Monday, March 22, 2010

PM&R: The Holy Grail?

Hi, kids! I'll be tackling two questions today:

My name is Brittany, and I am a third year medical student obsessing daily about what kind of doctor I should be. I struggle daily because I have loved mostly all of my clinical experiences thus far and could truly see myself in a variety of different fields. All around me my classmates are making decisions about career choices, and it just does not seem like an easy choice to me! Considering family life and how it will factor into whatever choice I make makes the decision even more difficult.

So, my question is how did you choose the specialty you went into? Was there a moment or a series of choices or did it just make sense? How much did family factor into this decision?

I realize that everyone says, "do what you love and you'll be alright." However, I love medicine as a whole and different specialties for various reasons, sometimes completely unrelated--there are other factors that influence this decision, and I am curious how others dealt with them.

And more specifically:

My name is Alli and I'm an MS 3 who is in search of the holy grail in medicine-- a profession that provides both financial stability and flexibility. Here's my story: I live with my boyfriend, and future fiance, on Long Island and as I get deeper into looking into residency I am petrified. I love my boyfriend, and want nothing more to have a family (why didn't I want to be a math teacher again??) but I'm really concerned, not only about juggling being a mother and wife with being a doctor, but about finances. I am SO in debt and my boyfriend is a firefighter and doesn't make much money, meaning I would be the primary breadwinner (shudder). Is there a medical field that exists that would allow me to provide for my family while also being a dedicated wife/mother? Don't get me wrong, I'm not trying to get out of working hard and I honestly love what I do. I'm just afraid that years later I will burn out and realize that I wasn't there for my family and that I could have made just as much money doing something else. I have already ruled out certain specialties that I have an interest in because I'm afraid they demand too much (i.e. surgery, ob/gyn) and others because while they might be low key they don't have enough financial stability (i.e peds). I honestly love pediatrics, and was considering it up until I discovered physiatry. Physiatry is a great field, and certainly a strong second choice. I was just wondering your thoughts on my situation, if you have any input about physiatry programs in NY and physiatry salaries in general for a future Mother in Medicine.

OK, since I just blew a bunch of space posting those questions, I'm going to cut right to the chase and be brutally frank here:

For many graduating med students, lifestyle matters. A lot. When we applied to med school, we all had a convincing story about how we want to help people, blah blah blah. And maybe at the time, we meant it. Or at least, some of us did. But when it comes time to decide what specialty we want to do for the rest of our lives, other things become more important than just "helping people" and generally doing good. We've all got loans, rent, children or potential children, future alimony payments, etc., so money is important. And many of us have gone through waking up at 4AM for surgery rotations (on Saturday! horrors!) and decided that's not so much for us.

I'm going to continue to be brutally frank. Get ready:

I don't like to work that hard. I don't particularly like to wake up at 4AM. In fact, even 7AM is a bit early for me. And that whole going to work on weekends thing? Not a fan. Or staying up the entire night on call? Also, not my favorite thing. When I was entrenched in my third year of med school, I realized that I desperately wanted a 9 to 5 type of job. Lots of people have 9 to 5 jobs. Why not me? Why?? Why did I have to suffer through 3+ years of a horrible lifestyle in residency just to possibly have an equally busy practice after residency? I had already worked SO HARD in med school. It wasn't fair. IT WASN'T FAIR DAMMIT!

There were specialties out there that could have catered to the lifestyle I wanted. Dermatology residents have it pretty good. But my grades weren't good enough for that. My grades were good enough for radiology perhaps, if I was willing to go anywhere. But I wasn't. I was following my husband where he wanted to go for his career. (Yes, I was one of THOSE women.)

The brutal frankness continues below...

If you want an eas(ier) lifestyle during residency and your options are limited by your grades and/or geography, there are two options: psychiatry and PM&R.

Psychiatry: Everyone knows what a psychiatrist is. I know this, because people accidentally call me a psychiatrist about five times a day. In any case, psychiatry wasn't for me. I won't get into the reasons, but I was pretty sure about that.

So that left PM&R, which stands for either Physical Medicine & Rehabilitation or Plenty of Money & Relaxation, depending on who you talk to. I did a rotation as a med student, expected to be bored, but actually really liked it. I did my residency in PM&R and it was.... easy. It was rare that I had to wake up before 7AM. I got home most days around 5PM. I spent maybe one or two nights in the hospital during my entire residency. I had a life like a normal human being. Amazing.

The field itself is a hodgepodge of different things. One day you're directing the care of a 24 year old with a new spinal cord injury, the next day you're treating a 60 year old stroke patient. I injected a lot of knees, shoulders, and spines. I performed hundreds of electromyography studies. I got to see young patients who couldn't run two marathons next week because of knee pain. I did acupuncture as part of my residency. I worked races. I had fun.

