whats the best way to explain what PM&R is

[myrandom2003]

just wondering what you guys say when people (including some doctors) ask if PM&R is the same as physical therapy/physical therapist?

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[Taus]

I'll let the more experienced people here talk about the way to describe it as a whole, but as for the above thing about PM&R/PT: You can use this analogy (I got this from one of the speakers at the national conference).... Doctor is to Pharmacist, as Physiatrist is to Physical Therapist.

 

[drusso]

Well, if the person doing the asking is a physician I sort of look at them like they're a pleasant but ******ed child and answer, "Where again did you go to medical school?" implying that asking such a question at their stage of their career should cause them to be a little embarrassed...would they ask such a question of a radiation oncologist (who supervises rad techs) or a pulmonologist (who supervises respiratory techs)?

If they're a lay person, patient, or an allied health professional I explain that I'm a Physical Medicine and Rehabilitation Doctor, sometimes called a physiatrist or more commonly just a "Rehab Doc" and that we supervise physical therapists in our department and medically manage disability. That usually suffices.

 

[Wifty]

I tend to describe PM&R as THE quality of life doctor and that they supervise PTs and others as a team effort to give the best quality possible to a person.

This seems to make alot of sense to most people but personally, I am not fond of the term PM&R because it is confusing to people and I think it is limiting as to what is really done.

With smiles,
Wifty

 

[rehab_sports_dr]

One of my colleagues calls us "function-ologists" which I think helps people understand.

I like to use formal definitions, because I think one of the keys getting people to take our field seriously is a consistency of terminology.

2 formal systems I like to use

1. Use the Rusk model of medicine: there are 3 prongs to medicine- prevention, treatment of acute problems, and rehabilitation. PM&R is one of the few specialties focusing on all 3 aspects of treatment.

2. Make the distinction between an impairment, disability, and handicap, and that the role of the physiatrist is minimizing the extent to which impairments become disabilties and handicaps.

In general, I find that whenever a medical student asks me something, I like to give them a list of 3 things to memorize. The didactic component tends to help them retain the information and treat with more respect.

 

[paz5559]

just wondering what you guys say when people (including some doctors) ask if PM&R is the same as physical therapy/physical therapist?

Jay Smith of the Mayo Clinic gave a whole talk at the AAPM&R Annual meeting on this topic 2 years ago. His definition was one I actually thought highly enough to write down:

Experts in the comprehensive provision and orchestration of neuromusculoskeletal medicine

 

[Sohalia]

Well, if the person doing the asking is a physician I sort of look at them like they're a pleasant but ******ed child and answer, "Where again did you go to medical school?" implying that asking such a question at their stage of their career should cause them to be a little embarrassed...would they ask such a question of a radiation oncologist (who supervises rad techs) or a pulmonologist (who supervises respiratory techs)?

😛
Had another MS4 ask me what PM&R was a couple months before graduation. I went through the explanation, but thought: even though Duke does not have a PM&R residency or even a formal department, you'd think MS4's would have come across the terms: "PM&R, physiatry" in doing the research to finalize their specialty choice!

 

[paz5559]

Well, if the person doing the asking is a physician I sort of look at them like they're a pleasant but ******ed child and answer, "Where again did you go to medical school?" implying that asking such a question at their stage of their career should cause them to be a little embarrassed...would they ask such a question of a radiation oncologist (who supervises rad techs) or a pulmonologist (who supervises respiratory techs)?

Dr. Russo has far more tact than I (just ask Dr. Moutvic, his PD!). Were that question asked of me at this point in someone's residency training, clearly the appropriate response ought to be a disdainful stare. Were it repeated ... let's just say it wouldn't be pretty,

 

[axm397]

A similar topic came up the other day with the very wise old Dr. Betts.

He said that we physiatrists do a very poor job promoting ourselves. If he were to walk into RIC any weekend and take a sample of patients and ask them who their doctors were - many of them would name their neurosurgeon across the street at Northwestern, some may name the PM&R resident but not know the attending, and the few that get the resident and attending right would not know they were physiatrists. He said we don't introduce ourselves as physiatrists (of course, he says phy-see-a-trists 😀 ) to our patients and "explain" rehab. We residents protested and said we do. Well then, he said, we need to keep reminding patients and families until they do remember... and perhaps, we need to learn to be more memorable... 😎

I also remember Dr. Press talking about how even to out own staff within our institution we do a poor job of promoting our services. He said he was talking to a PCT (patient care tech) one day who asked Dr. Press if he knew of a good Orthopod for his chronic low back pain. Dr. Press told the PCT he knows of many good Orthopods but that he may want to start by going to a physiatrist to manage his LBP. The PCT was suprised and exclaimed that he didn't know RIC docs handled those issues.

How are things at your institutions??

 

[rehab_sports_dr]

> He said that we physiatrists do a very poor job promoting ourselves.

This is very true. It is not uncommon for patients at Kessler to refer to their referring physician as "their doctor," even though a physiatrist is still managing their care.

As an aside, on one level this is true. I find that physiatrists tend to be overly deferential to their referring sources- perhaps moreso than doctors in other specialties.

> How are things at your institutions?

I agree- things are similar at our institutions. It is not uncommon, for example, for a speech therapist who works with our stroke patients to be unaware that physiatrists also manage sports injuries.

 

[DPT]

... "Rehab Doc" and that we supervise physical therapists in our department and medically manage disability. That usually suffices."

drusso,

You will offend most PTs if a patient tells the therapist that the rehab doc stated he/she "supervises the PT". This statement implies the rehab doc is superior to the therapists and does not facilitate a "team approach" of rehabilitating the patient.

It's like a QB stating he 'supervises' the offensive team. Just think what type of blocking you will receive by the front linemen with that attitude.

PTs are consultants. We are experts in optimizing mobility for the patient and you are an expert in the medical management of that patient.

I have worked 10 years in a University trauma 1 facility, mostly the burn and med/surg ICU, that does not have PM&R in acute care. They are not needed as we have the burn/ICU MDs to manage the patient medically. Once that patient moves to inpatient rehab, definately a PM&R would be helpful as the attending with the rehab background, but still..he/she does not 'supervise' PT/OT/ST.

 

[drusso]

... "Rehab Doc" and that we supervise physical therapists in our department and medically manage disability. That usually suffices."

drusso,

You will offend most PTs if a patient tells the therapist that the rehab doc stated he/she "supervises the PT". This statement implies the rehab doc is superior to the therapists and does not facilitate a "team approach" of rehabilitating the patient.

It's like a QB stating he 'supervises' the offensive team. Just think what type of blocking you will receive by the front linemen with that attitude.

PTs are consultants. We are experts in optimizing mobility for the patient and you are an expert in the medical management of that patient.

