Pain vs OR

[nlfru]

I am currently a CA2 and it seems like it is about that time to make up my mind about a pain fellowship, as the application process is right around the corner. I did not count on doing a fellowship at all, however I have really enjoyed my pain rotation and now dread going back to the OR. I am hoping that some of the more experienced pain attendings on this board could weigh in on my general feelings on pain medicine. My reasons for chosing pain are:

1. Tired of OR environment. I'm tired of zero respect not only for the anesthesia residents. My attendings get no more respect than we do and will throw us under the bus as often as possible. They run around kissing surgeon ***** all day long. Even the circulating nurses and housekeeping folks get in on the action. I feel like a nurse who specializes in kissing surgeon *****. Table up, table down. Better empty that foley or the PACU nurses will write you up and treat you in ways they would never dream of treating a surgeon.

2. Competion from nurses. There are nurses who think they can do our job better than us. This is no secret and they will tell anyone with ears. For the most part, administrators and patients do not know any better. While it is a concern of mine, it really goes back to the whole respect issue. It just puts me in a foul mood and dislike the CRNAs at my program.

3. Zero control. Lets just say the government or insurance goes wild with reimbursement cuts and says "anesthesia, you get a 90% cut. You now make 50K/year." I can not do a thing about that. I can't refuse to take medicare/medicaid because it is what the surgeon brings into the hospital. If I refuse to do cases from a certain party, I will quickly find myself looking for employment. Soon or later they will realize that they have that power. They are paying nurses 180K+ per year! This is a bubble that will burst. I also have no power over my schedule. The add on list of the surgeon dictates my life.

4. Bad **** happens in anesthesia. A lot of it can be managed in skilled hands. However, some of it can not. Massive MI, air embolisms, fat embolisms, MH, etc, etc. These patients are ticking time bombs just waiting to explode on my conscience and malpractice coverage. I am always on edge, which is a good thing for anesthesia. However, I bring that home with me, which I do not like.

Why pain:

1. Patient interaction. I actually do miss clinic work. I realize that some of these chronic pain patients are like black holes of energy. The little old ladies with a bulging disc are gratifying to me right now. Just being able to help someone who is legitimately in pain makes me feel a lot better. True, it might only be 10% of patients (or less) who are not interested in sitting on their couch, collecting their disability checks and "eating" percocet like it is candy. But at this moment in time, that 10% (or less) is worth it to me. Does this feeling tend to change?

2. Cool procedures. I think that this one speaks for itself.

3. Control. Just the feeling of being a real doctor again and not the b!tch to everyone in the OR. There is no one arguing with me about my plan of care.

4. It is a relatively new and evolving field. There is a lot of opportunity for research and advancement of the field.

5. I go home happy. I am not snapping at my wife and dreading the next morning.

In general, my family comes above all else. I started med school single and now I am married with kids. While I might be able to make more money in anesthesia, pain eliminates the numerous 24+ hr calls/weekends/holidays away from my family. So far I have loved it and enjoy what I do at work finally. Am I being a naive CA2? Are these legitimate reasons to go into pain? What am I missing?

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[powermd]

This is pretty much why I went into pain, and can confirm the positives you mention below.

Some negatives you may not recognize until you finish include pressure to prescribe more opiates than your comfortable with to make patients happy, who in turn make referring doctors happy. Not every PMD wants their patient on opioids, but plenty just don't care, and will stop sending you referrals after a few patients return to pester them. In a similar vein, you still have to kiss ass (surgeon ass is still the tastiest) to get and maintain a referral base. It's not quite as blatant as table up, table down, but it's there. You have to have a certain interest in difficult personality types, because these patients can really ruin your day if you let them frustrate you. You have to deal with addicts and chemical copers. Addicts are funny in a pathetic way. Copers are just plain annoying.

You are right that bad stuff happens in anesthesia- but when it happens on your watch, you can always fall back on the defense that the patient and surgeon decided that surgery must proceed, and you did everything in your power to help make that happen safely. In pain YOU are the surgeon. Any mistake in a 'totally elective procedure' is on you. I did a cervical epidural a few weeks ago and got what looked like a posterior spinal artery angiogram after dye injection (good LOR, good anatomical position). Yikes!! (I pulled out and went to T1-2 and the procedure went fine).

An unexpected positive is being deluged with hot industry reps bringing you lunch every other day!

I am currently a CA2 and it seems like it is about that time to make up my mind about a pain fellowship, as the application process is right around the corner. I did not count on doing a fellowship at all, however I have really enjoyed my pain rotation and now dread going back to the OR. I am hoping that some of the more experienced pain attendings on this board could weigh in on my general feelings on pain medicine. My reasons for chosing pain are:

1. Tired of OR environment. I'm tired of zero respect not only for the anesthesia residents. My attendings get no more respect than we do and will throw us under the bus as often as possible. They run around kissing surgeon ***** all day long. Even the circulating nurses and housekeeping folks get in on the action. I feel like a nurse who specializes in kissing surgeon *****. Table up, table down. Better empty that foley or the PACU nurses will write you up and treat you in ways they would never dream of treating a surgeon.

2. Competion from nurses. There are nurses who think they can do our job better than us. This is no secret and they will tell anyone with ears. For the most part, administrators and patients do not know any better. While it is a concern of mine, it really goes back to the whole respect issue. It just puts me in a foul mood and dislike the CRNAs at my program.

3. Zero control. Lets just say the government or insurance goes wild with reimbursement cuts and says "anesthesia, you get a 90% cut. You now make 50K/year." I can not do a thing about that. I can't refuse to take medicare/medicaid because it is what the surgeon brings into the hospital. If I refuse to do cases from a certain party, I will quickly find myself looking for employment. Soon or later they will realize that they have that power. They are paying nurses 180K+ per year! This is a bubble that will burst. I also have no power over my schedule. The add on list of the surgeon dictates my life.

4. Bad **** happens in anesthesia. A lot of it can be managed in skilled hands. However, some of it can not. Massive MI, air embolisms, fat embolisms, MH, etc, etc. These patients are ticking time bombs just waiting to explode on my conscience and malpractice coverage. I am always on edge, which is a good thing for anesthesia. However, I bring that home with me, which I do not like.

Why pain:

1. Patient interaction. I actually do miss clinic work. I realize that some of these chronic pain patients are like black holes of energy. The little old ladies with a bulging disc are gratifying to me right now. Just being able to help someone who is legitimately in pain makes me feel a lot better. True, it might only be 10% of patients (or less) who are not interested in sitting on their couch, collecting their disability checks and "eating" percocet like it is candy. But at this moment in time, that 10% (or less) is worth it to me. Does this feeling tend to change?

2. Cool procedures. I think that this one speaks for itself.

3. Control. Just the feeling of being a real doctor again and not the b!tch to everyone in the OR. There is no one arguing with me about my plan of care.

4. It is a relatively new and evolving field. There is a lot of opportunity for research and advancement of the field.

5. I go home happy. I am not snapping at my wife and dreading the next morning.

In general, my family comes above all else. I started med school single and now I am married with kids. While I might be able to make more money in anesthesia, pain eliminates the numerous 24+ hr calls/weekends/holidays away from my family. So far I have loved it and enjoy what I do at work finally. Am I being a naive CA2? Are these legitimate reasons to go into pain? What am I missing?

 

[SleepIsGood]

I am currently a CA2 and it seems like it is about that time to make up my mind about a pain fellowship, as the application process is right around the corner. I did not count on doing a fellowship at all, however I have really enjoyed my pain rotation and now dread going back to the OR. I am hoping that some of the more experienced pain attendings on this board could weigh in on my general feelings on pain medicine. My reasons for chosing pain are:

1. Tired of OR environment. I'm tired of zero respect not only for the anesthesia residents. My attendings get no more respect than we do and will throw us under the bus as often as possible. They run around kissing surgeon ***** all day long. Even the circulating nurses and housekeeping folks get in on the action. I feel like a nurse who specializes in kissing surgeon *****. Table up, table down. Better empty that foley or the PACU nurses will write you up and treat you in ways they would never dream of treating a surgeon.

2. Competion from nurses. There are nurses who think they can do our job better than us. This is no secret and they will tell anyone with ears. For the most part, administrators and patients do not know any better. While it is a concern of mine, it really goes back to the whole respect issue. It just puts me in a foul mood and dislike the CRNAs at my program.

3. Zero control. Lets just say the government or insurance goes wild with reimbursement cuts and says "anesthesia, you get a 90% cut. You now make 50K/year." I can not do a thing about that. I can't refuse to take medicare/medicaid because it is what the surgeon brings into the hospital. If I refuse to do cases from a certain party, I will quickly find myself looking for employment. Soon or later they will realize that they have that power. They are paying nurses 180K+ per year! This is a bubble that will burst. I also have no power over my schedule. The add on list of the surgeon dictates my life.

4. Bad **** happens in anesthesia. A lot of it can be managed in skilled hands. However, some of it can not. Massive MI, air embolisms, fat embolisms, MH, etc, etc. These patients are ticking time bombs just waiting to explode on my conscience and malpractice coverage. I am always on edge, which is a good thing for anesthesia. However, I bring that home with me, which I do not like.

Why pain:

1. Patient interaction. I actually do miss clinic work. I realize that some of these chronic pain patients are like black holes of energy. The little old ladies with a bulging disc are gratifying to me right now. Just being able to help someone who is legitimately in pain makes me feel a lot better. True, it might only be 10% of patients (or less) who are not interested in sitting on their couch, collecting their disability checks and "eating" percocet like it is candy. But at this moment in time, that 10% (or less) is worth it to me. Does this feeling tend to change?

2. Cool procedures. I think that this one speaks for itself.

3. Control. Just the feeling of being a real doctor again and not the b!tch to everyone in the OR. There is no one arguing with me about my plan of care.

