Pain Questions

[PAINISGOOD]

Hey all you pain docs!

I am a first time poster who is very interested in pursuing a pain management fellowship and would like to know more about pain management. Here are my questions:

1) How long does it take to put in a pump and a stim in private practice? I know it takes much longer in academics because of fellows.

2) One pain doc I worked with told me that it is not practical to do pumps and stims in private practice because for the time it takes to do one pump/stim you can do several epidurals and make more dough and don't have to deal with the complications of such a procedure. He told me it is better to refer these procedures to a surgeon. Any opinions of this?

3) He also told me that these procedure should be done by surgeons (general, or neurosurgeons) because they can make a better pocket versus someone who is anesthesia or PM&R trained. Any thoughts?

4) Why don't neurosurgeons, orthopods do stims? Is there a turf battle?

Well that is all I have for now. I hope to get some answers!!

thanks in advance!

PAINISGOOD

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[Aether2000]

I would suggest business school as an alternative. Such an intense focus on detailed post fellowship practice finances and how to maximize profit could be perceived as a person wanting to become a mindless block jock. You certainly don't need a fellowship to achieve that goal.

 

[PAINISGOOD]

I would suggest business school as an alternative. Such an intense focus on detailed post fellowship practice finances and how to maximize profit could be perceived as a person wanting to become a mindless block jock. You certainly don't need a fellowship to achieve that goal.

Hey,

I think you misunderstood. I am not asking about how to maximize profit from a pain practice but just opinions on what this pain doc told me!

I agree with you that the doc that told me this is all about the money. I believe you should be able to use all modalities to treat pain well and not just think about the bottomline! But can you or anyone else please answer questions 1, 3 and 4?

thanks!

PAINISGOOD

 

[PainFellow]

The doc you spoke with is full of bull and I suspect his advice stems from a combination of greed and inadequate training. First of all, neurosurgeons DO implant pumps and stims. At my center, we take turns with the neurosurgery fellows so that we both are equally well trained. Also, making a pocket is not rocket science. If properly trained, anyone can do it and do it well. However, having said that, I will also add that I am at a top program with amazingly well trained faculty and very high volumn. Many interventional fellowships (both anesthesia and pm&r) lack the volumn and faculty necessary to become proficient in the more invasive proceedures. This is why it is crucial to obtain a top fellowship. Unfortunately, the doc you worked with sounds like a "block jock". These guys are only in it for the money and give us all a bad name. They are universally disliked by those of us committed to high quality patient care...hence the somewhat sarcastic, but totally justified response by algosdoc.

 

[Aether2000]

It usually takes about 1-1.5 hrs for a stim, 1-2 hrs for a pump implant. There are many other considerations such as is the office set up to precert, monitor, refill, and take care of complications. Surgeons indeed do about 50% of these implants and may have an advantage in surgical skills, but the creation of a pocket is not rocket science. The experience of the individual, whether a surgeon or pain management, in implanting these devices is the most important feature. Pumps require revisions due to infection, catheter migration and require trouble shooting via pump myelograms or indium scans. Stims have lead migration and thinning of the skin over the stim generator as their main reasons for revision.
There are some minor turf battles...most surgeons don't want to be bothered with perc lead stim placements and would rather perform a laminotomy for neurosurgical lead placement (a much more invasive procedure, but with some advantages). Some surgeons work with pain management...the surgeon implants the permanent while the pain management does the temp lead placement for stims. Beware of unscrupulous surgeons who want the pain management doc to manage their implanted pumps, sometimes at a net loss to the pain physician. If the surgeon implants it, he is responsible for it. BTW, I am happy that you want to be a doctor instead of a block jock.

 

[Doctodd]

Maybe if you specify where these procedures will be done, it will be easier to answer your question. For example, i currently do basic injections in my office under flouro. I can do more invasive procedures at a nearby ASC(ambulatory surgical center) which i have to drive to and wait for the room to be prepped, etc. So yes, it might take longer to do a pump/stim when looking at the big picture. However, you can do the trial with temporary leads in your office and it shouldnt take long. Also take into account the follow ups and time it takes to deal with complications, which you may not get reimbursed for.

