1. Dismiss Notice
  2. Download free Tapatalk for iPhone or Tapatalk for Android for your phone and follow the SDN forums with push notifications.
    Dismiss Notice
  3. Hey Texans—join us for a DFW meetup! Click here to learn more.
    Dismiss Notice

All About Pain Management

Discussion in 'Pain Medicine' started by 1000questions, Dec 9, 2008.

  1. 1000questions

    Joined:
    Oct 9, 2008
    Messages:
    7
    Likes Received:
    0
    Status:
    Pre-Medical
    Aside from a small handful of posts, pain management has been pretty much ignored. :confused: I want to get a big, broad discussion of this subspecialty going, so contribute anything you can...

    1. What is lifestyle like? Salary? Compared to general anesthesia?

    2. What is private practice pain clinic like? Solo private practice?

    3. Do pain management specialists still do occasional OR work or are they purely seeing patients in a clinical setting? On-call duties? Rounds?

    4. Future job outlook? Better than general anesthesia (especially with CRNAs)?

    5. What is daily case-load like for pain guys? Variety? Interesting?

    6. Anything else? Experiences as resident, as physician, anecdotes, insights, other opinions, pros and cons of the field, etc. If you have experience in or knowledge of the field, contribute anything you can...

    Thanks! :)
     
  2. Note: SDN Members do not see this ad.

  3. Bluemirage

    Bluemirage Senior Member
    10+ Year Member

    Joined:
    Nov 2, 2003
    Messages:
    387
    Likes Received:
    2
    Status:
    Fellow [Any Field]
    There is a reason why pain is not discussed much here. There is an entire forum dedicated to pain and should answer all of your questions and more: Pain Medicine forum.
     
    #2 Bluemirage, Dec 9, 2008
    Last edited: Dec 9, 2008
  4. 1000questions

    Joined:
    Oct 9, 2008
    Messages:
    7
    Likes Received:
    0
    Status:
    Pre-Medical
    ah.. of course.. many thank
     
  5. 1000questions

    Joined:
    Oct 9, 2008
    Messages:
    7
    Likes Received:
    0
    Status:
    Pre-Medical
    ah.. of course.. many thanks
     
  6. Jeff05

    Jeff05 Senior Member
    10+ Year Member

    Joined:
    May 30, 2001
    Messages:
    1,059
    Likes Received:
    2
    Status:
    Attending Physician
    ok. lets.
    i would transfer this post to pain sdn/pain rounds though.
    1. lifestyle usually involves no overnight in hospital (anes - usually overnight in hospital/home call with real potential to come in)
    2. what do you mean what is it like? more specific questions are in order.
    usually though, see followup every 15 min, new patient 30-45min, a day or two in fluoro suite. more time if you're "jockin."
    3. some practices, including academics, can mix OR/office. so, you can see patients one day, and do OR another day. or just see pain and do OR call.
    4. job outlook. likely, and this is PURE OPINION, but i think that fellowships will be more sought after in a couple of years. anesthesia will be just fine - crna's and all. pain will be just fine, as well. if the whole system is reformed, ALL salaries will go down, NO ONE will be safe.
    5. case load - pain patients. lots of them. interesting? it's what you make it. EVERYTHING BECOMES ORDINARY AND ROUTINE. you have to extract personal satisfaction from the job based on human contact (my opinion).

    i'm guessing you're a med student/intern. ask yourself this question. WHAT DO YOU WANT FROM LIFE? money? security? portability? respect from collegues? admiration from patients/lay people? free time? adrenalin rushes? desire to connect with people? pick a specialty based on that. the actual CONTENT is much less important - again, $hit gets old. quick.

    i get satisfaction from, at baseline, providing a safe/neat (yea, i'm 4nal about perfect taping and bloodless a lines and such)/pleasant/minimally painful/efficient anesthetics. but, why i really come to work is to comfort the patient. to empathize. to make them feel like there is someone really watching them in that scary/horrible machine of the hospital. doing pain next year to learn things that make me better at that.




