for lateral femoral cutaneous nerve and many of those patients are very obese and ultrasound is time consuming

why are these academic people making these fancy ultrasound workshops and claim their superiority while in the real world, it has no efficacy and most likely will not get reimbursed?!?

academic ultrasound is far from the real world. Oh. I even saw the academic people claiming to see DRG on ultrasound!!! It is great that u see but what are u gonna do with this ?

Thank you. Pretty much what I said in my other post. I had an idiot attending who did facets under US - I don't think he actually hit the facets at all. It seems he had no idea what he was doing or looking at. I've had attending in residency do injections for knees under US. What the heck? For triggers there is no point - and you are right very few times is US reimbursed. Given the obese patient population it really distorts anatomy so US is pretty useless for a lot of things.

 

[sloh]

Meh US is more for feeling fancy than anything else. Most injections don't need US and if you truly want to ensure adequate injection accuracy then use fluoro. Very few people truly are good at US. US is a difficult skill to learn and even for people who are good at it, it is unclear whether injections under US are truly accurate. Fluoro is really the way to go if you truly want accuracy. However for most outpatient non pain injections US is really not needed in prob over 90% of injections.
And inpt. reimbursement is not that low - I know in residency given lack of business or financial teaching it is thought that inpt. is a poorly paid area of PM&R - but that is quite incorrect. In the right setting inpt PM&R can make a significant deal of money, more so than pain procedures without the massive overheard that pain has.

My first job out of residency was with Kaiser. I was so excited to use my ultrasound skillzzz. I asked about potentially using it for intra-articular hip injections. The chief looked at me and said "most of our referrals here are for low back pain. Any of our hip injections, we just refer to radiology so the injections can be performed under fluoro."

 

[Butterfly23]

no need for ad hominems, tbh.

My comment from above still stands. I'm not talking about establishing efficacy for certain injections. I'm talking about how ultrasound facilitates improved outcomes by allowing you to visualize your target and medication distribution.

Well i have had good comments from the patients saying ultrasound guided iniection lasted longer for knee pain. Duh i aspirated 100 cc of synkvial fluid. I was happy with those comments but at the end we are dealing with same shxx
“supposedly more accurate” injections where is the study showing ultrasound guided injection showed longer effects than placebo. Most of studies that prove the accuracy of ultrasound is from cadaver studies. Is that really accurate measurues?? Does the accuracy prove the better outcomes??? At the end you are talking about similar outcomes because essentially we are dealinng with degenerarive conditions that are recurrent!! Which means they will come back again and at the end u are just waiting for all other treatments resources to be depleted.

 

[j4pac]

Well i have had good comments from the patients saying ultrasound guided iniection lasted longer for knee pain. Duh i aspirated 100 cc of synkvial fluid. I was happy with those comments but at the end we are dealing with same shxx
“supposedly more accurate” injections where is the study showing ultrasound guided injection showed longer effects than placebo. Most of studies that prove the accuracy of ultrasound is from cadaver studies. Is that really accurate measurues?? Does the accuracy prove the better outcomes??? At the end you are talking about similar outcomes because essentially we are dealinng with degenerarive conditions that are recurrent!! Which means they will come back again and at the end u are just waiting for all other treatments resources to be depleted.

But with that rationale...why do an injection at all?

 

[PMR2008]

Well i have had good comments from the patients saying ultrasound guided iniection lasted longer for knee pain. Duh i aspirated 100 cc of synkvial fluid. I was happy with those comments but at the end we are dealing with same shxx
“supposedly more accurate” injections where is the study showing ultrasound guided injection showed longer effects than placebo. Most of studies that prove the accuracy of ultrasound is from cadaver studies. Is that really accurate measurues?? Does the accuracy prove the better outcomes??? At the end you are talking about similar outcomes because essentially we are dealinng with degenerarive conditions that are recurrent!! Which means they will come back again and at the end u are just waiting for all other treatments resources to be depleted.

U/s guided knee joint injections can be over kill. Unless patient is obese or has severe OA. I would rather do it right with guidance than risk missing my target and have an unsatisfied outcome. To each their own. U/S guided shoulder joint and hip joint are so much easier for me to do than using fluoroscopic guided.

 

[runfastnow]

As a privademic (moving more and more away from the academic work) sports/spine physiatrist in a sports med ortho group I echo the surgeons want MRIs and are not going to trust an US - I have had 2 cases out of 1000s in the last year in which US changed management - everything else is MRI. As stated before US is a tool in an otherwise large bag of options. 90+% of the time in sports/spine the patient tells you what their diagnosis is through a decent history and physical exam only further confirms or helps make one of two to three diagnoses most likely.

