Introspection about a career in pain...

[Timeoutofmind]

Half way though CA2 year here. I am strongly considering pain medicine. The more I think about and look into it, the more it seems like a great fit for me. Its a pretty amazing field actually. But I have one hangup...

The thing about anesthesia is....as painful as dealing with ridiculous surgeons is, very stressful at times, and the overnight calls suck, etc...at the end of the day, I feel I have done some definite and real good (e.g. the person has a new knee, or the infected gall bladder is out).

I know, especially looking through some of these threads here, that pain is not all sunshine and roses...that you have to deal with difficult peronsality types, chemical copers, etc. I am OK with that.

My one hesitancy is this: between the constant narcotics negotiations and trying to fix everyone's complex psycho-socio-emotional-spiritual multifactorial pain issues with a needle, in all honesty, do you ever feel like it's just a customer service job/making a living without a more lasting and strong impact in people's lives? I know its not always black and white...but I am asking if it at the end of the day. you feel you signficantly impact the quality of life of the majority of the patients you see, or if the interventions we can offer are just a drop in the bucket of the real issues facing chronic pain patients? Are most of your patients reasonable people who want to get better and are willing to exert some effort as such, or people just looking to cope chemically with the tough aspects of life?

I dont want to look back at the end of my career and feel as though I haven't done some real and definite good for humanity...as that is the reason we all went into this craziness in the first place!

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[clubdeac]

I feel like I make a lasting impact most days of the week. More days than not I have patients come back that are MUCH improved by something I've done with a significant change in their quality of life. This could be due to simple things like starting lyrica, doing an ESI, CT injection, or GTB injection or it could be from RF, phenol neurolysis or SCS. Sometimes it's the simple things that end up meaning a lot to someone. Coming from a rehab background, I couldn't be happier doing pain. In fact, I don't think I could really be all that satisfied doing anything else with that training, unfortunately.

 

[emd123]

the overnight calls suck, etc...!

Being able to have a normal life, without working all night is big, and should not be underestimated. That's good for the soul, and family life.

.at the end of the day, I feel I have done some definite and real good (e.g. the person has a new knee, or the infected gall bladder is out)

If you go to work each day with the goal of "doing real good," you will. It comes in more subtle forms. You can save a life by not prescribing opiates to someone abusing meds, someone that everyone else is willing to prescribe to. You can save a life by treating the pain of someone suicidal because they're in so much agony. You can help countless people by offering them healthy choices for their pain relief. Of course some will not be help-able, because they may choose what is more toxic. You must be able to accept this.

My one hesitancy is this: between the constant narcotics negotiations ,

There should absolutely be no "constant narcotic negotiations." If you are doing this, you have lost already, have failed, and are being manipulated and are co-dependent. You are the doctor, you recommend what you recommend. If they agree, then great. If not, they can seek a second opinion. Period. If it's a dire emergency, they can go to the ER. Never, EVER, prescribe under pressure or due to manipulations or "negotiations." There are many protocols that can make this clear to patients and referring doctors such that this nonsense is kept to a minimum. These things are discussed on other threads. I don't prescribe benzos (except 1-2 tabs for a stim trial or MRI), soma, roxicodone, methadone, or crazy doses of meds, and I have zero tolerance for aberrancy. I'm not shy about saying, "I believe the risks of opiates outweigh the gains" or "opiates have failed" if it's true in a patient. These patients move on to the practices that tolerate this. I'm also not afraid to say, "You need an addiction/psych doctor, not a pain doctor" if it's the right thing for a patient. I also sleep well at night.

trying to fix everyone's complex psycho-socio-emotional-spiritual multifactorial pain issues with a needle,

This can't be done, so you shouldn't even be trying.

feel you signficantly impact the quality of life of the majority of the patients you see,

Does it have to be a "majority"? Always 51% or more? I don't know, but I offer what I think will help, and I refuse to offer what will hurt. A lot of patients don't come back. That's okay. I'm content not being the busiest guy in town. I can't help everyone, but I can offer things that will "do no harm." In today's world, that's a big deal.

