anes vs PMR

[dayz]

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I was wondering if someone could tell me what the difference is in going through anes or pmr to get to pain. Like how competitive it is to get a pain fellowship, salary, life style, pros and cons, etc.

thanks!

 

[PMR 4 MSK]

The two fields are worlds apart during residency, only to come crashing together (often violently) for pain fellowship. Anesthesia is being in surgery, on one side of the head or the other depending on rotation. PM&R is all wards and clinics - acute CVA, TBI, SCI and MSK. Programs differe on how much inpt vs outpt.

Anesthesioloists come in about 6 am and leave about 3. PM&R more 8 - 5.

In PM&R, we train the pts to move and think again by doing puzzles in OT. In anesthsia, it's the anesthesiologist doing the puzzles while the pt sleeps... 😀

 

[mid|ine]

Choose the residency you like better. You may not do pain in the future and what you will be left with is the residency you did.

 

[Jeff05]

come in at 6 and leave at 3...
where can i sign up?

 

[Aether2000]

The pain fellowships have become so egalitarian that they must accept applications from those completing residencies in medical genetics, allergy medicine, etc regardless of how unqualified the base training is prior to pain fellowship. On the other hand, most of what anesthesiologists and PMR learn in residencies do not apply directly on a day to day basis to chronic pain. I personally think PMR would be a better choice for undergrad residency. I was trained in an anesthesiology residency.

 

[Buckeye Anes]

With all that being said, to answer part of your question, statistically the majority of fellowship spots go to anesthesia trained residents. However, you can get a spot out of either residency.

 

[panetrain]

I agree, anesthesia is currently a hot field and certainly not a bad fall back. Additionally, you can often practice pain and anesthesia after your pain fellowship. This set up, for many, is just as clinically and financially satisfying. Also, when your establishing your pain practice and business is slow, you can supplement your income with extremely lucrative anesthesia locum single weekday gigs or weekend gigs.😀 Im sure there are pros and cons to both fields, but being anesthesia myself, I only see pros to the latter. 😉

Choose the residency you like better. You may not do pain in the future and what you will be left with is the residency you did.

 

[DistantMets]

Basically Anesthesia gets to "Pain Medicine" by getting their base in taking care of acute post op pain. PM&R gets there by medically taking care of chronic MSK and neuropathic pain, they also take care of acute/subacute pain on inpatient rehab units. They both typically do rotations in Pain/Spine care clinics. So they kind off meet in the middle.

 

[brori]

Do what suites your personality type. If you love pharmacology, etc, I would do anaesthesiology. If you really like patient interaction choose PM&R. PM&R is 30%ortho, 30% neurology, 15%internal medicine, 15% pain medicine, 10% social work/psych. I chose PM&R due to personal experience (saw a PM&R doctor for non-operative treatment of partially torn achilles) PM&R doctors tend to see the "big picture", have a good physical exam and differential diagnosis, and tend to involve multidisciplinary approach to patient problems.

For example. Pain problem XYZ. Treat with medications, physical therapy, involve psych, ergonomic evaluation, patient positioning habits, diet and exercise habits. Consider interventional procedures. Consider referral to endocrine/nutritionist if BMI issues. Consider orthotics, etc, etc, etc.

 

[Tenesma]

even though i am an anesthesiologist --- i still have PMR envy (primarily because of their excellent MSK training).

 

[Jcm800]

if you like coming in super early, like its still dark outside early, staying late, (not)sleeping in a hospital, being cold, dehydrated, and curious when you may be able to pee next, definitly investigate anesthesia...

but if you ever have a serious cario-pulmonary issue, you will be at home dealing with this...

 

[SSdoc33]

even though i am an anesthesiologist --- i still have PMR envy (primarily because of their excellent MSK training).

i think PM&R training SHOULD prepare you to have good background for pain medicine. whether or not that actually happens in residency is a different story. it is definitely dependent on which residency you go to, and there is huge spectrum of great programs (a few) to mediocre ones (many). i can understand the MSK lust of the anesthesiologists like algos and tenesma, but often times, a good physiatrist picks that up along the way outside of their formal training....

 

[Aether2000]