Think what is the best for the patient. If you are thinking about how many ESI's or facet blocks you are losing by doing a pump stim, then it isnt in the best interests of the patients for you to do any pumps/stims. I personally dont do pumps or stims any more cuz i dont want to be "married" to the patient for the long term when it comes to the usually inevitable complications.

T

 

[paindefender]

The guy who gave you advise is right. Do not listen to the guys who advise on doing your own implants. Total waste of time and resources. Surgeons are surgeons and were trained to do surgery.Do the trial and have someone do the surgery and deal with the complications.

 

[Aether2000]

There are indeed complications that must be dealt with and if you are not set up to handle them, then I agree it is not worth doing the implants. But if you can deal with the surgical implications then my advice is that in order to be a more complete physician with a focus outside of the monolithic physician performing epidural steroid injections all day, then it will benefit both the patients and ultimately your practice.
There is a sea change coming in pain management in which even the sacred epidural steroid injection will come under fire (justifiably so), and those who have pegged their entire livelihood to this procedure, will either have to adapt to the changes coming or get out of the field altogether. Having the broadest perspective possible is the most useful approach to pain management in the long run.

 

[Doctodd]

Having the broadest perspective possible is the most useful approach to pain management in the long run.

I agree. What about arthritis and facet blocks followed by RF? What about joint viscosupplementation? What about discograms and perc discs? These procedures broaden the spectrum IMHO.

Like i said before but maybe didnt make it clear enough, if you are busy worrying about how many procedures you are losing out on by doing a pump/stim, then maybe you arent doing what you really enjoy. You will best serve your patients by doing what you enjoy most, because ultimately you will be better at it.

T

 

[paindefender]

If the epidural comes under fire, implants will evaporize and pain management will be reduced to ashes.

 

[Aether2000]

I don' t know if doom and gloom are necessary outcomes of the demise of an overused procedure that has not been demonstrated to be more effective than a medrol dose pack...unless you know a study demonstrating such. Pain management will improve through advances in technology and in medications. Hopefully a coalescence of philosophies and organizations working to bring about a residency program will avert the ashes. The profession is in a very weak state politically at this time.

 

[paindefender]

I don' t know if doom and gloom are necessary outcomes of the demise of an overused procedure that has not been demonstrated to be more effective than a medrol dose pack...unless you know a study demonstrating such. Pain management will improve through advances in technology and in medications. Hopefully a coalescence of philosophies and organizations working to bring about a residency program will avert the ashes. The profession is in a very weak state politically at this time.

Actually, I know of very few good studies, if any, that support most of what pain physicians do (stimulators, pumps, nucleoplasty,dekompressor, laser diskectomy, etc). The weak state of the specialty is mostly due to the lack of cohesion between pain physicians.

 

[paz5559]

Actually, I know of very few good studies, if any, that support most of what pain physicians do (stimulators, pumps, nucleoplasty,dekompressor, laser diskectomy, etc). The weak state of the specialty is mostly due to the lack of cohesion between pain physicians.

Please feel free to post the studies you refer to, so this discussion can be elevated to a reasonably academic level.

 

[greywater]

I am embarrassed by the predators that infest our specialty. If you're a good doctor and manage your business well the money will come. You don't have to do wallet biopsies and discriminate on low-yield procedures.

In Texas, where I practice, Medicare cut pump refill reimbursement. Several pain docs discharged their Medicare pump patients, who were then frantically calling around trying to find someone to manage their pump. One guy in the DFW area who used to be "Mr. Pump" suddenly lost his enthusiasm for the procedure. I hope there's a special place in Hell reserved for these people.

I follow a very simple philosophy in my practice: "Do well by doing good". After 25 years it still works.

 

[drugdealer3000]

I am embarrassed by the predators that infest our specialty. If you're a good doctor and manage your business well the money will come. You don't have to do wallet biopsies and discriminate on low-yield procedures.

In Texas, where I practice, Medicare cut pump refill reimbursement. Several pain docs discharged their Medicare pump patients, who were then frantically calling around trying to find someone to manage their pump. One guy in the DFW area who used to be "Mr. Pump" suddenly lost his enthusiasm for the procedure. I hope there's a special place in Hell reserved for these people.

