Should I Bail on Pain?

[Timeoutofmind]

Wanted to get some feedback from the more seasoned folks out there:

I am a fellow on the job interview trail. At this point, there is a position that I would likely to take which seems just about perfect.

1. The practice does not prescribe at all, just makes recommendations
2. Good pay, partnership track, very well managed practice, etc
3. Reasonable patient load 25 per day is around the max
4. Partner is a sophisticated proceduralist willing to teach
5. No IT pumps, will do procedures that dont pay well because they believe in them, etc (basically they try and be ethical)

Here is my dilemma: I am hesitating a little bit before making the definite step forward.

The crux of the issue to me is that, honestly, all the negativity with the debates about the efficacy/marginal data of IPM really give me pause, and gets me down. It bothers me emotionally. Take this thread below:

http://forums.studentdoctor.net/thr...ination-of-spinal-injection-coverage.1180948/

Other large scale analyses by third parties seem to make similar statements. Such as the following:

https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/id98TA.pdf

We could talk all day about how all these reviewers etc are biased, but I am not a conspiracy type, and honestly, probably the evidence just is not all that great.

I have seen people apparently benefit from the procedures we perform during this fellowship year, but how can I let anecdotal experiences trump the opinion of experts and summary of the published literature?

I went into medicine to help people. After all these difficult years of training, I dont want to take a good gig with a great lifestyle if I am basically selling people on something that is not realistically going to help them. I feel like even if some stuff about Anesthesia sucks, at least I can sleep knowing that I am doing some good for some people every day. I do understand that some of the surgeries we do are bogus, so Anesthesia is not 100% doing good for people all the time, but it seems much more clear cut to me.

Should I go back to the OR?

As a final complicating factor, my wife would be seriously bummed and hesitant about me going back to the OR's, due to lifestyle considerations. We have a kid, etc. (Really got my but kicked as a resident lol!) Maybe it is selfish of me to think this way, and I should just be more of a family guy is the right thing to do with the more reasonable lifestyle of pain.

I am not trying to be dogmatic, and I respect that chronic pain patients are complicated and we have limited tools, the alternative treatments are also poor, etc, so I do see both sides of the coin here. I guess the most honest option would be to just tell patients that spine surgery often doesnt work, opioids dont work, and IPM does not work, and they should just cope as best as they can with whatever mix of taichi/weightloss and exercise/psychology/quiting smoking/heat/ice/stretching/TENS/whatever else they feel like?

I had some of these reservations prior to starting fellowship, but I was so burnt out with Anesthesia I wanted to at least do the fellowship and gain more knowledge/experience in the field before I ruled it out.

I thought for a while about just trying to do cancer pain, as neurolytic procedures/tunneled epidural catheters/blasting these people with opioids is definitely efficacious and are meaningful interventions. But it seems that these jobs are not to be found, and oncologists rarely refer to pain docs.

Has anyone faced a similar dilemma out there?

I am pretty torn/stressed out as I am down to the wire with some of these decisions.

I was thinking maybe I will take the job and try it for at least a year or two in order to truly give it a fair shot, and then bail if my concerns continue?

Thank you for your thoughts.

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[willabeast]

i looked up mortality rate for vaginal deliveries developing world. it is 1.5/100. i understand this is a bit of an exaggeration, but that implies 98.5% of the time women would be fine without an obstetrician.
similarly most Americans would be fine if they never saw their primary care docs for colds, headaches, back aches, trouble sleeping, etc.
IMHO the vast majority of medical care as currently practiced in the USA is not needed. that includes OR anesthesia BTW.
most honest medical MD thing to do in the USA is become a plastic surgeon, specialize in rhinoplasties or breast procedures. alternatively, establish a clinic in Africa somewhere.
I don't know what your destiny will be, but one thing I know: the only ones among you who will be really happy are those who will have sought and found how to serve.
Albert Schweitzer


Read more at http://www.brainyquote.com/quotes/authors/a/albert_schweitzer.html#UHZRXWRRtZPLMbHO.99

 

[y2janitor]

I know the crux of your question is a deep philosophical dilemma, that I don't have an answer for, but dude that job offer you described sounds pretty sweet.

