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thoughts on PM&R

Discussion in 'PM&R' started by prominence, Dec 21, 2001.

  1. prominence

    prominence Senior Member
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    i have heard many good things about physical medicine and rehabilitation. however, i have been told that this specialty is not for anyone. what qualities are needed by a med school student going into PM&R? what are the pros and cons?

    from what i know, pm&r does not a stressful residency, 50 hour weeks are normal after residency, and the pay is decent ($130,000). plus, there are many subspecialty options to choose from, i.e. pain management, sports medicine, etc. this all sounds good to me. am i missing something about this field?
     
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  3. Devdas

    Devdas Senior Member
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    YES!

    You will miss something...
    There is no night calls in this field. :D
     
  4. prominence

    prominence Senior Member
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    can anyone else share their thoughts on this topic?
     
  5. Betrayed

    Betrayed Junior Member

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    PM&R is an ILL-DEFINED specialty. Although it has been around for more than 50 years, many leading hospitals don't have physiatrists on staff. If they do have them, they are there almost as an afterthought. Physiatrists are like relief pitchers put into the game when you are either 20 runs ahead or 20 runs behind. For the most part, physiatrists are tolerated, not respected by other physicians.

    PM&R can be basically divided into inpatient and outpatient physiatry. Inpatient physiatry is NOT a growth area. This seems a little paradoxical given the aging population. However, the healthcare system is placing major emphasis on getting people out of hospitals as quickly as possible or keeping them out of hospitals altogether. The American Academy of PM&R has done a 180 degree turn in the past 5 or 6 years. In 1995 or 1996, the Academy commissioned a study (I think it was by the Lewin group) to look into the future of PM&R. The study concluded that the musculoskeletal area was NOT a growth area. However, in the past year or two, an update to that study says that muculoskeletal medicine IS the future of PM&R and that inpatient physiatry will shrink. Visit the Academy website at <a href="http://www.aapmr.org." target="_blank">www.aapmr.org.</a> Apparently, even the Academy doesn't know what its future is.

    My gut feeling is that INPATIENT physiatry is dead. For a long time rehab hospitals had DRG exempt status. This has shielded them from some of the financial pressures general hospitals have been facing. This will soon change as Medicare alters the way that it looks at inpatient rehabilitation. Lengths of stay will probably get shorter. There has been speculation that rehab hospitals will be penalized financially if a patient is not discharged home but instead is discharged to an extended stay facility (nursing home). This will be done to hopefully stem the abuse by for-profit rehab hospital chains in admitting patients who are not appropriate for acute inpatient rehab. Some of these for-profit chains have their nonphysician administrators (often a speech therapist or physical therapist) make the medical decision as to who is an appropriate patient to admit to their rehab hospital. A PHYSIATRIST HAS NEVER SEEN THESE PATIENTS FOR AN INPATIENT CONSULT TO DETERMINE APPROPRIATENESS! It is a bad position for an ethical physician to be in.

    Inpatient rehab can be classified as: 1) ACUTE- the patient can tolerate AND benefit (?require) from 3 hours of therapies per day. This is the MOST COSTLY inpatient rehab ~$1200 or more PER DAY. 2) SUBACUTE- less intense therapies, often in a skilled nursing facility at a cost ~$400 to $600 per day. 3) NURSING HOME- limited therapies and the least costly at ~$1200 PER WEEK.

    It is easy to see why 3rd party payers prefer to send total knee and total hip patients to subacute facilities or nursing homes where they can get physical therapy only-NO PHYSIATRIST REQUIRED!

    The elder statesmen and stateswomen who comprise the American Board of PM&R as well as the "leadership" of the American Academy of PM&R have been agonizingly slow to recognize the changes sweeping American medicine and to take corrective action. They remind me of the tired, old men of the former Soviet politburo who would vote as one even as their country was going down in flames.