I follow a very simple philosophy in my practice: "Do well by doing good". After 25 years it still works.

Don't cross the picket line.

I applaud "Mr. Pump". Thanks to the awful laws in this country doctors can be shafted by insurance companies and the federal government. The average voter would rather vote about prayer in school than on decent health care initiatives. "Mr. Pump" is not a slave. His actions are the ONLY way to illustrate to patients what the government and insurance companies are doing to modern medicine. Look at ANY country with socialized medicine and you will see that they have gone on strike when pushed too far. Thanks to the interpretation of anti trust laws in the US doctors cannot get together and strike.

FYI "Mr Pump" is not alone. I know plenty of primary care doctors that refuse to see Medicaid pts because its just not worth the hassle for the peanuts the government is throwing them.

I read an article about an OB doc that basically had a contract with his patients that said anyone he treated could NOT sue him under any circumstances. The problem was malpractice got so high he was going to leave the area. That left his patients in the position of having to travel 50+miles to get OB care. Guess what, they signed and he told his malpractice insurer to go to hell.

If you leave these pain patients high and dry with their pumps and tell them its the governments fault they will write and call their congressman, and you'll see some changes. Unfortunately the average consumer puts more effort into purchasing a flat panel TV than into their own health care.

Anyway this is a natural evolution with a lot of things in medicine. The government cuts reimbursement to the point its not even worth doing anymore. Look at flu shots. Wonderful idea, but a lot of docs took too many loses with them and finally quit doing them in the office.

 

[Mister Mxyzptlk]

All these years I thought I was supposed to tailor the treatment to the patient and not my wallet. Thanks for clearing this up.

There are ways to get things done without punishing the people who place their well-being in our hands.

BTW, people who are left high and dry with their pumps don't write letters to their Congressmen.

 

[drugdealer3000]

All these years I thought I was supposed to tailor the treatment to the patient and not my wallet. Thanks for clearing this up.

There are ways to get things done without punishing the people who place their well-being in our hands.

BTW, people who are left high and dry with their pumps don't write letters to their Congressmen.

I don't think preserving the integrity of the profession is "tailoring the treatment for your wallet". I made a number of interesting observations about modern American society and medicine, and I find it interesting that that is the sole conclusion you drew from my post.

I don't mean to be rude or confrontational, but in the couple of days I've been posting on this forum I've noticed a very disturbing trend. Anyone's who's posts don't read like a well polished medical school application personal statement is immediately demonized as wanting to profit at a patient's expense by certain people. I for one have NEVER said anything of the kind. There is a serious amount of splitting going on here. The world is not black and white. There are a lot of people in many diverse professions that improve the lives of numerous people AND make a good living while doing it. These two things are not necessarily contradictory or mutually exclusive.

Insurance companies, HMOs, and the federal government are wrecking the healthcare system. We eat less but we will survive. What about the women in the article I read that would have to travel 50 miles for OB care if the malpractice insurance companies had their way and ran the last doctor out of town?

Why do you say people that are left high and dry don't write letters to their Congressmen? Medicare is a government run program. Most of the people on Medicare are >65 yo. The AARP requires you to be over 50 for full membership. The AARP has been ranked by Fortune as the most powerful lobby in the United States. So you cease unprofitable procedures and explain to your AARP member patient that its Medicare's fault. They go home and call up AARP. AARP brings the hammer down on DC and the cuts are halted. Of course you need all docs to hold the line.

Look what happened with rushing women out of the hospital after they delivered. The public outcry was loud enough that the powers that be backed off.

You don't have to be all about $$$, but you don't have to be walked all over either. There is a middle ground. I thought this forum was mature enough and experienced enough that we could frankly and openly discuss that middle ground in a relaxed manner... I guess we all know what they say about assuming.

 

[Mister Mxyzptlk]

Why do you say people that are left high and dry don't write letters to their Congressmen?

I'm sorry. There I go speaking from experience again. Do you think I haven't tried to get patients to write letters? Very few patients are activists. The ones in chronic severe pain even less so.

