Strongly considering dropping Neuro for PMR

[Bossman2313]

Hello

I was looking to find some support here or have you guys give me some light at the end of the tunnel.

I am finishing in my 4th month of intern year and I can say that I despise the floor months and the ICU. I just can't stand the amount of paperwork and how busy I am. I just feel like a glorified secretary and I'm barely spending time with patients because I'm always so stressed about paperwork.

This got me thinking forward to my neurology residency. Because of my experiences on the floors/ICU here I am not looking forward to Neurology residency at all. Everyone tells me how we are the busiest service in the hospital. I can't help but imagine the neurology floor will be just like the medicine floor. The Neuro ICU will be just like the medicine ICU. Neurology is so complex I don't know if I can even survive.

I was originally drawn to it because I think its so fascinating as a topic. I also completed two months of rotations as a student with private practice neurologists (which I think was a mistake because I had no exposure to ACADEMIC neurology w/ a training program). These guys had the best lifestyle ever. PAs do all the work in the hospital, attending comes rounds then goes to clinic. I really like the clinic aspect of neurology.

Everyone says you can't make money as a general neurologist. Even if you do EMG EEG or whatever other billable procedure it seems like its hard to make it comparable to other subspecialists in neurology. I understand there is a huge demand for neurology right now but I don't see how our compensation is going to be good with Obamacare especially.

I see my PMR colleagues and all of them are so happy and cant wait to do PMR residency because its even more chill than Transitional Year according to them. The latest MDMA salary survey demonstrates PMR makes more on average than Neurology. I see them taking electives and always trying to do procedures and injections because PMR appears to have a tremendous amount of procedural training. This is also where teh money is.

I am not an academic. My original plan was to be a private practice neurologist and I just wanted to help people. It seems like Neurology residency sucks, is super demanding just like medicine, and the compensation isnt too much better than an IM hospitalist. PMR seems like its so chill and they get compensated very well for their work. In fact I know its much easier to get into pain management as a PMR as opposed to Neuro.

Can someone please clear my thinking or am I just all fogged up from Intern year/floor months???? Can someone give me some positive insight? I know I sound like I just want to make money and chill but you know what thats partly true. Like I said I'm not academic I have many outside interests in medicine and I just want to be good at what i do. I feel like I can only do that if I'm not stressed or so busy all the time. Should I make the jump?

Thank You for reading my rant. I probably offended a bunch of people. Sorry.

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[bustbones26]

Hello

I was looking to find some support here or have you guys give me some light at the end of the tunnel.

I am finishing in my 4th month of intern year and I can say that I despise the floor months and the ICU. I just can't stand the amount of paperwork and how busy I am. I just feel like a glorified secretary and I'm barely spending time with patients because I'm always so stressed about paperwork.

This got me thinking forward to my neurology residency. Because of my experiences on the floors/ICU here I am not looking forward to Neurology residency at all. Everyone tells me how we are the busiest service in the hospital. I can't help but imagine the neurology floor will be just like the medicine floor. The Neuro ICU will be just like the medicine ICU. Neurology is so complex I don't know if I can even survive.

I was originally drawn to it because I think its so fascinating as a topic. I also completed two months of rotations as a student with private practice neurologists (which I think was a mistake because I had no exposure to ACADEMIC neurology w/ a training program). These guys had the best lifestyle ever. PAs do all the work in the hospital, attending comes rounds then goes to clinic. I really like the clinic aspect of neurology.

Everyone says you can't make money as a general neurologist. Even if you do EMG EEG or whatever other billable procedure it seems like its hard to make it comparable to other subspecialists in neurology. I understand there is a huge demand for neurology right now but I don't see how our compensation is going to be good with Obamacare especially.

I see my PMR colleagues and all of them are so happy and cant wait to do PMR residency because its even more chill than Transitional Year according to them. The latest MDMA salary survey demonstrates PMR makes more on average than Neurology. I see them taking electives and always trying to do procedures and injections because PMR appears to have a tremendous amount of procedural training. This is also where teh money is.

I am not an academic. My original plan was to be a private practice neurologist and I just wanted to help people. It seems like Neurology residency sucks, is super demanding just like medicine, and the compensation isnt too much better than an IM hospitalist. PMR seems like its so chill and they get compensated very well for their work. In fact I know its much easier to get into pain management as a PMR as opposed to Neuro.

