Work Under Orthopedic Surgery?

[Llenroc]

I was speaking last night with an Anesthiologist who works at an academic hospital. He is a family friend. He asked me what I want to go into, and I said tentatively PMR. He said, "I've never heard an American graduate say that before.", which I was kind of expecting.

I told him I liked PMR for its clinical and procedural aspects, as well as predictable work hours, low stress, and lifestyle - and I told him I wasn't "desperate" to get into something, because I have above average board scores. I could do IM specialty or Anesthesiology or ER, but I wasn't interested in those things that much.

Anyway, I asked him exactly what he didn't think was favorable about PMR, and he said he thought Orthopedic Surgeon's in the future would try to encroach on PMR's business. At his hospital already, PMR is part of Orthopedic Surgery.

Now that just scares the **** out of me.

I'm a 3rd year student coming off 2 months in Surgery, and the only worse than working with those people is working under them. They treat their nurses and scrub techs like absolute dirt. And in the trauma bay, I've seen Surgery interns slap around 50 year old ER attendings. Of course, these guys were General Surgeons, but I don't think Orthopedic Surgeons are all that much different.

How much truth do you think there is to Orthopedic Surgery trying to take over PMR? And in general, on the job how much do you have to deal with Surgeons? I understand there's a fair bit of face time with surgeons involved, but how much power do these guys have to order you around? And how much dependent on them are you for business?

---

Members don't see this ad.

 

[salmonella]

Most orthopedic surgeons don't want to deal with PM & R patients. I mean, ortho guys are busy enough in the OR doing surgeries. They love to operate instead of doing interventional pain procedures that are not hardcore enough to pique their interest. In general they hate clinics, hate chronic pain patients. I doubt they would want to sit around in clinic all day seeing fibromyalgia or doing EMG.

I think the more realistic threats come from anesthesiologists with pain management skills, or the newly created Doctor of Physical Therapy degree.

 

[Disciple]

To the OP:

I think there's a little bit of misunderstanding there. Orthopedic surgeons generally want no part of what Physiatrists do (unless it's private practice Worker's Comp and there's money to be made by dispensing meds in the clinic, but that's another story).

So really, as a Physiatrist it depends on what your "niche" is.

1. General inpt rehab: You will take care of patients S/P TKA, THA's, ORIF, etc. The surgeons would rather not ever have to set foot on the rehab unit. They are too busy with acute issues and surgery.
2. SCI or TBI. Generally doesn't have anything to do with Ortho unless you consult one of them for tendon lengthening, etc.
3. Peds rehab: May work more closely with peds Ortho for the CP kids, etc.
4. Sports med: You will handle the non-surgical care. Ortho groups often hire FP sports docs in this same role, so, the more skills you have (hint-EMG/ultrasound), the more valuable you will be and the higher your salary will be.
5. Pain/Spine: This is where it gets interesting. The Ortho Spine Surgeons (and Neruosurgeons) will generally want you to handle all conservative care. Again, the more skills you have, the more procedures you will be able to keep within the group and the more valuable you will be. If you are able to do the full range of interventional stuff, you will bring in more revenue and thus your salary (productivity bonus) will be higher. Busy spine surgeons will be too occupied with fusions, discectomies and disc arthroplasty to delve into conservative management. On the other hand, if some of your procedures are direct alternatives to traditional surgical procedures, your performance of those procedures may not be welcome within that group. So, one big advantage of employment with surgical groups is that a full stream of referrals should be ready and waiting for you. The catch is that the larger and more dominant the Ortho group, the less your chances for partnership or a decent salary (they're not going to offer partnership to someone who brings in a whole lot less revenue to the group than they do). I have several friends employed by large Ortho or Neurosurgical groups, and this tends to be the general trend. If you partner with one to a few surgeons and play a big role in getting the group started, your chances are obviously better.

6. If you go out on your own or sign on with a "pain" or single specialty PM&R group, Ortho surgeons can still be a great referral source. But,
that doesn't mean that you can't market to PCPs and get the patients before they get shunted to the surgeon. Again, marketing is key. If you do go out on your own it behooves you to have as many skills as possible. Why? Because if you can't do something, your referrals will simply go to someone who can do what you can't. Either that or a patient won't be referred to you until they've had every possible procedure performed on them and then they're sent to you for a PT eval or for "functional restoration".

The situation with PM&R being part of the Ortho department is not all that uncommon. Check more than a few PM&R residencies and you will find this to be the case. All it means is that in that particular hospital system, PM&R is not strong enough or politically influential enough to have its own department. In looking at established independent PM&R departments, you will find that these departments were founded on solid inpatient care and research, generally not musculoskeletal care. The above comment by your family friend signifies the still prevalent stereotype of PM&R being a step down for the American grad and Physiatrists sitting around on an inpatient unit all day not doing a whole lot. Even Physiatry based academic spine centers are usually part of Ortho or Neurosurg depts. It seems PASSOR is trying to change this (and is why I'm a proponent of PM&R residents giving talks to other residency programs within their hospital system), but to the majority of the medical community, this impression of PM&R still exists.

 

[drusso]

I was speaking last night with an Anesthiologist who works at an academic hospital. He is a family friend. He asked me what I want to go into, and I said tentatively PMR. He said, "I've never heard an American graduate say that before.", which I was kind of expecting.

He's yanking your balls and doesn't know what he's talking about. Next time, come back with, "Yeah, but how come administering anesthesia is considered *BOTH* within the scope of practice of nursing and medicine? That makes me uncomfortable..." That'll get his attention...

 

[Hemisphere]

that's a good comeback but I would preface it with...

well I guess times have changed since you applied to residency... back in the dark ages anyway, in my graduating class ( a U.S. allopathic school) we had 3 people who applied and matched into PM&R.

then use the above as the finisher... i guess it depends how badly u want to destroy him for saying that lol...


It seems to me that most institutoins with residency programs have there own department, it's the one's without that are still part of and orthopedic and rehab department. probably because they cannot find enough inpatient physiatrists to work there to merit their own department. probably becuase they don't have their own department in the first place lol, it's a vicious cycle. honestly, it's also partially a reflection of the fact of being a relatively new field, and also our own field's lack of interest in academic inpatient physiatry that only institutions with this level of interest have come to develop independent departments. If anything the trend seems that more instiuttions especially name academic medical institutions have developed thier own pm&r departments rather than ortho subsuming rehab departments. and by the way pm&r will probalby continue subsumng anesthesia procedures judging by all the talk on this board lol