Pain fellowship versus critical care- input needed

[Hoya11]

I just looked at the curriculum at Cedars-Sinai, and imagined that the average pain fellowship is probably not better. 90+% of the stuff listed there is useless for OR anesthesia.

I am not saying that I am as good at everything as fellowship-trained people. I am saying that one does not need a fellowship for certain things. As much as it hurts some egos, one doesn't need a fellowship to anesthetize healthy kids for low-risk procedures, for example. Or for most neuro procedures. Or for a huge part of OB. Or for single-shot regional anesthesia. And the list can go on. Will fellowship-trained people be better at these than competent generalists? Probably, but it's the difference between good enough and better.

I haven't, but I doubt you learned that on the OB floor during your pain fellowship. Are you saying that one needs a pain fellowship to dose a Remi PCA?

No, I can't. Can you, without fluoro? How frequently do you need that skill in OB?

Again the question comes if you can without fluoro. I know a number of anesthesiologists who would attempt it with US guidance. And again the question comes about how frequent and important this actually is.

Now you are trying to do some grandstanding. I am sorry I overestimated you.
Yes, I can. And this, too, is extremely rare. Plus one can get a pain consult for that.

I might be doing it the "archaic" way (there is more than one way to skin a cat), but I don't see any department hiring pain people just for the OR, meaning that the way I/we do it is good enough. One doesn't need a pain fellowship for 99% of the pain-related stuff we deal with in the OR/PACU (and it doesn't make a big difference for 90% of them).

Rarely do things "get advanced" with OR anesthesia, and when they do, there are usually many other ways to bypass them. I am not arguing that a pain fellowship-trained anesthesiologist will not be outstanding at everything s/he was trained for. I am just saying that most of her training will not make big difference in the OR, something I cannot say about CCM.

So one should not do pain if one wants to practice only OR anesthesia. Again something I cannot say about CCM.

TL; DR
A pain fellowship background is about as relevant in most OR cases as CCM training is for ASA 1/2 patients.

Oh well now that you have looked at the curriculum..

If a non-pain fellowship trained anesthesiologist suggested a remi-pca for laboring patient vs a pain trained doc, dont you think this new and different idea would be better accepted when coming from someone who is an expert in the field? Im guessing you dont do a lot of OB.

Caudals are easy to do blind and i have done over 100 for adults and over 50 for laboring patients with hardware in place, yes blind without fluoro. How deep do you insert your needle?

Blind Spinal analgesia midline within the scar is OK. Epidural is not (there is no ligament, the spine has been decompressed, and therefore wet tap is inevitable)
An epidural above or below the scar is Ok as the ligament is intact. See you have to understand the hardware is off midline at the pedicles on either side so the space is wide open but just no ligament. Interpreting an old post-op spinal x-ray can help guide you, how many generalists can do that?


How about someone with hardware in place for knee replacement who requests spinal, just do general because you dont understand the nature of back surgery? Or tell the laboring woman with hardware sorry theres nothing we can do for you?

Look, I have followed your posts here for a long time, you seem like a good reasonable guy, and I agree with what you are saying in general.

I especially agree that you should not do the fellowship if you dont want to do pain. I wish I didnt spend that year making 50k.

But I do disagree that it was entirely useless to my current anesthesia practice.

---

Members don't see this ad.

 

[deleted171991]

I don't do OB, but I always appreciate good teaching.

 

[Sirach38]

Dude, then you should not do anesthesia. Given the future of this specialty, don't do it unless you're in love with it.

The only reason I'm struggling with this is BECAUSE of the future of this specialty according to many posters on this forum. I am in love with anesthesiology and have not liked anything else in med school nearly as much. Not even close. However, the doom and gloom on this forum has made start looking for alternative specialties with a better future that I can "tolerate".

 

[deleted171991]

Then all you need is a backup plan. So either pain or CCM.

Or cardiac/peds/regional, but with higher future risks (expect CRNAs to encroach on the latter two, and reimbursements/salaries to decrease across the line).

 

[Arch Guillotti]

However, the doom and gloom on this forum has made start looking for alternative specialties with a better future that I can "tolerate".

