Will I Like Pm&r

[filedsearcher]

I rotated through PM&R and am not sure if I will enjoy being a physiatrist. I really enjoyed the spinal cord, tbi, stroke rehab. I did not like the ortho, orthotics, prosethetics. Pretty much I like all the neuro stuff, don't like any of the ortho/sports medicine stuff.

I realize that I will have to deal with all the ortho stuff during residency, but will I be able to run a efficient and earn a nice salary with only practcing the neuro side of it, or am I better off going into neurology?

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[Disciple]

There are a good number of programs who won't make you do much MSK stuff or Orthotics/Prosthetics, so don't worry about it.


As for your earning potential, it depends on what your definition of a "nice salary" is. Salaries either general Neurology or Physiatry (maybe you could be a medical director to supplement your income) are not that high, but each specialty has its own subspecialties which tend to reimburse better.

 

[ampaphb]

As for your earning potential, it depends on what your definition of a "nice salary" is. Salaries either general Neurology or Physiatry (maybe you could be a medical director to supplement your income) are not that high, but each specialty has its own subspecialties which tend to reimburse better.

Like anything, it depends on how hard you are willing to run - I have friends who make 125K, and I have friends who make 5-600k doing inpatient - all a matter of your willingness to work harder, longer, and smarter than the next guy.

 

[topwise]

Even if you don't love the msk stuff, you need to ask yourself if you can tolerate it. Because even if you have a program that focuses much more on inpt rehab (and many do), the msk stuff is on the board exam so you have to know it. But I think it's worth it to put up with a little ortho if it means you'll eventually be doing something you love.

I've been considering inpt rehab as a career and from what I can tell in the early stages of my job search (very early), the job prospects are excellent. No need for a fellowship unless you feel you want that extra training. You can also do consults in rehab, which pays well also, without the burden of running an inpt unit.

If you're doing neurology, it's going to be all about diagnosis and treatments with medications. Physiatry is what comes after that.
I can't tell you which one is right for you.

 

[ampaphb]

Even if you don't love the msk stuff, you need to ask yourself if you can tolerate it. Because even if you have a program that focuses much more on inpt rehab (and many do), the msk stuff is on the board exam so you have to know it. But I think it's worth it to put up with a little ortho if it means you'll eventually be doing something you love.

I've been considering inpt rehab as a career and from what I can tell in the early stages of my job search (very early), the job prospects are excellent. No need for a fellowship unless you feel you want that extra training. You can also do consults in rehab, which pays well also, without the burden of running an inpt unit.

If you're doing neurology, it's going to be all about diagnosis and treatments with medications. Physiatry is what comes after that.
I can't tell you which one is right for you.

Understand that most of our experience with neurologists in in the inpatient setting. Just as there are outpatient PM&R docs in the real world, there are lots of neurologists who, when they get out, focus on pain (typically headache) or balance issues (and these are populations no one else wants to treat, in general). So while in an academic setting neurologists are al about the diagnosis, in the real world, they do just fine ecconomicaly, if that is what they want.

 

[Llenroc]

I did a month long rotation in General/Ortho rehab., and I think there were maybe 2 ortho patients the entire month. They gave me the option of following Stroke patients as well who were on the same floor, which I did.

Very few orthopedic surgery patients are going in for stays in rehabilitation hospitals these days.

 

[topwise]

Understand that most of our experience with neurologists in in the inpatient setting. Just as there are outpatient PM&R docs in the real world, there are lots of neurologists who, when they get out, focus on pain (typically headache) or balance issues (and these are populations no one else wants to treat, in general). So while in an academic setting neurologists are al about the diagnosis, in the real world, they do just fine ecconomicaly, if that is what they want.

I wasn't implying that neurologists just focus on diagnosis. But the treatments they prescribe are usually medicines, whereas physiatrists have a more "holistic" treatment approach. For example, I've never seen a neurologist teach a patient exercises to do, which I have seen several physiatrists do.

And physiatrists get to diagnose as well.

Hmm.... I just noticed that spellcheck recognizes the word "neurologist" but not the word "physiatrist". Wow.

 

[ampaphb]

But the treatments they prescribe are usually medicines, whereas physiatrists have a more "holistic" treatment approach.