I have worked 10 years in a University trauma 1 facility, mostly the burn and med/surg ICU, that does not have PM&R in acute care. They are not needed as we have the burn/ICU MDs to manage the patient medically. Once that patient moves to inpatient rehab, definately a PM&R would be helpful as the attending with the rehab background, but still..he/she does not 'supervise' PT/OT/ST.

Things obviously vary from institution to institution...

At my institution (a large quatrenary care and international referral center), therapy services are coordinated through a physiatrist.

Primary services, with the exception of orthopedics, do not certify therapy services. There are standing orders and protocols for certain conditions, (arthroplasty, dysphagia, etc--just like there are standing protocols in primary care medicine for nurse practitioners and physician assistants; or just as paramedics operate in field under standing orders from an Emergency Medicine physician) but physiatrists hold the legal and feduciary responsibility for certifying that the therapy services provided are medically necessary.

CMS is pretty clear about that point and we take their concerns seriously as our institution is one of the country's largest recipients of therapy service revenue from CMS. I'm not sure how that fact or duty can offend anyone. If CMS decides that we're doing a poor job of that, we'll all be standing in the same soup line. And, it's not clear to me how making sure that therapy services are necessary and medically appropriate detracts from a multidisciplinary team approach. Who else is qualified to do it?

My understanding of multidisciplinary care is not that "everyone is equal," but that everyone's skills are maximally used to the benefit of the patient...

You'll have to take my word that our therapists appreciate that almost all patients requiring therapy services have a physiatrist involved in their care. You'll also have to take my word that primary services are very happy not to be called by therapists asking about restrictions and what not. Most primary services, especially surgical services, are disinterested in the disability management piece and don't like to bothered with it so they're are very pleased that physiatry takes care of all that.

When these issues do arise, therapists have a familiar, like-minded, knowledgable, and "disability-savvy" physician to run things by. When was the last time you found an ICU intern's advice about a prosthetic prescription or adaptive equipment particularly helpful??

 

[DPT]

"And, it's not clear to me how making sure that therapy services are necessary and medically appropriate detracts from a multidisciplinary team approach. Who else is qualified to do it?"

Totally agree with you for the inpatient rehab setting..but you are involved during acute care for all therapy patients? Why would you need an MD to act as a middleman from the therapist providing the rehab to the primary team, be it ortho, plastics, ct, burns, trauma...From experience (University of Texas Medical Branch in Galveston), it is not needed in acute care. We go straight to the residents/faculty with questions/concerns and, you'll have to take my word, that they do not mind it coming from a therapist who is providing the rehab . You'll also have to take my word we prefer hearing the clarifications from the primary source instead of a translation of what they said about our questions. I don't know...maybe new grads and students would appreciate it, but for experienced therapists, it would ba a hassle to have a middleman to the primary.

So I guess my question is...if having PM&R consultants in acute care is so effective and required legally to 'certify' therapy (not sure what that means), why is it not a standard of care at all facilities?

 

[bbbmd]

OK, I do not want to get involved in this "debate", but there is no PM&R department at UTMB! Great PT school as I work with a lot of their graduates and they pump out excellent therapists, but since there is no PM&R consultant that sees patients in the ICU and acute care setting there, you may not know just how beneficial a Physiatrist can be in that setting.

In Houston, where many of the UTMB PT grads practice (a few good friends of mine) we work TOGETHER in improving the quality of care for the patients in the acute care setting. We are most helpful to the primary team when it comes to TBI, SCI, Polytrauma rehab and medical management as we are able to see the BIG PICTURE and better utilize the talents of the PTs/OTs and Speech to improve outcomes. I value your expertise in improving mobility, but Physiatrists could better asses the patient's need for pain meds, spasticity meds and neurostimulants that may limit rehab progression and your efforts in mobilizing the patients. I cant count the number of times during my training where the therapists have said- "no further gains from therapy- d/c from PT" and then PM&R gets consulted, gives some pain meds, spasticity meds, recommend splinting, start stimulants and VIOLA--> new goals!!! That is why rehab is a team approach!!!

I do not want to start "turf" wars with the therapists, but you need to put things in perspective as to what will benefit OUR patients more given our individual expertise.

B

 

[bbbmd]

By the way, many of the inpatient acute care therapists here (Texas Medical Center Institutions) are the first ones to write "recommend PM&R consult" in the charts for the primary care team. I dont know how it works just south of us in Galveston, but its interesting that there seems to be such a dichotomy when it comes to "rehab services" in two cities just 45 minutes away. In my opinion, UTMB needs to invest in a Physiatrist.

Im curious to hear what residents in other programs have to say. I assume that there really are no concerns like this in settings where therapists work with Physiatrists. In my experience, we have great relationships and VALUE what each other does.

B

 

[DPT]

I agree with you B. Great post. I also work at LTACs/SNFs in the area and will often times recommend a PM&R consult to a particular physiatrist that we all respect and work very well together. There are a few others that we don't really care for who have an ego problem and dictate inappropriate orders on a regular basis. (ie. PT walk pt. 4x daily, PT use a tilt table...when the patient is walking in the parallel bars, PT use bilat. AFOs...when the patient has fair DF strength and walks fine without them.etc.) The physiatrist we like will suggest or ask to consider a PT/OT intervention, but does not write an order for it and underline it 5 times.

Not sure why UTMB does not have PM&R service, nor do they even have an inpatient rehab for an 800+ bed facility. That's probably why. It was cut about 5 years ago but that's a different study. I would welcome the program if they all had your attitude and respect for therapy B.

My main point to the original post was to suggest not saying PM&R 'supervises' therapists. It triggers a defensive response and turf war. When I asked a group of PTs/OTs/STs today about it (most work in the medical center), the responses were mainly "I don't recall that in our state practice act."

We work together to optimize a patient's functional independence.

 

[Sohalia]

DPT, I find your posts very interesting...(and somewhat concerning).

 

[DPT]

Hi Sohalia. What particularly do you find concerning? I'll try to elaborate.

 

[bbbmd]

I would welcome the program if they all had your attitude and respect for therapy B.

My main point to the original post was to suggest not saying PM&R 'supervises' therapists. It triggers a defensive response and turf war. When I asked a group of PTs/OTs/STs today about it (most work in the medical center), the responses were mainly "I don't recall that in our state practice act."

I know that "supervision" is a touchy subject between Medicine (MD/DO) and Physical Therapy- I am going to completely shy away from this subject because it can become very nasty. But, for the sake of the med students and new residents reading this thread--> Look up your State's stand on Direct Access to Physical Therapy. You will have a better understanding of why this is such a touchy subject for DPT, drusso and myself (as well as the senior residents and attendings on this forum).

