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PHYSICAL MEDICINE AND REHABILITATION
Physicians who specialize in PM&R are physiatrists, rehab doctors, physical rehab doctors, and may further distinguish themselves based on subspecialty. I often say I am a spinal cord injury rehab doctor.
PM&R in its many forms focuses on the restoration of function, physical impairments, and community reintegration. We don’t practice alone, we need our fellow professions in the disciplines of rehab nursing, physical therapy, occupational therapy, speech therapy, and recreational therapy. Depending on the practice, you are likely to work often with referring specialties such as neurosurgery, orthopedics, internal medicine, critical care to name a few. In addition, in a hospital setting in particular, there are other ancillary services to utilize to address the holistic, coordinated care of the patient.
AN OVERVIEW OF PM&R
PM&R is the discipline concerned with preventing, diagnosing, and treating a variety of neurologic, musculoskeletal, and cardiopulmonary disorders through rehabilitative measures. A typical patient base can include, but not limited to, those with conditions such as strokes, spinal cord injuries, traumatic brain injuries, burn injuries, postchemotherapy and cancer deconditioning, sports injuries, multiple sclerosis, amyotrophic lateral sclerosis, and, in children, cerebral palsy, spina bifida, muscular dystrophy, and postoperative orthopedic procedures. Because of the vast spectrum of diseases, physiatrists can focus on one (or more) of these medical problems. For instance, in many practices, there are physicians who subspecialize in pediatric rehabilitation and take care of only these younger patients. The practice of one physiatrist can look vastly different from that of her colleague.
Physiatrists coordinate the rehabilitative care of people with physical impairments and disabilities using an interdisciplinary approach. The physiatrist becomes quite adept at integrating the rehabilitation program in light of the patients’ medical conditions, for example, prescribing precautions during physical therapy and monitoring medical stability. They prescribe pharmacologic agents to treat conditions such as spasticity, musculoskeletal pain, and neurologic pain. Physiatrists formulate specific regimens including physical, occupational, and speech therapy, as well as coordinate care from other professionals, such as, psychologists, neuropsychologists, dieticians, respiratory therapists, vocational counselors, orthotists, prosthetists, rehabilitation equipment engineers, sports/fitness trainers, and doctors of other medical specialties. Every regimen is tailored to prepare the patient to meet a particular goal or set of goals.
It is the physiatrist, with the help of the rehabilitation team, who sets goals for the patient. With the PM&R specialist as the team leader, they meet at appropriate intervals during a patient’s hospital stay to discuss the patient’s progress, goals, and any pertinent social or psychological issues. The team also includes, in an important sense, the patient and his or her family, with whom the physician also meets to ensure open lines of communication. Education of both the patient and family is essential to increase the likelihood that the patient’s physical and social needs are met. Ultimately, this means a successful integration into society.
Other essential responsibilities include prescribing assistive technology and adaptive devices to augment the patient’s level of functioning: a wheelchair or walker to increase mobility, a communication device, or a hand-held reacher to allow greater independence in performing activities of daily living. To do so, physiatrists assess the difference between a person’s functional level and the functional level required to perform a specific task. Physiatrists, along with other professionals of the team, evaluate whether a wheelchair is of the appropriate size and the seat is positioned at the right angle. There are many factors to consider when evaluating the best choices to optimize performance. Physiatrists are the experts at determining the energy expenditure required of patients with orthotic and prosthetic devices and prescribe these devices accordingly. In rehabilitation care, the patient’s basic neurologic and musculoskeletal function is essential, as well as many psychosocial issues that affect the patient’s participation in the community.1 As public policy and education advocates, physiatrists play a major role in public awareness of safety. In this specialty, therefore, you will find many opportunities to speak out for patients’ rights and if interested, to participate in this community. This advocacy has supported the Americans with Disabilities Act of 1990. Disabled people now have greater access to public places and transportation.
