Jumping Into the World of Physical Medicine & Rehabilitation

Session 194

Dr. Mathew Saffarian is a Program/Fellowship Director at Michigan State University who shares what life is like as a physiatrist. Mathew is an osteopathic physician who specializes in Physical Medicine & Rehabilitation (PM&R), specializing in sports and spine. This specialty, also known as physiatry, not psychiatry, but physiatry. It’s a lesser known specialty. And so today, we’re going to talk all about sports and spine in the Physical Medicine & Rehabilitation world.

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[01:34] Interest in Physical Medicine & Rehabilitation

Mathew didn’t really know what PM&R was until his second year of med school when he was introduced to it by a couple of his instructors.

Then he started looking more into it and started to learn that PM&R was involved in the procedural side of Sports Medicine. And he has always wanted to do something with his hands, hence the procedural aspect appealed to him.

[02:49] Common Myths or Misconceptions in the PM&R World

When it comes to PM&R you can do so many different things with it. A lot of people see only two scopes, either the inpatient rehab side, where you’re just rehabilitating stroke and spinal cord injuries, or the chronic pain side.

One deterrent to a lot of people is that if they go into PM&R, they’re going to have to be dealing with chronic pain on a daily or regular basis. This isn’t necessarily true, otherwise you can become more of a pain specialist. And so, you can integrate the sports and spine world together so you have a more of a younger athletic base population.

The procedural based practice can be focused around young, healthier active patients than just a chronic pain type that has that negative stigma.

When it comes to the outpatient PM&R world, whether you go into pain, interventional spine, sports, it’s important to be a team player. Because if you’re doing the sports world, you’re dealing with a lot of athletic trainers and coaching staff. And then when it comes to pain stuff, too, there’s going to be some pain psych involved again, as well as a rehab specialist, PT, and OT.

[05:19] Other Specialties They’re Working the Closest With

With his sports background, Mathew works mostly with orthopedic surgery and primary care sports medicine.

When you’re out in private practice, you may be working closely with neurosurgery. If you’re doing more of a pain-based practice, you’ll get neurosurgery involved to where they’ll send you for your procedural type stuff prior to them taking on the surgery or for electromyography (EMGs).

Then when you’re in the inpatient setting, you often work closely with general neurology. They could be dealing with peripheral nerves issues that might pop up on a patient setting and other polyneuropathy that need to be worked up.

[06:56] The Hidden Treasure of Medicine

Mathew likes to call PM&R as the hidden treasure of medicine because most people don’t know about it. And so, if you’re interested in something neuro musculoskeletal, at least do a rotation or look into PM&R more closely because it might be something that matches your interest.

If you have an interest in the peripheral nervous system, neuro musculoskeletal system, you should at least do a rotation with a physiatrist to better learn what they do because it might be something that really interests you.

[08:40] Types of Patients

Mathew explains that he has already carved out a niched as an interventionist. Patients are being sent to him for EMG from the surgeons or from neurology. Other things are non operative patients. Or patients go to him before they go to surgery with ortho that want to try other interventional procedures such as epidurals, even regenerative medicine.

“The biggest booming part of PM&R right now is the regenerative medicine stuff.”Click To Tweet

As PM&R specialists, they’re looking at PRP or stem cells for peripheral tendinopathies as well as for mild to moderate osteoarthritis in different joints. And this is typically the patient population he’s getting. It varies anywhere from focal neuropathies all the way up to tendinopathies. There’ll be patients from younger athletes and all the way up to an 85-year-old individual.

[10:05] Typical Day

Mathew tries to vary his practice as much as possible so he doesn’t only focus on one thing. He’s not just the regenerative medicine guy, so he tries to do a little bit of everything. Throughout the week, his clinics tend to be all different. He may have a regular PM&R clinic and then he’ll have procedure clinics which will be a half day of EMGs. And then after that, he’ll have a half day of procedures. Those could range from the regenerative medicine stuff with PRP and stem cells to epidurals and fluoroscopy injections.

He also has clinics at their sports medicine office, seeing a younger and more athletic patient population. And then on top of it all, he does a concussion clinic for another half day a week. He will go to one of their other ancillary clinics, and do a sports concussion clinic, focused more on younger athletes with mild traumatic brain injuries.

Being procedure-heavy, Mathew says that students can develop their hand-eye coordination and ability to do procedures, if this is something they’re interested in.

He explains that through practice, you have the ability to get comfortable with not just the procedure itself or the manipulation of the needle, but using the image guidance to help them, whether it be fluoroscopy or ultrasound. It just takes time and it takes practice.

[12:59] Taking Calls

PM&R patients are all stable, whether it’s in the inpatient setting or in your outpatient clinics. They have an inpatient setting at the hospital so they split the call because you have to run on the weekends on the patient and the inpatient rehab floor. So maybe over a whole year, he’ll take one or two weekends.

And again, they’re low acuity and most of the patients are stable and they’re just coming in making sure that their rehabs have gone well over the weekend. and they’re answering any questions that they or their family members may have that are up visiting for the weekend.

And when it comes to the pain side of things and the sports medicine side, if you do all patient-based practice, you’re really in control of your schedule. And so the evenings and the weekends that Mathew works is because he chooses to work because he’s covering events at Michigan State University.

And so, if it wasn’t for the sports medicine side of things, the call would be very easy and light as you’re pretty much in control of your own hours. In fact, he never has to spend the night in the hospital.

