Anesthesia vs. PM&R for pain management / spine

[Spongeman7]

Hey guys! So I'm interested in pain management and was just wondering what the real differences of going into something like spine from PM&R or interventional pain from anesthesia was. I would ideally like to go into pain management through an anesthesia residency, but anesthesia seems to be getting more and more competitive, could you do something similar going through PM&R? I've also seen the compensation for pain management and anesthesia, and it seems much higher than PM&R but can't they both do similar procedures and have similar practices. In theory could a PM&R procedural doc make equivalent to an anesthesia pain doc? Thanks for the help in advance.

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[Dr. Ice]

Do a search. This topic is covered an almost obscene amount at this point

 

[Spongeman7]

Do a search. This topic is covered an almost obscene amount at this point

Couldn't find anything specifically related to the pay difference and just wanted to get different perspectives, but thanks for the help!

 

[Dr. Ice]

Hey guys! So I'm interested in pain management and was just wondering what the real differences of going into something like spine from PM&R or interventional pain from anesthesia was. I would ideally like to go into pain management through an anesthesia residency, but anesthesia seems to be getting more and more competitive, could you do something similar going through PM&R? I've also seen the compensation for pain management and anesthesia, and it seems much higher than PM&R but can't they both do similar procedures and have similar practices. In theory could a PM&R procedural doc make equivalent to an anesthesia pain doc? Thanks for the help in advance.

Do anesthesia pain, then moonlight doing gas which is really hot right now. You’ll retire well fed.

You’re not gonna wanna fall back on pmr if pain tanks or doesn’t work out unless you like doing subacute consults. Asking someone how many steps they have in their house is social work not being a doctor, and this is coming from a pmr doc.

 

[Spongeman7]

Do anesthesia pain, then moonlight doing gas which is really hot right now. You’ll retire well fed.

You’re not gonna wanna fall back on pmr if pain tanks or doesn’t work out unless you like doing subacute consults. Asking someone how many steps they have in their house is social work not being a doctor, and this is coming from a pmr doc.

Ahh got it, thanks! Do you happen to know if income is similar between spine thru pm&r and interventional pain thru anesthesia?

 

[bedrock]

.

 

[bedrock]

Do anesthesia pain, then moonlight doing gas which is really hot right now. You’ll retire well fed.

You’re not gonna wanna fall back on pmr if pain tanks or doesn’t work out unless you like doing subacute consults. Asking someone how many steps they have in their house is social work not being a doctor, and this is coming from a pmr doc.

lol, Dr ice. This is why I don’t engage with those newbies that are too lazy to search the forum but want to be spoon fed.

Millennials….

 

[oneforfighting]

Ahh got it, thanks! Do you happen to know if income is similar between spine thru pm&r and interventional pain thru anesthesia?

Putting the many variables aside…if you work hard, work smart, work efficiently and do good work then you’ll make plenty either way. Main difference would be if you plan to fall back on your main specialty at some point down the road.

 

[BobBarker]

Medicare pays everyone the same amounts/cpt code.

 

[clubdeac]

Make the same. Just depends on your practice setting and set up

 

[au bon pain]

Do psych—>pain.

The “fallback” of doing cash-only solo practice psych remains one of the few golden tickets left in medicine (and one that has no expiration date in sight).

 

[lmsanscafe]

PM&R. Do you wanna get regular sleep and not work weekends during residency? I bet you do. If you are pretty set on pain, then this is definitely the best way to go for your QOL. Go to a procedural heavy program with early and plenty exposure to pain, and you'll be set.

 

[PainDoc2025]

PM&R. Do you wanna get regular sleep and not work weekends during residency? I bet you do. If you are pretty set on pain, then this is definitely the best way to go for your QOL. Go to a procedural heavy program with early and plenty exposure to pain, and you'll be set.

this is the way

 

[po_boy]

PMR. Anesthesia maybe just helps you with ILESI reps. You likely won't learn anything useful about pain diagnoses in anesthesia residency. You'll work nights and weekends, and wake up too early.

 

[Dr. Ice]

PMR. Anesthesia maybe just helps you with ILESI reps. You likely won't learn anything useful about pain diagnoses in anesthesia residency. You'll work nights and weekends, and wake up too early.

Yes but gas is a better fallback than asking someone how many steps they have in their house.

 

[po_boy]

Yes but gas is a better fallback than asking someone how many steps they have in their house.