Physiatrists as consultants are able to recommend rehabilitation, type of rehabilitation, and to what extent. A physiatrist has the right and responsibility to withhold inpatient rehabilitation from ineligible patients, such as hospice patients who are not expected to regain much function before the end of their lives. As you can tell, an entire array of possible ethical situations can confront a physiatrist. But just like any other area of medicine, patients are free to obtain second opinions. Conceivably, one physiatrist may not accept a patient for rehabilitation while another deems him or her an appropriate candidate. Occasionally, we are pressured to accept patients who we deem as inappropriate, in particular in the acute inpatient rehab setting. Dealing with this pressure requires fortitude and to consider the best interest of the patient.
Other ethical issues physiatrists face include concerns of distribution and access to health care resources. They may find themselves spending increasing amounts of time convincing an insurer that physical rehabilitation will benefit the patient and it will ultimately save money and resources. Some physiatrists also work with patients along the entire continuum of their lives. For instance if a patient has a severe traumatic brain injury (TBI) and follows up regularly with a physiatrist to help coordinate health care, end-of-life discussions may come up, and at the appropriate time and setting a rehab doctor may be involved in his/her care. In fact, the American Board of Physical Medicine and Rehabilitation (ABPMR) has an accredited hospice and palliative care fellowship that it shares with the American Board of Internal Medicine (ABIM) and eight other specialties.
Physiatrists do not just treat patients with severe disability, however. In recent years, the field of PM&R has also attracted many who are interested in sports medicine—working with trained athletes—and performing arts rehabilitation—working with performers, such as musicians and dancers. Sports medicine doctors can become athletic team physicians. The goals of care for the professional athlete and the performer are obviously different than for a patient who has moderate to severe disability. In these cases, the physiatrist is focused on enhancing the performance or is treating an injury, for instance, due to repetitive movements. For both the athlete and performer, PM&R specialists are trained in dynamic interventional techniques that can enhance balance and proprioception and increase the range of motion and strength.
REASONS WHY PHYSIATRISTS LIKE PM&R
Perhaps you like a particular facet of PM&R, such as working with people after a major life event has caused a new physical impairment, and you like knowing what happens to patients after they leave the hospital. Do you have a particular life experience that motivates you to work with people with physical impairments? Are you fascinated by neuroanatomy, musculoskeletal system, or have athletic experience and see yourself working in sports medicine? The thing about PM&R is that since there are so many facets and practice settings, it may be a good fit for your professional objectives.
✓ Enjoys caring for chronic problems.
✓ Can be satisfied by small successes (possibly over long periods of time).
✓ Is a creative, hopeful, easy-going person.
✓ Can lead an interdisciplinary health care team.
✓ Likes being heavily involved in patients’ lives.
Dr. Howard Rusk, a pioneer in the field of rehabilitation medicine, identified three phases of medical care: preventive, curative, and rehabilitative. He insisted that the last phase should not be “passive convalescence,” but active training to regain function and achieve greater independence and quality of life.2 It is the attending physiatrist who prescribes physical and occupational therapies and coordinates goals among the interdisciplinary teams. The patient population consists of people with both chronic and acute medical conditions requiring rehabilitation: orthopedic patients after a hip or knee replacement, patients who have suffered strokes, or patients with major injuries leading to paraplegia and tetraplegia. The PM&R specialist can also be involved in managing heart transplant patients and other cardiopulmonary rehabilitation. PM&R doctors can treat both the young and the old, for this type of care is needed among all people, regardless of age. For myself, I liked the fact that I had some say in what my day-to-day life would be like, based on what I did and where. I initially wanted to do all outpatient work during my medical school years, but once I found my subspecialty, I appreciated more traditional inpatient services offered to those with serious medical conditions and significant physical impairment.
