Physical Medicine and Rehabilitation

Physicians who specialize in Physical Medicine and Rehabilitation (PM&R) are called physiatrists. A physiatrist treats patients with physical impairments or disabilities that limit daily functioning and impair quality of life. Physiatrists provide a spectrum of care, from diagnosis to treatment and rehabilitation in patients of all ages with a focus on the following:

1. Rehabilitation of patients with severe physical impairments primarily in inpatient rehab hospitals, with some follow-up in the outpatient setting. The physiatrist leads a team of rehabilitation professionals that includes physical therapists, occupational therapists, recreational therapists, rehabilitation nurses, psychologists, social workers, speech language pathologists, and others. The types of conditions that are commonly treated by physiatrists and the rehabilitation team include: spinal cord injuries, traumatic brain injuries, amputations, multiple trauma, stroke, back problems, cancer, burns, post-orthopedic surgery, neuromuscular conditions, pediatric congenital disorders, and other conditions.
2. Diagnosis and treatment of musculoskeletal conditions (both acute and chronic conditions). These range from from industrial, sports, and performing arts injuries to degenerative conditions as common as arthritis or low back pain, and more complex pain syndromes. In the setting of musculoskeletal medicine, physiatrists are experts in non-surgical, conservative solutions to musculoskeletal/orthopedic conditions. This type of practice is typically outpatient/clinic based with numerous types of injection techniques, often under fluoroscopic or ultrasound guidance.

• Nationally, there is a deficiency of rehabilitation specialists. There is an excellent job market now, and with the population aging, it is projected that the demand for physiatrists will continue. The outpatient-based musculoskeletal job openings are most popular right now.
• Approximately half of PM&R residents choose to pursue a career in general rehabilitation and the other half pursue fellowships. The most popular fellowships include Interventional Pain Management, Sports Medicine, Interventional Spine, Traumatic Brain Injury, Spinal Cord Injury, Pediatrics, and more recently Cancer Rehabilitation. Most of the fellowships are 1 year, except for pediatrics, which is a 2 year fellowship.
• Right now, Pain Management and Interventional Physiatry are "hot". Many residency graduates are pursuing Fellowships in Pain (either PM&R based or anesthesiology based programs) or Sports & Spine. Becoming board-certified in Pain requires a one-year fellowship. The interest and growth of this subspecialty is driven by impressive financial reimbursements and a desire to have a procedure-oriented practice.
• Additionally, untrasound-guided injections and musculoskeletal untrasound are becoming essential components of the future of PM&R, and many residency programs are increasing untrasound incorporation into their residency didactic and clinical experiences.
• According to AAPM&R, the median annual salary for physiatrists in clinical practice ranges between $200,000 to $276,510. However, in an Interventional/Pain-based practice, the upper limit can be much higher. One of the overall benefits of PM&R is that there is very little call or weekend coverage.

• The University of Maryland is now jointly affiliated with the residency program at Sinai Hospital of Baltimore, and the program director there is Melanie Brown, M.D. She is very helpful as an advisor, and if you rotate at Sinai, it would be a good idea to impress her and get a letter of recommendation. The field is small, and the residency program directors know one another well.
• Also, Dr. Henry York, a physiatrist at the University of Maryland Rehabilitation & Orthopaedic Institute (UMROI, formerly Kernan Orthopedics and Rehabilitation) is a tremendous resource and has offered to mentor students interested in PM&R.
• Dr. Idris Amin is a PM&R Sports Medicine physician who is a recent addition to the University of Maryland PM&R faculty. He is very interested in medical education and would likely be interested in having students work with him.
• In prior years, Dr. Samuel Mayer, the Vice Chair of Education of the Johns Hopkins PM&R Department, has been a great mentor and has welcomed students to shadow as well as apply for elective rotations at their program. Inquiries can be sent to their Residency Coordinator, Nicole Prioleau.

• Do a rehabilitation elective rotation late in the third year or early in fourth year to confirm your interest in the field and to make a good impression on those who you will ask to write letters. At least one letter from a physiatrist is required; two letters, however, is ideal. There is an in-house rotation at UMROI, where you will work closely with three physiatrists that can write good letters on your behalf.
• An away rotation is strongly recommended, especially since University of Maryland does not have a home residency program. Many students commonly do 2 away rotations; however, 3 is rare and not recommended. A good option if you would like to stay in/around Baltimore is at Sinai (see above). Another advantage of an away rotation is that the in-house UMROI rotation is heavily inpatient, and rotating at a more outpatient focused institution may provide a fuller view of the non-inpatient aspects of PM&R.
• Most away electives can be attained through VSAS/VSLO, but some programs may require a unique seperate application that can be found at the program’s website. An away rotation is an opportunity for you to audition, and for you to better get to know a program, its residents, and its faculty. If there is a program that you are strongly interested in, definitely try to do a rotation there if possible.
• Many PM&R applicants do away rotations at top-tier programs. This is not necessary, but it can be helpful. Again, PM&R is a small field and growing more and more competitive. A letter from a big name or a faculty at your top choice can go a long way.
• The other recommendation letters often come from faculty in internal medicine (since you will need one for your preliminary year applications anyway) and those in closely related fields, such as neurology. If you have significant research experiences, a letter from your research advisor can help.