To be politically correct, I shy away from saying "supervision". However, DPT cannot deny that once a Physiatrist is consulted, or when the Physiatrist is the primary in the rehab hospital/unit, it is the Physiatrist who is the rehabilitation TEAM LEADER. The physiatrist will coordinate care between the therapies because, of all the members on this team, it is the physiatrist that can see the big picture. This can also be translated into an outpatient setting. For complex cases requiring the services of multiple therapies, the physiatrist can determine which therapies would be the most beneficial for the patient, therefore utilizing therapy resources more efficiently. There have been countless times where a FP doc, Orthopod, Anesthesia Pain doc continued to write for therapy orders even if the patient did not benefit from it--> poor utilization of services and EXPENSIVE. There has to be a system of checks and balances out there and the Physiatrist is the best person for this given that we understand disability more than anyone in the medical and allied health fields. So, I guess I wouldnt say "supervise", rather I would say "lead" or "guide" the team (PCPs, Orthopods, DPTs, OTs, STs, Neuropsych) to provide the most appropriate care.

B

 

[PMRDr]

One thing that I find concerning about our field is the amount of PM&R specialist who have an inferiority complex. Many people in this field feel the constant need to self affirm themselves by saying such nonsense as "Doctor is to Pharmacist, as Physiatrist is to Physical Therapist" or continously try to convince themselves that physical therapists require their "supervision" or whatever else you like to call it. It may be true that we often act as team leaders (i.e. inpatient rehab in particular) but to suggest that this is essential in all situations is utterly ridiculous. In most states, including mine, patients have direct access to physical therapy services and do not require a referral. I agree completely with DPT in that this attitude is not conducive to team work and does not foster an optimal working environment for the rehab team. We will not grow as a specialty until we stop this turf war with PT's and understand that we offer seperate services from our allied health professionals. We are medical doctors and as such have access to medical interventions such as prescription medications and diagnostic imaging and test. PT's are able to autonomously handle many conditions without such interventions or "supervision". However, there are many sitiuations when these become essential, and that is when our services are required. So, in closing, be secure in yourself and your training and stop this pissing contest with your rehab colleagues.

 

[DPT]

I could not have said it any better PMRDr. Thank you.

By the way, this question about the difference between a 'rehab doc' and the patient's 'physical therapy doc' will likely be heard more in the future as all PT programs transition to the Doctor of PT (DPT).

 

[bbbmd]

"One thing that I find concerning about our field is the amount of PM&R specialist who have an inferiority complex. Many people in this field feel the constant need to self affirm themselves by saying such nonsense as "Doctor is to Pharmacist, as Physiatrist is to Physical Therapist" or continously try to convince themselves that physical therapists require their "supervision" or whatever else you like to call it."

"Dito"

"It may be true that we often act as team leaders (i.e. inpatient rehab in particular) but to suggest that this is essential in all situations is utterly ridiculous."

"Dito"- Dont need to see all therapy patients, nor do I want to!!!

"In most states, including mine, patients have direct access to physical therapy services and do not require a referral."

I didnt know this was in MOST states. I will not comment on this, but I will have to stand by the academy. Here is a link on their website with regard to their current stance on this subject:

http://www.aapmr.org/hpl/legislation/wthousemtg.htm

"I agree completely with DPT in that this attitude is not conducive to team work and does not foster an optimal working environment for the rehab team. We will not grow as a specialty until we stop this turf war with PT's and understand that we offer seperate services from our allied health professionals. We are medical doctors and as such have access to medical interventions such as prescription medications and diagnostic imaging and test. PT's are able to autonomously handle many conditions without such interventions or "supervision". However, there are many sitiuations when these become essential, and that is when our services are required. So, in closing, be secure in yourself and your training and stop this pissing contest with your rehab colleagues".

Well said!!!

 

[rehab_sports_dr]

I agree with the greater points made by BBBMD and DPT, in that therapists should be treated as valuable professionals and colleagues, and not subordinates.

That said, the starting point for this thread was the fact that many people have no idea what a physiatrist is, and often think we are a physical therapist.

I think it is important to clarify that we are indeed physicians with a different skill set than physical therapists, because it implies a misunderstanding of the skill set of a physiatrist. Therefore, I think it is important to let our colleagues what we offer that a physical therapist cannot (medications, medical diagnoses, injections, electrodiagnosis, etc.), and equally important to clarify what we do NOT provide that a physical therapist can (a PT diagnosis (which is similar, but still distinct, from our evaluation), and actual provision of therapy, which physiatrists very rarely do).

The elephant in the room, of course, is that not only is our training different than a PT's, it is far more comprehensive. It does a disservice to PM&R to pretend that their a "seperate but equal" detail in our training. While it is true that experienced PT's know more about certain things than physiatrists do, it is more common the other way around. And in this sense, the physician (physiatrist or otherwise) provides an important role in overseeing the care of many patients (but not all) that require therapy.

Bottom line, physiatrists have to continue to fight for our role in the provision of comprehensive therapeutic care, so that our importance is not ignored.

 

[Dr. Dix]

I could not have said it any better PMRDr. Thank you.

By the way, this question about the difference between a 'rehab doc' and the patient's 'physical therapy doc' will likely be heard more in the future as all PT programs transition to the Doctor of PT (DPT).

I read with great interest as the discussion on this thread unfolded. Although I agree with most things BBB and DPT have said, I do have to draw the line at calling DPTs "physical therapy docs". Much like you wouldn't call a PharmD a "pharmacy doc", I don't thnk DPTs should be called "physical therapy docs".

the term "doc" implies a medical doctor, which carries a lot of implications for the patients, including the ability to give medical advice, diagnose and treat medial problems, etc. As many in the lay community don't even know that Dr. Phil is not a real "doctor", it would be terribly confusing and even dangerous to promote the use of the term "physical therapy doc".

I respect the work DPTs do and their expertice. At the same time, I think DPTs should respect the work and difference in training we physicians have gone through. As a physician who gets called to the therapy gym several times a day by therapists who have patients who complain of dizziness or chest pain, I think physicians and therapists can maintain a respectful relationship while understanding our own limitations and abilities.

If there is someone sick in the theater and they ask for a "doctor" in the house, would DPTs identify themselves as "therapy docs" and offer to help?? If a pregnant woman in physical therapy goes into labor, can the therapists deliver the baby? 😕

 

[CasaElGato]

If a pregnant woman in physical therapy goes into labor, can the therapists deliver the baby? 😕

As much as I love PM&R, I am not sure I would want a physiatrist to deliver babies in the rehab gym either. I am going into PM&R and have delivered a total of 5 babies in my long illlustrious medical career to date with a resident right behind me and an ob/gyn attending attending away in the corner of the room (and this will probably be my grand total). Anyone can probably fake a NSVD but how about a more complicated presentation? I think it would be time to consult ob/gyn (inhouse like Harborview) or 911 stat (freestanding like Helen Hayes).