I dislike diagnostic US as MRI is more useful for both me and my partners - perhaps that makes me a substandard ultrasonographer. Since we see a lot of high school athletes I will pull out the US machine to demonstrate (usually the lack of) pathology to help calm the kid and parents or for other particularly high strung patients. Outside of this US is most useful for peripheral joint/tendon/ligament procedures. I do have patients that request US for knee (or other accurate blind) injections as they feel it makes the injection more effective which I am happy to offer, use for obese patients, and for joint aspirations.

IMO any spine procedure performed without NASS or SIS (my strong preference) guidelines is borderline negligence: i.e. I was a model at an AMSSM course in which they were demonstrating cervical facet injections with US. This is insane use of US given it's current state much less the inability to use contrast to confirm vascular flow, etc.

Until ortho and neurosurgery residents are also sufficiently trained in US diagnostics to trust the modality trying to use it as an equivalent to MRI is going to fail. No amount of diagnostic non-inferiority studies from PM&R, FM, AMSSM, AAP, AAPM&R, etc. is going to change that.

 

[PMR2008]

As a privademic (moving more and more away from the academic work) sports/spine physiatrist in a sports med ortho group I echo the surgeons want MRIs and are not going to trust an US - I have had 2 cases out of 1000s in the last year in which US changed management - everything else is MRI. As stated before US is a tool in an otherwise large bag of options. 90+% of the time in sports/spine the patient tells you what their diagnosis is through a decent history and physical exam only further confirms or helps make one of two to three diagnoses most likely.

I dislike diagnostic US as MRI is more useful for both me and my partners - perhaps that makes me a substandard ultrasonographer. Since we see a lot of high school athletes I will pull out the US machine to demonstrate (usually the lack of) pathology to help calm the kid and parents or for other particularly high strung patients. Outside of this US is most useful for peripheral joint/tendon/ligament procedures. I do have patients that request US for knee (or other accurate blind) injections as they feel it makes the injection more effective which I am happy to offer, use for obese patients, and for joint aspirations.

IMO any spine procedure performed without NASS or SIS (my strong preference) guidelines is borderline negligence: i.e. I was a model at an AMSSM course in which they were demonstrating cervical facet injections with US. This is insane use of US given it's current state much less the inability to use contrast to confirm vascular flow, etc.

Until ortho and neurosurgery residents are also sufficiently trained in US diagnostics to trust the modality trying to use it as an equivalent to MRI is going to fail. No amount of diagnostic non-inferiority studies from PM&R, FM, AMSSM, AAP, AAPM&R, etc. is going to change that.

Agree with you. But how do you see bicep subluxation on an MRI?(just one of many examples) Also it is pretty often that patient have tendonitis which is painful but not showing up on MRI. Again it one of the tools that we have and should not replace a good history, exam or the know how of when it is better to order an MRI. If it is not changing my management I prefer not ordering MRI. At least in the private practice world I am not ordering as many MRI's because I don't have an admin asking me to improve utilization (off course this is not directed directly at you runfastnow)

"The United States occupies top usage ranks" among health systems worldwide, they write, "with population rates of annual [CT] scans (245 per 1000 people) and [MRI] scans (118 per 1000 people) that are 5 and 3 times higher than those of Finland, respectively."

America performs far more CT and MRI scans than other countries. There's 'virtually no evidence' that's helpful, researchers say.

In a JAMA opinion piece, researchers from Stanford University and Mayo Clinic raise alarms about the prevalence of

www.advisory.com

"An indication for MRI would be strong clinical suspicion of pathology based on appropriate clinical screening that would make the patient/client inappropriate for conservative management"

The role of MRI in musculoskeletal practice: a clinical perspective - PMC

This clinical perspective presents an overview of current and potential uses for magnetic resonance imaging (MRI) in musculoskeletal practice. Clinical practice guidelines and current evidence for improved outcomes will help providers determine the ...

www.ncbi.nlm.nih.gov

Ultrasound has a pretty steep learning curve and I think getting residents exposed to it early on to help improve MSK anatomy knowledge makes sense to me.

