After 12 years of Private Practice, I'm Seriously thinking About Pain

Dec 23, 2013
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I rarely post here so apologies for posting only when help is needed. I'm a partner in a busy private practice anesthesia group in Las Vegas. I've been where I am since 2003, after completing a peds anesthesia fellowship. To be honest, it has gotten a bit dull. Here in Vegas, anesthesia pretty much follows surgeons. I am on staff at 12 plus hospitals and surgery centers. Hospitals here are trying to switch to Anesthesia/CRNA employees/contractors. Sooner or later they will succeed. Anyway, my reasons for considering pain are

1) OR anesthesia is getting very boring. There is zero intellectual challenge in it for me. I like most of my surgeons. I like working with most of the OR staff. But the boredom is bothering me.

2) I like the procedures pain specialists do. I see them when I do sedation cases for pain procedures. I like the closer patient interaction. As a Med student/Resident, I hated clinic. Now I'm beginning to miss it. Yes, a lot of pain patients are annoying, but so are a lot of PEOPLE in general.

3) Sooner or later, I'm going to have to leave town and set up practice somewhere else (CRNAs are fine if they are already there, but in a town where most of us do our own cases, it means some anesthesiologists are going to have to leave.) If I'm starting over anyway, I'd just as soon do it now when I'm younger and have more options.

But at this point I haven't applied for anything for years. I have no idea how to do it and haven't written a resume. I have no idea if Pain fellowships would even consider someone out of residency/peds fellowship for so long. I have no publications. Should I consider unaccredited fellowships?

Any advice would be helpful.
 

emd123

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I rarely post here so apologies for posting only when help is needed. I'm a partner in a busy private practice anesthesia group in Las Vegas. I've been where I am since 2003, after completing a peds anesthesia fellowship. To be honest, it has gotten a bit dull. Here in Vegas, anesthesia pretty much follows surgeons. I am on staff at 12 plus hospitals and surgery centers. Hospitals here are trying to switch to Anesthesia/CRNA employees/contractors. Sooner or later they will succeed. Anyway, my reasons for considering pain are

1) OR anesthesia is getting very boring. There is zero intellectual challenge in it for me. I like most of my surgeons. I like working with most of the OR staff. But the boredom is bothering me.

2) I like the procedures pain specialists do. I see them when I do sedation cases for pain procedures. I like the closer patient interaction. As a Med student/Resident, I hated clinic. Now I'm beginning to miss it. Yes, a lot of pain patients are annoying, but so are a lot of PEOPLE in general.

3) Sooner or later, I'm going to have to leave town and set up practice somewhere else (CRNAs are fine if they are already there, but in a town where most of us do our own cases, it means some anesthesiologists are going to have to leave.) If I'm starting over anyway, I'd just as soon do it now when I'm younger and have more options.

But at this point I haven't applied for anything for years. I have no idea how to do it and haven't written a resume. I have no idea if Pain fellowships would even consider someone out of residency/peds fellowship for so long. I have no publications. Should I consider unaccredited fellowships?

Any advice would be helpful.
I was 8 years post residency, zero publications and in the wrong specialty (EM) and still got in. Apply to every accredited program and hope for the best. Do it.
 
OP
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Thanks a lot, EMD. I think I will. Since I'm terrible at business, I'm happy to join an established practice and be their block monkey, as long as they have a reasonable package. And at least for a while, don't mind doing a weekend of call every month, just because I want to keep my skills and a little extra money always helps. By any chance, did you do any ER work after fellowship training? Because that is a very good skill set and I would hate to loose it after working so hard to gain it.
 

Disciple

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Thanks a lot, EMD. I think I will. Since I'm terrible at business, I'm happy to join an established practice and be their block monkey, as long as they have a reasonable package.
Sounds like that would be an Ortho group.

What if you join an established pain practice and they want you to be their psyche/narcotic monkey?