There is also the question of volume and hot-button issues. Sending pregnant women home quickly after childbirth affects a lot more people than denied pumps. It's also easier to get media attention when young mothers are being kicked to the curb than it is to explain why pumps are important to a select subset of pain patients.

I think it's abundantly clear why you are encountering resistance here. Most of us find it repellent to withhold treatment to make a political point. This is what you advocate.

 

[savealife]

Interesting Psychology Experiment: If this guy's nickname was "IWantToHealAlltheChildren" instead of "drugdealer3000", would everyone still be jumping down his throat about his views?

 

[ampaphb]

Interesting Psychology Experiment: If this guy's nickname was "IWantToHealAlltheChildren" instead of "drugdealer3000", would everyone still be jumping down his throat about his views?

If "IWantToHealAlltheChildren" advocated "leaving pump patients high and dry" and was primarily concerned about "considering pain because I want to get out and make a lot of $$$ fast" so that he could "make >$1 million a year", to fulfill "My goal regardless of what I do is to make a lot of $$$" then you bet he would be criticized equally!

 

[Mister Mxyzptlk]

Interesting Psychology Experiment: If this guy's nickname was "IWantToHealAlltheChildren" instead of "drugdealer3000", would everyone still be jumping down his throat about his views?

Hey, we only LOOK stupid.

 

[Tenesma]

gorback - not to agree with anything that drugdealer has said (i disagree with almost everything he said) - BUT,

I choose not to treat patients with United (unless they pay cash) for political reasons (ie: United treats me like crap)... so if I choose to do that (and it is slowly working in my favor), why can't physicians take similar stances on larger issues... we aren't denying "Emergency" care, we are denying for all purposes "elective" care...

 

[savealife]

If "IWantToHealAlltheChildren" advocated "leaving pump patients high and dry" and was primarily concerned about "considering pain because I want to get out and make a lot of $$$ fast" so that he could "make >$1 million a year", to fulfill "My goal regardless of what I do is to make a lot of $$$" then you bet he would be criticized equally!

While I truthfully have entered medicine for the so-called "right" reasons, I look around at my medical school class, a group of people that will have "MD" next to their name come this May, and I know that a large portion of them have this same attitude about becoming physicians.

While I don't condone the way drugdealer3000 thinks, it's a fact that many people in medical school feel this way. A lot of the attendings I've worked with feel this way, too. But, I've never seen one of those attendings make an intentional decision that would be harmful to a patient... it's one thing to have the intention to make a lot of money without any true interest in patient health care, it's another to make egregiously wrong decisions for your own capital benefit. So the real question is, are you wiling to sacrifice the care of a patient if it would amount to a large monetary gain for you as a physician?

If you answer "yes" to this, then you ARE an awful person and you're doing this for the wrong reasons.

 

[Mister Mxyzptlk]

gorback - not to agree with anything that drugdealer has said (i disagree with almost everything he said) - BUT,

I choose not to treat patients with United (unless they pay cash) for political reasons (ie: United treats me like crap)... so if I choose to do that (and it is slowly working in my favor), why can't physicians take similar stances on larger issues... we aren't denying "Emergency" care, we are denying for all purposes "elective" care...

You are not obligated to take all comers. I dropped Aetna several years ago, and I restrict my Workers' Comp. The response to cuts in W/C rates created such a crisis from doctors opting out that W/C is now proposing to increase rates.

I don't know why there isn't a similar attitude towards private payers, most of whom pay worse than W/C here. I suspect it's because unlike a government program like W/C you can't jump in and out at will with a private plan. People are probably afraid it will be a one-way ticket off the panel. I think if we had "any willing provider" laws it would help immensely. Somehow that initiative got lost back in 90s.

My main point here is that the patient places him/herself in your hands and trusts in your superior knowledge and expertise. Once you accept them for treatment there is a duty to avoid conflicts of interest and you are supposed to place their best interests above your own (within bounds of reason).

In the case of pump refills, the problem wasn't that the reimbursement was below cost, it was because it was too low of a profit margin. I think that is incredibly mercenary.

 

[Mister Mxyzptlk]

While I truthfully have entered medicine for the so-called "right" reasons, I look around at my medical school class, a group of people that will have "MD" next to their name come this May, and I know that a large portion of them have this same attitude about becoming physicians.

