2 years later

[bronchospasm]

So let me ask you pp guys, what would you be happy making if you could work only 30 hrs a week, including all work i.e. paperwork, administrative work etc.? Oh and you take 8 weeks off a year. What kind of annual income could you generate doing that?

I'd say about 350-450K plus benifits. Now that depends on a lot of other factors like overhead, office visit vs procedures etc.

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[Jcm800]

So let me ask you pp guys, what would you be happy making if you could work only 30 hrs a week, including all work i.e. paperwork, administrative work etc.? Oh and take 8 weeks off a year. What kind of annual income could you generate doing that?

ONE MILLION DOLLARS!!!!!

 

[powermd]

ONE MILLION DOLLARS!!!!!

 

[olafa]

8 weeks off in private practice.... seriously! I find it hard to get off for more than 2, patient load backs up, staffing is hard because they need to work too

 

[clubdeac]

8 weeks off in private practice.... seriously! I find it hard to get off for more than 2, patient load backs up, staffing is hard because they need to work too

A huge anesthesia pain practice in Charlotte has 10 weeks off per year

 

[lonelobo]

A huge anesthesia pain practice in Charlotte has 10 weeks off per year

Anesthesia the one specialty that even PMR thinks is lazy

 

[melancholy]

Licensed clinical social workers are cheaper.

Go with an MFT

 

[melancholy]

ONE MILLION DOLLARS!!!!!

lol are you slipman?

 

[melancholy]

interesting topic. from my perspective as someone in an HMO system, the difference is learning all the shortcuts, politics, and nuances in my healthcare system to get things needed for my patients. Since the general PT's do not have much time or resources to do a lot of individualized care, I've had our clinic develop small group classes to teach patients how to use TENS units for pain flare as well as use during exercise, a trigger point release class using theracanes (but still customized based on pt's active trigger points), and an exercise based class that teaches basic strategies and mechanics for re-conditioning (i.e. for the deconditioned or fibro patient) to try and make the best use of limited resources as we have limited chronic pain PT FTEs. The psych part is huge though and you want a behavioral specialist who can use many types of strategies to help get patients motivated, overcome fears, develop coping strategies to get better compliance with your treatment plan to get them on the road towards better health. I also ended up doing a lot more trigger point injections than I envisioned. Some of them are a wash, but since most of my patients are referred to me after going through several epidurals for back pain or for pseudoradiculitis (which ends up being referred pain from active trigger point, IT band pain, referred pain from hip down ant thigh, referred pain from SI joint down posterior thigh, etc.), I find that TPI gets some buy-in from patients if they have a myofascial component of pain, even if they get only relief with the local anesthetic. If most of their pain is temporarily relieved and their MRI is relatively clean, I can usually get them to buy into "rehab" among other strategies geared towards myofascial pain. If they get numbing superficially but all the pain is deep down, then usually will look at facets and underlying structures. A lot of soft tissue injuries that are undiagnosed, so a good MSK exam when other interventions and imaging don't yield anything is important (keep an open mind and have a good PT to refer to with good hands on diagnostic skills and won't call everything radiculopathy). There is generally a way to explain what course of events led to a patient's current chronic pain state and why they feel they way they do (pain amplifiers, increased sensitivity, etc.), so if you can really identify some of these things, at least patients may have a better idea of what they are dealing with and then the plan will hopefully give them a way to better take control of their symptoms rather than the reverse. It has also become much easier to reinforce boundaries that are set with medications or treatment plan compliance which I think it is important in order to make life less stressful and chaotic. Having the system in place helps quite a bit if you have the resources and the right people around you.

 

[olafa]

A huge anesthesia pain practice in Charlotte has 10 weeks off per year

that probably why they are a huge group - everyone is working part time. Probably in larger groups easier to get coverage and shift schedules w staff so there is minimal impact to the clinic, but is private practice small group I don t think you will find this scenario. Only one that comes to mind is the VA and its neither of the above.
Working 30hrs is essentially 3/4 FTE so whatever you would expect at 40-50 hr typical work week divide it out. Other benefits should be less too s part time employee do not get what full time does, production bonuses as well so that is a factor.