That's the way it's going these days.
 

oreosandsake

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one of my co-fellows practiced for almost 10 years in a busy busy anesthesiology group prior to coming back for pain fellowship. it was a bit of a transition to be in that training mode and have superiors much younger than him i think... but he got through it. last i heard, he's very happy
 

emd123

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Thanks a lot, EMD. I think I will. Since I'm terrible at business, I'm happy to join an established practice and be their block monkey, as long as they have a reasonable package. And at least for a while, don't mind doing a weekend of call every month, just because I want to keep my skills and a little extra money always helps. By any chance, did you do any ER work after fellowship training? Because that is a very good skill set and I would hate to loose it after working so hard to gain it.
I keep my EM boards up, and got credentialed to do shifts if I wanted but was too busy. I ended up way too busy and didn't do any EM shifts during fellowship. Pain has ended up working out well enough, it is the skill I want to keep up. I have no desire to go back. Been there done that. Had my fun. The year leading up to fellowship (acgme) I did a ton of extra shifts though, to save up money for fellowship, but none during, or since. I feel like I've got something better now, for me.
 
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emd123

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Go for it! But, leverage your anesthesia background and do a quality ACGME-accredited fellowship first.
Agree. Too much to learn without a fellowship, and if you're going to do one, acgme is better since you can get abms Pain boarded. It was brutally painful to give up a year's salary after being out 8 years, but was worth it.
 

Ducttape

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Agree. Too much to learn without a fellowship, and if you're going to do one, acgme is better since you can get abms Pain boarded. It was brutally painful to give up a year's salary after being out 8 years, but was worth it.
In your case though changing did come with a significant income increase. Doing pain won't give an increase in salary for the OP.

On the other hand, he can always go back to anesthesia....

Interventions are a major part of pain but the clinic is even more so ( unless you want to be a needle jockey). Tail someone for a few days - in the clinic - to make sure you don't start getting chills being back in a clinic....
 

algosdoc

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My experience with anesthesia was similar- could train a janitor to do 99% of cases using general anesthesia without any other medical background. Seriously skull splittingly boring work chained to an anesthesia machine after hours....
 

EtherBunny

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Go for it!

Pain is a great field. Yes it has its own set of drawbacks like any field of medicine but on balance it's a really great career path. No regrets on my end.

In terms of the logistics of applying...
1) Contact your residency program coordinator. Although you're 10 years out of the gate, you're still an alumnus. Take advantage of it. I'm sure the program has some connections with the pain medicine world.
2) Go out to dinner with the pain guys that you come into contact with (you mentioned that you occasionally provide sedation for their cases). I'm sure they'll have some pearls of advice for you.
3) Look into Stanford. They have a peds pain fellowship--the only one in the country (if I'm not mistaken). This would be a great fit for you. It could also be an easy way to transition into a more formal pain fellowship at a great place (Stanford included).

Good luck! Don't be discouraged. I know a guy who was in private practice for almost 10 years before he completed a pain fellowship. He's a VERY happy guy.
 
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SSdoc33

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Go for it!

Pain is a great field. Yes it has its own set of drawbacks like any field of medicine but on balance it's a really great career path. No regrets on my end.

In terms of the logistics of applying...
1) Contact your residency program coordinator. Although you're 10 years out of the gate, you're still an alumnus. Take advantage of it. I'm sure the program has some connections with the pain medicine world.
2) Go out to dinner with the pain guys that you come into contact with (you mentioned that you occasionally provide sedation for their cases). I'm sure they'll have some pearls of advice for you.
3) Look into Stanford. They have a peds pain fellowship--the only one in the country (if I'm not mistaken). This would be a great fit for you. It could also be an easy way to transition into a more formal pain fellowship at a great place (Stanford included).

Good luck! Don't be discouraged. I know a guy who was in private practice for almost 10 years before he completed a pain fellowship. He's a VERY happy guy.
dont do a peds pain fellowship, for the love of god.
 
