So you want to be a physiatrist, or a physical medicine & rehabilitation doctor, also known
as PM&R for short. You like the idea of dealing with chronic physical illness and having a
chill lifestyle. Let's debunk the public perception myths, and give it to you straight. This is
the reality of PM&R. Dr. Jubbal, MedSchoolInsiders.com.
Welcome to our next installment in So You Want to Be. In this series, we highlight a
specific specialty within medicine, such as physiatry, and help you decide if it’s a
good fit for you. You can find the other specialties on our So You Want to Be playlist. If you
want to vote in upcoming polls to decide what future specialties we cover, make sure you’re
subscribed. If you’d like to see what being a physiatrist
looks like, check out my second channel, Kevin Jubbal, M.D., where we'll be covering a day
in the life of a PM&R doctor in the future.
PM&R is the jack-of-all-trades specialty focusing on both inpatient and outpatient management
of non-operative orthopedics and neuro-rehabilitation. These are the primary physicians for certain
nervous system or non-surgical orthopedic disorders, offering both medical and procedural
treatment modalities. These are the doctors handling their unique conditions on an ongoing
and outpatient basis. Some patients present with spinal cord or
traumatic brain injuries, for whom you'll manage their pain, neuropathy, and bowel and
bladder care. Other patients may have other mixed connective tissue or nervous system
issues that you'll treat, such as mallet finger or jersey finger.
There are a few ways to categorize the specialty.
Non-operative orthopedics includes diagnosing and treating peripheral nerve diseases. This
often includes procedures with ultrasound or fluoroscopy assistance, or injections of
various types. For example, trigger point injections with lidocaine or steroids are
used at sites of myofascial pain, whereby there is tightness around a muscle focal point.
This is a rapidly evolving area of PM&R, with research and new therapies in regenerative
medicine such as platelet rich plasma, mesenchymal stem cells, or peripheral nerve stimulators.
Neuro-rehabilitation focuses on traumatic brain and spinal cord injuries, and is primarily
inpatient in nature. These physiatrists serve as the patient's primary hospitalist, not
as a consulting service, for patients requiring neuro-rehabilitation. Their main area of specialization
is in dealing with the neuromuscular diseases and related issues, and they may consult other
specialties, like pulmonology, neurology, and other specialties for specific concerns.
This is very collaborative and highly inter-disciplinary, working with a wide variety of specialists
and therapists, from physical therapists and occupational therapists to speech therapists,
recreational therapists, and respiratory therapists.
The practice of physiatry varies substantially between practice settings.
Academic physiatrists deal primarily with brain and spinal cord injuries. These tend
to be more severe cases than in other practice settings, and are heavy on neuro-rehabilitation.
As with any academic position, research and teaching residents and medical students is
part of the job. On the other hand, some clinical aspects are more relaxed because you'll have
residents to help carry out various clinical responsibilities. Overall, there are fewer
procedures, and therefore lower compensation, because more of your cases will be traumatic
brain, spinal, or stroke in nature. Community physiatrists deal with less severe
cases in comparison to academia. On average, you'll have more outpatient orthopedics, more
procedures, and higher compensation. While your academic colleagues will be dealing with
more amyotrophic lateral sclerosis, also known as ALS, or unique cases of Guillain Barre
syndrome, you'll be doing more EMG's as a community physiatrist, for things like ulnar
entrapment, carpal tunnel, and basic radiculopathies. Private practice physiatrists are uncommon,
unless they specialize in pain or sports. Part of the reason private practice is uncommon
is that owning your own rehabilitation center is expensive, requiring a large interdisciplinary
team to treat a small number of patients.
There are a handful of misconceptions about PM&R, as it's a smaller specialty most lay
people haven't even heard of. First, get used to people asking if you're
a physical therapist, or your friends and family requesting stretching exercises. PM&R
doctors are physicians, not PT's. While physical therapists are prescribing exercises and therapy
treatment plans, the physiatrists manage the medications, pain, spasticity, neuromuscular
dysfunction, and general medication management. Second, because it's a newer and smaller specialty,
many of your physician colleagues won't even know what you do. You'll get random consults
for things that are not appropriate, like a hospitalized patient who hasn't gotten out
of bed in several days.
After medical school, PM&R residency is 4 years. As with any specialty, intern year
will be a mix of various specialties, many of which are less clinically relevant to your
future as a PM&R doctor. As a PGY2, you'll be focused primarily on inpatient rehabilitation.
Every residency requires at least 12 months of acute inpatient rehab, and you'll get the
majority of that in your second year. The rest will be clinic and consult months cycled
throughout. As a PGY3 and PGY4, you'll have more elective time, usually with more relaxed
schedules and relaxed call. These will also be the years where you can gain greater exposure
to procedures, such as EMG's and injections. In terms of competitiveness, you're in luck,
as PM&R ranks second to last, above only family medicine. While the match rate is lower than
expected at roughly 90%, USMLE Step 1 has averaged 224 and Step 2CK at 238. Given the
relative lower competitiveness, it tends to be more DO and IMG friendly as well, although
it's been trending upward. To see the full list of specialties by competitiveness, check
out my videos explaining the methodologies and the full data set.
Because it's less competitive, the stereotype is that its for students who didn't do well
on their USMLE or who wanted to do orthopedics but couldn't get in, but I don't think that's
fair to the specialty. Medical students that apply into PM&R are generally optimistic,
as it's an almost necessary trait in the rehabilitation setting. You'll have to be encouraging to
your patients and help inspire hope.