PMR as a background training for pain is certainly not perfect...it has many flaws, but it is more clinically oriented than the technical nature of anesthesiology, and PMR residents have a decent understanding of outpatient clinic operations with their experience. What is missing in PMR is evidence based medicine. The fact is that most of the physical medicine diagnostic maneuvers are based on repetition from past generations of physicians with few having been validated as to specificity or sensitivity for a particular condition or set of conditions. Those of us not trained in the maneuvers view them as compelling and somewhat mysterious, but when subjected to rigorous evaluation, many fall apart. Can we really tell the axis of rotation of the SI joint arthropathy and the displacement distance on physical exam? Does the Yeoman's test have any validity to SI arthropathy and what is the specificity and sensitivity? PMR is definitely advancing some of these questions into the harsh limelight of scientific scrutiny, but to do so places the brave souls conducting such tests in the crossfire of colleagues that view themselves as being more gifted diagnosticians when data is presented by researchers demonstrating a negative correlation between physical exam and pathology. The pathetic IMEs and highly insurance industry supported occupational physicians use these examinations as the holy grail of patient pathology, and when patients fail to demonstrate the expected findings, they are labeled as having psychosomatic diseae or are overtly fabricating symptoms. So these examinations are misused as much as they are used appropriately in the US, and may cause financial and medical injury to patients due to their intentional misinterpretation. Where PMR can help us all would be to publish a list of BS physical diagnostic techniques that have shown not to correlate to anything in a significant manner. Then we could select validated tests only, while jettisoning the conclusions of physicians that are paid to misinterpret patient pathologies.
Yet, PMR is definitely a far better road to the integrated practice of pain medicine than is anesthesiology with its excessive focus on blind needle techniques in residency, use of the demonstratedly inaccurate stimulation techniques to localize nerves, and the numerical focus on general anesthesia vs regional anesthesia. The pain fellowship helps correct the erroneous notions regarding pain patients imparted by anesthesiology programs that would simply export anesthesiology techniques into the clinical realm of pain medicine. But what percentage of what is learned in anesthesiology and PMR is actually useful on a daily basis in clinical pain medicine? For anesthesiology it is approx 25% or less based on surveys I have done in the past: I am unsure of PMR but certainly it is not 50%. So why do we waste the time of physicians training them in residency programs that are not relevant to pain medicine? Why not just train them in pain medicine from the time of medical school graduation? The answer is politics and turf protection. Until we are able to move beyond those barriers, we will be forever relegated to wasted years of physician training in residency and inadequate training time in pain fellowships. PMR is not the perfect segue into pain, but it is the best we have currently.

 

[Buckeye Anes]

Yet, PMR is definitely a far better road to the integrated practice of pain medicine than is anesthesiology with its excessive focus on blind needle techniques in residency, use of the demonstratedly inaccurate stimulation techniques to localize nerves, and the numerical focus on general anesthesia vs regional anesthesia. The pain fellowship helps correct the erroneous notions regarding pain patients imparted by anesthesiology programs that would simply export anesthesiology techniques into the clinical realm of pain medicine.

"It is better to be thought ignorant than to open your mouth and remove all doubt." So...thanks for opening your mouth.

 

[lobelsteve]

Yet, PMR is definitely a far better road to the integrated practice of pain medicine than is anesthesiology with its excessive focus on blind needle techniques in residency, use of the demonstratedly inaccurate stimulation techniques to localize nerves, and the numerical focus on general anesthesia vs regional anesthesia. The pain fellowship helps correct the erroneous notions regarding pain patients imparted by anesthesiology programs that would simply export anesthesiology techniques into the clinical realm of pain medicine.

"It is better to be thought ignorant than to open your mouth and remove all doubt." So...thanks for opening your mouth.

I love when a resident can openly call an ISIS board member an idiot and not even know it.

Buckeye Ane$: you will be a needle monkey or you will be a gas passer, but you you will need a lot of education and training to be a pain specialist.

 

[Buckeye Anes]

I love when a resident can openly call an ISIS board member an idiot and not even know it.

Buckeye Ane$: you will be a needle monkey or you will be a gas passer, but you you will need a lot of education and training to be a pain specialist.

Never said I wouldn't need training/education hence the need for a fellowship. However, I don't feel like the completely unprepared idiot for doing an anesthesia residency that was implied. As for ISIS board member....awesome....congrats

 

[Aether2000]

If anesthesia training is so good, you need to ask yourself:
1. What percentage of patients have you rendered general, MAC, regional anesthesia?
2. What percentage of your time has been spent in a clinic setting outside the OR or OB?
3. How are your attendings trained in musculoskeletal medicine and how much actual training by hands on demonstration have you had?
4. What percentage of all injections
/catheter placements you do have used fluoroscopy or ultrasound?

People in anesthesiology residency are not idiots, but they lack enough training or experience to know what they don't know regarding pain medicine. They are completely different fields

 

[Finally M3]

Yet, PMR is definitely a far better road to the integrated practice of pain medicine than is anesthesiology with its excessive focus on blind needle techniques in residency, use of the demonstratedly inaccurate stimulation techniques to localize nerves, and the numerical focus on general anesthesia vs regional anesthesia. The pain fellowship helps correct the erroneous notions regarding pain patients imparted by anesthesiology programs that would simply export anesthesiology techniques into the clinical realm of pain medicine.

"It is better to be thought ignorant than to open your mouth and remove all doubt." So...thanks for opening your mouth.

Seriously, man, you're fighting a losing battle. You're calling out as ignorant, as a resident, an anesthesiologist attending who is practicing pain. You really don't have a leg to stand on.

To OP; both have pros and cons. Do what you like rather than viewing either as a stepping stone to a pain fellowship, because you're going to have a miserable 4 years either way then.

 

[Ligament]

My former fellowship director, who is an anesthesiologist by residency and fellowship director in an anesthesiology department, hates being referred to as an anesthesiologist. He is a Pain Medicine specialist and he'll make that clear to you. I now feel the same way when people call me a physiatrist (well, I don't "hate" that term but it is so inaccurate to what I do on a daily basis you get the idea).