I dont want to look back at the end of my career and feel as though I haven't done some real and definite good for humanity...as that is the reason we all went into this craziness in the first place!

If this is your goal, absolutely you can achieve it, but it has to be your goal. If your goal is to make $1,000,000, or to dominate your market, be the #1 stim guy in your state or city, or anything else, then it may not be possible. It also may mean you practice very differently from some of the people teaching you.

I think if this is your attitude and goal, the specialty of Pain Medicine absolutely needs more people like you.

 

[powermd]

As an anesthesia resident you only have a tiny piece of the picture of a career in pain medicine within your grasp. It's a whole world unto itself, and you'll never really appreciate it all until you're immersed in it.

When I was a CA-2 I decided to take a chance on pain because:
1. I wanted to do more than stool sit or supervise CRNAs for decades.
2. I wanted to use a wider variety of medical skill sets than just anesthesia/critical care.
3. I hated night call.
4. I liked the idea of having my own office and not working for a hospital/institution.
5. The pay is great, and lifestyles are flexible.
6. People in the field seemed thrilled to be there.

All of this has been true/beneficial for my career so far.

What I would add now that I've been practicing pain medicine for five years:

1. Have a desire to learn the musculoskeletal system structure and function, and how people use and abuse their bodies. It's taken a while to develop the knowledgebase (and I was in no way fully prepared coming out of fellowship), but I can diagnose 75% of what comes through my office in less than 60 seconds based on history and a simple exam.

2. It's more important to your career than anything else that the patient LIKE YOU. That means taking a little time for chit chat and finding a way to get the patient to identify with you. If you're an affluent suburb kind of doc, you need to learn how to talk with blue collar people on their level. You must also develop a sensitivity to catch judgmental statements before they leave your lips. Unless you are specifically being asked by the patient or another doctor to comment on a patient's (fill in the blank with whatever addictive or self-destructive behavior you like), just don't go there.

3. Be okay with persistent gloom and doom on the reimbursement horizon. But remember this, no matter what CMS does with reimbursement for pain medicine, the most common reason patients go to the doctor is for pain. There will never be a shortage of the problem. Built a reputation for excellence in your community, and you will always have a job.

Oh, and finally, I don't miss anesthesia!

Half way though CA2 year here. I am strongly considering pain medicine. The more I think about and look into it, the more it seems like a great fit for me. Its a pretty amazing field actually. But I have one hangup...

The thing about anesthesia is....as painful as dealing with ridiculous surgeons is, very stressful at times, and the overnight calls suck, etc...at the end of the day, I feel I have done some definite and real good (e.g. the person has a new knee, or the infected gall bladder is out).

I know, especially looking through some of these threads here, that pain is not all sunshine and roses...that you have to deal with difficult peronsality types, chemical copers, etc. I am OK with that.

My one hesitancy is this: between the constant narcotics negotiations and trying to fix everyone's complex psycho-socio-emotional-spiritual multifactorial pain issues with a needle, in all honesty, do you ever feel like it's just a customer service job/making a living without a more lasting and strong impact in people's lives? I know its not always black and white...but I am asking if it at the end of the day. you feel you signficantly impact the quality of life of the majority of the patients you see, or if the interventions we can offer are just a drop in the bucket of the real issues facing chronic pain patients? Are most of your patients reasonable people who want to get better and are willing to exert some effort as such, or people just looking to cope chemically with the tough aspects of life?

I dont want to look back at the end of my career and feel as though I haven't done some real and definite good for humanity...as that is the reason we all went into this craziness in the first place!

 

[Timeoutofmind]

Thank you very much for your thoughtful replies.

I found them very helpful.

I am on the pain train! Chooo-chooo!

 

[clubdeac]

Actually may want to check out the 2014 reimbursement thread before making that decision....