     
  7. Arch Guillotti

    Arch Guillotti Senior Member
    Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Aug 8, 2001
    Messages:
    7,452
    Likes Received:
    1,129
    Status:
    Attending Physician
    Moving to the appropriate forum...
     
  8. 1000questions

    Joined:
    Oct 9, 2008
    Messages:
    7
    Likes Received:
    0
    Status:
    Pre-Medical
    Wow--thanks for the honest response. I get tired of all the self-righteous, "you-have-to-practice-medicine-for-one-reason-only-and-it-can't-be-money-or-lifestyle" crap people spew on some of these forums.

    I guess I want to be able to treat patients again and again in a way that I can develop small, working relationships with them--and help them with serious, life-altering problems. What's also nice is that I'm always torn between IM primary care and something more "exciting" like ortho, and anesthesia + pain gives you the ability to be in the OR or run a private solo practice or do both.

    After that, it's all about the money and the ability to tell my secretary, "clear my schedule on the 29th and 30th--I'm taking a long weekend skiing" or "finish my schedule up early on Friday--my son's got a football game." That kind of independence is a big one for me.

    Which leads me to my next questions:

    You mention that pain involves no overnight, but does pain have to involve any call at all? Would a pain doc even have to be hospital-affiliated? To what extent could a pain doc with in-office flouro run a clinic based entirely on in-office, outpatient procedures and never have to go anywhere else to administer treatment? At a young age, ER call and running here and there might be great, but, eventually, that type of practice sounds ideal.

    And, lastly, what impact would these decisions (not being hospital affiliated/working completely out of the office) have on patients? For example, an IM primary care could choose not to round or take call and to leave his patients in the hands of a hospitalist once they're admitted, but I wouldn't consider that to be good care. Are there any procedures (I'm not familiar with all of them) that simply could not be done in-office that patients would be missing out on? A solo, independent practice with nothing to do outside of scheduled hours would be nice, but patient care is paramount.

    Sorry all for the long post--thanks.
     
  9. PMR 4 MSK

    PMR 4 MSK Large Member
    SDN Advisor 5+ Year Member

    Joined:
    Oct 1, 2007
    Messages:
    4,182
    Likes Received:
    24
    Status:
    Attending Physician
    You can do an all-office based pain practice, but you may be limiting yourself. Some procedures should not or cannot be done in the office - implanting stims and pumps, e.g. Also, many insurance plans require privleges at a local hospital to be on the plan - plus you need to take the patient somwhere when the sheet hits the fan. You could dump them in the ER but that is bad medicine. You really should have a good working relationship with a hospital. Just stay as far away from the administrators as you can - they're not your friends or allies.

    Most pain docs just take call for their own patients, or a rotating call for a group, or just cross-covereage for vacations and days off. Many do hospital consults on request. There is usually no ER-required call schedule for admits or to see people in the ER.

    PM&R has afforded me all the opportunities you describe - I take off whenever I want, no call, no eveneings or weekends.
     
  10. Jeff05

    Jeff05 Senior Member
    10+ Year Member

    Joined:
    May 30, 2001
    Messages:
    1,059
    Likes Received:
    2
    Status:
    Attending Physician
    you may have to take pain call - this involves getting calls from the hospital. you will very rarely have to go in, in most cases. you do not have to be affiliated with a hospital, most procedures can be done in the office. including procedures that need anesthesia - lots of rules regarding this...

    if your patient is admitted to a hospital, you can only round on the there is you have privilages at that hospital.

    as an aside, running here and there, for ME, is not good, at any age.

    bottom line, you can make your practice whatever you want. lots of inpatients, or no inpatients. several partners to share calls.