 

[Jeff05]

greater than 90% of all my blocks are ultrasound guided. have used u/s on multiple occasions for epidural placement in difficult patients. have done over 400 blocks (not including spinal and epidural). i have done at least that many epidurals and spinals. over 50 thoracic epidurals.

i'm pretty sure that my dexterity with needles and imaging is much better than any PMR resident. i think that's important, as pain fellowship is only 11 months. certainly a CA1 resident at the end of the year is not an epidural expert, but we expect PMR folk to be that as pain attendings after only 1 year.
I'm pretty good with suturing - central lines, a lines. PMR has not tied a knot since MS3 surgery rotation.

I'm going to be an interventional pain management physician. the interventional part is really important. the physical dx is also CRUCIAL, but the fellowship builds on existing experience (because i got a great base in med school and i did a year of internal medicine and btw as an anesthesia resident my upper and lower ext exam and knowledge of muscles and innervation is excellent, my knowledge of all pain blocks and acute pain management is pretty good (several months of mandatory pain management during residency) as well as profound understanding of pain pathways, local anesthetics, opioids, etc). I've done celiac plexus blocks and I can manage the hypotension that develops immediately, PMR hasn't and can't.

so, i don't really agree, at this point, that PMR is the BEST path to pain management.

 

[PMR 4 MSK]

so, i don't really agree, at this point, that PMR is the BEST path to pain management.

Agree, either is a way there. There are many paths to the same end point, and we all practice different aspects of the field. I send pts out for pumps, stims and plexus blocks. WHile the anesthesia guys in town don't usually refer to me (some arrogance there, but that's another story), I do get some of their "failures" and am able to treat many of them in ways they didn't think of. Sometimes they couldn't think past the needle, other times, their MSK knowledge was obviously not enough.

They can perform some miracles that I can't or won't, I can do things they can't. It should be a symbiotic relationship, but territorialism and prejudice interfer too much.

 

[nvrsumr]

greater than 90% of all my blocks are ultrasound guided. have used u/s on multiple occasions for epidural placement in difficult patients. have done over 400 blocks (not including spinal and epidural). i have done at least that many epidurals and spinals. over 50 thoracic epidurals.

i'm pretty sure that my dexterity with needles and imaging is much better than any PMR resident.

I dont want to get in a pissing match but I did 400+ fluoro guided injections as a PMR resident including cervical and sympathetic blocks. Plus I did hundreds in total of blind intraarticular injections and peripheral nerve blocks as well as 200+ EMGs probably sampling more than 2000 muscles with a needle. Oh yeah, I also did iliopsosas US guided botox injections plus all the other blind botox injections and phenol neurolysis for spasticity, finally we managed all the baclofen pumps.

Anesthesiologists better at reading imaging?! Are you nuts? I have no idea how many hundreds of MRIs, plain films and CTs I read as a resident(without looking at the report until I was done)

Suturing in a line is not a "surgical skill".

Threading a thoracic epidural blindly (which Ive done multiple times) is of no utility in pain practice(outside of some zebra situation) and doing blind epidurals (of which Ive done many) for pain mangement is not the standard of care in any community in the US, except maybe a VAH.

To all the other anesthesia pain guys on this board please excuse my rant. I learned a ton(including msk exam) from my anesthesia pain medicine attendings in fellowship. I also do not agree that PMR is the "best" way. What is purported above is just blatant ignorance though.

 

[SSdoc33]

greater than 90% of all my blocks are ultrasound guided. have used u/s on multiple occasions for epidural placement in difficult patients. have done over 400 blocks (not including spinal and epidural). i have done at least that many epidurals and spinals. over 50 thoracic epidurals.

i'm pretty sure that my dexterity with needles and imaging is much better than any PMR resident. i think that's important, as pain fellowship is only 11 months. certainly a CA1 resident at the end of the year is not an epidural expert, but we expect PMR folk to be that as pain attendings after only 1 year.
I'm pretty good with suturing - central lines, a lines. PMR has not tied a knot since MS3 surgery rotation.

I'm going to be an interventional pain management physician. the interventional part is really important. the physical dx is also CRUCIAL, but the fellowship builds on existing experience (because i got a great base in med school and i did a year of internal medicine and btw as an anesthesia resident my upper and lower ext exam and knowledge of muscles and innervation is excellent, my knowledge of all pain blocks and acute pain management is pretty good (several months of mandatory pain management during residency) as well as profound understanding of pain pathways, local anesthetics, opioids, etc). I've done celiac plexus blocks and I can manage the hypotension that develops immediately, PMR hasn't and can't.

so, i don't really agree, at this point, that PMR is the BEST path to pain management.

i think that it is generally agreed that anesthesiologists are better with the needle after residency, and physiatrist may have better MSK skills/training with disability. the idea of a fellowships is to improve the areas that are weak. jeff05, seriously, don't call out a whole specialty without knowing what you are talking about. if you are solely interested in the interventioanal aspect here, then you will be a poor pain practitioner.

