Addiction then Pain

[lots-o-questions]

Hey SDN world. Long time lurker, I have been planning on doing an addiction fellowship since I started medical school, recently came to the conclusion that I want to also do a pain fellowship.

While my institution is very well respected in the world of Addiction/Psych it is not a major household academic name such as JHSM, B&W, M-G, Yale, Mayo, Columbia, and so forth. It would be really nice to just stay here and do fellowship for logistical reasons such as avoiding yet another move, and the entire headache of switching to a different institution (paperwork, getting new VA clearance [oh no!] and so forth).

Two things that are pulling me away from staying at the home institution are:

1. There is a part of me that would like to go to another program/institution to get the exposure to a different system and culture. How valid is this thought? Would getting some training somewhere else, be different enough that it would add value to my educational experience?
- To answer some anticipated questions A no I do not plan on staying in the area of my current institution for the rest of my career. B No I don't know where I want to end up in the long run it probably wont be a big city therefore while I'm glad to train in one I will likely not end up staying where I would anticipate going for most Addictions fellowships.


2. To set myself up to get into pain, I worry that it may be more prudent to go somewhere with a big "brand name" such as the locations noted above. I plan to ask this question over in the pain forum to get their thoughts, but would be interested in hearing opinions from this group as well. Obviously having somewhere like Yale or Harvard on my CV would help some-what in the application process. However I'm struggling to appreciate how much.
Also in response to anticipated questions A yes I have been able to do quite a bit of procedures during residency, B Yes I do I recognize its SUPER hard to get into pain from psych.

Thanks in advance I anticipate I will have more questions as this thread gets going.

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[Sushirolls]

Let's unpack this.
Why? Why do you want to do these two fellowships? What do you hope to do with two fellowships?
That will help us give feedback. What's your game plan, vision, desire for your future career?

The answer right now, without knowing your why, is a strategic approach.
Apply to both and rank pain first. Then if you failed to match pain, apply for pain the following year after having completed the addictions. Granted I don't know the timing of either of these if that plan is viable or not.

 

[FlowRate]

Agree with sushi that those questions are an important starting point.

To skip ahead a little, my sense is that pain is most viable as a fellowship for psychiatrists if you train (residency) somewhere that has a pain fellowship and do some rotations with them. You're behind the ball as far as procedures and general medical knowledge so there will be catching up to do. I feel like we might have a pain trained person on the psych forum but I can't remember who it is. Probably like you said better answered on the pain forum.

 

[TexasPhysician]

I’m not seeing the value in doing these 2 fellowships together.

Pain fellowships are interventional in nature. The focus is on procedures and avoidance of opioids these days. You’ll already be helping those avoid addiction by doing it well. To land a fellowship, expect to do pain research, publish, and do many electives in the field. Psych has a hard time matching pain.

Addiction fellowships in my experience are the opposite. You help detox patients, but you also lead groups and do more motivational therapy. Fellowships are easy to come by.

 

[hallowmann]

I agree that I'm curious of what you're planning to do with both training. Now you certainly could do Pain and then focus on interventional with the ability to also prescribe MAT as an option to your patients (you don't need a fellowship for this, just CME/waiver training). You'd also be able to use methadone for pain treatment, but NOT for OUD for obvious legal reasons.

Even if you want to do primarily Addiction, but have the ability to treat people with non-interventional pain management, you could do this even with simply an addiction medicine fellowship. You don't necessarily need the pain training as long as you spend enough time learning the pain medical treatment side during residency and addiction fellowship.

Now the only situation I could see that you might need both is to run an addiction medicine service or treatment facility while simultaneously offering interventional pain management to those patients. In that case, that seems like a complicated plan, but more power to you. I still would probably do Pain first, because it will be easy to get an Addiction fellowship. I would much like sushi suggested apply to both, rank for pain, then addiction and see where things land.

I actually do know someone who applied to both, failed to match pain, then continued on in an in-house addiction fellowship, then reapplied and got into a pain fellowship in a less desirable area. I don't know that the big name for fellowship is necessary, but I would strongly consider the places with both addiction and pain in-house, especially if the pain has taken "non-traditional" pain applicants in the past.

 

[lots-o-questions]

Let's unpack this.
Why? Why do you want to do these two fellowships? What do you hope to do with two fellowships?
That will help us give feedback. What's your game plan, vision, desire for your future career?

