What is Physical Medicine and Rehabilitation?

Physiatrists empathize readily with their patients and treat the whole person rather than a single organ system or disease. They frequently work with a team of allied health professionals to provide a comprehensive rehabilitation program for the patient. The physiatrist is a team leader. Physiatrists also use the medical history and physical examination in combination with x-rays, laboratory studies and other diagnostic techniques in patient management. Physiatrists frequently elect to use special techniques such as electrodiagnosis. Some also perform injections into the joints or spine.

The physical medicine aspect of the field deals with the diagnosis and treatment of acute and chronic pain and musculoskeletal disorders such as cervical or lumbosacral radiculopathies, rotator cuff tendonitis, sports medicine, low back pain and injured worker programs. Pathophysiologic problems commonly treated by physiatrists include spinal cord injury, cerebral vascular accidents, muscular dystrophies, traumatic brain injury, amputations, polio, cerebral palsy and multiple sclerosis. Such diagnoses are generally considered to encompass the rehabilitation segment of the specialty.

The relationship of a physiatrist with other medical specialties is generally good. Physical Medicine and Rehabilitation complements the work of providers in other areas of medicine by providing additional patient services .

Areas of special interest practiced by many in the field of physical medicine and rehabilitation include electrodiagnostic medicine, spinal cord injury, brain injury, strokes, sports medicine, occupational medicine, physical medicine, general rehabilitation, amputee management, orthotic management, pediatric rehabilitation, and geriatric rehabilitation. Fellowships have been developed in some of these areas and are being developed in other areas. Double boarding is available through combined programs between the American Board of PM&R and the American Board of Pediatrics or the American Board of Internal Medicine.

The income of a physiatrist depends largely on the setting of the doctor—private practice versus academics and focus of work (research, patient care, administration). Salary and income also vary depending on the number of procedures a physician performs. In general, physiatrists are well-compensated comparable to other medical and surgical subspecialties. Formal survey reports with detailed compensation information are available online.

Generally, PM&R falls into a class I category for malpractice coverage. This is the lowest-risk category with the lowest premiums. However, this may vary by state depending on the specifics of an individual physician’s practice.

Some PM&R residency programs start at the PGY 1 level with a transitional year or year of internal medicine built into the program. Other programs start at the PGY 2 level with training encompassing only physical medicine and rehabilitation. In both cases, a resident needs to complete one year of internship prior to beginning the three-year program of physical medicine and rehabilitation. The three-years of PM&R are essentially divided between inpatient and outpatient rotations. The emphasis and strength of inpatient versus outpatient varies with different programs.

This is a very competitive residency, and growing interest in the field is further increasing the desirability of available positions. Some of the factors that make applicants more competitive include clinical honors, AOA, research experience, publication, unique background that supports well-defined goals, and excellent performance on a PM&R elective during medical school.

The best way to find out about programs is to talk with program graduates, current residents, program faculty, and faculty at your own medical school. National rankings such as U.S. News and World Report may be helpful, but those listings tend to be skewed toward the larger programs throughout the country; they tend to measure reputation of research output rather than quality of training.

Medical students should take an elective rotation in PM&R to get a better understanding of the specialty and decide if PM&R is the right place to focus a medical career. It is most sensible to take an elective in PM&R before the application process for residency training. Because the focus of medical student education is a broad training in medicine, only one PM&R elective is usually advised.

Some students believe it is best to do a rotation at the program where they would like to train. The advantage of doing this is obvious; one sees firsthand the opportunities and challenges of a particular program. Less apparent is that the program gets a much closer look at the student as well. Some programs may consider students who have taken electives with them more seriously than other candidates, but in general there is enough mobility of residents that the location of the elective is of secondary importance to the performance on that rotation.

Traditionally students entering PM&R have taken electives in areas such as orthopaedics, neurology, neurosurgery, urology, anatomy, rheumatology and geriatrics. These are areas of medicine that have close ties to PM&R. Many of the patients seen by PM&R doctors have diagnoses related to these disciplines.

Grades and board scores are among the few objective measures that residency programs have to evaluate students. Grades can be used by a program to decide whom to invite for an interview. Often more important, the Dean’s letter describes the student’s clinical interpersonal and professional skills. Letters of recommendation and the interview may outweigh grades.

The AAMC states that the National Board scores are not appropriate measures in the resident-selection process. The reality is that many programs do consider them if they are available.

PM&R is a specialty with great opportunities for academic, hospital based or private practice. Clinical as well as administrative positions are available. Many practitioners enjoy a balance between inpatient and outpatient work. Others enjoy administrative or research work or consulting. Still others emphasize exclusively inpatient or outpatient. Part-time positions are available. In general there is a great availability of wide selection of geographic locations and practice types for physiatrists.

The diversity of the specialty, the emphasis on long-term patient relationships, the quality-of-life issues, the types of diagnoses encountered, and the emphasis on function in a holistic approach to patients make physiatry a satisfying career choice for many physicians. This specialty has high levels of flexibility and is intellectually challenging—a satisfying and financially rewarding career choice. As a physiatrist matures professionally, it is possible to redirect the area of practice, yet still remain in the field, allowing for an interesting lifelong career.

It is recognized that the future development of this specialty will, to a major extent, be based on its ability to document the validity of its therapeutic approaches based on solid research. A growing emphasis on evidence-based medicine and evaluation of clinical practices signals significant demand for research in the field of Physical Medicine and Rehabilitation.

The teaching opportunities in physiatry are excellent. Physiatry is taught in the majority of the United States medical schools. There are multiple faculty openings in academic physiatry.

Many physicians choose this specialty because the lifestyle is attractive. The nature of many of the patient’s problems is such that “call” need not be burdensome or intrusive on family life. It is a specialty that can be practiced part time both successfully and satisfyingly. Conversely, many physicians in this specialty spend long hours providing patient care equaling the hours of many in the more traditionally acute specialties. Often the reason is that the demand for physiatric services far exceeds the number of physicians available to provide the required care. For most physiatrists, quality of life is as important an issue for themselves and their family as it is for their patients.

Physiatrists are present in every state but tend to cluster more in urban communities. They have a strong presence on both the East and West coasts but also have grown in recent years throughout the Midwest and the South.