 

[DPT]

I did not mean to imply therapists will call themselves 'PT docs', rather 'Doctors of Physical Therapy'. I was simply stating a patient might call a DPT the 'PT doc' for short.

I don't believe it requires an MD to be able to call a person doctor. Do you think a doctor of dentistry, podiatry, optometry, or a number of other doctoral degrees (PhDs, etc) should not be called doctor as well? I know several PTs, OTs, and STs with PhDs who call themselves doctors in the clinic. I have never heard a patient confuse them for a medical doctor as they make it clear they are therapists and not just "Dr. ____."

I personally choose not to call myself 'doctor' in the acute care setting and do not expect it from my colleagues, even though I earned the degree (which typically involves additional training in Diff. Dx, pharmacology, and radiology to prepare therapists for direct access) Maybe things will change in the future though. Also, I would like to point out that a DPT is in no way even a comparison to an MD as you well know. Your training is FAR BEYOND ours and, as rehab sports dr pointed out, FAR more comprehensive.

This subject of being called doctor has been debated for years in our profession. If you would like to learn more about it, please go to www.rehabedge.com It is under the 'future of PT' forum. It is also a great website and the therapists there would welcome your insight to rehab medicine.

In closing, here is the APTA's stance taken from the apta website:
Once I get a DPT (transition) degree, can I be called "Doctor ______?"

Yes, and possibly, no. Conferral of the DPT degree means that the graduate is entitled to all of the rights and privileges associated with the doctoral degree. However, whether, where, or when a practitioner exercises those rights and privileges (eg, a request to be referred to as Doctor Jones) is a matter of professional judgment based on a variety of factors, including the need for sensitivity during a period of transition for physical therapy to a doctoring profession.

In spite of aforementioned rights and privileges associated with the clinical doctorate, it is possible that a PT practice act or other health profession practice act precludes a physical therapist from being called "Doctor" in the clinical setting. Such a rule may be enforced during the early stages of the transition of physical therapy to a doctoring profession and/or until such time as the state laws are changed.

 

[rehab_sports_dr]

I personally believe that when people call themselves doctor, they should be very conscious of the setting and the how the patient might interact.

For example, I am an MD-PhD, and I had my PhD before I was an MD. Back when I was a 3rd year medical student, while I was ok with my friends referring to me as a doctor in social settings, I was very insistent that my colleagues NOT call me a doctor around patients, because it implied a level of expertise to which I was not entitled. The patients deserved to understand that I was a clincian in training.

I think this applies to physical therapists as well. The doctorate in PT implies a greater PT knowledge-base, but it does not imply the same knowledge base as a physician. My impression is that most patients would misconstrue the title of doctor in reference to a doctorate in PT. I think this is inappropriate.

To me, it is similar to those nuses who have PhDs in nursing. They have a higher knowledge base in nursing, but I don't think they should refer to themselves as doctors in front of patients. To do so misrepresents their skill sets to patients.

 

[paz5559]

I am curious - if you hold yourself out to be a doctor of PT because of your DPT degree, does that mean you consider chiropractors and lawyers doctors as well (degrees DC and JD, respectively)?

Only 20 states allow unlimited direct access at this point (http://www.fsbpt.org/publications/DirectAccess/) so it is not a majority)

The relevant difference between inpatient team work and outpatient turf battles regarding referrals is not the need for teamwork - it is the far better lobbying job PT's have done below the radar in the state legislatures to gain the right to direct access. That doesn’t make it ethical, better for the patient, or right - it means the PT's out maneuvered us politically.

Are PTs ALLOWED to see patients without referrals in those states? Yes. Are PT's ABLE to autonomously handle many conditions without such interventions or "supervision"? There is the 64 thousand dollar question, and I for one, am no where near as certain as DPT or PM&R Dr appear to be.

When a patient's care is being supervised by a physician, there are checks (medical history, periodic evaluations for appropriateness of continuation of care) that are inherently necessary, but potentially run counter to the PT's business interests.

Lastly, if PT's feel qualified to make those medical judgments that patients can safely undergo therapy, I wonder, when something goes wrong, if the PT ought to be held to the standard of the ordinary and reasonable PHYSICAN, rather than therapist, when it comes to malpractice responsibilities. After all, if therapists feel qualified to be making medical judgments, shouldn't they be held to the same standard any physician would be?

 

[drusso]

I think that Paz hits the nail on the head. I'm a little surprised by the reaction on the forum to the idea that physiatrists supervise the medical rehabilitation of patients receiving therapies services. I thought that this has been the foundation of our field and has always been a "no brainer" for me.

The fact that acutely injured and disabled patients need comprehensive rehabilitation services during their acute hospital stay, during the post-acute phase of recovery, and coordinated multidisciplinary follow-up is a fact that all leading professional organizations, including the Amercan College of Surgeons who accredits trauma centers, recognizes. I think what separates top centers of excellences from smaller, community-based programs is the level of integration of these services and the degree to which they are medically supervised.

We all know that where there exists a shortage of specialists, generalists pick up the slack. At some places general surgeons do thoracotomies, cataract removals, fracture setting and ORIF, and even CABGs, but this does not mean that general surgeons are the ideal practitioner for these cases. Similarly, at some centers rehab services are fragmented and lack any comprehensive medical rehab supervision, but this is not necessarily preferred either. I'm sure that at some places, therapists "go at it alone" evaluating and treating patients, but I still believe that the medical supervision and coordination of rehab services has value for patients and improves patient safety.

So, I want to clarify for DPT how this process works since I sense that he believes that medical supervision unervalues the role of therapists as autonomous clinicians...

Let's say that a trauma patient comes to our center as a Level II or higher. A PM&R consult is reflexsively triggered. The consult is triaged to a supervisor who decides which PM&R team will see the patient based upon the primary diagnosis, mechanism of injury, or special-needs population. At our center these include Spinal Cord Injury, Acquired Brain Disorder (Stroke, TBI, etc), Pediatrics, General Ortho Trauma, Acquired Limb Loss (amputee and dysvascular), or Cancer. Each team is comprised of a staff physiatrist, a resident physiatrist, 6-12 therapists (PT, OT, Speech), a social worker, a nurse educator, and a psychologist.

Every day representatives from the team (usually the attending physiatrist, the resident physiatrist, and one or two therapists from each discipline) meet to briefly discuss the new consults and review new issues for established patients. Then, the resident begins seeing new consults. This is the part where I introduce as a rehab doctor and explain the role of our team and my role as someone who supervises the delivery of rehab services in the hospital. I examine the patient, review their medical history, their social history, their family history and review their care to date. Then, I leave recommendations for preventing secondary complications, therapy services, maximizing their function, relieving their pain, and start thinking about dismissal planning and out of hospital needs. I know many residents in other programs so sometimes I pick up the phone and call them about urgent medical issues that are often overlooked (pain, ileus, undiagnosed injuries, etc). After I'm done, the therapists begin seeing the patient right away and deliver therapy as individually prescribed. The whole team follows the patient through their acute hospitalization until dismissal or transfer to acute rehab where another inpatient team picks up the patient.

