Anesthesia residents that are planning on doing/did a pain fellowship, what made you want to?

[Spongeman7]

M2 here just considering going into anesthesia and potentially pain, and was wondering what made you want to go into pain since I know the day to day is quite different from general anesthesia. Also, did you always plan on going into pain and you just had to get through anesthesia residency? Or was it something you realized after starting residency. If you always knew you wanted to do pain, was there a reason you went the anesthesia instead of PM&R or other route?

Thanks so much for your responses in advance!

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[TheNolano]

I initially found pain as a med student. The head of our anesthesia rotation was a private practice pain doc, one of the true old school single practice types. I loved my rotation with him. I also had been flirting with anesthesiology, but not totally convinced. Pain solidified my choice.

Early in anesthesia residency, I was having a rough time. Didn't feel comfortable, felt overwhelmed, decided to go all in on pain as an out from what felt like my OR inadequacy. But you apply for pain 18 months before you finish residency. It's kind of wild. During my last year of anesthesia residency, something clicked and I loved it. But I had already matched pain, so I figured I would give it a shot.

Now that I am halfway through pain fellowship, I am happy with my choice. Pain is a totally different specialty, really unique skillset, and opens some doors. That being said, the anesthesia market is the best it's arguably ever been, which makes it hard. Who knows if that will continue though. Pain will always pay enough to provide for your family, and can have a very different lifestyle (fewer weeks off, but no nights or weekends). At the end of the day, I can always go back to anesthesia, and still do shifts every weekend.

Ultimately I think it will come down to what jobs I can find where I want to live. Right now, I lucked into a small private practice pain group that pays wells, is in an area I want to live, does all the advanced stuff I want, and has a good clinic/proc ratio. Will probably sign for that job and see how I feel in a few years.

Long story to say, choose your residency first. I would not recommend doing PMR or anesthesia just to "get to pain." You have no idea what your future hold. Choose a residency you think you like and see how you feel in 4 years. It's a long journey, with many good choices.

 

[Status Sciaticus]

Chicks, money, power, and chicks.

 

[drusso]

Chicks, money, power, and chicks.

Facts.

 

[BSM_OTO]

I was set on anesthesia since college. Then found a pain anesthesiologist while networking with anesthesiologists, and fell in love with pain. Then realized I love msk/pain so much more than anesthesia, and wished I could just go into interventional pain / sports medicine. Then found the gem called PM&R. Now I'm doing PM&R.

To answer your question though, most people do a pain fellowship from anesthesia because you can make similar to anesthesia money (now anes is prob higher than pain from an employment standpoint) but you don't have to take call or do nights. Pain is a 9-5 gig. Also, you're not the #2 guy in the OR anymore. I don't think most people realize until they're actually in the OR that anesthesia is a field for people without egos. You have to cater to douchebag surgeons and a great thing about pain is you get to be the proceduralist in the suite and there's no god complex surgeon running the OR anymore. Also, much easier to be a solo or small group private practice person in pain than anesthesia.

Downsides, as everything has negatives, is that pain patients suck, many pain treatment modalities walk a fine line between scientifically proven and snake oil, and you need to do notes, clinic vists etc and other BS that anesthesiologists get to skip out on.

 

[luckybuck]

I was set on anesthesia since college. Then found a pain anesthesiologist while networking with anesthesiologists, and fell in love with pain. Then realized I love msk/pain so much more than anesthesia, and wished I could just go into interventional pain / sports medicine. Then found the gem called PM&R. Now I'm doing PM&R.

To answer your question though, most people do a pain fellowship from anesthesia because you can make similar to anesthesia money (now anes is prob higher than pain from an employment standpoint) but you don't have to take call or do nights. Pain is a 9-5 gig. Also, you're not the #2 guy in the OR anymore. I don't think most people realize until they're actually in the OR that anesthesia is a field for people without egos. You have to cater to douchebag surgeons and a great thing about pain is you get to be the proceduralist in the suite and there's no god complex surgeon running the OR anymore. Also, much easier to be a solo or small group private practice person in pain than anesthesia.