OP
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Thanks all for the great advice and encouragement. And thanks, EtherBunny, for the Stanford suggestion, but I fear I would not be competitive. I would be quite satisfied with just about any ACGME accredited program, and if none are a available would consider non-Accredited if I'm confident it gives truly useful training. If not then I will just have to stay in the OR. For 2016, a lot of deadlines have already passed. I'm trying to gather documents and I'm so clueless, I went to ERAS and after registering they ask me for an "Electronic Token" which you apparently get from your Med School Dean. I'm an FMG so not sure how that will work. But anyway, I don't want to trouble everyone with technical questions. I'll figure it out.
 

emd123

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Thanks all for the great advice and encouragement. And thanks, EtherBunny, for the Stanford suggestion, but I fear I would not be competitive. I would be quite satisfied with just about any ACGME accredited program, and if none are a available would consider non-Accredited if I'm confident it gives truly useful training. If not then I will just have to stay in the OR. For 2016, a lot of deadlines have already passed. I'm trying to gather documents and I'm so clueless, I went to ERAS and after registering they ask me for an "Electronic Token" which you apparently get from your Med School Dean. I'm an FMG so not sure how that will work. But anyway, I don't want to trouble everyone with technical questions. I'll figure it out.
Don't sell yourself short on your competitiveness. Think of it from a program directors perspective. Would you rather have a brand new baby doctor, just one day born out of residency, or someone with solid real world experience and more maturity?

As long as they don't sense an ego issue or that you'd refuse to humble yourself as house staff for a year, some may jump at the shot to get someone with some real world experience, and the ability to function independently with more confidence.

Don't sell yourself short. We all know the "I'm The Best Resident The World Had Ever Seen" show is nothing more than potential based on how someone functions in a highly protected and controlled environment, as opposed to a real track record, out in the real world. Especially being from the most pain-politically correct specialty, you could probably hand pick your spot.
 

Ducttape

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Don't sell yourself short on your competitiveness. Think of it from a program directors perspective. Would you rather have a brand new baby doctor, just one day born out of residency, or someone with solid real world experience and more maturity?

As long as they don't sense an ego issue or that you'd refuse to humble yourself as house staff for a year, some may jump at the shot to get someone with some real world experience, and the ability to function independently with more confidence.

Don't sell yourself short. We all know the "I'm The Best Resident The World Had Ever Seen" show is nothing more than potential based on how someone functions in a highly protected and controlled environment, as opposed to a real track record, out in the real world. Especially being from the most pain-politically correct specialty, you could probably hand pick your spot.
most program directors would, unfortunately, rather have a new resident who is flexible and teachable rather than an adult learner that is fixed in his ways and unwilling to change them. when you interview, it is imperative that you demonstrate to the PD and all people (including current fellows) that you are not stuck in your ways and are very approachable and interested in learning their the right way.

do show them that you can function independently in those tasks that they do all the time, which will save them a lot of work. ie inserting and managing epidurals, regional blocks, inhouse consults, postoperative pain management (as all ACGME pain programs are supposed to have some acute pain experience, and the pain docs hate inpatient Pain call). this is one reason that many PD choose from in house - a lot less teaching of the stuff they dont want to bother with, and a lot less hand holding on the time consuming required junk that is really not essential to a chronic pain practice.
 

emd123

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most program directors would, unfortunately, rather have a new resident who is flexible and teachable rather than an adult learner that is fixed in his ways and unwilling to change them.
They way I look at it, you've got to bet on your strengths to win, and bet that someone will recognize them in you. That's what I did and it worked for me. I got an acgme fellowship position, against the odds (150 applications for 5 positions at the program I got into). If you bet on the likelihood that your weakness will prevent you from succeeding, you're certain to fail. My advice to @MDtraveler is to bet on his strengths and go for the win, not bet on his weaknesses and expect to lose. It's a choice that we all make, whether consciously, or by default.
 