4. It is a relatively new and evolving field. There is a lot of opportunity for research and advancement of the field.

5. I go home happy. I am not snapping at my wife and dreading the next morning.

In general, my family comes above all else. I started med school single and now I am married with kids. While I might be able to make more money in anesthesia, pain eliminates the numerous 24+ hr calls/weekends/holidays away from my family. So far I have loved it and enjoy what I do at work finally. Am I being a naive CA2? Are these legitimate reasons to go into pain? What am I missing?

I too can affirm a lot of what you said. i think a lot of guys go into pain for the reasons you mentioned above.

Only bad thing is, in anesthesia, after work you go home and can 'forget' about things....in pain...not ALWAYs the case. but I think the freedom and autonomy are well worth the trade off.

 

[ultm8frisbee]

I am currently a CA2 and it seems like it is about that time to make up my mind about a pain fellowship, as the application process is right around the corner. I did not count on doing a fellowship at all, however I have really enjoyed my pain rotation and now dread going back to the OR. I am hoping that some of the more experienced pain attendings on this board could weigh in on my general feelings on pain medicine. My reasons for chosing pain are:

1. Tired of OR environment. I'm tired of zero respect not only for the anesthesia residents. My attendings get no more respect than we do and will throw us under the bus as often as possible. They run around kissing surgeon ***** all day long. Even the circulating nurses and housekeeping folks get in on the action. I feel like a nurse who specializes in kissing surgeon *****. Table up, table down. Better empty that foley or the PACU nurses will write you up and treat you in ways they would never dream of treating a surgeon.

2. Competion from nurses. There are nurses who think they can do our job better than us. This is no secret and they will tell anyone with ears. For the most part, administrators and patients do not know any better. While it is a concern of mine, it really goes back to the whole respect issue. It just puts me in a foul mood and dislike the CRNAs at my program.

3. Zero control. Lets just say the government or insurance goes wild with reimbursement cuts and says "anesthesia, you get a 90% cut. You now make 50K/year." I can not do a thing about that. I can't refuse to take medicare/medicaid because it is what the surgeon brings into the hospital. If I refuse to do cases from a certain party, I will quickly find myself looking for employment. Soon or later they will realize that they have that power. They are paying nurses 180K+ per year! This is a bubble that will burst. I also have no power over my schedule. The add on list of the surgeon dictates my life.

4. Bad **** happens in anesthesia. A lot of it can be managed in skilled hands. However, some of it can not. Massive MI, air embolisms, fat embolisms, MH, etc, etc. These patients are ticking time bombs just waiting to explode on my conscience and malpractice coverage. I am always on edge, which is a good thing for anesthesia. However, I bring that home with me, which I do not like.

Why pain:

1. Patient interaction. I actually do miss clinic work. I realize that some of these chronic pain patients are like black holes of energy. The little old ladies with a bulging disc are gratifying to me right now. Just being able to help someone who is legitimately in pain makes me feel a lot better. True, it might only be 10% of patients (or less) who are not interested in sitting on their couch, collecting their disability checks and "eating" percocet like it is candy. But at this moment in time, that 10% (or less) is worth it to me. Does this feeling tend to change?

2. Cool procedures. I think that this one speaks for itself.

3. Control. Just the feeling of being a real doctor again and not the b!tch to everyone in the OR. There is no one arguing with me about my plan of care.

4. It is a relatively new and evolving field. There is a lot of opportunity for research and advancement of the field.

5. I go home happy. I am not snapping at my wife and dreading the next morning.

In general, my family comes above all else. I started med school single and now I am married with kids. While I might be able to make more money in anesthesia, pain eliminates the numerous 24+ hr calls/weekends/holidays away from my family. So far I have loved it and enjoy what I do at work finally. Am I being a naive CA2? Are these legitimate reasons to go into pain? What am I missing?

Looks like you've made your mind, what's your question? Start emailing your attendings about writing you LOR's for pain fellowships, tell your wife she aint getting the benz for another year. Start sending your stuff out in the spring.

 

[lobelsteve]

Only bad thing is, in anesthesia, after work you go home and can 'forget' about things....in pain...not ALWAYs the case. but I think the freedom and autonomy are well worth the trade off.

I think that is the sign of a good pain doctor. Transference, countertransference, some sort of emotional bond that builds confidence in the patient that you will make some of the hurt go away. Pretty sure this is what Ben Crue was talking about.

 

[nlfru]

A fellowship position has been promised to me so no worries there. I wanted to see if I am missing anything. I went into anesthesia with delusions of happy work environment, team approach to the patient, stable (ie no constant CRNA BS or penny pinching administrators dying to talk to the next AMC) employment and tons of cool procedures on appreciative patients. Just trying to make sure that I'm not being so incredibly naive about pain as I was about anesthesia. My overall impressions are those above and I'm glad to hear that others don't find them too delusional. We only get a 3 month elective prior to taking the dive and applying. Thanks for the replies.

 

[Jcm800]

A fellowship position has been promised to me so no worries there. I wanted to see if I am missing anything. I went into anesthesia with delusions of happy work environment, team approach to the patient, stable (ie no constant CRNA BS or penny pinching administrators dying to talk to the next AMC) employment and tons of cool procedures on appreciative patients. Just trying to make sure that I'm not being so incredibly naive about pain as I was about anesthesia. My overall impressions are those above and I'm glad to hear that others don't find them too delusional. We only get a 3 month elective prior to taking the dive and applying. Thanks for the replies.

I will caution you, more to be the devils advocate. I am a pain doc, in practice for a few years. I also hated anesthesia RESIDENCY...

Private practice anesthesia is VERY palatable and pleasant and collegial in many arenas. Not every where. Where I was at, I got a long great with the nurses, techs, surgeons. In private practice, the nurses, techs, are on ANESTHESIAS side (if there is a side)

so dont let life as a resident make you think that is the only way out there. Go on the anesthesia board and ask the same questions. I have lots of friends that are surgeons, and I have done anesthesia for them, and it is FUN, actually. Yes the table has to go up, but if i asked someone to hand me a napkin, they would do it, its not a power thing. its just that you have the REMOTE...

Pain is great, but it sucks. FOR ME, anesthesia sucks more. I just dont like the act of providing anesthesia, and if that is your main deterent, pain is a good option. However, if its about respect, and the environment, dont go into pain just for that. A nice cushy private practice job, leaving at 3 pm, and off post call makint 350k with 8 weeks of vacation, where you dont empty the foley, people listne and trust your judgment, and you dont have to kiss ass, just be a good doctor, might be what you are looking for...its out there.

Now, i gotta go back and get yelled at by this ER dump that is out of his vicodin that his PCP "assured" him i would fill, but wont...it would be nice to put him to sleep...

 

[powermd]

Now, i gotta go back and get yelled at by this ER dump that is out of his vicodin that his PCP "assured" him i would fill, but wont...it would be nice to put him to sleep...

That's what "sedation day" is for!

 

[nlfru]

I will caution you, more to be the devils advocate. I am a pain doc, in practice for a few years. I also hated anesthesia RESIDENCY...

Private practice anesthesia is VERY palatable and pleasant and collegial in many arenas. Not every where. Where I was at, I got a long great with the nurses, techs, surgeons. In private practice, the nurses, techs, are on ANESTHESIAS side (if there is a side)

so dont let life as a resident make you think that is the only way out there. Go on the anesthesia board and ask the same questions. I have lots of friends that are surgeons, and I have done anesthesia for them, and it is FUN, actually. Yes the table has to go up, but if i asked someone to hand me a napkin, they would do it, its not a power thing. its just that you have the REMOTE...

Pain is great, but it sucks. FOR ME, anesthesia sucks more. I just dont like the act of providing anesthesia, and if that is your main deterent, pain is a good option. However, if its about respect, and the environment, dont go into pain just for that. A nice cushy private practice job, leaving at 3 pm, and off post call makint 350k with 8 weeks of vacation, where you dont empty the foley, people listne and trust your judgment, and you dont have to kiss ass, just be a good doctor, might be what you are looking for...its out there.

Now, i gotta go back and get yelled at by this ER dump that is out of his vicodin that his PCP "assured" him i would fill, but wont...it would be nice to put him to sleep...

I appreciate you playing the devils advocate. All of the negative points about anesthesia that I mentioned are just the highlights of things that push me over the edge. Truthfully, I don't really enjoy anesthesia aside from those issues. I can tolerate it though which is more than I can say for many other specialties. Along with everything else, I don't think I'm cut out for 24 hr calls. At about 17 hrs my brain is mush and I feel dangerous. Maybe that's just me being a pu$$y though. Definitely my most minor issue when considering pain.

 

[Jeff05]

if you are really interested in pain, but aren't sure (very few people are SURE) and do not have any major financial obligations, do the fellowship. i agree, i think anesthesia residency is worse than a pleasant private practice.

i knew that i would not be able to grind out anesthesia day after day.

 

[PMR 4 MSK]

The CRNAs that are out for your job in the OR are now out for your job in the pain clinics.

Pain becomes a dumping ground only if you let it. You decide who you will see and who you will treat with what tool.

Opioids are one tool. If you feel pressured to prescribe opioids against your better judgement, just say no. You don't want those referrals anyway. Let them go whine to the PCP.

For the past 5 years, I have stonewalled every single referral who showed up with just enough pills to get them through to see me, with demands and manipulation to prescribe huge doses of opioids right then and there. Not one of them ever came back for a second visit. Thank God!

Now I can no longer remember the last time I had one of those - probably 2 years ago.

 

[specepic]

The CRNAs that are out for your job in the OR are now out for your job in the pain clinics.

Pain becomes a dumping ground only if you let it. You decide who you will see and who you will treat with what tool.

Opioids are one tool. If you feel pressured to prescribe opioids against your better judgement, just say no. You don't want those referrals anyway. Let them go whine to the PCP.

For the past 5 years, I have stonewalled every single referral who showed up with just enough pills to get them through to see me, with demands and manipulation to prescribe huge doses of opioids right then and there. Not one of them ever came back for a second visit. Thank God!