 

[drpainfree]

honestly, even after your fellowship you still don't see what you're doing benefits patients, you should NOT be doing it.

period, end of story.

you'll most likely be miserable to go into full-time pain management if you don't have confidence and faith in yourself.

stay in or

 

[drusso]

This specialty is under intense scrutiny and chronic pain patients are not a group of people who attract a lot of sympathy. In fact, most doctors think that patients with chronic pain are crazy, lying, or both. Under current payment models it is almost impossible to do an adequate job "treating the whole patient" without giving away a lot service (i.e. working for free). The field thirsts for leaders to "man up" and advocate for resources that justify the intensity of work that is required to do this job well. Most physicians are not "built" that way, have little interest in doing that work, or honestly could care less.

I'm "terminally differentiated" into a physiatric pain specialist. If I were starting over, I'd strongly consider fields and opportunities that were less politicized and allowed for more entrepreneurial work. Buyer beware.

 

[Ducttape]

go into pain.

believe in yourself. believe in what you do help people, because it does, some people. IPM doesnt help everyone though.
be aware of the limitations of IPM and be ready to cut losses, or treat them differently.

and by the end of the day, if you still feel you are not helping people, you will be making lots of $$ and have financial security.


and go volunteer. or work for the local medical society. do pro bono work. or maybe do a little OR at an ASC, then volunteer to go overseas. work in a soup kitchen. learn yoga and teach your patients how to do the downward dog as they get in position for their lumbar RFA...

you yourself do not have to be defined by your job.

 

[freddydpt]

I think the bottom line is that you have to have passion for what you do. If it's not anesthesia, and it's not pain, there are other things for physicians to do. With that said, if you are looking for a lifestyle job that won't be so political, why not do ASC anesthesia? I'm not an anesthesiologist, but I've heard those are fairly laid back gigs with good pay.

 

[hyperalgesia]

I would do pain but keep anesthesia current. Whatever you do, it will get routine. You will never get complete fulfillment from any field of medicine.

 

[BobBarker]

Stick with pain. You do help people. My elderly patients and veterans are very rewarding to treat.

 

[Dr. Ice]

Go back to the or if you are feeling this way now because the real world of pain is not as rosy as fellowship is. The reality sets in when as an attending your first procedural treatment doesn't result in nearly as good of an outcome as you thought it would. It is a tough field. Managing patient expectation is difficult. Every now and again you will get a slam dunk off your treatment and your pateient will be eternally grateful. I can tell you that percentage of patients is not the norm. You have to be a pretty patient person because many of these pain patients will make you want to bang your head against a wall.

The lifestyle is good though..no question. No call no weekends. Procedures can break up the monotony of all day clinic and or vise versa. If you are efficient and have good business sense you can set yourself up nicely with maybe even not working the full 5 day work week and still doing well financially.

You have to decide what's most important to you and what your limitations are and what you are willing to accept from your job..and then just roll with it.

 

[lobelsteve]

Stick with porn. Lots of chicks, good money, great drugs. Pressure is about the same as medicine but no real consequences if you keep screwing up.

 

[bronchospasm]

Try pain for a few years.... If you like it continue. If you don't. go back to gas... Or if you decide do a mix of both.

At least that is what I'm planning on doing.

In pain, some days everyone is getting better. Some days everyone is worse. I think that everyday even if 1 patient comes back and says that you have helped them, over 30 years of practice you will have helped a lot of patients.

Pain is definitely More rewarding than gas, but can get monotonous as well. Better pay. And everyone in town thinks you are a shady pill pusher.

On the flip side Gas can be monotonous and there is no recognition.. "Hey Anesthesia"

The way I look at it, you'll make at least 400K whatever you choose and whether you are happy or sad. And believe me it is a good position to be in.

Better still take up steve's advice

 

[powermd]

Take the job and don't look back.

Once you start practicing real world pain outside of an academic setting you will see the benefits of the work we do. Particularly if you work in a non-ghetto, ethical practice. I love what I do. My only fear is that short-sighted politicians will kill the field one day. If you can live with that, the rewards are there. You wouldn't believe how many of my patients say these exact words to me: "Thank God you guys are here."

Wanted to get some feedback from the more seasoned folks out there:

I am a fellow on the job interview trail. At this point, there is a position that I would likely to take which seems just about perfect.

1. The practice does not prescribe at all, just makes recommendations
2. Good pay, partnership track, very well managed practice, etc
3. Reasonable patient load 25 per day is around the max
4. Partner is a sophisticated proceduralist willing to teach
5. No IT pumps, will do procedures that dont pay well because they believe in them, etc (basically they try and be ethical)

Here is my dilemma: I am hesitating a little bit before making the definite step forward.

