Anesthesia vs. PM&R for pain management / spine

[lobelsteve]

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

Airway, bagels, and coffee

vs

Plenty of Money and Relaxation.

We are not talking surgery hours before the 80hr limit.

---

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[RoloTomassi]

Sometimes I think IR would be cool. A lot of different procedures, no clinic. But hate being tied to hospital/call.

 

[MitchLevi]

Sometimes I think IR would be cool. A lot of different procedures, no clinic. But hate being tied to hospital/call.

One of my best friends is IR and works a lot. Tons of call and pts die regularly.

 

[RoloTomassi]

One of my best friends is IR and works a lot. Tons of call and pts die regularly.

Well nevermind then

 

[au bon pain]

I recall almost all the faces of patients who died in my ER. Looking back, it was far from the worst part of the job.

 

[Ducttape]

im sorry for you...

i only remember a few. there were so many, being level 1 trauma center and 2nd busiest er in the state at the time....

or selective memory.

then again, im sure others here probably think im dr. death.

your choice.

 

[MitchLevi]

I think it's more of the fact some of these IR cases drag on and on and on, and often it's in situations where you know the end result. Seems like tons of cases at odd hours and a lot of requests for things that the requesting doctor ought to do for themself...Like putting a G-tube in someone and it's general surgery making the request on a Friday at 8PM.

He showed me a picture of his fluoro time for one case - It was over 80 minutes of fluoro.

 

[Ducttape]

the hospital based IR typically use 2 min of fluoro time for SI injections.

 

[cowboydoc]

the hospital based IR typically use 2 min of fluoro time for SI injections.

Ours uses almost that much time of CT exposure for the same.

 

[au bon pain]

im sorry for you...

i only remember a few. there were so many, being level 1 trauma center and 2nd busiest er in the state at the time....

or selective memory.

then again, im sure others here probably think im dr. death.

your choice.

Yup that makes sense.
My memory is very selective…while I’m terrible remembering things like names of extended family I don’t see much, unfortunately those faces have a forever place. All but one of my ERs was very high acuity so there’s a…collection.

I wasn’t trying to be all woe is me though—I knew that would be a crappy aspect of the field when I signed up. Was more trying to express just how sharply downhill EM has gone and how the list of crappy things EM docs have to deal with continues to grow…definitely no longer recommend it to med students.

 

[bedrock]

I wasn’t trying to be all woe is me though—I knew that would be a crappy aspect of the field when I signed up. Was more trying to express just how sharply downhill EM has gone and how the list of crappy things EM docs have to deal with continues to grow…definitely no longer recommend it to med students.

Can you please elaborate on what are the changes that caused EM to go sharply downhill?
Just curious as someone who seriously considered EM, 20 years ago.

 

[SSdoc33]

Sometimes I think IR would be cool. A lot of different procedures, no clinic. But hate being tied to hospital/call.

I’m like the IDEA of IR. A few cool cases here and there. But a lot of baggage

 

[BobBarker]

IR looks like a very fun specialty from the outside but lots of high acuity, lots of call, and some low paying procedures at all hours (central lines, pigtail chest tubes).

 

[au bon pain]

Can you please elaborate on what are the changes that caused EM to go sharply downhill?
Just curious as someone who seriously considered EM, 20 years ago.

A confluence of many factors, but probably the biggest ones are:

*Private equity buying up physician-owned groups.
Predictively results in lower levels of physician coverage, increased midlevel coverage (arguably more dangerous than any other field of medicine), and, of course, pay cuts. PE groups view physicians as nothing more than widget makers and liability sponges… and as that becomes apparent in all facets of your job, you really begin to question why you keep showing up.

*For profit-hospitals and private equity groups creating EM residencies at ERs that shouldn’t have them.
This happens for two reasons, both of which are 100% about money: the short term gain of very cheap labor and then longer term gain of flooding the market to tip the balance of power to the hands of employers…and so lower labor costs in the long-term.
As the ACGME and ABEM don’t have the balls to step in and stop this nonsense, nor do any of the EM societies have either the spine or the resources to do anything…this reckless expansion went unchecked. Compared to when I was applying to residency a little over a decade ago, I think the total number of EM residency spots has literally doubled.

