Which aspects of PM&R are a "Turn-OFF" for some?

[prominence]

"Plenty of money & relaxation" sounds great. But there are aspects of every specialty that are not desirable, and therefore may make the specialty not suitable for everyone.

For example, violent patients may scare off some from becoming a psychiatrist. Dealing with overprotective parents may turn-off some from becoming a pediatrician. Interacting with female patients who prefer a female OB/GYN doctor may dissuade some male med students from possibly considering a career in OB/GYN. I could easily continue pointing out the negatives for each medical specialty.

What are some of the negative/underappreciated aspects WITHIN the specialty of PM&R?

Note: These negaitive aspects of PM&R should not focus on other doctors disrespecting PM&R docs or their misunderstanding of what the actual field of PM&R entails.

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[rehabmd]

I am an outpatient physiatrist and find it frustrating that I order pnf, scapular stabilization , plyometrics for the right reasons but I have no idea what it looks like. it is something I am trying to learn on my own now that I have graduated. i wish formal residency training included physical therapists teaching us their insights to understanding kinesiology and patient centered musculoskeletal examination. The patients and referring docs think we have that expertise but it's our therapists who do. We are not really experts if we donot understand what we are ordering. And we lose credibility as a specialty. I was a very diligent resident and learned everthing that I was taught and would have greatly appreciated a greater emphasis on physical therapy aspects. I understand the pharmacology of the medications I order for the nurses to administer but I do not really understand the orders I write to physical therapists to administer. All those months of general inpatient rehab scut work made me into a super medical intern, but that is not why people will refer patients to me in the future-they will refer to internists who are experts on inpatient medical care. The months on spinal cord did make me an expert in something that other medical specialists dont feel comfortable handling, but I found that to be the only real valuable inpatient experience i had.

 

[Nikiforos]

Almost anything that a physiatrist does can be done better by another medical specialist.

neuro issues---> neurologist

musculoskeletal issues--> orthopedist, rheumatologist (Physiatrists are better at osteopathic manipulation and chiropractic treatment which many regard as quackery)

medical issues--> internist

spinal injections and interventional pain management--> anesthesiologist

EMG's --> neurologist (some physiatrists are good)

 

[Nikiforos]

INPATIENT REHAB-- DUMP SERVICE, lots of social work, closer to nursing home mentality than acute hospital care, little "rehab" but lots of medical issues (SOB, CHF, chest pain, PE's, pneumonia, GI bleeds, falls from bed,) difficult patients and families unhappy to be in rehab

OUTPATIENT REHAB-- DUMP SERVICE, lots of Worker's Comp liars, car accident "victims," secondary gain issues up the bazoo

 

[drvlad2004]

Originally posted by Nikiforos
INPATIENT REHAB-- DUMP SERVICE, lots of social work, closer to nursing home mentality than acute hospital care, little "rehab" but lots of medical issues (SOB, CHF, chest pain, PE's, pneumonia, GI bleeds, falls from bed,) difficult patients and families unhappy to be in rehab

OUTPATIENT REHAB-- DUMP SERVICE, lots of Worker's Comp liars, car accident "victims," secondary gain issues up the bazoo

Houston, I think we have a hater. Once again, your comments are misguided and ignorant . It sounds like somebody has issues with DOs. You sound as if you've never done a PM&R rotation. It's better to hear from someone who at least an elective in physiatry. I do partially agree with inpatient rehab, but only in terms of medical issues. You have to expect more IM with doing inpatient rehab.

I guess that, once in a while, we have to get a disgrunted poster on this peaceful PM&R forum. It helps establish some equilibrium.

 

[Nikiforos]

mrvlad, don't assume anything. I am an ex-physiatrist, fellowship trained in an anesthesiology pain management fellowship.

I am truthfully posting my opinion in response to the question posed by prominence. You, on the other hand, still have a long way to go in your training and apparently have not even graduated from osteopathic school yet.

Most physiatrists-in -training and wannabes like yourself who post on this forum seem especially thin-skinned. Why the insecurity?

 

[Loves_Chai]

Dr. Nikiforos,

You were trained as a physiatrist with pain medicine fellow training. From your last post it seems that you do not do this career now.