 

[drusso]

interesting topic. from my perspective as someone in an HMO system, the difference is learning all the shortcuts, politics, and nuances in my healthcare system to get things needed for my patients. Since the general PT's do not have much time or resources to do a lot of individualized care, I've had our clinic develop small group classes to teach patients how to use TENS units for pain flare as well as use during exercise, a trigger point release class using theracanes (but still customized based on pt's active trigger points), and an exercise based class that teaches basic strategies and mechanics for re-conditioning (i.e. for the deconditioned or fibro patient) to try and make the best use of limited resources as we have limited chronic pain PT FTEs. The psych part is huge though and you want a behavioral specialist who can use many types of strategies to help get patients motivated, overcome fears, develop coping strategies to get better compliance with your treatment plan to get them on the road towards better health. I also ended up doing a lot more trigger point injections than I envisioned. Some of them are a wash, but since most of my patients are referred to me after going through several epidurals for back pain or for pseudoradiculitis (which ends up being referred pain from active trigger point, IT band pain, referred pain from hip down ant thigh, referred pain from SI joint down posterior thigh, etc.), I find that TPI gets some buy-in from patients if they have a myofascial component of pain, even if they get only relief with the local anesthetic. If most of their pain is temporarily relieved and their MRI is relatively clean, I can usually get them to buy into "rehab" among other strategies geared towards myofascial pain. If they get numbing superficially but all the pain is deep down, then usually will look at facets and underlying structures. A lot of soft tissue injuries that are undiagnosed, so a good MSK exam when other interventions and imaging don't yield anything is important (keep an open mind and have a good PT to refer to with good hands on diagnostic skills and won't call everything radiculopathy). There is generally a way to explain what course of events led to a patient's current chronic pain state and why they feel they way they do (pain amplifiers, increased sensitivity, etc.), so if you can really identify some of these things, at least patients may have a better idea of what they are dealing with and then the plan will hopefully give them a way to better take control of their symptoms rather than the reverse. It has also become much easier to reinforce boundaries that are set with medications or treatment plan compliance which I think it is important in order to make life less stressful and chaotic. Having the system in place helps quite a bit if you have the resources and the right people around you.

Interesting...

Do you feel like your employer is using your knowledge and skills optimally and encouraging you to practice at the "top of your license?" Or, are they downgrading your training?
Couldn't lesser trained ancillary staff could provide most of those services more cheaply and efficiently than using a fully-trained specialist physician? Couldn't a RN be trained to give a trigger point injection? They give IM shots all the time... Couldn't a MA teach patients how to apply a TENS unit? Or, maybe an Ipad video?

 

[melancholy]

Interesting...

Do you feel like your employer is using your knowledge and skills optimally and encouraging you to practice at the "top of your license?" Or, are they downgrading your training?
Couldn't lesser trained ancillary staff could provide most of those services more cheaply and efficiently than using a fully-trained specialist physician? Couldn't a RN be trained to give a trigger point injection? They give IM shots all the time... Couldn't a MA teach patients how to apply a TENS unit? Or, maybe an Ipad video?

The way our big machine is set up is for you to do your specific job on the assembly line based on your primary specialty. thus the chronic pain doc (PM&R or IM but pain boarded) does the med management, you send to the spine interventionalist or the anesthesia interventionalist for your choice of block shop, some are triaged to surgery and others are sent back to you. The ability to do multiple things and expand is tricky in this setting and esp since once they find a model at one facility or region that has established "best practices" that provide good results and numbers, the idea is to try and emulate that elsewhere within the whole region. it does seem like some providers are able to carve out little pieces of their own to be unique in different ways and offer more services, but it is not widespread and there is still the obligation to do the job requirements on the assembly line. Since the potential for chronic pain doctor in our program to do fluoro procedures is rare, yes i'd say that were a downgrading of training b/c there is a lot of med management to be done, but there had been so many complaints about fragmented care that we were able to convince our spine clinic to work on getting us fluoro access although getting up to full speed will take more months.

Hmm.. don't RN's give IM shots based on orders for the injected medicine IM? not sure if you could code it as a TPI if an RN. There may be union issues based on if that is in their job requirements. Also, there is a lot to finding the appropriate active trigger points, using the right needle gauge and length to get to the right target and elicit triggering or twitch response, etc. Anatomy knowledge will be quite limited.

