Sara Cohen, MD

Disclosures

October 05, 2009

It was third year of medical school. I was at the midway point, when the excitement of being in the hospital had started to wear off and the fatigue was starting to set in. I had just finished internal medicine, a field I had once contemplated as a career but was no longer feeling as sure about.

While at a restaurant with some of my fellow students, I started venting to an older and wiser fourth-year med student named Pete. I whined that the medicine wards made me feel like I was just rushing patients in and out, to the point where I had to struggle just to remember the names on my small census. I didn't enjoy taking care of seriously ill patients, who were always teetering on the edge of death. I hated having to tell family members that their loved one had died. I preferred long-term stable patients whom I could watch improve over time, but there were few of those on the medicine ward. I also felt overworked and too exhausted to be as good a doctor as I wanted to be.

I wanted a residency where I could have regular hours and not just feel as if I were in a persistent groggy haze in which I could barely function.

"You know what would be perfect for you?" the very wise Pete asked after listening to all my gripes. "You could become a physiatrist."

"A what?"

"A physiatrist," Pete said. "That's a specialist in PM&R."

"What does PM&R stand for?" I asked.

"Plenty of Money and Relaxation," another fourth-year quipped.

Actually, it stands for physical medicine and rehabilitation, a lesser-known specialty that's been accredited since the 1940s. Most medical schools don't require a rotation in PM&R, so our residency programs are always getting refugees from other specialties who learned about PM&R a little too late.

It can be complicated to explain to a lay person what we do because the field is so diverse. And that's one of the things I love about it. Basically, PM&R involves the diagnosis and restoration of functional ability and quality of life in patients with disorders of the nervous and musculoskeletal systems.

Residency training in PM&R includes 1 year of internship, which can be a preliminary or transitional year, followed by 3 years of specialty training in PM&R. Some residencies combine the 4 years into 1 program. Generally, the first year focuses on the inpatient rehabilitation aspects of the field, whereas senior residents practice more outpatient physical medicine with a lighter call schedule.

The rehabilitation part (the "R" in PM&R) involves the long-term care of patients with disorders of the central nervous system, such as brain injury, spinal cord injury, and stroke. We also care for patients with amputations and orthopedic injuries. Our job as the physician on the inpatient rehab unit is to oversee the care of these patients and work with a team of therapists and other staff to maximize the patient's function. Although the interventions we use will not "cure" patients, we help them to make the most of what they've got.

Rehab patients remain on the unit for weeks or even months. As a result, during my residency I was able to build relationships with them and their families, as well as see the long-term outcomes of treatment. I have a shelf in my apartment filled with gifts from patients who were very grateful for the treatment they received on our unit.

The job opportunities in rehab are plentiful these days, with a whole new generation of injured veterans in need of our services and an aging population at high risk for stroke and other problems that may require inpatient rehab.

For the physiatrist who prefers outpatient work, there's the physical medicine end of PM&R. Residents are trained in general musculoskeletal and sports clinics, where we diagnose and treat nonsurgical back pain, knee pain, shoulder pain, or pain in any other joint. For med students who have an interest in pain medicine but don't enjoy anesthesia, PM&R residency provides extensive training in pain management, including titration of pain medications and performing fluoroscopic spine or joint injections. (We call PM&R a painless path to pain.) Residents also receive training in electrodiagnosis, where we learn to diagnose nerve and muscle disorders ranging from carpal tunnel syndrome to Lou Gehrig's disease and myopathy.

I know many med students are very concerned with lifestyle and salary. As that fourth-year student joked, PM&R stands for Plenty of Money and Relaxation. According to the Medical Group Management Association's Physician Compensation and Production Survey in 2007, the median salary for physiatrists after 1-2 years in practice is $213,701. For those who have done a 1-year fellowship, the salary is quite a bit more.

In terms of lifestyle, PM&R is exactly what I was looking for. The hours are very predictable, even for a resident. I never felt too tired to function, and I think I was a better doctor because of it. I took call from home, even during my first year of residency training. After internship, I can say how amazing it is to be able to sleep in my own bed every night. And more important, there were only about 2 nights in my daughter's life when her mother wasn't there to put her to bed.

All in all, I can't imagine a better fit for me than PM&R. I've made it one of my goals to help spread the word of this specialty so that no medical students miss out on what might be the perfect field for them.

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