Like any career, there may be some aspects of your day-to-day work that are less than appealing, but physiatrists, often are able to tailor their practices, to some degree, based on their interests and professional goals. Unfortunately, many misconceptions about rehabilitation medicine exist. “Early in my career, I found it disconcerting that many other physicians didn’t know very much about my specialty,” commented a university-based physiatrist. “Over the years, I have found it rewarding to educate others about my career, especially because I enjoy my career so much.” Patients are often transferred to “rehab” by internists and surgeons as part of discharge planning without fully understanding or appreciating the purpose of this care. Rehabilitation hospitals that provide inpatient programs are not simply “dumping grounds” after an acute hospitalization. At times, it can be rather frustrating to deal with this misunderstanding among colleagues. However, in most circumstances, cooperation from both parties, the physiatrist and the referring physician, can be negotiated. You are the one imbued with the power to decide if and when it is appropriate for a patient to begin a rehabilitation program. All physiatrists, therefore, value the virtue of patience when educating others about the importance of rehabilitation medicine. Their decisions are ultimately based on clinical expertise and their patients’ best interests.
There is room for many different interests and practice types in physiatry—all of which focus on coordinating rehabilitative care and addressing each physical impairment or disability. For instance, if you like procedures then consider sports medicine or interventional pain subspecialties, or you can do fluoroscopically guided spine or joint injections. Physicians who choose this field often want to do physical work, without the intensity or time pressure of major surgery. There is a role for procedures in most patient populations; however, this is practice dependent.
PM&R is a specialty with great variety. Some say that PM&R’s organ system is the musculoskeletal system. However, rather than focusing on one organ system, the physiatrist collectively evaluates and treats deficits in function that result from one or more anatomical or physiological abnormality. One physiatrist commented that she liked the fact that PM&R “is not limited to any one organ system—it is not even limited to the body—but includes the psychosocial aspects of the patient’s care.”
THE DOCTOR–PATIENT RELATIONSHIP
Would you like to build long-lasting relationships with your patients? And inspire people to do their best? The doctor–patient relationship is a valuable and rewarding part of a career in PM&R. You meet patients after an acute decline of functional status and help them overcome their limitations, thus building long-term connections. Or you may be encouraging a patient to continue to maintain the baseline functional status. One of the many rewards in physiatry is the enormous sense of fulfillment and purpose in day-to-day activities. Although clinical improvement may be slow in many instances, small gains over time in a patient’s function and quality of life make it worth all the effort.
We know from data that a patient under the care of a rehabilitation doctor has a higher chance for significant functional improvement from a recently acquired physical impairment. The earlier you establish this relationship, the better the outcome. The PM&R doctor is a constant source of stability and encouragement. Many patients prefer to see only their physiatrist for medical care. Their clinics are usually more accessible to people with disabilities, and patients may feel greater acceptance by the clinical staff. A career in PM&R also means that you must feel comfortable discussing difficult topics at the appropriate time, from sexuality and reproductive issues, to bowel and bladder care and in many cases prognosis for recovery. Topics must be addressed with care and sensitivity, which is part of what being a good physician is all about.
Many physicians who choose this specialty have been influenced by personal experience with disability, either their own or of someone they know. What is your own interest in working with people who have disabilities? Do you feel comfortable in their presence? If you ask PM&R specialists why they chose this specialty, the overwhelming response is that they “like taking care of people.”
HOW TO BE AN EXCELLENT PM&R PHYSICIAN
A superb understanding of neuroanatomy, neurophysiology, and the musculoskeletal system serves as the basis for your daily practice when evaluating patients and discussing rehabilitation plans with colleagues. A good physiatrist can execute the neurologic examination as good as any neurologist and the musculoskeletal examination as skillfully as any orthopedic surgeon or rheumatologist. As directors of an interdisciplinary team, physiatrists are also adept at coordinating people and tasks.
In an inpatient rehabilitation facility, the physician manages many chronic medical issues, such as controlling blood sugars in the diabetic patient, continuing antihypertensive medicines for the stroke patient, and administering cardioprotective agents for the post-heart-attack patient. Other medical complications that may occur under a physiatrist’s care include neurogenic bladder and bowel, autonomic dysreflexia, and spasticity. A PM&R doctor must be adept at managing acute situations, too. When preventive measures fail, the rehabilitation doctor must either handle an acute scenario or delegate the responsibility to the appropriate party. Moreover, a good PM&R specialist is astute at determining when a previously stable patient becomes acutely ill. Some are born with this intuitive skill, while others develop it with experience.