     
  11. nvrsumr

    nvrsumr Member
    10+ Year Member

    Joined:
    Apr 25, 2002
    Messages:
    1,729
    Likes Received:
    366
    Status:
    Attending Physician
    I know guys who do their implants under local and conscious sedation. Many other surgical specialties are doing more and more in the office-think of what the plastic and derm guys are doing. Office based anesthesia is developing into its own subspecialty. If pumps and stims are not already being done in the office they likely will be soon (of course with the important caveat-getting paid)
     
  12. joshmir

    joshmir Senior Member
    10+ Year Member

    Joined:
    Nov 17, 2003
    Messages:
    578
    Likes Received:
    13
    Status:
    Attending Physician
    are you saying some guys implant stims and pumps in the office?

    is this clearly legal or clearly illegal? or a gray area?

    thx
     
  13. Ligament

    Ligament Interventional Pain Management
    Physician Lifetime Donor SDN Advisor Classifieds Approved 10+ Year Member

    Joined:
    Jan 8, 2002
    Messages:
    4,783
    Likes Received:
    1,164
    Status:
    Attending Physician
    I think I understand what you are getting at, but the law has nothing to do with whether we implant in the office. The insurance companies determine this. They simply won't pay you if you do it in an office. But you can still do it if you want to and the patient will pay out of pocket for it.
     
  14. 1000questions

    Joined:
    Oct 9, 2008
    Messages:
    7
    Likes Received:
    0
    Status:
    Pre-Medical
    I'm digressing a bit, but this out-of-pocket thing is something I've never been able to grasp. I've heard of plastic surgeons doing it, even with non-elective procedures. Why would someone be willing to pay out of pocket for a procedure they could have done elsewhere within their insurance plan?
     
  15. PMR 4 MSK

    PMR 4 MSK Large Member
    SDN Advisor 5+ Year Member

    Joined:
    Oct 1, 2007
    Messages:
    4,182
    Likes Received:
    24
    Status:
    Attending Physician
    They wont - they are sometimes willing to pay a higher deductable for a convienience factor, but won't pay the whole thing. Or they'll go for it and just never pay you.
     
  16. badasshairday

    badasshairday Vascular and Interventional Radiology
    10+ Year Member

    Joined:
    Apr 6, 2007
    Messages:
    3,884
    Likes Received:
    299
    Status:
    Resident [Any Field]
    Can't you sue them for not paying you? I don't get how people can just blow off medical bills. They don't do that for any other industry. Try getting the cab driver to take you from point a to point b and pay him a fraction of the cost... see how that goes.
     
  17. Doctodd

    10+ Year Member

    Joined:
    Jul 4, 2005
    Messages:
    3,035
    Likes Received:
    288
    medical bills are the easiest to get out of and most people who dont pay theirs know that......go to creditboards.com and search a bit for more info if you really want to

    T
     
  18. ampaphb

    ampaphb Interventional Spine
    10+ Year Member

    Joined:
    May 13, 2007
    Messages:
    4,352
    Likes Received:
    721
    Status:
    Attending Physician
    In office implantation of trial stimulators are clearly legal. Many carriers will, indeed, pay for them, in light of their lower overall cost than the exorbitant facility fees some ASCs and hospitals charge. However, given how expensive the equiptment is, you should ALWAYS get pre-authirization for these procedures.

    The problem arises if something untoward occurs. Is it "standard of care" in your community to do in-office trials? Were you trained to do these in fellowship? If something bad happens, do you have the equipment, plan, and ability to address it in an emergent fashion.

    So yes, it is legal. Yes, you will get paid for it. But you still have to decide if the financial upside is worth the added risk your practice will incur.
     
  19. PMR 4 MSK

    PMR 4 MSK Large Member
    SDN Advisor 5+ Year Member

    Joined:
    Oct 1, 2007
    Messages:
    4,182
    Likes Received:
    24
    Status:
    Attending Physician
    When I had my own solo, private pratice, I tried many ways to get the money. Turning pts over to collections only works if they care about their credit rating or will need to buy a new house - so mnay don't. I've tried taking people to small-claims court. They never show up and I get a judgement against them. That and $5.00 will get you a carmel-mocha latte. I have never had someone pay the judgement. Your only hope is that the judge will isssue a bench warrant, they'll be pulled over and then arrested. They'll see the judge and he'll order them to pay, they'll agree, then walk out and not pay.

