What Does Academic PM&R Sports Medicine Look Like?

Session 97

Dr. Brandee Waite is a physical medicine and rehabilitation (PM&R) specialist who practices in an academic setting for almost 15 years now. She talks about her specialty, types of patients, and the things she likes the most and least about her practice.

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[01:30] Interest in PM&R

Brandee actually didn’t even know PM&R existed until the summer after her second year in medical school. It was a relatively small specialty on the west coast.

She and her friends were reading about the different specialties they could possibly take. One of them told her that PM&R actually fit her personality. It actually talked about how the specialty involves patients and their functions in their day-to-day life.  With a background in fitness and dance, she figured out it was a great fit for her.

'I'm very passionate about people being able to live full lives and I feel like function and activity are a part of that.'Click To Tweet

They basically described PM&R as an intersection of neurology, orthopedics, neurosurgery, and psychiatry. She thought she highly liked most of those things.

[04:10] Traits that Lead to Becoming a Great PM&R Doctor

You have to like working with other people. The PM&R physician is the leader of the care team who works very closely with the physical therapists, occupational therapists, and nursing staff.

They work in an in-patient rehab setting to really address all of the rehabilitation needs for patients. These may include learning how to dress again or walk again.

'Physical medicine and rehab is definitely a specialty of a team care approach.'Click To Tweet

Hence, you have to be able to work on a team that will have additional input with you as the guide. Some PM&R doctors do procedures, others don’t.

Brandee further subspecialized into musculoskeletal as a PM&R doctor. Since she’s very much into dance, fitness, and sports, she liked the aspect of taking care of athletes. Plus, she likes to do a lot of procedures so she found it as a really good fit for her.

[06:45] Other Specialties She Considered

Brandee initially wanted the OB/GYN route. But what really sold her into PM&R was when she did a rotation in PM&R.

The doctor she rotated with was an outpatient musculoskeletal specialist, who was double-boarded in Rheumatology and PM&R. He was prescribing pool therapy for people with back pain and lower extremity problems. And she had never seen any other physician who did such as a way to deal with those problems.

As a dancer and fitness instructor, Brandee used to teach water aerobics during summer time. She knew it just made so much sense.

Brandee doesn’t like primary care and so she knew she was going to do a specialty and OB/GYN was the one she ended up liking the most. More so, she just didn’t love her rotations in internal medicine.

She went into PM&R not even knowing that she wanted to do a sports medicine fellowship. It was basically just the overall function for general musculoskeletal care and the rehabilitative aspects for people with neurologic and orthopedic injuries.

And as she went more into it, she found that the subspecialty was even more exciting to her than the rest. Hence, she ended up doing it.

[11:52] The Roots of PM&R and Types of Patients

PM&R actually came about way back after World War II. A lot of people came back with disabilities and primary care physicians didn’t know how to care for an amputee or one with a spinal cord injury.

'Beyond just the immediate care of stabilizing them, but how do they live their lives and move forward with being a contributing member of society? That's where PM&R had its roots.'Click To Tweet

Currently, Brandee sees a lot of people with knee arthritis and knee problems. She sees a range of people from professional athletes to a woman with cerebral palsy who has lived an ambulatory life.

They basically see any problem that is affecting a joint that’s not part of the skull or the spine. Although there are PM&R doctors that do spine treatment. They have separate sports and spine clinics at their office, and she only works on the sports side.

Sometimes, she sees patients where they have to do “investigative” medicine. They take histories and listen for nuances. They do a strong physical exam combining elements of neurologic exam, orthopedic exam, and general exam.

Other times, some patients come to her already with a diagnosis from their primary care doctors. This would then be a different conversation.

[14:50] Taking Calls

In their group, they have a lot of subspecialists. They have some general PM&R doctors as well as some neuromuscular specialists and pediatric rehab specialists. They have a 20-bed inpatient acute rehabilitation hospital.

That being said, she takes calls about six times a year over the weekends. She is on call from home from 5pm-8am during the course of the week that she’s on call.