After completing a PM&R residency, you can subspecialize further with fellowship.
Pain is a 1 year fellowship and is the most competitive, resulting in the highest compensation
for PM&R doctors. You can go into pain through PM&R, but also after residency in anesthesia,
neurology, or psychiatry. You'll be dealing with chronic pain patients,
which some find depressing, but others find deeply meaningful. A large part will be prescribing
pain medications, although given the opioid epidemic, physicians are moving more toward
procedures. These includes radiofrequency ablations for facet pain, epidural injections,
and spinal cord stimulators. This is great for those who like working with their hands,
as it's more procedural than other PM&R subspecialties.
Pediatrics is a 2 year fellowship focusing primarily on cerebral palsy. You'll be managing
spasticity and doing a few procedures like botox injections in spastic muscles.
You'll also come across some rare conditions like Duchenne's muscular dystrophy, Becker's
dystrophy, spina bifida, myelomeningoceles, and meningoceles. Because these are so rare,
you'll more or less become these patients' primary care physician, often continuing care
into their adulthood. This is the fellowship for those who not only
enjoy working with kids, but who are also very patient.
Sports medicine is a 1 year fellowship and is the second most competitive subspecialty.
You can also get into a sports medicine fellowship after a residency in family medicine or emergency
medicine as well. It's a procedure-heavy subspecialization,
including primarily steroid, hyaluronic acid, and platelet rich plasma injections, and also
the occasional EMG. Sports medicine also includes regenerative medicine, ultrasound, and sideline
coverage on sports games. This is the fellowship for physiatrists who
love sports and working with their hands.
Palliative care is a 1 year fellowship that focuses on improving the quality of life for
patients living with serious chronic illnesses. It's not quite hospice care, which is more
focused on the terminally ill, but you will still have some end-of-life patients who can
make substantial improvements and prolong their lives beyond the initial prognosis.
Cancer is common amongst this patient population, and you'll be helping managing pain and making
patients more comfortable. This is for the physiatrists who are positive and wouldn't
mind dealing with a great deal of death and end-of-life care.
Traumatic brain is a 1 year fellowship that's more academic in nature and is more heavily
concentrated at larger research centers. You'll be dealing with traumatic brain injury sequelae,
including headaches, changes in attention, and behavioral changes. New innovative therapies
are on the horizon, such as stem cells and other regenerative medicine to regrow damaged
tissue. On average, you'll have more complicated patients and more complicated rehabilitation
management. This is for the physiatrists who don't mind
some research, are ok with uncertainty, as there is more trial and error, and want to
work in an academic center.
Spinal cord is also a 1 year academic fellowship, focusing on spinal cord injuries rather than
brain injuries. Thankfully, spinal cord injuries are becoming less common in modern era with
improvements in safety technology, such as airbags in cars. Most spinal cord injuries
are the result of either elderly patients falling or hyperextension injuries.
There's a lot to love about PM&R. It's heavily team focused, and you'll be working with PT,
OT, and speech therapy on the regular, in addition to case management and liaisons to
help coordinate care at outside hospitals. In terms of lifestyle, your hours are predictable
and not too long – expect no more than 8 hours per day, and no nights or weekends,
with minimal call. For the lifestyle demands, you will be getting compensated quite well,
around $300,000 on average. If you enjoy the musculoskeletal system but
don't enjoy the operating room or being scrubbed in, PM&R allows for an office-based practice
with shorter and smaller procedures.
While PM&R is a great specialty, it's definitely not for everyone. It's slower paced and requires
a great deal of patience. After all, rehab takes time. You'll have to enjoy the small
victories and the ups and downs of treatment and management, as patients aren't generally
getting back to 100% baseline functional status. For some, this can grow quite frustrating.
Patients and families can often have unrealistic expectations and hope to return to their prior
baseline. The reality of them eventually seeing that long term assistance is part of their
future is difficult and disheartening. And chronic pain patients are not everyone's
cup of tea. Even if you don't specialize in pain, you will be seeing some of these patients.
How can you decide if PM&R is the right field for you?
Those who are happiest in the field tend to be optimistic, seeing the potential for patients
who present with terrible disease and finding the silver lining and ways to improve.
It's not nearly as hands-on as something surgical, but you should enjoy procedures, as it is
more procedural than the average office-based specialty.
And finally, if you're collaborative and enjoy working with others in an interdisciplinary
team-based approach to patient care, you'll get a great deal of that with physiatry.
Special thanks to Dr. Benjamin Shekhtman, physiatrist and current Insider at Med School
Insiders, for helping me in the creation of this video.
Are you hoping to become an physiatrist? To get into medical school and match into a desirable
PM&R residency, you’ll need to not only crush your MCAT and USMLE, but also shine
on your personal statement, secondaries, interviews, and other soft components of your application.
At Med School Insiders, our PM&R doctors can help you get there. We've had over 3,500 customers
so far and have an industry leading 99% customer satisfaction rating. That's not an accident
— we've obsessed and invested heavily over the past few years in creating our proprietary
systems that allow us to consistently provide excellent service and deliver stellar results.
That's the Med School Insiders difference. Learn more about why our customers love us
at MedSchoolInsiders.com. Thank you all so much for watching! If you
enjoyed this video, check out So You Want to Be a Sports Medicine Doctor, or another
specialty on our So You Want to Be playlist. Much love, and I'll see you guys there.