Non-interventional vs Interventional Pain

[Turducken21]

I apologize for my ignorance but I’ve seen forum posts on here as well as job postings talking about interventional and non-interventional pain. I understand the concept as far as the difference in their day to day work but am curious if there is any difference in their training. Are there specific fellowships for interventional and non-interventional or are they combined? Also, are “interventional” positions reserved for anesthesia or can someone from PMR, neuro, psych etc also focus on interventional pain? Thanks in advance.

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[RoloTomassi]

Anyone can do non interventional pain. The additional training is for procedures. All the above specialties can do interventional pain with adequate additional training.

 

[bedrock]

I apologize for my ignorance but I’ve seen forum posts on here as well as job postings talking about interventional and non-interventional pain. I understand the concept as far as the difference in their day to day work but am curious if there is any difference in their training. Are there specific fellowships for interventional and non-interventional or are they combined? Also, are “interventional” positions reserved for anesthesia or can someone from PMR, neuro, psych etc also focus on interventional pain? Thanks in advance.

As rolo said, anyone will a medical license can write controlled substances. No fellowship required.
But it’s not particularly enjoyable if that is your entire job. In my area there are “pain clinics” run almost solely by NPs. In other areas , some FP or IM docs do solely medical pain management.

Regarding pain fellowships (where you learn interventional pain procedure). They are technically open to all specialties but >95% of pain fellowships are filled by either PMR or anesthesia residency graduates.

If you’re a med student interested in pain, I would shoot for one of those two residency programs. If you’re already a resident in another specialty, it is hard (not impossible but dramatically harder) to match into an ACGME pain fellowship

 

[Turducken21]

Thank you for the responses. I did a year of EM and then switched to psychiatry. Realized I didn’t quite like the acuity of EM (or the outlook) and enjoyed the continuity and impact you have in psychiatry. I did like the procedures though and miss them from time to time. I’m considering pain as somewhat of a combination of impact and procedures. It’s been fun to learn about the field, thank you all.

 

[Doctodd]

Why didn’t you like the outlook of EM?

 

[GatorCHOMPions]

Why didn’t you like the outlook of EM?

Just go peruse the EM sub forum and look at some of the titles of recent threads. There is a projected oversupply of 10k EM physicians by 2030. There is also diminishing physician ownership and therefore the last sliver of control for EM docs. I know this is happening everywhere, but being both EM and Pain boarded you don’t know what lack of control is until you’ve worked in the ER pit for a few years. I’m hospital employed Pain now and the control factor is 10x better.

DEFINE_ME

 

[cowboydoc]

Thank you for the responses. I did a year of EM and then switched to psychiatry. Realized I didn’t quite like the acuity of EM (or the outlook) and enjoyed the continuity and impact you have in psychiatry. I did like the procedures though and miss them from time to time. I’m considering pain as somewhat of a combination of impact and procedures. It’s been fun to learn about the field, thank you all.

I trained with a psychiatrist in pain fellowship and there is one in my area now. In training, the psychiatrist had terrible hands early in the year, but made a great pain doc eventually. Your year of EM serves you well to mitigate that issue. Getting some rotations where you do some procedures would help.

Frankly, there are some programs that probably wouldn't give you serious consideration, but some would be quite open to a psychiatrist pursuing pain. When applying, look at recent grads and apply to programs that have some diversity of applicants regarding primary training track.

 

[Turducken21]

Just go peruse the EM sub forum and look at some of the titles of recent threads. There is a projected oversupply of 10k EM physicians by 2030. There is also diminishing physician ownership and therefore the last sliver of control for EM docs. I know this is happening everywhere, but being both EM and Pain boarded you don’t know what lack of control is until you’ve worked in the ER pit for a few years. I’m hospital employed Pain now and the control factor is 10x better.

DEFINE_ME

Well put and thanks for your insight. I realized the good old days of EM were ending and because I was never an “EM or die” kind of person and really enjoyed another field, I decided to make the switch.

 

[Turducken21]

I trained with a psychiatrist in pain fellowship and there is one in my area now. In training, the psychiatrist had terrible hands early in the year, but made a great pain doc eventually. Your year of EM serves you well to mitigate that issue. Getting some rotations where you do some procedures would help.

Frankly, there are some programs that probably wouldn't give you serious consideration, but some would be quite open to a psychiatrist pursuing pain. When applying, look at recent grads and apply to programs that have some diversity of applicants regarding primary training track.

