The DO | Patient Care | In the Field

DOs a natural fit for physical medicine and rehabilitation

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The median annual compensation for all U.S. physiatrists is $241,000. (Source: Medical Group Management Association’s 2010 Physician Compensation Survey)

This is the second in a series of articles profiling medical specialties. The first article focused on anesthesiology.

Despite the limited number of AOA-approved residency programs in physical medicine and rehabilitation—two in New York, one in Michigan and one in Florida—osteopathic physicians have been making a big impact on this small but rapidly growing specialty. In fact, 23% of current residents in allopathic PM&R programs are DOs.

Mutual attraction characterizes the relationship between the specialty and DOs. Requiring a whole-patient approach to care, excellent communication skills and an understanding of the interrelationship of structure and function, PM&R has many of the same expectations and training emphases as osteopathic medicine. Because manual medicine is one of the main interventions used in PM&R, the specialty draws osteopathic medical students serious about osteopathic manipulative treatment. In turn, many of the 79 PM&R residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) find DO graduates to be especially well-prepared.

The median annual pay for PM&R physicians, commonly called physiatrists, is close to $240,000, putting it in the mid-range for medical specialties. But tremendous variation exists in compensation for physiatrists, depending on practice type and subspecialty, says Christina A. Richardson, DO, the president of the American Osteopathic College of Physical Medicine and Rehabilitation (AOCPMR).

More than money, however, other lifestyle factors lure roughly equal numbers of men and women into the field. Physiatrists generally work reasonable hours. “A lot of practices don’t take call or the call that they take is very minimal and is shared among a large group of physiatrists,” notes Dr. Richardson, who practices in Traverse City, Mich.

More important, the specialty can be deeply fulfilling. “The fundamental premise that function and structure are interrelated and both can be modified is simplistically beautiful,” observes John R. Carbon Jr., DO, of Warwick, R.I., who trained in the Sinai-Johns Hopkins PM&R program in Baltimore in the late 1990s. “The ability to get a post-stroke hemiplegic to walk is not only fascinating but rewarding, as is the ability to ease the adverse affects of spondylosis without spinal surgery or strong medications.”

With the primary goal of improving function and promoting independence, physiatrists treat patients who have all manner of disabilities, chronic diseases and impairments—from spinal cord injuries, brain injuries and limb amputations to cerebral palsy, multiple sclerosis and amyotrophic lateral sclerosis. Many PM&R physicians subspecialize in sports medicine and pain medicine, while some focus on patients with specific conditions and limitations. Physiatrists practice in hospitals, rehabilitation centers and outpatient settings and sometimes pursue careers in academia.

The breadth of the specialty appeals to J. Michael Wieting, DO, a professor of PM&R and the dean of clinical medicine at the Lincoln Memorial University-DeBusk College of Osteopathic Medicine in Harrogate, Tenn. “I wanted a specialty in which I could see a mixture of patients in an outpatient setting, where I could develop long-term relationships with many patients but also see some patients in the short term on a consulting basis,” says Dr. Wieting, who has practiced PM&R for more than 25 years. “I also wanted to treat patients of all ages. In my practice right now, patients range in age from 8 to older than 90. I love that.”

In Dr. Richardson’s view, PM&R brings together some of the most exciting and cognitively challenging aspects of many different specialties. “It was my interest in musculoskeletal medicine that first drew me to a rotation in PM&R. But through that rotation, I discovered that some of my other loves were also part of this field,” she explains. “I liked the trauma of emergency medicine, but I wanted to be able to follow up and know what was going on with patients afterward. I liked the puzzles that neurology offered. I liked the complexity of internal medicine. And I liked the diagnostics of orthopedics. Physiatry is an amalgam of all of these fields.”

Doubling in size from approximately 5,000 to 10,000 physiatrists in the past 20 years, the specialty offers many career opportunities. PM&R will continue to grow in demand as the population ages and requires more rehabilitative services for chronic disease management, musculoskeletal dysfunction, neurologic impairment and chronic pain.

The right stuff

Exceptional interpersonal skills are a must for anyone contemplating a career in physical medicine and rehabilitation. “Rehab medicine attracts very outgoing, very personable individuals who really like to engage with their patients,” Dr. Richardson says. “We tend to follow people for many years, even decades.”

Besides establishing long-term relationships with patients, physiatrists must be skilled at working with emotionally vulnerable populations. “In rehab medicine, we are helping people in the darkest moments of their lives in many cases,” Dr. Richardson explains. “We are there for some of the lowest of the lows and the highest of the highs. It takes a special person to be part of that process.”

Dr. Carbon notes that physiatrists tend to be down-to-earth individuals who communicate with patients using common language, not medical jargon. For example, he says, to advise a patient to quit smoking, “a physiatrist might well say, ‘Dylan, you’re still smoking two packs of butts a day? Are you nuts?’ ”

Physiatrists frequently touch patients and not just during physical examinations and manipulation. “In a typical interaction with a patient, a physiatrist will say, ‘I will hold you here, and I want you to push against me as hard as you can,’ ” Dr. Carbon notes.

In addition, PM&R specialists often demonstrate the rehab exercises they recommend. “A physiatrist might explain, ‘This is how to use a wall for stretching your calf muscles—watch,’ ” says Dr. Carbon.

“Those who are timid or afraid of ‘getting dirty’ should not get into PM&R,” Dr. Carbon warns.

Physiatrists also must be team players and leaders who excel at care coordination. “We are trained to work with physical therapists, occupational therapists, psychologists and speech therapists, using their skills in addition to our own clinical acumen and hands-on skills to guide patients through the rehabilitation process,” says Leonard B. Kamen, DO, the AOCPMR’s vice president.

Because PM&R patients commonly are involved in workers’ compensation cases, lawsuits, automobile accidents involving more than one insurance carrier, and other complex legal tangles, physiatrists need to be able to effectively argue a cause or a case, Dr. Carbon points out.

While PM&R specialists need to be smart, resourcefulness and creativity matter more than memorization and test-taking skills. “One of the tools I carried around with me as a resident in Baltimore was a shoehorn,” Dr. Carbon remembers. “I used it more than a stethoscope. It came in quite handy when I examined feet, assessing sensation, muscles, skin vascularity and gait. Without it, I wouldn’t have been able to get patients’ shoes back on.”

5 Responses

  1. Deja Vu on May 2, 2012, 6:38 p.m.

    It is the enhanced diagnostic abilities of the neuromusculoskeletal training and less the OMT treatment skills that create the finer physiatrists. Imagine the advantage DO’s have in an allopathic residency with their osteopathic gait analysis skills that very few MD residents ever even skimmed over. The tissue palpating experience for finding spasm and trigger points and integrating that information relative to somato-visceral patient pathologies as well.

    DO’s rock rehab!

  2. Tayson DeLengocky on May 2, 2012, 7:04 p.m.

    Relevance of osteopathic medicine

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