• Research is not crucial for a successful match, and many successful applicants have little to no research experience (or interest). With that said, PM&R, as a field, is investing heavily into developing a more robust research community and infrastructure. To this end, many academic programs are looking for research minded applicants, which can be a big plus. Dr. Macko, a neurologist at the VA, does a lot of neuro-rehabilitation research. Dr. Braun at UMROI is an MD, PhD that is also well connected and is starting her research program in stroke rehabilitation. There are a number of additional research projects at UMROI that you can get involved in.
• The Association of Academic Physiatrists offers a summer research program (Rehabilitation Research for Medical Students or RREMS) where students work with a research mentor on a project that will be presented at the AAP national conference: Association of Academic Physiatrists

• PM&R residency begins after an internship year (PGY1: either Transitional or Prelim. Medicine or Prelim. Surgery), and the residency is three years in length (PGY2-PGY4).
• A handful of programs offer a four-year categorical option. The internship year is very similar to a preliminary. medicine year, and sometimes offers one month of PM&R in that year. The advantages to these programs are that you don’t have to move twice, you will gain familiarity to the system, many of the built-in electives are geared towards PM&R, and you get to know many of the consultants whom you may have to call once you’re a PM&R resident.
• Residency is usually close to 50/50 inpatient/outpatient. The ACGME requires 12 months of inpatient and 12 months of outpatient. With the job market trend towards outpatient physiatry, many programs have increased the outpatient focus (50-70%) and are emphasizing or increasing musculoskeletal medicine training.
• Call is very light compared to other specialties. For example, some programs have this type of call schedule: q-7 in PGY2, q-14 in PGY3 and no call in PGY4. Programs may either have in-house vs. home call. While many residents enjoy the convenience of home call, in-house call usually gives residents a post-call day.

• Several of the top programs are competitive. The remaining institutions accept a wide range of applicants. Just like in other specialties, the higher your class rank and the more honors you have, the more attention you’re likely to receive initially. However, in this field, personality plays an important role. As noted above, the team concept is very important to PM&R. Programs will probably learn the most about your ability to be a team leader and a team player from your letters of recommendation. Lastly, programs want to see that you have a real interest in and enthusiasm for this field.
• Interest in this field has swelled in recent years. But many of the applicants for this field are still foreign graduates or DOs; there is an advantage coming from a US allopathic medical school.
• Attend the American Association of PM&R (AAPMR) national conference in the fall if you can! During the conference there is a residency fair where medical students can talk to PM&R residents and Program Directors. In November 2019 it will be in San Antonio, TX and in November 2020 it will be in San Diego, CA. The Association of Academic Physiatrists national conference is smaller than the AAPMR conference and is usually held in February or March each year.

• The preliminary year in internal medicine is an excellent preparation for inpatient rehabilitation rotations. Most inpatients on the rehab. service will have general medical issues that physiatrists must be able to address and manage (Inpatient rehab involves quite a bit of internal medicine). The transitional year, on the other hand, usually offers more elective time.
• Many top residency programs are based at “stand-alone” rehab hospitals. In these situations, the physiatry resident is the only in-house physician on call, so a rigorous medicine internship can be valuable. However, residents who have completed internships with a wide range of difficulty suggest that they felt adequately prepared.
• Some people who hope to gain additional hands-on skills to do a preliminary surgical year, which will fulfill the internship requirement. However, this is much less common.

• The number of programs to which you apply should be determined by the competitiveness of your application. If you are a solid student with good letters, obtaining interviews is a given at the not top-tier places. It is probably overkill to interview at more than 10-12 PM&R programs, although the field is progressively becoming more competitive. Most programs interview October thru January, with the greatest portion in November and December. It is also important to consider that you will be applying to and interviewing for internships at the same time as for PM&R.
• For information about planning away rotations, choosing which programs and how many to apply to, one of the best resources is students from the past year or two who have matched into PM&R.

• American Academy of PM&R: http://www.aapmr.org/ Excellent website and great starting point to learn about PM&R, including a timeline for preparing for PM&R residency. Explore!
• Association of Academic Physiatrist: http://www.physiatry.org/ 
• Directory of Physical Medicine and Rehabilitation Residency Training Programs can be found via the Association of American Physiatrists : http://www.physiatry.org/?page=program_directors 

For additional information please contact Brandon Hassid.
 

Revised: February 13, 2019