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What is Physiatry?
Physical Medicine & Rehabilitation (PM&R), Rehabilitation Medicine, and Rehabilitative Medicine are all terms used to describe what a physiatrist does.
A physiatrist, pronounced fizz ee at' trist or fizz i’ a trist, is a physician who has received specialized training in physical medicine and rehabilitation (PM&R). PM&R, or physiatry, is the branch of medicine emphasizing the prevention, diagnosis, treatment, and rehabilitation of disorders which can include, Neuro-Musculo-Skeletal and psychologic components that produce temporary or permanent functional impairment.
Physiatry is unique among medical fields in that its area of expertise addresses the function of the whole patient, as compared with a focus on an organ system or systems. Suffering an acute injury or living with chronic illness can affect the way people move and communicate, and their role in the home and workplace. Physiatry is about patient-centered care and maximizing independence and mobility with the goal of returning patients to their role in society.
What is the History of the Specialty?
One of the specialty’s true pioneers was Frank H. Krusen, MD. Having undergone treatment for his own tuberculosis, Dr. Krusen later researched the uses of physical medicine and soon made it his career. After initiating a program in physical therapy at Temple University, Dr. Krusen moved to Mayo Clinic in 1936 where he developed a Department of Physical Medicine. His training program there developed into the first three-year residency in physical medicine in the United States.
Dr. Krusen along with fourteen other “physical therapy physicians” (as physiatrists were known at the time) found themselves with different interests and concerns than their colleagues the physical therapists and radiologists. They began to promote physical medicine as a specialty. They asked the American Medical Association (AMA) for specialty status and an examining board for physical medicine.
In 1938, Dr. Krusen proposed the term “physiatrist” to identify the physician specializing in physical medicine. To avoid confusion with psychiatry, he proposed a different pronunciation, with emphasis on the third syllable. However, it wasn’t until 1946 that the AMA sponsored the term.
The American Board of Physical Medicine
Starting in 1936, Dr. Krusen and 13 other pioneering physiatrists began a decade of work to establish physical medicine and rehabilitation as a specialty. During those years there were many meetings and letters between physiatrists, the AMA, the American Board of Medical Specialties (ABMS), and specialty boards already in existence. Many supported the idea, including the War Department and the US Navy. Everyone agreed there should be certification, but opinions differed on how it should be based and financed. Some thought physical medicine should have its own specialty status, while others thought certification should be a division of another existing specialty board. Academy members also considered forming an autonomous board on their own with the hope that it might later be recognized by ABMS.
In early 1947, Drs. Krusen, Walter Zeiter, and John Coulter presented yet another revamped plan for the organization and financing of an American Board of Physical Medicine and Rehabilitation to ABMS. This time they succeeded. On February 27, the American Board of Physical Medicine was incorporated. It was officially recognized by ABMS and the AMA, and Dr. Krusen was named the first chairman.
That year, almost 80 physicians took the first Board exam in Minneapolis. Written exams were given on the first day and oral exams were given on the second day. Later that month, 91 physiatrists were approved as charter diplomates in physical medicine. Around 30 of the physical medicine “pioneers” received certification without having to take the exam.
What does a physiatrist do?
Physiatrists maximize what a patient’s function and assist the patient in adapting to any impairment and limitations.. A physiatrist should be consulted when pain, weakness, or disability is preventing a patient from achieving their desired level of independence/impacting their quality of life.
- Physiatrists work in a variety of environments including inpatient, outpatient, and consulting roles. They can practice solo, in groups, hospitals, and academic settings.
- Physiatrists do detailed evaluations including physical examination, Electrodiagnosis with EMG and assessing multimodal imaging studies to determine diagnoses.
- In addition to management used in general medical practice, physiatrists prescribe therapeutic exercise, prosthetics / orthotics, and adaptive devices to treat patients of all ages.
- Physiatrists facilitate physiologic adaptation to disability to prevent complications or deterioration secondary to disabling conditions.
- Physiatrists use a wide range of interventions including manual therapy, electrical stimulation, ultrasound, injections, and acupuncture.
- The goal of the physiatrist is to provide medical care to patients with pain, weakness, numbness, and loss of function so that they can maximize their physical, psychological, social, and vocational potential.
As people survive conditions that once would have been fatal, the field of physiatry is moving to the forefront of medicine. The specialty serves all age groups and treats problems that touch upon all major systems of the body.
