Sara Cohen, MD

Disclosures

November 14, 2011

The classic joke is that PM&R stands for "Plenty of Money and Relaxation." Although there is some truth to that, PM&R actually stands for physical medicine and rehabilitation, a lesser known specialty that aims to restore impaired patients' function and quality of life.

Specialists in PM&R, also known as physiatrists, typically treat patients with musculoskeletal or neurologic deficits. In an inpatient rehabilitation setting, physiatrists may lead a team or offer consultations for patients with traumatic brain injury, spinal cord injury, stroke, amputations, musculoskeletal injuries, and chronic pain, among other impairments. If a patient with a brain injury is having difficulty walking, for instance, a physiatrist will examine his gait and work closely with therapists to determine what interventions might help him walk more smoothly.

Problems such as spasticity and pain are common on inpatient rehabilitation units, and physiatrists are experts at addressing these problems by adjusting medications and giving steroid and botulinum toxin injections.

In an outpatient setting, a physiatrist can wear many hats. Some practices focus on long-term follow-up of patients who have had a previous stay on an inpatient rehabilitation unit. Other specialists focus on musculoskeletal issues such as back or shoulder pain and offer fluoroscopic-guided steroid injections and other interventions. Still others specialize in performing diagnostic studies such as electromyography. Many physiatrists incorporate all of these elements into their practices.

Similar to other specialties such as neurology or dermatology, PM&R requires a preliminary or transitional internship year and 3 subsequent years of specialty residency training. Some programs include the intern year as part of their program, whereas others start training at the PGY2 level. Some physiatrists go on to fellowship training, but many leap straight into practice after residency.

PM&R may not have the glamour or public recognition of other specialties, but there are numerous benefits to being a physiatrist:

High Demand

In this economic climate, it makes sense to think about which specialties will have the most demand. An aging population means more strokes, joint replacements, amputations for vascular problems, and cardiopulmonary disease. There will be a growing need for physiatrists to oversee inpatient and outpatient rehabilitation for these patients.

Among young veterans returning from Iraq and Afghanistan, the prevalence of chronic pain and postconcussive syndrome from mild traumatic brain injury is 81.5% and 66.8%, respectively.[1] While working at the Veteran's Administration, I found that there was great demand for physiatrists to address these and other issues resulting from combat.

Good Work-Life Balance

PM&R offers a lifestyle with reasonable hours, even during residency. As a resident, I generally worked from 8 AM to 5 PM on weekdays, and about 1 weekend per month. We took call from home (this varies between residency programs) and I had some call nights when I never got paged.

Lifestyle after residency depends largely on the sort of practice you join, but hours tend to be regular because emergencies are rare in rehab. I also know several physiatrists who work part-time. I work as an inpatient rehabilitation consultant, which allows for reasonable hours and a lot of flexibility in my schedule -- which is especially great when you have small children or other similar demands at home.

Good Compensation

Assistant professors earn an average salary of $180,000, and the mean for associate and full professors is $210,000.

Physiatrists in private practice tend to earn more than those in academia, especially when they include electromyography, botulinum toxin injections for spasticity, and fluoroscopic-guided steroid injections for pain, all of which have high reimbursement rates.

Versatility in Practice

You can do a lot of procedures or none. You can work in an inpatient or outpatient setting or both, and you can focus on older or younger populations. You can even work at sporting events.

Interesting perspective in pain management. For those medical students keen on a career in pain management, picking PM&R instead of anesthesiology may provide a better understanding of the pathophysiology behind musculoskeletal pain.

Numerous subspecialty opportunities. Besides subspecializing in pain medicine, physiatrists can pursue an ACGME-accredited fellowship in spinal cord injury, sports medicine, pediatrics, neuromuscular medicine, or palliative care; these may be 1- or 2-year appointments. Additional nonaccredited fellowships also offer extra training.

Geographic opportunities abound. Resourceful physiatrists will find that there are many areas in the country that PM&R has not yet infiltrated, offering great opportunity for expansion. For example, a colleague of mine moved to Florida many years ago as the only physiatrist in her area; she set up a now-thriving practice with little competition.

Positive patient atmosphere. PM&R is an upbeat field, because you help patients who are on the road to recovery. As the saying goes, you "add life to years, not years to life." My first patient in PM&R residency came to us on the traumatic brain injury unit in a minimally conscious state; I will never forget how, months later, he shook my hand and wished me good luck with my new baby.

Uncharted (research) territory. Large research areas remain untapped in this developing field. For example, trazodone is commonly used as a sleep aid in patients with traumatic brain injury, but there have been no large-scale studies to back up this practice. In addition, other medications used off-label on rehab units as well as new technologies could benefit from clinical studies.

Match success. Because PM&R is not as "glamorous" as other fields, it is easier to match in PM&R than in other specialties that have similar hours and salary.

You will have useful advice. You will be able to provide expert advice to all your friends and relatives with joint pain. (On second thought, that may be a disadvantage.)

The greatest disadvantage of PM&R also stems from the fact that the specialty is not well known and is very diverse: your colleagues and patients may wonder what physiatry is and what you do. Ultimately though, they will likely be grateful that you do it.

To learn more about PM&R, visit the American Academy of Physical Medicine & Rehabilitation's Website.

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