THE TYPICAL DAY OF A PHYSIATRIST
The daily responsibilities of a physiatrist vary as the combination of practice type, patient population, and subspecialty practice would dictate. In PM&R, the types of conditions you will treat encompass a variety of functional impairments. For example, an older patient population provides more opportunities to work with stroke rehabilitation and hip and knee replacements. A younger population, on the other hand, may present with more traumatic injuries, such as those suffered in sporting accidents, motor vehicle collisions, or violent crimes.
Practice settings are varied and include an inpatient rehabilitation hospital, day rehabilitation center, and outpatient clinic. Many physiatrists have the responsibility of caring for patients at two or more types of locations. The type of daily work will depend on the geographic region (whether at an academic center or in a private practice group), subspecialty interest, and referral base.
In an inpatient rehabilitation setting, there are three areas crucial to a patient’s health. A PM&R specialist is first responsible for managing any acute medical issues, such as hypertension, diabetes, and infectious disease. Second, you address medical concerns uniquely related to rehabilitation. These include pressure ulcers and problems related to proper bowel and bladder function. You may find yourself placing urinary catheters, measuring urinary bladder volume, disimpacting bowels, or debriding ulcers at the bedside. Third, there are functional rehabilitation issues to consider. In an acute rehabilitation setting, patients stay in rooms with beds much like other hospitals, but there are also physical therapy gyms and other therapy spaces where small miracles take place daily. A PM&R physician might also want to evaluate patients during their therapy sessions. For instance, a physical therapist might demonstrate a patient’s limited flexibility for the physiatrist so that he could, in turn, prescribe or recommend other exercise or modalities to enhance the patient’s range of motion. Interdisciplinary team rounds are also an important part of PM&R. In this group, various allied health professionals share information about patient progress and, as needed, revise their goals for patient care. These comprehensive rounds enable PM&R specialists to get the whole story on the progress and treatment of their patients.
In some cases, day rehabilitation centers are often the next setting to which a patient with a complex disability, traumatic brain injury, or stroke will be discharged after inpatient rehabilitation. “Day rehab” supports the notion that each comprehensive rehabilitation program can be tailored to suit the specific needs of each individual patient. The model focuses on patients who could benefit from a longer, more intense outpatient rehabilitation than would be prescribed with just one outpatient therapy alone. Therefore, these patients participate in various disciplines, usually two or more, and may include physical therapy, occupational, or speech therapy 3 to 5 days per week. In addition, there are vocational rehabilitation counselors and measures to determine functional capacity for work. At these facilities, there are physiatrists who manage the patients’ rehabilitative medical care while supervising their therapies’ gains.
Outpatient practice in PM&R is as important as inpatient rehabilitation. These clinic visits allot time to determine new goals, evaluate patient progress, and troubleshoot issues along the way. However, there is a host of physiatrists whose primary practice is all outpatient care, so if their patient requires inpatient, acute, or rehabilitation care, they will fall under another physician’s care/service. This physiatrist will likely treat more common conditions such as osteoarthritis, back pain, myofascial pain, and musculoskeletal injuries. Outpatient physiatrists are more sports, spine, and musculoskeletal oriented. They take care of patients with both subtle and severe impairments and may become more involved in worker’s compensation cases. Keeping patients motivated to perform their home exercise program is an important part of the continuum of care. They may also find time in their schedule to perform more interventional work, like facet joint injections, spinal injections for discogenic pain, or hip injections.
Prevention
Physiatrists encourage their patients to live safely, maintain safe homes, and wear helmets and proper equipment when participating in sports and recreational activities. In an effort to reduce the probability of injury, for example, a physiatrist who is the physician for a sports team makes judgments as to whether it is safe for a player to continue participating. In general, education plays a key role in the effort to prevent both initial injury and disease and the complications that result from injury and disease.
Diagnostics
The history and physical examination are essential tools in this specialty. Often patients are referred to PM&R specialists after receiving an initial diagnosis (and in some cases after the initiation of treatment). Sometimes patients are referred to a PM&R doctor with a diagnosis, but during the evaluation, and even over time there may be another more accurate diagnosis or the condition for which the patient was referred is not causing distress, but another issue related to the diagnosis is the chief complaint. Therefore, the physiatrist must then re-evaluate the situation and bring new, creative solutions to the table.