*Incredibly poor/unpredictable ED staffing and ancillary resources. The majority of ERs have never been the "fully staffed" kind of place. 10 years ago ER nurses were raging about having shifts where they'd have somewhat high staffing ratios that were probably not safe (1:4 or 5 semi-sick patients) and then peri-covid it could go to 1:8 or 9 or 10...wildly unsafe. And very few places listened to them...so with covid there was an understandable accelerated exodus of RN and techs from many ERs. This kind of thing destroys your efficiency, drastically increases wait times, delays care, and decimates department morale. I've had shifts where 1/3 of the scheduled nursing staff would "call out" and there'd be no coverage for them. All this severely limits what you can do for patients. Then when you get more "help" it's often brand new nurses (who a decade ago wouldn't have been allowed to start their career by working in any reasonably-high acuity ED). So they understandably make mistakes, especially with critical patients. But when you finally do stabilize a critically ill patient, there's sometimes nowhere to send them anyway. Which brings us to perhaps the most critical problem...

*Increasing amounts of moral injury…no support, no system capacity, increased boarding times, insolent and sometime violent patients, employers leaving you out to dry, idiotic press gainey scores, frivolous lawsuits, oblivious admin, wildly unrealistic patient expectations, wildly unrealistic consultant expectations, preposterous societal expectations that the ER is the place to get everything fixed, etc…all the while trying to do the actual medicine like catch critical diagnosis, treat things promptly, prevent morbidity, occasionally revive the dead, and more regularly keeping the nearly-dead undead while trying to connect them with definitive care.

Saying "moral injury" can sound wishy-washy and abstract, so here's some examples:

Example A: ER doc on shift before me sees a patient with GIB badly needing scope. On-call GI says pt "too sick" to be scoped at our hospital and they recommend transfer to tertiary care center. ER doc calls 7 such places across 3 states (cannot spend any more time on the phone as he's also managing a full department) and nobody has capacity to accept so patient put on waitlists. He then begs our on call GI to at least come see the patient and try. They refuse (against hospital by-laws). I come on to start my shift as patient slowly bleeds out in our ED and and outgoing doc signs patient out to me with the plan = "to die" because no GI doc could/would see the patient. Fortunately family was there for the end. On-call GI doc "investigated" by hospital and no substantive repercussions. One of the most gut-wrenching aspects of cases like this is that you know that if the patient was just driven to one of the bigger hospitals hospital ERs than their GI docs would have then had to see the patient and the scope would've happened. But if you dare told the patient that, it would trigger an EMTALA violation by which the government can fine you 50k, you'd likely be fired and have trouble getting another job, and you'd be easily sued if anything bad happened to the patient on the way there (even though they'll clearly die if they continue to hang out in your ER).

Example B: Busy evening in the ER and EMS brings in a CPR in progress. Younger looking patient, reports of minimal down time, as we're going through typical ED code stuff we start getting brief runs of ROSC before pt codes again in PEA. I notice one leg clearly bigger than the other and take a look at pts heart with bedside sono and see right ventricle is way dilated. So with massive PE possible I look at my little code team and tell them I want to push lytics but it'll commit us to doing CPR for at least 30 minutes or until we get sustained ROSC...basically, it's gonna tire the heck our of staff and kill throughput through the department, but hey this is why we're here. Patient ends up living and transferred to ICU. Next day on shift some C-suite suit comes over to me and asks why a family member of a local politician had such a "long" length of stay in the ED (for their bull**** complaint) when I was working the code and "we just need to do better." Then a few hours later my ED director comes up and tells me how expensive alteplase is and the patient is almost certainly going to be brain damaged from the downtime before CPR etc and it wasn't worth it and tied up other dept resources blah blah blah. Two days later ICU doc tells me patient is extubated and completely neuro intact. ED director still tells me I was "reckless with resources." To brighten my day I go to see the patient now on the floor. Introduce myself and patient says: "Oh you're the one. You should have called my sister before bringing me back, she would have told you I would've been happier to stay dead. I didn't give you permission to do what you did and you really should have called my sister."
Lol yup good times in the ED...