The answer right now, without knowing your why, is a strategic approach.
Apply to both and rank pain first. Then if you failed to match pain, apply for pain the following year after having completed the addictions. Granted I don't know the timing of either of these if that plan is viable or not.

Love the questions thank you.

Why? Why do you want to do these two fellowships? What do you hope to do with two fellowships?

Addiction: So I've been interested in addiction since undergrad, and hope to always have at least a few addiction patients in my schedule. I worked at an inpatient rehab as a tech for two years and fell in love with watching the recovery process. Addiction in some form or another has been part of my long term plans as noted in my first post since the beginning of my medical education. I am confident I could DO all the addiction work I want without a fellowship, I think (in part) it has always been my assumed path and it feels strange to deviate, and at the end of the day I love it.

Pain: I am a combo med / psych resident and love living at the clinical intersection of these two worlds. I think I defiantly scratch that itch in addiction and find that Pain would allow me to further flex the clinical skills of procedures (which I really enjoy, and have a decent amount of under my belt (I love LP's and Centrals- Thora's and para's are ehh) - Yes I fully recognizing not as much as an Anesthesia resident), reading imagining, actually touching patients (this is the only place I can think of where people generally would not voice concern over a psychiatrist touching their patient), using my skills in manipulation (DO- no I recognize I am not going to cure cancer with OMT but dang I can make you feel better than you did when you walked in), and treating medically and psychiatrically complex individuals.

An example of a visit that I would love would be to bill 30 min of therapy surrounding weight loss (MI, CBT, mindfulness, whatever), possibly decreasing opioid burden, using some multimodal medical management, doing some OMT, injecting a Knee, and then planning an ESI for a week or two out, with the goal to be that we will loose weight in the next 6-12 months, so we possibly don't have to keep doing the interventions.

I did a presentation to my local rheum department on Mindfulness and its effects on those with chronic disease and pain, and found some pretty cool data. Examples being two groups with psoriasis who were doing something like 20 min a day of UVA/UVB to treat their skin, and they had one group listen to a guided meditation while doing their 20 min tx. The mindfulness group had visible recovery (or whatever their outcome goal was I cant remember exactly) had something like a 3 fold faster recovery than the non-mindfulness group (something like average of 35 days of Tx compared to 90 days of Tx). Another example was people making some really impressive drops in Chronically elevated CRP for a sustained period of time (12 mo. I think) by just doing mindfulness technics. While I don't see myself as a formal researcher, I would LOOVE to be involved in the world that is messing around with this kind of stuff.

I also feel that if I do pain and have 2 or 3 half days of procedures under the formal umbrella of "pain" where I generate a bunch of money for the system, as long as I'm willing take a slight pay cut (oh no! only making 250-300 instead of the 350-400: the audacity), I will likely have the freedom to do all the other stuff that I enjoy that likely does not generate the big bucks.

 

[Celexa]

I am a proponent of training in different places. I see a myopia in people who do all their training in one place that they often don't even know they have. You go somewhere else, turns out some of the accepted wisdom and ways of doing things is not nearly as universal as you were taught.

That being said, does it outweigh all other factors? No. But is there a clear training benefit to going somewhere new, I would say yes.

Re questions specifically about addiction and pain fellowships I don't know enough to be useful but I do wonder at the masochism of continuing to train when you already did a dual program, lol. Usually I only see utility in piling on that type of specialization if someone is carving out a very specific academic niche at a research instituion.

 

[Sushirolls]

Big Box shops are not going to be so keen on a person dipping toes in Pain world and another. They will want you to be 100% pain, or even 100% psych. They won't care about addictions.

With what I read in your description of the why, I think you are better off doing the addiction fellowship. Stop there, then open your own primary care clinic. Practice as an internist first, but you then have the experience to keep your patients internal for psych needs.

Psych and Pain will manifest greatly in any Primary care clinic.

You will also be able to potentially achieve the 350-400k doing that, despite not doing the full fluro suite stuff pain does.

With your PCP clinic, have shared medical appointments with different emphasis. A pain. A Rheum, A HTN, etc, etc, and then during those group med checks, you can infuse the mindfulness / wellbeing stuff you aspire to.

The addiction, if your practice doesn't have enough, or what you want, then go be the director at a local methadone clinic. Or muster up the cash and start your own.

I think you can have 'it all' by skipping pain, and opening your own practice.

 

[TexasPhysician]

Love the questions thank you.

Why? Why do you want to do these two fellowships? What do you hope to do with two fellowships?