Now I can no longer remember the last time I had one of those - probably 2 years ago.

what do you do with the "just running out" referrals? What about withdrawl? Do you give them nothing or a taper?

thx

 

[hyperalgesia]

what do you do with the "just running out" referrals? What about withdrawl? Do you give them nothing or a taper?

thx

No taper. They get to go back to their supplier or dealer. Or they can go to the ER. Withdrawl is not a pain management diagnosis.

 

[PMR 4 MSK]

No taper. They get to go back to their supplier or dealer. Or they can go to the ER. Withdrawl is not a pain management diagnosis.

Bingo.

I did not create the monster, I'm not gonna kill it.

You know, if a PCP called me up and said "Look, I f'ed up, got this bozo on 400 mg MSO4/day and I need help getting outta this, can you help me?" I'll go a mile to help him.

But when they send someone over without a call, a head's up or anything, and only enough pills to get them through until their 10 am appt, next dose due at 2 pm and no pills left - e.g. the last Rx was for 37 pills because that would get them through to that appt time, they can fix it themselves.

They would never, ever do the same thing to cardiology, nephrology, etc.

 

[Jcm800]

No taper. They get to go back to their supplier or dealer. Or they can go to the ER. Withdrawl is not a pain management diagnosis.

Amen!

 

[yancantcook]

this is exactly something I am debating right now except I'm in the middle of my pain fellowship at a very reputable academic institution.

I'm debating between staying at academic OR anesthesia/acute pain vs hospital based private practice OR.

Pain has great hours but I often feel more "tired" at the end of the day than OR anesthesia, the endless flow of pain patients is very mentally draining and unlike anesthesia there is no "down time" throughout the day. all day it is non stop mental exhaustion in dealing with patients crying, depressed, "whole body aches", why doesn't this work mentally. the procedures in pain are rewarding and very fun to do which is great though.


Any new academic attendings liking the OR as a non resident? I like the OR still, doing alines, central lines, regional blocks, etc. The surgeon are annoying though and the lack of respect is someonething we deal with in the OR daily.


Anyone regret going into chronic pain and wished they went to the OR or actually went back to the OR?

 

[lonelobo]

Pain has great hours but I often feel more "tired" at the end of the day than OR anesthesia, the endless flow of pain patients is very mentally draining and unlike anesthesia there is no "down time" throughout the day. all day it is non stop mental exhaustion in dealing with patients crying, depressed, "whole body aches", why doesn't this work mentally. the procedures in pain are rewarding and very fun to do which is great though.

?

Sounds like you were made for Academics

 

[ssmallz]

OP, your reasons for doing pain are exactly why I left anesthesia. Anesthesia is not a job, it's a lifestyle and if you can't accept that you will never be a successful happy anesthesiologist. The best part about pain is that it's a job. At the end of the day you get to home, eat dinner, and sleep in your own bed. To me you can't put a price on that

 

[yancantcook]

OP, your reasons for doing pain are exactly why I left anesthesia. Anesthesia is not a job, it's a lifestyle and if you can't accept that you will never be a successful happy anesthesiologist. The best part about pain is that it's a job. At the end of the day you get to home, eat dinner, and sleep in your own bed. To me you can't put a price on that

That is a great point, pain has 8-5 M-F hours with no true emergencies every. However, the typical day-to-day may be draining depending on who you talk to.

What about academic OR anesthesia/regional compared to private practice pain hours? In private practice you will be on call several times a month overnight but in academics, that is much less. One academic place I'm speaking with has 8 (10pm-7am) night per year as well as 8 weekend days/night (12 shifts) for the entire year.

 

[Aether2000]

There are true emergencies after hours and to dismiss the possibilities is to become so complacent as to invite disaster. The true emergencies can be neurological post injection, abscesses in a stimulator or pump, and emergencies from excess local being administered. If you do not have coverage after hours and just want to be a daytime doc, forget it. Also, the joy of sticking needles into people is rapidly diminishing with the number of procedure limitations and eliminations by insurers. And to think you get more respect? Not when there are chiropractors, radiology techs, Pas, NPs, and CRNAs that are doing exactly what you do as a pain physician. Pain used to be a lateral move from anesthesia but it is now an increasingly monetary and constricted specialty. It is not all doom and gloom but it is also not a mindless needle jockey banker job any longer. However what is happening in pain is happening all throughout the field of medicine, but it is more evidence in pain.

 

[emd123]

There are true emergencies after hours and to dismiss the possibilities is to become so complacent as to invite disaster. The true emergencies can be neurological post injection, abscesses in a stimulator or pump, and emergencies from excess local being administered. If you do not have coverage after hours and just want to be a daytime doc, forget it. Also, the joy of sticking needles into people is rapidly diminishing with the number of procedure limitations and eliminations by insurers. And to think you get more respect? Not when there are chiropractors, radiology techs, Pas, NPs, and CRNAs that are doing exactly what you do as a pain physician. Pain used to be a lateral move from anesthesia but it is now an increasingly monetary and constricted specialty. It is not all doom and gloom but it is also not a mindless needle jockey banker job any longer. However what is happening in pain is happening all throughout the field of medicine, but it is more evidence in pain.

Agree, but post injection emergencies are (should be) very uncommon. Regarding pump and stim abscesses, there's a simple solution. Don't do pumps and only trial stims. That way you're implanter is responsible for all post-stim implant infections.

Regarding this: "If you do not have coverage after hours and just want to be a daytime doc, forget it. "- I am on call 24 hr per day, 365, but by not implanting, I get maybe 1 call per month on average. They all end with, "Please call the office at 8am, I'd be happy to work you in ASAP, if it cannot wait, please go to the ER immediately." The only time I've been in a hospital in the last 2.5 years since I started my practice was when my wife broke her ankle, never once for a patient of mine. I set it up this way.

As far as respect as a physician, having my butt kissed isn't what drives me, so it's not a big issue for me. Generally I rarely feel disrespected except by people I appropriately seeking meds I won't prescribe and that's easy to discount. If you want to feel treated with disrespect as a physician, go work as an ER doctor, anywhere, not to mention suffering that on 1/2 of all holidays and weekends your whole career, and 1/3 of the time between the hours of midnight and 8am. That's by drunks spitting on you, taking care of criminals in handcuffs, psychotic patients, working with nurses you didn't hire and can't fire, and have your job threatened by administrators because you got knocked down a star on your lasts months patient satisfaction survey by a "customer" who was a drug addict seeking meds to sell or inject who down rated you. I feel much more respected and much less disrespected as a Pain MD, than I used to as an EM MD, and that's by a mile.

As far as complications post local injection, I can honestly say I've injected local in probably 10s of thousands of patients at this point, in my pre-pain carrier and now in pain and I don't think I've ever seen a delayed or serious one that affected a patient after they left my sights. I did hear about an ortho that made someone seize from local, but the guy injected 7 or 8 10-cc vials of lido in a kid with tons of lacerations and the kid seized. Keep the amount down and side effects should be exceedingly rare.

Maybe Pain really sucks for some depending on their practice setup, and I can't say Pain is perfect, but it's way, way, better than what I personally used to do. Somehow I've managed to keep relatively banker-like hours despite all the doom and gloom. And that is pretty sweet, I must admit.

 

[lobelsteve]

If you never met a patient in the ED or at the hospital, someone else took care of your patient in crisis and you "lost them to follow up".

 

[yancantcook]

Agree, but post injection emergencies are (should be) very uncommon. Regarding pump and stim abscesses, there's a simple solution. Don't do pumps and only trial stims. That way you're implanter is responsible for all post-stim implant infections.

Regarding this: "If you do not have coverage after hours and just want to be a daytime doc, forget it. "- I am on call 24 hr per day, 365, but by not implanting, I get maybe 1 call per month on average. They all end with, "Please call the office at 8am, I'd be happy to work you in ASAP, if it cannot wait, please go to the ER immediately." The only time I've been in a hospital in the last 2.5 years since I started my practice was when my wife broke her ankle, never once for a patient of mine. I set it up this way.

As far as respect as a physician, having my butt kissed isn't what drives me, so it's not a big issue for me. Generally I rarely feel disrespected except by people I appropriately seeking meds I won't prescribe and that's easy to discount. If you want to feel treated with disrespect as a physician, go work as an ER doctor, anywhere, not to mention suffering that on 1/2 of all holidays and weekends your whole career, and 1/3 of the time between the hours of midnight and 8am. That's by drunks spitting on you, taking care of criminals in handcuffs, psychotic patients, working with nurses you didn't hire and can't fire, and have your job threatened by administrators because you got knocked down a star on your lasts months patient satisfaction survey by a "customer" who was a drug addict seeking meds to sell or inject who down rated you. I feel much more respected and much less disrespected as a Pain MD, than I used to as an EM MD, and that's by a mile.

As far as complications post local injection, I can honestly say I've injected local in probably 10s of thousands of patients at this point, in my pre-pain carrier and now in pain and I don't think I've ever seen a delayed or serious one that affected a patient after they left my sights. I did hear about an ortho that made someone seize from local, but the guy injected 7 or 8 10-cc vials of lido in a kid with tons of lacerations and the kid seized. Keep the amount down and side effects should be exceedingly rare.

Maybe Pain really sucks for some depending on their practice setup, and I can't say Pain is perfect, but it's way, way, better than what I personally used to do. Somehow I've managed to keep relatively banker-like hours despite all the doom and gloom. And that is pretty sweet, I must admit.

every specialty has some kind of emergency, that is "emergent" to them. pain has a lot less emergencies that cause stress/anxiety but the patients you see on a daily basis maybe a constant slow drain of your soul.

compare that to a supportive academic OR environment where you have politics to deal with but don't have the constant drain of "painful" patients and have a few calls and be in a more stimulating environment.

any pain providers wish you were back in the OR instead?

 

[Disciple]

Bingo.
You know, if a PCP called me up and said "Look, I f'ed up, got this bozo on 400 mg MSO4/day and I need help getting outta this, can you help me?" I'll go a mile to help him.

