All About Pain Management

[1000questions]

Aside from a small handful of posts, pain management has been pretty much ignored. 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!

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[Bluemirage]

Aside from a small handful of posts, pain management has been pretty much ignored. 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!

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.

 

[1000questions]

ah.. of course.. many thank

 

[1000questions]

ah.. of course.. many thanks

 

[Jeff05]

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.

Aside from a small handful of posts, pain management has been pretty much ignored. 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!

 

[Arch Guillotti]

Moving to the appropriate forum...

 

[1000questions]

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.

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.

 

[PMR 4 MSK]

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.

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.

 

[Jeff05]

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.

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.

 

[nvrsumr]

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.

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)

 

[joshmir]

are you saying some guys implant stims and pumps in the office?

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

thx

 

[Ligament]

are you saying some guys implant stims and pumps in the office?

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

thx

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.

 

[1000questions]

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.

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?

 

[PMR 4 MSK]

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?

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.

 

[badasshairday]

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.

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.

 

[Doctodd]

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

 

[ampaphb]

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.

 

[PMR 4 MSK]

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.

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.

 

[Tenesma]

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.

 

[Aether2000]

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.

 

[Tenesma]

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.

 

[PMR 4 MSK]

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?

 

[Tenesma]

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.

 

[ghost dog]

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.

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!!

 

[ampaphb]

Last I checked, 100% of bupkis is still bupkis

 

[ghost dog]

Last I checked, 100% of bupkis is still bupkis

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

Yeehaw!

I love screwing with you people.

 

[lobelsteve]

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

Yeehaw!

I love screwing with you people.

Canadian dollars?
Isn't that monopoly money?

 

[ghost dog]

Canadian dollars?
Isn't that monopoly money?

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.

 

[mille125]

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.

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

 

[mille125]

Canadian dollars?
Isn't that monopoly money?

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

 

[ghost dog]

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

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

 

[Jeff05]

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...