Because our teams are large, our patients are complicated, and our therapists rotate in different areas of the practice, the only consistent contact that the patient and their family has is their primary team (usually overworked and tired surgery interns who are responsible for "running the floor") and their rehab team. Different therapists from the team may see patients on different days depending upon the work flow and therapist availability.

I think that DPT can see that the system is highly integrated, very multidisciplinary, coordinated, and, yes, physician directed. I think that this system provides excellent care because of the central role of physician management. Yet, our therapists and our teams have no turf issues or professional hostility directed toward PM&R physicians---at least none that I've encountered. They can't bill for what we do: Medically evaluate and treat patients. And we can't bill for what they do: Deliver therapy services. Since we all work in the same department, all the money goes into one pot. We all have a stake in making the process as efficient and profitable as possible. Our outpatient practice works in a similar fashion although there does exist more "direct therapy evals" based upon standardized treatment protocols and previous evaluation by another physician...rheumatology, ortho, selected neurosurgical patients, etc.

I would like to know how things run in the abscence of physiatrist oversight where DPT works...

 

[DPT]

Sure. Each service (trauma, burns, ortho, plastics, ICUs..) will have their own case manager(s) and a primary PT and OT. The primary team consults therapy services when the patient is medically stable or a consult is generated during team rounds.

The PT evaluates the patient, determines the PT plan of care, and screens for other services such as OT or ST, requesting consults when appropriate. If there are any concerns regarding mobilization, additional fractures, exposed tendons, signs of DVT, questionable lab values,..we consult with the primary team and clarify any precautions. Good communication is the key and the primary team is generally within earshot to answer questions. For example, in the burn ICU a team member is either in the tub room or in the unit. Another reason I believe communication is excellent at UTMB vs. other facilities I’ve worked is everybody writes in the same progress notes...MD, care managers, therapists, consulting services...It is a perfect time line of what has occurred each day. There are not different sections of a medical chart where the physician must flip through to find a patient’s progress in therapy and readiness for discharge. In my experience with that type of system, the MD typically does not take the time to look it up and there is a communication breakdown. The therapists work closely with the primary team and CMs in determining DC plans such as the next appropriate setting (inpt rehab vs. SNF vs. LTAC vs outpt PT vs. HHPT), equipment needs, need for family training, home safety eval, PT clearance for discharge home, etc...

If there is a pain control issue, the pain service is consulted. If there is a need for spasticity management and neuro is not the primary team, neuro is consulted. It is physician directed, but by the primary team.

Most of my experience is in acute burn rehab. I'm curious...Is PM&R involved in burn rehab at your acute facility? Most of what I have read about PM&R is in areas such as TBI, CVA, SCI, amputee, and other areas, but I haven't seen anything about burn rehab. Thanks.

 

[jsaul]

Sure. Each service (trauma, burns, ortho, plastics, ICUs..) will have their own case manager(s) and a primary PT and OT. The primary team consults therapy services when the patient is medically stable or a consult is generated during team rounds.

The PT evaluates the patient, determines the PT plan of care, and screens for other services such as OT or ST, requesting consults when appropriate. If there are any concerns regarding mobilization, additional fractures, exposed tendons, signs of DVT, questionable lab values,..we consult with the primary team and clarify any precautions. Good communication is the key and the primary team is generally within earshot to answer questions. For example, in the burn ICU a team member is either in the tub room or in the unit. Another reason I believe communication is excellent at UTMB vs. other facilities I’ve worked is everybody writes in the same progress notes...MD, care managers, therapists, consulting services...It is a perfect time line of what has occurred each day. There are not different sections of a medical chart where the physician must flip through to find a patient’s progress in therapy and readiness for discharge. In my experience with that type of system, the MD typically does not take the time to look it up and there is a communication breakdown. The therapists work closely with the primary team and CMs in determining DC plans such as the next appropriate setting (inpt rehab vs. SNF vs. LTAC vs outpt PT vs. HHPT), equipment needs, need for family training, home safety eval, PT clearance for discharge home, etc...

If there is a pain control issue, the pain service is consulted. If there is a need for spasticity management and neuro is not the primary team, neuro is consulted. It is physician directed, but by the primary team.

Most of my experience is in acute burn rehab. I'm curious...Is PM&R involved in burn rehab at your acute facility? Most of what I have read about PM&R is in areas such as TBI, CVA, SCI, amputee, and other areas, but I haven't seen anything about burn rehab. Thanks.

yes most burn units consult physiatry...it is part of the training

 

[DPT]

What does a physiatrist do in the burn ICU?

 

[axm397]

What does a physiatrist do in the burn ICU?

I think having a physiatrist START their evaluation and rehabiltiation planning of a burn patient in the acute care setting makes a lot of sense - like having a physiatrist take part in the initial eval and treatment of spinal cord injuries. Our presence allows for prevention of common complications, and earlier initiation of therapeutic modalities. there's also the continuity of care issue. I think families like having a physician they can talk to about their concerns, discharge plans, etc.

For example: From the Lehigh valley hospital burn center website:
Physiatrist
The physiatrist is a doctor who specializes in physical medicine and rehabilitation for persons who have disabling conditions. He directs the rehabilitation, nursing and other members of your care team. The physiatrist sees all critically injured patients admitted to the burn center, setting rehabilitation goals and coordinating the best treatment plan.

Many top programs in the country, including Hopkins, Baylor, HSS, Cornell, to name a few have physiatrists on staff in the burn unit directing rehabilitation. the hopkins burn center faculty includes THE Dr. DeLateur - http://www.hopkinsmedicine.org/burn/faculty/index.html

The VA systems utilizes physiatrists in that role as well: "Individuals are identified for referral to BIP through the military, VA personnel, and/or self-referral. A number of self-referrals were a result of "word of mouth" recommendations from other BIP patients. Patients initially receive a comprehensive medical evaluation by a physiatrist. This evaluation includes self-reported medical history and current complaints, followed by a comprehensive medical examination from a physician specializing in rehabilitation medicine. Findings from these initial assessments trigger appropriate treatments and/or referrals to other specialists in the areas of brain injury evaluation and treatment, amputation management and prosthetics, hearing impairment, and emotional adjustment/stress management. All BIP patients receive ongoing case management and follow-up services. " from http://www.vard.org/jour/05/42/4/belanger.html

Some of the things we are trained to do: wound care/scar prevention, speaking with families about return to home/society, coordinating care for the associated psych issues (PTSD, etc), pain management, ruling out HO before casting program, treating and preventing infection, if respiratory problems exist - managing them including trach and vent management, management of electrolyte imbalance and nutrition, dealing with sleep disorders, treating co-morbidities and complications, if any other injuries co-exist (commonly, TBI, SCI, etc) we treat that as well. As a matter of fact, our program director published an article on burn rehab: Inpatient rehabilitation following burn injury: patient demographics and functional outcomes. Arch Phys Med Rehabil. 2005 Oct;86(10):1920-3. Our PD takes care of many burn patients at RIC and patients come from all over the country - surgeons and other specialists all respect him and his role as a physiatrist directing their patients' rehabilitation. They are in direct contact with him as the patient progresses, and they discuss treatment options for complications and sequele of the burn.