But when they send someone over without a call, a head's up or anything, and only enough pills to get them through until their 10 am appt, next dose due at 2 pm and no pills left - e.g. the last Rx was for 37 pills because that would get them through to that appt time, they can fix it themselves.

So, we all have that problem with certain PCPs.

How does everybody here feel when a midlevel does it?

 

[Disciple]

Pain becomes a dumping ground only if you let it. You decide who you will see and who you will treat with what tool.

Opioids are one tool. If you feel pressured to prescribe opioids against your better judgement, just say no. You don't want those referrals anyway. Let them go whine to the PCP.

For the past 5 years, I have stonewalled every single referral who showed up with just enough pills to get them through to see me, with demands and manipulation to prescribe huge doses of opioids right then and there. Not one of them ever came back for a second visit. Thank God!

Now I can no longer remember the last time I had one of those - probably 2 years ago.

Instead of antagonism with the referral sources, what about just letting your marketing materials/conversations portray you as a total needle jockey?

Then, when referrals come in, you pick out appropriate patients, expertly manage their meds, address all issues, etc.

Sends mixed messages? Too passive-aggressive?

 

[ssmallz]

So, we all have that problem with certain PCPs.

How does everybody here feel when a midlevel does it?

I will help out any member of the community who is looking for help weaning a patient off of inappropriate med whether that be a PCP, NP, PA or whatever. If a patient is serious about getting off opioids then I am happy to offer whatever services I can

 

[ferning]

How do practice pain medicine and not address the opiate epidemic? Specialty exists because of people strung out on dope because surprise surprise it should have never been rx to chronic pain patients.

If all u want is respect that u dont get in the OR though, there are enough pleasant people dependent on opiates to fill a practice. ...Or you can d/c them with referrals to others or the ER

Do everyone a favor and fight legislation against surgical center moratoriums. You can then employ surgeons and be the boss. Plus you can negotiate private insurance contracts. Lowering costs compared to hospitals is where u make money. Outside of a hospital you are not required to employ nurses, their pay and benefits to good techs or too attract surgeons

though while still providing better care when u and the surgeon are not pressured to perform surgeries that are better off not done

 

[Hoya11]

I was chief fellow in one of the largest and most respected pain fellowships. I recently graduated and initially took a job doing PP pain. Let me just tell you it was MUCH different than fellowship. As a fellow, and in academics in general, you are shieled from the INDUSTRY of pain medicine (and most of all medicine today). Those reps coming to your office are not your friend, they have probably had 5 different jobs in the last 5 years selling anything they can. Now they are selling unneccessarily expensive back braces, new long acting formulations of opiates, stimulators, pumps, any new gadget they can sell. They look at you as a revenue stream, as will your group. Get ready to sell your soul for that sweet 8-3 job. Get ready to spend coutnless hours dealing with workers comp people appealing for a procedure (that probably wont help anyway) for a patient with some BS complaint ( a slip and fall, car accident claim, work-related injury). All in the name of supporting and "helping" people stay home, take opiates, not work, and have hard working people make up for it. VERY rarely would I see a normal person with pathology that I cuold cure or at least significantly help with an injection. In hindsight, I think most of the procedures being done were just so the patient can get there opiates or have continued pay and not work. Is that what you want to do with your life? Suck up to industry lawyers? reps? PCPs? drug addicted loser patients? I get that the hours are great but come one. I think people with their head in the sand touting the "combined therapy" with injectinos and opiates is OK, but I think they just do not realize that the patients are just doing the injections for secondary gain, and if those things were not on the table, ie no opiates or pay for not working, MANY less people would be willing to go through injections (which we love to perform so much). I think we as pain doctors also think that the injections help more than they do, when they do not USUALLY alter the course of illness.

I went back to anesthesia after less than a year in PP pain. It feels great. Taking care of actually sick people who need my help in a critical situation. Doing blocks is still part of my day usually and I love it, especially doing them much better and faster than my colleagues. Not worrying about referrals, or numbers of injections per month, or bonuses, or retaliation from the DEA, or my drugged out patients getting into trouble and having it effect me. I come to work, I do a job that is very important and requires expertise and skill and cool under pressure. Then I go home when the work is done. More time off, less worrying (if any) about the business side of medicine that unfortunately SOO many other doctors HAVE to worry about. I think that Ortho, Onc, and Pain doctors are the most guilty of succumbing to this industry. Im not sure this sentiment is shared by the pain doctors on this board, whether they have a different situation or just do not realize what they are actually doing: causing more harm than good all in the name of early days and high pay. Take the opiates away and that would change a lot. I really doubt that pain management will be the same in 10 years. It seems like a huge scam to me.

 

[lobelsteve]

I was chief fellow in one of the largest and most respected pain fellowships. I recently graduated and initially took a job doing PP pain. Let me just tell you it was MUCH different than fellowship. As a fellow, and in academics in general, you are shieled from the INDUSTRY of pain medicine (and most of all medicine today). Those reps coming to your office are not your friend, they have probably had 5 different jobs in the last 5 years selling anything they can. Now they are selling unneccessarily expensive back braces, new long acting formulations of opiates, stimulators, pumps, any new gadget they can sell. They look at you as a revenue stream, as will your group. Get ready to sell your soul for that sweet 8-3 job. Get ready to spend coutnless hours dealing with workers comp people appealing for a procedure (that probably wont help anyway) for a patient with some BS complaint ( a slip and fall, car accident claim, work-related injury). All in the name of supporting and "helping" people stay home, take opiates, not work, and have hard working people make up for it. VERY rarely would I see a normal person with pathology that I cuold cure or at least significantly help with an injection. In hindsight, I think most of the procedures being done were just so the patient can get there opiates or have continued pay and not work. Is that what you want to do with your life? Suck up to industry lawyers? reps? PCPs? drug addicted loser patients? I get that the hours are great but come one. I think people with their head in the sand touting the "combined therapy" with injectinos and opiates is OK, but I think they just do not realize that the patients are just doing the injections for secondary gain, and if those things were not on the table, ie no opiates or pay for not working, MANY less people would be willing to go through injections (which we love to perform so much). I think we as pain doctors also think that the injections help more than they do, when they do not USUALLY alter the course of illness.

I went back to anesthesia after less than a year in PP pain. It feels great. Taking care of actually sick people who need my help in a critical situation. Doing blocks is still part of my day usually and I love it, especially doing them much better and faster than my colleagues. Not worrying about referrals, or numbers of injections per month, or bonuses, or retaliation from the DEA, or my drugged out patients getting into trouble and having it effect me. I come to work, I do a job that is very important and requires expertise and skill and cool under pressure. Then I go home when the work is done. More time off, less worrying (if any) about the business side of medicine that unfortunately SOO many other doctors HAVE to worry about. I think that Ortho, Onc, and Pain doctors are the most guilty of succumbing to this industry. Im not sure this sentiment is shared by the pain doctors on this board, whether they have a different situation or just do not realize what they are actually doing: causing more harm than good all in the name of early days and high pay. Take the opiates away and that would change a lot. I really doubt that pain management will be the same in 10 years. It seems like a huge scam to me.

Stop beating around the bush and tell us what you really think.

 

[Taus]

The practice type that the OP and the last poster describe is a far cry from what I do, but I realize that can appear to be the norm for some. I couldn't do that type of practice all day every day either and agree that rarely is an injection going to make much of a difference in that setting. Plenty of pain docs are fine w that model (nearly all on opioids, in house uds, dme, pain creams, high% wc/PI cases, high volume procedures w frequent repeats in perpetuity). I'll never make as much money as them, but I sleep well at night with how I practice.

If you are qualified to be and market yourself as a comprehensive non-operative spine (and musculoskeletal if pmr) specialist than you may see an entirely different patient base than the "chronic pain" setting. I see plenty of acute patients mixed in with patients with only several months of back/neck/peripheral joint pain. Rarely stereotypical chronic pain patients, who are on high dose opioids, tried everything and life is in a downward spiral. I'm fine to see that too, as I often have something unique to offer and am under no obligation to take over a narcotic regimen I didn't start and don't agree with. Most of my patients adamantly do not want to be on opioids or are part of the 10-15% I prescribe to who are using low dose appropriately and are functional members of society. Most are in the 55+ crowd. A lot had to do with choosing my practice wisely. It's very enjoyable and satisfying work.

If you go into pain primarily bc "you like the blocks" you'll be miserable.

 

[hyperalgesia]

I was chief fellow in one of the largest and most respected pain fellowships. I recently graduated and initially took a job doing PP pain. Let me just tell you it was MUCH different than fellowship. As a fellow, and in academics in general, you are shieled from the INDUSTRY of pain medicine (and most of all medicine today). Those reps coming to your office are not your friend, they have probably had 5 different jobs in the last 5 years selling anything they can. Now they are selling unneccessarily expensive back braces, new long acting formulations of opiates, stimulators, pumps, any new gadget they can sell. They look at you as a revenue stream, as will your group. Get ready to sell your soul for that sweet 8-3 job. Get ready to spend coutnless hours dealing with workers comp people appealing for a procedure (that probably wont help anyway) for a patient with some BS complaint ( a slip and fall, car accident claim, work-related injury). All in the name of supporting and "helping" people stay home, take opiates, not work, and have hard working people make up for it. VERY rarely would I see a normal person with pathology that I cuold cure or at least significantly help with an injection. In hindsight, I think most of the procedures being done were just so the patient can get there opiates or have continued pay and not work. Is that what you want to do with your life? Suck up to industry lawyers? reps? PCPs? drug addicted loser patients? I get that the hours are great but come one. I think people with their head in the sand touting the "combined therapy" with injectinos and opiates is OK, but I think they just do not realize that the patients are just doing the injections for secondary gain, and if those things were not on the table, ie no opiates or pay for not working, MANY less people would be willing to go through injections (which we love to perform so much). I think we as pain doctors also think that the injections help more than they do, when they do not USUALLY alter the course of illness.