 

[panetrain]

I know I'm currently naive to pain medicine, but this thread is my first exposure to the apparent wide-spread dissidence between Anesthesia and PMR in this field. That's sad, as if this field was not already receiving enough blows from the medical community. It seems as though these two groups (Gas and PMR) currently dominate the field of pain. However, I don't think this will be the case for long. It was a frequent occurrence during this last year's interview season to be seated next to applicants from ER, IM, FP, Occupational Therapy?, Neuro, Psych etc...😕 Based on this observation, it would appear that current pain program directors would disagree that one specialty is significantly more qualified than another to practice pain medicine.

 

[lobelsteve]

Never said I wouldn't need training/education hence the need for a fellowship. However, I don't feel like the completely unprepared idiot for doing an anesthesia residency that was implied. As for ISIS board member....awesome....congrats

Though you may not know who algosdoc is....

He is a thought leader for the entire field and will hopefully be the guy that helps pry pain medicine out of the anesthesia department, away from the physiatrists, and gets it set up with its own residency program.

He is a hybrid pain specialist/surgeon and does far more complicated things around the spine than anyone else I know or have heard of. He also does a fair amount of bench research.

 

[Aether2000]

Thanks Steve, you are too kind.
My ultimate point is that there is no residency program in anesthesia or PMR that doesn't waste a significant amount of time of the physician that could be better spent learning the art and science of pain medicine, including all aspects of pain. The sub sub specialty of interventional pain will survive only if we produce the data to continue to support the expensive procedures that on average cost the insurers 6-10 times the cost of an office visit with med management using cheap drugs. So, is interventional pain 600-1000% better than medication management? If so, we need the numbers to prove it because that is what the insurers focus on most: large numbers of expensive procedures without Level I evidence to support their use. It is my contention that if we don't produce this data in the next few years (the window is closing fast), then we may be in deep trouble. The number of procedures we can offer is mind boggling, but we need proof. The bar is now much higher than it used to be. So, we need a comprehensive program that produces researchers, balanced clinicians with an expansive fund of knowledge, and educators that can teach the many facets of the field of pain medicine. The fellowship programs puts us one step ahead of the CRNAs, but is insufficient to train physicians to be a complete pain physician. Perhaps the anesthesia residencies have improved significantly but as late as a few years ago, blind interlaminar ESI were the predominate modus operandi in surveyed residency programs. Pain medicine went beyond this phase longer than a decade ago, yet we still just scratch the surface of what would be possible if we had the mechanism to self sustain the profession through research and novel approaches. Ultimately the better trained physician will potentially bring better therapies to their patients, who suffer continuously nearly every day. We owe it to those who suffer to develop a full residency program.

 

[Buckeye Anes]

Thanks Steve, you are too kind.
My ultimate point is that there is no residency program in anesthesia or PMR that doesn't waste a significant amount of time of the physician that could be better spent learning the art and science of pain medicine, including all aspects of pain. The sub sub specialty of interventional pain will survive only if we produce the data to continue to support the expensive procedures that on average cost the insurers 6-10 times the cost of an office visit with med management using cheap drugs. So, is interventional pain 600-1000% better than medication management? If so, we need the numbers to prove it because that is what the insurers focus on most: large numbers of expensive procedures without Level I evidence to support their use. It is my contention that if we don't produce this data in the next few years (the window is closing fast), then we may be in deep trouble. The number of procedures we can offer is mind boggling, but we need proof. The bar is now much higher than it used to be. So, we need a comprehensive program that produces researchers, balanced clinicians with an expansive fund of knowledge, and educators that can teach the many facets of the field of pain medicine. The fellowship programs puts us one step ahead of the CRNAs, but is insufficient to train physicians to be a complete pain physician. Perhaps the anesthesia residencies have improved significantly but as late as a few years ago, blind interlaminar ESI were the predominate modus operandi in surveyed residency programs. Pain medicine went beyond this phase longer than a decade ago, yet we still just scratch the surface of what would be possible if we had the mechanism to self sustain the profession through research and novel approaches. Ultimately the better trained physician will potentially bring better therapies to their patients, who suffer continuously nearly every day. We owe it to those who suffer to develop a full residency program.

Now this post I completely agree with. Also I feel anesthesia residency has advanced in that at my institution we only do "blind" epidurals when we can't use fluoro. We also do the vast majority of our regional (>80%) with ultrasound. Maybe I was too harsh in my criticism earlier, but the earlier statements seemed pretty inflammatory/anti anesthesia. In the end we are/or will be on the same team so my apologies.

 

[Jeff05]

how do we get level I evidence?
double blind placebo controlled studies with sufficient power seem like an impossibility.
how do you envision such evidence will come about?
i'm genuinely interested.

 

[drusso]

I was thinking about this topic as I was doing a kind of knarly SCS explant today--you know the type: Hx of multiple revisions, lots of scar tissue, etc. There is simply not good training around for the bulk of what we do. I think anesthesia base training as some benefits and so does physiatry. I think that both are lacking from a surgical standpoint. I think that there a few good fellowships that do a heroic job of trying to work it all into one year, but most are lacking in some core skill-set that you need to really do this job well. We need our own bonafide residency program.