And that's just a little part of what we are trained to do as physiatrists.

I'm sure there are political forces behind every decision made in medical institutions and turf wars everwhere. Not sure why UTMB does not have a physiatrist - or a rehab unit for that matter...I work at an institution where physiatrists and therapists work very well together with no attitude/turf war problems. We all have different roles on the team and mutual respect for each other. The therapists expect me to "solve" medical issues as they arise and we in turn do our best to minimize issues that can negatively impact therapeutic progress and keep therapy the priority of the patient's stay. As patients being admitted to in-patient rehab gets sicker and sicker, the more the need for a properly trained physiatrist to direct the rehabilitation care. The medical directors at RIC have the respect and admiration of the therapists. The therapists at RIC are top notch and probably some of the best in the country. I have had the pleasure of establishing many quality relationships with the therapists at this institution. I only hope that DPT can enjoy that kind of relationship with physiatrists in the future.

 

[jsaul]

What does a physiatrist do in the burn ICU?

you and this thread are becoming trite.

pain control, neuropathic pain control, sleep wake cycle recalibration, opitimize nutritional intake during the period of catabolism, balance medical needs of the patient and their rehabilitation, monitor and diagnose and treat for HO. etc, etc, etc...

if you need to know more about all this-- just do yourself a favor, stop trolling this board, leave your sheltered work place and travel a little bit north on this road called I-45 to a place called the texas medical center- your mecca and get "enlightened"

 

[DPT]

Thanks axm. It does make sense and RIC is very well respected!

Jsaul...simmer down. Just a question.

Clearly there are different models of burn care in Galveston (Shriner's Burn Hospital for Children and Blocker Burn Unit at UTMB) and what you refer to as "the mecca". I discussed this topic with a plastic surgeon today who did his residency at the Shrine/UTMB. He stated that the burn units there are completely "surgeon-driven" and it has been that way since the days of Dr. Blocker. There is no physiatrist on the burn teams. Take a look for yourself.

http://www.totalburncare.com

I just wanted to point out this difference and provide some insight of why I was unsure of a physiatrist's role in acute burn rehab. jsaul...Before making a statement like 'drive up 45 and get enlightened', take a look at the research being pumped out of Galveston on burn care advancement. If you feel the quality of care can be improved with a physiatrist onboard, feel free to call Shriner's and ask for Dr. Herndon. I'm sure he will be receptive to 'being enlightened'.

Thanks for the information on PM&R!

 

[paz5559]

Lastly, if PT's feel qualified to make those medical judgments that patients can safely undergo therapy, I wonder, when something goes wrong, if the PT ought to be held to the standard of the ordinary and reasonable PHYSICAN, rather than therapist, when it comes to malpractice responsibilities. After all, if therapists feel qualified to be making medical judgments, shouldn't they be held to the same standard any physician would be?

DPT, I notice you did not comment on the above, and would appreciate your insight regarding the matter

 

[Spine Specialist]

DPT, I notice you did not comment on the above, and would appreciate your insight regarding the matter

No one can get away from Paz...

 

[jsaul]

Thanks axm. It does make sense and RIC is very well respected!

Jsaul...simmer down. Just a question.

Clearly there are different models of burn care in Galveston (Shriner's Burn Hospital for Children and Blocker Burn Unit at UTMB) and what you refer to as "the mecca". I discussed this topic with a plastic surgeon today who did his residency at the Shrine/UTMB. He stated that the burn units there are completely "surgeon-driven" and it has been that way since the days of Dr. Blocker. There is no physiatrist on the burn teams. Take a look for yourself.

http://www.totalburncare.com

I just wanted to point out this difference and provide some insight of why I was unsure of a physiatrist's role in acute burn rehab. jsaul...Before making a statement like 'drive up 45 and get enlightened', take a look at the research being pumped out of Galveston on burn care advancement. If you feel the quality of care can be improved with a physiatrist onboard, feel free to call Shriner's and ask for Dr. Herndon. I'm sure he will be receptive to 'being enlightened'.

Thanks for the information on PM&R!

why would I call a hospital in galveston? Why?
things are done differently in different institutions. Everyone knows that.

Simply put, you have come onto an doctor's board and trolled. You asked a question and it was answered.

If you have some agenda or some issues then go back and talk with your beloved plastic surgeon.

 

[DigableCat]

Looks like "RAY" has ideas and plans already. Thanks for the link DPT.

http://www.rehabedge.com/cgi-bin/ultimatebb.cgi?/ubb/get_topic/f/38/t/000007.html#000027

I believe that we should move to supplant physiatrists by preswcribing meds, imaging and even pursuing EMG and NCV certifications. I strongly believe that it is in the best interest of our profession, to push our skill set and begin to mandate DPT level clinicians and mandatory CEU's. I realize this is not comfortable for everyone, but I truly believe that we have so much to offer that tose that don't share in the exploring the full potential of our field are providing a signficant drag force to the obvious directionthe field is taking. I truly do not mean to offend anyone, I just feel very passionate about our abilities and am sometimes frustrated with what seems to be a lack of confidence by many about moving forward in various areas eg: DPT, imaging etc. I believe to survive in the aggressive and volatile health care arena that a profession must subject itself to strong standards and goals to evolve and face potential obseletism. I invite any and all criticism or support.

http://www.rehabedge.com/cgi-bin/ultimatebb.cgi?/ubb/get_topic/f/10/t/000077.html#000023

I agree and disagree with some of the points regarding salary. For most of us we have been steeped in a tradition of passive recipient of referrals from doctors including physiatrists with little to no knowledge of the intricacies of rehabilitation. The skill set required of a master clinician is grossly underestimated. Why should a physiatrist with a few years of residency in rehab and typically a frac tion of the working knowledge commnad what they do.

I knew of many PTs who felt very similar to this.

 

[paz5559]

Looks like "RAY" has ideas and plans already. Thanks for the link DPT.

http://www.rehabedge.com/cgi-bin/ultimatebb.cgi?/ubb/get_topic/f/38/t/000007.html#000027



http://www.rehabedge.com/cgi-bin/ultimatebb.cgi?/ubb/get_topic/f/10/t/000077.html#000023



I knew of many PTs who felt very similar to this.

