Why PM&R is good if interested in Sports Medicine

[MedBronc23]

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I advise many of the students at my medical school that I went to and that is associated with my Pre-lim program. I have my reasons for telling them why our field translates well to career in sports/MSK/non-surg ortho. But I wanted to know some of the upper level PM&R residents and/or staff/private docs' thoughts on the subject.

Also, I know a lot of the stronger outpatient/msk/sports exposure PM&R programs because sports and spine was my draw to the field. Yet, I did not interiview everywhere and I do not know everything for sure.

Mayo, Utah, Colorado, Washington, Davis, RIC, MCW, UTSW, Idiana, Michigan (stronger spine than sports from my experience), Harvard/Spaulding, Temple are some of the places that stood out and caught my attention as being strong in sports/msk. These were some places high on my rank list because of this reason. I know I am missing some places strong at MSK and sports on East Coast and midwest. Maybe someone can shed light so I can help guide my young minds better.

Thanks for the help all. My goal is to recruit the best and brighest medical students to our field each chance I get. I feel so blessed that a doc showed me how rewarding, fulfilling, and fun our field can be. The only way I see our field advancing is attracting the best fit, smartest, and most innovative people we can to PM&R. I hope all the residents and attendings out there share this sentiment.

 

[PMR 4 MSK]

Let's look at the various routes to MSK and Sports in medicine:

FP - Minimal training in MSK prior to Sports fellowship. Even then, the focus is on prevention, screening and acute injuries. 9/10 acute sports injuries are treated with RICE, so you don't have to be too exact on the Dx. Most injuries are self evident - sprains, strains, contusions, etc. If RICE doesn't work, it's PT and NSAIDs. Beyond that, everything else is referred out.


Ortho - The most intense 5-6 years of your life. You have to be good, fast and willing to sacrifice your mother to get get ahead. You then live to do surgery, not to practice medicine. Only the strongest survive.

Neuro - Focus is on the brain and spine, and to a lessor extent, the peripheral nervous system. MSK training is less than neuro, for obvious reasons. Much of neuro is traditionally diagnostic, and then medications for treatment, or referral to neurosurg.

Rheum - 3 years of IM, followed by fellowship. You focus on prescribing drugs that are more poison than not. You spend as much of your time treating the side effects of your treatments, as you do treating the primary disease. You are second to none at treating arthritis and auto-immune disorders, but spine training is traditionally lacking. Rheum is clinic-based, but also get very sick inpatients to consult on. E&M and joint injections are what pay your bills. Some are now making money running infusion clinics for the newer DMARDs. I've met many Rheum's who say if they had known about PM&R, that would have been their career choice instead.

Podiatry - different medical school and limited focus, but there are plenty of Sports Pods out there. However, you spend a lot of time burring down onychomycotic nails of 90 year-olds.

PM&R - You spend half of your residency doing things you are unlikely to do when you graduate. The field suffers from a huge identity disorder. But you get full-spectrum MSK training that overlaps all the above fields. Your residency work hours are less than most fields, and call is minimal compared to other fields as well. A PM&R graduating resident should not need fellowship to do sports medicine, or general outpt MSK.

Did I miss anything?

 

[fozzy40]

I did want to add to what PMR 4 MSK has said...

I do think that PM&R resident exposure to the musculoskeletal system is better compared to the other specialties listed above. However, exposure to the full scope of sports medicine does vary across all specialties in residency. Musculoskeletal medicine and sports medicine are often talked about interchangeably but there are differences that newbies should understand. A good chunk of what sports medicine physicians do see are musculoskeletal issues, which we are well-equipped to see out of residency. However, there are other aspects of sports medicine which are not necessarily covered during residency that one should consider doing a fellowship i.e.:
- concussion management
- return to play
- acute fracture management
- event coverage
- sports nutrition and supplementation
- sports psychology
- kinesiology
- athletic issues specific to pediatrics and women

Remember to keep these issues in mind when developing your career goals and the decision to do a fellowship.

 

[Tenacious DO]

Don't forget the Derm issues of Sports Med. Football/Hockey/Wrestling are fraught w/ fungus & rashes. This is an area I feel a Family-Sports Med doc may be better prepared...I guess I will just remember, "if it's wet, dry it...and if it is dry, wet it."