 

[MavFab]

Most students don’t understand the first thing about the finance of medicine. This is a major issue. Thinking US is a key to their training despite garbage reimbursement is a side effect thereof. They don’t know what they don’t know. Many academics are fairly out of touch with the rest of medicine. This combo leads to spending a lot of time in training focused on things of little consequence and neglecting things that would be highly valuable once in practice.

As an incoming resident, I am curious about what things are important in practice, but often neglected in residency?

 

[TheGreatestTrochanter]

If you are efficient I think it is very useful for many things in sports/MSK medicine. But you have to know what those are, when to use it, and most importantly what you are looking at and for. YOu need 100s of normals to know the abnormals, just like with radiographs. Finding a ganglion cyst, being able to tell a large cuff tear vs just a contusion, eval for FDS/FDP avulsions, skiiers tumb looking for a Stenner lesion are just a few that come to my head that are extremely helpful, and save time stress and money for the patient and the system. Neuromuscular ultrasound is super helpful as a tool alongside EMGs as well. If you are looking at every shoulder though it is an increase of all of those for the system. I think few people just fresh from residency are set up for success for really being able to confidently use ultrasound as a diagnostic tool.

 

[PMR2008]

As an incoming resident, I am curious about what things are important in practice, but often neglected in residency?

Self promotion, leadership outside of the hospital system, being efficient, staff management, marketing(learning how to get referrals), Med legal, billing, financial independence(different models including 1099) etc. I am sure @cowboydoc can add more.

 

[runfastnow]

As an incoming resident, I am curious about what things are important in practice, but often neglected in residency?

This leans more towards private practice, but can apply to academic jobs:
- Financial planning (personal and professional)
- Retirement planning and investing (read White Coat Investor, Psychology of Money, Random Walk Down Wall Street, Rich Dad Poor Dad, and listen to The Motley Fool podcasts as a starting point).
- Billing and revenue cycles
- Clinic and documentation efficiency
- Networking in your community/institution
- The fact that publications and presentations do not matter unless you are hoping to be in academic leadership (even then I'm not sure how much it does because academic PM&R is so inbred between Mayo, Spaulding, UW, etc. that people from these programs seem to just trade positions up the academic ladder and spots on "important" review articles).
- Building a reputation of being ethical, reliable, and open to getting patients in ASAP from referral sources goes 1,000,000x further than any publication, award, or academic title will.

 

[j4pac]

I agree that the business side of medicine should be taught better...in med school and residency. But is it taught better in other specialties relative to PM&R?

 

[runfastnow]

I agree that the business side of medicine should be taught better...in med school and residency. But is it taught better in other specialties relative to PM&R?

Medicine as a whole ... terrible.

At my residency it was a big emphasis, but partly because of our resident and PD mix - each class had at least one MD, MBA (that was me for our class) or person who was a finance/accounting/business undergrad and the PD was also a lawyer who emphasized that we knew the business and legal side of medicine.

Anecdotally the specialties that I have seen with best business training are optho and plastics with less so ortho (based on subspecialty). FM and IM notoriously seem to be terrible at it.

 

[PMR2008]

The vast majority of residency training programs are in large academic hospitals. Some programs are smaller/community based with diverse teaching faculty. My residency was in a free standing community IRF and the attendings were part of a a private practice group. They taught us how to run a practice and all the other points noted above. I remember my attending spending 30 minutes with me on the first day of outpatient clinic as a PGY2 on how to document and bill. By the end of the rotation he was having me bill and he would double check my codes. I highly doubt academic attendings would ever do that but they should.

 

[timisdaman]

This leans more towards private practice, but can apply to academic jobs:
- Financial planning (personal and professional)
- Retirement planning and investing (read White Coat Investor, Psychology of Money, Random Walk Down Wall Street, Rich Dad Poor Dad, and listen to The Motley Fool podcasts as a starting point).
- Billing and revenue cycles
- Clinic and documentation efficiency
- Networking in your community/institution
- The fact that publications and presentations do not matter unless you are hoping to be in academic leadership (even then I'm not sure how much it does because academic PM&R is so inbred between Mayo, Spaulding, UW, etc. that people from these programs seem to just trade positions up the academic ladder and spots on "important" review articles).
- Building a reputation of being ethical, reliable, and open to getting patients in ASAP from referral sources goes 1,000,000x further than any publication, award, or academic title will.

Alright you young'ns. Notice how the top 3 are money related? Unfortunately, that is appropriate. If you can't maximize those, then you are cheating yourself and your family!