I know when you say "holistic" what you intend us to understand is inclusive, but holistic, to me, fits into the world of chiros, alternative med providers, prolo advocates, accupuncturists, Ayurvedic practitioners, detoxification advocates (ie. colon therapy), energy healers, and naturopaths (ie practitioners for whom EBM is a foreign concept, and in it's place is the retort that, if the evidence isn't there, you just didn't do the study right, cause in my hands ...).

I, for one, would prefer not to be lumped in with these wackos.

 

[LauraDO]

I know when you say "holistic" what you intend us to understand is inclusive, but holistic, to me, fits into the world of chiros, alternative med providers, prolo advocates, accupuncturists, Ayurvedic practitioners, detoxification advocates (ie. colon therapy), energy healers, and naturopaths (ie practitioners for whom EBM is a foreign concept, and in it's place is the concept that, if the evidence isn't there, you just didn't do the study right, cause in my hands ...).

I for one, would prefer not to be lumped in with these wackos.

I believe the official reply from the CAM practitioners is

"It is impossible to prove in a scientific study because it is ENERGETIC in nature"

(picture an herb sending sonar healing waves which penetrate the patients organs and miraculously heal them)

 

[Shalom77]

I know when you say "holistic" what you intend us to understand is inclusive, but holistic, to me, fits into the world of chiros, alternative med providers, prolo advocates, accupuncturists, Ayurvedic practitioners, detoxification advocates (ie. colon therapy), energy healers, and naturopaths (ie practitioners for whom EBM is a foreign concept, and in it's place is the retort that, if the evidence isn't there, you just didn't do the study right, cause in my hands ...).

I, for one, would prefer not to be lumped in with these wackos.

Does this mean I'm in trouble since I used the word "holistic" in my personal statement? (well I did add the comparison "than surgery" - so maybe I'll be ok. )

If someone is interested in researching some of these "alternative therapies" (the more mainstream ones) in the interest of providing more of an evidence base - would they be considered a "wacko" or not? I have wondered if any PM &R programs are "integrative medicine" friendly or not. It's a touchy area to ask about because of the "wackiness" factor. But actually CAM did not even cross my mind when I used the word "holistic."

 

[njdevil]

I think holistic is a very appropriate word in describing physiatry.

 

[ampaphb]

I think holistic is a very appropriate word in describing physiatry.

It may well be at it's etymological core, but the same way catholic means universal, but is generally used to refer to a particular religion, holistic may mean emphasizing the importance of the whole and the interdependence of its parts, but the generally accepted implication is identifying with principles of holism in a system of therapeutics, esp. one considered outside the mainstream of scientific medicine, as naturopathy or chiropractic, and usually involving nutritional measures (ie. wacko fringe CAM)

 

[SSdoc33]

i think its kind of like the word "wellness" as in "my back hurts, so i went to a wellness center."

it gives me the chills just to type that sentence.

 

[topwise]

I know when you say "holistic" what you intend us to understand is inclusive, but holistic, to me, fits into the world of chiros, alternative med providers, prolo advocates, accupuncturists, Ayurvedic practitioners, detoxification advocates (ie. colon therapy), energy healers, and naturopaths (ie practitioners for whom EBM is a foreign concept, and in it's place is the retort that, if the evidence isn't there, you just didn't do the study right, cause in my hands ...).

I, for one, would prefer not to be lumped in with these wackos.

Actually, on the west coast, PM&R does take a more alternative approach. I don't believe in most of the things you mentioned, but I do an acupuncture clinic every Monday. I think PM&R is probably less about EBM than most other specialties of medicine.

 

[topwise]

OK, I'm a dork, but:

http://dictionary.reference.com/browse/holistic medicine

"Holistic medicine: An approach to medical care that emphasizes the study of all aspects of a person's health, including physical, psychological, social, economic, and cultural factors."

I think that for some, but not all, this DOES define what we try to do in physiatry. Not all physiatrists may think this way, but definitely more so than neurology!