 

[Doctodd]

Yet, PMR is definitely a far better road to the integrated practice of pain medicine than is anesthesiology with its excessive focus on blind needle techniques in residency, use of the demonstratedly inaccurate stimulation techniques to localize nerves, and the numerical focus on general anesthesia vs regional anesthesia. The pain fellowship helps correct the erroneous notions regarding pain patients imparted by anesthesiology programs that would simply export anesthesiology techniques into the clinical realm of pain medicine.

"It is better to be thought ignorant than to open your mouth and remove all doubt." So...thanks for opening your mouth.

Wow i missed all the fun......hey Buckeye, there really isnt any use in being offended cuz we are all on the same team. If you had a really bad day today, we understand and have been there too. If not, you have been hanging around arrogant surgeons too long.

IMHO anesthesiology can learn MSK in a few months, but PMR cannot learn anesthesiology in a few months. There were many PMR topics i disliked and find useless in a pain fellowship and beyond, such as Orthotics/prosthetics, SCI, TBI to name a few. Even the mundane topics in anesthesiology would seem to help you with at the very least manual dexterity, which would help with playing with needles. Any anesthesiologist could correct me if im wrong. Maybe im just in a "grass is always greener" phase.

 

[Aether2000]

The acquisition of level I evidence is easiest to obtain through the use of double crossover studies. Patients are assured in this manner they will receive the non-placebo if they receive no relief from what they assume is placebo...
We are all on the same team, and because I so strongly believe that, I have taught courses for ASIPP, ISIS, PASSOR, NASS, and several of the surgical societies....I never leave a meeting without learning something from talented individuals with special skills and capabilities.
I apologize if I offended any by my missive...we lack perfection in pain medicine education, which we can best see that through examination of our own imperfect background training. We desire to improve the system of pain medicine by forging ahead with the future. Given the proposed changes in health care, this may be either the perfect time for amalgamating a new specialty or may spell our demise. My hope lies in the former.

 

[Disciple]

Where PMR can help us all would be to publish a list of BS physical diagnostic techniques that have shown not to correlate to anything in a significant manner. Then we could select validated tests only, while jettisoning the conclusions of physicians that are paid to misinterpret patient pathologies.

There is an excellent physical examination book that does just that:

http://www.amazon.com/Musculoskeletal-Physical-Examination-Evidence-Based-Approach/dp/1560535911

 

[Disciple]

But what percentage of what is learned in anesthesiology and PMR is actually useful on a daily basis in clinical pain medicine? For anesthesiology it is approx 25% or less based on surveys I have done in the past: I am unsure of PMR but certainly it is not 50%.

I think it could be 50%, but this is highly dependent on the program, assumes as least a 50/50 split inpt/out training, and assumes training in one of the musculoskeletal/spine heavy programs.

I've found even a little bit of value in the inpt rehab training, as day rehab programs and acute rehab units (running team conferences, etc.) are very similar in set-up to "chronic pain" functional restoration programs, which currently seem to be quite popular in my state.

 

[Disciple]

There were many PMR topics i disliked and find useless in a pain fellowship and beyond, such as Orthotics/prosthetics, SCI, TBI to name a few.

Really?

I recently did an IME on patient with a Tibialis Posterior tendon tear where I had to comment on what kind of orthosis he should get.

Had another IME on a patient with SCI and conus injury after L1 burst fracture, fusion T11-L3 with chronic back pain and paraplegia. Was asked to comment on future care for pain management and maintainence care (labs, urodynamic studies, etc.) for the SCI.

I hope you were joking about MSK only taking a few months to learn. I tried to focus most of residency on learning musculoskeletal evaluation, and to this day still attend lectures/workshops by Michael Geraci, Gary Gray, etc. to improve my skills.

In my opinion, a cookie cutter set of manual muscle testing, DTR's, straight leg raise and sensory exam to light touch is not that great of an exam.

Learning MSK is not simply pulling out your old muscle/nerve charts from medschool 1st year anatomy, it's learning/visualizing how the muscles, bones and tendons move in concert that makes the subject matter difficult, and even more difficult to conceptualize.

Orthotics and Prosthetics (essentially questions about biomechanics/kinematics) has on average been one of the lower scoring sections on SAE and PM&R board exams for the past several years. Now, picture one of your chronic pain patients walking down the hall (antalgic gait, cane he/she may or may not need in the wrong hand, increased anterior pelvic tilt/lumbar lordosis, Pes Planus, no radicular symptoms-just lumbar/buttock and trap/interscapular pain)

If you can't evaluate him, it's either opiates or let the physical therapist figure out what's wrong.

 

[Disciple]

I was thinking about this topic as I was doing a kind of knarly SCS explant today--you know the type: Hx of multiple revisions, lots of scar tissue, etc. There is simply not good training around for the bulk of what we do. I think anesthesia base training as some benefits and so does physiatry. I think that both are lacking from a surgical standpoint.

So how did you case go?😀


As a non-surgeon, what I've found most difficult is not so much the suturing, but the cutting/dissecting, working through small yet deep incisions, getting adequate visualization, etc.