 

[MedBronc23]

Ok the Derm issues. Do not come at us with that dude. Anyone who did a prelim year in something should be able to take care of wounds...if not vasc surg or wound care consult should be placed...Here is a thought.... we see alot of decubitus, burns, and wounds in our general rehab care of patients. I think we are probably ok with sports derm issues. If not we are probably just as capable as FP. I have seen plenty of rashes in my med prelim to know how to take care of fungal rash. I am not dissing Primary Care sports...I am just saying I do not see how they have any leg up.

As far as the other comments, I thought they were great. However, I disagree somewhat because I think we get this in our residency training

- concussion management: We do see this its called TBIs. I know at Mayo we have a whole concussion clinic in the sports dept. I am sure other PM&R programs have similiar.
- return to play : I do think this aspect has to be honed in fellowship because it requires continuity of care...you usually only rotate through sports for a few months in residency so this may be hard to master
- acute fracture management : agreed ortho has the step on us here.
- event coverage: This was important to me. All of my top 5 programs I ranked last year offered me this. It was extremely important to have an outlet or programs to cover HS, amateur sports, and collegiate events in residency. Mayo offers this (football and hockey coverage and also marathons and other special events). I know Utah, RIC, Michigan, Colorado, Stanford, Baylor Dallas, Spaulding/Harvard, Indiana, Washington, MCW, UTSW, Temple were some places that offered sports coverage opportunities to interested residents.
- sports nutrition and supplementation: Definitely in fellowship
- sports psychology: Fellowship but honestly most sports depts have a Psy-D (Doctor of Psychology) on staff to this. This is their fortay.
- kinesiology: I think with all the gait analysis, PT orders, movement disorders, msk that we have a good grip on this after 3 years...and it translates well to a career in sports.
- athletic issues specific to pediatrics and women: This may be program dependent. When I was at Colorado, their sports med pm&r doc did alot with women's sports and was one of the experts. MCW was like this as well. I think some of the docs at Harvard/Spaulding/Mass General are also good at this. I saw more of a variety and all ages when I rotated through sports at Mayo...although we saw lots of adolescents which I loved.

Even though as a PM&R sports doc I may never do SCI, TBI, inpatient stuff or tx spasticity with botox...it all plays into the knowledge base in my opinion. I will be able to do EMG and NCS on my patients which is a great strength in my opinion. I loved the MSK aspect, the injections, MSK ultrasound, and also strong spine exposure.

I appreciate everyone's input. I think it is all very helpful...except the derm comment...kind out of left field IMHO.

 

[fozzy40]

Ok the Derm issues. Do not come at us with that dude. Anyone who did a prelim year in something should be able to take care of wounds...if not vasc surg or wound care consult should be places...Here is a thought we see alot of decubitus, burns, and wounds in our general rehab care of patients. I think we are probably ok with sports derm issues. If not we are probably just as capable as FP. I have seen plenty of rashes in my med prelim to know how to take care of fungal rash. I am not dissing Primary Care sports...I am just saying I do not see how they have any leg up.

As far as the other comments, I thought they were great. However, I disagree somewhat because I think we get this in our residency training

- concussion management: We do see this its called TBIs. I know at Mayo we have a whole concussion clinic in the sports dept. I am sure other PM&R programs have similiar.
- return to play : I do think this aspect has to be honed in fellowship because it requires continuity of care...you usually only rotate through sports for a few months in residency so this may be hard to master
- acute fracture management : agreed ortho has the step on us here.
- event coverage: This was important to me. All of my top 5 programs I ranked last year offered me this. It was extremely important to have an outlet or programs to cover HS, amateur sports, and collegiate events in residency. Mayo offers this (football and hockey coverage and also marathons and other special events). I know Utah, RIC, Michigan, Colorado, Stanford, Baylor Dallas, Spaulding/Harvard, Indiana, Washington, MCW, Temple were some places that offered sports coverage opportunities to interested residents.
- sports nutrition and supplementation: Definitely in fellowship
- sports psychology: Fellowship but honestly most sports depts have a Psy-D (Doctor of Psychology) on staff to this. This is their fortay.
- kinesiology: I think with all the gait analysis, PT orders, movement disorders, msk that we have a good grip on this after 3 years...and it translates well to a career in sports.
- athletic issues specific to pediatrics and women: This may be program dependent. When I was at Colorado, their sports med pm&r doc did alot with women's sports and was one of the experts. MCW was like this as well. I think some of the docs at Harvard/Spaulding/Mass General are also good at this. I saw more of a variety and all ages when I rotated through sports at Mayo...although we saw lots of adolescents which I loved.