I went back to anesthesia after less than a year in PP pain. It feels great. Taking care of actually sick people who need my help in a critical situation. Doing blocks is still part of my day usually and I love it, especially doing them much better and faster than my colleagues. Not worrying about referrals, or numbers of injections per month, or bonuses, or retaliation from the DEA, or my drugged out patients getting into trouble and having it effect me. I come to work, I do a job that is very important and requires expertise and skill and cool under pressure. Then I go home when the work is done. More time off, less worrying (if any) about the business side of medicine that unfortunately SOO many other doctors HAVE to worry about. I think that Ortho, Onc, and Pain doctors are the most guilty of succumbing to this industry. Im not sure this sentiment is shared by the pain doctors on this board, whether they have a different situation or just do not realize what they are actually doing: causing more harm than good all in the name of early days and high pay. Take the opiates away and that would change a lot. I really doubt that pain management will be the same in 10 years. It seems like a huge scam to me.

What do you do when a sell-out orthopod needs you to anesthetize a workers comp spine case? I agree with you for the most part though. You have to work hard to not fall into the traps, which are everywhere. The most pride I take in my work is not in the procedures I do, it's what I DON'T do.

 

[emd123]

I was chief fellow in one of the largest and most respected pain fellowships. I recently graduated and initially took a job doing PP pain. Let me just tell you it was MUCH different than fellowship. As a fellow, and in academics in general, you are shieled from the INDUSTRY of pain medicine (and most of all medicine today). Those reps coming to your office are not your friend, they have probably had 5 different jobs in the last 5 years selling anything they can. Now they are selling unneccessarily expensive back braces, new long acting formulations of opiates, stimulators, pumps, any new gadget they can sell. They look at you as a revenue stream, as will your group. Get ready to sell your soul for that sweet 8-3 job. Get ready to spend coutnless hours dealing with workers comp people appealing for a procedure (that probably wont help anyway) for a patient with some BS complaint ( a slip and fall, car accident claim, work-related injury). All in the name of supporting and "helping" people stay home, take opiates, not work, and have hard working people make up for it. VERY rarely would I see a normal person with pathology that I cuold cure or at least significantly help with an injection. In hindsight, I think most of the procedures being done were just so the patient can get there opiates or have continued pay and not work. Is that what you want to do with your life? Suck up to industry lawyers? reps? PCPs? drug addicted loser patients? I get that the hours are great but come one. I think people with their head in the sand touting the "combined therapy" with injectinos and opiates is OK, but I think they just do not realize that the patients are just doing the injections for secondary gain, and if those things were not on the table, ie no opiates or pay for not working, MANY less people would be willing to go through injections (which we love to perform so much). I think we as pain doctors also think that the injections help more than they do, when they do not USUALLY alter the course of illness.

I went back to anesthesia after less than a year in PP pain. It feels great. Taking care of actually sick people who need my help in a critical situation. Doing blocks is still part of my day usually and I love it, especially doing them much better and faster than my colleagues. Not worrying about referrals, or numbers of injections per month, or bonuses, or retaliation from the DEA, or my drugged out patients getting into trouble and having it effect me. I come to work, I do a job that is very important and requires expertise and skill and cool under pressure. Then I go home when the work is done. More time off, less worrying (if any) about the business side of medicine that unfortunately SOO many other doctors HAVE to worry about. I think that Ortho, Onc, and Pain doctors are the most guilty of succumbing to this industry. Im not sure this sentiment is shared by the pain doctors on this board, whether they have a different situation or just do not realize what they are actually doing: causing more harm than good all in the name of early days and high pay. Take the opiates away and that would change a lot. I really doubt that pain management will be the same in 10 years. It seems like a huge scam to me.

Agree with Taus.

Pain sucked for you, because your first job was a high-dose-opiates-for-injections mill. Sad, because it doesn't have to be that way. You're the doc. Don't write an Rx or recommend an injection you don't think will likely do more good than harm. It can take a strong person with a good morale compass to say, "No," but it's that simple. You saw you didn't have the stomach for it, and I commend you for doing the right thing by getting out. As far as reps...

Are you kidding me? In one second you tell your office manager, "No more reps allowed in, unless I call them." Done, problem solved. You don't work for them, they work for you. I call a stim rep when we're doing a trial or programming otherwise I don't allow or invite them in. I have lunch out of the office and if a rep is there with food, it sits there uneaten by me and the rep unheard by me. They know it's wasted on me.

As far as opiates: You have to dig deep, before you go into Pain and commit to prescribing only when you feel it's beneficial and not when its harmful or shady. Did you go work for some sleaze show that expected you to cover and sign sleazy scripts? If so, that's very unfortunate, but it's not the fault of those who've chosen a more ethical route, and take their oath seriously.

Pain needs more docs that are going to do the right thing. Not more to go along with a sleazy pills-for-injections model. Plus, I don't push or require my patients to have injections, nor should anyone else. Many get none. Many get an injection once in a while and no opiates. Some get both. Patients that get repeated injections usually get then because they say, "Doc, remember that shot you gave me three months ago? It helped, can I have another?"

There's no reason to force injections on patients or require some robotic "series of three" as a condition of continuing meds. That's absurd. Sorry you saw a real sleazy side of Pain, and no one showed you the ropes on how to do it right, and in a way you could be confident you're helping people or at the very least "Do no harm."

Plus, it's easy for everyone to espouse the risks and abuse potential of opiates, but when you demand people drill down and commit to an outright ban, on opiates for those without terminal illness <6 mos to live, or surgery/broken bone <6 wk, they all buckle, their spines go weak and say, "No, you can't ban them, some people NEED them."

And there you are, having come full circle back to a place where strong minded, ethical doctors are needed to make that determination while balancing a realistic level of compassion, tempered with an honest assessment of the risks, combined with real, not feigned, monitoring and oversight. It's so happens, that is a very hard thing to do.

There can be temptations. Just know what you stand for, have a moral compass, stick to it when difficult and get in with a group that agrees. Otherwise, go solo. Don't think that sleazy, harmful or unnecessary profit driven care isn't rampant and growing in hospital-based Medicine. It is endemic. (Unnecessary surgeries with life/limb threatening complications, unnecessary radiation inducing CT scans, resistance causing unnecessary antibiotics, to name only a few). You may feel it's easier to divide the responsibility since you're going along to get along and not driving the ship, but it goes on in a tremendous way and many are complicit just the same, if not more so unless you stand up for what's right. When supposedly free of ethical concerns in the OR, do you report that surgeon to the medical board, you know full well is terrible or does unnecessary spinal fusions?

 

[Hoya11]

Agree with Taus.

Pain sucked for you, because your first job was a high-dose-opiates-for-injections mill. Sad, because it doesn't have to be that way. You're the doc. Don't write an Rx or recommend an injection you don't think will likely do more good than harm. It can take a strong person with a good morale compass to say, "No," but it's that simple. You saw you didn't have the stomach for it, and I commend you for doing the right thing by getting out. As far as reps...

Are you kidding me? In one second you tell your office manager, "No more reps allowed in, unless I call them." Done, problem solved. You don't work for them, they work for you. I call a stim rep when we're doing a trial or programming otherwise I don't allow or invite them in. I have lunch out of the office and if a rep is there with food, it sits there uneaten by me and the rep unheard by me. They know it's wasted on me.

As far as opiates: You have to dig deep, before you go into Pain and commit to prescribing only when you feel it's beneficial and not when its harmful or shady. Did you go work for some sleaze show that expected you to cover and sign sleazy scripts? If so, that's very unfortunate, but it's not the fault of those who've chosen a more ethical route, and take their oath seriously.

Pain needs more docs that are going to do the right thing. Not more to go along with a sleazy pills-for-injections model. Plus, I don't push or require my patients to have injections, nor should anyone else. Many get none. Many get an injection once in a while and no opiates. Some get both. Patients that get repeated injections usually get then because they say, "Doc, remember that shot you gave me three months ago? It helped, can I have another?"

There's no reason to force injections on patients or require some robotic "series of three" as a condition of continuing meds. That's absurd. Sorry you saw a real sleazy side of Pain, and no one showed you the ropes on how to do it right, and in a way you could be confident you're helping people or at the very least "Do no harm."

Plus, it's easy for everyone to espouse the risks and abuse potential of opiates, but when you demand people drill down and commit to an outright ban, on opiates for those without terminal illness <6 mos to live, or surgery/broken bone <6 wk, they all buckle, their spines go weak and say, "No, you can't ban them, some people NEED them."

And there you are, having come full circle back to a place where strong minded, ethical doctors are needed to make that determination while balancing a realistic level of compassion, tempered with an honest assessment of the risks, combined with real, not feigned, monitoring and oversight. It's so happens, that is a very hard thing to do.

There can be temptations. Just know what you stand for, have a moral compass, stick to it when difficult and get in with a group that agrees. Otherwise, go solo. Don't think that sleazy, harmful or unnecessary profit driven care isn't rampant and growing in hospital-based Medicine. It is endemic. (Unnecessary surgeries with life/limb threatening complications, unnecessary radiation inducing CT scans, resistance causing unnecessary antibiotics, to name only a few). You may feel it's easier to divide the responsibility since you're going along to get along and not driving the ship, but it goes on in a tremendous way and many are complicit just the same, if not more so unless you stand up for what's right. When supposedly free of ethical concerns in the OR, do you report that surgeon to the medical board, you know full well is terrible or does unnecessary spinal fusions?