The doom and gloom level has always been high on this forum. In a way, it is self-selection to some degree. Doom and gloom is much higher on a physician only site that I peruse sometimes. Goes with the territory.

 

[Sirach38]

Then all you need is a backup plan. So either pain or CCM.

Or cardiac/peds/regional, but with higher future risks (expect CRNAs to encroach on the latter two, and reimbursements/salaries to decrease across the line).

Yeah, with the doom and gloom I've heard I think I'll need two back up plans. Perhaps CCM and pain or cardiac and sleep. I think doing two fellowships will ensure me a job if anesthesiology dies in the future...this is my current plan. We'll see what the future holds.

 

[deleted171991]

Yeah, with the doom and gloom I've heard I think I'll need two back up plans. Perhaps CCM and pain or cardiac and sleep. I think doing two fellowships will ensure me a job if anesthesiology dies in the future...this is my current plan. We'll see what the future holds.

I sincerely hope this was sarcasm.

 

[Sirach38]

The doom and gloom level has always been high on this forum. In a way, it is self-selection to some degree. Doom and gloom is much higher on a physician only site that I peruse sometimes. Goes with the territory.

Does that mean doom and gloom here should be taken with a grain of salt?

 

[deleted171991]

Everything you read online should be taken with a grain of salt.

 

[Sirach38]

Everything you read online should be taken with a grain of salt.

I tend to give more weight to stuff said on these forums by attendings than I would on other internet sites. It seems like in general, on the anesthesiology SDN, physicians tend to be very helpful and I feel like I can trust a lot of what they say.

 

[Sirach38]

I sincerely hope this was sarcasm.

No sarcasm unfortunately...

 

[deleted171991]

I tend to give more weight to stuff said on these forums by attendings than I would on other internet sites. It seems like in general, on the anesthesiology SDN, physicians tend to be very helpful and I feel like I can trust a lot of what they say.

Don't forget that people also tend to vent anonymously online. Plus they might just be unhappy at their specific workplaces. So try to eliminate the extremes and average out the rest.

 

[BobBarker]

'Most choose pain because they suck passing gas.' - paraphrased from @FFP

Are you serious??? I guess it comes down to your own experiences but I have never been impressed by the anesthesia skills of the CCM fellowed people either. You will be better because you have years of anesthesia practice under your belt where they graduated residency, did no anesthesia during fellowship, and immediately started supervising part time. I certainly don't suck and will practice pain exclusively for a number of reasons already mentioned by others above. And no I don't think my pain fellowship is going to make me better in the OR. I doubt I set foot on the other side of the drape again. It is a 1 year fellowship to learn what I consider a completely different specialty.

 

[deleted171991]

I should have said many, not most. In my residency program, most people who go the pain route are unremarkable at anesthesia (some even at pain). The best anesthesiologists usually choose CT. I do realize this is very subjective.

Many, if not most pain attendings I know are very intelligent people, and some of them are/were also good anesthesiologists. I am constantly impressed by those who post here, but I think most people do pain because they don't want to practice OR anesthesia, not because they want to practice both. I am sorry if I offended any of the pain docs here.

 

[algodoc]

Answer was easy for me. Just go to the gaswork and find jobs - CCM 7 jobs Pain 60 jobs.Pain clinic generated income 1.4 mln for the hospital last year .Anesthesia group got stipend from the hospital 4.5 mln and critical care over 1mln . Guess who received huge incentive and who was asked to reduce expenses.and requested to employ more mid-levels . Guess who had nice call from cardiothoracic surgeon kindly asking for help as his patient has intractable pain post thoracotomy and guess who had nasty call suggesting total incompetence as his patient was not doing well after CABG. Choice is yours. Anesthesia will be dead in 5 years - CRNA's are replacing MD anesthesia everywhere.
There is not a single study showing benefit of MD over CRNA anesthesia care ( we all know that the difference is tremendous ) but they using it to lobby and they are very successful

 

[deleted171991]