Even though I was a mother for most of my residency, I was still able to be a great resident. I knew my shit, I was responsible, I was enthusiastic (and I was also modest). I was able to fulfill all my work responsibilities and beyond, had free time to study, time to spend with my daughter, and even *gasp* time for myself. In most other residencies, I would have had to sacrifice something.

On graduation, there were definitely job opportunities, although you may have to be a little flexible about geography. Also, for people interested in research, PM&R is wide open, especially compared with older fields. Now for the salary: according to the Medical Group Management Association's Physician Compensation and Production Survey in 2007, the median salary for physiatrists after 1-2 years in practice is $213,701. A lot of my class ended up doing one year fellowship to specialize in Pain, which commands a much higher salary.

The worst thing about the field is that nobody knows what I do. Even my parents don't know. I mean, nobody here is writing a post called "What is a Pediatrician?" It gets tired to keep explaining to patients what a physiatrist is, especially since the answer requires a few paragraphs.

Let me be totally clear though:

Do NOT do PM&R just because it's easy. We hate it when med students say that and it's always a big mistake to go that route. PM&R is a really fun field with lots of procedures and a chance to really develop relationships with your patients. It's got a good lifestyle, which is something I love about it, but is only one of many things I love about the field. If you work in a field you love, you'll never work a day in your life. (I never really could have been a dermatologist.)

Also, please check out my FAQ on PM&R.


  1. Great post! Just wanted to add that radiation oncology is another relatively family-friendly option. No overnight call during residency, mostly clinic work with clinic hours and well-compensated. Like Fizzy said, I would never tell someone to choose this because they wanted something easy. You are treating cancer patients! But, if you are interested in developing close relationships with patients, many of whom you can help, doing a combination of direct patient care and technical treatment planning and having a better balance of home and work life, check out radiation oncology. One caveat, germaine to this blog, is that there are fewer women in radiation oncology than in many other specialties. So women, we need you!!
    --a rad onc resident

  2. Sorry, neglected to write rad onc resident and mom to three little ones

  3. Ah, but keep in mind that rad-onc is super competitive! :)

  4. rad onc resident again: I know this is a digression but I'm not sure it is actually as competitive as is rumored. Only anecdotally, i was not at the top of my med school class, did a modest research project and I think my strongest asset was that I am a people person and was well rounded. So don't let rad onc scare you away. You can do it if you want and you don't have to be a superwoman.

    1. Not to pry, but what made you well-rounded? What types of things are good to focus on to make oneself stand out and be considered well-rounded?

  5. What about pathology? I'm a path resident and my lifestyle is pretty darn great.

  6. Thanks Rad Onc Mom. I am a post bac pre med ... so I expect to have kids well before residency rolls around - but radiation oncology interests me. Good to hear from a mom who is enjoying it.

    Thanks also to Fizzy. I've enjoyed your posts as a reader - including this one. I don't see why doctors have to be saints on top of being professionals. One of two should be enough.

  7. I forgot all about pathology! I might have considered that, but microscopes gave me huge eyestrain. Plus I sort of like patient contact :)

  8. What's with everyone saying that they don't want to work 100 hours a week because they "want to be a good wife and mother."

    Not that there's anything wrong with wanting those things, but personally, I don't want to work 100 hours a week because it sucks!

  9. OMDG: It's interesting because I think being a mom gives you license to work less hours. When looking for a job, everyone acted like I was insane when I said I wanted to work 3/4 time, but when I said I had a small child, everyone was suddenly OK with it. But even if I didn't have a child, I think I'd like to work 3/4 time! Why not have an easier life?

  10. This is my answer to Brittany:

    I followed and still believe (and still tell my students) do what you love and it will work out. I can honestly say that lifestyle issues were not one of my top concerns when choosing general internal medicine. I struggled between peds and medicine- loved my peds rotation, especially outpatient peds clinic. Eventually, I chose medicine since I realized it is reasoning and talking with adult patients that I really enjoyed.

    On rotations, I identified most with the internists and accordingly, my main mentors were internists.

    Along the way, I switched from primary care to hospitalist to medical educator, and I have to tell you, I could not be happier with my decision. Of course, I did pick a field that women are well-represented in, maybe I'd feel differently if I fell in love with surgery where it might be harder to find that balance.

    I think it helps to find mentors who seem to be doing what you hope to be doing in the future No matter what the lifestyle, if you are doing something you don't love, it's not going to fulfill you in the long run. I think I am a better mother because my work does fulfill me.