    Medicine is unique in that someone comes to us for a service and we send the bill to someone else, who then decides retro-actively if they will pay or not. They will base that decision on a mountain of rules to see if you dotted the I's, crossed the T's got the precert, filled in the right numbers, etc. Then maybe, just maybe, they'll pay you, in 60 - 90 days, unless they come up with a reason not to.

    Medicine used to be you wrote the doctor a check, his secretary gave you a HCFA form, and you sent it to your insurance company for "reimbursement." We took that term and now apply it to doctors - we are being "reimbursed" for our services. BS. We are being paid, not reimbursed. That little change in wording changes one's thinking and perspective on being paid.
     
  20. Tenesma

    Tenesma Senior Member
    10+ Year Member

    Joined:
    Jun 11, 2002
    Messages:
    5,332
    Likes Received:
    127
    Status:
    Attending Physician
    i agree w/ PMR...

    patients that don't pay within 90 days - rarely will EVER pay. the few exceptions were those patients whose bills going to the wrong address...

    i do keep a collection list that is integrated into my scheduling software --- so if anybody who is on the collection list tries to schedule or request disability papers or prescriptions or anything else, they are told that they need to meet their financial responsibility or else we can't do anything --- 90% will just hang up and never call again.

    i remember posting in a previous post re: securing accounts with credit card information - and am sitll interested in you guys feedback on that.

    a few local practices require credit card numbers up front - and any unmet balance/co-pay/co-insurance/deductible gets automatically billed to the credit card... because these are sub-specialties and the next closest sub-specialties are 40-60 minutes away, they get away with this and i haven't heard ONE patient complain about it.

    those practices have literally close to ZERO in collections.
     
  21. algosdoc

    algosdoc algosdoc
    10+ Year Member

    Joined:
    May 3, 2005
    Messages:
    3,783
    Likes Received:
    1,460
    Status:
    Attending Physician
    We take credit cards up front for self pay patients and do charge them if they no show as an "administrative fee". We also accept credit cards as payment, and use a check verification service with any checks. We hold prescriptions until the current day's bill is paid and if there is any outstanding balance, payments on that balance must be made before scripts are received. Payments for new patient and followup visits are collected in advance of the actual visit before seeing the physician or NP.
    We do not prescribe expensive drugs for self pay patients, therefore no oxycontin.
    Our accounts receivable are very very low. Everyone knows the rules and must play by them; accordingly we are able to keep our prices much lower than the guy down the street charging $2000 for an epidural injection.
     
  22. Tenesma

    Tenesma Senior Member
    10+ Year Member

    Joined:
    Jun 11, 2002
    Messages:
    5,332
    Likes Received:
    127
    Status:
    Attending Physician
    algos: i do the same... BUT...

    what do you do about those patients who
    1) state they have insurance, you verify eligibility/benefits --- you treat them over several weeks/months --- only to have insurance say sorry, patient is actually NOT eligible.... patient now has a balance of several thousand...

    2) have insurance, but have a weird %co-insurance system and their insurance doesn't allow charging up front for procedures --- you do 2 medial branch blocks and an RF and the patient's responsibility is $480 - and patient doesn't pay.

    etc, etc, etc...

    if i had the credit card system in place that i alluded to, i would collect all of that... instead of the current situation, where i basically end up providing free care.
     
  23. PMR 4 MSK

    PMR 4 MSK Large Member
    SDN Advisor 5+ Year Member

    Joined:
    Oct 1, 2007
    Messages:
    4,182
    Likes Received:
    24
    Status:
    Attending Physician
    But then what do you do if the credit card is maxed and the chares denied, or it's a debit card and there's no money in the bank account?
     
  24. Tenesma

    Tenesma Senior Member
    10+ Year Member

    Joined:
    Jun 11, 2002
    Messages:
    5,332
    Likes Received:
    127
    Status:
    Attending Physician
    they don't take debit cards

    re: maxed out credit cards - if the total is too much for credit card and gets denied then they just re-charge at $100/month until the balance is paid off...
    otherwise, you are right - it will become a non-paid account.
     
