Questions about PM&R

[premed72]

MS2 here. I am curious to learn more about the scope of practice of PM&R, bread and butter cases, daily routine etc. I haven't had much exposure to this specialty yet and just wondering if anyone here can provide some info! 

Thanks 

[Galaxsci]

Sure I'll give this one a go, I'm a current PM&R resident. I'm pretty convinced it's the best specialty in medicine as long as you like neuro and MSK. That said, it's a really tough specialty to get any exposure to because there's few lectures in pre-clerkship and rarely rotations in clerkship (school-dependent), so try your best to shadow and learn more about it. 

Scope: The scope is very broad. The primary practice areas are inpatient rehab (MSK, amputee, brain injury, stroke, and/or spinal cord injury), outpatient rehab (clinics to follow those patients, with other domains like cardiac and cancer rehab), sports medicine, electromyography (EMG), and pain (both interventional and non-interventional). You can also create areas for yourself, for example, there's a new staff physiatrist who recently created a niche in "pain during/after pregnancy". 

Bread and Butter: As you can imagine, this is highly variable depending on what area you're in. In inpatient MSK, you're typically dealing with patients with polytraumas (ex: car accident with a fractured femur and humerus). Brain injury is typically patients who have had fairly significant traumatic brain injuries, but in outpatient settings, you can also fairly frequently see patients with moderate-severe concussions. Amputee, stroke, and spinal cord injury rehab are probably self-explanatory. EMG is for patients with likely peripheral nerve dysfunction (radiculopathies, compression neuropathies, ALS, myasthenia, etc.). And in interventional pain, you're typically doing joint injections, spinal facet injections, nerve blocks, epidurals, radiofrequency ablations, etc. for patients with joint/back pain.

Daily Routine: Again, highly variable depending on your type of practice. Most people work in either inpatient and outpatient rehab or exclusively outpatient clinics doing EMG/pain/sports, both of which are nice because you don't have to do the same thing every day. The general work schedule for the vast majority of physiatrists in all settings is 8-5, Monday to Friday (typically with Friday afternoon off), with no evenings and no/minimal call. In inpatient rehab, you'll typically spend your day rounding on patients and seeing new consults. It's a relaxed pace because most of the follow-up patients won't have many new findings from the prior day, so you can spend more time seeing the new patients and ensuring you do a thorough assessment. In outpatient settings, it's a very similar daily routine to any other outpatient clinic. 

Miscellaneous: Just want to address two things that people tend to misconstrue about PM&R. First, physiatrists essentially never do physical therapy with the patient. We prescribe physical therapy all the time, but that's the domain of the physiotherapists and the occupational therapists. Our domain is similar to any other physician - prescribing medications, non-pharmacologic treatments, and performing interventions (such as the pain interventions above) when necessary. We certainly work closer with the therapy team than most/all other specialties, but there is a pretty clear line between their domain and ours. Second, the patient population varies tremendously depending on what area you go into. Most people rotate through general medicine and see patients who are "discharged to rehab" and assume that's the main population physiatrists deal with. In fact, we're not involved at all in the vast majority of internal medicine patients discharged to rehab. The population varies from pediatric to elderly, with a typical outpatient being around 40-50 and typical inpatient around 65 (trauma skewing much younger, stroke skewing older). 

 

Let me know if you have any other questions! 

 

[premed72]

On 9/19/2021 at 11:59 AM, Galaxsci said:

Sure

Hey Galaxsci, thank you! - I really appreciate your thorough explanation of PM&R. 

Just a few followup questions (apologies in advance if they sound naive):

1. so would you say a majority of your work is "hands on" I.e procedural? This is important for me as I am interested in a field that offers more of a hands on vibe.

2. how much of PM&R involves a "diagnostic" component when managing your patients.

3. aside from MSK and neuro, are there any other domains of medicine that you commonly need to be well versed in. you mentioned you manage cardiac and cancer patients - what depth of knowledge and scope of practice in these fields is required for you?

4. What other medical specialists do you have to frequently work with as part of a team - id assume you are communicating with multiple different specialities as rehab is required in multiple domains? 

 

[Bambi]

I would assume there is a component of the practice that deals with Workmen's Compensation cases from work related injuries. 

[Galaxsci]

On 9/25/2021 at 6:57 PM, premed72 said:

Hey Galaxsci, thank you! - I really appreciate your thorough explanation of PM&R. 

Just a few followup questions (apologies in advance if they sound naive):

1. so would you say a majority of your work is "hands on" I.e procedural? This is important for me as I am interested in a field that offers more of a hands on vibe.

2. how much of PM&R involves a "diagnostic" component when managing your patients.

3. aside from MSK and neuro, are there any other domains of medicine that you commonly need to be well versed in. you mentioned you manage cardiac and cancer patients - what depth of knowledge and scope of practice in these fields is required for you?

4. What other medical specialists do you have to frequently work with as part of a team - id assume you are communicating with multiple different specialities as rehab is required in multiple domains? 

 

No problem, nothing is really a naive question about PM&R because it's such a black box within medicine!

1. It depends on what you choose to do for your practice. Physiatry is broad enough that you could do no procedures or you could do mostly procedures. The majority of physiatrists do some "procedural" things, but it's not the mainstay of their practice because most people who go into the field prefer clinics and want procedures to mix things up, rather than the other way around. However, there are certainly some physiatrists who spend 75% of their time or more doing procedural things. It's really about how you choose to structure your practice, rather than something inherent to the specialty.  

2. Not totally sure what you're getting at here, but I'd say most of it is pretty diagnostic. A lot of patients come to a physiatrist (as an outpatient) without a clear diagnosis and often leave with a lot more clarity around what's actually going on. Inpatient physiatry tends to be more black and white because patients are typically coming to you after a major injury and it's clear what happened. That said, I'd say most specialties in medicine are pretty diagnostic, until you actually make the diagnosis, then it's just about managing the thing you previously diagnosed. 

3. Yes and no. You definitely need a good understanding of body systems and general medicine in order to be a good physiatrist, but there aren't overly specific domains needed. You only need an in-depth understanding of cardiac or cancer patients if you're going into cardiac rehab or cancer rehab. 

4. We typically work closely with ortho, neurology, rheum, plastics, and occasionally others (oncology, neurosurgery, etc). Plastics is the one that probably needs a little explaining - we work closely with plastics in clinics that perform nerve and tendon transfers for patients with severe. complex injuries. We'll do the diagnostics and EMG to determine which nerves are damaged and which are spared, we'll discuss in real-time in a shared clinic with the plastic surgeons, and they'll plan a nerve transfer based on the joint assessment.

[Galaxsci]

On 9/25/2021 at 8:48 PM, Bambi said:

I would assume there is a component of the practice that deals with Workmen's Compensation cases from work related injuries. 

Yeah there can be. Worker's Comp, independent medical assessments, military work, etc. can be part of the practice as well. Most physiatrists do some aspect of this sort of work to supplement their main practice because it tends to be more lucrative than the OHIP work.