Trainee Talk: The Neuromuscular Physiatrist - How PM&R Fits Into the Neuromuscular Field

Meiling: My name is Dr. James Meiling, and I am a current PGY-4 resident in physical medicine & rehabilitation (PM&R) at the Mayo Clinic in Rochester, Minnesota. With the blossoming increase of interest in neuromuscular (NM) and electrodiagnostic (EDX) medicine among PM&R residents, understanding the potential role of PM&R within these subspecialties and what PM&R can uniquely add to this field is vital. Today we will be discussing the NM physiatrist: How PM&R fits into the NM field. To help facilitate this discussion, I am excited to introduce our guest, Dr. Nassim Rad. Dr. Rad is an assistant professor in the department of rehabilitation medicine at the University of Washington in Seattle, Washington. In addition to her clinical duties as a NM physiatrist, Dr. Rad serves as the University of Washington Medical Center’s MDA/ALS and EMG Centers’ Rehab Director. Thank you, Dr. Rad, for joining us for this discussion today.

Rad: Thank you so much for having me today.

Meiling: The first question to start us off is, “What is the field of NM medicine?”

Rad: NM medicine is a field typically thought of as within neurology where the focus is on a combination of EDX medicine as well as diagnosing and management of NM disorders which would primarily focus on peripheral nervous system, NM junction, and diseases of muscle.

Meiling: In order to practice NM medicine, what different pathways can you take?

Rad: Great question! Historically it was thought of as a field that was only open to neurology residents. I would say that that is the most common route – to pursue a NM fellowship after a neurology residency. But, we now know that PM&R residents can also apply to NM fellowships. They have a lot to offer and gain from the fellowships.

Meiling: It is kind of a small number of us who are in PM&R and NM medicine. How does the pathway to NM medicine from physiatry differ from the more common pathway from neurology?

Rad: Another great question! To start with some of the more basic differences, our PM&R residents typically apply to fellowships in their early 4th year, with an exception for some of the earlier routes [such as pain medicine]. Neurology residents are applying to fellowships earlier in their 3rd year. For PM&R residents, they would have to start looking into this fellowship potential earlier in their career path, which means they would also want to have an earlier exposure to NM medicine before electing to go into the fellowship. The fellowships, themselves, are the same for neurology and PM&R residents, that is, when you are talking about strictly NM medicine fellowships. 

There are some fellowships that are separate from NM medicine that sometimes get lumped into the same category. These are [clinical] neurophysiology fellowships. These would exclude PM&R residents because they also include the practice of EEG. With some of these fellowships, neurology residents can go down that path and still practice NM medicine and incorporate EMGs.

Meiling: Would you recommend that a PM&R resident who is interested in this path seek out EMG and NM exposure pretty early on?

Rad: I would. That would give them a better idea if this were something they are interested in. When they are designing their clinic schedules with their particular programs, I think it is always beneficial to let their programs know that this is something that may be of interest to them. This way, early in their 3rd year, they can get slotted into EMG rotations. Then, depending on their program, they may be able to work in electives in neurology NM clinics. If they are at a place that has a NM physiatrist, they can maybe get some elective time in that regard as well. 

The other hidden area of NM medicine is in pediatric rehabilitation. While there are no pediatric NM rehabilitation fellowships, most, or many I should say, of the pediatric conditions in rehab are NM disorders. Having rotated through a pediatric clinic, especially a pediatric MDA clinic, would be quite useful.

Meiling: Is that what you did as a PM&R resident, rotate through pediatrics? What was your path?

Rad: The thing that first got me interested in NM medicine was taking care of ALS patients as a part of our inpatient rehab service. I really liked working with them and their families. I realized that, for me, I really wanted to have a better idea of how they were diagnosed and take care of the patient from start to finish. I could already witness that most of their needs after diagnosis were rehab-related, but I didn’t want to miss that key aspect of diagnosis and prognosis. That was the first thing that got me interested, which was within rehab. 

I was also really interested in EMG procedures. I was able, after identifying my desire to work with ALS patients, to schedule EMG rotations earlier on during my 3rd year. 

