So You Want to Be a Physiatrist (PM&R)

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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.

 

What is PM&R?

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 vs Neuro-Rehabilitation

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 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 interdisciplinary, working with a wide variety of specialists and therapists, from physical therapists and occupational therapists to speech therapists, recreational therapists, and respiratory therapists.

Academic vs Community vs Private Practice

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.

Common Misconceptions

There are a handful of misconceptions about PM&R, as it’s a smaller specialty most laypeople 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.

 

How to Become a Physiatrist

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 it’s 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 to 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.

 

Subspecialties within PM&R

After completing a PM&R residency, you can subspecialize further with fellowship.

Pain

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 include 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

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

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

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

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

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.

 

What You’ll Love about PM&R

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.

 

What You Won’t Love About PM&R

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.

 

Should You Become a Physiatrist?

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.

Thank you all so much for watching! If you enjoyed this article, check out So You Want to Be a Sports Medicine Doctor. 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.

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.

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