As I've said before, we have to be both healers and businessmen. And as everyone on this forum knows, I pay a lot of attention to the business side, as do my colleagues. You'd have to be either extremely wealthy or a complete fool to ignore the business aspects. The goal is to maintain the proper mix of doctor and businessman.

 

[ampaphb]

You are not obliged to acept all NEW patients. However, once a doctor-patient relationship has been estableished, you are open to a charge of patient abandonment if you stop seeing a class of patients (e.g. pump patients) at a time when there is no one else in the area willing to take on their care.

 

[drugdealer3000]

I'm sorry. There I go speaking from experience again. Do you think I haven't tried to get patients to write letters? Very few patients are activists. The ones in chronic severe pain even less so.

There is also the question of volume and hot-button issues. Sending pregnant women home quickly after childbirth affects a lot more people than denied pumps. It's also easier to get media attention when young mothers are being kicked to the curb than it is to explain why pumps are important to a select subset of pain patients.

I think it's abundantly clear why you are encountering resistance here. Most of us find it repellent to withhold treatment to make a political point. This is what you advocate.

I appreciate you sharing your years of experience. I didn't mean to discount them. I applaud you for explaining to your patients how the healthcare system actually works. Lord knows no one else has any vested interest in getting the truth out. I guess my point was if every niche practitioner showed solidarity eventually word may get out. It may not be as dramatic in the beginning as the new mothers scenario which is why it would require even more effort.

I don't think any one of us knows what was going on in "Mr Pumps" mind. Actually since you're in the biz you may have a better idea. Even if you told me the old and the new price I wouldn't be able to tell you whether they were reasonable. I just don't like doctor bashing. We don't have the whole story and because this guy had an issue with compensation he must be evil. I think that's nuts given some of the cuts that have gone on in health care.

I'm not so concerned about the pain guys and the anesthesiologists. I'm worried about the family practice guys and the general internists. Just because things are relatively much better for an Anesthesiologist doesn't mean they shouldn't show solidarity with their underpaid counterparts. I don't see what's selfish and money grubbing about giving up business on the principal of supporting a colleague in need.

By your own admission you demand cash payments from some of your patients even if they have insurance. And this is nobler than withholding non emergent care for a political point how? You do realise a lot of doctors on this planet would find your actions "repellent". That doesn't mean they should come on a forum and bash you with over the top posts.

 

[drugdealer3000]

You are not obliged to acept all NEW patients. However, once a doctor-patient relationship has been estableished, you are open to a charge of patient abandonment if you stop seeing a class of patients (e.g. pump patients) at a time when there is no one else in the area willing to take on their care.

Leaving the principals of medicine aside for a moment lets talk about business.

It is NEVER a good idea to break major laws when running a business. Your point about abandonment is well taken. I don't know in what scenario Mr. Pump would be allowed to cease performing his previous services.

Some people on this forum have mentioned not rendering emergency care to a patient. That is against the law. Therefor from a BUSINESS point of view a bad idea. Obviously the patients in the "Mr. Pump" scenario are not emergency cases. Every emergency room is required to treat patients regardless of their ability to pay. If you as a doctor are on call and refuse to see a patient in the ER for financial/political reasons you have broken the law and are eligible for losing your privileges at the hospital... which wouldn't be a good thing for your business.

If you write a bunch or Rx without medical indications you have broken the law and are eligible for either a restricted license or completely losing your license.

As someone who is interested in business I have no interest in seeing my six figure investment flushed down the toilet.

Ethics are something you can debate. The law is not negotiable.

 

[drugdealer3000]

Tenesam, savealife, Thanx for contributing as well. Your posts were insightful. I'm glad you can disagree and still contribute something. Actually I'm thankful for all the people that disagreed but still contributed something. Its all been educational.


Origin of drugdealer3000

I'm drugdealer3000 because I am going into anesthesia. It wasn't my original choice. Some of the gas stuff was taken. Drugdealer was already taken. It was getting late and I finally typed in drugdealer3000 and it worked. Its just a witty name that had nothing to do with pain. Perhaps an unfortunate choice given the nature of the subsequent posts.

