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Restoring health and hope

The New Physician May-June 2007
Physiatry at a glance

  • Average starting salary: $160,000
  • Residency slots: 78 for PGY-1; 274 for PGY-2
  • Residency requirement: one year of internship and three years of residency training
  • Number of U.S. practitioners: 7,500

Directory of PM&R Residency Training Programs

The Medical Student’s Guide to Physical Medicine and Rehabilitation

For medical students with little exposure to the field, physiatry is just a game-winning Scrabble word. In fact, it’s one of the fastest growing and diverse medical specialties of the 21st century.

Also called physical medicine and rehabilitation (PM&R), physiatry focuses on helping patients with disabling conditions—from simple mobility issues to complex cognitive impairment—reach their maximum level of function. Physiatrists are trained to treat any disability—arising from either disease or injury—involving any organ system. They practice in major rehabilitation centers, acute care hospitals and outpatient settings.

Those having some familiarity with the specialty may write it off as simply advanced physical therapy. “That’s a common misconception,” says Dr. Laura Hobart, an osteopathic resident in her second year at the University of Arkansas for Medical Sciences. “In fact, we are the team captains, coordinating occupational therapists, physical therapists, social workers, psychologists and everyone else involved in the care of a patient in rehab. When a patient has problems urinating and his therapist doesn’t know what to do, we are the go-to guys.”

One aspect of the specialty that practitioners love is its variety. Today, physiatrists treat an extensive range of conditions, including arthritis, stroke, neurological disorders, musculoskeletal conditions, traumatic injuries—including brain and spinal cord injuries—chronic pain, work and sports injuries, and chronic diseases. Patients can range in age from infants to the elderly. Physiatry also employs some of the most exciting new medical technologies coming onto the market in the areas of electrodiagnostics and state-of-the-art adaptive equipment.

It’s not hard for physiatrists-in-training to find one or more facets of the field to get very excited about. “My absolute favorite patients are those with brain injury,” says Hobart. “Some will come onto your service unable to speak or communicate at all, except by blinking an eye to let you know someone is in there. But when they leave, they are walking and talking. It’s like watching a child grow up, or a flower bloom. It’s the most amazing experience a physician can have.”

Hobart came to the field through her experiences in osteopathic manual medicine. “I wanted to see the allopathic approach to some of these techniques, and in PM&R I realized there was so much more involved. It is about helping people get through difficult times in their lives, and making the most of what they have.”

Physiatry began to develop as a specialty in the 1930s when doctors began to treat musculoskeletal and neurological problems, and gained prominence soon after when disabled veterans returning from World War II sought help to regain productive lives. It was certified by the American Board of Medical Specialties in 1947. At that time there were 91 physiatrists practicing in the United States; today there are almost 8,000. Practitioners have increased by more than 35 percent in the last decade, yet physiatry is one of the few medical specialties where there is a relative workforce shortage. Medical education simply can’t keep up with the patient population boom.

According to the National Center for Health Statistics, 34.3 million people (12 percent of the U.S. population) are physically limited in their usual activities due to a chronic condition. More than 7 million use assistive technology—canes, walkers and wheelchairs—for mobility impairments, and more than 4 million use assistive devices such as back braces and artificial limbs to compensate for musculoskeletal impairments. Then there are those with acute conditions like low-back pain, shoulder pain or neck pain. Ten percent of all visits to physicians’ offices in the United States involve musculoskeletal conditions, and these figures are expected to increase as the baby-boom generation ages.

“One of the best things about this field is that it’s wide open, and you can create your own niche,” says Dr. Christopher Taylor, a fourth-year resident in the department of PM&R at Froedtert Memorial Hospital at the Medical College of Wisconsin. “I have seen the gamut of what the field involves, and have been able to pick apart my interests. This is a specialty where you can do what you want to do, where you want to do it, and how.”

Taylor plans to do a fellowship focusing on both sports medicine and spine care. The training will involve interventional pain management—a passionate area of interest for him. “Pain medicine has really been dominated by the anesthesiology field, but PM&R is now getting much more involved in doing procedures,” typically treatments using injections, he notes.

Like many of his peers, Taylor arrived at his career choice in a roundabout way. In medical school, he knew little about physiatry, but with an interest in sports medicine, was considering orthopedics. After failing to match in that highly competitive field, he began a program in general surgery, but soon “developed a picture of surgery I was not happy with. I couldn’t see myself doing just that, and I felt like burnout was a real possibility,” he says.

While doing a burn medicine rotation in Washington, D.C., he worked with physiatrists at the National Rehabilitation Hospital. “The doctors there opened my eyes to the field. For me, my interest came out of working with burn patients—it was mind-blowing that I could [work with just these patients].” After completing a year of research in burn rehabilitation, he was accepted to the PM&R program at Wisconsin.

Taylor has observed that many come into physiatry motivated by the experiences of friends, family members or themselves who needed rehab. Once in training, students soon realize that the medical model is very different from other specialties. “It’s not the pathology model—the focus is not treatment; it’s to return or regain function, which can come in many forms. The goal may be to get the patient to walk again, or just to gain better positioning in a wheelchair,” which can really improve quality of life, he explains. “The fruits of our labor come in a different form.”

Physiatrists can also enjoy long-term patient relationships, providing primary care to people with long-term disabilities. “Our job is to manage all aspects of their health, like their skin, bladder and bowel, and spasticity,” Taylor says. “For spinal-cord injured and chronic stroke patients, even if they have a cold, we see them first.”

Postgraduate education requires one year of internship and three years of residency training. Typically, the intern year is spent in a transitional year program, and residents match in PGY-2, but a few programs are now offering a combined four-year residency. In 2006, according to the National Resident Matching Program, 78 PGY-1 slots were offered and 95-percent filled, and 274 PGY-2 slots were offered and 94-percent filled. Just over half of all slots were filled by U.S. medical graduates.

Residents typically study internal medicine, orthopedics and neurology, and many go on to serve one or more fellowships in such areas as electrodiagnostics, pain management, spinal cord injury or brain injury. The American Board of Physical Medicine and Rehabilitation has agreements with the boards of pediatrics, internal medicine, neurology and psychiatry in which a five-year combined training program leads to dual certifications in PM&R and one of the affiliated specialties.

The work/life balance of a physiatrist is reasonable, particularly for those who work in an outpatient setting. Even in hospitals, the schedule is relatively predictable. “Rehab call is a lot different,” says Hobart. “There are no admissions to your service, since patients are already at the hospital. You still get emergencies as you would on a medicine floor—we recently had one patient who contracted appendicitis—but you can somewhat control when patients come onto your service.”

Hobart plans to do some type of fellowship when she completes her residency, but that time “seems pretty far away for me.” She is considering pediatric rehab, seeing it as a particularly rewarding area. “Children don’t view themselves as ‘broken’ like adults do. They see their wheelchairs as extensions of their own bodies, so they have a lot more potential to recover than adults, both physically and emotionally.”

Indeed, physiatrists’ patients often recover very slowly, so it’s a specialty not suited for those who like the instant gratification of fixing traumatic injuries or removing tumors. “You really need to be patient,” says Taylor. “The work we do can be very subtle, so you have to keep an open mind, and be open to different and creative ways of benefiting your patients.”
Martha Frase-Blunt is editor of The New Physician.