Can't disagree with that.

I will say that if you think you will ever fall back to Anesthesia based off your Pain rotation(s) in residency for whatever reason, spare yourself the heartache and don't go into pain.

 

[agolden1]

There is one major difference I have noticed as far as which specialty to go into which I feel like hasn't been covered on this forum as much.

A few years ago when pain was more competitive, it seemed like many more fellowships valued Anesthesia trained applicants over those from other specialties. Might be less of an issue now.

After fellowship, some jobs prefer applicants with a similar baseline training. For instance, PMR groups will want someone PMR/pain trained may want someone with a PMR background. Anesthesia/pain may want someone with an anesthesia background. Many orthopedic groups in my general region want PMR/pain over anesthesia/pain.

If there's a specific geogrpahic area you hope to practice when you're done (realizing this is a long way off and lot could change), maybe try and get a sense of the groups are like and what they could be looking for as far as background training and tailor your approach to this. If they don't seem to care, then pick whichever specialty you like more.

 

[Doctodd]

If I could do it again, I would do anesthesia and then pain.

 

[po_boy]

If I could do it again, I would do anesthesia and then pain.

Why is that? I feel that I would do PM&R. I feel like my couple of rotations in anesthesia residency and fellowship left A LOT to be learned about physical exam, etc.

 

[Dr. Ice]

Why is that? I feel that I would do PM&R. I feel like my couple of rotations in anesthesia residency and fellowship left A LOT to be learned about physical exam, etc.

Meh..I’m not saying physical exam isn’t important, but there’s a reason why for billing and coding, PE has become less of a criteria

 

[DMBandFan86]

It’s the same answer as the post you had in the PM&R forum…

You can generally make more if you moonlight as anesthesia. But a lot of pain docs don’t want to do that so it doesn’t really matter (unless you are wanting to do that). If you do PM&R you can still make good money doing IPR, but volume is key. Bill 20+ level 2 and some level 3 in a day is good money. But the idea of doing pain, would be a goal to typically do pain.

Also, as someone who does inpatient rehab. I haven’t asked someone about their home set up since I was a medical student. So I’m not sure what the point is about that. I guess if you’re insane you ask people about stuff like that. Otherwise the computer auto fills that stuff.

 

[RoloTomassi]

Bill 20+ level 2 and some level 3 in a day is good money.

1. Your definition of good is a lot different than most
2. Seems like you're undercoding

 

[polymyalgia_rheumatica]

If I could do it over, I’d also pick anesthesia over PMR. I’m noticing there are a lot more postings looking for anesthesia/pain rather than pain from other specialties. I assume that’s because the demand for anesthesia services is high at the moment.

 

[Magnus Acus]

One thing I never see written in these discussions, is that if you’re dead set on pain, you are probably interested in MSK. You probably want to be primarily in a clinic with lots of procedures mixed in. You probably want to be autonomous (not working directly with/under another physician). You probably want daytime work hours, minimal call.

All this is basically PM&R. You can do outpt PM&R MSK clinic with lots of procedures, like 70% of pmr is this model. So if you go this route and don’t match pain, you’re like 70% there. Obviously pain provides cooler procedures, OR time etc.

If you want to work in the OR all day titrating sevo and pushing IV meds, that’s fine, however it is radically different than your target of interventional pain. To boil down to “well the anesthesia market is hot right now” is insane to me.

 

[drg123]

One thing I never see written in these discussions, is that if you’re dead set on pain, you are probably interested in MSK. You probably want to be primarily in a clinic with lots of procedures mixed in. You probably want to be autonomous (not working directly with/under another physician). You probably want daytime work hours, minimal call.

All this is basically PM&R. You can do outpt PM&R MSK clinic with lots of procedures, like 70% of pmr is this model. So if you go this route and don’t match pain, you’re like 70% there. Obviously pain provides cooler procedures, OR time etc.

If you want to work in the OR all day titrating sevo and pushing IV meds, that’s fine, however it is radically different than your target of interventional pain. To boil down to “well the anesthesia market is hot right now” is insane to me.

Well put. If you KNOW in advance that the end-point is pain, then PM&R residency intrisically aligns better with the end-point. Of course, there is superfluous stuff too (IPR), but as you said, by the time you're done, you're most there, even without fellowship. Pain Fellowship just expands the arsenal and increases pay ceiling. If both OR anesthesia or outpatient MSK is equally interesting to you, then perhaps Anesthesiology is a better route given the financial moment its having. But how many pepole are truly equally interested in both?