Addiction: So I've been interested in addiction since undergrad, and hope to always have at least a few addiction patients in my schedule. I worked at an inpatient rehab as a tech for two years and fell in love with watching the recovery process. Addiction in some form or another has been part of my long term plans as noted in my first post since the beginning of my medical education. I am confident I could DO all the addiction work I want without a fellowship, I think (in part) it has always been my assumed path and it feels strange to deviate, and at the end of the day I love it.

Pain: I am a combo med / psych resident and love living at the clinical intersection of these two worlds. I think I defiantly scratch that itch in addiction and find that Pain would allow me to further flex the clinical skills of procedures (which I really enjoy, and have a decent amount of under my belt (I love LP's and Centrals- Thora's and para's are ehh) - Yes I fully recognizing not as much as an Anesthesia resident), reading imagining, actually touching patients (this is the only place I can think of where people generally would not voice concern over a psychiatrist touching their patient), using my skills in manipulation (DO- no I recognize I am not going to cure cancer with OMT but dang I can make you feel better than you did when you walked in), and treating medically and psychiatrically complex individuals.

An example of a visit that I would love would be to bill 30 min of therapy surrounding weight loss (MI, CBT, mindfulness, whatever), possibly decreasing opioid burden, using some multimodal medical management, doing some OMT, injecting a Knee, and then planning an ESI for a week or two out, with the goal to be that we will loose weight in the next 6-12 months, so we possibly don't have to keep doing the interventions.

I did a presentation to my local rheum department on Mindfulness and its effects on those with chronic disease and pain, and found some pretty cool data. Examples being two groups with psoriasis who were doing something like 20 min a day of UVA/UVB to treat their skin, and they had one group listen to a guided meditation while doing their 20 min tx. The mindfulness group had visible recovery (or whatever their outcome goal was I cant remember exactly) had something like a 3 fold faster recovery than the non-mindfulness group (something like average of 35 days of Tx compared to 90 days of Tx). Another example was people making some really impressive drops in Chronically elevated CRP for a sustained period of time (12 mo. I think) by just doing mindfulness technics. While I don't see myself as a formal researcher, I would LOOVE to be involved in the world that is messing around with this kind of stuff.

I also feel that if I do pain and have 2 or 3 half days of procedures under the formal umbrella of "pain" where I generate a bunch of money for the system, as long as I'm willing take a slight pay cut (oh no! only making 250-300 instead of the 350-400: the audacity), I will likely have the freedom to do all the other stuff that I enjoy that likely does not generate the big bucks.

I’m going to walk you through this financially, because there is a lot of hoops here.

I think you would take a big pay cut, under $200k. This would make less than an average psychiatrist, not average pain. This formula is not structured at all for insurance reimbursement. You’d need to build very slowly cash-only with high net worth pain patients.

MI is not considered therapy by insurances the last I checked. You can’t bill for it. You could do other therapy with addiction. Procedures require more staff and prep. Your overhead just got a lot higher, but you won’t need the extra staff very often as you can go hours with just meds/therapy. Planning when to pull other multiple PT staff would be a headache. Injectables expire. You need volume to use them up or you lose money.

ESI and other pain procedures can require expensive equipment and lots of staff. You can’t afford that without doing a lot of procedures. It would be like buying a TMS machine with a 100 cash pay patient clinic. You would never recoup your money.

Most pain clinics don’t want PT pain physicians. Maybe you could get on with a group for 3 days a week, but it will likely be high volume. Otherwise it makes more sense monetarily to hire a FT pain person and a NP to maximize work flow. It is a struggle to fill and manage 1-1.5 day clinics for physicians. The clinic would lose patients due to lack of availability and follow-up. You can’t afford to get a bad reputation.

FT pain with some CME on addictions makes sense.

FT addiction psychiatrists working with pain physicians makes sense.

Having a therapist work with a psychiatrist makes sense.

While the idea is great and may provide great care, this would be really hard to even keep such a clinic open financially. Losing money for a few years is a distinct possibility.

 

[adiradirim]

If you want to do non-interventional pain management, you can probably just find a job out of residency or you can do addiction fellowship and work in a non-opioid pain clinic or an primary care or addiction clinic where you address these things and maybe do clinic procedures like small joint injections or some ultrasound guided joints. However, a lot of advertised "non-interventional pain" jobs just want to pay you 200k to write opioids for the pain docs while they're in the procedure suite. I think this is BS honestly... similar to how some psychiatrists refuse to treat ADHD with stimulants.