1. Sorry for the rant, I do realize that my 1st job was probably an extreme example and overly malignant money-driven place in general.
2. I did not have the authority to not see reps, I was depended on to market via them as part of my job (see #1) But I do not think that kind of practice model is uncommon so look out. How many grads are going into private practice straight out of fellowship? Think that group is not going to try and have you do sleazy stuff like that? Maybe not in academics of BFE, but otherwise probably.
3. I do honestly believe most pain doctors have a similarly sleazy practice but do not realize it. Putting in Pumps? Stimming more than a couple times a month? Shame on you. All industry driven BS.
4. "Some get injections, Some get opiates, SOme get both." Get out of here - Most get opiates, some get injections too, few get no opiates, very few get no opiates and get injections. That is just reality.
5. "Can I have that injection that you gave me three months ago?" That is called you being manipulated by your lovely patients. That will be followed up by "Can I have more Percocet? Can you call it in for 3 months?"
6. About the spine cases and other BS that I do anesthesia for: Well I totally understand your point. Anyone making money in medicine will have to deal with some of this BS. All I can say is that I feel much better giving the sedation and analgesia for these procedures and being an angel of mercy to the terrible powers that force these kinds of procedures on people. Whether it be an unnecessary fusion, or a PEG tube in a 90 year old stroked out lady, I do honestly feel better being on the anesthesia, parasitic, mocking side of it, though I do do the cases. I often do have the opportunity though to talk the family, patient, or surgeon out of these procedures, which I love. But I hear you, the whole system is broken. It does honestly feel better though to step back and mock it as opposed to being knee deep in the worst part of it. I go home at the end of the day and people are breathing, pain free, through surgery because of me. Not eating opiates sitting at home planning on who to sue next.

7. And what does it mean to be a "spine specialist"? That you do these silly blocks? That you know an algorithm to diagnose some syndromes that you inevitably do a silly block for or give opiates for? Pain is a man made specialty and the world would be fine if it was managed by sports medicine docs and orthopods. What "unique" treatments are you offering? Opana? Neurontin? Elavil? God knows they all are miracle drugs.

8. I didn't go into pain solely because " I liked blocks", though I do like blocks. I moved, did the fellowship, and took the job initially because I was fascinated with the idea of pain management. What are the best treatments, What kinds of pain syndromes are there, I was very interested in the pathophysiology, and I liked the idea of treating suffering people. IN fellowship (and I suspect in academics some places) this is what I spent my time doing, and I didn't care about money. In PP, it was all about money, and there was no one truly suffering, just society for having to carry these losers who are the real bread and butter of chronic pain in PP.

 

[Taus]

1. Sorry for the rant, I do realize that my 1st job was probably an extreme example and overly malignant money-driven place in general.
2. I did not have the authority to not see reps, I was depended on to market via them as part of my job (see #1) But I do not think that kind of practice model is uncommon so look out. How many grads are going into private practice straight out of fellowship? Think that group is not going to try and have you do sleazy stuff like that? Maybe not in academics of BFE, but otherwise probably.
3. I do honestly believe most pain doctors have a similarly sleazy practice but do not realize it. Putting in Pumps? Stimming more than a couple times a month? Shame on you. All industry driven BS.
4. "Some get injections, Some get opiates, SOme get both." Get out of here - Most get opiates, some get injections too, few get no opiates, very few get no opiates and get injections. That is just reality.
5. "Can I have that injection that you gave me three months ago?" That is called you being manipulated by your lovely patients. That will be followed up by "Can I have more Percocet? Can you call it in for 3 months?"
6. About the spine cases and other BS that I do anesthesia for: Well I totally understand your point. Anyone making money in medicine will have to deal with some of this BS. All I can say is that I feel much better giving the sedation and analgesia for these procedures and being an angel of mercy to the terrible powers that force these kinds of procedures on people. Whether it be an unnecessary fusion, or a PEG tube in a 90 year old stroked out lady, I do honestly feel better being on the anesthesia, parasitic, mocking side of it, though I do do the cases. I often do have the opportunity though to talk the family, patient, or surgeon out of these procedures, which I love. But I hear you, the whole system is broken. It does honestly feel better though to step back and mock it as opposed to being knee deep in the worst part of it. I go home at the end of the day and people are breathing, pain free, through surgery because of me. Not eating opiates sitting at home planning on who to sue next.

7. And what does it mean to be a "spine specialist"? That you do these silly blocks? That you know an algorithm to diagnose some syndromes that you inevitably do a silly block for or give opiates for? Pain is a man made specialty and the world would be fine if it was managed by sports medicine docs and orthopods. What "unique" treatments are you offering? Opana? Neurontin? Elavil? God knows they all are miracle drugs.

8. I didn't go into pain solely because " I liked blocks", though I do like blocks. I moved, did the fellowship, and took the job initially because I was fascinated with the idea of pain management. What are the best treatments, What kinds of pain syndromes are there, I was very interested in the pathophysiology, and I liked the idea of treating suffering people. IN fellowship (and I suspect in academics some places) this is what I spent my time doing, and I didn't care about money. In PP, it was all about money, and there was no one truly suffering, just society for having to carry these losers who are the real bread and butter of chronic pain in PP.

Will respond in more detail when have more time. I suspect that my practice and patients align more to what you think of when you say "sports medicine". What do you think happens when an average educated middle aged or older person who works full time and has a "normal life" has a herniated disc causing a radic, axial back pain or rotator cuff issue lasting a few months.... turn into an opioid and bonbon chugging sloth? Outside of work comp and the like.... They want to get better, go to PT, take some basic meds (NSAID, tramadol, neurontin, etc) and if not getting better or miserable from the pain they get an injection or 2 and usually improve. These people exist... think of your colleagues, your parents... In the right practice you'll see just as much or more of this type of patient than the stereotypical chronic pain patient.

 

[emd123]

1. Sorry for the rant, I do realize that my 1st job was probably an extreme example and overly malignant money-driven place in general.
2. I did not have the authority to not see reps, I was depended on to market via them as part of my job (see #1) But I do not think that kind of practice model is uncommon so look out. How many grads are going into private practice straight out of fellowship? Think that group is not going to try and have you do sleazy stuff like that? Maybe not in academics of BFE, but otherwise probably.
3. I do honestly believe most pain doctors have a similarly sleazy practice but do not realize it. Putting in Pumps? Stimming more than a couple times a month? Shame on you. All industry driven BS.
4. "Some get injections, Some get opiates, SOme get both." Get out of here - Most get opiates, some get injections too, few get no opiates, very few get no opiates and get injections. That is just reality.
5. "Can I have that injection that you gave me three months ago?" That is called you being manipulated by your lovely patients. That will be followed up by "Can I have more Percocet? Can you call it in for 3 months?"
6. About the spine cases and other BS that I do anesthesia for: Well I totally understand your point. Anyone making money in medicine will have to deal with some of this BS. All I can say is that I feel much better giving the sedation and analgesia for these procedures and being an angel of mercy to the terrible powers that force these kinds of procedures on people. Whether it be an unnecessary fusion, or a PEG tube in a 90 year old stroked out lady, I do honestly feel better being on the anesthesia, parasitic, mocking side of it, though I do do the cases. I often do have the opportunity though to talk the family, patient, or surgeon out of these procedures, which I love. But I hear you, the whole system is broken. It does honestly feel better though to step back and mock it as opposed to being knee deep in the worst part of it. I go home at the end of the day and people are breathing, pain free, through surgery because of me. Not eating opiates sitting at home planning on who to sue next.

7. And what does it mean to be a "spine specialist"? That you do these silly blocks? That you know an algorithm to diagnose some syndromes that you inevitably do a silly block for or give opiates for? Pain is a man made specialty and the world would be fine if it was managed by sports medicine docs and orthopods. What "unique" treatments are you offering? Opana? Neurontin? Elavil? God knows they all are miracle drugs.

8. I didn't go into pain solely because " I liked blocks", though I do like blocks. I moved, did the fellowship, and took the job initially because I was fascinated with the idea of pain management. What are the best treatments, What kinds of pain syndromes are there, I was very interested in the pathophysiology, and I liked the idea of treating suffering people. IN fellowship (and I suspect in academics some places) this is what I spent my time doing, and I didn't care about money. In PP, it was all about money, and there was no one truly suffering, just society for having to carry these losers who are the real bread and butter of chronic pain in PP.

Wow. You must have gotten in with a real sleazy group of guys. Yikes. I'd try again to convince you it can be done in an honest, ethical and rewarding way, but I don't think you'd believe me at this point. Regardless, I'm glad you found greener pastures and that you're happier now. Good luck.

 

[Ducttape]

there is some truth in what Hoya says, but it is dependent on the practice.

i take umbrage to a few points. first, in your own practice, you establish the rules. for example, for me, few get opioids. the only ones that get opioids on the first appointment are cancer patients already on opioids and need help with their regimen. most of my practice is providing PCPs with help in appropriate and safe care that may not resolve their patient's pain, but will not lead to overdose, misuse, and societal issues such as increased availability on the open market. i only see stim reps now. no other reps, particularly no cream or UDS reps. most of the drug reps have been fired after the Sunshine act went into effect.

second, anesthesia does a significant role in modern medical care. but as an anesthesia specialist, how do you feel when 99% of patients never remember your name, even if you did save their lives, 98% of patients dont know that you are a real doctor and that there is a difference between you and a nurse ("advanced" or not - and if you believe the CRNA societies, there is no difference), and, for most surgeons, you are "Anesthesia On"?
https://video.search.yahoo.com/video/play;_ylt=A0LEViwkk59Uh.IA8.0PxQt.;_ylu=X3oDMTBsa3ZzMnBvBHNlYwNzYwRjb2xvA2JmMQR2dGlkAw--?p=anesthesia on commercial&tnr=21&vid=ACA74A31463AC18248E1ACA74A31463AC18248E1&l=31&turl=http://ts2.mm.bing.net/th?id=UN.608053531415020053&pid=15.1&rurl=https://www.youtube.com/watch?v=aBHdRW5oa2k&sigr=11bgo5oo9&tt=b&tit=Ford Sync Anesthesia On - 2008 Super Bowl Commercial&sigt=11ke48eli&back=https://search.yahoo.com/yhs/search?p=anesthesia+on+commercial&ei=UTF-8&hsimp=yhs-001&hspart=mozilla&sigb=134bnrbbc&hspart=mozilla&hsimp=yhs-001

As an addendum, you might have been content working in an academic or (gasp) hospital based pain practice (assuming that the hospital system does not see your role as a sole profit making venture, but rather as an integral part of a hospital system providing comprehensive care...)