 

[Doctodd]

The only negative about anesthesia is the dingus surgeons. Anesthesia just opens more doors. Hospitals aren’t closing down OR’s….but they’re closing down rehab units.

 

[MitchLevi]

There should be zero level 2 visits

 

[powermd]

Who do you fit in with?

You have to spend 3 years with your residency colleagues- may as well enjoy it. Gas guys are action-oriented, and love the OR. They're also engaged by, rather than turned off from, the life and death stuff. Time to get the paddles? Big line in the neck? 6 drips? Belmont auto-tranfuser? Hell yeah. At the time, it was the only place I wanted to be. It was hard work at times, but lots of fun, and sometimes exciting (or terrifying). The OR is like a job shop. You're hanging out with your buds, listening to music, and getting a job done. Yup, sometimes there's night work, but if you're at a big program, you're not fully overnight that often. Eventually, I realized I wanted to do way more with my career than babysit patients under anesthesia and put out fires. So while I miss the OR a little bit, I was happy to move on to something new, as well as a new setting. Now I have my own little solo practice set up like a job shop. There's music playing. I see my consults. I do some IV infusions kinda like anesthesia. Procedures with needles and stuff. And the patients mostly happy and appreciative. I enjoy how I spend my days.

 

[nvrsumr]

I took beeper call on my 16ft ski boat as a pmr resident. Every warm day for 3 years.

 

[lmsanscafe]

Surgical intern year to get comfortable and good in the OR, followed by PM&R residency with heavy outpatient/procedural experience, followed by ACGME pain fellowship with full spectrum neuromodulation experience, is the best route to go in my humble opinion.

 

[lobelsteve]

I dislike the OR. I do a half day a week. 2-4 cases. Always delays, hassles, clearance issues. 5 people plus in the room and rarely do I work with the same people. The techs love to touch everything on the Mayo and keep moving stuff. I tell them to just load needles and don’t touch anything going into the body. Too much paperwork, too many hassles.

 

[CleanUp]

Surgical intern year to get comfortable and good in the OR, followed by PM&R residency with heavy outpatient/procedural experience, followed by ACGME pain fellowship with full spectrum neuromodulation experience, is the best route to go in my humble opinion.

There’s no way one gets comfortable and good in the OR in one year. Surgical intern year is basically running the floors and putting in orders.

 

[lmsanscafe]

There’s no way one gets comfortable and good in the OR in one year. Surgical intern year is basically running the floors and putting in orders.

Disagreed. People here claim that 10 SCS trials get you comfortable for doing it in practice…speaking from my own experience, but you don’t think scrubbing as first and second assist for 60+ gen surg and plastic cases get you comfortable setting up the OR, prepping/draping, making an incision, sewing/tying, and wielding a bovie? Some of those are hemicolectomies, whipples, double mastectomies etc.. ie way more invasive than the things that we do in our lives. I would highly encourage any med student serious about pain to go this route as I think this is where the future is going.

 

[DMBandFan86]

1. Your definition of good is a lot different than most
2. Seems like you're undercoding

This is talking about inpatient coding. If the AP had to fall back on PMR and did inpatient. Level 3 is the highest level you can code. So I’m not sure what you mean by undercoding. That would be the same as billing every outpatient a level 5 visit.

 

[sevo00]

Surgical intern year to get comfortable and good in the OR, followed by PM&R residency with heavy outpatient/procedural experience, followed by ACGME pain fellowship with full spectrum neuromodulation experience, is the best route to go in my humble opinion.

lol surgical interns don’t go in the OR. They’re are relegated to scut work on the floors

 

[CleanUp]

Disagreed. People here claim that 10 SCS trials get you comfortable for doing it in practice…speaking from my own experience, but you don’t think scrubbing as first and second assist for 60+ gen surg and plastic cases get you comfortable setting up the OR, prepping/draping, making an incision, sewing/tying, and wielding a bovie? Some of those are hemicolectomies, whipples, double mastectomies etc.. ie way more invasive than the things that we do in our lives. I would highly encourage any med student serious about pain to go this route as I think this is where the future is going.

Perhaps our experiences of what an intern does are vastly different

 

[Doctodd]

I took beeper call on my 16ft ski boat as a pmr resident. Every warm day for 3 years.

Going into residency because it’s easy is not a positive trait.