OP
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Advice taken, emd123. I will apply to every program where the deadline has not passed for 2016. If I'm rejected by all, then will weigh options between unaccredited and trying again earlier for 2017. I'm not quite young, but I've got at least 25 years of practice left in me (barring the unforeseeable, of course) and would rather spend them doing pain than in the OR.

A separate question: Has anyone from an unaccredited program ever managed to get the ABA to let him/her sit for the pain boards? Or is that simply never done? Are any of the other pseudo boards worth anything? But for now, let me concentrate on the positive and optimistic, rather than worst case scenarios.
 

Ducttape

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I think you are too late for this coming academic year, starting June 2016. The match is coming up, programs have all interviewed.

Get things all ready for 2017, so you can aggressively hit the ground running. In fact one other suggestion - call your old program and see if they will allow you to tail someone for a couple of weeks. This can make sure you want to do the work and give you a valuable contact person who could help you get in their program...

And to answer your last question - no to all. Can't sit for ABMS boards. Other boards in my opinion are not that useful.
 
OP
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2017 I guess will give me time to put things in order before taking a huge income hit. I'll still keep my ears to the ground in case anyone opportunity comes up sooner.

Thanks again for all of your replies.
 

nvrsumr

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Had a co fellow who was obgyn went back and did gas then pain fellowship

Honestly, i would consider finding a gas group with some pain docs that will hire you on the cheap and teach you the procedures....
 

hyperalgesia

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In just a few short years I will be able to retire in a developing country. My next life will have nothing to do with the American Healthcare system. Not that I haven't appreciated it. But for me the investment phase of this whole industry is over.

Maybe I just need a vacation...
 
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A Witty Fool

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In just a few short years I will be able to retire in a developing country. My next life will have nothing to do with the American Healthcare system. Not that I haven't appreciated it. But for me the investment phase of this whole industry is over.

Maybe I just need a vacation...
If it's that hard to make a great return on investment then I have to wonder why the heck I'm going into it...
 

emd123

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If it's that hard to make a great return on investment then I have to wonder why the heck I'm going into it...
Note he said "I will be able to retire..." soon. That means = investment has paid off. We're all doing fine. Ignore excessive doom and gloom.
 
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hyperalgesia

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If it's that hard to make a great return on investment then I have to wonder why the heck I'm going into it...
Emd123 is absolutely right. I just meant no more investment for me now, in reference to the op's situation. If I were starting over, I would absolutely do it again. I don't know of other professions that offer the kind of satisfaction, autonomy and financial return that we have. It's worth it!
 
OP
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Just out of curiosity, has anyone reading this know of someone who did an unaccredited fellowship and managed to get a good job 'Somewhere?' The question is not "is non ACGME as good as ACGME" Of course it isn't. The question I'm curious about is "Could a non ACGME pain fellowship lead to something better than what I have now?" which is a successful but mind-numbingly boring OR practice, with quite a lot of call.
 

hyperalgesia

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Just out of curiosity, has anyone reading this know of someone who did an unaccredited fellowship and managed to get a good job 'Somewhere?' The question is not "is non ACGME as good as ACGME" Of course it isn't. The question I'm curious about is "Could a non ACGME pain fellowship lead to something better than what I have now?" which is a successful but mind-numbingly boring OR practice, with quite a lot of call.
I know several people who did non-accredited fellowships and are doing all interventional pain now and are high quality docs making a good living. If you don't get the ACGME, there is no shame at all in non-ACGME. The silver lining of non-acgme is that they might be more flexible with you doing anesthesia on the side. Plus they sometimes pay more. Pain is not always rosy but never boring. You should go for it.
 

Jcm800

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I know several people who did non-accredited fellowships and are doing all interventional pain now and are high quality docs making a good living. If you don't get the ACGME, there is no shame at all in non-ACGME. The silver lining of non-acgme is that they might be more flexible with you doing anesthesia on the side. Plus they sometimes pay more. Pain is not always rosy but never boring. You should go for it.