I don't know enough about MA's and what their job requirements are and whether they are able to do that sort of education with a medical device. I know the rehab department made videos for back pain, shoulder pain, foot pain, etc. but then they sort of made it almost a requirement for patients to watch the video first, then get a telephone call from the PT, then the individdual appt.

 

[Disciple]

I hope everyone who has participated in the discussions regarding how to provide multidisciplinary pain care to the indigent in a cost-effective manner is reading these posts.

Melancholy,

In regard to trying to set-up fluoro privileges etc. within the system, as a path or lesser resistance, have you considered trying to transfer to the other departments you described?

In your experience, and your interactions with your fellow Kaiser doctors, when it comes down to it, is the pension the big selling point? other benefits? I'm glad you're doing well, but what you describe sounds like it could be a soul crushing experience for certain doctors, that gets worse over time.

I've known a few orthopods who started out in private practice and didn't do so well, went into Kaiser (or competitor hospital system) for a couple of years and then came back out into private practice, opting for the daily struggle of the independent practicioner. Have you seen this much with your fellow pain or PMR doctors?

 

[sloh]

i rotated with a kaiser pain physician as a 4th year medical student. he lamented the fact that he had no access to fluoro and was forced to pretty much indiscriminately wean all patients off opioids. he wasn't able to fulfill his wishes of starting his own practice b/c he needed a job immediately post-fellowship due to being the only breadwinner in his family. great hours and benefits though

 

[melancholy]

I hope everyone who has participated in the discussions regarding how to provide multidisciplinary pain care to the indigent in a cost-effective manner is reading these posts.

Melancholy,

In regard to trying to set-up fluoro privileges etc. within the system, as a path or lesser resistance, have you considered trying to transfer to the other departments you described?

In your experience, and your interactions with your fellow Kaiser doctors, when it comes down to it, is the pension the big selling point? other benefits? I'm glad you're doing well, but what you describe sounds like it could be a soul crushing experience for certain doctors, that gets worse over time.

I've known a few orthopods who started out in private practice and didn't do so well, went into Kaiser (or competitor hospital system) for a couple of years and then came back out into private practice, opting for the daily struggle of the independent practicioner. Have you seen this much with your fellow pain or PMR doctors?

Well, I considered applying to an opening in my local spine dept that does the interventions, but then later changed my mind for multiple reasons. There are other facilities where they do have a setup for someone to split time between chronic pain and interventional spine, but I don't think it's very common. If PM&R went into an non-op ortho position, there also wouldn't be any fluoro spine procedures although not sure if they would allow other sorts of guided procedures. apparently our local sports med guy has an MSK ultrasound machine that isn't being used really...

It may be partial propaganda that we are fed constantly by leadership, but there is a sense of stability with a large organization like Kaiser/TPMG where salaries go up consistently, bonuses come a few times a year, no pay cuts, etc. The pension is probably a draw for people to stay long-term as well as the fact that here, you get paid the same whether you see 1 patient or 10 patients a day, so there is not that constant drive to market and to bring in more business or patients. I have not known any PM&R or pain docs who went to Kaiser and went back to private practice afterwards. I know one PM&R spine that left for an academic position somewhere else. There is a lot of convenience to just come in and do your work. The infrastructure is good and efficient as the big machine thrives on efficiency, metrics, etc and that is a strength of Kaiser. Sure, there are headaches like turf battles, politics, limited resources of this or that, slow progress to make changes, restrictions in some aspects of practice styles, and sometimes staff personnel issues that usually involve union. I think for my personality, I was initially a bit skeptical about Kaiser in training, but it seems like private practice for some has become more difficult and more people are looking at Kaiser now.

I do think there are plenty of passionate practitioners who would roll over and die if they could not practice every aspect of pain management including fluoro interventions, but I came into this position knowing it would be little to none or very limited, but I learned that with time, you can make changes if you can validate it with leadership. While the flexibility to make changes faster is not there, it's fast enough for me if I am going to stay another 20+ years lol.

Coming from my fellowship training, my style of opioid prescribing and monitoring was different from the practice of those currently there, so there had to be some moderation on both sides but I think it is for the better now. I continue to focus and push for more treatment options to offer than just medications and I think even though it is cheaper to give a pill than a lidocaine patch, PT, etc, there are enough people in leadership who understand the vision and can support more comprehensive pain management.