    I also think acting internships (or sub-internships) do help solidify that --when you have more opportunities to really do the work, to have those relationships with patients, and to know whether you've found how you want to spend your career.

  11. Hey now! Don't you be dissin' pathology, Fizzy. We may be cross-eyed and nerdy, but we think we're really cool, and that's all that matters, right? I can't wait to meet you and stick a needle in your lump or perform an apheresis consult on you. There's your patient contact:)

    I never knew what PM&R was until today. Wow. Makes me jealous. Wonderful post!! Now I've got to go work on one of mine - I'm late - KC's gonna kill me. You know. Cause she's the type.

  12. Thanks for the essay Fizzy. I really enjoyed learning more about PM and R. And about the origin of your screen name.

  13. Gizabeth, I also forgot to mention that in order to become a pathologist, you must have EAR HAIR, and since I don't, I had to choose a different field! :P Hehe.

    (Seriously, one of the pathologists I worked with had massive amounts of ear hair.)

  14. You should see the fabulous braids and ponytails I can make with my ear hair. You would be jealous.

  15. KC, I have slowed down on advising medical students to "do what you love and it will work out"...because it doesn't always, honestly. It's very different to "love" being in cardiothoracic surgery as a 4th year med student and to "love" it eight years later when you've been through a brutal residency and are trying to find a job in a city that your spouse and family can survive in.

    I try instead to encourage them to think about "everything you love" -- work content, but also family, hobbies, sports, other ambitions -- and think about a specialty that will allow you to do all of those things. I just don't think it's realistic to say to a 26 year old med student of EITHER gender that if they really love neurosurg, it will all work out, and they will also be able to have three kids and not have to hire a nanny and have a spouse who works outside the home and go rockclimbing every other weekend and have dates with their partner every week and learn to play guitar. Don't you think?

  16. Anonymous, thanks for that comment. I like how you encourage students to consider everything they love - I think that's good advice.

    My advice of "do what you love" comes from worry that students will give up early pursuing a specialty that will most fulfill them, thinking solely of "lifestyle" and end up regretting the decision later, or even leaving medicine completely. This is broadly-doled advice given in the context of internal medicine where there is such a range of what people can do.

    Maybe I'm too idealistic about this, but I do feel like some students resign themselves to a second choice, not being fully informed about what might be possible with their first.

  17. I wouldn't write off dermatology so fast. If you really want to do it see if you can do some research in the field with your schools derm department. Do some rotations in the derm department at your school and at other programs that you're interested in. Personal contacts are important. Be personable and helpful - you may just get in. It's not impossible. I thought it was at one point, but it's not.

    The lifestyle is wonderful and the day to day work is very rewarding. There's a good mix of surgery, medicine, pathology, cosmetics. Plus we see all age groups and both sexes from newborns to over 106yo. The financial rewards are there too. I only work 3 days a week and my husband is a stay at home dad. Granted we live in a low-cost-of living area, but that was a conscious choice we made to live a lifestyle that works for us.

  18. Does anyone have a comment on if heme onc is doable as a mom? I know radonc is much more lifestyle friendly, but I think my heart is less with linear accelerators and more with avastin. I just don't know if doing 2 applications(vs 1), 6 years(vs 5), and much much more call/hours(vs little call and out by 7 most nights) be worth it. Any thoughts?

  19. I would also like to know more about rad onc vs. heme/onc.

  20. Great post. Question for you Fizzy: I'm a DC who spent the past year studying spine diagnostics and management at what is now the largest ortho group in the US (yes, first DC to do so). I've been schooled in the works of the great non-surgical spine experts (Jim Rainville, Jim Weinstein, Rick Deyo, etc.) and I have a question for you: do you think PM&R can occupy the need for non-surgical spine care? This is an area of major concern in healthcare, as it is under-appreciated in the current system, and far too many patients receive poor information, fail to be informed about natural history, etc. and instead receive no advice or inappropriate advice such as "you have degenerative disc disease and if you don't do anything it will only get worse" (we know this not to be the case!). Perhaps worst of all, patients who do not receive proper advice about their non-surgical spine pain often end up seeking endless treatment out of frustration and become chronic pain patients. Just wondering your thoughts. I'm heading back to med school, and my goal is still to tackle this problem.

    Thanks! Jim Eubanks DC, MS

  21. I hope you respond! But I have been interested in this field and I was wondering when you went to college what did you major in? Biology? Kinesiology? I'm not sure ...??? Help?

  22. Great contributions.

    May I ask, where did you do your residency? Which programs teach acupuncture along with clinical curriculum?

    please and thank you,


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