Is PM&R Boring?

[WashingtonR]

I'm in the 1st week of my M4 PM&R rotation. I really wanted to like this rotation, and was strongly considering going into PM&R. But so far, it feels pretty boring. Mostly stroke patients. We manage bowel regimens, mostly for constipation. They have neuropathic pain - we start gabapentin. They have HTN - we add on another antihypertensive. The most exciting thing to happen so far was a patient getting an AKI 2/2 TMP-SMX renal toxicity. Overall it's felt like IM-light. The outpatient clinic has been mostly patients asking for refills and referrals for various services. It feels like the physicians are more case managers than diagnosticians.

For context, I like IM. I like the deep thinking about difficult problems. Where's the deep thinking in PM&R? Where are the really difficult problems of diagnosis and management that make you really use all that doctor brain power?

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[drg123]

First, a lot of medicine is reacting to new problems or issues with standard therapies. So not specific to PM&R. Most of IM will be like thar too. But your impression of IPR is one that many share, including many residents. The diagnosis has been made by someone else already. Your job is to now manage the issues that have arisen from the primary issue (e.g. stroke). Some find this very satisfying. Some don't.

I'd say, if you're looking for more of a diagnostic component, you're going to find it more in outpatient MSK medicine or neuromuscular. Every joint/pain related concern that enters the door, it's your job to figure out what is the cause. I find this mentally satisfying, although like everything, if you do enough of it, it becomes rote. Neuromuscular and electrodiagnostic medicine will all work out your brain a lot, and these are paths open to PM&R. You have to just decide what it is you want. Some folks in PM&R don't care for the diagnostic component as much, and value more the procedural component (putting a needle or device somewhere to relieve pain).

Keep an open mind. Try to get more of the above things and see if it works your brain out enough.

I'll also say, regarding IPR. We get really medically sick patients at our facility. Many attendings refer these issues to the IM hospitalists, but there is nothing stopping you from doing the IM part yourself. You can be as 'in charge' as you want to be and there would be no shortage of issues. But it will be standard stuff like infections, COPD/CHF exacerbations, AKI, etc, with the occasional zebra. If the zebras interest you more than anything, consider just doing IM.

 

[JBM16BYU]

I agree with the above. If you are interested in diagnostic components, you will likely find that more in outpatient. Musculoskeletal Medicine or Sports Medicine will allow you to diagnose all the reasons a person's knee, shoulder, hand, finger, hip...etc... hurt. Pain/Spine will be similar with neck and back pain... trying to diagnose "why do you hurt?". Neuromuscular/Electrodiagnostic Medicine is also very diagnostic heavy (I mean, electro"diagnostic" has it in the name). You will find times to diagnose inpatient, but I agree that sometimes it can feel like you are just already managing previously diagnosed conditions.

One of the great things about PM&R is that it really is a vast field and you can mix and match your practice a bit to find what you like and what you don't. In order to properly guide treatment though, the correct diagnosis is key. I can't tell you how many people were sent to the EMG lab with "definitely carpal tunnel syndrome" and they didn't have EMG evidence of CTS, rather, it was very apparent they had tennis elbow, thumb arthritis, etc.

 

[DMBandFan86]

Lol, everything in medicine becomes routine eventually.

Once you get out of an academic setting, every IM hospital lung admission will be treated for PNA + copd + chf at the same time. You will do that 8 times per day and then do it again the next day. If that doesn’t work then send them to another hospital.

Don’t go into ICU / pulmonary. You literally see about 4-5 diagnoses and do the same few procedures on everyone. IV fluids, broad spectrum antibiotics, intubate, steroids, insert CVC and art line, trach and Peg some, then rinse and repeat.

If you go into ortho, you will do just hips. Or just shoulders. All day long and see the same things over and over. What makes it exciting is perfecting the art and being better at it then anyone else.

Yup, jobs are boring. All of them are. Sorry to break that to you. But you should find what you like most and get satisfaction from (and something that pays you well). Most people go into rehab because we find satisfaction in helping patients recover. We spend a lot of time with them and listen to them. I would say just about none of us care about blood pressure meditation adjustments or DM care, but like the other poster said you can always do those things yourself if you think it adds more fun to the job. You still get paid the same if you do it yourself or have a IM consultant do it.

Overall rotations are supposed to help you decide if you like a field or not. Most of us wanted to go into something else when we started medical school and through rotations found something else. I think that you may be finding that as well. Best of luck, but remember most of us think IM is very boring and we would rather eat socks then do that.