Can someone please clear my thinking or am I just all fogged up from Intern year/floor months???? Can someone give me some positive insight? I know I sound like I just want to make money and chill but you know what thats partly true. Like I said I'm not academic I have many outside interests in medicine and I just want to be good at what i do. I feel like I can only do that if I'm not stressed or so busy all the time. Should I make the jump?

Thank You for reading my rant. I probably offended a bunch of people. Sorry.

Okay, first of all, there is a light at the end of the tunnel, so hang in there.

Listen, EVERY medical service gets $hat upon during their academic residency years. Yes, there are many neuro programs out there that admit to their service, thus, become somewhat of a glorified internal medicine service, it happens.

By the way, I am a general neurologist that is about to take the UCNS exam on headache medicine (so you might as well just say I am a general neurologist ) and I do EMG for simple things, and I am VERY HAPPY with my salary. I just got out of practicing in the military setting and I was highly wanted by many people, trust me!!

There are some overlapping features between PMR & neuro, sure, especially EMG and neuromusculoskeletal medicine but even that specialty is not all sunshine and rainbows either. Remember, the grass always looks greener on the other side.

Look, my residency was HIGHLY academic and I felt left behind. I think I was the only resident that did less than 90th percentile on inservice exams and my co-resident in my class year scored 100th percentile very year. I had NO guidance or help. I felt as if my residency bent over backwards to help the guys that did not need it, so I hear yah!! Believe me I felt VERY unprepared whenever I became a PGY-2, I did not know where to begin, and I had NO guidance. Whenever I asked for guidance, I was given vague advice.

Look, hang in there, every program has their strengths and weaknesses. Its just not the same after residency, trust me, it is a much more enjoyable lifestyle .

I would just caution you that a switch to another specialty is not always a good idea. Also, have you talked to your PD yet? I stormed my PD's office at the start of PGY-3 and told him my concerns. You just have to do it in a manner that is not confrontational and they will have a serious conversation with you. I know your fears, trust me. I spent an entire residency around brilliant people and was treated as if I was too dumb to take care of a goldfish, and I was miserable, but I got through it. Eventually, I found my way and things clicked. I pick up on so many things today that apparent brilliant neurologists have missed. I enjoy my job these days.

PM me, I will give you the guidance and prescription for success that NOBODY ever gave to me.

 

[Mattchiavelli]

I understand there is a huge demand for neurology right now but I don't see how our compensation is going to be good with Obamacare especially....procedural training. This is also where teh money is

and you don't think with proposed healthcare changes via "obamacare" or any other reforms that procedural reimbursements are going to get more even with non-procedural reimbursements? Just pointing ou that you're contradicting yourself a little bit,

 

[neglect]

You have to look inward here. If you still like clinical neurology and neurosciences, then perhaps it is still for you. If you like making diagnoses, thinking about cases, brains, lesions, and neurologic phenomenon, then it might be for you. You certainly will not be making any diagnoses in PM&R. Not to disrespect the entire field, but they do not diagnose anything (or such a small fraction that it doesn't matter), they seem to simply manage therapy services and act as hospitalists to not-sick patients. They seem redundant to me, and although they steal lucrative procedures from neuro and ortho and rheum, they don't do them well (I can only speak to the NCV's, which I'd call single blind studies. I have literally been asked to interpret NCV/EMGs done by PM&R, and many times I'm consulted just to put them into context).

It seems you don't have the confidence in yourself to hack neurology. I disagree with this. Within neurology there are people who are super geniuses, who scored >90% on every test, who love the intellectual process of neurology (not to call myself a genius, but I'm one of the people who got into neurology out of love for the thought process and disdain for the thoughtless jobs), and there are people who got into it because they are caring people and neurologic diseases are terrible and they want to help them, and there are people who just want to make money and do NCV's or caths. In short, I now realize that there are diverse tracks into neurology and this diversity is good for our profession. Anyway, you're entering a neurology training program. If you don't know anything, who cares? That's sort of the point of training: to train you to become a _____. Just don't have the toxic combination of laziness, stupidity, and arrogance.

But if you're looking to make big bucks, then neurology is likely not for you. If that's your motivation, then I'd look past PM&R into the big paying specialties. It isn't too late for that! If you feel that you must earn well into the 200's and above after graduation, then you have absolutely got to cancel plans to enter neurology, perhaps take another year in medicine, and do something else.