 

[emd123]

Actually may want to check out the 2014 reimbursement thread before msg'ing that decision....

If you're basing you're career choice on whose pay the Government is slashing or raising, you're right. Based on that, you shouldn't become a doctor at all, but one of these:

"Chiropractic- UP 12% overall,
Clinical psych/social work- UP 8%
Nurse Anesthesia- UP 3%"

See CMS 2014 thread, page 18, for the specialty breakdown of the winners and losers:

http://forums.studentdoctor.net/index.php?threads/2014 CMS.1043607/

 

[Ligament]

I love what I do. All specialties except fckng leeches like NPs and CRNAs are hurting.

 

[emd123]

I love what I do. All specialties except fckng leeches like NPs and CRNAs are hurting.

And chiro

12% CMS increase

 

[bronchospasm]

Practiced anesthesia for 5 years and then having just started my practice right out of fellowship, I can tell you that Pain is very rewarding. Every patient is different, they have their own story and being able to relate with them at a different level is huge. Most patient seek your help because they need relief and being able to impact their lives however small it may be is very satisfying. Something that I never experienced as an anesthesiologist. .. Not dealing with difficult surgeons and 3 am labour epidurals are an added bonus.

And if you start your own practice, there is a sense of accomplishment...

No right answer here... Pick one and don't look back.

 

[Squishyface]

I'm a practicing anesthesiologist in a mixed model (CRNAs and AAs) at a mid sized hospital. I've been out of residency ten years and have had my fill of 7-8 overnight calls per month (my wife really loves these...having two small kids and another on the way soon), hospital admins, toxic surgeon personalities, and contracts/subsidies that just don't seem to materialize. I'm currently the chairman of my group and I'm gaining some experience at running a group, both the business and administrative sides. I actually love my job and make a decent amount ($450k or so). However, seeing the big picture, I'm also thinking about doing a pain fellowship in the next few years and going that route. My reasoning is as follows...

As a CA2 resident, you are still doing your specialty rotations, and I know when I was at that stage I couldn't see the big picture. The big picture is that mid level providers are here to stay and there is not a whole helluva lot anyone can do about it. You can hope that significant differences in outcomes show up, but I don't think that's going to happen. As practice models become more efficient and we move into managed care models, anesthesiologists will become a mix of staffing CRNAs and administrators for preoperative surgical homes (look that up....it's very important). So your options, if you go the gas passing route, are to learn to work with and supervise crnas and aas or learn a whole lot about IT/data collection and the peri operative surgical home. Either way, salaries and subsidies are on the decline and private practice models like my own will be a rare occurrence 5-10 years from now. I'm not even sure docs who go it alone in ORs doing hearts will be a sustainable model in the future. We have basically made anesthesia very safe to the point that a well trained nurse can do 99% of our job.

That part is depressing, and telling how good I've become at sudoku and crossword puzzles over the past ten years is not what you want to hear. However, I consider my career very rewarding. I make a good living, even though my schedule is hectic. I enjoy going to work and love my job. My wife hates my hours and there is basically no way for her to go back to work while I'm doing this job. So there are downsides.

From what I've read on this forum so far, pain medicine is going through its own trials and cuts. However, there will never be a shortage of pain patients....just a shortage of insured pain patients, there is no call, you can be master of your own domain (ie start your own business), set your own hours, and chances are you will make more money in the long run with a more stable schedule. That may not be true of hospital based pain practices, I'm not sure.

As far as advice for you....either way your career will be rewarding. If you are a good doctor, you will help every patient you come in contact with, whether it's getting them through a tough procedure or canceling that same procedure due to a safety issue, putting a scs in a patient or telling them that you won't give them narcotics. Definitely do more pain rotations your ca3 year if you can. I did six months of hearts...and don't even do those now...lol. Either way..good luck!

 

[SeniorWrangler]

Pain management is a field that will never go away in our lifetimes, but I expect the situation for reimbursement and coverage of pain *procedures* to get tighter and tigher as far as the eye can see.