 

[j4pac]

A lot depends on where you are. The patient complexity was much higher at my IRF in residency than my IM internship.

 

[Chelsea FC]

It’s as boring and exciting as any field in medicine. End of the day it’s a job. Get that 🍞

 

[RangerBob]

I do inpatient rehab. I liked that PM&R was "boring." Diagnostic workups don't really excited me. But meeting new patients/hearing their stories and seeing them improve, talking with our interdisciplinary team, that's what I find enjoyable.

If the diagnostic workup is what you enjoy the most, you should probably look more at outpatient PM&R (MSK/sports/spine/EMG/pain).

As others say above, everything becomes routine eventually--with any job. I enjoy my routine and find it meaningful, and it gives me lots of time to spend with my friends/family/hobbies, which is generally what brings most people the bulk of their happiness.

 

[RodofEbullience]

Where's the deep thinking in PM&R? Where are the really difficult problems of diagnosis and management that make you really use all that doctor brain power?

Previous posters have already explained well enough that everything in medicine will get boring in the daily grind. But I'll specifically address this question.

I'm doing inpatient rehab and the most challenging and rewarding aspect of the job is figuring out how to get the patients who are "falling behind"/not progressing as expected during their stay to make improvements and meet their goals prior to discharge. There can be a multitude of reasons why someone may be doing poorly with intensive rehab (aside from the fact that some of them shouldn't have been cleared for AR in the first place, but I digress). You could be thinking of infection, electrolyte abnormality, new neurologic pathology, medication adverse effect, psych issues, poor nutrition, uncontrolled pain, etc. It's a day-to-day problem that requires a broad knowledge of medicine and also years of experience specifically in the rehab setting seeing these kinds of patients. You also at times will need to think a bit outside the box (i.e when I trialed methylphenidate for a poorly progressing post-COVID patient who then subsequently started walking hundreds of feet and was able to go home not too long afterwards). This challenge will only get greater as more medically complex patients are approved to come to IRF.

 

[lejeunesage]

You may be on to something!

The most exciting parts of PM&R is the procedures: EMG, Botox, fluoroscopy, and US-guided injections.

Clinic? There's a diagnostic aspect to it, but it quickly becomes routine. The vast majority of back pain isn't that exciting. And the treatment for a lot of MSK injuries/complains end up being rest + modalities + therapy.

On the inpatient side, my job definitely looks like IM-lite, because I don't like to consult. The most complex patients are the spinal cord injury

One of the most underappreciated aspects of clinical rotations is finding your tribe. What I liked the most about my rotations as a medical student is that the attendings were so chill and relatable, and that things were for the most part low stakes. Mistakes were also really forgivable. For someone like me who was extremely distractible, likely from untreated ADHD, I couldn't have asked for a better fit.

But this is because excitement is not something I ever wanted out of a job. Temperamentally, I would have been extremely poorly suited for EM, surgery, or even IM. If PM&R hadn't existed, I would have become a neurologist.

This might not sound like you at all, and that's completely okay. It's better to find out now. If excitement is what you're after, you might want to line up a rotation with a PM&R proceduralist, and if you're not in love with that they do, you'll probably be happier in a different field.

Good luck!

 

[PMR2008]

I am 10 years post residency.
I don't find PM&R boring at all. There is so much to learn. I have gained a number of skills over the years. New procedures, diagnosis, imaging techniques, medications, injections etc.
A job can be as boring as you would want it to be. Physiatrist are IMO the best MSK/Neuro detectives. We have a deep understanding of biomechanics, pathology, prognosis and how it impacts function. I get paid big bucks by hotshot attorneys because I posses that combo.

Today I diagnosed the following conditions missed by multiple docs. Psoriatic OA, CRPS, TMJ, Ulnar Neuropathy, vitamin D deficiency, peroneal neuropathy, cluneal nerve pain, Piriformis pain, trigger finger, metatarsalgia, adhesive capsulitis, EDS, shoulder labral tear. It was an interesting day in clinic since every single patient came to see me for 2nd/3rd opinion. Prior to seeing me they were offered therapy/medications/surgery and no one had the proper diagnosis. All the above required taking a complete history, proper exam, using ultrasound as a tool and ruling out more common conditions.
If you are truly interested in PM&R and what it can offer patients you will never be bored.

 

[j4pac]

I don’t find it boring. If I did I wouldn’t have decided to do it for a living. But if you find it boring, don’t do it