 

[Hank Rearden]

If you think you're going to escape paperwork by going into PM&R, you're kidding yourself. Your patient will have just come from another floor in the hospital, with a full H&P and d/c summary from the prior service, yet you have to write a whole new H&P and orders. Super annoying. Will it be a bit less demanding in terms of patient load than neurology? Sure, but the practice of PM&R is also boring. You set a plan in motion on admit, and after that you are more or less a glorified manager for the PT/OT/speech specialists. They run the show and you just get involved if someone develops a UTI or DVT. Outpt PM&R is a bit more interesting, but you can do EMGs just as easily and probably more effectively as a neurologist. Do they make more money? A little more, but we're talking 300k instead of 200k or 400k instead of 300k. All of those figures are an insane amount of money and will be more than enough for you to live on, trust me.

My goal here is not to belittle PM&R. I do rehab related research in addition to my clinical duties and definitely considered PM&R for residency. I find rehab research fascinating, but the clinical practice of PM&R just isn't as exciting as neurology.

 

[cbest]

Disclaimer: PM&R resident here.

Not arguing with comments about inpatient rehab. It's a lot of managing basic medical issues and doing out best to manage pain, bowel/bladder dysfunction, spasticity, etc in order to have our patients more fully participate in therapy sessions where I truly believe the gains are made. Not planning on practicing inpatient but info feel its important.

Outpatient spine/sports/MSK medicine is where our best diagnostic and management skills are showcased. Our neuromusculoskeletal exam is the best in the game and our non-operative management of many neurological and MSK conditions is (probably) the best option patients have a large chunk of the time.

In terms of EMGS/NCS, I'm pretty surprised by the comments so far. I know at my institution, we get more studies/resident under our belts than the very prominent Neurology program does. That's just an N=1 though so ill leave it at that. I'd say we're pretty damn good at studies as they pertain to a lot of conditions encountered in an outpatient MSK clinic.

Pick PM&R if you want to have a great deal of knowledge of neuromusculoskeletal topics and focus on your patients' function and improvement in their quality of life, no matter the physiatric patient population (stroke rehab, spinal cord injury, sports medicine, interventional spine, etc). The idea that our field lacks diagnostic and critical thinking is unfounded and limited to observations of only one aspect of our very broad specialty.

Don't go into PM&R if you're looking for a great deal of prestige or opportunities to make life or death decisions. We're not going to be a specialty that'll ever appear on TV shows and we'll likely have to explain our specialty to patients and colleagues for the rest of our careers. Having said that, if you do your job well, the difference you can make in the lives of both your patients and their loved ones is all the recognition you'll need!

 

[danielmd06]

Okay. Most people are in this position at your point in the ballgame (and even afterwards).

You had a very positive experience with outpatient neurology as a student, and possibly didn't realize the far reaching effects and just plain work that was going to be involved with being a junior resident. You seem like many medical students and residents to put a true premium on not being busy (nothing wrong with this). You hate paperwork and social work and book keeping as much as the rest of us. Now, you are questioning the price to be paid to be a neurologist.

You could do psychiatry and it would be easier (but then you'd have to actually practice psychiatry at the end of the road), or PM&R and it would be easier (and you have lucrative fellowship options in the form of pain medicine or working with an ortho practice seeing their non-operative cases). You may even be thinking of IM or EM. Both of these are 3 year residencies (EM might be 4 where you are) with good fellowship choices. EM is among the cushiest of residencies you can do, and the private practice paycheck is hefty.

And finally, unlike your compatriots in their prelim/intern years, you won't be moving on to a senior residency position in IM, or switching to a cushy residency like radiology, or entering a hard residency (like neurosurgery) that might be difficult but promises a luxurious salary at its finish. You'll be a junior resident all over again. If it's like what I had to do, you'll find the neurology service worse than the IM service in certain ways. There are huge numbers of patients. There are fewer residents, students, and rotators to share the load. The patients may be difficult from a psychiatric standpoint (like pseudoseizures or intractable headaches), or super sick (like an intracranial hemorrhage). Your hated stacks of paperwork will multiply and your social wizarding skills will be further tested.

And it's going to likely be bad and you'll definitely think from time to time about switching to somethings else. I certainly did.

Problem with that line of reasoning is that residency doesn't last forever. None of them. So you cannot or should not base your career decisions on a residency and MGMA salary tag alone. I'm shocked at how many students do this (and then are surprised or dissapointed when everything is said and done). At the end of training you will finally get to that much vaunted "dessert" phase where you are in fellowship or practice. And then my friends, you can do whatever you want. You can work as much or as little as you wish, and you can almost tailor pick a salary. You can live at the mountains or the beach. Neurologists are in high demand. And calculated to be in progressively higher demand as the years pass. And you can practice big chunks of your sub-specialty from fellowship (many neurologists *love* to do this and paradoxically avoid any bit of possible adult neurology that isn't within the purview of movement disorders/neuroimmunology/sleep/stroke/neuromuscular etc).

