PM&R isn't derm without the board scores. The people who are actually making a lot of money from PM&R are people doing mostly interventional pain, which then makes it essentially pain medicine. However, PM&R without pain specialization would be the odd man out in terms of getting those patients. And if you're going to practice pain medicine, you would be better off doing an anesthesiology residency. The essential problem with PM&R out in the community is that they are competing with other providers for the same patients. If it's a MSK problem, they likely will get referred to sports medicine. If it is neuro problem, it will be referred to neurology. Only a very small subset of the population will be referred directly to PM&R. In fact, I don't think I have ever referred anyone to PM&R in clinic. Most PM&R docs in the community that I know of work with orthos and neurosurg and take care of these patients post-op, sparing the surgeons for the OR.
Derm is the king of their domain, despite what people think about "other" providers. Yes, derm makes a good chunk of money from cosmetics, but the real key to derm is the fact that they can see A LOT of patients in not a lot of time. And with the low number of providers, they are always booked full. Even if you take away cosmetics entirely, they still bank. And they are still first in line as far as derm cosmetic procedures. The kind of people who can pay out of pocket are the same kind of people who will demand an actual board certified dermatologist.
Some inaccuracies here, and a skewed viewpoint perhaps due to inexperience.
I agree, PM&R is not Derm without the board scores. Derm is highly desirable due to the combination of lifestyle and income potential, relatively speaking. The income potential comes from quick office based procedures in high volume. Additionally, they have kept the number of trainees per year, relatively low. Derm is a well defined specialty.
There needs to be clarification on the whole "pain" thing. Anyone from any base specialty can train in "pain management". What does that say about it as a specialty? Pain management has become a four letter word for most insurers, due to the overall costs of treating this patient population. The practice model of the typical interventional pain practice, over the past 15-20 years, fuels these costs due to co-dependency (opioids for procedures) developed between pain physicians and their patients. That model is rapidly dying with Obamacare, ACOs, etc.
Enter Physiatrists. Physiatrists are generally now favored by insurers to manage patients with sub-acute/chronic musculoskeletal problems. Physiatrists are non-surgical neuro-musculoskeletal doctors. We're not so much concerned with symptom management as we are with accurate, comprehensive diagnosis, rehabilitation, and improvement in functional status. Ask your local IPA or national insurers providing work-comp coverage in your region what they think about Physiatrists having first crack at musculoskeletal patients with subacute or chronic pain symptoms. They may even be willing to show you their utilization and outcome data. A core tenet of Physiatry is to take those with the highest levels of disability, and improve their level of function. In the typical "pain managment" practice, "who cares what's actually wrong with the patient, the surgeon or other specialist was supposed to figure that out, my job is to manage the pain medications and do procedures". I see this in my community daily, moreso with pain physicians nearing retirement. Take a look at Kaiser's model. It's now Physiatry dominant. Patients deemed high risk for delayed recovery and generating higher expenditures are referred to their multidisciplinary pain program, at a centralized location, at which point, the emphasis becomes patient education and cognitive behavioral therapy. I agree that there may be few referrals of musculoskeletal patients to the PM&R department in the academic setting. Boundaries and referral patterns are well defined in the academic setting and it is unlikely that anyone is going to go against the culture of an institution if he/she wishes to keep their job. Was the same when I was a resident.
When PM&R first got heavily involved in the musculoskeletal arena (90's), we were dependent on Ortho and Neurosurg to refer musculoskeletal patients. Hence, the large number of Physiatrists in multispecialty surgical practices. More and more, this is going away. The specialty has traditionally been ill-defined. We constantly have to explain to patients and other physicians what it is that we actually do. What we do have, however, is great diversity/versatility in our practices. Ask some of the Physiatrists who were fortunate enough to grandfather into pain
and sports medicine. For some of those guys it was high volume interventional, EMGs, ultrasound and
no opioid management. Add in in-office PT and ownership in a surgery center, med-legal work, and it was a nice 9-5, out-patient only based practice. I'm always a bit surprised when other physicians still assume the predominant base of PM&R is still inpatient rehab. Perceptions take time to change I guess. Another advantage is that we can re-invent ourselves much more easily than well defined specialties. This is becoming increasingly important. Check out some of the threads regarding how to create a non-opioid, cash-based "pain management" practice. Short answer, it would be very difficult. Say "Pain Management" and the first thought of most patients and physicians is still "narcotics clinic".
In summary, Derm is well defined and stable. A safe bet if one can get a spot (and actually has interest in the field). Physiatry is ill-defined and for those willing to think outside the box (in terms of creating a niche) and in my opinion is the best specialty for those who would like to have a near 100% musculoskeletal practice.
Last point, I do feel anesthesiology is the easiest pathway to "pain management".
...thanks for the feedback