What is the difference between physical therapy and physiatry?
Physiatrists and physical therapists treat patients with the same types of conditions. However, physiatrists are physicians who have completed medical school plus four years of residency training.
A common misconception of physiatrists is that they are the ones who are actually performing the therapies. In general, physical therapists are trained in the clinical features of common musculoskeletal pathology, musculoskeletal examination, developing a treatment plan and exercise regimen, and physical modalities (including heat, cold, TENS). Physiatrists, on the other hand, make and manage medical diagnoses and prescribe the therapies that physical therapists will subsequently perform. Despite these differences, both therapists and physiatrists collaborate and communicate to ensure patients are receiving appropriate treatment.
The role of the physiatrist is to manage a patient’s medical issues as they participate through the rehabilitation process. A physiatrist will assess the patient and assure that the patient is medically stable to participate in therapies. Medical issues specific to rehabilitation include pain management, neurogenic bowel and bladder, spasticity management, and disease education. Furthermore, a physiatrist will manage other co-morbid conditions (e.g., hypertension, diabetes, CAD, COPD, etc.) in order to prevent further medical complications.
What conditions do physiatrists treat?
Physiatrists primarily treat conditions of the bones, muscles, joints, and central/peripheral nervous system that affect a person's ability to function.
A physiatrist is trained to manage a variety of disorders/diseases but practitioners often will specialize. Because of the broad spectrum of conditions treated and the comprehensive nature of their training, physiatrists are uniquely-positioned to adapt to new technologies and changing trends in health care.
Areas of focus include:
- Examples: Spinal Cord Injury, Traumatic Brain Injury, Stroke, Multiple Sclerosis, Amyotrophic Lateral Sclerosis, Parkinson’s Disease
- Examples: Chronic Pain Management, Complex Regional Pain Syndrome (previously named Reflex Sympathetic Dystrophy), Back Pain, Arthritis, Carpal Tunnel Syndrome
- Examples: Osteoarthritis, Osteoporosis, Rheumatoid Arthritis, Fibromyalgia, Back Pain and Sacroiliac Joint Dysfunction
- Examples: Achilles Tendonitis, Iliotibial Band Syndrome, Turf Toe, Medial & Lateral
Epicondylitis, DeQuervain’s Tenosynovitis, Rotator Cuff Pathology, Acromioclavicular Separation, Biceps Tendonitis, Stress Fractures, Concussion
- Examples: Joint Replacement, Organ Transplantation, Left-Ventricular Assistive Devices, Cardiac / Pulmonary Rehabilitation
Pediatric functional and developmental disorders:
- Examples: Cerebral Palsy, Muscular Dystrophy, Spina Bifida, Down Syndrome
- Examples: Fine Arts (music, dance, vocal), Cancer, Cardiac, Pulmonary, Family Training (for home care), Pelvic Pain, Alternative and Complementary Medicine, Palliative Care
What types of treatments and procedures do physiatrists perform?
In the inpatient setting, physiatrists provide general medical treatment similar to internal medicine to maintain medical stability and provide secondary prevention of disability. Physiatrists do not perform surgery do many procedures for diagnosis and treatment. Many of these procedures may require fellowship or advanced training to perform. These procedures include:
- EMG (electromyography): inserting fine needle electrodes in muscles and observing the recorded motor unit potentials when the muscles are activated to help distinguish whether weakness is due to muscle or nerve dysfunction (i.e., myopathy vs. neuropathy).
- NCS (nerve conduction studies): use of electrodes to record motor and sensory responses that are propagated by electrical stimuli. This test can help distinguish location of a nervous system lesion (radiculopathy, peripheral neuropathy, motor neuron disease, or neuromuscular junction).
- Peripheral joint injections: injections to help diagnose and treat bone and soft tissue disorders often seen in orthopedic, rheumatologic, and sports medicine disorders such as knee osteoarthritis, rotator cuff tendinopathy, and epicondylitis.
- Trigger point injections: lidocaine or dry needling can be used as an adjunct to proper exercise and physical therapy to treat trigger points, thought to be sources of chronic myofascial (soft-tissue) pain.