Hopefully, I don't know as many, but my knee-jerk response is, if they wanted to practice medicine, they should have gone to med school.

 

[drusso]

Looks like "RAY" has ideas and plans already. Thanks for the link DPT.

http://www.rehabedge.com/cgi-bin/ultimatebb.cgi?/ubb/get_topic/f/38/t/000007.html#000027



http://www.rehabedge.com/cgi-bin/ultimatebb.cgi?/ubb/get_topic/f/10/t/000077.html#000023



I knew of many PTs who felt very similar to this.

Obviously, these individuals do not understand that only increasing access does nothing to improve quality. More to the point of this thread, I think that we've just discovered where PT's stand on scope of practice issues from a stakeholders point of view.

It's frightening that someone can believe learning to diagnose, treat, and rehabilitate neuromusculoskeletal disorders (a combination of two of the most complicated and poorly understood organ systems in the human body) can be done in isolation from a comprehensive medical education. Do you really expect some to learn electrodiagnosis without being grounded in a basic neurology education?

The higher ground issue is that all patients deserve quality neuromusculoskeletal care in this country. The USBJD has been hammering this point home. Increasing Access to services by expanding scope of practice in no predictable way affects quality (value/cost). Neuromusculoskeletal medicine and rehabilitation is complex and requires an in depth medical knowledge of the normal and disordered functioning of virtually every human organ system. This training is only provided through a comprehensive medical education.

 

[rehabmd]

I believe the issue is not that the neuromuscular examination skills of PTs are inferior to physiatrists. In my experience, the neuromusculoskeletal exam skills of most PTs are equal if not superior clinically to graduating physiatrists. (I dont know what happens after they graduate) PTs are trained by therapists and lectured frequently by clinicians such as orthopods, neurologists etc. So PTs now have stepped into our diagnosis territory but our academic rehab depts dontr require them to teach us what they do and know, which is ALOT of knowledge and skills(that patients and other doctors value). Whenever I attend musculoskeletal conferences sponsored by orthopods and neurologists, there are far more PTs that attend than physiatrists. The academic conference budget at the "academic" physiatry institution I work at is greater for PTs than physiatry attendings. Most orthopods and neurologists here in NYC hire PTs over physiatrists, and most academic rehab depts give PTs direct access to outpatient rehab, and there are more female PTs who hold Associate Professor and Professor titles than female MDs in virtually all of the NYC rehab depts. THeir skills are valued more financially, as well, eg most early intervention programs in NY pay $200 for a Pediatric Physiatrist or a SPecial Educator (who is not a clinician)to do a neuromusculoskeletal screening eval of Gross motor, fine motor, language, social, and adaptive behavioral skills-takes about 1-2 hours. If I refer that patient for a supplemental PT eval, the PT gets paid atleast $300 for their eval, since they are consisdered neuromusculoskeletal specialists. The issue unforunately is one of denial in the inadequate outpt training of physiatrists. When they graduate its often too late to learn skills. THey are fatigued from being on call putting IVs in the 100 bed inpatient unit to learn during or after residency. I speak having worked and trained physiatry residents in all the three NYC programs. Because my specialty is pediatric rehab, I work with and teach pediatric, orthopedic, family medicine and physiatry residents at various hospitals. I have to admit that my family medicine residents are much stronger than my physiatry residents when it comes to understanding comprehensive musculoskeltal care. The difference is that my family medicine residents are more accountable to the patients since they are primary care doctors. Many of my graduating physiatry residents are the the only outpatient residents I train who feel entitled to walk out the door at 4PM and refer the patient to ortho, neuro or PMD or PT if the patient's history and exam requires them to work past 4 PM. They dont consult with therapists about functional issues or outcomes of their treatments bc its not acute management , but they dont do acute mangement either. Many of my physaitry residnets just want to stick a needle in a patient w/o taking a hx or PE. THe FP residents who are trained by sports medicine FPs are better at how to do a neuromusculoskeletal exam, generate a muscuoskeletal differentioal diagnosis, and counselling their patients about nutrition and holistic health care and showing their patients how to actually do exercises, which is something my physiatry residents defer to PTs. I think our specialty has a lot of potential, but physiatry residents need to be taught that in order for them to get patients they need to have the same level of accountabiltiy, responsibilty toward their chosen profession as other outpatient physicians and therapists.

Obviously, these individuals do not understand that only increasing access does nothing to improve quality. More to the point of this thread, I think that we've just discovered where PT's stand on scope of practice issues from a stakeholders point of view.

It's frightening that someone can believe learning to diagnose, treat, and rehabilitate neuromusculoskeletal disorders (a combination of two of the most complicated and poorly understood organ systems in the human body) can be done in isolation from a comprehensive medical education. Do you really expect some to learn electrodiagnosis without being grounded in a basic neurology education?

The higher ground issue is that all patients deserve quality neuromusculoskeletal care in this country. The USBJD has been hammering this point home. Increasing Access to services by expanding scope of practice in no predictable way affects quality (value/cost). Neuromusculoskeletal medicine and rehabilitation is complex and requires an in depth medical knowledge of the normal and disordered functioning of virtually every human organ system. This training is only provided through a comprehensive medical education.

 

[axm397]

I believe the issue is not that the neuromuscular examination skills of PTs are inferior to physiatrists. In my experience, the neuromusculoskeletal exam skills of most PTs are equal if not superior clinically to graduating physiatrists. (I dont know what happens after they graduate) PTs are trained by therapists and lectured frequently by clinicians such as orthopods, neurologists etc. So PTs now have stepped into our diagnosis territory but our academic rehab depts dontr require them to teach us what they do and know, which is ALOT of knowledge and skills(that patients and other doctors value). Whenever I attend musculoskeletal conferences sponsored by orthopods and neurologists, there are far more PTs that attend than physiatrists. The academic conference budget at the "academic" physiatry institution I work at is greater for PTs than physiatry attendings. Most orthopods and neurologists here in NYC hire PTs over physiatrists, and most academic rehab depts give PTs direct access to outpatient rehab, and there are more female PTs who hold Associate Professor and Professor titles than female MDs in virtually all of the NYC rehab depts. THeir skills are valued more financially, as well, eg most early intervention programs in NY pay $200 for a Pediatric Physiatrist or a SPecial Educator (who is not a clinician)to do a neuromusculoskeletal screening eval of Gross motor, fine motor, language, social, and adaptive behavioral skills-takes about 1-2 hours. If I refer that patient for a supplemental PT eval, the PT gets paid atleast $300 for their eval, since they are consisdered neuromusculoskeletal specialists. The issue unforunately is one of denial in the inadequate outpt training of physiatrists. When they graduate its often too late to learn skills. THey are fatigued from being on call putting IVs in the 100 bed inpatient unit to learn during or after residency. I speak having worked and trained physiatry residents in all the three NYC programs. Because my specialty is pediatric rehab, I work with and teach pediatric, orthopedic, family medicine and physiatry residents at various hospitals. I have to admit that my family medicine residents are much stronger than my physiatry residents when it comes to understanding comprehensive musculoskeltal care. The difference is that my family medicine residents are more accountable to the patients since they are primary care doctors. Many of my graduating physiatry residents are the the only outpatient residents I train who feel entitled to walk out the door at 4PM and refer the patient to ortho, neuro or PMD or PT if the patient's history and exam requires them to work past 4 PM. They dont consult with therapists about functional issues or outcomes of their treatments bc its not acute management , but they dont do acute mangement either. Many of my physaitry residnets just want to stick a needle in a patient w/o taking a hx or PE. THe FP residents who are trained by sports medicine FPs are better at how to do a neuromusculoskeletal exam, generate a muscuoskeletal differentioal diagnosis, and counselling their patients about nutrition and holistic health care and showing their patients how to actually do exercises, which is something my physiatry residents defer to PTs. I think our specialty has a lot of potential, but physiatry residents need to be taught that in order for them to get patients they need to have the same level of accountabiltiy, responsibilty toward their chosen profession as other outpatient physicians and therapists.