 

[hyperalgesia]

8. I didn't go into pain solely because " I liked blocks", though I do like blocks. I moved, did the fellowship, and took the job initially because I was fascinated with the idea of pain management. What are the best treatments, What kinds of pain syndromes are there, I was very interested in the pathophysiology, and I liked the idea of treating suffering people. IN fellowship (and I suspect in academics some places) this is what I spent my time doing, and I didn't care about money. In PP, it was all about money, and there was no one truly suffering, just society for having to carry these losers who are the real bread and butter of chronic pain in PP.

If you want to feel like you are "doing the right thing", practicing ethically, etc, you have to forget about the $$. I work at the VA and have a small part time PP and do not partake in the sleaze business. No industry sponsored goodies, no work comp, no narcotics, no inappropriate and greed driven treatment. I don't get paid very much but that's my choice. Pain has its share of charlatans but it's the charlatans who are guilty, not the medical field.

 

[powermd]

Get ready to sell your soul for that sweet 8-3 job. Get ready to spend coutnless hours dealing with workers comp people appealing for a procedure (that probably wont help anyway) for a patient with some BS complaint ( a slip and fall, car accident claim, work-related injury). All in the name of supporting and "helping" people stay home, take opiates, not work, and have hard working people make up for it. VERY rarely would I see a normal person with pathology that I cuold cure or at least significantly help with an injection.

Sounds like my first job out of fellowship! Did you go to work for the same guy?

Thankfully I got out after a year and found a great practice where I get to do 100% of what I want to do, 0% of what I don't. I help patients for real everyday, solve interesting puzzles everyday, AND I make good $$. That's a tall order, and I got very lucky. Sorry to hear about your bad experience, but that comes from the lack of adequate standards in our young field combined with the greed and weak morals of some of our colleagues.

I'm glad you are happier back in anesthesia.

 

[nvrsumr]

Pain can be one of the best jobs in medicine: Autonomy. Hours. Thank you cookies.

own gig/no narcs=job satisfaction

 

[yancantcook]

Pain can be one of the best jobs in medicine: Autonomy. Hours. Thank you cookies.

own gig/no narcs=job satisfaction

I think if you can find a decent pain practice, that may be very satisfying.

However, the way I see the future of pain, private practice 10 years down the line is not as optimistic. Unfortunately, the procedures that we do don't really help patients all that much unless they are active in PT and want to help themselves, yet we do them because it pays the bills and its something to do. Patient's on opioids almost never want to come down because they hurt too much without them. Insurance is constantly denying medications and procedure reimbursements will come down and it is only a matter of time because LESI aren't even worth doing anymore. I see plenty of patient's that got into a MVA and now years later still aren't any better and are blaming every little pain from the accident, "per my lawyer" and the workman's comp that hurt his groin that never wants to work again, not even a desk job. We are constantly get depositions from BS personal injury lawyers (scum of the earth btw) and under threat of lawsuits from litigious patients....

I had a optimistic outlook for pain going into the fellowship but now that I am 50% completed the year, I dread doing a private practice pain job. Academic pain may be better off and more insulated from the things PP pain has to deal with and that may be the way to go. The reasons above are why I am leaning towards academic OR/acute pain instead of regular pain in the "real world"

 

[Papa Lou]

I think if you can find a decent pain practice, that may be very satisfying.

However, the way I see the future of pain, private practice 10 years down the line is not as optimistic. Unfortunately, the procedures that we do don't really help patients all that much unless they are active in PT and want to help themselves, yet we do them because it pays the bills and its something to do. Patient's on opioids almost never want to come down because they hurt too much without them. Insurance is constantly denying medications and procedure reimbursements will come down and it is only a matter of time because LESI aren't even worth doing anymore. I see plenty of patient's that got into a MVA and now years later still aren't any better and are blaming every little pain from the accident, "per my lawyer" and the workman's comp that hurt his groin that never wants to work again, not even a desk job. We are constantly get depositions from BS personal injury lawyers (scum of the earth btw) and under threat of lawsuits from litigious patients....

I had a optimistic outlook for pain going into the fellowship but now that I am 50% completed the year, I dread doing a private practice pain job. Academic pain may be better off and more insulated from the things PP pain has to deal with and that may be the way to go. The reasons above are why I am leaning towards academic OR/acute pain instead of regular pain in the "real world"

You guys complaining will have to be more reasonable than that. This is a bit ridiculous. This tirade is self-indulgent and pretends to be naive. Yes this is palliative medical care but who doesn't already know that? Do you think spine surgeons are "fixing" pain? Do you think most surgeons are out there crushing it in the "fixing" game? No. A joint replacement is not a fix, it's a replacement. A spine decompression doesn't mean you get a new fixed body, it's just a way to work around the problem, same as a total knee replacement is a workaround for your crappy OA knee. Nobody can undo years of punishment on their body but we can make it tolerable. We can palliate them. We provide a solution/alternative to surgery for a large percentage of patients who would otherwise go under the knife. You make a huge difference in controlling pain, which is inevitable! Palliation is what almost all of medicine is. First do no harm (because we're not out there to do godly miracles..our solutions are limited in efficacy so at least do no harm!).
PT is not a cure either but it helps right? Well we're making people hurt less so they can do the PT which would otherwise be too painful. What's the defect with that? Get your patients off opiates as much and often as you can..simple as that. As for those MVA patients you are ranting about give me a break! You think b/c you have an MD you're going to change personalities that easily? B/c you stick some needles you're going to get people to stop blaming others for their shortcomings/take more responsibility and action in their lives? No, that's going to require extraordinary effort to try to move that mountain and even then failure rate is very high. People will always be around to get money by screwing the system whether legally or illegally. Again this is not news. What's the big deal? Be a great pain doctor, try to make a difference every day, and don't have ridiculous expectations if you don't want to have them.

 

[Disciple]

I will help out any member of the community who is looking for help weaning a patient off of inappropriate med whether that be a PCP, NP, PA or whatever. If a patient is serious about getting off opioids then I am happy to offer whatever services I can

I was referring specifically to the situation where there is no phone call from the referral source, and the patient shows up with exactly the number of pills to last until their initial appointment with you.

 

[Disciple]

1. Sorry for the rant, I do realize that my 1st job was probably an extreme example and overly malignant money-driven place in general...

A little bit negative and jaded, but a lot of truth here.

The practice styles of the members of this forum, in general, are the exception, not the rule.

If procedures are cut down far enough, and ACOs become the dominant model, the role of the "pain doctor" will be to oversee large Kaiser style group pain programs while also serving as pseudo-addictionologist for the "lost generation" of opioid dependent patients.

I've already seen these types of positions described in the recruiting for several large hospital systems.

 

[yancantcook]

You guys complaining will have to be more reasonable than that. This is a bit ridiculous. This tirade is self-indulgent and pretends to be naive. Yes this is palliative medical care but who doesn't already know that? Do you think spine surgeons are "fixing" pain? Do you think most surgeons are out there crushing it in the "fixing" game? No. A joint replacement is not a fix, it's a replacement. A spine decompression doesn't mean you get a new fixed body, it's just a way to work around the problem, same as a total knee replacement is a workaround for your crappy OA knee. Nobody can undo years of punishment on their body but we can make it tolerable. We can palliate them. We provide a solution/alternative to surgery for a large percentage of patients who would otherwise go under the knife. You make a huge difference in controlling pain, which is inevitable! Palliation is what almost all of medicine is. First do no harm (because we're not out there to do godly miracles..our solutions are limited in efficacy so at least do no harm!).
PT is not a cure either but it helps right? Well we're making people hurt less so they can do the PT which would otherwise be too painful. What's the defect with that? Get your patients off opiates as much and often as you can..simple as that. As for those MVA patients you are ranting about give me a break! You think b/c you have an MD you're going to change personalities that easily? B/c you stick some needles you're going to get people to stop blaming others for their shortcomings/take more responsibility and action in their lives? No, that's going to require extraordinary effort to try to move that mountain and even then failure rate is very high. People will always be around to get money by screwing the system whether legally or illegally. Again this is not news. What's the big deal? Be a great pain doctor, try to make a difference every day, and don't have ridiculous expectations if you don't want to have them.

I agree that if you go into pain with the approach that we aren't really going to cure patients but from the approach of "palliative care" then the treatments and interventions we do all make more sense. Do no harm I guess.

 

[powermd]

Palliation is what almost all of medicine is.

Exactly.

Do blood pressure medications "fix" high blood pressure? How about any other chronic daily medication?

Wouldn't it be awesome if you could a five minute procedure like an epidural steroid injection that would provide 8-12 weeks of relief from high blood pressure, diabetes, etc?

What would that be worth?

Hmm.. maybe there is value in epidural steroid injections after all. And yet yancantcook believes these are "hardly worth doing anymore".

 

[lobelsteve]

Exactly.

Do blood pressure medications "fix" high blood pressure? How about any other chronic daily medication?

Wouldn't it be awesome if you could a five minute procedure like an epidural steroid injection that would provide 8-12 weeks of relief from high blood pressure, diabetes, etc?

What would that be worth?

Hmm.. maybe there is value in epidural steroid injections after all. And yet yancantcook believes these are "hardly worth doing anymore".

HTN is such a subjective phenomenon. Just saying...

 

[CSmith912345]

Hoya,

I understand your arguments but they are a little disingenuous. You seem to put pain physicians at a higher moral standard than almost any other physician by your logic. Your argument is basically that since some patients aren't becoming productive citizens of society, the pain physicians are at "fault" for taking "advantage of the system".

Problems with your argument include:

1) Patients who are on disability often get this without the pain physician. There are tons of lawyers who do disability. Often, the patients already have disability before coming to see the pain physician. Therefore, the pain physician will not be the reason for them getting on disability.