[14:32] What the Sports Events Look Like

As the head team physician for men’s and women’s soccer here at MSU, Mathew provides sideline coverage. They’re available for any medical needs that are present during the game. They’ll also be there with an athletic trainer.

And so, they stand on the sideline next to athletes. With any injuries that occur acutely, the athletic trainer will go out and see the athlete or see the athlete on the sideline. Then they just wait in the background and if the athletic trainer needs anything, they will call them. Then they’ll come over and assess the patient and help make the decision whether the athlete can return to play or not.

'It just makes it easier if you have the knowledge and the background of that sport to be able to take care of those athletes and get them to be more compliant with their programs.'Click To Tweet

[19:44] How to Be a Competitive Fellowship Applicant

Mathew says the biggest thing is work ethic. Most of their fellows that have been accepted are members of their own residency program.

During their residency, some of the things they’re looking for is that they’re volunteering to help cover events and do things outside of the general residency requirements.

If there’s a special olympics event or a high school football game that needs to be covered, they’re looking for volunteers to cover that. And they should be willing to go out there and spend their Friday night or Saturday morning helping cover those events and be an active member of their community.

A lot of residents make a push towards research because it’s important. Other things they look for are work ethic and people who want to be there, and who want to learn and work hard.

'The most important thing is looking to do more outside of just the minimal requirements of the daily rotation.'Click To Tweet

[21:25] What Fellowship Looks Like

At Michigan State University, they have a two-year fellowship. The first year is an interventional spine, which they call an EMG year. They’ll spend time up in the PM&R office, learning how to do different flow, guided and ultrasound-guided procedures. They also get some further training in EMG. Then after that first year, you help cross covers and weekend calls. You serve as a part time attending where you help staff with the residents, etc.

After that year, you’ll do the second year, which is ACGME-accredited for sports medicine. And then they’ll work more down in the sports medicine office where Mat works.

They have the primary care, sports medicine attendings and the orthopedic surgeons. And then that’s where you’ll get to experience and exposure to the Division 1 college athletics. That’s where you’ll learn how to do more of the sideline management and refine your musculoskeletal skills.

[23:21] Osteopathic Manipulation in Athletic Populations

Mathew believes having an osteopathic background is important in their athletic population. Oftentimes, in the training room, they’ll do manipulation for back pain, hip pain, whatever it is.

They even have one study where they’re looking at stress fractures in some of their cross country athletes. They’re working on manipulation to see if that would help decrease the incidence of stress fractures among some more runners.

Then they look at leg length issues and help correct somebody’s leg length issues. At Michigan State University, the osteopathic side of things plays a huge role in their sports medicine treatment.

PM&R necessarily isn’t just EMGs and pain. They also help with chronic tendinopathies. They can help make a difference in some of the weekend warrior population or ex-military folks who have chronic injuries dating back to their times of service.

[25:30] What He Wished He Knew Before Getting into PM&R

Mat thinks he got lucky in the sense that as he went through it, the specialty was changing a little bit. He started research at that time, and as he was going through it, he was realizing what you could do with PM&R.

Then he realized he could develop this niche that was different from anybody else because most of the guys at their institution were either on the pain side, or just strictly Pain Medicine, or just strictly in-patient. And that’s when the regenerative medicine stuff started to make a big push.

Then the next biggest thing was Concussions. And so they needed to start to see rehab from concussions. It wasn’t just neurology, but it was also physical medicine rehab.

Right at that time while he was in med school in 2008 to 2010, the specialty changed a little bit. Mat thought he caught it at the right time and the perfect time. If it would have been a little bit earlier, he might have missed that. And if he was going to lay a little bit later, he might have been a little bit late to the game. And so, it was perfect timing for him as things started to evolve.

[27:10] Most and Least Liked Things

Mat’s favorite procedure is an ultrasound-guided percutaneous tenotomy. One of the specific pathologies he treats is calcific tendinopathy, specifically, to the rotator cuff. And he likes using the machine with patients who come in with shoulder pain that’s interfering with their function and their ability to do different things.

On the flip side, what he likes the least is the chronic pain management stuff. And when you get to patients who can’t get better, it frustrates you.

If he had to do it all over again, Mat would still have chosen the same specialty. And what he tries to always stress to students is that he loves his job because it’s a great job. He gets to work with Division 1 athletes and practice the way he wants to.

'Every day coming to work to me is a joy. I don't hate anything about my job. And if I could do it all over again. I'll do the same thing.'Click To Tweet

[29:40] Major Changes Coming Into the Field

Mat explains that insurance authorizations are becoming more and more difficult nowadays. He’s spending more and more time on the phone doing peer to peer with different physicians trying to get approval to do different procedures.

As far as how the field might be changing, Mat says the regenerative medicine area of practice is going to be the biggest area that changes within the next 10 to 15 years.

'The regenerative medicine area of practice is going to be the biggest area that changes within the next 10 to 15 years.'Click To Tweet

Additionally, you’re going to start to see more and more studies that back PRP and possibly stem cells.

[30:37] Final Words of Wisdom

If you have an interest in anything that’s neuromusculoskeletal, it’s important and vital that you at least do a PM&R rotation with somebody to get some exposure to the field. And don’t be disappointed if it’s just an in-patient rehab rotation or it’s someone who’s more neuro musculoskeletal based. That might be something that you can morph into a practice that you would find joy in.