Thank you
@JBM16BYU for the follow up! There are not a ton of resources out there for PM&R residents when it comes to pursuing a neuromuscular fellowship.
Not sure if you will see this post, but some other questions I had as a PM&R resident considering neuromuscular fellowship are...
Do you feel that the neuromuscular fellowship will greatly change your practice setting compared to not doing the fellowship?
Are you able to do a mix of neuromuscular and general PM&R clinic after fellowship? Or do most people after fellowship just focus on neuromuscular conditions afterwards
How did you prepare for neuromuscular fellowship?
Is there bias in hiring of Neuromuscular neurologists vs Neuromuscular physiatrists given PM&R cannot take neuro call?
I do feel that a neuromuscular fellowship will change my practice. I am much more comfortable with neuromuscular conditions in practice now than previously. As PM&R, we get pretty comfortable with prescribing therapies, DME, orthotics, prosthetics, pain, etc. What we aren't as good at, typically, is a wide neurologic differential and diagnostic work-up. What labs to order to evaluate neuropathies? When to order biopsies? When to order SFEMG? etc. Also, my neurologic physical exam has improved x1000 as a work with neurologists. You kind of have a foot in both worlds.
Things I definitely didn't know much about coming from PM&R: immunosuppressant medications, IVIG/PLEX, genetics, muscle/nerve/skin biopsy pathology and interpretation, wide WIDE neuromuscular differential
In addition, in a typical PM&R residency, your EMG experience will likely be focused on more carpal tunnel syndrome, radiculopathies, ulnar neuropathies, and maybe identifying polyneuropathies. However, one of my goals in a neuromuscular fellowship was to be able to critically think through whatever EDX test can come through the door. Things like facial neuropathies, NMJ disorders, demyelinating neuropathies, motor neuron diseases, complex plexopathies, parsonage-turner syndrome, traumatic nerve/plexus injuries, myopathies, myositis, inpatient/ICU EMGs for myasthenic crisis or GBS, and even pediatric EMGs are things you become much more familiar with during fellowship. Single-fiber EMG is also something that you won't typically learn in residency and is usually acquired during a fellowship. Also, knowing when you can alter the tests when you need to and how to interpret an altered test is important (for example, it's kind of hard to do a median antidromic sensory NCS to digit 2 if digit 2 has been amputated. What will you do then? How will you evaluate the median sensory then?) If I didn't do a Neuromuscular fellowship, I would not feel as comfortable evaluating and working up these things.
Even having fantastic MSK ultrasound experience during residency, my neuromuscular ultrasound (NMUS) skills have just amplified my prior ultrasound skills even more!
After fellowship, the type of job you practice is completely up to you. You can practice as a neuromuscular medicine physician (just like our neurology colleagues); you can practice as an electrodiagnostic physician; you could practice in a mix of 1/2 general PM&R 1/2 neuromuscular. Really, whatever you would like to do and however you will in that niche. I know of PM&R neuromuscular docs who practice primarily research, ones who do research with heavy ALS clinic, ones who do pure neuromuscular, ones who do ALS clinic with musculoskeletal clinic, those who do EMG with peripheral nerve injury clinics, etc.
You prepare for fellowship by paying attention and performing well in residency. Every rotation in residency has something you can use in fellowship. Just some examples:
-Pain Medicine- some neuromuscular conditions are inherently painful and so it's important to be able to evaluate pain, learn your neuropathic pain medications and be comfortable prescribing them, be able to talk about the different types of spine injections, read spine MRIs, and be able to talk about chronic pain
-Sports Medicine- ultrasound is widely used in both fields. Learn how to use an ultrasound machine, the knobology. Learn a good MSK exam because there are lot's of neuromuscular patients who have joint contractures, painful joints, and mimickers of neurologic conditions.
-Pediatric rehab- at least at my fellowship we do see children at the pediatric MDA clinic, including children with CMT, Duchenne's, Congenital myopathies, SMA, Myotonic dystrophies, etc. Learn a good child exam, learn the appropriate milestones (especially gross and fine motor). Learn appropriate orthotic prescription management.
-Neuro rehab- Learn spasticity management for your ALS/PLS/HSP patients. Learn a neurologic exam (and then get taught even more of a neurologic exam during fellowship). Feel comfortable with ordering therapies, DME, orthotics, wheelchairs, etc. Learn botox injections, both EMG-guided and ultrasound-guided (If available). Be able to assess gait and fall prevention.
-Amputee- amputations are a very real risk for patients with neuropathies, especially inherited neuropathies. Evaluate for wounds. Be able to counsel on proper footwear, wound prevention, fall assessments. I have had several patients with neuropathies who have undergone amputations at one point in their life and it's important to try and prevent more.
-Inpatient PM&R- many NMD patients show up on rehabilitation units, particularly those with Guillain-Barre Syndrome, ALS, critical illness myopathies, critical illness neuropathies, etc. Learn as much as you can about their presentations, their work-up, and then their rehab course when you get them.
-SCI- get really comfortable with wheelchair assessment and management. It'll be incredibly helpful for your ALS, PLS, SMA, Duchennes, myopathies, IBM, etc. (you get the picture) patients.
-EMG- obviously this is a big one. Just do as much as you can. See as much variety as you can. Be able to do the NCS and EMG. I personally really like the Preston & Shapiro textbook and am reading that cover-to-cover during fellowship.
Your last question about bias in hiring. Perhaps? Like I said earlier, PM&R neuromuscular physicians are a rare breed. There are not many of us. In fact, out of all of the fellows this year in neuromuscular fellowships, there are currently 5 PM&R fellows. During the job hunt I found that every place wanted a PM&R neuromuscular physician that I asked, both in academia or in private practice (more as THE EMG guy), but many do not understand exactly what it is that we do. It takes a lot of education, both to the neurologists about your PM&R training and how your unique skills can be valuable to their fellowship and also to the PM&R physicians that you are more than the carpal tunnel/radiculopathy EMG guy. It is a niche, and in my personal bias, a hidden gem. In this world of neuromuscular medicine, you are truly helping people to maximize their function despite their acquired or inherited neuromuscular conditions. It is very satisfying.
