1. Physical Medicine and Rehabilitation
Kelly M. Scott, MD
Associate Professor, PM&R
UTSW Medical Center
Sept 21, 2015

2. What is Physical Medicine and Rehabilitation?
“The Best Kept Secret in Medicine!”

3. Physical Medicine and Rehabilitation
PM&R
Physiatry (fizz-ee-AT-tree or fizz-EYE-a- tree)
Rehabilitation Medicine
PM&R doctors are also called:
Physiatrists
Rehab doctors

4. PM&R
“Physiatrists, or rehabilitation physicians, are nerve, muscle, and bone experts who treat injuries or illnesses that affect how you move.”
-from the AAPM&R website
My definition:
“I am a medical doctor (MD) who treats disorders of muscles, nerves, and joints and the way that those things interact with each other to cause people to have problems with pain and function.”

5. Physiatrists are… A cross between: Orthopedists (non-operative)
Neurologists
Rheumatologists
Internists
Psychiatrists
Social Workers

6. What types of patients?
There is a large diversity of different patient populations and disease states that we treat in PM&R
Some physiatrists treat a little bit of everything, and some specialize in treating one or two things
PM&R docs work both inpatient and outpatient, depending on types of patients seen, acuity of patient presentation, and MD preference
Most physiatrists find their niche and excel at that
You can pick a few varied things, have a schedule where you do different things on different days – keeps life interesting

7. PM&R patients
Many different disease states and conditions, but they typically all have some things in common:
Decreased function or mobility
Pain
+/- Cognitive or psych component (or both)

8. PM&R patients – “inpatient”
Brain injury

9. PM&R patients – “inpatient”
Brain injury
Spinal cord injury

10. PM&R patients – “inpatient”
Brain injury
Spinal cord injury
Stroke

11. PM&R patients – “inpatient”
Brain injury
Spinal cord injury
Stroke
Amputation

12. PM&R patients – “inpatient”
Brain injury
Spinal cord injury
Stroke
Amputation
Neurologic:
Parkinsons
Multiple sclerosis

13. PM&R patients – “inpatient”
Brain injury
Spinal cord injury
Stroke
Amputation
Neurologic:
Parkinsons
Multiple sclerosis
Orthopedic:
Trauma, s/p hip and knee replacements

14. PM&R patients – “inpatient”
Brain injury
Spinal cord injury
Stroke
Amputation
Neurologic:
Parkinsons
Multiple sclerosis
Orthopedic:
Trauma, s/p hip and knee replacements
Burns

15. PM&R patients – “inpatient”
Brain injury
Spinal cord injury
Stroke
Amputation
Neurologic:
Parkinsons
Multiple sclerosis
Orthopedic:
Trauma, s/p hip and knee replacements
Burns
Generalized debility, transplant, LVAD

16. PM&R patients – “outpatient”
All of the things on the preceding slide, AND…
Back/neck pain, spinal conditions

17. PM&R patients – “outpatient”
Back/neck pain, spinal conditions
Sports medicine

18. PM&R patients – “outpatient”
Back/neck pain, spinal conditions
Sports medicine
Musculoskeletal injuries

19. PM&R patients – “outpatient”
Back/neck pain, spinal conditions
Sports medicine
Musculoskeletal injuries
Rheumatologic disease and arthritis

20. PM&R patients – “outpatient”
Back/neck pain, spinal conditions
Sports medicine
Musculoskeletal injuries
Rheumatologic disease and arthritis
Neuropathies, peripheral nerve injuries, myopathies, ALS, Myasthenia, etc.

21. PM&R patients – “outpatient”
Back/neck pain, spinal conditions
Sports medicine
Musculoskeletal injuries
Rheumatologic disease and arthritis
Neuropathies, peripheral nerve injuries, myopathies, ALS, Myasthenia, etc.
NCS/EMG

22. PM&R patients – “outpatient”
Back/neck pain, spinal conditions
Sports medicine
Musculoskeletal injuries
Rheumatologic disease and arthritis
Neuropathies, peripheral nerve injuries, myopathies, ALS, Myasthenia, etc.
NCS/EMG
Spasticity

23. PM&R patients – “outpatient”
Back/neck pain, spinal conditions
Sports medicine
Musculoskeletal injuries
Rheumatologic disease and arthritis
Neuropathies, peripheral nerve injuries, myopathies, ALS, Myasthenia, etc.
NCS/EMG
Spasticity
Pain management