The crux of the issue to me is that, honestly, all the negativity with the debates about the efficacy/marginal data of IPM really give me pause, and gets me down. It bothers me emotionally. Take this thread below:

http://forums.studentdoctor.net/thr...ination-of-spinal-injection-coverage.1180948/

Other large scale analyses by third parties seem to make similar statements. Such as the following:

https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/id98TA.pdf

We could talk all day about how all these reviewers etc are biased, but I am not a conspiracy type, and honestly, probably the evidence just is not all that great.

I have seen people apparently benefit from the procedures we perform during this fellowship year, but how can I let anecdotal experiences trump the opinion of experts and summary of the published literature?

I went into medicine to help people. After all these difficult years of training, I dont want to take a good gig with a great lifestyle if I am basically selling people on something that is not realistically going to help them. I feel like even if some stuff about Anesthesia sucks, at least I can sleep knowing that I am doing some good for some people every day. I do understand that some of the surgeries we do are bogus, so Anesthesia is not 100% doing good for people all the time, but it seems much more clear cut to me.

Should I go back to the OR?

As a final complicating factor, my wife would be seriously bummed and hesitant about me going back to the OR's, due to lifestyle considerations. We have a kid, etc. (Really got my but kicked as a resident lol!) Maybe it is selfish of me to think this way, and I should just be more of a family guy is the right thing to do with the more reasonable lifestyle of pain.

I am not trying to be dogmatic, and I respect that chronic pain patients are complicated and we have limited tools, the alternative treatments are also poor, etc, so I do see both sides of the coin here. I guess the most honest option would be to just tell patients that spine surgery often doesnt work, opioids dont work, and IPM does not work, and they should just cope as best as they can with whatever mix of taichi/weightloss and exercise/psychology/quiting smoking/heat/ice/stretching/TENS/whatever else they feel like?

I had some of these reservations prior to starting fellowship, but I was so burnt out with Anesthesia I wanted to at least do the fellowship and gain more knowledge/experience in the field before I ruled it out.

I thought for a while about just trying to do cancer pain, as neurolytic procedures/tunneled epidural catheters/blasting these people with opioids is definitely efficacious and are meaningful interventions. But it seems that these jobs are not to be found, and oncologists rarely refer to pain docs.

Has anyone faced a similar dilemma out there?

I am pretty torn/stressed out as I am down to the wire with some of these decisions.

I was thinking maybe I will take the job and try it for at least a year or two in order to truly give it a fair shot, and then bail if my concerns continue?

Thank you for your thoughts.

 

[Disciple]

I guess the most honest option would be to just tell patients that spine surgery often doesnt work, opioids dont work, and IPM does not work, and they should just cope as best as they can with whatever mix of taichi/weightloss and exercise/psychology/quiting smoking/heat/ice/stretching/TENS/whatever else they feel like?

You would be telling the truth, but that approach doesn't "work".

I would take the pain job and try it out for a year. Get a real taste of private practice pain management, and then re-evaluate.

Sounds like you are luke warm on both pain and anesthesia.

More than likely, over the course of your career, you will have to figure out some type of work/position/niche that is palatable. Given the limited information you've provided, you likely won't find this in purely pain or anesthesia. Use the next couple of years to explore the possibilities. Think outside the box.

 

[Disciple]

I'm "terminally differentiated" into a physiatric pain specialist.

I disagree. Maybe? The PMR part gives some wiggle room.

 

[BobBarker]

The right surgeries help the right patients. I have found a humongous epidural abscess with osteo and discitis, two huge extruded discs, many severe lumbar stenosis and multiple severe cervical stenosis. I have found cancer four times. Many, many compression fractures as well. This is in 6 months. Our job is to take these patients seriously and get the information that is needed to try to help them. That may be surgery, oncology, or me and a strykerplasty.

The biggest value I bring to my community is that I help my patients address what needs to be addressed. I had a 65 year old woman had one arm crippled by polio and the other severely damaged from years of overuse. I was pushy, got her to the right surgeon, and for various reasons it took 6 months for her to have her surgery. This surgery should have happened years ago. Her and her daughter are just as happy with me as the surgeon. Because in their words, "I never gave up on them."

Don't give up on pain. I did none of the above things as a fellow and I practice completely different from the faculty at the university.

 

[deleted472101]

Trying pure anesthesia out first before trying Pain out first might be easier. Growing a patient base and just dropping them isn't the nicest thing for patients.