Despite the above, I feel lucky to have done EM. The practicality of the actual swath of medicine it covers cannot be rivaled by any other field. I've had some good saves, plenty of losses, and have better stories than most. I didn't run "from" EM but rather ran "to" Pain when I found out it was an approved path...EM started to most severely spiral out of control a bit after that.

Anyway, that was long-winded but hopefully makes the point-- while the knowledge and skillset of EM is swell, you're quite lucky you picked something else.

 

[Ducttape]

i should also mention to au bon pain's list that patients literally have changed.

yes, i left ER many years ago but have several friends that i talk to frequently who continue to struggle in EM...


volumes have increased tremendously.

patient expectations of their ER visit have changed, as au bon mentioned, and it is major societal shift. a cure is expected, instead of stabilization and follow up with a primary care physician. instead of "am i okay", it is "why am i not getting a CT scan/MRI/seeing the specialist, you're just a lowly ER doc".

litigious nature of ER medicine has increased markedly.

 

[bedrock]

i should also mention to au bon pain's list that patients literally have changed.

yes, i left ER many years ago but have several friends that i talk to frequently who continue to struggle in EM...


volumes have increased tremendously.

patient expectations of their ER visit have changed, as au bon mentioned, and it is major societal shift. a cure is expected, instead of stabilization and follow up with a primary care physician. instead of "am i okay", it is "why am i not getting a CT scan/MRI/seeing the specialist, you're just a lowly ER doc".

litigious nature of ER medicine has increased markedly.

That must be very frustrating.

Bosses trying to push ER docs to do less than needed at the threat of your job. Meanwhile, patients push ER docs to do more than is needed with the threat of lawsuits.

ER docs stuck in the middle. Damn.

 

[drrosenrosen]

Wow, ABP, both of those stories are as bad or worse than anything I've gone through in my career. I can't understand how anyone could continue in ED. Either one of those things happening would really wreck me for a long time.

 

[au bon pain]

Wow, ABP, both of those stories are as bad or worse than anything I've gone through in my career. I can't understand how anyone could continue in ED. Either one of those things happening would really wreck me for a long time.

Yeah, unfortunately I’ve never met an EM doc who doesn’t have stories like this.

Another fun fact that neither ducttape or I mentioned: 30% of ER patients will never pay a penny for their care…yet you HAVE to see them (even if they’re swearing at you, threatening you, assaulting you, etc). And these same patients retain every right to complain to the hospital, state med board, and/or sue you for anything and for however much their heart desires. While I enjoy caring for the poorest of the poor (still do for a small percent of my pain patients)… just another example of how the deck is stacked against the ER doc.

But the ER can have its delights. I remember walking over to check on a patient I’d intubated and to touch base with family I’d heard had arrived. A few steps outside the room I’m met with the unmistakable scent of McDonald’s. I step in and a woman in her mid-60s is hunched over the patient, methodically stuffing french fries into his mouth around the ET tube. I grab her hands and ask her what the hell she is doing. As she turns to fully face me, it becomes evident that she’s drunk and high as a kite. She burps, and calmly says “he huuungy.”

 

[MitchLevi]

But the ER can have its delights. I remember walking over to check on a patient I’d intubated and to touch base with family I’d heard had arrived. A few steps outside the room I’m met with the unmistakable scent of McDonald’s. I step in and a woman in her mid-60s is hunched over the patient, methodically stuffing french fries into his mouth around the ET tube. I grab her hands and ask her what the hell she is doing. As she turns to fully face me, it becomes evident that she’s drunk and high as a kite. She burps, and calmly says “he huuungy.”

Haha.

Reminded me of my muscular dystrophy kid in the ICU actively dying at 21 or so years of age. Dad and brother show up 2-3x per day sitting with him. Really sad situation. Very poor family. One day the dad asks us how long the young man has to live, and we're basically telling him any time now we expect him to die...He asked if we can take his Foley out so a few "friends can come in and see to his needs."

We really have no clue what that means. We then realize there are two super trashy, yet wildly hot young women accompanying the dad and the brother. Hahahahaha.

"Sir, he's on a ventilator and is essentially unconscious. We can't do that. It wouldn't have the desired effect anyways man..."

 

[lobelsteve]

Haha.