24. PM&R patients – other/emerging niches
Cardiac rehab
Pulmonary rehab

25. PM&R patients – other/emerging niches
Cardiac rehab
Pulmonary rehab
Cancer rehab

26. PM&R patients – other/emerging niches
Cardiac rehab
Pulmonary rehab
Cancer rehab
Pelvic rehab (pelvic pain, voiding/defecatory dysfunction, sexual dysfunction)
Pregnancy rehab

27. PM&R patients – other/emerging niches
Cardiac rehab
Pulmonary rehab
Cancer rehab
Pelvic rehab (pelvic pain, voiding/defecatory dysfunction, sexual dysfunction)
Pregnancy rehab
Pediatric rehab (CP, muscular dystrophies, spina bifida)

28. PM&R patients – other/emerging niches
Cardiac rehab
Pulmonary rehab
Cancer rehab
Pelvic rehab (pelvic pain, voiding/defecatory dysfunction, sexual dysfunction)
Pregnancy rehab
Pediatric rehab (CP, muscular dystrophies, spina bifida)
MS rehab

29. PM&R patients – other/emerging niches
Cardiac rehab
Pulmonary rehab
Cancer rehab
Pelvic rehab (pelvic pain, voiding/defecatory dysfunction, sexual dysfunction)
Pregnancy rehab
Pediatric rehab (CP, muscular dystrophies, spina bifida)
MS rehab
Movement disorders rehab

30. PM&R patients – other/emerging niches
Cardiac rehab
Pulmonary rehab
Cancer rehab
Pelvic rehab (pelvic pain, voiding/defecatory dysfunction, sexual dysfunction)
Pregnancy rehab
Pediatric rehab (CP, muscular dystrophies, spina bifida)
MS rehab
Movement disorders rehab
Performing arts medicine

31. PM&R patients – other/emerging niches
Cardiac rehab
Pulmonary rehab
Cancer rehab
Pelvic rehab (pelvic pain, voiding/defecatory dysfunction, sexual dysfunction)
Pregnancy rehab
Pediatric rehab (CP, muscular dystrophies, spina bifida)
MS rehab
Movement disorders rehab
Performing arts medicine
Palliative rehab

32. PM&R procedures/technologies
We are not surgeons, we aim to treat conservatively
But we utilize many procedures and technologies to help our patients
It’s a good specialty for people who like to use their hands and be technical but who don’t want to be a surgeon

33. PM&R procedures
Injections – joint, muscle, bursa, etc. Also spinal under fluoroscopy.

34. PM&R procedures
Injections – joint, muscle, bursa, etc. Also spinal under fluoroscopy.
Pain procedures (fellowship training) – rhizotomies, nerve/plexus blocks, implantable spinal cord stimulators or pain pumps, etc.

35. PM&R procedures
Injections – joint, muscle, bursa, etc. Also spinal under fluoroscopy.
Pain procedures (fellowship training) – rhizotomies, nerve/plexus blocks, implantable spinal cord stimulators or pain pumps, etc.
Nerve conduction studies / Electromyography

36. PM&R procedures
Injections – joint, muscle, bursa, etc. Also spinal under fluoroscopy.
Pain procedures (fellowship training) – rhizotomies, nerve/plexus blocks, implantable spinal cord stimulators or pain pumps, etc.
Nerve conduction studies / Electromyography
Musculoskeletal ultrasound for diagnosis and injection guidance

37. PM&R procedures
Injections – joint, muscle, bursa, etc. Also spinal under fluoroscopy.
Pain procedures (fellowship training) – rhizotomies, nerve/plexus blocks, implantable spinal cord stimulators or pain pumps, etc.
Nerve conduction studies / Electromyography
Musculoskeletal ultrasound for diagnosis and injection guidance
Botox/phenol injections for spasticity
Baclofen and morphine pump management

38. PM&R technologies
Prosthetics
Orthotics

39. PM&R technologies Prosthetics/Orthotics
Functional electrical stimulation

40. PM&R technologies Prosthetics/Orthotics
Functional electrical stimulation
Modalities (therapeutic ultrasound, fluidotherapy, paraffin baths, iontophoresis, biofeedback)

41. PM&R technologies Prosthetics/Orthotics
Functional electrical stimulation
Modalities
Lokomat for gait training, Armeo for arm training

42. PM&R technologies Prosthetics/Orthotics
Functional electrical stimulation
Modalities
Lokomat, Armeo
Robotic rehabilitation technologies

43. PM&R technologies Prosthetics/Orthotics
Functional electrical stimulation
Modalities
Lokomat, Armeo
Robotic rehabilitation technologies
Wii-hab!