Lastly, I was able to request to work with NM neurologists and rotate through [with them]. I will admit that that was later in the course; I had applied or had already started thinking about applying. There is only so much elective time and there is a lot of rehabilitation you want to cover during your residency.

Meiling: When it came to going to fellowship, were you primarily trained by neurologists or a mix of neurology and PM&R? Who trained you in NM medicine?

Rad: In my fellowship, I was trained by neurologists, so the practice was a neurology-based fellowship. I was fortunate to make many great contacts within the rehab department at the University of Michigan [where I did my fellowship]. The EMG lab at the University of Michigan has rehab physicians, as well as neurology physicians, so I was able to interact with them and learn a little bit about how they did EMG. All the official training, though, was through the neurology department.

Meiling: As a PM&R resident going into a neurology department [for fellowship] for the year, what were some unique things that you experienced?

Rad: I will admit that, at first, I was very intimidated. Even through the application process. I had had a year of internal medicine, 3 years of PM&R, and then I was going into a fellowship that would expect a higher level of expertise and training in a completely different field. I will say that one of the things I did to help me feel better was being proactive about my NM education. I started a lot of self-learning through textbooks. When I joined my fellowship, I was really reassured by everybody. I went to a fellowship that was very strong, in terms of teaching. I was also reassured by the fact that most neurology residents don’t get a lot of NM exposure unless they actively seek it out. In some ways, they are very similar to PM&R residents going into NM fellowships. I would say that the weaknesses and the things that definitely had a steep learning curve, for me, were immunotherapies and certain diagnoses, especially more on the inflammatory side. The things that came a little easier to me were peripheral nerve and peripheral nerve anatomy. Additionally, to graduate from PM&R residency, we must complete – a portion of which is observed – 200 EMGs. This is a large number! Many of our neurology residents may have shadowed some EMGs, or they may have never done an EMG because there is no requirement. I think that some of the technical skills, while you continue to fine tune them during fellowship, are a little easier at the start of the fellowship.

Meiling: What are some skills you gained from a NM fellowship that set you apart from a general physiatrist who also has had exposure to EMG during residency?

Rad: Great question! I would say that there are a lot of different points I could bring up here. One of the most important points is that 50% of my fellowship, and at least 50% of most [NM] fellowships, focused on the disease itself. Diagnosing the disease. Management of the disease, including medication management. Those are parts that we don’t typically see as a PM&R resident. We interact with that part when we see these patients in rehab clinic, but we are not taking ownership of that part. That was a huge skill set! On top of that, in terms of EMGs, by the sheer volume and having so many different teachers giving you different perspectives, even the skill sets of carpal tunnel and radiculopathy screens you learn in PM&R residency grow. Also, depending on the PM&R residency program, we don’t typically get the referrals for motor neuron disease, NM junction, or myositis, so you just open your window to learning how to appropriately perform those EMGs aside from just learning about them in a textbook. In my fellowship, I was also able to do single fiber EMG and muscle biopsies. Nowadays, there may be opportunities for NM ultrasound learning, which I think would just add to the ultrasound learning that PM&R residents are getting.

Meiling: So there are quite a few skills you can obtain doing a NM fellowship that you wouldn’t normally get doing a PM&R residency for 4 years.

Rad: Absolutely. I think you can kind of compare it to general neurologists who also practice and incorporate some of the NM medicine diagnoses as well. Many times those general neurologists will re-refer to NM colleagues within the neurology field. I think that is an equal comparison to make.

Meiling: After fellowship you can sit for a board exam through PM&R. Can you tell us a little bit about that?

Rad: Yeah! I would say that most fellowships would encourage that you take the board exam. I can’t speak to each fellowship to say whether they are required or not, but after fellowship you can sit for the NM medicine board exam. It is offered to both neurology and PM&R. It is the exact same board exam, whether you are a neurology or PM&R resident. If you are a PM&R resident, when you recertify for your NM medicine subspecialty you will do that through the American Board of Physical Medicine and Rehabilitation, but a neurologist would do it through their own board. 