Answer was easy for me. Just go to the gaswork and find jobs - CCM 7 jobs Pain 60 jobs.Pain clinic generated income 1.4 mln for the hospital last year .Anesthesia group got stipend from the hospital 4.5 mln and critical care over 1mln . Guess who received huge incentive and who was asked to reduce expenses.and requested to employ more mid-levels . Guess who had nice call from cardiothoracic surgeon kindly asking for help as his patient has intractable pain post thoracotomy and guess who had nasty call suggesting total incompetence as his patient was not doing well after CABG. Choice is yours. Anesthesia will be dead in 5 years - CRNA's are replacing MD anesthesia everywhere.
There is not a single study showing benefit of MD over CRNA anesthesia care ( we all know that the difference is tremendous ) but they using it to lobby and they are very successful

The question remains: Why so many pain jobs suddenly, and why do I see pain docs switching back to anesthesia and indicating poor reimbursements as the main reason? There is a finite number of patients willing to undergo/pay for pain procedures.

Oh, and I wouldn't hold my breath about the field not being ripe for nurse encroachment. They already do a ton of chronic pain consults. The next step is learning some regional anatomy, and start doing some simpler pain procedures, such as epidural injections or medial branch blocks. We already allow CRNAs to place epidurals blindly.

 

[epidural man]

The best anesthesiologists usually choose CT.

You must have recently graduated residency. Please put on your phone calendar an alert to come back and check this statement in 10 years. You will probably laugh, then be embarrassed and how ridiculous and short sighted this is (and many of the other statements you have made in this thread).

 

[deleted171991]

You must have recently graduated residency. Please put on your phone calendar an alert to come back and check this statement in 10 years. You will probably laugh, then be embarrassed and how ridiculous and short sighted this is (and many of the other statements you have made in this thread).

I was talking about my program specifically, at the time of my residency. Very subjective and n=small. Just reread my previous post.

I might be naive, but not that naive.

 

[gasdoc77]

The question remains: Why so many pain jobs suddenly, and why do I see pain docs switching back to anesthesia and indicating poor reimbursements as the main reason? There is a finite number of patients willing to undergo/pay for pain procedures.

Oh, and I wouldn't hold my breath about the field not being ripe for nurse encroachment. They already do a ton of chronic pain consults. The next step is learning some regional anatomy, and start doing some simpler pain procedures, such as epidural injections or medial branch blocks. We already allow CRNAs to place epidurals blindly.

Regarding the CRNA pain fellowship........

http://home.coa.us.com/Pages/default.aspx

 

[murdoc9]

Anyone care to comment on the "burn-out" factor for those practicing a mix of anesthesia and critical care?
obviously it depends on practice environment, specific hospital, closed vs. open, etc. But in general, any thoughts?

 

[EtherBunny]

The question remains: Why so many pain jobs suddenly, and why do I see pain docs switching back to anesthesia and indicating poor reimbursements as the main reason? There is a finite number of patients willing to undergo/pay for pain procedures.

Oh, and I wouldn't hold my breath about the field not being ripe for nurse encroachment. They already do a ton of chronic pain consults. The next step is learning some regional anatomy, and start doing some simpler pain procedures, such as epidural injections or medial branch blocks. We already allow CRNAs to place epidurals blindly.

There's a big misconception among CRNAs that interventional pain medicine is simply an extension of regional anesthesia--i.e., doing blocks. In effect, some CRNAs (and evidently physicians on this forum) think that you can simply learn regional anatomy after CRNA school, practice a few "simple" pain procedures, and (magically) you'll be proficient in pain medicine. This is an absolute fallacy. The problem is that many of the skills acquired in anesthesiology and CRNA training are not transferrable to pain medicine. Sure, anesthesiologists and CRNAs are quite skilled at procedures, but frankly the procedures aren't the hard part of interventional pain medicine. The tough part is the medicine--i.e., the diagnosis and management of disease.

There is a tremendous emphasis on traditional doctoring skills in pain medicine--i.e., taking a thorough history to generate a differential diagnosis, performing a focused (typically multi system) physical examination to narrow your differential, rationally ordering tests and interpreting the results of the tests within the context of the findings on history and physical to clinch the diagnosis. Furthermore, you typically can't rely on the radiologist's report from cross-sectional imaging (I don't anyways), because the reports are typically not very helpful for decision making. You have to look at the images yourself and draw your own conclusions. How many CRNAs do you know that can interpret an MRI or CT?