Downsides, as everything has negatives, is that pain patients suck, many pain treatment modalities walk a fine line between scientifically proven and snake oil, and you need to do notes, clinic vists etc and other BS that anesthesiologists get to skip out on.

Current resident here. I feel like there are so many pros and cons to each it makes for a hard decision. Its honestly hard to know at this stage what I want my life to look like in the future. I've rotated in pain and really enjoyed it and was sort of set on it, but one positive of anesthesia I recently thought about is the ability to take a new job somewhere else and not really have any loose ends to deal with because you don't "own" your patients. That and having more vacation typically

 

[DOctorJay]

When changing jobs in a clinical specialty like Pain you’re going to have to deal with the 1-2 year ramp up as well. Jumping from one OR to another won’t affect your income as much.

 

[bedrock]

When changing jobs in a clinical specialty like Pain you’re going to have to deal with the 1-2 year ramp up as well. Jumping from one OR to another won’t affect your income as much.

Yep. I must admit if doing it over again, I would have done anesthesia pain for the flexibility.

 

[po_boy]

Do you really want to talk to 30 pain patients all day every day? Or do you like your patients asleep?

Is sleeping in your own bed, and having weekends off important to you?

Do you want more or less time off? Anesthesia usually affords you more time off, especially compared to private practice pain.

 

[Dr. Ice]

Yep. I must admit if doing it over again, I would have done anesthesia pain for the flexibility.

Doing subacute consults is def not a good “fall back”

 

[Status Sciaticus]

Do you really want to talk to 30 pain patients all day every day? Or do you like your patients asleep?

Is sleeping in your own bed, and having weekends off important to you?

Do you want more or less time off? Anesthesia usually affords you more time off, especially compared to private practice pain.

Do you really want to have no say in your schedule and cater to surgeons all day every day? Do you like being told what to do and when to do it?

Do you like doing cases in the middle of the night? Do you like being woken up to do epidurals because the patient thought she could handle it at 8PM but then decided she couldnt at 4AM?

Do you like having the potential and high likelihood to make more than you will ever make as an anesthesiologist?

 

[manowar rules]

Autonomy is King. And I never have to hear another tone page again.

 

[sevo00]

Do you really want to have no say in your schedule and cater to surgeons all day every day? Do you like being told what to do and when to do it?

lol. Always makes me chuckle when I hear this thing about why someone dislikes anesthesia due to this surgeon issue. I’ve been an attending for a few years now, and not once have I felt like I “catered” to surgeon or that I’m being “told what to do”. Yeah some surgeons have made a few dick remarks but I’ve put them in their place immediately. They’re all bark and no bite. It’s a tough guy act plain and simple on their part. I’m a grown ass man, I promise you no one is talking down to me at work. If someone doesn’t want to be an anesthesiologist because they’re afraid of dealing with surgeons, then sorry to say it’s because you’re a weak ***ch. learn to stand up for yourself and this problem evaporates.
I’d much rather put a surgeon is his or her place than deal with whiny chronic pain patients all day.

 

[Status Sciaticus]

lol. Always makes me chuckle when I hear this thing about why someone dislikes anesthesia due to this surgeon issue. I’ve been an attending for a few years now, and not once have I felt like I “catered” to surgeon or that I’m being “told what to do”. Yeah some surgeons have made a few dick remarks but I’ve put them in their place immediately. They’re all bark and no bite. It’s a tough guy act plain and simple on their part. I’m a grown ass man, I promise you no one is talking down to me at work. If someone doesn’t want to be an anesthesiologist because they’re afraid of dealing with surgeons, then sorry to say it’s because you’re a weak ***ch. learn to stand up for yourself and this problem evaporates.
I’d much rather put a surgeon is his or her place than deal with whiny chronic pain patients all day.

Really? You're saying that when a surgeon makes a case an emergency in the middle of the night, youre not being told what to do, even though its not a real emergency?