On Saturdays and Sundays, they go in and make rounds to see all the patients while the other doctors have their weekends off.

'All of the doctors in our group share in that call so it gets the whole year of weekends covered.'Click To Tweet

[16:15] Choosing Academic Setting over Community Setting

Brandee chose the academic setting over the community route not for the money obviously. After ten years, all her students were paid. She owns a home, takes care of her family, and travels a lot.

'What I like is the idea of continuing to be engaged in education and staying up on the latest things.'Click To Tweet

She saw that in the community, there was not so much focus on keeping up with what’s the latest thing that has come out recently. It was more of a struggle for them to get out and go to conferences and collaborate with other people in their field.

Additionally, she likes teaching. She feels that her presence in the residency program might mean more as a woman and an underrepresented minority in the field. Plus, she gets more time off to travel to attend conferences.

'My presence at an institution on that level might help expose some people to our field that might not otherwise look at it if you don't see somebody that looks like you in the field.'Click To Tweet

[18:42] Work/Life Balance

You figure out how to do the balance. She doesn’t take that many calls. However, in sports medicine, she ends up spending more time covering games. This takes additional time to her regular call schedule.

She is married and has two kids. She’s lucky to have support from her family. Ultimately, you just have to be efficient with your time and what’s required of your documentation. Eventually, you will be able to figure this all out.

'In any field of medicine, there is that curve of figuring out how to go from being the student or the trainee to being the one where you've got to take care of everything.'Click To Tweet

Brandee sees 15-22 patients a day. Her last patient is usually scheduled at 4:15-4:30 so she rarely stays in the office beyond 6 pm.

In addition, she’s also a fellowship director, the director of their clinic, and the chief for sports medicine. Hence, she has other administrative and leadership responsibilities that she has to take care of.

Because of this, she doesn’t necessarily have to see patients five days a week all day everyday due to her other responsibilities. So she could have half a day in the clinic and probably take a half day or full day for administrative time.

[21:30] Doing Procedures

Brandee does a lot of ultrasound-guided procedures. Some doctors use X-ray guidance while she does ultrasound.

'In physical medicine and rehab nationally, there's also more and more of interest in regenerative medicine.'Click To Tweet

PM&R has this interest in regenerative medicine which involves cells and biologic materials to treat diseases like stem cell injections or platelet-rich plasma injections. They don’t do stem cell injection at their office but they do some plasma injections.

A lot of PM&R doctors do an interventional spine or a pain fellowship. They can then do epidural steroid injections for back pain or injections into the facet joints or the zygapophysial joints for back or neck pain.

Some doctors do EMG and nerve conduction study, which involves an electrical study of the extremities or face to measure different nerve functions.

[23:15] The Training Path

The PM&R residency takes four years. Some residencies have all four years at the same spot. While some have internships somewhere else and you just do 3 years of PM&R at the site.

You can do a one-year transitional internship or just a preliminary medicine year. Then you can do your three-year PM&R residency. Brandee took this route before doing a 1-year sports medicine fellowship after finishing residency.

Brandee thinks PM&R is getting more and more competitive. They’ve noticed that they’re getting more and more applications each year. The board scores are getting higher and higher.

It’s not as competitive as Dermatology or Neurology. But out of the medical subspecialties people can go into, PM&R is becoming more competitive. Although location plays a role too. East coast and west coast spots tend to be more selective or more competitive than those in the middle of the country.

'As long as you are very adequate in what you do, you don't have to be at the top of the class in order to secure a residency spot.'Click To Tweet

[25:10] What Makes a Competitive Applicant

At Brandee’s institution, they have a small residency program with only 3 residents per year. For their program, they want to make sure that people are very self-motivated and very collegial.

Having advanced clerkships in neurology, orthopedics, medicine, rehab, psychiatry, and those other subspecialties related to PM&R can be very helpful.

For people going into sports medicine, they look at whether they’ve done some volunteer work at local high schools or colleges. They look at any shadowing experience with a sports medicine doctor.