Even though as a PM&R sports doc I may never do SCI, TBI, inpatient stuff or tx spasticity with botox...it all plays into the knowledge base in my opinion. I will be able to do EMG and NCS on my patients which is a great strength in my opinion. I loved the MSK aspect, the injections, MSK ultrasound, and also strong spine exposure.

I appreciate everyone
s input. I think it is all very helpful...except the derm comment...kind out of left field IMHO.

Thanks for the clarification about concussions and TBIs. I'll make sure to pass that on to my co-residents🙄

What you typically learn in residency is subacute management of moderate to severe TBIs. Most of our efforts are trying to manage symptoms so that the patient can participate in 3 hours of therapy and so that they can be as safely independent at home. Even at that point, it takes months or years for these patients with moderate to severe TBIs to get back to work or school if it's possible. Managing these patients is similar but different to managing mild TBIs (aka concussions.)

It is true that there are sports psychologists that can help counsel your patients. My comment on this was that it's important for the sports medicine practitioner to get understand the psychology of sports so that you can develop an effective approach for your treatment plan. I was not implying that you counsel them yourselves.

Exposure and proficiency are two different things and I do think that PM&R residencies can prepare you well for sports medicine fellowships. But as you mentioned, not all programs are created equally and exposure does vary across the country.

It's great to see your enthusiasm though!

 

[MedBronc23]

I suppose I get a "here's your sign" moment for the TBI comment. I appreciate fozzy' response.

My real point is that what we do plays into each aspect of our practice no matter what venue of rehab we go into.

I agree that we all need to have a good psychological base in all areas of practicing physiatry. We deal with some people who truly need our help in reframing the meaning of "life" whether they are a 5 star athlete knocked down in their prime or a mother of 3 with a SCI from an MVA.

I do not think anything we learn about is in vain. Maybe I am being an idealist about this, but I really chose the field because I like every aspect of it: from neurogenic bladder to spasticity to sports.

I think we just fit the needs of the athlete patient better than our FP and IM colleagues. We cannot compete against the surgeries when they are truly indicated. But we have the knowledge, clinical and procedurally that frankly set us apart in the sports world.

I just think it has taken some time for mainstream sports medicine to take notice.

 

[fozzy40]

I suppose I get a "here's your sign" moment for the TBI comment. I appreciate fozzy' response.

My real point is that what we do plays into each aspect of our practice no matter what venue of rehab we go into.

I agree that we all need to have a good psychological base in all areas of practicing physiatry. We deal with some people who truly need our help in reframing the meaning of "life" whether they are a 5 star athlete knocked down in their prime or a mother of 3 with a SCI from an MVA.

I do not think anything we learn about is in vain. Maybe I am being an idealist about this, but I really chose the field because I like every aspect of it: from neurogenic bladder to spasticity to sports.

I think we just fit the needs of the athlete patient better than our FP and IM colleagues. We cannot compete against the surgeries when they are truly indicated. But we have the knowledge, clinical and procedural skills that frankly set up apart in the sports world.

I just think it has taken some time for mainstream sports medicine to take notice.

Could not agree more 👍...Seriously, keep up the enthusiasm! We certainly need it in the field. There's a lot of misconception about what we do and "Debbie downers" amongst our colleagues. We should all be this enthusiastic about educating medical students particularly in other specialties about our field.

 

[MossPoh]

Thanks for the help all. My goal is to recruit the best and brighest medical students to our field each chance I get. I feel so blessed that a doc showed me how rewarding, fulfilling, and fun our field can be. The only way I see our field advancing is attracting the best fit, smartest, and most innovative people we can to PM&R. I hope all the residents and attendings out there share this sentiment.

I feel all that is needed are more people like you. I'm interested in exploring PM&R, but my school doesn't have a program in it. I'm also interested enough to say "I'm interested" but not to actively go out and find someone over any other field that piques my interest. In the end, I fear that this could cause it to fall to the wayside relative to other specialties that are easier for me to define and that I see on a more routine basis.

