bumping an old thread- any thoughts on the above from practicing anesthesia/ccm docs?
I'm a practicing interventional pain physician with a background in anesthesiology (and a surgical subspecialty). I think both fields have a bright future (not necessarily from the standpoint of reimbursement, but then again ALL fields in medicine are in the crosshairs of the lovely "cost containment" movement by third party payors), but in many ways they are very different in practice.
The differences:
**Lifestyle--This is a HUGE difference between the fields. Interventional pain, for the most part, is an outpatient based practice with very few (if any) emergencies. Hours are highly predictable (typically 8-5 PM, M-F). Home call is the norm and it's pretty rare to be called at night about anything, which means that you get to sleep in your own bed without interruption every night. Most interventional pain physicians don't work on weekends or holidays. Critical care is a different animal entirely because of the higher acuity of the patients.
**Coordination of care--Interventional pain doesn't require much coordination of care, whereas intensivists often have to coordinate and oversee the care of many different consultants.
**Pressure to multitask--Critical care typically requires a heavy dose of multitasking, as you have to simultaneously care for all of the patients on a unit. Interventional pain practices, in contrast, typically have a linear work progression (i.e., you essentially march through the day, one patient at a time). I personally hate being torn in a variety of directions at once, which is why pain medicine is great for my personality. I get to focus on one thing at a time.
**The acuity of patients--This is an obvious difference. Intensivists take care of the sickest patients in the hospital. Interventional pain medicine patients, on average, aren't very sick, at least not acutely. They have their fair share of comorbid chronic illnesses (no question about that), but you rarely encounter any urgent, life threatening conditions on daily basis.
**Reliance on objective data for medical decisionmaking--Critical care involves an enormous, steady stream of objective data (PA pressures, ABG data, etc.), the analysis of which plays a key role in medical decisionmaking (I would argue it's more important than physical examination or history taking). Decisionmaking in pain medicine, in stark contrast, is heavily dependent on the history and physical examination, and less so on objective data (although cross sectional imaging and EMG play an important role in my medical decisionmaking). This is an important distinction between the two fields, because some people feel more comfortable working with the deluge of objective data in critical care as opposed to the "gray area" of pain medicine. I, for one, love the art of taking a great history and performing a focused physical examination to pin down the diagnosis. I can't stand the "drinking from the fire hydrant" phenomenon in critical care, in which you literally get buried in objective data on an hourly basis.
**Psychological issues in patient encounters--Another big difference between the two fields. Comorbid mood disorders are extremely common in pain medicine and they have to be addressed in patient encounters. As an intensivist, of course, you won't have to deal with comorbid mood disorders because life threatening conditions take precedence.
**Third party payor hassles--I don't know about critical care, but insurance companies are a royal pain in the ass in the field of interventional pain (and all other procedural fields of medicine that deal with insurance). I can't stand them, but again it's not unique to interventional pain. I've yet to meet a single physician who doesn't hate insurance companies. Maybe critical care is more insulated from these issues? (I don't know on this one).
Despite all of the differences, there are some key similarities between the subspecialties:
**Both subspecialties involve a significant degree of
ownership in patient care, which is immensely valuable nowadays. This is the fundamental problem with OR anesthesiology--anesthesiologists don't have any ownership of patients in the operating rooms. Surgeons are the physicians who bring patients to the operating rooms and the patient's loyalty, by virtue of the fact that they've had a chance to meet the surgeons in clinic beforehand, is heavily weighted towards the surgeon. Surgeons are viewed as source of profit, whereas anesthesiologists are viewed as an expense by hospitals. Interventional pain is interesting in this respect, because if you do procedures in a hospital (implants or trials), you're treated like a surgeon by the hospital staff, because you're a source of profit for the hospital. VERY different experience from what I went through as an anesthesiology resident. Also, when patients ask to speak with "the doctor" they're referring to you. Having your own patients definitely has its benefits.
**Both fields involve a lot of "traditional" (for lack of a better word) doctoring skills--i.e., performing histories and physicals to generate differential diagnoses, rationally ordering tests to confirm your suspicions, treating conditions, and dealing with the aftermath of your treatments (hopefully positive). Critical care, of course, relies more heavily on objective data streams than pain (less on history taking), but the overall emphasis on critical thinking, differential diagnosis, etc., is very similar between the two fields.
**Both fields will provide you with a more visible presence in health care settings. OR anesthesiology is often an invisible specialty, operating behind the scenes without any gratitude or recognition, whereas ICU and interventional pain are not like this at all. Patients and their families are often extremely grateful for the care they receive.
**Another similarity is the procedural orientation of both fields. There are lots of cool procedures in the ICU setting (lines, ECHO, drains, etc.) and, of course, there are TONS of procedures in interventional pain. So, if you enjoy working with your hands, you'll like both fields.
**Midlevel encroachment is less of problem for both of these subspecialties, because both fields require the unique skill sets and very broad knowledge base that physicians possess (you really need to know a lot of medicine for both to do a good job). The key to being an effective interventional pain physician is patient selection, and this is where all of the training that physicians acquire in medical school, internship, residency, and fellowship is emphasized. Nurses, regardless of the amount of "advanced training" they pursue, simply aren't in the same ballpark as physicians when it comes to diagnosis and management of disease, especially when these things fall outside of established protocols. Physicians are the gold standard in both of these areas. Always have been and always will be.
**Job markets are WIDE OPEN for both subspecialties. There are tons of jobs out there for pain and I know that critical care is a hot commodity because of all the leap frog stuff (i.e., the mortality benefit associated with having intensivists) and hospitals scrambling to close their units.
Anesthesia based CC has the worst hours, lowest hourly pay, is high in risk, has limited employment options, is moving more towards pay for performance, which demands maintaining unrealistic universal parameters for all patients regardless of the clinical situation, You'll be the hospital administrator's employee with little autonomy regarding time off, hours worked etc....And...rectal tubes oozing poo into ass bags in every patient. Sick, sounds like a nightmare!!!
