Chronic Pain without a fellowship

[cowbydoc]

I wanted to get advice from all the people that use this forum. I was recently approached by a pain doc here in my hometown about possibly joining his practice. I am not pain trained but he says that he would rather train someone he likes and can get along with as a partner rather than "some random person who could be a jerk and happens to be fellowship trained". He has an established practice that seems well set up and he does very well financially. I have concerns, mainly about future reimbursements, possible referral issues and my viability in practice after he retires 10-15 years from now. What do you guys think? I'm a new grad and my job opportunities in this specific region of the country are limited and this has fallen in my lap. Thanks for the help.

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[narcusprince]

I would opt not to take the job. Chronic Pain patients in my experiance are some of the most difficult to manage and these patients a lot of times are very well informed on your board certification and fellowship training. As soon as a procedure did not go well or patient outcome not to their satisfaction the lawyers come around. Not sure you could get covered for malpractice either in a 100% pain practice. Would you be willing to do a fellowship in pain and call back in a year? G0od luck finding work!

 

[BobBarker]

I think you would be ok if you are practicing in the state that I think you are as far as litigation goes. Many older anesthesiologists doing pain in this state without fellowship.

 

[gasdoc77]

I would take that gig in a second. Plenty of docs have done it successfully. Everyone who gives advice will have their personal bias and reasons for their position. It will take longer to ramp up your skill set than fresh out of fellowship, but you will likely reach the same endpoint if you are self disciplined. Its obvious which route is the gold standard, but their are many pain boards out there if you look around. As for reimbursements, aren't there nurses that have been doing pain in many states?

 

[IlDestriero]

Tell him you'll see him in a year.

 

[IlDestriero]

Tell him you'll see him in a year.

I actually know someone who did this. She was slave labor for 2 years. Then he wanted to hire her as a junior partner, she wanted to leave and had trouble finding a job with this pseudo fellowship.

 

[IlDestriero]

And my friend Google tells me that she is currently NOT practicing pain. That sucks.

 

[sleepallday]

All depends on what the contract looks like, what kind of practice he has, and how well you know him.

If everything looks good…I would go for it. You don't need a fellowship to practice pain.

 

[epidural man]

I did a pain fellowship.

Here is the problem facing pain. The money comes from procedures. However, this is quickly changing. Reimbursements are shrinking and insurances are starting to refuse to pay for a lot of the procedures. This is due to a lack of clear efficacy data - and crappy literature (NEJM recent article) from severly biased physicians that negate the effects of procedures.

You can absolutely learn a lot of pain procedures, but I don't think you will ever feel really comfortable with complicated procedures (kyphoplasty, intrathecal delivery systems, spinal cord stimulation, discograms, implanted peripheral nerve catheters for cancer pain, neurolytic blocks, stellates, celiace plexus blocks, etc). I think without a fellowhip, you will never get comfortable dealing with complicated pain patients that need more than epidurally placed steroid. For example, cancer patients are complicated patients, and they ALWAYS stretch my abilities.

In addition, procedure pain is on the ropes. The real answer to much of pain medicine is functional restoration programs - which you will care little or know little about - and your pain friend will also know nothing about it.

Having said all that, you certainly can be happy and make a great living for a while doing bread and butter procedures. I would MAKE SURE he doesn't make you see opioid patients and just refill a bunch of patient's opioid scripts.

I also think you will be expected to be an "expert" in all things pain medicine - meaning the neurobiology of pain and all the funny conditions that go with it (CRPS, central pain, fibromyalgia, migraine headaches, lime disease pain, phantom limb pain, etc). You can learn that stuff from a lot of studying.

 

[OffPiste]

I am also pain trained, and tend to agree in many respects with epidural man's analysis. Pain, like all of healthcare, is being pressured on all fronts. Unfortunately, many of the problems with pain stem from these types of non-accredited fellowships, which has given pain somewhat of a wild-west image, with tremendous variation in training and standards. I know several senior colleagues who I view as mentors that never did a true fellowship, and are great clinicians. However, I think the days of this type of practice are over, and view the arrangement in question as just a way for an unscrupulous senior partner/owner to make some easy money, rinse, and repeat.
We have already seen in a number of states the requirement that pain clinics be licensed, often requiring an owner who has some proof of fellowship training and board status. It is not a far stretch to see that insurers may start to make similar stipulations. In fact, some carriers in my region will not credential docs who have not done a formal ACGME fellowship with real board certification( ie: ABA, etc).
I fret daily about what the future holds for interventional pain. But, that being said, those worries are the same in gas, and many other fields. Look at the battle axe that CMS took to Pathology this year. Tough times all around.
But, there are no shortage of pain patients, and it is much easier to carve a niche in pain and feel relatively safe professionally for quite some time.