If you want to do full spectrum pain management, my recommendation would be to apply to pain and see if you get in then use addiction as a backup to boost your resume while you do more rotations, research, and make more connections during residency. The pain application timeline starts with apps going out 1.5 years before graduation, interviewing 1 year before graduation and you find out if you match in October 8 months before graduation. I'm not sure what addiction's timeline is. You need to be set on pain early and already have a CV geared towards pain. If you don't match pain and have to reapply, you'll probably be simultaneously reapplying to pain while applying to addiction. However, coming from FM/Psych you really will gain very little from a year doing addiction that you couldn't get in practice, besides possibly making you more interesting for pain fellowships.

A lot of pain jobs are seeing 6-8 patients per hour with very little time for therapy. Conversion to procedures is usually 20-30% of patients on average if you also do medication management. There are also very special pain jobs set in true multidisciplinary clinics with significant psychology support that would allow you to see 2-4 people per hour and take a significant pay cut, despite billing for therapy. You also wouldn't be seeing enough patients to have the volume for 1.5 days of procedures per week. You might get a half day worth of procedure patients. You also need volume to maintain your skills with procedures. The difficulty of trying to do pain and addiction is that they're often opposing goals and patients are bought into one mindset or the other. It might work if you market yourself as opioid free... but then will you prescribe suboxone? Hard to navigate both at the same time honestly, but I'm sure it can be done in a very special setting.

These positions exist, but you will be tied to a Big Box Shop. I'd be surprised if private practice groups would have interest in a position like this due to poor reimbursement and earning potential. Once you start trying to find hospital jobs that split departments, you get into very annoying problems. Pain is often Anesthesia, Addiction might be Psych or Medicine, and then maybe Psych wants a piece of you because they're understaffed. You will likely be creating a position that doesn't exist already so honestly you need to be talking to places about a job ASAP. These positions take months to years to develop and negotiate.

Good luck!

Source: psychiatry trained pain fellow currently on the job hunt

 

[hallowmann]

Love the questions thank you.

Why? Why do you want to do these two fellowships? What do you hope to do with two fellowships?

Addiction: So I've been interested in addiction since undergrad, and hope to always have at least a few addiction patients in my schedule. I worked at an inpatient rehab as a tech for two years and fell in love with watching the recovery process. Addiction in some form or another has been part of my long term plans as noted in my first post since the beginning of my medical education. I am confident I could DO all the addiction work I want without a fellowship, I think (in part) it has always been my assumed path and it feels strange to deviate, and at the end of the day I love it.

Pain: I am a combo med / psych resident and love living at the clinical intersection of these two worlds. I think I defiantly scratch that itch in addiction and find that Pain would allow me to further flex the clinical skills of procedures (which I really enjoy, and have a decent amount of under my belt (I love LP's and Centrals- Thora's and para's are ehh) - Yes I fully recognizing not as much as an Anesthesia resident), reading imagining, actually touching patients (this is the only place I can think of where people generally would not voice concern over a psychiatrist touching their patient), using my skills in manipulation (DO- no I recognize I am not going to cure cancer with OMT but dang I can make you feel better than you did when you walked in), and treating medically and psychiatrically complex individuals.

An example of a visit that I would love would be to bill 30 min of therapy surrounding weight loss (MI, CBT, mindfulness, whatever), possibly decreasing opioid burden, using some multimodal medical management, doing some OMT, injecting a Knee, and then planning an ESI for a week or two out, with the goal to be that we will loose weight in the next 6-12 months, so we possibly don't have to keep doing the interventions.

I did a presentation to my local rheum department on Mindfulness and its effects on those with chronic disease and pain, and found some pretty cool data. Examples being two groups with psoriasis who were doing something like 20 min a day of UVA/UVB to treat their skin, and they had one group listen to a guided meditation while doing their 20 min tx. The mindfulness group had visible recovery (or whatever their outcome goal was I cant remember exactly) had something like a 3 fold faster recovery than the non-mindfulness group (something like average of 35 days of Tx compared to 90 days of Tx). Another example was people making some really impressive drops in Chronically elevated CRP for a sustained period of time (12 mo. I think) by just doing mindfulness technics. While I don't see myself as a formal researcher, I would LOOVE to be involved in the world that is messing around with this kind of stuff.