If youre doing a case in the middle of the night because a surgeon decided that its an emergency, you are in fact being told what to do. Unless of course you are flat out refusing to do cases classed as emergencies in the middle of the night.

 

[sevo00]

Really? You're saying that when a surgeon makes a case an emergency in the middle of the night, youre not being told what to do, even though its not a real emergency?

If youre doing a case in the middle of the night because a surgeon decided that its an emergency, you are in fact being told what to do. Unless of course you are flat out refusing to do cases classed as emergencies in the middle of the night.

if its not a real emergency, then i say its not a real emergency and will not do the case. if it is a real emergency, then ofcourse I am doing the case because its whats best for the patint.

 

[ProPropofol]

if its not a real emergency, then i say its not a real emergency and will not do the case. if it is a real emergency, then ofcourse I am doing the case because its whats best for the patint.

That has not been my experience. Often, the hospital expects us to do cases that are "emergencies" because the "surgeon says it's an emergency", regardless of my own clinical judgement. I envy the ability to not do cases that you believe can wait until the morning.

 

[GoBeers]

there is literally a 160 reply thread in anesthesia forum titled "garbage clearance" lol
there is so much downward pressure from hospital admins, surgeons and proceduralists .
i think it'd be easier dealing with occasional whiny pain consultations then deal with the same colleagues trying to screw you .

the worst i get in pain clinic is the pain patient complaining for a couple minutes about not getting opioids before i end the conversation
the worst that can happen in anesthesia is potentially the patient dies in the OR or you get fired for obstructing cases repeatedly.

 

[lobelsteve]

if its not a real emergency, then i say its not a real emergency and will not do the case. if it is a real emergency, then ofcourse I am doing the case because its whats best for the patint.

And if the patient dies without going to the OR?

 

[sevo00]

And if the patient dies without going to the OR?

Huh? Then i would have down the case to begin with. Part of knowing what’s an emergency is a part of anesthesia training. Plus I talk to the surgeon about the risk benefits of waiting or not. We have an actual discussion. Decisions aren’t made in a vacuum by solely one person. If you can’t recognize a real emergency from a nonemergency then I don’t know what to Tell you

 

[addoncase]

The story of pain salary making potentially more than Anes….you find seldom cases of this in the current market. If Anes wanted to increase their work with a few more sifts a year they easily can make more too. Of course this depends on what region of the country you are in, the need, market rates etc

Those pain docs making a lot are seeing a lot of pts if that’s your thing seeing 35+ pts a day by all means go for it. You cannot reasonably have an interaction with that many pts in a day.

at the end of the day it’s what makes you happy, what annoyances you can live with and what things you absolutely loathe and don’t want to deal with ever again.

There is no right answer. Everyone is different. Most important is that you feel satisfied with your work and you come home and leave work at work , and don’t dread going back in the next day to deal with the “surgeons” or the “annoying pain pts”

 

[Ferrismonk]

I still do OB call. Had a case the other night where a patient came into triage and decided she wanted an elective C-section at 2AM. No clinical reason other than she didn't want to do labor since she had a rough time last time. She was 9cm with painful contractions. She was NPO for only 2 hours. No IV started, no current bloodwork in process, no PRBCs available, no IV bolus given which is normal prior to neuraxial anesthesia in OB.

I talk with the OB and patient and stating this is not an appropriate elective case. There was no medical reason for the c-section and she wasn't optimized. I offer an epidural for pain control as an alternative. The OB states she needs to do the C-section because it's an emergency.

Would you have not done the case?

I did. Discussed the risks with the patient/OB. Started an IV, drew labs, gave IV bolus, did neuraxial anesthetic. If any single thing went wrong with that baby, that mother, or the birth in general, I guarantee I would have no leg to stand on if sued. If the surgeon says it's an emergency, they're the expert for that problem and it's an emergency. Period.