I'm sorry you feel that way - I do have to say that the diversity of training across PM&R residency programs is probably a strength and a weakness. At RIC, therapists give residents lectures on specific therapeutic modalities and they attend our grand rounds, etc. We are allowed to attend any course offered by the RIC academy - whether it be geared towards therapists or clinicians. We have sessions taught by OMM fellows on osteopathic manipulation. We rotate with chiropractors. We try to extract the best of all modalities for our education. We are required to do rotations in "therapy" where we shadow various therapists to learn what they do so we can understand how best to facilitate their work. We also learn about "actual exercises" and many of us give our patients some basic exercises to do until they get to their therapy sessions. We obviously don't have the time to spend doing what therapists do best. We are required to be observed AND videotaped performing history and physical examinations to ensure we learn basic neuromuscular examination. We have weekly sports and spine physical exam series and anatomy courses. I don't think we regularly leave before 5 or 6 pm unless we are extremely lucky with our admissions. Many of us stay until 8 - 9pm and come in at 6am. I don't think (that I know of) any of the therapists hold "professor" positions.

So I think the variability within our professional training programs despite all the ACGME requirements can become a problem for us - but sounds like most programs are getting better every year.

 

[Disciple]

I believe the issue is not that the neuromuscular examination skills of PTs are inferior to physiatrists. In my experience, the neuromusculoskeletal exam skills of most PTs are equal if not superior clinically to graduating physiatrists. (I dont know what happens after they graduate) PTs are trained by therapists and lectured frequently by clinicians such as orthopods, neurologists etc. So PTs now have stepped into our diagnosis territory but our academic rehab depts dontr require them to teach us what they do and know, which is ALOT of knowledge and skills(that patients and other doctors value). Whenever I attend musculoskeletal conferences sponsored by orthopods and neurologists, there are far more PTs that attend than physiatrists. The academic conference budget at the "academic" physiatry institution I work at is greater for PTs than physiatry attendings. Most orthopods and neurologists here in NYC hire PTs over physiatrists, and most academic rehab depts give PTs direct access to outpatient rehab, and there are more female PTs who hold Associate Professor and Professor titles than female MDs in virtually all of the NYC rehab depts. THeir skills are valued more financially, as well, eg most early intervention programs in NY pay $200 for a Pediatric Physiatrist or a SPecial Educator (who is not a clinician)to do a neuromusculoskeletal screening eval of Gross motor, fine motor, language, social, and adaptive behavioral skills-takes about 1-2 hours. If I refer that patient for a supplemental PT eval, the PT gets paid atleast $300 for their eval, since they are consisdered neuromusculoskeletal specialists. The issue unforunately is one of denial in the inadequate outpt training of physiatrists. When they graduate its often too late to learn skills. THey are fatigued from being on call putting IVs in the 100 bed inpatient unit to learn during or after residency. I speak having worked and trained physiatry residents in all the three NYC programs. Because my specialty is pediatric rehab, I work with and teach pediatric, orthopedic, family medicine and physiatry residents at various hospitals. I have to admit that my family medicine residents are much stronger than my physiatry residents when it comes to understanding comprehensive musculoskeltal care. The difference is that my family medicine residents are more accountable to the patients since they are primary care doctors. Many of my graduating physiatry residents are the the only outpatient residents I train who feel entitled to walk out the door at 4PM and refer the patient to ortho, neuro or PMD or PT if the patient's history and exam requires them to work past 4 PM. They dont consult with therapists about functional issues or outcomes of their treatments bc its not acute management , but they dont do acute mangement either. Many of my physaitry residnets just want to stick a needle in a patient w/o taking a hx or PE. THe FP residents who are trained by sports medicine FPs are better at how to do a neuromusculoskeletal exam, generate a muscuoskeletal differentioal diagnosis, and counselling their patients about nutrition and holistic health care and showing their patients how to actually do exercises, which is something my physiatry residents defer to PTs. I think our specialty has a lot of potential, but physiatry residents need to be taught that in order for them to get patients they need to have the same level of accountabiltiy, responsibilty toward their chosen profession as other outpatient physicians and therapists.

RehabMD,

I'm sorry to hear how things are done in NYC, but I don't think this is the case for even the majority of the rest of the PM&R world.

I would dare say that Musculoskeletal training is becoming or has become prominent within Physiatry and Physiatric training. Check the leadership for the AAPM&R for the upcoming year. Look at PASSOR, ISIS, NASS and the ACSM. Ask your senior residents about the competitiveness for musculoskeletal and interventional fellowships in the past several years.

I'll be graduating from residency this month, and if most FP sports fellows, etc. were vastly superior to me in performing a neuromusculoskeletal exam I would be humiliated. The city I'm training in has 5 PM&R residency programs. I would say 4 of 5 provide good Neuromusculoskeletal training with 2 or 3 being exceptional.

To help residents less fortunate in their training opportunities, we need standardization(ACGME), meaning required rotations and training more specific than "Outpt care in disability". Something along the lines of "non-operative spine care, sports medicine, general musculoskeletal clinic, acute and chronic management of pain" and the clinics attached to tradional rotations in SCI, TBI, amputee, etc. Educational objectives need to be identified and met (PASSOR PE competencies list, etc.)

Many of the Musculoskeletal leaders in our field trained in the late 80's and early to mid 90's and are finally taking leadership positions within our specialty.

We seem to be heading in the right direction.