Why not surgery

[surgonco]

Surgery attending here...
A resident asked me today why surgeons (obviously do procedures, interact with pain on a routine basis) do not have a pain subspecialty. I guess is because it is difficult for us to abandon the operating room but wanted to post this in this forum to see what are your thoughts on this

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[hyperalgesia]

Probably just not that much interest by most surgeons. Otherwise, I'm sure your training would offer another unique perspective to pain pts.

 

[clubdeac]

Because as surgeons you can't "fix" pain. Hate to say it but unless it's acute or subacute pain due to an anatomical abnormality, surgeons can't do squat about pain. In fact often times they cause worse pain which then becomes chronic: Post herniorrhaphy pain, post mastectomy pain, post thoracotomy pain, abdominal pain from adhesions, phantom limb pain, stump pain, neuroma pain, FBSS, battered root syndrome.... Maybe surgeons should be required to do an extra year in pain before they are allowed to practice in their primary specialty. On second thought, keep cutting. That may put me out of business

 

[Silent Cool]

Because people who enter pain do so primarily because they don't want the lifestyle of surgeons. Unlike surgeons, they don't live to work; instead, they work to live. I think most surgeons couldn't tolerate the non-masochistic lifestyle of pain docs--banker's hours and $$$-bills, ya'll .

Or it could be that there just isn't enough interest and that it is more or less controlled by anesthesia departments. That might also be it. Or I could totally be FOS.

 

[powermd]

Surgery attending here...
A resident asked me today why surgeons (obviously do procedures, interact with pain on a routine basis) do not have a pain subspecialty. I guess is because it is difficult for us to abandon the operating room but wanted to post this in this forum to see what are your thoughts on this

Good question, I'm sure there are lots of valid answers.

My perspective would be lack of exposure to the field among surgery residents, and perhaps lack of interest. The major appeal of pain to the anesthesiology resident is that it gets us out of the OR, gets us out of (real) night call, and allows us to learn and use a new skill set. Surgeons want to be in the OR, self-selected for tolerance of painful night call, and are already using a wide skill that includes the very gratifying ability to fix a patient surgically. Surgeons are also heavily invested in the skill set learned in the course of surgery residency. Learning the skill set of pain medicine takes years more. The fellowship is short, but really getting good at pain takes years more experience seeing and successfully managing the vast array of problems people can present with.

I disagree with clubdeac who said surgeons don't fix pain, that's nonsense. The medical problems that lead to surgery are often painful, and the surgery usually takes away the pain. The best part of my day is when a patient comes in for follow up telling me they are now pain free because of something I did. Surgeons already get to experience that joy in the course of practicing their primary specialty. They have no reason to go looking for it in a much tougher patient population.

Now what my colleague was probably referring to was scar-tissue related chronic pain as a consequence of surgery. More cutting does not fix the problem. One example he gave was post-herniorraphy pain. I have "fixed" this many times with injections carefully placed using ultrasound guidance with a goal of splitting adherent fascia planes. Is that not a form of a surgical procedure? Why couldn't a surgeon do this if he or she were appropriately trained?

 

[lobelsteve]

Pain practice is opposite of surgery practice. Long interactions and tons of Psychiatry/Psychology.
There is no fix for chronic pain. It is called management for a reason. This is not the personality type that goes into surgery.
We are interventional psychologists. And detectives. Shoulders to cry on. Not just anatomical fix it men.

 

[clubdeac]

Good question, I'm sure there are lots of valid answers.

My perspective would be lack of exposure to the field among surgery residents, and perhaps lack of interest. The major appeal of pain to the anesthesiology resident is that it gets us out of the OR, gets us out of (real) night call, and allows us to learn and use a new skill set. Surgeons want to be in the OR, self-selected for tolerance of painful night call, and are already using a wide skill that includes the very gratifying ability to fix a patient surgically. Surgeons are also heavily invested in the skill set learned in the course of surgery residency. Learning the skill set of pain medicine takes years more. The fellowship is short, but really getting good at pain takes years more experience seeing and successfully managing the vast array of problems people can present with.

I disagree with clubdeac who said surgeons don't fix pain, that's nonsense. The medical problems that lead to surgery are often painful, and the surgery usually takes away the pain. The best part of my day is when a patient comes in for follow up telling me they are now pain free because of something I did. Surgeons already get to experience that joy in the course of practicing their primary specialty. They have no reason to go looking for it in a much tougher patient population.

Now what my colleague was probably referring to was scar-tissue related chronic pain as a consequence of surgery. More cutting does not fix the problem. One example he gave was post-herniorraphy pain. I have "fixed" this many times with injections carefully placed using ultrasound guidance with a goal of splitting adherent fascia planes. Is that not a form of a surgical procedure? Why couldn't a surgeon do this if he or she were appropriately trained?