Reminded me of my muscular dystrophy kid in the ICU actively dying at 21 or so years of age. Dad and brother show up 2-3x per day sitting with him. Really sad situation. Very poor family. One day the dad asks us how long the young man has to live, and we're basically telling him any time now we expect him to die...He asked if we can take his Foley out so a few "friends can come in and see to his needs."

We really have no clue what that means. We then realize there are two super trashy, yet wildly hot young women accompanying the dad and the brother. Hahahahaha.

"Sir, he's on a ventilator and is essentially unconscious. We can't do that. It wouldn't have the desired effect anyways man..."

Could it hurt to try?

 

[MitchLevi]

Could it hurt to try?

TBH, that's an interesting ethics Q.

 

[Ducttape]

i would have let them. you can always put the foley back in later, or a texas cath.


in your case, a doc can really help without doing anything, sometimes.


funniest case was actually when i was doing ICU. chronic vented patient with severe brain injury. comatose. minimal brain function.

his wife brought in 2 signs, one with a huge red BUSH and the other with a small blue Dukakis and she said that he blinked his eye to the BUSH sign as his vote



my saddest memory was the opposite - allowing an elderly man just sit in the trauma bay for a couple of hours while his wife passed. she had been brought in by EMS from assisted living even though she was DNR. they'd been married for 50 years. he just wanted to sit by her side until she passed.

i sat with him for a while, until i had to go.




cant remember if it was to take care of another patient or go pee... thats the nature of ER.

 

[SSdoc33]

A confluence of many factors, but probably the biggest ones are:

*Private equity buying up physician-owned groups.
Predictively results in lower levels of physician coverage, increased midlevel coverage (arguably more dangerous than any other field of medicine), and, of course, pay cuts. PE groups view physicians as nothing more than widget makers and liability sponges… and as that becomes apparent in all facets of your job, you really begin to question why you keep showing up.

*For profit-hospitals and private equity groups creating EM residencies at ERs that shouldn’t have them.
This happens for two reasons, both of which are 100% about money: the short term gain of very cheap labor and then longer term gain of flooding the market to tip the balance of power to the hands of employers…and so lower labor costs in the long-term.
As the ACGME and ABEM don’t have the balls to step in and stop this nonsense, nor do any of the EM societies have either the spine or the resources to do anything…this reckless expansion went unchecked. Compared to when I was applying to residency a little over a decade ago, I think the total number of EM residency spots has literally doubled.

*Incredibly poor/unpredictable ED staffing and ancillary resources. The majority of ERs have never been the "fully staffed" kind of place. 10 years ago ER nurses were raging about having shifts where they'd have somewhat high staffing ratios that were probably not safe (1:4 or 5 semi-sick patients) and then peri-covid it could go to 1:8 or 9 or 10...wildly unsafe. And very few places listened to them...so with covid there was an understandable accelerated exodus of RN and techs from many ERs. This kind of thing destroys your efficiency, drastically increases wait times, delays care, and decimates department morale. I've had shifts where 1/3 of the scheduled nursing staff would "call out" and there'd be no coverage for them. All this severely limits what you can do for patients. Then when you get more "help" it's often brand new nurses (who a decade ago wouldn't have been allowed to start their career by working in any reasonably-high acuity ED). So they understandably make mistakes, especially with critical patients. But when you finally do stabilize a critically ill patient, there's sometimes nowhere to send them anyway. Which brings us to perhaps the most critical problem...

*Increasing amounts of moral injury…no support, no system capacity, increased boarding times, insolent and sometime violent patients, employers leaving you out to dry, idiotic press gainey scores, frivolous lawsuits, oblivious admin, wildly unrealistic patient expectations, wildly unrealistic consultant expectations, preposterous societal expectations that the ER is the place to get everything fixed, etc…all the while trying to do the actual medicine like catch critical diagnosis, treat things promptly, prevent morbidity, occasionally revive the dead, and more regularly keeping the nearly-dead undead while trying to connect them with definitive care.