- Musculoskeletal ultrasound: although it has been used for decades as a modality to deliver deep heat in therapies, ultrasound is now being used in the outpatient setting to evaluate soft tissue abnormalities such as rotator cuff tears and other tendinopathies, popliteal cysts, and carpal tunnel syndrome. This technology also allows for improved placement of needles for delivery of treatment without exposure to ionizing radiation.
- Spasticity management: spasticity is a common complication related to CNS injury (e.g., SCI, stroke, cerebral palsy). Physiatrists treat spasticity by using oral antispasticity agents, botulinum toxin injections, phenol injections, and intrathecal baclofen pump management to improve function and decrease pain.<
- Interventional spinal therapeutics: image-guided spinal diagnostics and injections, including discograms, interlaminar and transforaminal epidurals, and radiofrequency ablations, spinal cord stimulation, vertebroplasty/kyphoplasty, and intrathecal pump placements. These techniques are being used as a nonsurgical pain-relieving intervention for back pain and radiculopathy.
- Other procedures performed by some physiatrists include acupuncture, prolotherapy, platelet rich plasma injections, and autologous stem cell treatments.
What makes the practice of physiatry “multidisciplinary”?
Much of the practice of PM&R is built on the "team approach," a unique perspective on patient care. The patient's physical, functional, emotional, and psychosocial well-being are all considered in treatment.
The physiatrist is trained to lead and coordinate care with the rehabilitation team, which might include representatives from:
- physical therapy
- recreational therapy
- social services
- internal medicine
- orthopedic surgery
- occupational therapy
- rehabilitation nursing
- speech therapy
The physiatrist is trained in writing prescriptions for specific exercise programs for maintaining and increasing range of motion, strengthening muscles, improving proprioception (awareness of joint position in space), muscle relaxation, and aerobic fitness, all in the context of improving function.
- Examples include strengthening and enhancing proprioception in a runner's sprained ankle, improving range of motion and preventing contracture in a spastic spinal-cord-injured patient, or providing optimal cardiopulmonary fitness in someone who has recently suffered a myocardial infarction.
A physiatrist can also prescribe a host of assistive and adaptive equipment including gait and mobility aids, environmental control devices, communication aids, and various other tools to allow greater independence, optimal safety, and decreased energy expenditure in activities of daily living (ADLs).
One area of expertise is the selection and fitting of wheelchairs and appropriate seating. The PM&R physician is also specially trained to prescribe proper orthoses (e.g., upper and lower limbs, and back bracing) and to prescribe prostheses to amputee patients.
What is a residency in PM&R like?
Most PM&R residencies are three-year programs and offer positions starting at the PGY2 level, which means that the medical student must seek a transitional/preliminary year in addition to an advanced residency spot. Some residencies offer a four-year program which integrates the first year of basic clinical training into their curriculum.
A minimum of four years of graduate medical education from an allopathic or osteopathic medical school are required. Residency in physical medicine and rehabilitation consists of one year of general clinical training (internship / PGY1) followed by three years of physical medicine and rehabilitation training (PGY2-4). Most residents complete a preliminary medicine, transitional, or surgical internship to fulfill this requirement. Other acceptable internships can be done in family medicine, pediatrics, or a traditional osteopathic internship.
Some PM&R residency programs offer an internship along with a three years of PM&R training (PGY 1-4), which are known as categorical positions. However, a majority of PM&R residencies offer advanced positions which include only PGY2-4. Program requirements for a three-year program are 12 months of inpatient rotations and 12 months of outpatient rotations; the remaining 12 months are a variable inpatient/outpatient mix depending on the program. You may wish to investigate this variability when choosing a program that fits your interests.
- Severe deconditioning and general debility
- Neurologic disorders: multiple sclerosis, ALS, Guillain-Barré syndrome, and myasthenia gravis
- Complicated amputations, arthritides, fractures
- Brain injury: traumatic, neoplastic, ischemic
- Spinal cord injury
- Pediatrics: including cerebral palsy, spina bifida, muscular dystrophy and trauma
The remainder of the residency is filled with outpatient rotations, which may include the following:
- burn rehabilitation
- cancer rehabilitation
- cardiopulmonary rehabilitation
- chronic pain management
- general consults<
- hand clinic
- impairment evaluation
- industrial rehabilitation
- injection clinic
- musculoskeletal clinic
- pediatric clinic
- prosthetics and orthotics
- spine center
- sports medicine
- work hardening
- wound care center
Research is required or encouraged at most institutions. A maximum of six months within a four-year residency program is permitted for research, although each program has its own restrictions. A few programs offer positions in a Clinical Investigator Pathway in PM&R residency training, which is a five-year track, allowing an extra 12 months for research.