Thanks for your insight cowboydoc. I’ve read that, and am ok with the fact that some programs won’t be interested in me coming from psychiatry. It makes sense honestly. It’s good to hear that it’s not impossible though. It seems like it’s an uphill battle but so is anything worse pursuing. I’m not sure if I’ll end up going this route but we’ll see. Thanks again!

 

[drrosenrosen]

One of my attendings in fellowship was a psychiatrist. She brought an interesting perspective to things. You can train procedures - the reason that most anesthesiology based fellows are better at least at the beginning of the year is just repetition and practice. The hard part of this job is the mental processing, and I imagine from psychiatry you'd be better suited at things like setting boundaries with patients, knowing how to compartmentalize from patients crazy, and motivational interviewing. Those are all important parts of the job, too.

 

[Agast]

Psychiatry is really hot right now. My friend works 9-4, charges cash, her only overhead is her office space. Everything can be done online.

 

[Ferrismonk]

Psychiatry is really hot right now. My friend works 9-4, charges cash, her only overhead is her office space. Everything can be done online.

Interesting. Any idea what they're making?

 

[Agast]

Interesting. Any idea what they're making?

Apparently there are a few insurance plans she will take. Her cash rate is $400 for a 40 minute new patient evaluation, $175 for a 20 minute follow up. There are a lot of psychiatrists in my area that don't take any insurance at all. You'll notice the psychiatrist aren't dabbling in wellness/hormone/medspa like the rest of us...so the eatin' must be good

 

[HemorrhagicShock]

Is non-interventional pain medicine even a viable way to run a practice (that takes insurance/contracts with some bigger organization)?

 

[BobBarker]

Is non-interventional pain medicine even a viable way to run a practice (that takes insurance/contracts with some bigger organization)?

Sure, office visits pay on average a little over $100. That is plenty of money for most people.

 

[HemorrhagicShock]

Sure, office visits pay on average a little over $100. That is plenty of money for most people.

How many can one reasonably stack in an hour's worth of clinic time? Also, is that $100 gross or net after considering operating costs?

 

[BobBarker]

Gross. But if you aren’t doing interventions, you don’t need very much staff.

 

[cowboydoc]

How many can one reasonably stack in an hour's worth of clinic time? Also, is that $100 gross or net after considering operating costs?

15 min f/u, 30 new is pretty standard. Could definitely push that if motivated.

 

[BobBarker]

10 min f/u, 20 min new at my private practice. Very few double books.
Turned and burned a lot harder at the hospital.

 

[epidural man]

I know a pain-trained pychiatrist who is doing psych instead of pain because it pays so well.

We have trained two psych docs for pain. They do great. They bring a uniqueness to the field, and I really enjoyed training both of them (much better than those anesthesia and PM&R yahoos who won't even do rectals for their intake exam).

 

[Pain Applicant1]

Psychiatry is really hot right now. My friend works 9-4, charges cash, her only overhead is her office space. Everything can be done online.

I agree with this. Everything shifts and cycles. No one went into this field a few years ago and now there's a massive undersupply. At least for the next decade or so this should be a great specialty. You could probably easily start off with your own practice and do cash pay. 6-8 months back up here if you're lucky as a pt. If I was starting over, I would probably consider something like this over pain medicine if I was looking solely at supply and demand in today's market.

 

[SSdoc33]

Apparently there are a few insurance plans she will take. Her cash rate is $400 for a 40 minute new patient evaluation, $175 for a 20 minute follow up. There are a lot of psychiatrists in my area that don't take any insurance at all. You'll notice the psychiatrist aren't dabbling in wellness/hormone/medspa like the rest of us...so the eatin' must be good

double it, and that would be closer to the rates i am seeing

at least for the good ones

 

[HemorrhagicShock]

I agree with this. Everything shifts and cycles. No one went into this field a few years ago and now there's a massive undersupply. At least for the next decade or so this should be a great specialty. You could probably easily start off with your own practice and do cash pay. 6-8 months back up here if you're lucky as a pt. If I was starting over, I would probably consider something like this over pain medicine if I was looking solely at supply and demand in today's market.

For me as an ER doc unfortunately I don't have the pop-off valve of any kind of real cash pay 9-5 clinic-based practice. I suppose you could say urgent care, but for a lot of reasons that's just not comparable to a low-to-no overhead psych cash pay practice.