 

[Taus]

Going into residency because it’s easy is not a positive trait.

To that I say meh. Solid training with easy and infrequent call? Sign me up.

 

[nvrsumr]

Going into residency because it’s easy is not a positive trait.

That suntan lotion wasn’t going to apply itself. Haha.

Making sh** look easy is hard work.

 

[lmsanscafe]

lol surgical interns don’t go in the OR. They’re are relegated to scut work on the floors

Some programs may be that way, but my schedule was identical to that of the categoricals, so that’s important to make sure.

Responding so that a naive MS4 doesn’t read your generalization and rule out a surgical intern year.

 

[powermd]

I dislike the OR. I do a half day a week. 2-4 cases. Always delays, hassles, clearance issues. 5 people plus in the room and rarely do I work with the same people. The techs love to touch everything on the Mayo and keep moving stuff. I tell them to just load needles and don’t touch anything going into the body. Too much paperwork, too many hassles.

I dislike the hospital and everything that goes with it. Won't get me near one if I can avoid it.

 

[DrSpine]

Honest truth from a PM&R Guy:

Do you like waking up at 5 am everyday during residency for cases? Do you like being on call? Do you like dealing with patients possibly crashing? Go Anesthesia.

Are you a lazier person? Do you prefer to work M-F for most of residency, starting at 8 or 9, closing out at 5 pm? Do you prefer to not be on call as much? Yes, during inpatient rehab, you will have to be on call from time to time and start at 6 or 7, but that sheer number of that is far less than anesthesia. Do you also not like dealing with patient's crashing or serious situations? Then PM&R is your field.

We also focus more on MSK during our training.

 

[Taus]

Honest truth from a PM&R Guy:

Do you like waking up at 5 am everyday during residency for cases? Do you like being on call? Do you like dealing with patients possibly crashing? Go Anesthesia.

Are you a lazier person? Do you prefer to work M-F for most of residency, starting at 8 or 9, closing out at 5 pm? Do you prefer to not be on call as much? Yes, during inpatient rehab, you will have to be on call from time to time and start at 6 or 7, but that sheer number of that is far less than anesthesia. Do you also not like dealing with patient's crashing or serious situations? Then PM&R is your field.

We also focus more on MSK during our training.

Just bc one prefers everything in second paragraph doesn’t make them lazy….

 

[Espn123]

One simple fact is that it’s easier to get a good fellowship through anesthesia than PMR, if you look at the stats

 

[Magnus Acus]

Just bc one prefers everything in second paragraph doesn’t make them lazy….

Yeah I agree, “lazy” probably isn’t the term. For that matter anesthesia resident is very “lazy” compared to neurosurgery residency.

I work 50-70h a week, write research when I get home, then study after that. Plenty busy for most.

To the point though, anesthesia is undoubtedly more intrusive to one’s lifestyle.

 

[Magnus Acus]

One simple fact is that it’s easier to get a good fellowship through anesthesia than PMR, if you look at the stats

If you look at even more recent stats, it doesn’t matter what residency you go to. Pain had numerous premier spots go unfilled in 2023.

Our APD was trying to give away a spot at a major US institution to people planning on going general physiatry. Lol very turbulent environment right now.

 

[DrSpine]

Just bc one prefers everything in second paragraph doesn’t make them lazy….

I was kidding with the lazy line. That’s what other specialties describe PM&R typically. Lol

 

[sevo00]

Do you like waking up at 5 am everyday during residency for cases? Do you like being on call? Do you like dealing with patients possibly crashing? Go Anesthesia.

Don’t know where this lie started. I never woke up at 5am all through anesthesia residency. Woke up at 6, in hospital at 7, in the OR by 7:30

 

[stsa84]

Don’t know where this lie started. I never woke up at 5am all through anesthesia residency. Woke up at 6, in hospital at 7, in the OR by 7:30

Every place is different. We had to be in room with patient by 0645. I got there at 0615, woke up at 0515.

 

[Pain Applicant1]

Do psych—>pain.

The “fallback” of doing cash-only solo practice psych remains one of the few golden tickets left in medicine (and one that has no expiration date in sight).

This is what I would lean toward if I was just starting out. Also, if you open your own practice you can do whatever you want. You just need to think creatively and you'll find success no matter what, but having psych training will pretty much rain pts into your lap. Things always cycle. It's inevitable so don't forget to keep that in mind.