What made to stop and What do you do now?

 

[drusso]

Originally posted by Nikiforos
Almost anything that a physiatrist does can be done better by another medical specialist.

neuro issues---> neurologist

musculoskeletal issues--> orthopedist, rheumatologist (Physiatrists are better at osteopathic manipulation and chiropractic treatment which many regard as quackery)

medical issues--> internist

spinal injections and interventional pain management--> anesthesiologist

EMG's --> neurologist (some physiatrists are good)

I disagree.

Neuro: Sure, for the primary diagnosis of a neurological disease a neurologist is the expert, but ask a neurologist to design a rehabilitation for a MS patient or ask them to make recommendations regarding return to work issues and workplace modifications for a patient with Myasthenia Gravis and watch their eyes roll...

MSK: Have you worked with orthopedic surgeons? They're surgeons. If you have SOB do you go see a cardiothoracic surgeon or a cardiologist? Enough said. Rheumatologists understand rheumatic disease, but miss the boat about function.

Pain: Anyone can be a needle jockey, but physiatrists trained in pain offer a more comprehensive approach to patients.

 

[rehabmd]

I believe there is some truth to each reply above. I trained at a top medical school and a very good rehab residency program, and I did not feel that the rehab residency curriculum gave me the level of expertise that I needed in the care of musculoskeletal issues. Training at a large academic program gives you the ability to handle high volume clinic patients who do not require explanations for their musculoskeletal problems, but I notice now that private patients come in having searched the internet and seen chiropracters and require more sophisticated exams and explanations for their subtle musculoskeletal problems. Other than SCI(where you have more expertise than other docs in patient management issues such as vent management, baclofen pump trials, spasticity management, overall primary care), inpatient rehab is essentially a place where the rehab residents are used for scut work to generate income for the dept at the cost of their education and self-respect, where your consults are read by no one in the hospital, where a social workers or therapists opinion and insight is more valuable than the rehab doc, often because their expertise really is more valuable for those who request the consult. I really believe an OT has more to offer than I do about something as simple as implementing workplace modifications-how can I claim to if I have never seen an ergonomic evaluation during my training-I only ordered it. The only reason for the rehab consult is to get a therapist to start therapy ASAP. That is why most rehab dept chairman will pour money into their PT depts rather than their residencies. Most PT depts now are beginning to offer PT doctorate degrees because the recent medicare bill included legislation on direct patient referrals for therapists, bypassing MD's altogether in the very near future. Some states already allow them to needle EMGs. EMG'a are not difficult to do-most neurology depts use techs who are hs grads to do nerve conduction studies and they are better than most attendings bc all it is is a technical skill that gets better with repitition-anyone who lobbies for those skills can easily learn to interpret them as well. Many therapists are better than rehab docs at neuromusculoskeletal exams. That is because, unlike rehab residents, they are organized and plan ahead for their future, and most importantly, directly involved in patient care. Dermatologists and opthalmologists are proud of their outpatient focus, but we are not, and that why they are still competetive residencies. Ortho and neurosurgery chairmen look out for their residents by hiring nurse practitioners and PA's to do inpatient scut work, but no one looks out for our future education, because our leadership has to be weak in order to keep the inpatient beds filled. As rehab residents, we are rewarded for closing our eyes so your department can make money in the short term.

 

[Stinky Tofu]

I'm not interested in doing inpatient rehabilitation, but I'd disagree with some of what has been said here. There are many patients that Ortho, IM, Neurology, and Neurosurgery want to get rid of and send to us, but that's not necessarily a bad thing for the patient. Often they want to "dump" them because they've done all they are able to and now that they are stable, they want to move on to the next patient. After the acute care, there are still lots of issues that haven't been addressed or dealt with properly. I think we manage TBI, SCI, Stroke, and Amputee patients much better than they would be managed on a medical or surgical floor. While we wouldn't be able to manage acute medical issues as well as an Internist, we are able to provide things that Internists can't that can be valuable for the patient's or caretaker's day-to-day life after discharge. Botox/phenol/joint injections, appropriate orthotics, presribing neurostimulants, dealing with neurogenic bowel/bladder, decubitus ulcers, etc.