 

[axm397]

We have an acupuncturist/chiropractor at SSRC - she is trained in traditional oriental medicine as well. I've had the opportunity to shadow her and I do see a place for her kind of care - especially the elderly with lots of co-morbidities who just wouldn't tolerate any surgical procedures or heavy PT. I have seen both modalities give symptomatic relief - albeit temporarily. She is also very humble and personable. We have two chiros on staff at RIC and 2 physiatrists and a neurologist certified in acupuncture. There are also several residents and grads interested in the role of nutrition in some of the pathological processes we see in rehab and they are working on research - ex. creatine in stroke rehab, nutrition in CRPS, etc. I don't think those residents are "wackos" and would gladly have my family members cared for by them.

So I have to respectfully disagree with amphaphb - I do know that there are lots of quacks and "wackos" out there who take advantage of vulnerable and uneducated patients who are desperate for help.

I don't want to lump ALL acupuncturists in that group. There are definitely some well-respected physicians (a lot of them in PM&R) who are certified in acupuncture: http://www.hmieducation.com/gradlist_files/gradlist.htm

I also used the word "holistic" and "comprehensive" in my personal statement for residency and not once did any of the PDs question the use of that word and whether I meant acupuncture, aromatherapy, and other "alternative" therapy. I ended up at my first choice so I think my personal statement served me well - "holistic" and all.

 

[ampaphb]

We have an acupuncturist/chiropractor at SSRC - she is trained in traditional oriental medicine as well. I've had the opportunity to shadow her and I do see a place for her kind of care - especially the elderly with lots of co-morbidities who just wouldn't tolerate any surgical procedures or heavy PT. I have seen both modalities give symptomatic relief - albeit temporarily. She is also very humble and personable. We have two chiros on staff at RIC and 2 physiatrists and a neurologist certified in acupuncture. There are also several residents and grads interested in the role of nutrition in some of the pathological processes we see in rehab and they are working on research - ex. creatine in stroke rehab, nutrition in CRPS, etc. I don't think those residents are "wackos" and would gladly have my family members cared for by them.

So I have to respectfully disagree with amphaphb - I do know that there are lots of quacks and "wackos" out there who take advantage of vulnerable and uneducated patients who are desperate for help.

I don't want to lump ALL acupuncturists in that group. There are definitely some well-respected physicians (a lot of them in PM&R) who are certified in acupuncture: http://www.hmieducation.com/gradlist_files/gradlist.htm

I also used the word "holistic" and "comprehensive" in my personal statement for residency and not once did any of the PDs question the use of that word and whether I meant acupuncture, aromatherapy, and other "alternative" therapy. I ended up at my first choice so I think my personal statement served me well - "holistic" and all.

I am not sure there is ever a need to respectfully disagree with the likes of me. My opinions are worth exactly what you paid for them.

Residents are often smitten by authority figures, and the near cult of personality they their mentors enjoy. That being said, the next time you are at SSRC, ask them about RCTs for either accupuncture or chiropractic care (if you dare), for specific conditions (not all back pain, cause that is like asking for articles on all chest pain), and watch them start to dance.

Nutrition is another of those areas - I am certain your colleagues are doing good work, but in the real world, people go to CAM nutritionists. I have personally seen this scam. They are not covered by insurance, so it is an all cash transaction. There is all sorts of "sophisticated" testing done, at the end of which, the patient is told he/she needs this specific concoction, which only this particular doc has discovered. As luck would have it, he also sells it right here in the office!

Out in the real world, I will be happy to take a random sample of all those clinics who label themselves holistic, wellness centers, alternative, or pick your favorite adjective, and am willing to bet you that >90% are practitioners addressing the patient's "imbalances", or better yet, trying to address the "toxins" in patients systems.

Language is power, and while in the world of academia, people may use it to describe legitimate medical practice, you need to be careful to understand what the words have come to imply. Wellness, holistic, alternative, and complimentary are all perfectly good words. So are pro-life and pro-choice, yet we all immediately understand more than the plain meaning of those terms.

 

[topwise]

Is there really any point in arguing whether a word can mean different things to different people in different areas of the country or who have been exposed to different things? We may as well argue pop v soda

I wouldn't put the word "holistic" in bold letters above the name of my practice, but I think it's reasonable to use aspects of the philosophy of the word in your practice (without being a quack).