That is one of the absolute greatest strengths of neurology. You have more flexibility and options than practically anything else (except maybe IM). Yeah PM&R is cushy in private practice. And on the MGMA 2010 data set the median salary is $241.1k while neurology is $237.9k. This is hardly a lifestyle difference. You'll basically make the same money doing either. And for the record I did neurology and now practice 100% adult sleep medicine and would bet that my schedule/life is easier and I'm very likely making more money than PM&R guys at my point in practice. And you can note that sleep medicine (and pain medicine too since it's relevant to this discussion) are listed separately on the link: http://forums.studentdoctor.net/showthread.php?t=817247&highlight=mgma+2011

And you can certainly do pain medicine from neurology if you want. The key is to identify your desire to do this early and make a concerted effort to garner exposure in that branch of practice. See if you cannot do some manner of research. Maybe try and use some time to go to pain meetings. Make yourself competitive for the fellowship and you shouldn't have problems.

And if you like the "neuromusculoskeletal" exam so much, why not consider neuromuscular/EMG? What about a fellowship in sports neurology (a nascent field that looks pretty cool to me)?

I'm starting to ramble, so I'll just finish by reassuring you that residency ends, but practice is forever (unless you want to be a resident again). And money has this funny way of evening out across specialties depending on outpatient/inpatient ratio, seniority, location, volume, and nature of practice. Seriously. A great example is an FP attending who has a thread on this forum asking about neurology - and he makes $300k per year. My sincere advice is truly to focus on which part of medicine you really can see yourself carving out a practice in. Is it PM&R? Pain medicine? Neuromuscular? Outpatient general neurology? Make that decision, and the worries about transient paperwork, call shifts, and private practice salary will dissipate.

And pretty much everyone has been in your shoes. I found neurology to be the right fit for me and have no regrets. Would definitely do over again even if given the opprtunity to switch.

Good luck with your choice.

 

[neglect]

In terms of EMGS/NCS, I'm pretty surprised by the comments so far. I know at my institution, we get more studies/resident under our belts than the very prominent Neurology program does. That's just an N=1 though so ill leave it at that. I'd say we're pretty damn good at studies as they pertain to a lot of conditions encountered in an outpatient MSK clinic.

There's a danger here. More studies does not equate to competence. I could train a physical therapist to do a decent NCV if the question and the answer are CTS. He could do a hundred cases and feel competent. But without a foundation of nerve/muscle understanding, there is no foundation, there is no deeper questioning. There are only numbers without clinical context, rendering most studies useless outside mononeuropathy or mononeuropathy multiplex.

I have seen excellent studies by PM&R. But I have also seen studies that I cannot interpret, that do not correlate to the history and exam, that blow off hugely important findings in light of clinical data... You get the idea. It is also hugely frustrating when PM&R does these studies because, aside from mononeruopathies (which they sometimes inject with no benefit), neurology has to be brought in as a consultant to actually figure out what it all means.

The problem is that NCVs/EMGs are boring relative to neurology. But I urge all neurologists to learn them well. We should own this.

The idea that our field lacks diagnostic and critical thinking is unfounded and limited to observations of only one aspect of our very broad specialty.

Name the last 5 challenging diagnoses you made that no-one else did, which showed clinical acumen, and which made you proud of your clinical accumen (as in you saw it but others did not). Mine: 1. transverse myelitis in a anxious young woman (but then again, everyone always forgets cord). 2. NMO. 3. Complex seizures not syncope. 4. GBS with bulbar presentation, rapid treatment, rapid improvement. 5. Venous sinus thrombosis on head CT.

 

[GOINGDUMB]

And you can practice big chunks of your sub-specialty from fellowship (many neurologists *love* to do this and paradoxically avoid any bit of possible adult neurology that isn't within the purview of movement disorders/neuroimmunology/sleep/stroke/neuromuscular etc).

That sounds great, but why would you consider such as a paradoxical phenomenon?

 

[danielmd06]

That sounds great, but why would you consider such as a paradoxical phenomenon?

Because neurology is an extremely broad and often complicated field and it's easier to see things you are either specifically fellowship-trained for (like stroke) or something that was heavily covered during your residency.