44. PM&R technologies Prosthetics/Orthotics
Functional electrical stimulation
Modalities
Lokomat, Armeo
Robotic rehabilitation technologies
Wii-hab!
Many different other high-tech gadgets for patients with SCI, TBI, stroke, amputation

45. PM&R is Different… …from any other medical specialty in three key ways
1. Focus on Quality of Life
2. Team Approach to Patient Care
3. Holistic View of Patient

46. 1. Focus on Quality of Life
Most every other medical specialty:
Diagnose the problem and cure/fix it! (or at least improve it as much as you can…)
If you can’t fix it, what do you do?
Tell the patient to live with it!
PM&R is different because we start with the assumption that there are some things are NOT fixable.
Spinal cord injuries, nerve injuries, chronic pain, severe spinal spondylosis, amputations, strokes, brain injuries, etc.

47. 1. Focus on Quality of Life
Even if some things are not fixable, there are MANY things that can be done to improve QUALITY OF LIFE and FUNCTION!!!
We use our medical skills to improve:
Mobility
ADLs (Activities of Daily Living)
Self-independence
Muscle spasms/contractures/ spasticity
Pain
Sleep
Mood
Cognition

48. 1. Focus on Quality of Life
“Isn’t it depressing to work with people who have disabilities and chronic pain all day long?”
NO! It is actually one of the most uplifting and rewarding specialties because:
You help the patient and their family to understand that their life is not over!
You guide them through a process of gradual recovery of self-independence, self-esteem, and improved life quality

49. Myth: Physiatrists don’t diagnose anything… True or False? FALSE!!!
All the time, on inpatient and outpatient, your patients will present diagnostic challenges
You may not be the one to tell them they’ve had their initial stroke, but you will be the one to figure out why they are nauseous, or have shoulder pain, or have new arm weakness

50. 2. Team Approach “The Team”:
The people you interact with and cooperate with on a regular basis in order to deliver patient care
(excluding insurance companies, who we all would like to just forget about…)

51. 2. Team Approach
Most other medical specialties:
Doctor
Patient

52. 2. Team Approach
Most other medical specialties:
Doctor
Patient

53. 2. Team Approach
Most other medical specialties:
Doctor RN
Patient

54. 2. Team Approach
Most other medical specialties:
Doctor PA
Patient

55. 2. Team Approach PM&R is very DIFFERENT!
A physiatrist cannot operate independent from a team of professionals who all work together to improve the patient’s quality of life and function

56. 2. Team Approach
Patient PT OT
SLP RN
PCT
MSW
Psych
Voc
Family
Doctor

57. 2. Team Approach
Patient PT OT
SLP RN
PCT
MSW
Psych
Voc
Family
Doctor

58. 2. Team Approach
Manifests in different ways depending on the type of PM&R you practice
Inpatient: weekly or twice weekly meeting with the entire team in attendance, everyone discussing the same patient in the same room at the same time face to face
Often with patient and family in attendance
Outpatient: variable… a good outpatient physiatrist will still have weekly or other regular meetings with their team to discuss patients face to face

59. 3. Holistic View of Patient
By holistic, I do not mean the use of non- mainstream medicine (chiropractic, naturopathic, acupuncture, homeopathy, etc.)
Although some physiatrists do fully embrace these things and even practice them, particularly acupuncture
Holistic - relating to or concerned with wholes or with complete systems rather than with the analysis of, treatment of, or dissection into parts (Merriam Webster)

60. 3. Holistic View of Patient
Physiatrists need to look at the whole person and equally need to understand the patient’s living environment.
We realize that everything is interconnected and important
A physiatrist has to understand the patient’s life and living situation before they can hope to devise a treatment and rehabilitation plan to improve that patient’s function and QOL
Biopsychosocial model of patient care
Treat physically, treat psychologically
Look at their family situation, support structures
How many stories is their house? Are there steps to enter?

61. The stuff you really care about:
What is residency like?
What is the resident’s quality of life?
How competitive is it to get in?
What fellowships are available?
What is it like to practice as a physiatrist?
What would my quality of life be in PM&R?
$ or $$$ or $$$$$$$?