Then, of course, there's the whole management side of the equation in pain medicine. Patient selection for procedures is quite challenging--you can't simply do procedures on anything with two legs. It's not like regional anesthesia where there are clearly established protocols for certain types of surgeries. A patient presents for shoulder surgery...interscalene (provided that there aren't any of the standard contraindications). Knee surgery...fem/pop. It's not that simple in pain medicine. A patient that comes in with arm pain, for instance, could have a cervical radiculopathy, a plexopathy, a peripheral neuropathy, referred pain from a joint, ischemia (peripheral or cardiac), or it may represent something more sinister intracranially. Does it make sense to do a cervical epidural if the patient has ulnar neuropathy? What about thalamic pain syndrome. Ummmm, no. I think a physician, by virtue of the MASSIVE amount of training that we get in the diagnosis and management of disease, is light years ahead of any CRNA when it comes to differentiating among the various possibilities in this instance. This is precisely why I'm not worried about CRNAs encroaching in interventional pain. The truth of the matter is that, as a physician, I have a knowledge base and skill set in the diagnosis and management of disease that FAR EXCEEDS that of any CRNA.

Unlike anesthesiology, the knowledge and skills that I acquired in medical school, internship, and as a surgical resident are directly applicable to my everyday practice in interventional pain. I hardly use any of the knowledge and skills that I acquired as an anesthesiology resident, except for maybe ultrasound visualization of structures and loss of resistance technique for epidurals. That's it.

Pain medicine is SOOOOO different from anesthesiology. They might as well be completely different specialties. Pain medicine is a mix of radiology, PM&R, psychiatry, neurology, neurosurgery, and anesthesiology. Last time I checked, interpretation of cross-sectional imaging and how to examine the shoulder weren't standard fare in CRNA curricula.

Case in point:

The other day I was doing a stim trial for a patient with CRPS. A CRNA was in the room with me. He asked me what CRPS stands for. I told him, "Complex regional pain syndrome." A blank look on his face. "What's that?" he asks me.

Yeah....not worried about CRNAs in this field.

 

[deleted171991]

You don't have to convince me. You have to convince the crowd and the politicians. We'll talk again in 10 years.

And I am not saying they will do everything you do. I am not even saying they will do it without medical supervision. But don't be surprised if the CRNA model is translated to pain medicine by AMCs, especially for uncomplicated patients and simple procedures. There are already tons of NPs doing chronic pain consults under medical direction.

It's also happening in critical care, and many medical specialties. The difference there is, indeed, the medical knowledge. The problem with pain is that it's a paliative specialty; one doesn't cure the disease, just alleviates the symptoms. Of course some of the procedures are difficult and require experience, but so are many in anesthesia. You might be the one making the decisions but the big moneymakers, most of the procedures, especially the office-level simple ones. will be delegated to nurses, and all of you will be employed by the same management companies we are, for the same peanuts we are.

If I could do a bunch of basic pain procedures during my residency, so can any trained monkey. Just consider that. Just consider how many procedures during a week are too complicated for a nurse to do, or how many consults could not be dealt with by an experienced NP. That's the stuff you will be doing in 10 years or so.

We were not really worried about CRNAs in anesthesia 10 years ago either. We still are deluding ourselves with the idea that we will always supervise at least the ASA 3/4/5 patients and at least the difficult surgeries etc., all this while we are losing terrain visibly every single damn year. And every single damn year we are working more for less. And it's only 5 years since the **** has really started to hit the fan, and it won't take long to clog it.

In every state where we have independent CRNAs, you can bet there will be independent NP practice in many other specialties.

Remember what nurses did to family practice. Do you really think pain requires so much more medical knowledge (not procedural, which can be taught)?

 

[BobBarker]

CRNA's are forbade from pain practice in my state.

 

[deleted171991]

CRNA's are forbade from pain practice in my state.

Is it an opt-out state? I would expect the answer to be negative.

Oh, and the law can be changed. Any law. Just look at gay marriage, and go back just 5 years in history, not more.

Once the public is indoctrinated with the idea that nurses can do the same things for less, we will have to prove the contrary every day. Some will get burnt and believe us, some will get lucky and think that they got the same level of medical care from the nurse.