ACGME-accredited fellowships are available in pediatric rehabilitation, spinal cord injury, neuromuscular medicine, sports medicine, hospice and palliative care medicine, and interventional pain medicine. Non-accredited fellowships are available in cancer rehabilitation, neurorehabilitation, multiple sclerosis, spine, musculoskeletal, and research. These are typically one year in length with some exceptions.
How can I best prepare to be a good residency candidate?
As a first or second year medical student, exploring PM&R as an option can be done through shadowing, contacting local residents and faculty, and through pursuing research on a PM&R relevant topic. There are some “externships” in PM&R available at certain institutions to first year medical students during the summer between first and second year.
As a third or fourth year medical student, you may wish to consider rotating through a clerkship in PM&R. Understanding the depth and breadth of PM&R is crucial in expressing your interest in the field in your personal statement and during interviews. The rotation serves both for you to get to know a particular residency program and for the program to get to know you. Making a good impression on a program by being proactive, motivated, and interested can help your application. Identifying faculty members who can write you a solid letter of recommendation during this time is also important.
The major components of a residency application are board scores, medical school grades, Dean’s letter (a compilation of your evaluation and summary of your performance in medical school), letters of recommendation (at least one from a physiatrist), personal statement, CV (professional resume), and your performance on your interview (if you are invited for an interview). Because physiatrists work with teams of other healthcare professionals to care for a patient, program directors not only look for solid grades and board scores, but also team-oriented students with good communication skills. Research experience is not required for residency application, but may make your application stronger. The research does not have to be in PM&R. If you are looking for research in PM&R, talk to residents or faculty members at your institution and let them know you are interested in helping out.
If you are applying for both categorical positions (4-year programs) and advanced positions (prelim/transitional + 3-year PM&R), you do not necessarily need to write 2 completely different personal statements for PM&R and for the prelim/transitional year programs. For the prelim/transitional personal statement, you can add or revise the end of your statement to reflect why you are applying for a preliminary or transitional year program.
How should I prepare for a PM&R rotation?
If you are about to start a PM&R rotation, there are a few things that you can do to prepare. First, you can do some background reading on the area that you will be rotating in. One resource than many students and residents use is “Physical Medicine & Rehabilitation Pocketpedia,” a book that you can put in your white coat and reference while on rotation. Another popular reference book is “PM&R Secrets.” Additional references and textbooks can be found in the “What reading materials are helpful to learn more about PM&R?” section. Prior to starting the rotation, you can ask generally what type of setting you will be working in (inpatient rehabilitation, outpatient clinics, or a combination), and what patient population you will be working with so that you can read up on those areas. Another way to prepare is to review and refresh your neurologic and musculoskeletal physical examination skills. Regardless of which rotation you are doing, these are skills that you will definitely use during a PM&R rotation.
If you have PM&R rotations available at your institution, definitely take advantage of these opportunities, and speak with advisors, faculty, residents or other students on the best way to schedule these rotations. If you are able to do more than one rotation, try to see different aspects of PM&R and diversify your experiences (outpatient and inpatient, musculoskeletal and neurorehabilitation, adults and pediatrics, etc). If you are interested in doing away rotations at an outside institution, start this process early, at least 3-6 months in advance. Many institutions that accept rotating medical students have an application process, so check the PM&R residency websites for specific details and requirements.
What rotations are good for someone going into PM&R?
|Specialty ||Usefulness |
|Anesthesiology ||To understand the pharmacology and pathophysiology of pain and use of appropriate interventions, including medications |
|Neurology ||To learn neurologic exam techniques, management and complications of acute stroke, and secondary stroke prevention |
|Neurosurgery ||To learn neuroanatomy, neurologic exam techniques, neurosurgical emergencies, and neuroradiology |
Orthopedic Surgery/Sports Medicine
|To learn musculoskeletal anatomy, physical exam techniques, surgical and nonsurgical treatment of musculoskeletal injuries, casting and splinting techniques, and post-op precautions and management |
|Pediatrics ||To learn normal and abnormal functional development |
|Radiology ||To better understand and interpret radiological studies and to order appropriate imaging to work-up specific differential diagnoses |
|Rheumatology ||To learn joint injection and physical exam techniques |
|Urology ||To learn management of neurogenic bladder due to spinal cord injury, stroke, brain injury, and other neurologic disorders |
Subspecialty Boards: List
Lifestyle, Salary and Benefits
For the most part, the lifestyle of a PM&R resident is quite reasonable and predictable. As a general rule, inpatient services tend to be more time-intensive than outpatient rotations. Call schedules vary across different residency programs. Depending on the residency program, call can be taken from home or in-house. This can range from in-house call every fourth night to at-home call every 11th week.