Separate from the [NM medicine] board exam, you don’t have to be fellowship trained to sit for the AANEM EMG certification exam. The fellowship can help you meet some of the criteria. As PM&R residents, we have a certain number of EMGs completed [during residency], but you also need 6 months of independent practice. A lot of the fellowships, during the last 6 months, may meet that criteria, so you are also able to sit for your [EMG] certification examination right after fellowship. I should mention that even if you don’t do a NM fellowship you can sit for that [EMG] certification after you have completed the requirements while you are in practice.

Meiling: Fast forward. You have finished fellowship. You have gotten the [NM medicine] board certification. What does your personal practice look like now?

Rad: My practice right now is split almost evenly between clinic and EMG time. In my clinic time, most is devoted to NM rehabilitation. Specifically, I am in the ALS clinic and run the SMA clinic at the University of Washington. When I’m not in either of those clinics, I’m in MDA clinic. Sometimes I am either working in the large group setting or am in my own clinic. Sometimes I am making the diagnoses and following the patients from the time of diagnosis for the rest of their care, and sometimes I get NM rehabilitation referrals from my neurology colleagues after they have already made the diagnosis [in order] to address the patient’s rehab needs.

Meiling: The type of setting you can practice in as a NM physiatrist can vary. What are other NM practices like compared to what you currently do?

Rad: Absolutely! I should have clarified that I am in an academic setting, so things look a little different. There are lots of opportunities for growth and multidisciplinary clinics. You can also practice in hospital clinic settings that are non-academic. There is still a need for NM rehabilitation [in those settings]. I have had colleagues who are growing these types of clinics far from city centers. Without enough NM-trained physiatrists, patients are driving many hours away [to be seen]. These clinics can also exist, I don’t want to say in remote areas, but outside of large metropolis cities.

Meiling: You mentioned that you are at an academic center and are involved with the MDA and ALS multidisciplinary clinics. Can you tell us a little more about being involved with a multidisciplinary clinic and what your role is?

Rad: Absolutely! As part of a multidisciplinary clinic, you have a physician, a physical therapist, an occupational therapist, a speech therapist, a respiratory therapist, a nurse or nurse coordinator, social work, and advocacy group liaisons. Every multidisciplinary clinic looks different. We have that structure for our ALS clinic. Our MDA clinics, because we are an adult center, are a little more toned down, so it includes a physician, a respiratory therapist, and an advocacy group liaison. Every center will look a little different. Usually the most prototypical type is having both a neurologist and a PM&R physician in the clinic. When I am seeing patients, because I am NM-trained, I put on my “NM hat” and do medication management as well as [address] their rehab needs. In other clinics you may serve the role of addressing their rehab needs with your knowledge of NM disorders.

Meiling: Thank you very much for that. Any final advice for physiatry residents or aspiring-to-be-physiatry medical students who are interested in NM medicine?

Rad: Absolutely! I would say the biggest thing is exposure. There is so few of us, it can be hard for residents to get a true understanding of what this field could potentially be. I think if there is any resident out there who has an interest in neurorehab, which historically has been thought of as strokes, traumatic brain injuries, or spinal cord injuries, to throw in the possibility of NM medicine which also fits into the neurorehab-type field. I remember as a resident that EMGs can sometimes seem long and tedious, if you don’t have that initial passion for it, but I would say to keep an open mind to it as well. Once you learn the technical skills [of EMGs], I may be biased, but I do think they are pretty fun and engage a different part of your mind. This field is not something, historically, we get a ton of exposure to. There’s a lot we, as PM&R physicians, can bring to it the world of NM medicine. We are fortunate that we are in a generation where there are actual medication treatments available and gene modulating treatments that are changing the phenotypes of patients. Once a diagnosis is made, a lot of the management comes to rehab. These patients are thankfully living longer and that also means they are going to have different and unique rehab needs that you know that otherwise have not been addressed.

Meiling: Awesome! Well, Dr. Rad, thank you so much for joining us today and discussing a little more about the NM physiatrist.

Rad: Thank you so much for taking the time to reach out.