 

[melancholy]

i rotated with a kaiser pain physician as a 4th year medical student. he lamented the fact that he had no access to fluoro and was forced to pretty much indiscriminately wean all patients off opioids. he wasn't able to fulfill his wishes of starting his own practice b/c he needed a job immediately post-fellowship due to being the only breadwinner in his family. great hours and benefits though

There is one facility in northern california that has a unique perspective on opioid therapy for chronic pain which ends up being restrictive to a fault almost, however yes, there is more emphasis on tapering now more than ever. It is challenging to taper unmotivated patients and a pleasure to taper motivated patients. I use all other treatment options as well to manage pain to show them alternatives and I think that is where the satisfaction comes when they come off opioids and they are just more cognitively alert in the world and come out from the fog in many cases. Being in an enclosed HMO system, I do think about this as managing risk for our patient population and reducing the overall opioid load for our service area, so if i keep my eye on the big picture, tapering can still serve a greater good.

 

[sloh]

There is one facility in northern california that has a unique perspective on opioid therapy for chronic pain which ends up being restrictive to a fault almost, however yes, there is more emphasis on tapering now more than ever. It is challenging to taper unmotivated patients and a pleasure to taper motivated patients. I use all other treatment options as well to manage pain to show them alternatives and I think that is where the satisfaction comes when they come off opioids and they are just more cognitively alert in the world and come out from the fog in many cases. Being in an enclosed HMO system, I do think about this as managing risk for our patient population and reducing the overall opioid load for our service area, so if i keep my eye on the big picture, tapering can still serve a greater good.

i definitely see where you're coming from. that attending told me he understood the overarching goal of tapering patients off opioids but he was not on board with imposing that sanction on all patients as there were some patients that he deemed a reasonable amount would allow them to be functional without incapacitating pain. nevertheless, as an employed physician, he couldn't really buck the system

 

[drusso]

i rotated with a kaiser pain physician as a 4th year medical student. he lamented the fact that he had no access to fluoro and was forced to pretty much indiscriminately wean all patients off opioids. he wasn't able to fulfill his wishes of starting his own practice b/c he needed a job immediately post-fellowship due to being the only breadwinner in his family. great hours and benefits though

They got him by the balls.

 

[drusso]

Nevertheless, as an employed physician, he couldn't really buck the system

Did he ever disclose feeling guilty for surrendering his clinical judgment and what he believed to be in the best interests of his patient over to "group think?" I worry that our health care system is moving more in this direction every day.

 

[sloh]

Did he ever disclose feeling guilty for surrendering his clinical judgment and what he believed to be in the best interests of his patient over to "group think?" I worry that our health care system is moving more in this direction every day.

Yeah he did when we were in his office. Verbatim - "This is not how you ethically treat chronic pain patients."

Although.....I didn't need him to disclose it to me because it was patently obvious. He was quite candid with his patients that he had his hands tied and you could see the helplessness in his countenance.

 

[SCIronMike]

Well, I considered applying to an opening in my local spine dept that does the interventions, but then later changed my mind for multiple reasons. There are other facilities where they do have a setup for someone to split time between chronic pain and interventional spine, but I don't think it's very common. If PM&R went into an non-op ortho position, there also wouldn't be any fluoro spine procedures although not sure if they would allow other sorts of guided procedures. apparently our local sports med guy has an MSK ultrasound machine that isn't being used really...

It may be partial propaganda that we are fed constantly by leadership, but there is a sense of stability with a large organization like Kaiser/TPMG where salaries go up consistently, bonuses come a few times a year, no pay cuts, etc. The pension is probably a draw for people to stay long-term as well as the fact that here, you get paid the same whether you see 1 patient or 10 patients a day, so there is not that constant drive to market and to bring in more business or patients. I have not known any PM&R or pain docs who went to Kaiser and went back to private practice afterwards. I know one PM&R spine that left for an academic position somewhere else. There is a lot of convenience to just come in and do your work. The infrastructure is good and efficient as the big machine thrives on efficiency, metrics, etc and that is a strength of Kaiser. Sure, there are headaches like turf battles, politics, limited resources of this or that, slow progress to make changes, restrictions in some aspects of practice styles, and sometimes staff personnel issues that usually involve union. I think for my personality, I was initially a bit skeptical about Kaiser in training, but it seems like private practice for some has become more difficult and more people are looking at Kaiser now.