Patient’s functional history is important to assess premorbid functional level and set appropriate goals. They ask questions like, “How many stairs do you have at home?,” “What types of things can you do for exercise, before and now?,” and “How long have you required a cane?”
Physical examinations are often repeated during the care of a rehabilitation patient. The ability to remain objective, pay attention to details, and to chart progress is imperative. Often physiatrists are the first people to recognize a subtle physical examination finding, such as gait abnormality and muscle imbalances in patients referred by other physicians, muscle fasciculations that may lead to diagnosis of amyotrophic lateral sclerosis (ALS), or bowel and bladder changes that may herald a spinal cord condition.
To help define disease and its progression, all physiatrists make use of laboratory and radiological studies. Some also regularly perform electromyography (EMG), nerve conduction studies, and evoked potential studies—diagnostic modalities that residents in both PM&R and neurology are trained to use. Nerve conduction velocity test (NCV)/EMG studies are an extension of the clinical examination and assist with diagnosing neurological and muscle diseases: from radiculopathies, mononeuropathies, such as carpal tunnel syndrome, to motor neuron diseases such as ALS. There is a neuromuscular fellowship cosponsored by the ABPMR for further training in this area.
Therapeutics
Therapies used by PM&R physicians include physical therapy, ultrasound, cryotherapy, transcutaneous nerve stimulation, biofeedback, phonophoresis, and microwave diathermy. Physiatrists also perform intramuscular and intra-articular injections and neurotoxin injections for the management of spasticity. Because of the wealth of treatment options, the specific ones you choose depend on your preferences. For instance, someone who trained at an institution heavily involved in biofeedback research and treatment is more likely to use this technique. PM&R specialists who trained at a school that emphasized interventional procedures may tend to turn to injections and other minimally invasive techniques more often.
LIFESTYLE CONSIDERATIONS AND PRACTICE OPTIONS
Physiatry is a rewarding profession that allows the practicing physician to develop continuity of care with patients. Some physiatrists start solo practices, join medical groups with other physiatrists or a multispecialty practice, work in free-standing rehabilitation facilities, or remain in academics. For instance, a group of orthopedic surgeons may prefer having a PM&R specialist provide care for postoperative patients following hip and knee arthroplasty. Or a physiatrist in this group may care for patients who are not surgical candidates but have orthopedic-related medical problems. In this situation, physiatrists use their expertise to prescribe a program as part of the solution.
Physical medicine & rehabilitation |
$271,410 |
Source: American Medical Group Association.
Currently the demand in the field is growing due to aging population and advancement in trauma care. Many elderly patients require rehabilitation to reclaim lost strength and function after being hospitalized even for a relatively short period of time or during their stay at a nursing home. Every year, thousands of people are born with cerebral palsy or sustain severe traumatic brain injuries, and more people are surviving. As the population ages and the rate of survival from previously fatal accidents and illnesses continues to increase, the number of disabled people continues to rise.3 By 2020, it is estimated that 9 to 14 million people over the age of 65 will have moderate to severe disability.4
There are more than 8000 physiatrists in the United States, up from recent years. Expanding this specialty and training more physicians is required to meet the needs of patient care.5 Because PM&R is a referral-based specialty, the need for more physiatrists will only increase further as the medical community better understands and appreciates their skills and knowledge. Medical centers are now making a concerted effort to introduce PM&R to those students who may be interested in caring for people with acute and chronic disabilities or one day referring patients to a physiatrist.
Physiatrists’ patient population overlaps with those of several other specialists: nonsurgical orthopedic practitioners (who treat sports medicine and work-related injuries), neurologists (who treat pain, spasticity, neurological disorders), and anesthesiologists (who provide chronic pain management services). Neurologists and physiatrists perform thorough neurologic physical examinations, make use of EMG in diagnosis, and interpret neurologic imaging studies. But future PM&R physicians should not be overly concerned about competition within the health care marketplace. Although neurologists and physiatrists see many of the same medical conditions, they care for patients at different points in the medical timeline and vary when it comes to patient goals, treatment plans, and therapeutic modalities. In fact, some argue that they are actually part of a multidisciplinary team spanning practice boundaries.