For instance, outpatient movement disorders or outpatient neuroimmunology or outpatient neuromuscular may be relatively skipped in many programs in lieu of heavy inpatient and ICU exposure. When people finish their residency and then do a fellowship in X (not any of the above three examples), they may not feel comfortable managing those outpatient areas they have less exposure in.

Or they decide that they don't want to see chronic pain, headache, pseudoseizure, or dizzy patients for personal reasons.

 

[Bossman2313]

Ok. So I guess one of the reasons I am disappointed is because one of the factors in choosing Neurology was that it would be a bit easier than something like Internal Medicine and then gunning for a fellowship. I find the broadness of Internal medicine to be challenging and I like how neurology is pretty specific.

I thought because Neurology residency tends to have home call the PGY 3-4 years and in some cases all 3 years I thought that meant it wouldnt be as demanding as internal medicine. Now that I know I understand Neurology floors are just like internal medicine floors. Neuro ICU is just like Internal medicine ICU. My question now is does it really get better your more senior years? When you do rotations like EEG, EMG, Peds Neuro, movement disorder, etc..... Are those typicall just 8-5, 9-5 kind of months with weekends free?

Thanks for all the responses they have really helped.

 

[deleted102545]

It's a short 3 years compared to the rest of your career. You got this far so I'm sure you can pull it together to get through the tough months of neurology residency. I think neurology being easier than IM just because it's a speciality is a misconception that a lot of people have. All the IM rotators and many students I've seen go through neuro are shocked at our hours and work while on inpatient service. The more outpatient months are pretty sweet though!

 

[danielmd06]

My question now is does it really get better your more senior years? When you do rotations like EEG, EMG, Peds Neuro, movement disorder, etc..... Are those typicall just 8-5, 9-5 kind of months with weekends free?

The more senior I got, the easier the schedule typically got for me. I did have increased responsibility in terms of administrative work and elevation of skills and knowledge, but as a rule would have taken PGY-4 year all day over PGY-2.

For me the pediatric neurology months were awful in terms of hours. Everything else was ultra sweet. I did take neurology call on elective rotations, though. Definitely more 9-5 type schedule, however.

Of course, I did several months of sleep medicine...

 

[Acherona]

PGY4 is Amazing. Wish I could do it forever. Kinda like 4th year of med school.

 

[fozzy40]

To the OP, it sounds like you are just feeling the grind of inpatient medicine and being an intern. I would stick it out and wait until you get to a less busy service. I think it's very natural to question what your doing when pushed to do things you don't necessarily like doing. If you really are interested though, maybe you could set up an elective with a PM&R service or outpatient clinic and see how you feel after that month.

Name the last 5 challenging diagnoses you made that no-one else did, which showed clinical acumen, and which made you proud of your clinical accumen (as in you saw it but others did not). Mine: 1. transverse myelitis in a anxious young woman (but then again, everyone always forgets cord). 2. NMO. 3. Complex seizures not syncope. 4. GBS with bulbar presentation, rapid treatment, rapid improvement. 5. Venous sinus thrombosis on head CT.

I think that this speaks directly to why I chose PM&R versus other fields. Much of the emphasis/excitement is in the diagnosis My typical statement at the end of the day as a medical student was "now what." That's when I realized that making a diagnosis was not as important to me but helping the patient return to function. I enjoyed identifying personal goals of the patient, educating them and their family, medically managing co-morbidities directly related to the injury/disease (and/or the treatments themselves.)

From an inpatient perspective, we often do not make the primary diagnoses but we do manage/diagnose the medical problems that come along with the rehabilitation process. They do come with their challenges on a case to case basis i.e. diagnosing an acute MI in a patient with C5 tetraplegia. As an outpatient, I make plenty of primary diagnoses and/or catch missed diagnoses.

Here are my top 5 though:

1) Spasticity management of her RUE for a 32 yo female with right sided hemiplegia so that she can hold and breastfeed her baby.
2) Diagnosing and managing a pelvic floor disorder in a 26 yo newly married female who had not had sexual intercourse with their husband for 16 months after their honeymoon.
3) Helping a 14 year old girl with paraparesis secondary to conversion disorder wean from her wheelchair and off of completely unnecessary medication started by another service.
4) Helping a 25 year old patient with C7 tetraplegia get back to driving, working, and living independently.
5) Identifying a patient with an undiagnosed mood disorder who was sent to me for recurrent L5 radiculopathy s/p laminectomy.

May not be impressive or TV worthy for some but pretty awesome for me and my patients.