 

[Ronin1]

Back in my anesthesia days I would require the surgeon to document that it was an emergent case threatening life or limb. But OBs never gave a shi

Hard to beat pain for lifestyle comparatively though. Its basically shift work once you have an established practice except for dr Russo

 

[sevo00]

I still do OB call. Had a case the other night where a patient came into triage and decided she wanted an elective C-section at 2AM. No clinical reason other than she didn't want to do labor since she had a rough time last time. She was 9cm with painful contractions. She was NPO for only 2 hours. No IV started, no current bloodwork in process, no PRBCs available, no IV bolus given which is normal prior to neuraxial anesthesia in OB.

I talk with the OB and patient and stating this is not an appropriate elective case. There was no medical reason for the c-section and she wasn't optimized. I offer an epidural for pain control as an alternative. The OB states she needs to do the C-section because it's an emergency.

Would you have not done the case?

I did. Discussed the risks with the patient/OB. Started an IV, drew labs, gave IV bolus, did neuraxial anesthetic. If any single thing went wrong with that baby, that mother, or the birth in general, I guarantee I would have no leg to stand on if sued. If the surgeon says it's an emergency, they're the expert for that problem and it's an emergency. Period.

You left out the most crucial info. The OB said it’s an emergency based on what? Was there a strip that showed late decelerations? If there is nothing showing that the fetus is in danger then no I would say to wait until the morning. This has happened before and our chief backs up. Hell i don’t even have to say anything, the LD nurse manager herself stops inappropriate c sections in the middle of the night when there is no obvious indication. Did you ask the OB what the indication is? Did you look at the strip yourself?

 

[CleanUp]

1. I start at 8am - not at 7am which really means get their early, draw up meds, pre op the night before, talk to the patient and be in the room at “7 am”
2. I end at 3 - not when the board runner tells me to leave.
3. If I want to pee I can pee there
4. If I want to go out to lunch I can
5. If I want to break the time = money I can by getting revenue from another partner, midlevel, MRI/PT, facility fee - not by sitting on the stool more
6. If I want to work with a certain team in the room I can pick them
7. If I wanted to boost my income I could pick up medlegal cases. These have been extremely lucrative for me and I don’t have to sell my soul, either.
8. If I wanted to improve my workflow I could have someone take a history, scribe for me, put in orders - I don’t have to ask the patient when’s the last time they ate and if they have GERD.
9. I luckily take zero call, work zero nights, and work zero weekends. I know I’m not alone on this forum.
10. I can work from home doing video visits.
11. There seems to be innovation frequently. I’m challenged to stay up to date on the literature.

Pain is NOT for everyone as previously stated, though! Sometimes it can be a drag I admit that.

In my personal opinion I believe the trope about whiny pain patients demanding opioids as well as belligerent surgeons bossing around anesthesiologists are both extreme examples.

There is a sweet spot in both fields. Up to you what you want.

 

[Ferrismonk]

You left out the most crucial info. The OB said it’s an emergency based on what? Was there a strip that showed late decelerations? If there is nothing showing that the fetus is in danger then no I would say to wait until the morning. This has happened before and our chief backs up. Hell i don’t even have to say anything, the LD nurse manager herself stops inappropriate c sections in the middle of the night when there is no obvious indication. Did you ask the OB what the indication is? Did you look at the strip yourself?

Asked the OB and got an answer that didn't really mesh in my book. Doesn't matter though, I'm not the obstetrical specialist. If I refuse, and the baby gets injured in a vaginal delivery, I'm liable. Eff that.

You would refuse an anesthetic based on your personal interpretation of a FHR strip?

 

[lobelsteve]

Asked the OB and got an answer that didn't really mesh in my book. Doesn't matter though, I'm not the obstetrical specialist. If I refuse, and the baby gets injured in a vaginal delivery, I'm liable. Eff that.

You would refuse an anesthetic based on your personal interpretation of a FHR strip?

It's the problem with Anesthesia culture in many places. More about ego than anything else.
We had that problem a few years ago at my hospital. They fixed it. Now great leadership and if something is getting cancelled, they explain in Ortho terms to me. Bone broke me fix: nope, a sys tollie. (or something like that)