I do think there are plenty of passionate practitioners who would roll over and die if they could not practice every aspect of pain management including fluoro interventions, but I came into this position knowing it would be little to none or very limited, but I learned that with time, you can make changes if you can validate it with leadership. While the flexibility to make changes faster is not there, it's fast enough for me if I am going to stay another 20+ years lol.

Coming from my fellowship training, my style of opioid prescribing and monitoring was different from the practice of those currently there, so there had to be some moderation on both sides but I think it is for the better now. I continue to focus and push for more treatment options to offer than just medications and I think even though it is cheaper to give a pill than a lidocaine patch, PT, etc, there are enough people in leadership who understand the vision and can support more comprehensive pain management.

Wow, I could not imagine being in clinic every day and not having my fluoro time. My schedule is 7 W of clinic, 2 W of fluoro time, and 1 W of ET. I mix plenty of electrodiagnostics into my clinic time, and I also got them to purchase an ultrasound machine for our clinic so that I can pull some of the cases that I currently do in fluoro up to the clinic (hip injections, piriformis injections, glenohumeral injections, etc). I've been given the go ahead by my department chief to perform PRP injections in clinic. They've been doing PRP down in KP Orange County for a while now, so it's just a matter of setting up with the same vendor.

 

[101N]

i definitely see where you're coming from. that attending told me he understood the overarching goal of tapering patients off opioids but he was not on board with imposing that sanction on all patients as there were some patients that he deemed a reasonable amount would allow them to be functional without incapacitating pain. nevertheless, as an employed physician, he couldn't really buck the system

Tapering off or tapering down?

 

[melancholy]

Wow, I could not imagine being in clinic every day and not having my fluoro time. My schedule is 7 W of clinic, 2 W of fluoro time, and 1 W of ET. I mix plenty of electrodiagnostics into my clinic time, and I also got them to purchase an ultrasound machine for our clinic so that I can pull some of the cases that I currently do in fluoro up to the clinic (hip injections, piriformis injections, glenohumeral injections, etc). I've been given the go ahead by my department chief to perform PRP injections in clinic. They've been doing PRP down in KP Orange County for a while now, so it's just a matter of setting up with the same vendor.

Surprised they found enough support to build a business case to do PRP with ultrasound. Is it gen PM&R, ortho sports, or PM&R CPP based program that is doing this stuff down ther?

 

[SCIronMike]

Surprised they found enough support to build a business case to do PRP with ultrasound. Is it gen PM&R, ortho sports, or PM&R CPP based program that is doing this stuff down ther?

PRP in KP Orange County is performed by Orthopedics.

 

[Tenesma]

bronchospasm: congrats....

u are only 2 years into this and it sounds like you are happy. it aounds like u have set up some good parameters for how you want to practice.

it takes on average 5 to 7 years to get to the point where r practice runs truly on automatice, so you may be ahead of the curve

exciting about satellite.... what is motivation for that? is it for your ego? is it for increased income? is it to hire new doc? do you want to deal w extra oberhead and commuting? etc...

 

[bronchospasm]

bronchospasm: congrats....

u are only 2 years into this and it sounds like you are happy. it aounds like u have set up some good parameters for how you want to practice.

it takes on average 5 to 7 years to get to the point where r practice runs truly on automatice, so you may be ahead of the curve

exciting about satellite.... what is motivation for that? is it for your ego? is it for increased income? is it to hire new doc? do you want to deal w extra oberhead and commuting? etc...

Motivation for satellite really is to increase the workload temporarily so that I can bring in a partner next year. Also want to protect the market in terms of avoiding some national pain centres to come in and set up shop.

Motivation really is not money since I am happy with what I make. Is it ego? Not really. I'm happy with being anonymous. Don't care much for publicity. Or maybe it is ego. Who knows.

Like the challenge though, keeps life interesting... Otherwise it is same **** new day on most days

 

[clubdeac]

Motivation for satellite really is to increase the workload temporarily so that I can bring in a partner next year. Also want to protect the market in terms of avoiding some national pain centres to come in and set up shop.

Motivation really is not money since I am happy with what I make. Is it ego? Not really. I'm happy with being anonymous. Don't care much for publicity. Or maybe it is ego. Who knows.

Like the challenge though, keeps life interesting... Otherwise it is same **** new day on most days

What state do you practice in broncho?