Salaries for PM&R residents in their PGY2 year range from $40,000 to $60,000 per year, consistent with other specialty residencies. The annual salary does vary with region of the country and the local cost of living. There is typically a $1,000 to $3,000 raise in salary with each advancing year of residency. Moonlighting is the opportunity to work outside of your residency program—for example, in a private clinic or emergency room—to supplement your income. Moonlighting privileges are typically program dependent.
What is a career in physiatry like?
The physiatrist may choose a solo practice or a group setting-partnership or multispecialty group. He/she may affiliate with an academic institution, a private community hospital or clinic, a VA hospital, a skilled nursing facility, or a freestanding rehabilitation facility. The practice may consist of solely outpatient care (e.g., sports medicine clinic), inpatient care (e.g., stroke unit), or a combination of both. In many cases, the patient population will be referral-based and the physiatrist will act initially in a consulting role. Referrals come typically from neurosurgery, orthopedic surgery, neurology, oncology, vascular surgery, cardiology, rheumatology, trauma, transplant surgery, cardiology, cardiothoracic surgery, family practice, pediatrics, and internal medicine. If the patient is admitted into an inpatient rehabilitation unit, the physiatrist usually assumes both a primary care and specialist role.
How much do physiatrists make?
The mean gross income/W2 wages is higher for full-time physiatrists in a private solo practice (M =$319,295) than among physiatrists that are in an academic practice/faculty group (M = $222,648) or among physiatrists working for the VA (M = $191,029).This range is often greater than many primary care specialties but less than many surgical specialties. A physiatrist may earn more in medical directorships or interventional practices. Private practice settings typically offer more compensation while academic and other institutional positions can offer more stability, opportunities for research/grant funding, and potentially better lifestyles. In most cases, the harder you are willing to work, the more you have the potential to make. There are also significant regional differences, with more saturated markets offering lower pay and under-represented areas offering higher salaries. One must consider further the cost of living in any particular part of the country when comparing salary offers.
What are organizations in which physiatrists can participate?
For more information on the official specialty organization for physiatry:
The American Academy of Physical Medicine and Rehabilitation (AAPM&R): www.aapmr.org
- Founded in 1938
- Membership open to medical students, PM&R residents, board-eligible and board-certified physiatrists
- Primary sponsorship of the specialty board
Official journal: PM&R
AAPM&R Annual Assembly
This meeting provides a forum for continuing medical education, research presentations, a technical exhibition, special interest group meetings, career network services, and a program developed for residents including an educational symposium and business meeting of the Resident Physician Council.
The Resident Physician Council (RPC) of AAPM&R
RPC was formed to allow residents the opportunity to assist the Academy with administrative planning in the areas of medical education, practice, membership, residency review, health legislation, research, and marketing. RPC also publishes the PM&R Resident newsletter and endeavors to educate medical students, other residents, non-physiatric physicians, and the lay public about the field of PM&R. RPC is divided into an executive board, standing committees, and liaisons to the Academy committees and other organizations. The members consist entirely of peer-elected, appointed, or volunteer PM&R residents.
There are other professional organizations to which physiatrists may also belong:
For more information on academic or research-based practices:
The Association of Academic Physiatrists (AAP): www.physiatry.org
- Membership is open to PM&R residents, board-eligible and board-certified physiatrists who are affiliated with an academic setting.
Official journal: American Journal of Physical Medicine and Rehabilitation
AAP Annual Meeting
This meeting offers continuing education for physicians interested in improving their skills as practitioners and academicians, non-physician academicians who teach and conduct research in PM&R departments, PM&R residents, and physiatrists interested in education and research.