 

[drusso]

So how did you case go?😀


As a non-surgeon, what I've found most difficult is not so much the suturing, but the cutting/dissecting, working through small yet deep incisions, getting adequate visualization, etc.

That's about right...things kind of cruise along at a good clip until the closure, then it's like time stops...the circulators start taking their breaks, the CRNA's rotate...the Nazi OR scheduler keeps poking her head in, "How much longer, Dr?" Oh well...I take my time.

 

[Tenesma]

when i was an anesthesia resident and anesthesia pain fellow... i would have agreed with BuckEyeAnes and Jeff05...

However, now that I have been in (private) practice for a few years, I have realized how silly the arguments made by Buckeye and Jeff really are...

Anesthesia does not prepare you for chronic pain management in the least... having the technical skills to do peripheral blocks under ultra-sound guidance for peri-operative anesthesia doesn't really mean squat in chronic pain, having the technical skills to do thoracic epidural catheters means nothing in chronic pain, having the technical skills to manage post-operative pain with a PCA doesn't mean squat in chronic pain....

PMR is the superior field in my opinion, and out of it should grow a combined PMR/PAIN residency (also in my opinion).

I have seen PMR residents/Neuro residents/Psych residents become VERY proficient at a multitude of injections - even performing injections I don't have the cojones to do...

I have yet to see very many anesthesia residents become truly adept at MSK evaluation and managements... something that is all too important in chronic pain.

Not all chronic pain is a herniated disc...

I never realized how little I knew about physical exams, orthotics, gait stabilization, management of weakness/cord injuries, management of ligamentous/joint injuries, and the list goes on.

i work very hard in private practice to play catch up with these learning deficits... in order to provide better chronic pain management/medicine.

what is even more embarassing is that the Pain Board exam is totally anesthesia oriented, and doesn't even take into consideration what chronic pain really is all about...

 

[Ligament]

In my opinion, neither anesthesiology nor PM&R are ideal for pain practice.

Like drusso, I did a PM&R residency followed by an Anesthesiology based pain fellowship.

I learned a lot from my Anesthesiology attendings and residents. In particular about sedation (especially how NOT to sedate for pain procedures), PCAs, epidural infusions for cancer pain, tunneled epidural catheters, intrathecal medication management, and sympathetic neurolysis. I'm not saying I like this stuff, but I needed to learn it to round out my pain credentials. I'm sure I would not have learned this in a PM&R based fellowship and certainly did not learn this stuff in PM&R residency.

I agree that there should be a pain medicine residency program.

 

[Jcm800]

as far as advice for the original poster, I think the best words of wisdom were quouted earlier. four years is a long time, and things change. When i was in medical school preparing for a "career" i really didnt have clue what i really liked. thus i applied for and matched in general surgery. What a mistake that was...nonetheless i left and did anesthesia, but if you are going to do something for 4 years, you should like it...

beyond your ultimate plans, things change. you could come out and decide not to do pain, but did anesthesia (or PMR) because you thought it was "best pathway" and now dont want to do pain, OR anesthesia (or whatever)...

Its been clearly shown that if you are an aggrssive student/resident, who sincerely wants to learn and be a good doctor, you can do that from either anesthesia or PMR.

besides, i think we all agree you learn more in your first year as an attending then did in 4 years as a resident.


just remember if you do anesthesia, prepare to spend at least 200 overnights in the hospital over the 4 years (at least we did, if you average an overnight every 5th night or so...) depending on your internship choice.

 

[drusso]

Can't we all just get along? 😀

 

[brori]

Absolutely we should get along. We have been and are rapidly progressing our encroachment on NSG and OrthoSpine turf, we need to be united in this move.

 

[Stinky Tofu]

Absolutely we should get along. We have been and are rapidly progressing our encroachment on NSG and OrthoSpine turf, we need to be united in this move.

I agree with brori; the problem isn't Anesthesia vs. PM&R and we really need to be united as a group of Pain Physicians. The problem where I am is that over 60% of the spine surgeons here do their own "injections" despite the lack of any formal training. Personally, I have a problem with a spine surgeon who does 3 interlaminars, it doesn't work, then suddenly the patient is getting surgery all in the span of 4-6 weeks. The other common scenario here is a "positive" discography at more than one level done by the spine surgeon and then suddenly the patient is getting a 2 or 3 level fusion done by the same surgeon. I wonder how many of these patients needed surgery in the first place?

These scenarios are frequently seen when PCP's refer directly to a spine surgeon who does his or her own injections. Unfortunately, what winds up happening is that no one else is involved in their care until the laminectomy or fusion doesn't work and then suddenly they need to see "pain management" because we are the best ones to deal with pain which translates to "I've done all the things that reimburse well or will facilitate surgery and now I'd like someone else to deal with prescribing your opiates or figuring out what to do so I can go through the same limited algorithm on the next patient".

 

[brori]

These scenarios are frequently seen when PCP's refer directly to a spine surgeon who does his or her own injections. Unfortunately, what winds up happening is that no one else is involved in their care until the laminectomy or fusion doesn't work and then suddenly they need to see "pain management" because we are the best ones to deal with pain which translates to "I've done all the things that reimburse well or will facilitate surgery and now I'd like someone else to deal with prescribing your opiates or figuring out what to do so I can go through the same limited algorithm on the next patient".[/quote]

+1 been there. I feel your pain.