With regards to PTs being better at the MSK exam, I'd say that this is probably true to some extent, but those of us doing procedures are still better at the clinically relevant part of the MSK exam. Other differences are that we are can order and interpret images, perform and interpret EDX studies as an extension of our physical exam, order and interpret lab studies, and rule out other non-MSK pathologies than PTs can't. We have both attendings and residents that were former PTs, but I don't think that any of them would say that this has made than a better clinician than those of us who weren't.

I've been fortunate in that our program allows ample time for us to spend with Physical Therapists in different settings (TBI, SCI, Amputee, Spine, etc.) and we have the opportunity to train with the top Orthopods, Neurologists, Neurosurgeons, Rheumatologists, and Radiologists at a variety of the Havard-affiliated hospitals. Having been on a variety of different services at different hospitals, I feel that our role in the inpatient setting is to stabilize the patient, coordinate care, recognize and treat specific sequelaes, maximize their function, and to make sure certain tests or diagnoses weren't missed. In the outpatient physical medicine role, I feel that we are really the experts in non-surgical orthopaedics. Our role at the hospitals we rotate through is to do the gait analyses, EDX studies, Botox/Phenol injections, spinal interventions, medically manage the patient's pain/spasticity, and presribe the proper orthotics. Based on what we are or aren't able to do will determine whether or not the patient can avoid surgery and how well they will function in their daily lives.

While some of the above can be done by an Anesthesiologist or Neurologist, neither of them can offer the comprehensive medical orthopaedic care that we can. This is also the reason why many of the Physiatrists that I know (either personally or from my program) have opted to complete a PM&R residency after practicing as an Anesthesiologist, Internist, Physical Therapist, or Neurologist.

 

[Nikiforos]

Originally posted by drusso
I disagree.

Neuro: Sure, for the primary diagnosis of a neurological disease a neurologist is the expert, but ask a neurologist to design a rehabilitation for a MS patient or ask them to make recommendations regarding return to work issues and workplace modifications for a patient with Myasthenia Gravis and watch their eyes roll...

MSK: Have you worked with orthopedic surgeons? They're surgeons. If you have SOB do you go see a cardiothoracic surgeon or a cardiologist? Enough said. Rheumatologists understand rheumatic disease, but miss the boat about function.

Pain: Anyone can be a needle jockey, but physiatrists trained in pain offer a more comprehensive approach to patients.

NB: If most people had SOB, they would go to a primary care doctor or to the ER.

Unfortunately for PM&R, the analogy is NOT physiatry is to orthopedic surgery what cardiology is to cardiovascular surgery. The AAPM&R had a study about 8 years ago which showed that physiatry barely registered on the screen as to which medical specialty medical students would refer patients with musculoskeletal complaints. The reality is that most of these patients will first see their PCP. From there they are most likely to see ortho, rheum, or neuro. If they ever reach a physiatrist it will be much further down the line. That is probably why many physiatrists work for ortho--they would die of starvation without a ready access to patients. Sadly, some stoop so low to go to WORK FOR CHIROPRACTORS.

 

[Su4n2]

Nikiforos,

i live in NYC and where i live there are huge PM&R offices all over, including many who do pain, many who have PT, OTworking for them. in fact, i counted that around my house, i have seen 7 huge practices, and they list PM&R as the main and only doctor.

p.s i am not in the field, just an observation to your previous post.

 

[drvlad2004]

Originally posted by Nikiforos
mrvlad, don't assume anything. I am an ex-physiatrist, fellowship trained in an anesthesiology pain management fellowship.

I am truthfully posting my opinion in response to the question posed by prominence. You, on the other hand, still have a long way to go in your training and apparently have not even graduated from osteopathic school yet.

Most physiatrists-in -training and wannabes like yourself who post on this forum seem especially thin-skinned. Why the insecurity?

I understand and appreciate your opinions. Of course I know that I still have a long way to go. It just appeared to me that you are implying that PM&R is not a legitimate field of medicine compared to the other specialties that you describe are better.

I would like to reiterate what "Loves Chai" asked. After completing all those years of training in PM&R and even doing a fellowship in anesthesia pain management, what made you finally decide to quit PM&R? Also, what are you doing now?