I honestly didn't know the word "holistic" was so emotionally charged!!

 

[SSdoc33]

its not the WORD thats the problem here. its what that word means. its true that physiatry is probably closer to the alternative / wellness / holistic world than most other specialties. make no mistake about it : THIS IS A BAD THING. i dont know about you, but id like to be viewed by both patients and other physicians as an actual "doctor" as viewed in the traditional western sense. people dont go see doctors to drink some potion like we were in medieval times. they dont go to see us to change some strange energy flow pattern. they go to see us to get the best results that centuries of traditional western medicine has to offer. while its also true that the EBM in PM&R isnt the greatest, that is not a reason to practice all of this fringe-stuff non-sense. if anything, the lack of research should push you to stay more mainstream, not the reverse.

 

[topwise]

they dont go to see us to change some strange energy flow pattern.

Heh... you should tell this to my attending as he's wiping the acupuncture needle site to keep the chi from escaping.

Seriously though... I think it's my prerogative if I want to practice more alternative medicine and yours if you don't. I'm sure we'll both find patients.

 

[lobelsteve]

I am not sure there is ever a need to respectfully disagree with the likes of me. My opinions are worth exactly what you paid for them.

.

Folks, I am working on a script for SDN that can audit a post by ampaphb and that will deposit 2 cents per post via PayPal in an escrow account. In the event he posts something with a neutral bias or that is kind words of encouragement, I will pay him mathching funds including interest.

 

[ampaphb]

Folks, I am working on a script for SDN that can audit a post by ampaphb and that will deposit 2 cents per post via PayPal in an escrow account. In the event he posts something with a neutral bias or that is kind words of encouragement, I will pay him mathching funds including interest.

Get the sense someone has too much free time on his hands these days?

 

[lobelsteve]

I think it does Physiatry a great disservice to practice CAM and pass it off as standard of care medical practice. It would become quite important to delineate to your patients what the standard of care is, and when that does not work, that you will try some less used and less understood methods.

I'm with ampaphb on this, Physiatrists have an image and an identiy problem, and mucking it up with hocus pocus BS will just take us down a peg. You realize DC's are doing needle EMG's in a few states don't you?

 

[drusso]

I'm with ampaphb on this, Physiatrists have an image and an identiy problem, and mucking it up with hocus pocus BS will just take us down a peg. You realize DC's are doing needle EMG's in a few states don't you?

...and there's no need to appeal to hocus-pocus when there is SCIENCE available. Can acupunture help alleviate acute myofascial pain? Sure, once in awhile. Ditto for manipulation, relaxation, E-stim, etc. Most acute pain problems are self-limited anyway, so if patients pick-up some analgesia from physical modalities, great. But, after 32 chiropractic, acupuncture, or reflexology treatments, why does any one believe that the 33rd is going to do the trick??

 

[topwise]

I have no idea why I'm defending CAM cuz the truth is, I don't really buy into a lot of it myself. (I'm more interested in neurophysiology than anything.) I guess I just feel like being in a field like PM&R shouldn't be something that keeps you from practicing the kind of medicine you want. Are people attacking internists who practice some CAM? (Well, maybe...) I don't think anyone should say, "Because you're in PM&R, you MUST practice this way, or else the whole field will be disrespected." And I am training on the west coast, where a lot of the CAM stuff is a little more mainstream. I'm not saying it's voodoo medicine but a couple of the practices are utilized (like acupuncture).

I really hate the fact that we're all getting so defensive about our field When you like what you do, your patients appreciate what you do, you're helping people, and you're making money, what's the difference? Hopefully, we all went into this field because we love doing it. And just like in any field, people don't all practice exactly the same way.... some doctors swear by different meds or believe there's a difference between one PPI versus another. One thing I love about PM&R is that there's so many different possibilities within the field.

Most of all, I am super sorry I used the word "holistic"!

 

[lobelsteve]

Get the sense someone has too much free time on his hands these days?

I'm working two jobs and still making house calls. Top that!

To the OP: I like PMR because the docs are wise guys.

 

[peepadoo]

How about a note on the 50-60% of "western" medicine that does not have any research behind it, but is still practiced every day, due to forces that control our decisions.