 

[neglect]

I think that this speaks directly to why I chose PM&R versus other fields. Much of the emphasis/excitement is in the diagnosis My typical statement at the end of the day as a medical student was "now what."

I added the now what in []:
1. transverse myelitis in a anxious young woman (but then again, everyone always forgets cord). [steroids and then outpt disease modifying therapy for CIS/MS]
2. NMO. [rituxumab, hanging in there]
3. Complex seizures not syncope. [anti-seizure meds, fully cured]
4. GBS with bulbar presentation, rapid treatment, rapid improvement. [the rapid treatment was IVIG, great response, likely because we started it so quickly, walked home with trach scar]
5. Venous sinus thrombosis on head CT. [heparin, and outcome: no stroke, no hemorrhage]

In each case it was clear thinking that gave a difficult diagnosis. Each was treatable. Not everything is, but these were. And in some cases arriving at the proper diagnosis changed outcomes drastically.

Here are my top 5 though:

1) Spasticity management of her RUE for a 32 yo female with right sided hemiplegia so that she can hold and breastfeed her baby.
2) Diagnosing and managing a pelvic floor disorder in a 26 yo newly married female who had not had sexual intercourse with their husband for 16 months after their honeymoon.
3) Helping a 14 year old girl with paraparesis secondary to conversion disorder wean from her wheelchair and off of completely unnecessary medication started by another service.
4) Helping a 25 year old patient with C7 tetraplegia get back to driving, working, and living independently.
5) Identifying a patient with an undiagnosed mood disorder who was sent to me for recurrent L5 radiculopathy s/p laminectomy.

May not be impressive or TV worthy for some but pretty awesome for me and my patients.

These were all time most memorable? Depression in a pain patient? I think that's sort of my overall point about PM&R not making many diagnoses. And I just gave some cases from the last few months.

Spasticity: what's the catch? The spasticity might have helped her hold the kid if in the proper position. We have different minds for sure. I wonder why a 32 is hemiplegic. I also hate dealing with symptoms and not underlying disease states. If the etiology was a tumor, then it will have a different outcome from stroke. Strokes can do very well in the young. One reason I dislike treating symptoms only is because some things just get better, like stroke symptoms in the young.

Conversion disorders are very difficult, sometimes hard to diagnose, always hard to discuss and treat. Too bad insurance usually does not allow conversion disorder to be admitted. Again, these people have very variable courses, and it is hard to discern the course from the intervention effect.

 

[fozzy40]

I added the now what in []:
1. transverse myelitis in a anxious young woman (but then again, everyone always forgets cord). [steroids and then outpt disease modifying therapy for CIS/MS]
2. NMO. [rituxumab, hanging in there]
3. Complex seizures not syncope. [anti-seizure meds, fully cured]
4. GBS with bulbar presentation, rapid treatment, rapid improvement. [the rapid treatment was IVIG, great response, likely because we started it so quickly, walked home with trach scar]
5. Venous sinus thrombosis on head CT. [heparin, and outcome: no stroke, no hemorrhage]

In each case it was clear thinking that gave a difficult diagnosis. Each was treatable. Not everything is, but these were. And in some cases arriving at the proper diagnosis changed outcomes drastically.

Great cases and which many alike require rehab...which also needs "clear thinking." It's easy to think...all you need is some PT, OT, SLP but it's not that simple.

These were all time most memorable? Depression in a pain patient? I think that's sort of my overall point about PM&R not making many diagnoses. And I just gave some cases from the last few months.

Anytime I make a direct meaningful impact for a patient = memorable (in my book.) It's clear that making diagnoses drives you which is great. However, the big shortcoming in medical education is that there is a lot of emphasis on diagnosis (as it should be) but little education/awareness on managing patients if the treatment doesn't lead to a "cure." This is the role of the physiatrist: dealing with medical and functional problems directly related to a disease state and/or treatment.

Spasticity: what's the catch? The spasticity might have helped her hold the kid if in the proper position. We have different minds for sure. I wonder why a 32 is hemiplegic. I also hate dealing with symptoms and not underlying disease states. If the etiology was a tumor, then it will have a different outcome from stroke. Strokes can do very well in the young. One reason I dislike treating symptoms only is because some things just get better, like stroke symptoms in the young.

If only spasticity always fell into the best functional positions. Unfortunately, it does not in most cases. Spasticity can help as much as it can disable. There's a lot that goes into properly positioning the patient which I can go into if you want.