FELLOWSHIPS AND SUBSPECIALTY TRAINING
Some prominent figures in the field are proponents of PM&R as more of a primary care practice. They believe that residency programs in physiatry should train graduates to become primary care physicians for patients with disabilities. There are different opinions within the profession as to what this role would actually mean for the practice of PM&R. In addition, rehab physicians are practicing more general medicine as inpatients in rehab programs are being admitted sooner and with more complex medical histories. Advocates for a primary care model maintain that subspecialization detracts from a primary care focus, whereas others believe that the current movement toward subspecialization will strengthen, stabilize, and validate this discipline. Subspecialization however provides the physiatrist with a unique opportunity to be involved in more facets of the patient’s health care course.
Should you consider completing a fellowship? In some instances, residency training more than adequately prepares you to practice in a subspecialty area of interest. After all, on-the-job experience as a practicing physiatrist can be enough to mold a physician into a “subspecialist.” A physiatrist at a rehabilitation center agreed, “If you are hired into a position—for instance your first attending job—where you are doing mainly spinal cord injury or traumatic brain injury, then you will become an expert in those areas.”
However, as a clinician who completed a 1-year fellowship in my field of interest, I cannot imagine working in this field without that extra year to hone my skills. In addition, the subspecialties highlight how diverse the fields of practice are from sports medicine dealing with healthier active population to hospice care and being involved with patients who require assistance to meet their basic needs. This is illustrated by the breadth of subspecialty fellowships. Nevertheless, the decision to complete a fellowship is an individual decision based on your personal professional development plan.
• Number of positions available: 413
• 212 US seniors and 367 independent applicants ranked at least one PM&R program
• 99.7% of all positions were filled in the initial Match
• The successful applicants: 61.9% US seniors, 8.3% foreign-trained physicians, and 28.2% osteopathic graduates
• Mean USMLE Step I score: 226
• Unmatched rate for US seniors applying only to PM&R: 8.2%
Source: National Resident Matching Program.
Clinical fellowships in PM&R typically last 1 to 2 years, where the 2-year fellowships are often more research oriented. Subspecialty training allows the resident to become an expert in an area of rehabilitation before actually having to treat patients as an attending physician. In addition, fellowships continue, where residencies are left off, to promote learning of evidence-based practice of rehabilitation medicine. There are seven accredited ABPMR fellowships. Just a few years ago there were only three ABPMR-sponsored subspecialties accredited by the ACGME; now there are six subspecialties—SCIM, pediatrics, brain injury, sports medicine, neuromuscular medicine, and pain management.
You can become board certified in these areas following successful completion of the subspecialty examinations. Brain injury is relatively new and those who practice brain injury (at least 25% of their practice) can apply for examination without a fellowship. For up-to-date information it is recommended to follow the information on the ABPMR and ACGME websites.
Spinal Cord Injury Rehabilitation Medicine
Patients who have suffered trauma to their spinal cord have special medical issues related to the level and severity of injury. Physiatrists trained in this subspecialty learn how to manage acute problems such as autonomic dysreflexia or hyperreflexia, as well as chronic complications like urinary incontinence, wound care, infertility, and sexual dysfunction. They have to be able to respond to psychological factors, such as patients’ fear of re-injury and its effect on their disability. Spinal cord injury fellows not only become experts in the clinical care of acute traumatic spinal cord–injured individuals, but they also treat atraumatic spinal cord disorders such as multiple sclerosis, ALS, myelitis, spinal stenosis.