    Outpatient physiatry has some potential. BUT, YOU'VE GOT TO LOVE BACK PAIN. Physiatrists will often say they do "musculoskeletal" medicine. This USUALLY means low back pain and neck pain with a fair amount of "fibromyalgia." These are the bread and butter conditions of outpatient PM&R. Sports medicine is RARELY a big part of any physicians practice including orthopedic surgeons. It sounds glamorous but it is not the real world. As part of my training, I worked with an orthopedic surgeon for a major league baseball team. Contrary to popular belief, his practice was NOT mostly sports-related injuries. Sports medicine can be a PART of your practice but don't expect it to pay your bills.

    A big challenge for OUTPATIENT physiatrists is WHERE they get their patients. Most people with muculoskeletal complaints see their primary care physician (internist or family practice) first. Almost always, if a consult is needed, they will be referred to orthopedic surgeons or rheumatologists, NOT TO PHYSIATRISTS.
    Some physiatrists get around this by going to work for orthopedic surgeons. Do you know of any other physician specialtist who goes to work FOR another physician of a different specialty? Cardiologists don't generally work FOR cardiovascular surgeons. Many physiatrists apparently don't mind being ancillary help for orthopedic surgeons as long as the pay is good (and the pay is VERY good.) You get to do what the surgeons HATE to do,i.e. screen tons of back patients (many of whom are total crocks or crooks trying to cash in on secondary gain.) You also get to "manage" patients with failed back syndrome - they are the bane of every spine surgeon. Oh boy! Yipee! No wonder the orthopods "love" physiatrists. They let their "esteemed" physiatric serfs deal with workmen's comp claims, motor vehicle accident claims, etc. There was a physiatrist in MA whose practice was called THE MOTOR VEHICLE ACCIDENT CENTER - I'm not kidding. Another physiatric group told me that they get a significant number of referrals from personal injury lawyers. Physiatry has more than its share of sleazy characters.

    If you like thinking and being challenged, consider neurology or rheumatology. If lifestyle during residency and practice is MOST important to you, then PM&R may be a consideration BUT I strongly suggest doing outpatient. Speak to as many physicians as possible not only in PM&R but in other specialties. Don't ask friends - they may not want to hurt your feelings or steer you too strongly. Spend time in several PM&R practices AWAY from the distorted view of academic medical centers. Follow physiatrists as they do nursing home rounds, hold team meetings, hold family conferences, see their 10th workmen's comp patient of the day,etc.

    Above all, gather lots of information from as many sources as possible. Look at the classifieds in the back of ARCHIVES OF PM&R (a throwaway journal with articles written mostly by PT's and OT's.) Call some of the recruiters listed in the back of the journal. Learn to read between the lines. One recruiter told me bluntly that the jury is still out as to whether or not physiatrists and orthopods in the same practice will be a long term stable option. Check it out.

    GOOD LUCK WHATEVER YOU DECIDE!
     
  6. droliver

    Moderator Emeritus 10+ Year Member

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    Wow! What a genuinely interesting and insightful post on PMR as a field. I can't wait for the counteroffensive :D
     
  7. drusso

    Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    It's clear that you're not well suited to PM&R, perhaps you made a wrong career decision. PM&R deals exclusively with chronic disease and disability. It aims to give quality of life back to patients or prevent its decline. The field is not immune to all the other forces shaping medicine---why you seem to suggest that physiatrists are unhappier than the average physician is unclear to me. The overwhelming majority of physiatrists I know love what they are doing...and are making good money doing it. Survey after survey revealst that physiatrists have among the highest satisfaction of all the medical specialties.
    ---------
    Am J Phys Med Rehabil 1997 Mar-Apr;76(2):90-101 Related Articles, Books


    Practice and career satisfaction among physiatrists. A national survey.

    DeLisa JA, Kirshblum S, Jain SS, Campagnolo DI, Johnston M, Wood KD, Findley T.

    Department of Physical Medicine and Rehabilitation, UMDNJ-New Jersey Medical School, Newark 07103-2406, USA.