Have good letters of recommendation and show that you’re a hard worker. Get those letters from fields that are close to PM&R.

If your institution doesn’t have PM&R, you have to go out and look for places that do rotations. This was what Brandee did and she knew she had to do well at those places in order to get letters of recommendation.

[27:00] Bias Against DOs

Brandee says there are a lot of DOs in PM&R so she’s not seeing any bias at all. That said, certain residencies may have a screening and selection process coming from different DO schools.

'PM&R is a very good fit because they learn a lot about manual medicine and a lot of PM&R is about people's musculoskeletal dysfunctions.'Click To Tweet

[28:25] Subspecialty Opportunities

Some people do a traumatic brain injury fellowship. Concussion is a very hot topic in medicine today.

Others go into 2-year pediatric rehabilitation. They would subspecialize in debilitating diseases that affect muscular dystrophy in children or cerebral palsy.

You can also do pain management fellowship or neuromuscular disease fellowship (offered at UC Davis).

[30:15] Working with Primary Care and Other Specialties

'Many people think that PM&R is synonymous with pain management– and it's not.'Click To Tweet

What Brandee wishes primary care doctors to know about PM&R is that you can’t necessarily send a patient to a general PM&R doctor and expect him to do certain procedures. Understand that even within a practice, there is some breadth of expertise.

Also, physiatrists can be a very integral part of a sports medicine practice. Sometimes people think of orthopedics or internal medicine doing sports medicine. But PM&R is actually an incredibly good fit for sports medicine types of issue.

A lot of what they do is recommending how people can be more physically active, not just for the sake of sports. So use the PM&R doctors as a helper to help treat other chronic diseases by using exercise and physical activity.

Other specialties they work closely with include orthopedic surgery, neurology, and rheumatology.

[33:35] What She Knows Now That She Wished She Knew Going into Medicine

Brandee wished she had known more about the billing and argument issues. She’s also big on self-confidence but she sees a lot of people struggling with this. So she wishes they knew they’re smart enough to make a good contribution.

'Be confident and make a contribution. Be humble enough to learn from the people who are setting the scene for you.'Click To Tweet

[35:15] The Most and Least Liked Things About PM&R

Aside from doing injections, what Brandee really likes about her specialty is educating patients about their disease so they’re not reliant on their physicians for everything. She likes being able to help people make milestones and fully participate in them.

What she likes the least is arguing with insurance companies that don’t want to pay for MRI or procedure that she really thinks would help her patients.

[39:45] Major Changes in the Future of PM&R

She doesn’t see any major changes coming although she’s seeing how PM&R is now being more and more accepted.

After you take your regular board exams for internal medicine or family medicine, and if you do a fellowship, you can sit for the nonoperative sports medicine boards. It was only 11 years ago that PM&R doctors were allowed to start sitting for that exam. There were not a lot of fellowships that allowed PM&R doctors to join them.

There are only 20 or less accredited PM&R sports medicine fellowships in the country and Brandee would love to see more of that.

That being said, it can be very competitive to get into a fellowship just because there aren’t as many spots for PM&R doctors as there are for internal medicine or family medicine doctors.

'A lot of those fellowships are now opening their doors to PM&R doctors which haven't been before.'Click To Tweet

[41:11] Final Words of Wisdom

If she had to do it all over again, Brandee would still have chosen the same specialty.

Finally, her last piece of advice to those interested in sports medicine through the PM&R path is that you have to do your primary residency first.

If you’re so focused on what your subspecialty would be, sometimes you miss some of the learning opportunities that you can get along the way that will help you end up being a better physician overall.

Especially with sports medicine, if you’re so focused on getting your fellowship that you don’t do a good job in the other things you have to learn in order to get there, that will shoot you in the foot every time.

'You've got to really understand the basics of where you're coming from – your main specialty.'Click To Tweet

For people who really like musculoskeletal and body functions, Brandee thinks the pathway through PM&R is more interesting than going through family medicine or internal medicine. But if you love primary care, then the latter is definitely the way to go.

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