For more information on multidisciplinary approaches to rehabilitation:
American Congress of Rehabilitation Medicine (ACRM): www.acrm.org
- Founded in 1923
- Membership open to physicians and allied health professionals with an interest in PM&R
Official journal: Archives of Physical Medicine and Rehabilitation
ACRM Annual Meeting
This meeting provides a forum for continuing medical education with an emphasis on multidisciplinary perspectives, along with research presentations and a technical exhibition.
For more information on obtaining and maintaining specialty board certification in physiatry:
The American Board of Physical Medicine and Rehabilitation (ABPMR): www.abpmr.org
- Founded in 1947
- One of the 24 certifying boards of the American Board of Medical Specialties
- Establishes the requirements for certification and maintaining certification, creates its examinations, and contributes to setting the standards for PM&R
What reading materials are helpful to learn more about PM&R?
- Braddom RL. Physical Medicine and Rehabilitation. 4th ed. W.B. Saunders; 2010.
- Brukner, Peter and Khan, Karim. Brukner & Khan's Clinical Sports Medicine. 4th ed. McGraw-Hill Book Company Australia; 2011. The bible of sports medicine. It covers all aspects of diagnosis and management of sports related injuries.
- Campagnolo DI, Kirshblum S, Nash MS. Spinal Cord Medicine. 2nd ed. Lippincott Williams & Wilkins; 2010
- Frontera WR, Silver JK, Rizzo TD. Essentials of Physical Medicine and Rehabilitation. 2nd ed. W.B. Saunders; 2008.
- Frontera WR. Physical Medicine and Rehabilitation: Principles and Practice. 5th ed. Lippincott Williams & Wilkins; 2010
- Malanga GA, Nadler SN. Musculoskeletal Physical Examination: An Evidence Based Approach. Har/DVD ed. Hanley & Belfus,; 2005
- Preston & Shapiro. Electromyography and neuromuscular disorders. Clinical-Electrophysiologic Correlations. 3rd Ed. Saunders. 2012
- Braddom, Randall. Handbook of Physical Medicine and Rehabilitation. 2nd ed. Saunders; 2003.
- Cuccurullo SJ. Physical Medicine and Rehabilitation Board Review. 2nd ed. Demos Medical Publishing; 2009.
- Hoppenfeld S, Thomas H, Hutton R. Physical Examination of the Spine and Extremities. 1st ed. Prentice Hall, 1976
- Miller A, Heckert K, Davis B. The 3-Minute Musculoskeletal & Peripheral Nerve Exam. 1st ed. Demos Medical Publishing; 2008.
- O'Young BJ, Young MA, Stiens SA. Physical Medicine & Rehabilitation Secrets. 3rd ed. Mosby; 2007.
- Rathmell J. Atlas of Image-Guided Intervention in Regional Anesthesia and Pain Medicine. 2nd Ed. Lipincott, Williams & Wilkins; 2011
- Shatzer M. Physical Medicine and Rehabilitation Pocketpedia. 2nd ed. Lippincott Williams & Wilkins; 2012.
- Visco CJ & Chimes GP. Mclean Course in Electrodiagnostic Medicine. 1st ed. Demos Medical Publishing; 2008.
- Weiss L, Silver J, Weiss J. Easy EMG. 1st ed. Butterworth-Heinemann; 2004.
- Wyss J & Patel A. Therapeutic Programs for musculoskeletal disorders. 1st Ed, Demos Medical Publishing; 2013
- American Journal of Physical Medicine and Rehabilitation: http://journals.lww.com/ajpmr/pages/default.aspx, Lippincott, Williams & Wilkins, Subscriptions, P. O. Box 1630, Hagerstown, MD 21741. Customer service: (800) 638-3030.
- Archives of Physical Medicine and Rehabilitation: http://www.archives-pmr.org, W.B. Saunders, Periodicals Dept., 6277 Sea Harbor Drive, Orlando, FL 32821-9918. Customer service: (800) 654-2452.
- PM&R: http://www.pmrjournal.org, Elsevier, 3251 Riverport Lane, Maryland Heights, MO 63043. Customer service: (800) 654-2452.
- DeLisa et al. Common questions asked by medical students about physiatry. Am J Phys Med Rehabil 1990;69:259-265.
- Kirschner and Betts. Physical medicine and rehabilitation. JAMA1993;270:248-250.