Residency in PM&R requires 4 years of postgraduate training either with a preliminary year and 3 years in PM&R-specific training or a 4-year categorical program. There are currently 87 accredited programs. There are also positions in combined PM&R programs with additional training in neurology, pediatrics, or internal medicine. All require a general internship year (PGY-1), which can be internal medicine, surgery, or transitional. In a typical program, residents gain experience in both inpatient and outpatient rehabilitation medicine. The amount of work hours varies per individual program. Overnight call varies greatly among programs so it is important to understand each program’s expectations. Call can be relatively benign, or more intensive and fast-paced, especially as patients are transitioning to acute inpatient rehab sooner and sometimes sicker. Also the expectation varies based on the number of patients to be covered overnight. Some programs offer at home call versus in-house call. Resident physicians have monthly rotations that provide training in general rehabilitation of neurological conditions, deconditioning, strokes and spinal cord and traumatic brain injuries, as well as pediatric rehabilitation. Many programs have substantial elective time to gain experience in particular areas of interest within PM&R. If you are interested in a subspecialty, it is important to know how much training hours is available in that area, is it variable of competitive amongst other trainees to gain that experience.
Pain Management
Physiatrists can complete fellowships focusing on interventional pain and chronic pain management. The ABPMR offers board certification in pain medicine with anesthesiology and neurology. The number of programs and openings are likely to increase. As many physicians know, there is a huge need for pain specialists to assist in the care of this patient population. With its emphasis on procedures, pain medicine has become a lucrative area of expertise due to high reimbursements. The physiatrist will be able to integrate functionally based goals, and the intervention being a part of the overall care plan to address an issue.
Pediatric Rehabilitation
Although physiatrists can work with patients in all age groups, many choose to subspecialize in caring only for children with chronic disabilities whose issues are profoundly different from those of adults. Pediatrics rehabilitation specialists treat kids with cerebral palsy, muscular dystrophy, spasticity, burns, spina bifida, and developmental issues related to prematurity at birth. This fellowship provides additional time for physiatrists to develop their skills in integrating a child into an environment that stimulates development and increases their physical, cognitive, and social functioning. Pediatric rehabilitation is both specialized and diverse, given that the patients vary from infants to adolescents. Pediatric physiatry addresses those disorders potentially affecting children on a long-term basis, often involving multiple organ systems. The emphasis is on helping patients achieve developmental skills and independence in self-care and mobility appropriate to their age. The fellowship also addresses the role of the physiatrist as the coordinator of multiple services (medical, social, or educational), as well as the importance of acting as liaison and advocate for the child and family.
BRAIN INJURY REHABILITATION MEDICINE
Fellowships in brain injury rehabilitation tend to focus on traumatic brain injury but include those of other origins, such as anoxic injuries to the brain. Functional levels range from the comatose to the mildly cognitively impaired in brain injury patients. The fellowships are usually 1 to 2 years based on the length of the research component. Currently due to the relative small number of brain injury fellowships, the ABPMR allows diplomates to take the brain injury examination without the requirement of completing a fellowship via special criteria, such as having a significant (25%) of their current practice involving brain injury medicine.
In this fellowship, the physiatrist learns how to manage brain injury early while the patient is in the ICU or neurosurgery service and on rehab unit, outpatient, and day rehab programs. The fellow manages everything from acute agitation to long-term medical complications associated with brain injury. Caring for brain-injured patients ranges from prescribing plasticity enhancers to neurostimulants, to establishing behavioral modification protocols. Brain injury patients tend to have longer initial inpatient rehabilitation stays, and therefore this specialist needs to be very comfortable with dealing with the day-to-day medical issues that may arise. Outpatient work will likely include spasticity management with botulinum toxin injections, intrathecal baclofen pump management, serial casting, and pain management and becoming involved in the caregiver/carepartner system for those who require assistance or supervision. Intimate involvement in the patient’s care plan may require a lot of communication directing the key players and typically, requires the assistance of other professionals such as a social worker, psychologist, or primary care physician. This is the case with PM&R in general but especially in dealing with the brain-injured population. Most traumatic brain injuries result in mild disability and these people may need help with working on cognitive issues, ophthalmologic, neurological, and other symptoms while being reintegrated into the community. This specialist is intimately involved as a liaison to other professional and social services the patient might require for social integration. The ABPMR partners with the American Board of Psychiatry and Neurology (ABPN) to offer this board certification.