    To evaluate physiatrist career satisfaction and current practice patterns, a 15-page survey was mailed randomly to 400 fellow members of the American Academy of Physical Medicine and Rehabilitation. The 208 questionnaires (52%) returned revealed respondents' level of satisfaction with career choice, current practice, relationships with other physicians, their own residency training, and problems experienced that impede their practice. Factor analysis identified six areas of satisfaction: time demands, organizational support, current practice, current specialty, profession, and training. Problems with work consisted of four factors: external intrusions into practice, having to deal with non-rehabilitation problems, dealing with PM&R problems, and insufficient time for patients. Results showed that 75% of physiatrists were satisfied with their practice/profession. Satisfaction with current practice was greater with fewer external intrusions into practice, a larger percentage of income from traditional non-managed payment sources (including Medicaid), and less competition. Changes in health care, such as managed care, competition, and increased external regulations, appear to interfere with current practice. Variation in satisfaction was not significantly correlated with size of community, variation in rates of payment denials, workloads of greater than 50 hours per week, and a number of other factors that one might expect to affect satisfaction. Physiatrists had made many changes in their practice in response to the changes in the health care environment but had not cut care for indigent patients. Needs for greater residency training in outpatient clinics, physicians' offices, managed care, and long-term care settings were expressed. This is the first comprehensive published report on physiatric satisfaction in a changing health care environment. Further research in some of the areas will be required.
    -------

    A few thoughts:

    ---The financing of inpatient rehab is changing and this is good. DRGs drive the rest of medicine; why should PM&R be immune? Inpatient rehab will never go away because studies prove that patients who receive comprehensive inpatient rehab for a variety of conditions have better long term outcomes. Rehab needs to be cost-effective. Nothing wrong with that.

    ---Physiatrists don't feed off the left overs of orthopods and surgeons any more than cardiologists or neurologists feed off of cardiothoracic surgeons or neurosurgeons. There are a multitude of cardiology and neurology multispecialty groups where surgical and nonsurgical specialists work hand in hand. Physiatrists are highly sought after to join multidisciplinary practice groups because they are experts in conservative care. Surgeons know that they can't cut on everyone and instead of turning away non-surgical cases, why not refer to a non-surgical specialist in the practice and keep the money in the practice. Physiatrists don't join these groups as "employees" but as legitimate partners. The money is very good indeed.

    ---Increasingly, physiatrists are getting training in interventional techniques and minimally invasive spine surgery. These procedures used to strictly be the turf of interventional pain doctors and spine surgeons. I know countless physiatrists performing injections, IDET, blocks, etc.

    ---You recommend neurology or rheumatology, but it's unclear to me why these are more attractive fields than PM&R. Just how many whiney migraines can you see a day? Or, how many osteoarthritics? Every field has its bread-and-butter cases. I personally love neurology and considered it deeply. I chose PM&R after seeing how little neurologists do. Most don't even do EMGs as PM&R has more or less taken over electrodiagnostics. As for physiatrists being TOLERATED and not RESPECTED, I'm still not sure what you mean. Just how much respect does a neurologist get this days? Or a rheumatologist? You should hear how internists talk about surgeons and vice versa.

    PM&R is not for everyone. But it is for those who enjoy complicated cases, long-term care, electrodiagnostic medicine, and the potential for interesting procedures, medico-legal work, consulting, and more. All with the lifestyle and reimbursement of traditionally more competitive fields such as radiology or dermatology. Why more students don't choose PM&R is beyond me.
     
  8. The reason that more medical students do not consider PM&R is because they get little exposure to the field. However, I think more and more medical students are pursuing PM&R instead of fields like general surgery or IM.

    Last year, when one of my friends completed his PM&R residency, he was hired by Kaiser (huge HMO in CA) and was paid much more ($160,000) than what my friends were offered after having just completed IM or FP ($95,000-$120,000). He was hired to do general inpatient rehab and if an HMO like Kaiser pays as much for a physiatrist as they do for an ophthalmologist ($170,000), my guess is that inpatient physiatry is not dead.

    "However, the healthcare system is placing major emphasis on getting people out of hospitals as quickly as possible or keeping them out of hospitals altogether."

    How exactly is this different from any other aspect of medicine. This sounds like something that all physicians in any specialty have to deal with. Reimbursements are also shrinking and this also affects many areas of medicine. You should hear the general surgeons complain about how little they get paid for the work and hours they put in.