This is amplified when surgeon xyz implants the pump and refers to someone else for pump management. It's like sticking the big toe in the deep end, pulling out because it's too cold/hot, and then flying away to a country without extradition.

 

[pars]

As an "outsider" I was reading this post in a semi-amused state until StinkyTofu's comments...

I'm probably the only ortho spine surgeon who ever reads this board so I usually ignore the intermittent surgeon bashing because its usually at least funny...but I think that you need to at least re-evaluate your position.

Spine care whether operative, interventional, or non-operative is all about identifying pain generators and treating them appropriately. I would say that an orthopedic spine surgeon is in a particularly good position to make that call. That's what we are trained to do...because when we operate - the stakes are a lot higher than when we put a needle somewhere. As someone who does both, I think the risks of injections are not nearly the same as with surgery.

That's not to say that every surgeon who does injections is doing the right thing...but neither is every anesthesiologist or pm&r trained docs who do pain management. It's really interesting to read your gripe because most surgeons complain about pain management for the exact same reasons. Just giving injections until the insurance runs out and then sending them to the surgeon without any idea as to what the problem really is. Or sitting on a big disc herniation with a hot radic giving ESIs, facets, and RFs....then getting their lami and its too late... There is mismanagement in every field and most of us will make the wrong call every once in a while.

But many surgeons are trained to do injections... transforaminals, interlaminars, caudals, facets, rf, scs, spinal endoscopy. Let's be honest...the hard part isn't about getting the needle in the right place. That is pretty easy on a technical continuum. The hard part is in the diagnosis and clinical decision making.

A couple of points...
In regard to the spine surgeon's "limited algorithm"...what exactly is in your bag of tricks that a spine surgeon doesn't have? I can operate when I think its the better option. I can inject when I think it's the better option. I will admit that I am in no way on par with an anesthesiologist or physiatrist when it comes to medication management.

Your complaint about the surgeon doing the things that "reimburse well"... We get it...you want to be the one getting paid for the injections...

And the disco complaint...that may be a valid concern...But I personally think that I'm in a much better position to decide on an operation when I'm the one doing the discogram. I get some really important information about a patient during a discogram...it usually convinces me not to operate. Like when the skin injection is a 9/10 concordant pain or when they get leg pain 1 cm superficial to the facet.

Look, the bottom line here is that most of us spending our time reading/contributing to these posts are trying to do a better job with non-surgical spine care (aka pain management). Depending on your educational background you will be stronger or weaker in different areas. Get over your specialty label...

If you really want to advance the field of spine care then you should want surgeons doing some injections. It keeps us honest... If you're only interested in protecting your "territory" then I see your point.

 

[Tenesma]

pars... i am glad that you contribute to this forum...

however, i think it doesn't make any sense for a spine surgeon to be doing injections...

spine surgeons generate their income from surgery, and I would think that they would want to optimize their time so that they can operate, not manage meds and not perform injections....

ideally, a spine surgeon should find an interventionalist that is reliable and reasonable...

i agree w/ the point that the toughest part is clinical decision making... and in my opinion, the best decisions are made as a team... my local spine surgeons spend at least 10 minutes with me AND pain psych guy on the phone before ANY fusion that is for axial pain (unless it is an unstable degen./traumatic spondylolisthesis --- then it is kind of a no-brainer). it has reduced their fusion volume, BUT they/we are so much happier because their success rate is higher....

and my beef isn't with just the spine surgeons who do their own injections (and no they aren't trained that well at injections), it is also with those spine surgeons who own injectionists in their practice... because as somebody who has been there, it is inherently a self-serving process with a LOT of bias towards surgical intervention....

this may be a philosophical point, but why do we have the highest fusion rates in the world???

 

[Stinky Tofu]

But many surgeons are trained to do injections... transforaminals, interlaminars, caudals, facets, rf, scs, spinal endoscopy. Let's be honest...the hard part isn't about getting the needle in the right place. That is pretty easy on a technical continuum. The hard part is in the diagnosis and clinical decision making.

I hear what you are saying and I'm sure that many surgeons are probably just as proficient as some of the people out there doing injections, but that is part of the problem. There are too many people doing injections who shouldn't be. I think there are a lot of people who actually do have a hard time getting the needle in the right place so I really disagree with you. The only times we get asked to do injections from these injectionists are for injections in which they don't feel comfortable doing it themselves. I'm not saying the problem is isolated to spine surgeons and obviously you have a better understanding of the anatomy when compared to most other specialists. There are many neurologists where I practice doing "blind" facets and "blind cervical ESI's" and I'm at a major city.