I've actively read the stickied threads on here, in addition to the other websites and I still don't really have a grasp on it. I do love the idea of improving quality of life and I also enjoy working with athletes. I have a particular interest in olympic weight lifting, powerlifting and strongman with pain management, injury prevention and the overall mechanics of it. That being said, I still feel like I need to SEE someone in the field actively going out and telling me, "Hey, this is a great field. I'd love for you to come out and check things out." or getting in contact with different interest groups during the first 2 years to talk about stuff and plant the seed.

I feel like it is in that area that is under the radar because nobody hears anything about it at all. When someone desribes a preventative health residency I tend to think, "So, why didn't you just get your MPH and save a few years?". When PM&R is mentioned there is often a similar response where people relate it to physical therapy or the like because they don't have a grasp of it and have never worked with a mentor who was excited to show them what it is about.

 

[fozzy40]

I feel all that is needed are more people like you. I'm interested in exploring PM&R, but my school doesn't have a program in it. I'm also interested enough to say "I'm interested" but not to actively go out and find someone over any other field that piques my interest. In the end, I fear that this could cause it to fall to the wayside relative to other specialties that are easier for me to define and that I see on a more routine basis.

I've actively read the stickied threads on here, in addition to the other websites and I still don't really have a grasp on it. I do love the idea of improving quality of life and I also enjoy working with athletes. I have a particular interest in olympic weight lifting, powerlifting and strongman with pain management, injury prevention and the overall mechanics of it. That being said, I still feel like I need to SEE someone in the field actively going out and telling me, "Hey, this is a great field. I'd love for you to come out and check things out." or getting in contact with different interest groups during the first 2 years to talk about stuff and plant the seed.

I feel like it is in that area that is under the radar because nobody hears anything about it at all. When someone desribes a preventative health residency I tend to think, "So, why didn't you just get your MPH and save a few years?". When PM&R is mentioned there is often a similar response where people relate it to physical therapy or the like because they don't have a grasp of it and have never worked with a mentor who was excited to show them what it is about.

Don't feel alone. Many students (and residents/attendings) have difficulty fully understanding what PM&R. This is partly because of lack of exposure/opportunities (as you mentioned). Coming from a state that does not have a PM&R residency, I can definitely identify with you. The other reason is that in medical school we focus on acute medical diagnosis/management and curative treatments. We are not forced to think about what happens to our functional abilities once the medical treatment has been completed. The assumption with medical care is that once a diagnosis is made and a treatment plan has been initiated that the person will "get better" which just is not the case. Keep pushing on and trying to learn about the field...it's absolutely awesome.

I sent you a PM as well.

 

[MedBronc23]

Originally posted by MossPah
I feel like it is in that area that is under the radar because nobody hears anything about it at all. When someone desribes a preventative health residency I tend to think, "So, why didn't you just get your MPH and save a few years?". When PM&R is mentioned there is often a similar response where people relate it to physical therapy or the like because they don't have a grasp of it and have never worked with a mentor who was excited to show them what it is about.

As far as my initial PM&R exposure goes, I probably was at an advantage as a college athlete who was treated for a pretty severe C-spine injury by a Sports and Spine based physiatrist who was a friend of my father's. Even after that I kept both PM&R and orthopedics on my radar for careers in medical school. PM&R is not simply a preventative health specialty...we treat disability, dysfunction, pain, weakness, ect. that can all be acute or chronic issues. We can use medicines, modalities, therapies, alternative meds/therapies, or procedures to treat and we are experts in diagnosing neuromuscular pathology, illness, and impairment. I am not sure how we differ in anyone's perception of what a doctor is. but I know people think that we are in there doing the exercises with the patients, when really PT does this. It is frustrating, but I think you have to just reframe it in your brain. When I am excited and speak so highly of our field...educating people on what we can do and our broad based areas of expertise across a wide spectrum of diseases...people usually think its great and some of our colleagues are jealous because they did not knew we existed or had a misconception of what rehab and physical medicine truly is and is not.

The AAPM&R has a nice intro to the field for medical students on this website http://www.aapmr.org/career/students/PMRspecialty/Pages/medical-students-guide-to-pmr_a.aspx

Sounds like you are interested in sports, pain, and msk...This is where my passion lies. Feel free to pm me with any questions. Goes for any of our student doctors that want to know more about the field from a resident's perspective.

😎

 

[murphles]

When I was a resident we routinely did consults in the ED for concussion. If they did not pass the screen, they had a follow up visit with us in a week. And yes we kept them off sports in the mean time. We then had a detailed conversation about concussions and the emerging research at the time.....