Why Patients with Pain Should See a PM&R Doctor?: Interview with Dr. Mahmud Ibrahim

According to the CDC, approximately 50 million  Americans are suffering with chronic pain. At the same time, the US is facing an opioid crisis like never before. Patients are disillusioned with the healthcare system and many feel they are not getting adequate relief from their pain. However, there are many treatment alternatives available that many patients, and physicians, don’t know very much about. I had the pleasure to speak with a specialist, Dr. Mahmud Ibrahim, to tell us about his field and procedures he does.

1.         As a primary care physician, I find that when I refer patients to a PM&R physician, they are often confused about your specialty. What exactly is PM&R?

Dr. Ibrahim: PM&R (physical medicine and rehabilitation)  is all about restoring function. Physiatrists treat a wide variety of conditions from musculoskeletal injuries, spinal cord injury, traumatic brain injury, and pediatric developmental issues. We’re all trained to do electrodiagnostic studies to aid in the diagnosis of issues with the nervous system. We can treat all patients from birth to the very old. Pretty much, if something in your body isn’t working the way it should be, see a physiatrist.

2.         I became a family doctor because when I was doing my clinical rotations in medical school, I loved every rotation and just couldn’t decide which one I liked best. In family medicine, I can do some of everything. Why did you decide to specialize in PM&R?

Dr. Ibrahim: It was completely by chance that I even found out about PM&R. PM&R is a very small field and very few medical schools offer rotations in it. During my 3^rd year of med school, my first rotation was neurology and then I had 2 months of elective time. Most of the electives required medicine, surgery, or pediatrics as a prerequisite, but then I came upon PM&R which didn’t. I didn’t know much about the field. All I knew was that on neurology, we would admit a stroke patient, spend 3 days trying to figure out what was wrong with them, and then send them off to rehab. So when I came across PM&R, I figured at the very least, I could see where this magical land of rehab was that all our stroke patients went to get better, haha. I did a 2 week rotation at my medical school and really liked it. So in my 4^th year, I did a full month at Mount Sinai and just fell in love with the field. Like I said above, there’s so much within PM&R you can do. You can be procedure heavy if you like procedures, you can just see office visits if you want. And there was so much within PM&R that I could have further specialized into if I wanted. During my residency, I rotated in the MSK clinic and loved doing the spinal injections, so I decided to do a fellowship in Interventional Spine and Sports Medicine.

3.         When should I refer a patient to a PM&R doctor as opposed to an orthopedist?

Dr. Ibrahim: I always tell patients, “If you go to a barber, you’re going to get a haircut.” Basically, if it’s something that doesn’t absolutely need surgery, i.e., a fractured humerus, then most physiatrists should be able to manage a patient non-surgically. I can’t tell you how many patients I’ve had who told me that they were referred to an orthopedic or spine surgeon first and were told they needed surgery, but I was able to get them better with medications, therapy, and/or injections alone.

4.         What procedures do you do as part of your specialty?

Dr. Ibrahim: I pretty much treat everything from head to toe. With regards to the spine, I can perform injections from the base of the skull to the coccyx. I do epidural steroid injections, facet injections, radiofrequency ablations, spinal cord stimulator trials and implants, and disc procedures. With regards to the peripheral joints, I can inject pretty much every joint/tendon/bursa. I usually use ultrasound or fluoroscopic guidance to perform my injections to ensure that the injectate is going where it’s supposed to be going.

5.         We are all aware that there is an opioid crisis in the US. What is your opinion on this and how do you think it can be fixed?

Dr. Ibrahim: I think the reimbursement cuts have a lot to do with the opioid crisis. Physicians get paid much less now than they did even 5 years ago and as a result, they’re trying to cram in as many patients into a day as possible. So it becomes much easier to write a prescription for Percocet than to spend the time to exam the patient, find out what’s actually going on, and getting them the proper treatment. In addition, many physicians, especially primary care physicians, just simply don’t have the time or resources to check prescription monitoring and perform urine toxicology screens on patients so patients were able to get away with a lot. I think, NJ at least, is taking steps towards correcting the crisis by requiring all physicians to check PMP prior to prescribing an opioid. In addition, limiting first time Rx’s to 5 days will help deter abuse. Also, getting these patients to a specialist is key. As I said above, there are a lot of injections I can do to reduce a patient’s pain that don’t involve life long opioids.

6.         What conditions do you treat and is there one that you most find satisfying to treat?

 Dr. Ibrahim: I mostly treat musculoskeletal problems from head to toe. I enjoy doing the fluoroscopic spine injections, but I think the one condition that is most satisfying to treat is tendonitis because that’s one of those conditions that can linger forever, but can usually get better quickly with the proper treatment.

7.         As a sports medicine specialist who has worked at professional sporting events, what did you learn from doing that?

Dr. Ibrahim: I’d say the most valuable thing I learned at those events is how to think fast. It’s such a fast paced environment and everyone is waiting on you to make a decision about whether or not that player/boxer/wrestler can continue or not. Thankfully, the sports medicine physicians are mostly there in case something awful happens. Otherwise, the athletic trainers usually handle most issues.

8.         What would you like to see from referring doctors about patients being sent to you?

Dr. Ibrahim: I’m not too picky when it comes to referrals. I always appreciate them. Like I said, I think there’s a lot I can offer to patients that they may not have heard of or tried before.

9.         What else would you like to share about what you do as a PM&R specialist?

Dr. Ibrahim: When it comes down to it, I truly enjoy what I do. When I was 8 years old, my baby brother was born 2 months early. He suffered from a lot of developmental issues and spent the first year of his life in the hospital. I used to visit him with my parents all the time and I saw how the doctors there were doing everything they could to help him. That feeling really stuck with me. I don’t like giving up on patients. I try to do everything I can to get them better and back to doing the things they want to do.

10.     As a family doctor, one of the things I most dislike about my specialty is that we are forever doing prior authorizations for tests, procedures, and medications. Many specialists dump this work onto us, even for the things they are ordering. I often get frustrated getting denials and then not knowing what to do with the patient. What don’t you like about your specialty?

Dr. Ibrahim: Unfortunately, prior authorizations are wide-spread throughout medicine these days. That’s definitely a big pain. I’d have to say that the one thing I don’t like about my specialty is that many patients and physicians just see us as “the pain doctor.” I’ve had patients who were seeing me for one issue and mentioned that their PCP sent them to an orthopedic surgeon for their shoulder issue. Meanwhile, if they had just mentioned to me that their shoulder hurt, I could have treated that too.

More to come soon on this topic with Dr. Ibrahim on Physician’s Weekly!

Dr. Ibrahim is a graduate of NYU School of Medicine. He completed his residency in Physical Medicine and Rehabilitation and Sports Medicine and Interventional Spine fellowship at the Mount Sinai School of Medicine. Dr. Ibrahim has published several articles on musculoskeletal medicine. He is also a contributing author in a textbook on how to perform ultrasound guided injections. Dr. Ibrahim has provided sideline coverage at football games, captained the medical tents at the NYC marathon, and was a ringside physician for the Golden Gloves Boxing tournament. He currently treats patients at Performance Spine and Sports Medicine in East Brunswick, NJ.

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