 

[Spine Specialist]

Originally posted by drvlad2004


I would like to reiterate what "Loves Chai" asked. After completing all those years of training in PM&R and even doing a fellowship in anesthesia pain management, what made you finally decide to quit PM&R? Also, what are you doing now?

I guess Nikiforos has his right to remain silent!

 

[Nikiforos]

1) I am doing anesthesiology.

2) I left PM&R because I hated the social work aspects of both inpatient and outpatient. Many outpatients in PM&R practices are players trying to rip off the Worker's Comp system. ( I am not anti-worker-my dad was a member of a union.) Many others are fakers saying they were injured in car accidents--they always have lawyers and it was always the other guy's fault. Physiatrists are perceived by many to be enablers for these types of patients.

I wanted to return to a more scientific basis for my work and have found this in anesthesiology. I enjoy focusing on physiology and pharmacology--and doing procedures. There is much more of a direct link between my actions and the outcome for the patient. Chronic pain is of minimal interest to me. I enjoy doing regional blocks to manage post-op pain or the pain related to chilbirth. I am also interested in cancer pain.

 

[drusso]

Originally posted by Nikiforos
Physiatrists are perceived by many to be enablers for these types of patients.

I don't think that this is accurate at all. In fact, physiatrists widely are recognized by third-party payors, case managers, and federal programs as the most well suited specialist to manage patients with disability and chronic musculoskeletal issues.

Insurance case managers' perceptions of quality in back pain programs: Results of a focus study group

 

[Nikiforos]

It is very important to note that you do NOT say that OTHER DOCTORS recognize and respect the role of physiatrists. Most doctors prefer (and get) referrals from other doctors, not from case managers. Referrals from case managers, social workers, and lawyers degrade the "medical" aspect of the consultation and emphasize the "dispo" nature.

Of course, physiatrists focus and manage DISABILITY-- that is their only reason for being. Diagnosing and managing disease are of lesser interest to them.

The study you cite was not published in a journal widely read and respected outside the narrow circle of physiatrists. It is a self-serving study which likely could not withstand the scrutiny of a more respected publication.

 

[bbbmd]

Nikiforos... Sorry to hear that you initially chose a specialty not suited for you. Its nice to hear that you are happy now with ANESTHESIA. Unfortunatly it seems you were practicing a type of PM&R that could potentially and has obviously DRAINED you, making you bitter about the specialty as a whole. I would like to hear more stories about your workers-comp/out-patient practice, but that probably deserves a whole new thread. I personally like pain management, and like you, would like to sway away from chronic pain syndromes and treat ACUTE pain. After all, alleviating pain does improve function and lessen disability. Unfortunately you didnt see the value of PM&R for these types of patients like myself and the others on this forum. Medicine is both an ART and a SCIENCE.... i guess you lean more toward the SCIENCE aspect and I lean more toward ART... To each his own, my friend. Just wanted to post clarifications for those of us who are still passionate about PM&R, from a PGY2 standpoint:

"Physiatrists focus and manage DISABILITY"... I agree with you 100%. However, from my PGY2 experience, we also DIAGNOSE AND MANAGE DISEASES. Any acute medical/surgical issue on the inpatient rehab floor is rapidly assessed, DIAGNOSED and MANAGED by the Physiatrist. If we, PHYSIATRISTS, decide that the patient is NOT STABLE to continue with rehab we call respective specialists to either transfer out or help manage. Again, you are right, our main focus is to MANAGE disability. But we are PHYSICIANS that can recognize and manage common medical problems on the rehab floor. Would I want to treat a GI bleed, an MI, an Acute abdomen??? Probably not and neither would a dermatologist, ophthalmologist, radiologist or ANESTHESIOLOGIST becuase it is NOT THEIR FOCUS!!!

Diagnosing and managing disease is of GREAT interest to myself and my attendings. As physiatrists we take this ONE STEP FURTHER: Assessing how this disease process affects FUNCTION and DISABLITY. How we diagnose diseases- same as others: Imaging, labs, physical exam... And unique to PM&R and Neuro: EMGs. How we manage: same as other non-surgical specialties: with medications and, unique to PM&R... modalities. For those who are fellowship trained, more options for diagnosis and treatment are available (ie. diagnostic nerve blocks). And you are right, We must not forget that all of these things that we Physiatrists do are FOCUSED ON DISABLITY... OUR ONLY REASON FOR BEING!!!