I enjoy working with spine surgeons, value their opinions immensely, have excellent relationships with them, and involve them fairly early on in my patient's care because I don't believe I know everything and I want patients to understand all their options so they can make an informed decision. The spine surgeons I work with also believe I am the best one to offer non-surgical options for their patient's pain prior to surgery. I do believe that doing an ACGME-accredited fellowship and being board-certified in pain management does account for something so I do believe I have a few more things in my bag of tricks. I don't tell patients what type of spine surgery they should have and I don't believe a spine surgeon on his or her own can give as many options as I can to help a patient manage pain; after all, this is my area of expertise just as surgery is yours. My own personal observation where I practice is that the surgeons doing their own injections are much less likely to involve a pain physician or physiatrist until after the injections and surgery have been done. Again, I'm not saying that a spine surgeon can't learn to do these injections, but something feels wrong to me when the surgeon who is ultimately doing the surgery is the one providing all the non-surgical care. In doing this, they are discounting the value of other specialists. Maybe its just me, but I hear it all the time from my patients that they wish they had seen a pain physician prior to the decision to have surgery.

 

[SSdoc33]

pars, thank you very much for your post. we definitely tend to have a "anti-surgeon mentality" on this board, and it is refreshing to see another point of view.

i find it very rare to be able to speak with an OSS or NS and discuss the types or injections i do, why i do them, what the disco means in my opinion, and what type of injection is best for the patient. usually, they dont seem to know what im talking about, or care enough to listen. i credit you that you actually put some thought into this.

i think you'll agree that there are definitely some surgeons out there where you just look at a patient, and have to scratch your head. sometimes i get downright angry. these are the types that we typically bash. these are ones we wouldnt want performing the injections and the discos. these are the ones who we wouldnt let near a family member.

btw, we have the most fusions in the world b/c we have the highest percentage of spine surgeons. more surgeons = more surgeries, for better or for worse.....

 

[pars]

Your points are all well taken.

I would love to have a reasonable and independent physician to team up with for non-operative spine care. It would be great to see 10 patients per half day and have them all as surgical candidates. But that is just not reality for those of us who live in smaller towns.

There is also something to be said for nurturing a non-operative relationship with a patient. Patients appreciate that you tried other things before operating. I don't know of many orthopedic surgeons who don't inject a knee or try viscosupplementation before an arthroplasty... Ya, they make a lot more money operating on that knee than injecting it but they don't send them all off to rheumatology or PM&R. I'm not sure that I see the difference with an injection for stenosis or a hot disc...

What about the post-lami patient whose leg pain is gone but is still upset that their back hurts despite multiple pre-operative discussions that a lami is a leg pain surgery. It helps when you can block their facets...

I don't really want to do chronic pain management either medically or interventionally. As a surgeon I really don't have an interest in facet injections every 6 months. But acutely... I think it's an important tool.

Believe me I don't want to steal anyone's livelihood. I think it is important for surgeons to be well rounded in spine care. That is probably the road to fewer fusions... more options to offer or a better understanding of the options a pain management colleague can offer.

But you really can't complain about surgeons using needles when almost all pain management doctors are holding knives and bovies. That part sounds a lot like surgery and very little like anesthesia or physiatry. You just can't have it both ways.

 

[brori]

Pars thank you for contributions to the forum, I greatly appreciate your perspective. My best friend from medical school is ortho spine. He does many of his own injections and SCS implants. More and more surgeons in my community are using this approach.

 

[Stinky Tofu]

Pars, I would rather see my patient get an injection from someone like you rather than many of the injectionists (both surgeons and non-surgeons) in my community. The problem is that few of them are like you and put very little thought into the type of injection they are going to do or learning different ways to deliver the medication closer to the site of pathology.

One of the surgeons here does three L4-L5 ILESI's for every single patient irregardless of the site of pathology, the patient's symptoms, and the response to the first two injections. If you are referred to him for axial back pain only, bilateral leg pain, left L3 radiculopathy, or right S1 radiculopathy, you are getting the same injection x 3. I'm not saying surgeons are the only ones guilty of this here. Where I practice, it just seems like the surgeons here do not have the same skills as my colleagues who have done a fellowship or spent a significant amount of time during residency/post-residency learning these procedures. Again, I'm not saying they can't learn this, but none have been motivated to put the time and effort to be truly good at it because their true passion is surgery.

I guess I can understand why some surgeons might want to do their own injections when they look around and all they see is an "injectionist" who does blind epidurals in his or her office and refers back to the PCP for medical management with no suggestions at all. When there are reasonable and properly trained pain physicians all over town, it now no longer makes sense to me and the motivation seems to be unrelated to delivering the best possible care to the patient.

The fact that the definition of a pain physician could mean one of a million different things doesn't help either. Hopefully, in the future, a residency in pain management will eliminate many of the problems that currently exist in our field which ultimately leads to a misunderstaning of what we do by surgeons, PCP's, and patients. When that day comes, people might then actually know what your local pain physician has to offer.

I agree that we don't think twice about a knee surgeon doing Synvisc, but there's a big difference between knee injections and pain procedures which might call for a cervical RFL, cervical ESI, left L1 TFESI, stellate ganglion block, lumbar sympathetic block, ganglion impar block, etc. I would rather the spine surgeons here do a knee injection on my patient blindfolded before I would let them do a cervical ESI or L1 TFESI.