I was being a little cynical last night. Let me again clarify. Surgeons fix acute/subacute pain but usually there is little they can do for chronic pain with a KNIFE

 

[NJPAIN]

The surgical sub specialty of chronic pain management is functional neurosurgery.


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[Paddington]

I believe one of the ISIS founders has a background in General Surgery.

But for the most part, surgeons have zero interest in pain management. They give patients Percocet 10 tabs, and refill it a few (or more) times after an operation, then the problem is dumped in your lap when the patient is addicted.

 

[emd123]

Surgery attending here...
A resident asked me today why surgeons (obviously do procedures, interact with pain on a routine basis) do not have a pain subspecialty. I guess is because it is difficult for us to abandon the operating room but wanted to post this in this forum to see what are your thoughts on this

There's no reason they couldn't. It would take a few to do the fellowships, then apply for General Surgery to co-sponsor the subspecialty. My guess is that's it's primarily a lack of interest amongst surgeons.

 

[Paddington]

Why would you want them (or folks from other fields) becoming Pain Management doctors?

In America, every idiot and his brother seemingly has a Pain Management practice nowadays. When you go out of your subdivision if you turn right or left it doesn't matter as you'll pass some sort of Pain Clinic before you come across any gas station or grocer or government office. This has done no good for the overall health of the population and has lead to a loss of compensation and prestige for everyone in the field.

 

[surgonco]

Why would you want them (or folks from other fields) becoming Pain Management doctors?

In America, every idiot and his brother seemingly has a Pain Management practice nowadays. When you go out of your subdivision if you turn right or left it doesn't matter as you'll pass some sort of Pain Clinic before you come across any gas station or grocer or government office. This has done no good for the overall health of the population and has lead to a loss of compensation and prestige for everyone in the field.

I do think pain management helps our patients. I have referred several of them to pain clinics and on follows ups I have seen very good progress. I don't know if the supply is higher than what it should be but I disagree with saying that they do not help.

Rough crowd for surgeons. I think we do help with pain. In fact, lateral pj, sympathetectomies, whipple's, lap choles, etc done for ONLY pain. And like powermd mentioned, a lot of our interventions have decrease or reaction of pain as a direct consequence.

I do agree that we may make this worst: refilling narcotics may not be the best way to treat somebody.

Believe it or not, a lot of our patients are followed by us. We don't just operate and leave (think about all the cancer operations we do and the follow up this requires). Breast, colons, pancreas, lungs, ecf, crohn's... Just a few diagnosis that come to mind.

I don't think is unreasonable for a surgeon to be a pain specialist. It can also give the field a different perspective, just like anesthesia , pm&r, nsgy and psych offer different approaches.

Thanks for the replies! Very informative!

 

[emd123]

Why would you want them (or folks from other fields) becoming Pain Management doctors?

In America, every idiot and his brother seemingly has a Pain Management practice nowadays. When you go out of your subdivision if you turn right or left it doesn't matter as you'll pass some sort of Pain Clinic before you come across any gas station or grocer or government office. This has done no good for the overall health of the population and has lead to a loss of compensation and prestige for everyone in the field.

I don't think doing an ACGME Pain fellowship as a surgeon, then applying to your board to become official Subspecialty sponsors equals, "every idiot and his brother seemingly [having] a Pain Management practice." Pill mills don't do this. If everyone did it this way, we wouldn't have the rouges you talk about.

 

[powermd]

I don't think doing an ACGME Pain fellowship as a surgeon, then applying to your board to become official Subspecialty sponsors equals, "every idiot and his brother seemingly [having] a Pain Management practice." Pill mills don't do this. If everyone did it this way, we wouldn't have the rouges you talk about.

I agree.

There are some stereotypes here that should be identified. As competent, dedicated pain specialists, our perception that surgeon's don't care about pain and dump patients is a stereotype based on multiple bad examples we see. The very good surgeons do not operate, narc out, and dump. But there are a lot who do, for whatever reason.

The pain management field is riddled with these kinds of clowns too, and they might be more prevalent in our field due to the lack of adequate standards. After all, you can do a few weekend courses and call yourself a pain specialist. Harder to do that and get operating privileges as a surgeon.

 

[emd123]

I agree.

There are some stereotypes here that should be identified. As competent, dedicated pain specialists, our perception that surgeon's don't care about pain and dump patients is a stereotype based on multiple bad examples we see. The very good surgeons do not operate, narcs out, and dump. But there are a lot who do, for whatever reason.

The pain management field is riddled with these kinds of clowns too, and they might be more prevalent in our field due to the lack of adequate standards. After all, you can do a few weekend courses and call yourself a pain specialist. Harder to do that and get operating privileges as a surgeon.