62. PM&R Residency 3 years after an internship/transitional year
There are a handful of 4 year programs as well that incorporate the internship year
Including… UTSW!!!
The internship/transitional year:
You want to get a lot of medicine, you need to feel comfortable managing GIM problems – a lot of our acute rehab patients are very sick

63. PM&R Residency The 3 PM&R years are typically:
50% inpatient and 50% outpatient
Broad exposure across the board to all patient types, many/most procedures
200+ supervised NCS/EMG studies – you will be qualified to do these after graduation without a fellowship

64. PM&R Residency PM&R resident QOL: Internship: variable, mainly sucks
PGY2-4: also somewhat variable, but basically PM&R residents have it good
Our UTSW PM&R residents:
Rarely stay past 5:00pm
PGY2 and 3: on call 24 times per year (twice a month on average), 6-7 weekend days per year
PGY4 year: no call, no weekends

65. PM&R Residency and Competitiveness
Not bad, but getting worse by the year…
Quality of applicants, test scores increasing dramatically as more people find out about us
Less foreign/carribbean applicants are admitted
Lots of DOs interested, you compete with them as well
PM&R one of a handful to completely fill at the match – no spots left to scramble for
UTSW students
: 6 applied to PM&R
: 4 applied to PM&R
: 3 applied to PM&R
This year: at least 10 applying to PM&R!!!

66. PM&R Fellowships
You don’t have to do a fellowship, usually 50-70% of our residents do not
But if you want to:
Pain - ACGME
Sports Medicine - ACGME
Brain injury - ACGME
Spinal cord injury - ACGME
Neuromuscular (ALS, MG, NCS/EMG) - ACGME
Pediatric rehab (1-2 years) - ACGME
Palliative care – ACGME
Spine/Musculoskeletal
Cancer, multiple sclerosis, stroke, EMG, neuro rehab, amputee

67. Practicing physiatrist’s life
Inpatient vs outpatient or both
Generalist vs highly specialized
See only SCI patients, do only EMGs
Highly procedural vs no procedures at all
Rural vs city
Academic vs private practice
Lots of expansion in the VA system (wounded warriors)
Growth:
We are a growing specialty, the need is there and will continue to be there for more physiatrists
Baby boomers are aging
19.3% of Americans over age 5 currently have a disability – 2000 census
10% or 1 in 10 have a severe disability (also from 2000 census)
No problem getting a job!

68. Practicing physiatrist’s QOL
Very good!
Not paged away from your kids soccer game
Typically 9-5 job, M-F
Call: variable (depending on academic, group private, or solo private practice). Typically home call.
My call: 3 times a year for a week of home call (where I receive 0-3 pages per week), and I have to come in 5 weekends per year for 30-60min each day

69. Salary Better than an internist, family medicine, pediatrics
Less than a surgeon, radiologist, some other specialties
Depends a lot of type of practice and practice location
Starting salary (nonfellowship): typically $ ,000

70. Who makes a good physiatrist?
Someone who is patient
Good people skills, enjoys patient-doctor relationships
Good leadership skills – servant leader
Comfortable with slow change over time
Someone who is ok with not being able to fix everything
Someone who values quality of life (for their patients and themselves)

71. Drawbacks of PM&R Not many…
You have to be humble – no one will have heard of you or know what you do (not patients, fellow doctors)
Not the field to enter for a lot of glory
Not many opportunities for the “adrenaline rush”
You have to be ok with dealing with sad stuff
You have to be able to give bad news
You have to be ok with dealing with a lot of psychiatric illness

72. For more information… Dr. Sam Bierner – residency director
Terri Isbell – residency coordinator
Kimberly King – med student coordinator
Myself (Dr. Kelly Scott), Dr. Ben Nguyen, Dr. Heather Adair, Dr. John Thottakara, Dr. Jennifer Yang – med student committee members
PM&R Student Interest Group
Monthly SIG lectures by PM&R faculty on diverse topics within our field
– American Academy of Physical Medicine and Rehabilitation

73. RIC Summer Externship Rehabilitation Institute of Chicago
Summer Externship for students between 1st and 2nd year of medical school
8 week program, $3000 stipend
Learn about PM&R, participate in clinical care, do research project
Applications are due in early January…

74. In summary PM&R totally rocks and you should all go into PM&R!
QUESTIONS?