 

[Timeoutofmind]

Thank you for all the feedback. Truly appreciated.

Do you think it is feasible to go back to the OR if I have been doing pain only for two years and decide to bail? Have any of you done this? How was it?

 

[pastafan]

Thank you for all the feedback. Truly appreciated.

Do you think it is feasible to go back to the OR if I have been doing pain only for two years and decide to bail? Have any of you done this? How was it?

Two years of no OR anesthesia immediately after residency would make it difficult IMO to get hospital privileges. You would need to moonlight some in OR during that time.

 

[Hoya11]

To the OP, at your point i was still blind to the money/lifestyle of pain. I took the sweet job and said SEE YA OR! I was absolutely miserable. TOns of procedures. Tons of money. Miserable. Felt like my sole purpose waking up was to make money and not get in trouble. See my numerous previous posts about this issue by searching. I went back to anesthesia after fellowship plus 8 months as pp pain attg, which they did give me a little bit of a hard time about, but was not a huge obstacle. Now I am much happier and feel like an actual doctor again. I would heed your inner warnings and go to the OR and do a mix at least of both if any pain. People making comments like "if you dont have the confidence or whatever, then go back to the or" have their head in the sand. It has nothing to do with inner confidence or the practitioner that you are, it has to do with who you are as a person and what you perceive as successful and right and wrong and productive and not productive for society PM me for more PRN

 

[IN2B8R]

Doing the OR thing has its moments too... You have to determine what works out best for you, being an anesthesiologist watching everyone foul things up and telling you how to do your job, or doing IPM, where there are no cures 100 percent of the time. Yes, part of the brutality of operative anesthesia is dealing with the people and personalities around you.... To me, I would take any chronic pain patient over that! Be in control of your time--that outweighs anything else in our profession! Good luck!

 

[Timeoutofmind]

That makes sense about the moonlighting.

If I do not have the ability to moonlight where I will be practicing, and end up practicing for two years, and want to go back to the OR and they are giving me a hard time on credentialing...what do I do? Is there some kind of refresher course? Do people "shadow" for a while?

 

[painstop]

That makes sense about the moonlighting.

If I do not have the ability to moonlight where I will be practicing, and end up practicing for two years, and want to go back to the OR and they are giving me a hard time on credentialing...what do I do? Is there some kind of refresher course? Do people "shadow" for a while?

I went back to the OR (still do a little pain with my current group) after a couple of years of pain and I think the initial transition was very stressful. Credentialing may be an issue...I was supervising a few CRNAs at our ASC which made credentialing easier but that is different than being in a busy OR with complex cases...in retrospect I wished I had done some locums during those two years....it all comes back soon enough though. I took a Difficult Airway course and went to the ASA meeting as well as some refresher courses.

 

[Jcm800]

i would recommend finding a job that allows you to do both PP anesthesia and PP pain. I did this, and it confirmed to me that pain was the right way to go. So i quit the OR after 3 years of a 50/50 mix. Now 6-7 years later of 100% pain, on many days I would consider going back to that 50/50 mix, but lets face it, the grass is always greener. And OR anesthesia in a busy, large hospital can be stressful as **** with OB, emergencies, hearts etc. anesthesia at a smaller more community hospital that doesnt have open hearts, doesnt have NSG, or atleast only does the minimum, and does minimal OB, that might be better. Overnight call, doing epidurals, and emergent C-sections, and calling in back up to help oyu with the bowel obstruction that is going to die on your table, isnt also great.

but, yes, you can get refreshed if you dont do anesthesia, but from a confidence standpoint, i would recommend some anesthesia out of the gate, if you are having questions. I felt for me, that if i didnt do some OR anesthesia and be able to handle it after fellowship (and mind you, i barely did any anesthesia during my fellowship, save a few moonlighting nights here and there) there was no way i could have the confidence to go BACK to it, having never done it...

so your job sounds awesome, find a way to add some anesthesia...

50/50 is also a good route, because you will figure what you like better. Money is important, but its not everything, and if money is comparable, and it is probably, the pick what you like better and gives you a better life. But remember, the grass is ALWAYS greener, regardless of what you pick. so dont stress too much, do what you think is best, and if you make the "wrong" decision, change it... you will be fine

 

[Ducttape]

while doing residency, i saw at least 3 separate anesthesiology "attendings" who would shadow for a week/month to hone up on their skills.

if i had to go back to the OR, i would call my program and see if they would allow me to shadow. hopefully, that will never happen...