Saying "moral injury" can sound wishy-washy and abstract, so here's some examples:

Example A: ER doc on shift before me sees a patient with GIB badly needing scope. On-call GI says pt "too sick" to be scoped at our hospital and they recommend transfer to tertiary care center. ER doc calls 7 such places across 3 states (cannot spend any more time on the phone as he's also managing a full department) and nobody has capacity to accept so patient put on waitlists. He then begs our on call GI to at least come see the patient and try. They refuse (against hospital by-laws). I come on to start my shift as patient slowly bleeds out in our ED and and outgoing doc signs patient out to me with the plan = "to die" because no GI doc could/would see the patient. Fortunately family was there for the end. On-call GI doc "investigated" by hospital and no substantive repercussions. One of the most gut-wrenching aspects of cases like this is that you know that if the patient was just driven to one of the bigger hospitals hospital ERs than their GI docs would have then had to see the patient and the scope would've happened. But if you dare told the patient that, it would trigger an EMTALA violation by which the government can fine you 50k, you'd likely be fired and have trouble getting another job, and you'd be easily sued if anything bad happened to the patient on the way there (even though they'll clearly die if they continue to hang out in your ER).

Example B: Busy evening in the ER and EMS brings in a CPR in progress. Younger looking patient, reports of minimal down time, as we're going through typical ED code stuff we start getting brief runs of ROSC before pt codes again in PEA. I notice one leg clearly bigger than the other and take a look at pts heart with bedside sono and see right ventricle is way dilated. So with massive PE possible I look at my little code team and tell them I want to push lytics but it'll commit us to doing CPR for at least 30 minutes or until we get sustained ROSC...basically, it's gonna tire the heck our of staff and kill throughput through the department, but hey this is why we're here. Patient ends up living and transferred to ICU. Next day on shift some C-suite suit comes over to me and asks why a family member of a local politician had such a "long" length of stay in the ED (for their bull**** complaint) when I was working the code and "we just need to do better." Then a few hours later my ED director comes up and tells me how expensive alteplase is and the patient is almost certainly going to be brain damaged from the downtime before CPR etc and it wasn't worth it and tied up other dept resources blah blah blah. Two days later ICU doc tells me patient is extubated and completely neuro intact. ED director still tells me I was "reckless with resources." To brighten my day I go to see the patient now on the floor. Introduce myself and patient says: "Oh you're the one. You should have called my sister before bringing me back, she would have told you I would've been happier to stay dead. I didn't give you permission to do what you did and you really should have called my sister."
Lol yup good times in the ED...

Despite the above, I feel lucky to have done EM. The practicality of the actual swath of medicine it covers cannot be rivaled by any other field. I've had some good saves, plenty of losses, and have better stories than most. I didn't run "from" EM but rather ran "to" Pain when I found out it was an approved path...EM started to most severely spiral out of control a bit after that.

Anyway, that was long-winded but hopefully makes the point-- while the knowledge and skillset of EM is swell, you're quite lucky you picked something else.

amazing post.

write a book.

id buy it

 

[Baron Samedi]

The only thing I think I missed out on doing PM&R is comfort with IV sedation beyond versed/fentanyl, but I don't think that's worth picking one residency over another. Do whatever you find interesting. Four years is a long time.

 

[HinduHammer]

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).

Psych here. Not as simple as it seems my friend.

 

[bedrock]

Psych here. Not as simple as it seems my friend.

Details please

 

[HinduHammer]

Details please

Cash-only PP requires a lot of business acumen and marketing. First of all, most desirable areas are saturated. If you want to diferentiate yourself, what do you have to offer that's different? If you are Psychoanalytically trained or have some other strategy, you can differentiate yourself.

Once differentiated from the 'run of the mill' psychiatrist or, god forbid, "DNP with specialized training in ECT/TMS/CNN/HGTV/TCBY/BYOB", you have to build a business including finding a price point to bring in new patients but low enough to still make money; and to not egregiously go from say 200/hour to 500/hour within 12 months (breaking therapeutic alliance).

You have to spend a lot upfront to network, build a website or brand, market yourself, start getting patients, and doing great work so you increase your referral by word of mouth and have happy customers, and then keep going out to get referrals; you can't rest either, have to read and stay upto date on ketamine, whatever.

It's just not the Golden Ticket. There is no way to practice Good Psychiatry and make as much as Pain / Derm / Ortho without sacrificing your ethics, or being a phenomenal business person. If you can do the latter, sure, I suppose you can make it. assuming there are enough uber wealthy types who want to pay you this much given the state of the world right now.

edit: word in second sentence