Everything is boring after a while... Keep that in mind. Not trying to discourage you, but I think these feelings are inevitable for everybody. After 10 years of pain, I'm thinking about doing in anesthesia again ha ha. Not really, but I think 10-12 years is a long time, and after a long time everything gets somewhat boring. I don't think anything could be MORE boring than anesthesia, at least when I did it, there was no wi-fi in the ORs... But all things become routine. So if you love pain, and "hate" anesthesia, do it. If you are just bored, think long and hard of this is worth it. It probably is. And I guess you have a great option of going back and doing anesthesia in 2 years if it doesn't work out. You basically only gave up one year of income, which in the grand scheme of the next 25 years might not be so bad...

Best of luck!
 
OP
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Everything is boring after a while... Keep that in mind. Not trying to discourage you, but I think these feelings are inevitable for everybody. After 10 years of pain, I'm thinking about doing in anesthesia again ha ha. Not really, but I think 10-12 years is a long time, and after a long time everything gets somewhat boring. I don't think anything could be MORE boring than anesthesia, at least when I did it, there was no wi-fi in the ORs... But all things become routine. So if you love pain, and "hate" anesthesia, do it. If you are just bored, think long and hard of this is worth it. It probably is. And I guess you have a great option of going back and doing anesthesia in 2 years if it doesn't work out. You basically only gave up one year of income, which in the grand scheme of the next 25 years might not be so bad...

Best of luck!
Maybe after another 12 years, I'll switch to psychiatry :) Pain medicine might even be good training for it!!
 

A Witty Fool

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No need to do that. 75% of my days are spent managing psychiatric issues. Two birds with one stone.
I've heard having a psych background is a huge help in pain.
 

emd123

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Maybe after another 12 years, I'll switch to psychiatry :) Pain medicine might even be good training for it!!
Just shadow me for a day. One day in my clinic IS a psych residency. Lol
 

jollygoodfellow

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I am 6 years out of residency. Applied this year to almost 80 programs. I got 3 interviews...I would think myself competitive due to life and work experience, military service, publications and a Masters in Neuroscience. Didn't seem to help much.
It looks like from what I've experienced and people I've talked to at interviews it's all who you know and if you are fresh out of residency.
I am now currently sweating it out for the Match in a couple weeks. I will be looking at doing a non accredited program anywhere that will take me if I don't match. Or maybe reapply, I haven't decided.
I am reminded of a Mike and the Mechanics song...
 

Ducttape

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Reapply. Ask your residency if you can spend a few weeks going to clinic for observation. Get references through the anesthesiology program.

If that doesnt work, then think about non-accredited. But i wouldnt recommend, solely due to the fact that you will be limited on board certification (not because of quality of training, for the most part)
 

Ligament

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Wow, jollygoodfellow, sounds like you should have a lot of useful experience that would make you a great fellow. I cannot comprehend why Pain Medicine is as competitive as it is given our subspecialty is being systematically dismantled by the feds via regulation and payment cuts.
 

bronchospasm

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I practiced anesthesia for 5 years before starting my pain fellowshiP. I feel that practicing for the few years helped me mature as a physician and an individual.
Many programs will look at the experience as an asset.

Good luck.
 

willabeast

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i am retiring in 5 months. have done pain for 20+ years. when my chief was interviewing for a replacement (i do mostly interventional), seems like
they wanted (in order)
1. compatibility with the other docs in the group 2. ability to work as a team 3. willing to change practice patterns to suit what chief/admin/assistant chiefs desire (in other words, needs to follow orders) 4. in regards to fellowship, no indication at all that they wanted or even preferred a ABMS accredited fellowship.
FYI if i was looking for a interventional pain doc, i would look for
1. good with hands 2. smart 3. ABMS accredited fellowship 4. someone who does procedures i do not (for example pumps) 5. someone i get along with
i read somewhere that CEO's hire one of two ways - they either hire people smarter than they are, or they hire people they can control. bottom line - lots of different choices out there.