That was part of the context of my original question. I am considering doing a pain fellowship, and I was wondering if a non-procedural practice was doable because to me that seems like it would look similar to a psych cash pay practice on paper.

I am doing an observership with a pain medicine buddy of mine once the new year starts, he has his own clinic and actually owns shares in an ASC. It's a bummer to think we went to the same medical school and here we are at two very different points in our career satisfaction!

 

[Pain Applicant1]

For me as an ER doc unfortunately I don't have the pop-off valve of any kind of real cash pay 9-5 clinic-based practice. I suppose you could say urgent care, but for a lot of reasons that's just not comparable to a low-to-no overhead psych cash pay practice.

That was part of the context of my original question. I am considering doing a pain fellowship, and I was wondering if a non-procedural practice was doable because to me that seems like it would look similar to a psych cash pay practice on paper.

I am doing an observership with a pain medicine buddy of mine once the new year starts, he has his own clinic and actually owns shares in an ASC. It's a bummer to think we went to the same medical school and here we are at two very different points in our career satisfaction!

You can do very well not doing procedures and just seeing patients. 6 follow-ups per hour can add up quickly. Consider doing suboxone to help fill your schedule. Consider doing weight loss to fill up your schedule. Consider ancillaries like UDS testing if necessary. There are a million things you can excel at and that your license allows you to do.

I just skimmed through this thread so sorry if I'm missing something but are you miserable being an ER doc? There's nothing worse than hating to go to work every day. Consider taking the risk and starting off on your own. Take a course or two if necessary and shadow someone here and there. Offer a day of free labor if they willing to teach you. I bet you'll do great.

 

[lobelsteve]

You can do very well not doing procedures and just seeing patients. 6 follow-ups per hour can add up quickly. Consider doing suboxone to help fill your schedule. Consider doing weight loss to fill up your schedule. Consider ancillaries like UDS testing if necessary. There are a million things you can excel at and that your license allows you to do.

I just skimmed through this thread so sorry if I'm missing something but are you miserable being an ER doc? There's nothing worse than hating to go to work every day. Consider taking the risk and starting off on your own. Take a course or two if necessary and shadow someone here and there. Offer a day of free labor if they willing to teach you. I bet you'll do great.

Doing weight loss and addiction is a red flag for the DEA. If there are Rxs for amphetamines for weight loss and suboxone or opiates from same doctor- well that just sticks out and is asking to be investigated. Do not do it.

 

[bedrock]

Apparently there are a few insurance plans she will take. Her cash rate is $400 for a 40 minute new patient evaluation, $175 for a 20 minute follow up. There are a lot of psychiatrists in my area that don't take any insurance at all. You'll notice the psychiatrist aren't dabbling in wellness/hormone/medspa like the rest of us...so the eatin' must be good

Help me understand. Are there a lot of crazy people with cash to burn who will pay psych out of their own pocket? Most of the patients I have met who truly needed a psychiatrist over a PCP, could barely hold a job, let alone pay $400 cash each month.

 

[Agast]

During our psychiatry rotation the attending brought a manic patient to see us. She wanted to give us each $10,000 to go back to our respective home countries and work to create world peace. Turned out she was from an extremely wealthy family and whenever she had an episode she was literally giving away tens of thousands of dollars to randos who promised her they would go off and create world peace.

 

[cowboydoc]

During our psychiatry rotation the attending brought a manic patient to see us. She wanted to give us each $10,000 to go back to our respective home countries and work to create world peace. Turned out she was from an extremely wealthy family and whenever she had an episode she was literally giving away tens of thousands of dollars to randos who promised her they would go off and create world peace.

 

[Pain Applicant1]

Doing weight loss and addiction is a red flag for the DEA. If there are Rxs for amphetamines for weight loss and suboxone or opiates from same doctor- well that just sticks out and is asking to be investigated. Do not do it.

Who says you have to prescribe amphetamines for weight loss? Just do wegovy. Cherry pick the appropriate patients. Same with opioid dependency. Cherry pick those who are appropriate and respond well for Suboxone. That's the beauty of working for yourself, you can do and see whatever and whoever you want.

 

[lobelsteve]

Who says you have to prescribe amphetamines for weight loss? Just do wegovy. Cherry pick the appropriate patients. Same with opioid dependency. Cherry pick those who are appropriate and respond well for Suboxone. That's the beauty of working for yourself, you can do and see whatever and whoever you want.