Let's open up the skepticism. Be skeptical of alternative medicine, but let's not forget the robber in our own house here. Be wary of it all.

 

[DOctorJay]

common sense goes a long way too. I'm not trying to back up CAM but remember research isn't everything...

Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.
BMJ. 2003 Dec 20;327(7429):1459-61

 

[peduncle]

There is so many threads on this forum that revolve around the same question or concerns about PMR... whether one would like it as a profession.. whether it is doomed to failure.. is it boring... does it pay well... is it fulfilling. I definitely believe PMR residency calls for a certain breed of candidate. One who can tolerate long term care and does not mind dealing with chronic conditions.

I've pretty much decided on applying to it, but I had reservations of course, in the past. Por Ejemplo, I shadowed a PMR doc on a consult the other day. It was a patient who had to sadly have his arm aputated due to cancer. His main concern now was a little bit of pain and difficulty performing some daily activities such as buttoning his trousers or opening a bottle of spaghetti sauce. The doc ordered a TENS unit (hope I didn't get this incorrect) and showed him some nifty device on how to button his trousers. Then she ordered Occupatonal Therapy to help him out as well.....

So the patient was happy that someone was paying attention to his concerns, but as a medical student I was just confused on the role of the PMR doc at that point. At what point in that consult was there anything remotely medical?? Anything that I had learned about and loved in first and second year of medical school. It just didn't have that sort of excitement that other fields had (although "excitement" usually implies pathologic conditions that require immediate attention and could increase your stress level).

Now don't get me wrong, there were other aspects of PMR (like MSK) that I found awesome... but I think the problem that most people (medical student) have is that PMR seems very slow and doesn't seem to incorporate the exciting aspects of medicine as it deals with chronic patients after the initial diagnosis, initial treatment, or post-op care has already been done.

haha this topic has been beaten to death...

 

[topwise]

Now don't get me wrong, there were other aspects of PMR (like MSK) that I found awesome... but I think the problem that most people (medical student) have is that PMR seems very slow and doesn't seem to incorporate the exciting aspects of medicine as it deals with chronic patients after the initial diagnosis, initial treatment, or post-op care has already been done.

haha this topic has been beaten to death...

I think those are really good points. PM&R may have occasional moments of excitement (I've dealt with a good number of codes in my residency), but in general, the pace is slower. To me, that's a good thing! I like the more laid back pace and the lack of emergencies. I think it's a different kind of satisfaction in helping the patients you mentioned.

 

[peduncle]

So there lies one of my dilemmas. I love MSK, which means I'd probably try for a Sports/Spine fellowship. There are so many avenues to get into sports medicine however including Int Med, Orthopedics, Family Med.. and now I hear of this Podiatric Sports Medicine avenue. I definitely think that crowds the field way too much.

This including what I had written above just worries me.

 

[topwise]

Residents I've talked to say it's actually very difficult to get into a sports fellowship from PM&R.

 

[axm397]

Residents I've talked to say it's actually very difficult to get into a sports fellowship from PM&R.

depends on which sports fellowship

 

[peduncle]

Residents I've talked to say it's actually very difficult to get into a sports fellowship from PM&R.

Really!!??? shoot me now!

 

[topwise]

Really!!??? shoot me now!

Oh, I didn't want to scare you I don't want to make any broad generalizations, but this is just what I heard. All the senior residents in my program got rejected by every sports fellowship they applied to. Several of them got into great pain fellowships though, so it wasn't a matter of the resident quality (I don't think). I don't know why sports fellowships don't like us, cuz PM&R docs are probably much better at sports med than any of the other fields where the residents commonly do sports fellowships.

 

[axm397]

Oh, I didn't want to scare you I don't want to make any broad generalizations, but this is just what I heard. All the senior residents in my program got rejected by every sports fellowship they applied to. Several of them got into great pain fellowships though, so it wasn't a matter of the resident quality (I don't think). I don't know why sports fellowships don't like us, cuz PM&R docs are probably much better at sports med than any of the other fields where the residents commonly do sports fellowships.

Are you talking about family medicine sports fellowships? There are lots of sports fellowships within PM&R. In the past, we have had residents go on to train in Utah, Colorado, St Louis (Heidi Prather), Buffalo (Geraci), etc. etc.