2) How many people get fusion surgeries who don't get back to work and remain on high dosage opiates? From my experience, the vast majority of fusion surgery patients have remaining problems, requiring opiates. They often get on disability as well. By your logic, the surgeons are responsible for making a disability problem with many patients requiring high dosage opiates.

How many patients are willing to undergo surgery to get disability? I see this all the time. Often, surgeons will fuse patients for degenerative disc disease. The patient will subsequently get on disability and high dosage narcotics. In fact, most of the disability patients have undergone back surgery and no just "pain treatments".

From my experience, the only patients I will place on high dosages of narcotics are patients who had multi-level fusion surgeries (often multiple surgeries) who are totally disabled. Are the pain physicians responsible for these patients?

Are you not doing the anesthesia for spine surgery cases? Therefore, you are just as guilty for supporting the disability system as anyone. In fact, from my experience, since the vast majority of people I see get disability due to fusion surgeries, you are actually more guilty than anyone for providing anesthesia for these cases.


3) How many procedures in medicine are far overdone and provide little benefit? Lets be honest here. A list of examples of very limited benefit procedures include:

a) Fusion surgeries for degenerative disc disease/stenosis: far fewer of these patients get back to work than patients who don't get these surgeries. Other back surgeries are only temporary fixes with subsequent degenerative of other spinal levels. Even patients with laminectomy surgeries will often progress further in a few years to require more surgery. Fusion surgeries are almost always repeated multiple times due to degenerative at other levels.

b) Most oncology drugs that have been FDA approved in the last 15 years with a cost of10K-40K/month provide zero benefit (57/60) or only a few weeks of extra life in the hospital. This was shown on 60 minutes recently. Very little real progress in CA research outside of Gleevac in the last 40 years has been shown. Yet for far more money is being spent on these CA drugs than for "Pain medicine" per year.

c) Arthroscopic Surgery for OA due to "pain" is no better than placebo

d) Stents done for CAD outside of an acute MI (over 95% of stents performed in the USA). Studies from the VA with 10,000s of patients show no mortality benefit compared to just medication for CAD. Yet despite these findings, stent usage has gone up exponentially. Far more is spent on this area of medicine than pain medicine.

e) Lyrica at over 500 dollars/month only shows at best 20% pain reduction compared to placebo. Statins show less than 1/100 patients benefit. Most pharmaceutical drugs show very little benefit at extreme cost

f) Cardiac Ablation for most types of Atrial Flutter/Fibrillation shows no benefit over simple medications. Yet this is a growing business with >50K/ treatment. Outside of Afib that is intractable to medications (a very small minority of patients), ablations aren't beneficial over medications. Yet, this is being pushed as a first line treatment.


So if you are doing anesthesia for fusion surgeries, arthroscopic surgeries for cartilage problems, ablation/stents, etc, you are just as guilty as any pain doctor out there for this "problem" in medicine. In fact, due to the much higher costs of these treatments compared to pain medicine treatments, I could make an argument that you are FAR more guilty of this problem due to provision of anesthesia for these cases.

In medicine, the only things that has actually shown increased in lifespan have been vaccinations, antibiotics and improved sanitation. Outside of that, little progress has been made in treating most illnesses.

Many countries in Europe have populations that live much longer lives (on avg) than America, despite all of our "treatments". If pain medicine was fully eliminated, the costs of healthcare would not decrease by any appreciable extent. Therefore, you need to target the areas of the biggest abuse (in terms of dollars) before pointing fingers.

 

[CSmith912345]

You guys complaining will have to be more reasonable than that. This is a bit ridiculous. This tirade is self-indulgent and pretends to be naive. Yes this is palliative medical care but who doesn't already know that? Do you think spine surgeons are "fixing" pain? Do you think most surgeons are out there crushing it in the "fixing" game? No. A joint replacement is not a fix, it's a replacement. A spine decompression doesn't mean you get a new fixed body, it's just a way to work around the problem, same as a total knee replacement is a workaround for your crappy OA knee. Nobody can undo years of punishment on their body but we can make it tolerable. We can palliate them. We provide a solution/alternative to surgery for a large percentage of patients who would otherwise go under the knife. You make a huge difference in controlling pain, which is inevitable! Palliation is what almost all of medicine is. First do no harm (because we're not out there to do godly miracles..our solutions are limited in efficacy so at least do no harm!).
PT is not a cure either but it helps right? Well we're making people hurt less so they can do the PT which would otherwise be too painful. What's the defect with that? Get your patients off opiates as much and often as you can..simple as that. As for those MVA patients you are ranting about give me a break! You think b/c you have an MD you're going to change personalities that easily? B/c you stick some needles you're going to get people to stop blaming others for their shortcomings/take more responsibility and action in their lives? No, that's going to require extraordinary effort to try to move that mountain and even then failure rate is very high. People will always be around to get money by screwing the system whether legally or illegally. Again this is not news. What's the big deal? Be a great pain doctor, try to make a difference every day, and don't have ridiculous expectations if you don't want to have them.

Actually, most spine surgeons just see the patient for their surgery. They often do fusion surgeries on these patients (>1400% increase in the last decade). These patients are then "cured" and sent to the pain physician. These patients often are placed on disability and given high dosage narcotics due to worse pain than prior to surgery.

Yet I'm sure Hoya is doing the Anesthesia for these cases and keeping his mouth shut. Therefore, his "holier than thou" attitude is not justified since he is part of the problem.

 

[CSmith912345]

I think if you can find a decent pain practice, that may be very satisfying.

However, the way I see the future of pain, private practice 10 years down the line is not as optimistic. Unfortunately, the procedures that we do don't really help patients all that much unless they are active in PT and want to help themselves, yet we do them because it pays the bills and its something to do. Patient's on opioids almost never want to come down because they hurt too much without them. Insurance is constantly denying medications and procedure reimbursements will come down and it is only a matter of time because LESI aren't even worth doing anymore. I see plenty of patient's that got into a MVA and now years later still aren't any better and are blaming every little pain from the accident, "per my lawyer" and the workman's comp that hurt his groin that never wants to work again, not even a desk job. We are constantly get depositions from BS personal injury lawyers (scum of the earth btw) and under threat of lawsuits from litigious patients....

I had a optimistic outlook for pain going into the fellowship but now that I am 50% completed the year, I dread doing a private practice pain job. Academic pain may be better off and more insulated from the things PP pain has to deal with and that may be the way to go. The reasons above are why I am leaning towards academic OR/acute pain instead of regular pain in the "real world"

The disability problem is far bigger than just some pain physicians. If you removed all pain physicians from practice, there would be negligible decreases in disability. Most of these people would:

1) End up getting surgery on their back and subsequently get on disability because they "had back surgery and can't work". This is very common in my practice. Since I don't support disability for most patients, these patient's lawyers use the surgeon's records to get their disability approved.
2) Get disability for "mental disorders" such as "bipolar". I see tons of patients in their 20s and 30s already on disability for mental disorders, presumably due to psychiatrist evaluations
3) Get some PMR or PCP to sign off on disability

In my practice, I support almost no disability. Yet there are many people who come in with disability already. I will have patients in the process of getting disability for no good reason. These patients will get disability DESPITE my medical records stating there is no reason for them to be disabled.

The whole system is a racket supported by the govt. Don't be naive.

 

[101N]

I was chief fellow in one of the largest and most respected pain fellowships. I recently graduated and initially took a job doing PP pain. Let me just tell you it was MUCH different than fellowship. As a fellow, and in academics in general, you are shieled from the INDUSTRY of pain medicine (and most of all medicine today). Those reps coming to your office are not your friend, they have probably had 5 different jobs in the last 5 years selling anything they can. Now they are selling unneccessarily expensive back braces, new long acting formulations of opiates, stimulators, pumps, any new gadget they can sell. They look at you as a revenue stream, as will your group. Get ready to sell your soul for that sweet 8-3 job. Get ready to spend coutnless hours dealing with workers comp people appealing for a procedure (that probably wont help anyway) for a patient with some BS complaint ( a slip and fall, car accident claim, work-related injury). All in the name of supporting and "helping" people stay home, take opiates, not work, and have hard working people make up for it. VERY rarely would I see a normal person with pathology that I cuold cure or at least significantly help with an injection. In hindsight, I think most of the procedures being done were just so the patient can get there opiates or have continued pay and not work. Is that what you want to do with your life? Suck up to industry lawyers? reps? PCPs? drug addicted loser patients? I get that the hours are great but come one. I think people with their head in the sand touting the "combined therapy" with injectinos and opiates is OK, but I think they just do not realize that the patients are just doing the injections for secondary gain, and if those things were not on the table, ie no opiates or pay for not working, MANY less people would be willing to go through injections (which we love to perform so much). I think we as pain doctors also think that the injections help more than they do, when they do not USUALLY alter the course of illness.

I went back to anesthesia after less than a year in PP pain. It feels great. Taking care of actually sick people who need my help in a critical situation. Doing blocks is still part of my day usually and I love it, especially doing them much better and faster than my colleagues. Not worrying about referrals, or numbers of injections per month, or bonuses, or retaliation from the DEA, or my drugged out patients getting into trouble and having it effect me. I come to work, I do a job that is very important and requires expertise and skill and cool under pressure. Then I go home when the work is done. More time off, less worrying (if any) about the business side of medicine that unfortunately SOO many other doctors HAVE to worry about. I think that Ortho, Onc, and Pain doctors are the most guilty of succumbing to this industry. Im not sure this sentiment is shared by the pain doctors on this board, whether they have a different situation or just do not realize what they are actually doing: causing more harm than good all in the name of early days and high pay. Take the opiates away and that would change a lot. I really doubt that pain management will be the same in 10 years. It seems like a huge scam to me.

This part is too true: In hindsight, I think most of the procedures being done were just so the patient can get there opiates or have continued pay and not work.