 

[Doctodd]

Drugdealer.....on some days i want to agree with every word you said since it can get so frustrating. I feel like i am being preyed on by the "ethic-less" HMO's because of my ethics. It's all a big game and i sometimes enjoy learning to play. Today i didnt cuz i worked 12 long hours on a friday and risked my ass for a cocaine abusing medicaid patient in the ER for whom i will get about $40-60 yet can get hammered because it is medicaid. Not to mention that she can then try to sue me cuz i didnt treat her to her satisfaction(All i gave her was neurontin if you want to know). HMO's continue to cut reimbursement, yet their premiums go up.

I would really appreciate if some of you more experienced docs could post some of the things you have your patients read, sign(if Mr Pump or anyone similar is listening), or have your patients at least educated on. The flyer saying "I DIDNT PICK YOUR INSURANCE COMPANY" in a doctor's office just isnt as appealing, and just says "im angry". I want something constructive.

T

 

[Tenesma]

i have stopped looking at insurance coverage on ER patients or inpatients - because i feel it affects my care.... so what usually happens is i spend 1-2 hours with a difficutl patient, and then i look at the insurance... of course consultations in the ER and inpatient are never worth the money/time, but it is a kick in the groin when medicaid pays you $49 for 2 hours of work and then in follow-up pays you $17 per day... and those are usually the most complicated, litigious patients to begin with... i am seriously thinking about dropping out of medicaid - all the other specialists in my area have as well.

it all depends on what you can get away with - if you can survive without aetna then don't cow-tow to the them... my office staff explains that we are not in network with XYZ - they can either come see us and pay cash, or they can come see us out-of-network or we can make recommendations for another pain clinic (50 miles away) that does take XYZ. I would say that 90% are understanding... 10% are jerks about it... And my receptionist answer is that if they are unhappy with the available physicians for their XYZ insurance, then they need to talk to their HR department and complain...

so guess what, 3 companies in the last 6 months have changed out of XYZ to a far better insurance plan (for me at least) -

so you can have an impact.

now of course if you medicare is 50% of your practice and you are walking away from them (very hard to do because of their 2 year rule) - then realize your cashflow/incomes is going to be severely hampered.... if however 20% of those medicare patients stay with you and pay cash then you will probably be cashflow even and have for more time on your hands...

i have a friend who is cash only - took her forever to get started (ie: her salary was 30-40k/year for 3 years) but now she sees 10-15 patients a day and is making 350k/year and has NO billing issues whatsoever... of course her husband (a nurse) supported her during those 3 years.

 

[murphles]

Tenesma-was your friend doing pain management? Or some other specialty?

 

[Aether2000]

We actually have it quite good in the US compared to some other countries. I arrived back in the US today after teaching some of the pain docs in Europe, and found the Germans receive 32 euros per patient they treat and that is for 3 months of treatment regardless of how many patient visits or interventions. Many european physicians make only 20% of what the average pain physician makes.

 

[Tenesma]

32 euros that is about 44 bucks - so that is more than medicare pays me for a 99213.... that ain't so bad

not to mention that doctors are allowed to form unions over there...

they do have it pretty tough though - i was thinking of practicing over there (family reasons) and after speaking with a few anesthesiologists quickly changed my mind

1) most of it is "academic" meaning they have to wait for somebody to die or retire before they can move up the hierarchy - there was one OB/GYN who had finished his training but hadn't done a c-section in 2 years because there were too many people more senior than him - so he was getting paid to watch the surgery (that must suck because it wasn't a lot of money)

2) they have such crazy union/work/labor rules that if a patient transporters 36 hours are up they basically get up and leave, and the anesthesiologist becomes a patient transporter!!

3) the only way to make good money is to go completely private but you can only pretty much do that after 15-20 years of servitude to the "academic" hospitals - so the old guys are doing well

4) the advantages: they live in socialized states where education is free (for the most part), they don't have debt from medical school, their healthcare costs are minimal (socialized medicine) - and the governments subsidize A LOT (for example, in sweden, they will pay you 60% of your pay for 12 months if you have a child and take paternity-leave!!!!), and malpractice concerns are negligible unless you did something truly criminal...