"Dispo"... Yup, I hear that a lot as a resident. Not my favorite part of rehab, but as doctors of function who can assess the "medical" and "functional" status of the patient, we are the best suited PHYSICIANS in determining disposition. All physicians deal with "dispo", but if the patient is both MEDICALLY and FUNCTIONALLY complexed with elements of SOCIAL problems we play an important role in discharge planning. Neurosurgeons, orthopods, trauma know nothing about this complexity, but because Physiatrists lead the REHAB TEAM we can facilitate a SAFE, MEDICALLY APPROPRIATE and TIMELY discharge/transfer. Physiatrists are HOLISTIC, treating the WHOLE person, not just the disease and we think of what happens AFTER DISCHARGE more than any other specialty does!!!!

The Archives... Ive heard mixed feedback about this journal. Definitely a good journal for those within the rehab field and interested in research... From a practical point of view, JAMA and NEJM still ranks supreme, especially for the things you see in an inpatient setting. Lots of OUTCOMES research in the Archives which help us physiartists explain to families and patients what "research" has found about what to expect in the future re: their disability. I particularly find the SAE review of the Archives USEFUL!!!

I guess this goes to show that PM&R is NOT for everyone. For those considering the field: DO A ROTATION OR TWO. I am VERY happy with PHYSIARTY so far and many of my co-residents are not complaining either. Yes, lifestyle is amazing (even during residency), but more importantly I value what I do and couldnt see myself doing anything else. Nikiforos, thanks for your insight as a scarred ex-physiatrist and please share more stories about workers comp and your experiences with it.

 

[rehabmd]

The problem is we claim to be experts in disability but our training does not adequately prepare us. Most PGY2s will agree that they know more about acute medical manangement than their inpatient rehab attendings(maybe with the exception of the SCI attendings). If I prescribe a blood pressure medication or a pain medication and it does not work or has side effects, I can change my management plan without consulting a nurse. It is not the same with the therapy I prescribe for most of my patients. If the therapy is not working, I dont know any further questions to ask than "are you compliant with your home exercise program." If I want to know why therapy is not working, then I need to call their therapists-I am handicapped without them. If I ask my patients to demonstrate their exercises to me , I would not know if they are doing them correctly or not because no one ever took the time out in the residency training curriculum to show them. I was too busy providing what I consider to be good medical care on the inpatient unit. I had a lot to offer the inpatient unit during my rehab residency training bc of the preparation my medical school gave me; but that is not the career I wanted. I like to be good at what I do-I am not a quack who claims to be an expert in something when I am not-but unless I pay lots of money out of my own pocket for orthopedic physical therapy courses after residency, I will not be the kind of musculoskeletal expert I would send anyone I care about to. I think it is a shame to have to do that when there are so many therapy schools attached to the rehab departments.

 

[bbbmd]

rehabmd...

I am taking your experience with muskuloskeletal training during residency seriously... I am making it a point to go out of my way to learn the things that are important to rehab docs while I am a resident. We have all the resources as residents so I will go out and take advantage of them (PT school, OT school, Neuropsychologists, MSK fellows and attendings) rather than focusing just on the "medical"aspects. It is difficult to sway away from "medicine" having done an entire year of it, but as a PGY2 and from your experience I think the rest of us should focus more on being so-called "EXPERTS" in disability...

I do have several attendings who know SO MUCH more in terms of Physical Therapy than PTs themselves... One of them wrote a book on the Muskuloskeletal exam. Others are just amazing and the PTs ask them PT questions. So, we all can be experts and I am lucky that in my program there are several attendings that I can use as role models. Have you considered a muskuloskeletal fellowship??? Our fellows are walking kinesiology/anatomy books and I can confidently say that they are experts in disability!!! Oh, I dont think that the MSK system is the only aspect of DISABILITY and that PTs are the only other members of the rehab team, but you know that.