I also feel that if I do pain and have 2 or 3 half days of procedures under the formal umbrella of "pain" where I generate a bunch of money for the system, as long as I'm willing take a slight pay cut (oh no! only making 250-300 instead of the 350-400: the audacity), I will likely have the freedom to do all the other stuff that I enjoy that likely does not generate the big bucks.

So the person I mentioned that did the Addiction and then Pain fellowship is actually an IMP graduate. Personally, I will tend to agree, that while your hope is noble and will likely provide good care, I don't know how realistic it would be from a reimbursement standpoint. I will say, I have a relative in pain that does procedures 2-3 days a week and then is in his general clinic the rest of the days, which is a combination of pain and other things. He has also detoxed patients and would likely easily be able to incorporate MAT if he were interested.

I still don't think you need both fellowships. If you really want the interventional component, do a Pain fellowship. No need to do an addiction fellowship. I think you could do some it, but you will have to be connected to people who are doing purely non-interventional pain/physiatry who can feed into your procedure clinic to make up for seeing less patients on your clinic days (to give you more time).

 

[mistafab]

This is like 2 PHDs - you gotta just pick something and live with it at some point dude. Can't leave every door open on your way through life.

I'm a PGY2 psych resident but that's my 2 cents.

 

[psychemdoc]

Love the questions thank you.

Why? Why do you want to do these two fellowships? What do you hope to do with two fellowships?

Addiction: So I've been interested in addiction since undergrad, and hope to always have at least a few addiction patients in my schedule. I worked at an inpatient rehab as a tech for two years and fell in love with watching the recovery process. Addiction in some form or another has been part of my long term plans as noted in my first post since the beginning of my medical education. I am confident I could DO all the addiction work I want without a fellowship, I think (in part) it has always been my assumed path and it feels strange to deviate, and at the end of the day I love it.

Pain: I am a combo med / psych resident and love living at the clinical intersection of these two worlds. I think I defiantly scratch that itch in addiction and find that Pain would allow me to further flex the clinical skills of procedures (which I really enjoy, and have a decent amount of under my belt (I love LP's and Centrals- Thora's and para's are ehh) - Yes I fully recognizing not as much as an Anesthesia resident), reading imagining, actually touching patients (this is the only place I can think of where people generally would not voice concern over a psychiatrist touching their patient), using my skills in manipulation (DO- no I recognize I am not going to cure cancer with OMT but dang I can make you feel better than you did when you walked in), and treating medically and psychiatrically complex individuals.

An example of a visit that I would love would be to bill 30 min of therapy surrounding weight loss (MI, CBT, mindfulness, whatever), possibly decreasing opioid burden, using some multimodal medical management, doing some OMT, injecting a Knee, and then planning an ESI for a week or two out, with the goal to be that we will loose weight in the next 6-12 months, so we possibly don't have to keep doing the interventions.

I did a presentation to my local rheum department on Mindfulness and its effects on those with chronic disease and pain, and found some pretty cool data. Examples being two groups with psoriasis who were doing something like 20 min a day of UVA/UVB to treat their skin, and they had one group listen to a guided meditation while doing their 20 min tx. The mindfulness group had visible recovery (or whatever their outcome goal was I cant remember exactly) had something like a 3 fold faster recovery than the non-mindfulness group (something like average of 35 days of Tx compared to 90 days of Tx). Another example was people making some really impressive drops in Chronically elevated CRP for a sustained period of time (12 mo. I think) by just doing mindfulness technics. While I don't see myself as a formal researcher, I would LOOVE to be involved in the world that is messing around with this kind of stuff.

I also feel that if I do pain and have 2 or 3 half days of procedures under the formal umbrella of "pain" where I generate a bunch of money for the system, as long as I'm willing take a slight pay cut (oh no! only making 250-300 instead of the 350-400: the audacity), I will likely have the freedom to do all the other stuff that I enjoy that likely does not generate the big bucks.

Update please I’m dying to hear what you ended up doing as I am thinking about a possibly similar path and I see similar obstacles as others noted.

Also, can I DM you to ask more specifics?

 

[SeniorWrangler]

Yeah, focus on pain and procedures, in a pain clinic the focus is all on OUD, AUD and you probably already know plenty about that.

People are going to want to put you in a box of seeing opioid refills, OUD, and behaviourally dyscontrolled patients. You need to stay out of that box.

I have also, like adiradirim, seen people have trouble in academia bridging the gap between departments, Psychiatry vs Anesthesia.