Not sure what programs you are talking about. And what are the "great pain fellowships" that several of them got into?

 

[ampaphb]

Oh, I didn't want to scare you I don't want to make any broad generalizations, but this is just what I heard. All the senior residents in my program got rejected by every sports fellowship they applied to. Several of them got into great pain fellowships though, so it wasn't a matter of the resident quality (I don't think). I don't know why sports fellowships don't like us, cuz PM&R docs are probably much better at sports med than any of the other fields where the residents commonly do sports fellowships.

PM&R Sports fellowships, while competitive, are clearly friendly to our own. Non-PM&R based fellowships may not be

 

[topwise]

Are you talking about family medicine sports fellowships? There are lots of sports fellowships within PM&R. In the past, we have had residents go on to train in Utah, Colorado, St Louis (Heidi Prather), Buffalo (Geraci), etc. etc.

Not sure what programs you are talking about. And what are the "great pain fellowships" that several of them got into?

I don't know many of the details because I'm not interested in doing a fellowship in pain or sports. I just knew two residents in my program who got rejected from a bunch of sports programs and had to do pain by default. One of them had been very interested in sports and he told me that he wished he had known that the sports programs were biased against PM&R residents.

As I said though, this is all secondhand information. I'm just repeating the information a senior resident said to me. All strictly anecdotal. Can't uphold any of it in a court of law

 

[Louisville04]

I don't know many of the details because I'm not interested in doing a fellowship in pain or sports. I just knew two residents in my program who got rejected from a bunch of sports programs and had to do pain by default. One of them had been very interested in sports and he told me that he wished he had known that the sports programs were biased against PM&R residents.

As I said though, this is all secondhand information. I'm just repeating the information a senior resident said to me. All strictly anecdotal. Can't uphold any of it in a court of law

That senior resident was yanking your chain. Pain fellowships are competitive ....even for anesthesia residents.....rarely do you get one by default.

 

[topwise]

That senior resident was yanking your chain. Pain fellowships are competitive ....even for anesthesia residents.....rarely do you get one by default.

Haha... I don't think he was yanking my chain I didn't care enough to have my chain be yanked. I just know that he wanted a sports fellowship, got rejected to the 5-6 programs he applied to, then ended up going to one of the 3-4 pain fellowships that accepted him.

 

[njdevil]

Because there are only handful of sports/MSK pm&r fellowships, it is more competitive to get into v. a pain/spine fellowship by virtue of the numbers (many, many anesthia programs and significantly more passor approved spine programs than sports programs). If you are looking into sports and hell-bent on learning epidurals, you should apply to pain programs too to increase your chances on landing something.

 

[ampaphb]

Because there are only handful of sports/MSK pm&r fellowships, it is more competitive to get into v. a pain/spine fellowship by virtue of the numbers (many, many anesthia programs and significantly more passor approved spine programs than sports programs). If you are looking into sports and hell-bent on learning epidurals, you should apply to pain programs too to increase your chances on landing something.

Mayo (Smith), SSRC, MSU, Wash U (Prather), Atlantic Health System (Malanga), Stanford (Fredericson), BI (Gotlin), Buffalo (Geraci), Havertown (Chou), Utah (Willick), UW, Mayo Scottsdale, and UAB (Andrews) seem a bit more than a "handful"

 

[SSdoc33]

prather and MAYO scottsdale are not "sports" fellowships. unless they changed inthe last year, there is little or no exposure to sports med. also, are you talking about goodman's program in birmingham? i havent heard about any physiatrists working with andrews. there are other primarily sports fellowships, including andary at MSU, and a couple more in the midwest, if im not mistaken that are PMR based

 

[ampaphb]

prather and MAYO scottsdale are not "sports" fellowships. unless they changed inthe last year, there is little or no exposure to sports med. also, are you talking about goodman's program in birmingham? i havent heard about any physiatrists working with andrews. there are other primarily sports fellowships, including andary at MSU, and a couple more in the midwest, if im not mistaken that are PMR based

I listed any program in the PASSOR directory that dedicated 50% or less to spine

Andrews is separate from Goodman