  25. ghost dog

    2+ Year Member

    Joined:
    Aug 23, 2008
    Messages:
    830
    Likes Received:
    5
    Status:
    Attending Physician
    When I had my own solo, private pratice, I tried many ways to get the money. Turning pts over to collections only works if they care about their credit rating or will need to buy a new house - so mnay don't. I've tried taking people to small-claims court. They never show up and I get a judgement against them. That and $5.00 will get you a carmel-mocha latte. I have never had someone pay the judgement. Your only hope is that the judge will isssue a bench warrant, they'll be pulled over and then arrested. They'll see the judge and he'll order them to pay, they'll agree, then walk out and not pay.

    Medicine is unique in that someone comes to us for a service and we send the bill to someone else, who then decides retro-actively if they will pay or not. They will base that decision on a mountain of rules to see if you dotted the I's, crossed the T's got the precert, filled in the right numbers, etc. Then maybe, just maybe, they'll pay you, in 60 - 90 days, unless they come up with a reason not to.

    Medicine used to be you wrote the doctor a check, his secretary gave you a HCFA form, and you sent it to your insurance company for "reimbursement." We took that term and now apply it to doctors - we are being "reimbursed" for our services. BS. We are being paid, not reimbursed. That little change in wording changes one's thinking and perspective on being paid.


    Ah, Canada. Socialized medicine. Where the government pays the doctor 100% of the time. Gotta love it. Lovin' every minute of it Baby!!
     
  26. ampaphb

    ampaphb Interventional Spine
    10+ Year Member

    Joined:
    May 13, 2007
    Messages:
    4,352
    Likes Received:
    721
    Status:
    Attending Physician
    Last I checked, 100% of bupkis is still bupkis ;)
     
  27. ghost dog

    2+ Year Member

    Joined:
    Aug 23, 2008
    Messages:
    830
    Likes Received:
    5
    Status:
    Attending Physician

    Does $415,000 / year feel like nothing to yee America boy?

    Yeehaw!

    I love screwing with you people.
     
  28. lobelsteve

    lobelsteve SDN Lifetime Donor
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    May 30, 2005
    Messages:
    12,587
    Likes Received:
    2,685
    Status:
    Attending Physician
    Canadian dollars?
    Isn't that monopoly money? :laugh:
     
  29. ghost dog

    2+ Year Member

    Joined:
    Aug 23, 2008
    Messages:
    830
    Likes Received:
    5
    Status:
    Attending Physician
    Check out the mad burn skills on Steve-O!

    You never know when the American dollar is going to drop like Bill Clinton's pantoloons.
     
    #28 ghost dog, Jan 9, 2009
    Last edited: Jan 9, 2009
  30. mille125

    7+ Year Member

    Joined:
    Dec 8, 2006
    Messages:
    2,127
    Likes Received:
    8
    Status:
    Attending Physician



    academic anesthesiology is full of canadians....we had 13 in my department earning just slightly more than a fellow....what does that tell you? greener pastures I guess
     
  31. mille125

    7+ Year Member

    Joined:
    Dec 8, 2006
    Messages:
    2,127
    Likes Received:
    8
    Status:
    Attending Physician


    it is interesting that for the first time in recent history canadian dollars were worth more than american dollars last year....didnt last longer than a few days
     
  32. ghost dog

    2+ Year Member

    Joined:
    Aug 23, 2008
    Messages:
    830
    Likes Received:
    5
    Status:
    Attending Physician


    Overall, the Canadian dollar was (approximately) at par to the U.S. dollar from September 2007 to June 2008 ; a period of 9 months.
     
  33. Jeff05

    Jeff05 Senior Member
    10+ Year Member

    Joined:
    May 30, 2001
    Messages:
    1,059
    Likes Received:
    2
    Status:
    Attending Physician
    stop. you guys are grossly underpaid and have a pretty crappy system to work in. US has it's problems, but you don't see any americans going across the border to canada to get top of the line treatment.

    i will take our 60% collections over your 100% government reimbursement any day. any you shouldn't be bragging about making 415k canadian (350k us) in pain managment. that's starting salary right out of fellowship in these parts...
     

Share This Page