 

[Iamnew2]

I agree that the business side of medicine should be taught better...in med school and residency. But is it taught better in other specialties relative to PM&R?

Yes. I feel PM&R academically is too focused on non-sense. In my residency there was such a concern about how nurses "felt" about residents that my head would spin. I will never forget that I actually had to sit down with my advisor because one of the nurses complained that my pants were - get ready guys - wrinkled!!!!! I was like what? The advisor tells me - yes something like this might seem too personal but we do ask them to evaluate you all. *speechless* Sorry for the rant.
Anyways no training whatsoever in my residency in this reagrd. I think it's essential - because then you come out as an attending completely clueless. Coding, billing, insurance nonsense, etc should all be taught in residency. Instead of doing the 50th EMG rotation, probably a rotation should be focused on the actual practice of medicine.

 

[PMR2008]

Yes. I feel PM&R academically is too focused on non-sense. In my residency there was such a concern about how nurses "felt" about residents that my head would spin. I will never forget that I actually had to sit down with my advisor because one of the nurses complained that my pants were - get ready guys - wrinkled!!!!! I was like what? The advisor tells me - yes something like this might seem too personal but we do ask them to evaluate you all. *speechless* Sorry for the rant.
Anyways no training whatsoever in my residency in this reagrd. I think it's essential - because then you come out as an attending completely clueless. Coding, billing, insurance nonsense, etc should all be taught in residency. Instead of doing the 50th EMG rotation, probably a rotation should be focused on the actual practice of medicine.

Unfortunately it will never happen. Academic Physiatrist can not teach what they don't know. Also they are not interested in learning from "greedy private practice Physiatrist". I have had a opportunity to teach at a few local residency programs but the majority of "business of medicine" was taught by me directly during elective rotations (Don't PM me since I don't offer rotations anymore)

 

[Iamnew2]

Unfortunately it will never happen. Academic Physiatrist can not teach what they don't know. Also they are not interested in learning from "greedy private practice Physiatrist". I have had a opportunity to teach at a few local residency programs but the majority of "business of medicine" was taught by me directly during elective rotations (Don't PM me since I don't offer rotations anymore)

You are probably right. Just kind of sad.

 

[sloh]

Acute IPR can be very lucrative, much more than outpatient MSK. Many residents complain acute IPR is like internist-lite. True, but that’s just the medicine side. Residencies should emphasize teaching and streamlining all the non-medical related parts of running a high efficiency acute IPR unit, which is arguably more complex than the medicine component. Pretend you’re a 1099 and know exactly where the size of your paycheck comes from.

 

[PMR2008]

You are probably right. Just kind of sad.

There is only one solution to this. Residents need to demand these lectures. The chiefs should allocate time during the yearly didactic cycle and invite outside experts in finance, billing, marketing, contract negotiation, etc. It is so much easier to do it now with zoom etc.

 

[runfastnow]

There is only one solution to this. Residents need to demand these lectures. The chiefs should allocate time during the yearly didactic cycle and invite outside experts in finance, billing, marketing, contract negotiation, etc. It is so much easier to do it now with zoom etc.

Agree. If you are a resident reading this thread demand to be taught these things. We did this as residents and EVERYONE is happy that we had the support from our PD to have these lectures and "real life" education. It put us 4-5 years ahead of those who don't. I still give a personal and professional finance lecture to my old residency program so that business of medicine culture must still be there.

We all worked hard to become physicians and work hard at our profession and should be compensated for that work. Some may feel guilty or that physicians (especially us in private practice) are greedy, but I end every lecture about the subject with this (and to echo above posters):

Even if you do not desire personal wealth accumulation …. your family, heirs, alma mater(s), institution, research societies/interests, social/religious causes, and miscellaneous other philanthropic opportunities would appreciate your support.

 

[timisdaman]

For what it is worth, there is a brief "your first job" session at AAPM&R this year. It was held at AAP earlier this year, and hopefully will be again in 2022.

 

[Kissmyabjj]

I’ve had a few cases in which I was able to find something on ultrasound that was initially not called on an MRI. Off the top of my head:

1) proximal rectus femoris myotendinous junction injury in a soccer player with four years of anterior hip and thigh pain.
2) rectus femoris direct head calcific tendinopathy in a ballet dancer with six months of anterior lateral thigh pain.
3) Nearly full thickness tear of the posterior band of the gluteus medius tendon.

In each of the above cases I was able to reach out to the MSK radiologist, who was then able to identify the pathology on MRI and addend his previous dictation.