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.