Doing weight loss and addiction is a red flag for the DEA. If there are Rxs for amphetamines for weight loss and suboxone or opiates from same doctor- well that just sticks out and is asking to be investigated. Do not do it.

 

[Ducttape]

Who says you have to prescribe amphetamines for weight loss? Just do wegovy. Cherry pick the appropriate patients. Same with opioid dependency. Cherry pick those who are appropriate and respond well for Suboxone. That's the beauty of working for yourself, you can do and see whatever and whoever you want.

many docs who do this get burned out after a while of sticking to their high horses. however, in order to keep the hamster wheel going, some will collapse their morals. what happens then is that their volume ie $$$ increases as the druggies start to talking.



its easiest to never get involved, than to have the same tiresome argument with patients why they cant get dilautine or oxy or speed or ganga with their percs until one gives up (and then the money comes pouring in...)

 

[Pain Applicant1]

many docs who do this get burned out after a while of sticking to their high horses. however, in order to keep the hamster wheel going, some will collapse their morals. what happens then is that their volume ie $$$ increases as the druggies start to talking.



its easiest to never get involved, than to have the same tiresome argument with patients why they cant get dilautine or oxy or speed or ganga with their percs until one gives up (and then the money comes pouring in...)

I'm not understanding. Having good patients makes for a much better practice environment. I'm speaking from personal experience. A wee bit boring but definitely not burn out.

No need to collapse morals to keep hamster wheel going. There are plenty of opioid dependent patients out there who want and need help. Plenty to go around. These are typically good people who just happen to have gotten caught up in something awful and you're helping many of them out at the lowest points in their lives. I imagine it's something similar with food addiction and weight loss.

 

[Ducttape]

you are probably less likely to get burnt out if you weed out and do not see challenging patients.

it sounds like you are in a noncompetitive environment where you are the only pain doctor available, which allows you to cherry pick who you see. good for you, unattainable for the majority of pain physicians.

 

[Pain Applicant1]

you are probably less likely to get burnt out if you weed out and do not see challenging patients.

it sounds like you are in a noncompetitive environment where you are the only pain doctor available, which allows you to cherry pick who you see. good for you, unattainable for the majority of pain physicians.

I was the only one here - has not been the case for a long time. Some greedy anesthesia dude opened up a multispecialty clinic and hired a pain doc. Wanted to take over the whole town, including me. Also, the hospital got taken over by the university and they bought everyone else out or put them out of business. They tend to refer in-house only and are in cahoots with the anesthesia guy through their shared interest in the surgical center. I am one of the only solo practitioners around now.

I'm doing okay but just to go after those greedy SOBs I'm planning on starting my own PCP group. Who knows how it will evolve? Mainly just to get them fired up and give them a taste of their own medicine, lol!

 

[Ferrismonk]

I'm willing to bet that you won't be able to match the hospital salary and they will refer to the big system for specialists/imaging/etc anyway. The hospital/university will be glad you're bringing in new patients and sending them more business.

 

[Pain Applicant1]

I'm willing to bet that you won't be able to match the hospital salary and they will refer to the big system for specialists/imaging/etc anyway. The hospital/university will be glad you're bringing in new patients and sending them more business.

Okay, pinky bet, you're on. It'll be a fun little venture either way.

 

[SeniorWrangler]

Ok I’m going to break it down the way I see it, which is maybe not how anybody else sees it.
There are three kinds of pain practice:

1) Procedurally based pain care - this usually requires special training but it’s fun and can pay well.

2) Non-interventional pain management in a multimodal interdisciplinary setting — this can be rewarding too if you have good colleagues, hard to find outside of an academic center or the VA, you really need to be working with psychology, PT etc. to make a difference. Less money, less fun.

3) Opioid based pain management — this is hard and you get yelled at a lot, you have very complex regulations you have to follow in order to be legal and you still could be sued/arrested/investigated. If you do Bup for pain it’s better but it’s no panacea. Money isn’t that great unless you’re doing it wrong, in which case you might need to learn about extradition treaties and stuff like that.
You don’t need anything but a pen and pad for this but you really need to know a lot about pain to do it safely.

 

[SeniorWrangler]

Help me understand. Are there a lot of crazy people with cash to burn who will pay psych out of their own pocket? Most of the patients I have met who truly needed a psychiatrist over a PCP, could barely hold a job, let alone pay $400 cash each month.

There are, and always have been, two kinds of psych patients. There used to be two kinds of doctors that treated them too!