Sports, Spine, and Musculoskeletal Medicine
Physiatrists can subspecialize in the diagnosis and treatment of sports-related injuries or musculoskeletal problems. They primarily manage musculoskeletal diseases but are still very knowledgeable in general rehabilitation. These subspecialists also receive training in electrodiagnostic studies, trigger point injections, and fluoroscopically guided spinal injections. Their patients are athletes, workers, or any individuals with a physical impairment, subtle or more involved. They often care for the young patient who may have pain or declining performance in their workouts due to a physical injury. Fellowship will prepare this doctor to become effective and efficient in managing common complaints, such as low back, hip, knee, and shoulder pain, whether related to recreation or occupation activities.
NEUROMUSCULAR FELLOWSHIP
Once you begin your residency program you will start training in EMG, performing nerve conduction studies, evaluating patients for neuromuscular diseases. Diagnoses range from carpal tunnel syndrome (median nerve mononeuropathy at the wrist) to being involved in determining a rare neurological condition. This subspecialty certification has been offered since 2008 by ABPMR. It is a unique area of training that is shared with the specialty of neurology; in fact, the ABPMR cosponsors this certification. Oversight of the neuromuscular board certification examination is the responsibility of the ABPN. The field of neuromuscular medicine allows the physiatrist to be an integral part of the rehab, to diagnose and in many cases, prognosticate.
HOSPICE AND PALLIATIVE CARE
Hospice and palliative care is an interdisciplinary specialty and ABPMR sponsors with ABIM along with other medical subspecialty boards. ABIM administers and creates the examination. Why consider a career in PM&R?
PM&R is one of the youngest specialties in the medical profession. It became a member of the American Board of Medical Specialties in 1947 after the veterans of World War II returned home with amputations and other combat-related injuries.6 The separate disciplines of PM&R became a single entity when two prominent physicians—Howard Rusk (rehabilitation) of New York University and Frank Krusen (physical medicine) of the Mayo Clinic—began collaborating. Through their efforts, with funding from the US Department of Health, Education, and Welfare, opportunities for training in this new field of PM&R began to blossom. Now, more US senior medical students than ever before are choosing careers in physiatry.
For many this field allows them to practice both the science and art of medicine. The field continues to evolve as the demands of populations change. This field is full of rewards, both for the physician and the patient. The doctor–patient relationship is central to medical care, especially because physiatrists evaluate their patients in a holistic manner—involving both the body systems and the external ecosystem. The referral-based practice of PM&R also offers versatility: you can have a solo practice, be part of a multispecialty group practice, or work in academics. There is also a great deal of variety in terms of patient care, from bedside treatment to rehabilitation plans, from educational programs to patient advocacy. Within the small community of physiatrists, there are many opportunities for leadership, both in the public and private sectors. PM&R is a perfect specialty for all types of personalities—introverts, extroverts, cerebral, and exuberant individuals alike.
Medical students wanting to make a difference in the lives of patients suffering from acute and chronic disabilities should seriously consider this specialty. As a specialist in PM&R, you will become a beacon of hope for physically impaired and chronically ill patients. For those physicians who entered medicine to help people, there is no better choice than PM&R for a fulfilling medical career.
ABOUT THE CONTRIBUTOR
Dr. Vicki Anderson is proud to be an attending physician at Edward J. Hines Veterans Affairs Medical Center in Hines, Illinois. She completed her BS at Stanford University, moved back to her hometown of Chicago to complete both business and medical school at the University of Chicago, followed by PM&R residency at the Rehabilitation Institute of Chicago (now the Shirley Ryan AbilityLab residency program). She served as the program director for the spinal cord injury medicine fellowship at the Medical College of Wisconsin.
REFERENCES
1. Flax HJ. The future of physical medicine and rehabilitation. Am J Phys Med Rehabil. 2000;79:79–86.
2. American Academy of Physical Medicine and Rehabilitation website. www.aaPM&R.org. Accessed July 2006.
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