I know. People were saying this same garbage to me when I started asking about doing an ACGME pain fellowship from an ER background, a lot of it said from people on this forum. I plowed ahead anyways. Someone that is willing to do what it takes to get an ACGME Pain fellowship from a non-anesthesia/non-PMR background, then pass the ABMS boards, then apply to get their specialty to co-sponsor the Subspecialty has done as much, if not much more in some cases, than the guy who breezed through from the traditional pathways. The odds are way tougher. There's really no comparison to the "hang-a-shingle" people. That's why I think any time someone from a non-traditional specialty inquires about doing Pain, the responses should always be the same:

"Do an ACGME fellowship, apply for your specialty to co-sponsor Pain if needed, then pass the ABMS pain boards."

That's what people should be encouraged to do. Otherwise, you just encourage them to take a weekend course and hang a shingle if they think that's their only option. I think most of the discouragement thrown out there is primarily from self serving motivations, or general fraternity-hazing type behavior.

 

[hyperalgesia]

Rough crowd for surgeons. I think we do help with pain. In fact, lateral pj, sympathetectomies, whipple's, lap choles, etc done for ONLY pain. And like powermd mentioned, a lot of our interventions have decrease or reaction of pain as a direct consequence.

I think pain docs are generally supportive of quality clinicians getting trained and practicing pain mgmt, ESPECIALLY from diverse backgrounds. For some people, territorial issues predominate. But you know how it is, same thing in every field.

 

[Ducttape]

Why would you want them (or folks from other fields) becoming Pain Management doctors?

In America, every idiot and his brother seemingly has a Pain Management practice nowadays. When you go out of your subdivision if you turn right or left it doesn't matter as you'll pass some sort of Pain Clinic before you come across any gas station or grocer or government office. This has done no good for the overall health of the population and has lead to a loss of compensation and prestige for everyone in the field.

Popular misconception.
the IOM believes there are 3000-4000 pain management specialists in the US. that probably includes ABMS certified and non-ABMS certified physicians.

in comparison, ACS states in 2012 there were 20,345 orthopedic surgeons, and 4388 neurosurgeons.

do you feel the same about neurosurgeons, that every idiot and his brother has a Neurosurgical practice nowadays?

 

[ampaphb]

I believe one of the ISIS founders has a background in General Surgery.

Aprill - Radiology
Bogduk - Anatomy (http://www.newcastle.edu.au/profile/nik-bogduk)
Derby - Anesthesiology

 

[ampaphb]

Popular misconception.
the IOM believes there are 3000-4000 pain management specialists in the US. that probably includes ABMS certified and non-ABMS certified physicians.

in comparison, ACS states in 2012 there were 20,345 orthopedic surgeons, and 4388 neurosurgeons.

do you feel the same about neurosurgeons, that every idiot and his brother has a Neurosurgical practice nowadays?

Sadly, almost every chiropractic practice also describes what they do as "pain mangement". While a percentage of MD's do, indeed qualify as "idiots", I would argue that the vast majority of chiros would aptly be characterized by that moniker

 

[ParaVert]

There are way more than 3000-4000 "pain docs" in the US if you include every anesthesiologist, physiatrist, neurologist, orthopod and FP doing injections and writing scripts (don't even start me on CRNAs). There are no weekend neurosurgery courses (there are, but only by them/for them). It's impossible to own our specialty the way they do.

 

[Ducttape]

the way to do so is to establish only one board certification and a specific vetting process for those who have been trained - previously and in the future - to determine their competence. i am not of the opinion that our current ABMS board certification would accomplish this task, but it clearly is not covering the gamut of non-trained pain physicians.

 

[Jcm800]

I think pain docs are generally supportive of quality clinicians getting trained and practicing pain mgmt, ESPECIALLY from diverse backgrounds. For some people, territorial issues predominate. But you know how it is, same thing in every field.

"I know. People were saying this same garbage to me when I started asking about doing an ACGME pain fellowship from an ER background, a lot of it said from people on this forum. I plowed ahead anyways."

i agree. there is room enough for everyone, just not ER… they are barely docs. my god!

 

[Jcm800]

Sadly, almost every chiropractic practice also describes what they do as "pain mangement". While a percentage of MD's do, indeed qualify as "idiots", I would argue that the vast majority of chiros would aptly be characterized by that moniker

how chiropractors are able to even exist is beyond me. They lie and steal, sell snake oil, and somehow collect MEDICAL insurance dollars… Bill what they are doing as "physical therapy". To the point, where you see a patient and try to send them to therapy, and they are told they have met their PT limits for the year. The patient inquires into it, only to find that their local Chiro had been billing PT codes in addition to the quackery codes. Its its crazy to me.

 

[hyperalgesia]

how chiropractors are able to even exist is beyond me. They lie and steal, sell snake oil, and somehow collect MEDICAL insurance dollars… Bill what they are doing as "physical therapy". To the point, where you see a patient and try to send them to therapy, and they are told they have met their PT limits for the year. The patient inquires into it, only to find that their local Chiro had been billing PT codes in addition to the quackery codes. Its its crazy to me.

I am learning that the success of a business is 10% skill 5% luck and 85% marketing. Or something like that.