 

[cowbydoc]

Thanks for all the advice. All your concerns are the same ones I have, it is a tough decision. I appreciate all the input from you guys with experience in the real world, residency only teaches you so much.

 

[Yo GabbaPentin]

I am also pain trained, and tend to agree in many respects with epidural man's analysis. Pain, like all of healthcare, is being pressured on all fronts. Unfortunately, many of the problems with pain stem from these types of non-accredited fellowships, which has given pain somewhat of a wild-west image, with tremendous variation in training and standards. I know several senior colleagues who I view as mentors that never did a true fellowship, and are great clinicians. However, I think the days of this type of practice are over, and view the arrangement in question as just a way for an unscrupulous senior partner/owner to make some easy money, rinse, and repeat.
We have already seen in a number of states the requirement that pain clinics be licensed, often requiring an owner who has some proof of fellowship training and board status. It is not a far stretch to see that insurers may start to make similar stipulations. In fact, some carriers in my region will not credential docs who have not done a formal ACGME fellowship with real board certification( ie: ABA, etc).
I fret daily about what the future holds for interventional pain. But, that being said, those worries are the same in gas, and many other fields. Look at the battle axe that CMS took to Pathology this year. Tough times all around.
But, there are no shortage of pain patients, and it is much easier to carve a niche in pain and feel relatively safe professionally for quite some time.

Gee, I wonder why it has a wild-west image. You have pain "docs" walking up to random anesthesiologists offering to hire them. I know in certain rural areas of the country, the towns have the majority of practices run by non fellowship trained anesthesiologists who lost OR opportunities due to drug abuse!

For the majority, the only qualifications that a general anesthesiologist has is a comfort with blind epidurals in laboring patients. When's the last time you did a physical exam? This isn't anything against you, but I just think it's a bad idea. If you have a complication, you can count on getting absolutely raped. And what happens when the insurance companies require board certification in pain for reimbursement? There is talk of this happening.

There is also a huge financial negative for you. You are likely know next to nothing about billing for pain. The scenario I envision, is you being "trained" while doing a boat load of injections which he bills for while paying you peanuts. There are a lot of shady pain practices out there and most of the shadiest are in a panic mode right now. They all have a complicated formula related to collections and overhead which will leave your head spinning. I would be very very skeptical if I were you. Consider him a guy in a windowless van offering you a bunch of candy to get in.

 

[BLADEMDA]

Thanks for all the advice. All your concerns are the same ones I have, it is a tough decision. I appreciate all the input from you guys with experience in the real world, residency only teaches you so much.

Ask your "friend" to wait a year for you to join him. If he truly wants you as his partner then he will understand your desire to do an actual fellowship somewhere in pain. In addition, if he agrees to wait for you to join his practice he should be willing to put the terms of such an arrangement on paper with his signature. Now, with a real contract/agreement in hand you go find a pain fellowship ASAP.

 

[OffPiste]

Yo Gabba
Maybe you misunderstood my post.
I very much agree with you, and was replying to Cowboydoc's question about doing pain sans fellowship. I think that the opportunity he describes is questionable at best, and there is no way I could recommend anyone get involved with pain without fellowship training in this day and age. Can it be done? Sure. Bad idea, and usually associated with something shady.
I am boarded in both pain and gas. I would never even contemplate bringing someone into my practice who was not boarded in pain via ACGME fellowship from Anes or PMR.

 

[Yo GabbaPentin]

Yo Gabba
Maybe you misunderstood my post.
I very much agree with you, and was replying to Cowboydoc's question about doing pain sans fellowship. I think that the opportunity he describes is questionable at best, and there is no way I could recommend anyone get involved with pain without fellowship training in this day and age. Can it be done? Sure. Bad idea, and usually associated with something shady.
I am boarded in both pain and gas. I would never even contemplate bringing someone into my practice who was not boarded in pain via ACGME fellowship from Anes or PMR.

Nothing against you at all. Mostly just against the plethora of dirt bag pain docs ruining the entire specialty. You were just giving your best advise.

I'm fed up with the flood gates of pain open to whoever feels like jumping in. Non Fellowed anesthesia, neuro, FP, nurses, ortho, etc. The wild west is a freaking understatement! I'm waiting for the day an orthopedic doc comes up to me to offer "training" on how to do hip replacements.

Dollars to donuts that this "friend" is essentially going to try to squeeze a year or two of serious injection monkey production out of the OP at fellowship like salary in the name of "training."

 

[HenryH]

Several people have mentioned that the requirement that a doc to be board certified in pain management is likely to be proposed in the future; just out of curiosity, with this notion being tossed around, what's the deal with the CRNA/CMS pain management "victory" the AANA achieved about a year ago? Why would the gov't. care as to whether or not a physician is board certified if they seem to have no problem with the concept of CRNAs doing the same type of work, but (obviously) without board certification? Just curious...