    PM&R was not for me but it is certainly not the career that Betrayed describes. I did a two week rotation in PM&R as a medical student and the physiatrists there worked in a Rehab unit of the hospital doing EMGs, TBI, SCI, and Stroke. They were also working in the Spine Clinic and Orthopedics. The Physiatrists were all extremely happy with their job, compensation was quite good, and they were well-respected as well. Every field has both positives and negatives and PM&R is not any different. The compensation, lack of call, and hours certainly makes it an attractive option for those who are seeking these things as part of their future career.
     
  9. prominence

    prominence Senior Member
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    im interested in this field, but im having trouble finding information on PM&R. is it hard to find employment in PM&R, especially on the east coast? i know of several hospitals where they only have 1 PM&R doctor. where do PM&R doctors work? hospitals, private practice, with orthopedic surgeons?

    also, could anyone provide me with an estimate on the starting salary for a PM&R doctor after completing residency? how about 5 yrs after completing a residency? whats a good estimate of how many hrs a PM&R doctor works a week? is 50 hrs accurate? (esp. in the NY, NJ, PA area)
     
  10. prominence

    prominence Senior Member
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    can i get some answers to my questions posted in the above post?
     
  11. bigfrank

    bigfrank SDN Donor
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    Yes, some thoughts would be very helpful.

    Thanks, Frank
     
  12. Soupbone

    Soupbone Member
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  13. drusso

    Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    From the AAMC Website:

    "Results from the 2002 Match indicate a decrease in residency positions filled in six primary care specialties: family practice, internal medicine, pediatrics, medicine-pediatrics, internal medicine primary, and pediatrics primary. There were 373 fewer U.S. seniors filling these generalist residency positions, with 205 less positions filled overall; international medical graduates made up the difference with 116 more matches to these positions than last year.

    Some specialty areas experienced an increase in match rates compared to last year. Among these specialties are: anesthesiology, with a fill rate of 95.1 percent, a 7 percent increase over last year, and physical medicine and rehabilitation, for which the fill rate increased from 77.3 percent to 90.4 percent. Moreover, diagnostic radiology filled an additional 44 PGY-2 positions this year."
    ----------

    When I was interviewing at PM&R programs, several residencies pointed out that applications at individual programs were up almost 20%. Why? I think a combination of reasons has made PM&R more attractive to medical students:

    ---A shift away from primary care. Medical students simply do not want put up with the hassles of being a primary care doctor and would prefer the identity and prestige of being a specialist.

    ---An interest in physical fitness and fitness related medicine: PM&R is one of the three pathways to becoming a board-certified sports medicine specialist. The others being family medicine and orthopeadics.

    ---Increasing scope of practice. More physiatrists are opting for subspecialty training in pain, electrodiagnostic medicine, stroke, brain and spinal cord injury, etc. With subspecialty training comes increased reimbursement.

    ---Atmosphere. Rehab hospitals, for the most part, are sort of warm and fuzzy places where people learn to put their lives back together again, hence the advertising tagline of the American Academy of Phyisical Medicine and Rehabilitation: "Physiatrists: Doctors adding quality to life..."

    ---Chronic disease medicine. Goes with the whole "aging baby-boomer" philosophy of choosing a specialty with an increasing burden of disease. Boomers will be stroking out, getting joint replacements, and looking for treatment for their aching backs, necks, and extremities in increasing numbers. Because surveys shows that most primary care doctors feel least prepared to treat musculoskeletal disorders, this creates yet another referral conduit for physiatrists.

    ---Advances in the treatment of disability: Myoelectrically controlled prosthetics limbs, advanced materials, new motorized forms of personal transportation all promise to significantly impact the treatment and rehabilitation of the disabled.

    ---Lifestyle: Perhaps historically one of the leading reasons for choosing PM&R. For many, PM&R stands for "Plenty of Money and Relaxation."
     
  14. njdevil

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    PM&R docs work in many places:

    1. Private practice office
    2. Larger hospitals normally have a department for consult or to rehab tbi/sci/ortho/cardiac.
    3. Rehab hospitals such as Magee (PA), Moss (PA), Kessler (NJ)
    4. Orthopedic offices and institutes such as Rothman (PA)
     

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