anes vs PMR

[Ligament]

A warm "wecome back" to Stinky Tofu who was an inspiration to many of us over many years here on SDN. Where you been at Stinky?

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".

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[Aether2000]

One of the NASS Board members (a surgeon) told me last year that anyone can be taught to do injections, including non-physicians. This type of arrogance and ignorance is pervasive in some surgeon circles. We need a pain residency so we can begin to train physicians in pain surgery.

 

[pars]

I have a good guess as to who you are talking about. If it's who I think - I've also heard him say that you can teach anyone to do spine surgery too. I personally believe that the important factor is the clinical decision making.

Algos, I agree with you completely. I believe that people involved in spine care need more focused training. That involves surgeons and non-surgeons. The surgical skills needed for orthopedic surgery don't translate well to spine surgery. The skills needed to decompress a subdural hematoma are nothing like decompressing a C5 nerve root. By the same token deciding how to stabilize a trauma patient with a horrible airway doesn't help in deciding which facet joint is the pain generator.

In an ideal situation I think we'd (surgeons and non-surgeons) all share the first year or two of training. Then branch off into different directions with cross training along the way...just one man's humble opinion...

 

[Disciple]

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.

I agree completely. Pain specialists learned from Neurosurgeons to do pumps/stims. Surgeons were the first to do Kyphoplasty, etc.

I remember a previous post on this board about one interventionalist contemplating doing X-Stop.

In my community, some surgeons do their own injections, but a lot of them dispense meds out of their office (Soma, Oxy IR, even Ativan in some instances).

In a recent thread about multispecialty groups, it was stated that many PCPs would love to have a pain physician to dump their opiate patients on, and that sure, you could find a few procedures out of that. Whatever surgeons in my community are doing, alot of my referrals for procedures come from surgeons. What if a started a campaign against surgeons doing injections and dispensing meds? Whatever would happen, it would not be good for referrals or my standing in the community.

I don't believe that the best way to deal with competition is by trying to impose restrictions on other specialties.

If you want the patients referred to you first so that you can direct their care, become a superior diagnostician with a wide array of treatment options that leads to better outcomes. Market yourself appropriately and let your skills speak for themselves. Deliver a better product.

If you want higher standards, support multidisciplinary organizations such as ISIS, that are on the forefront (This is why I'm not really into organizations such as ASRA or the AAP (Association of Academic Physiatrists)).

We can't really accomplish anything as separate little special interest groups each with its own agenda.

Remember, it took a joint statement from AAPM, ISIS, ASIPP and NANS to oppose the ACOEM Guidelines.

 

[Tenesma]

agree w/ disciple

it is all about marketing... the key is to underline what disciplie said... you have to market yourself (and then also prove it) as a guy who can evaluate non-myelopathic pain patients and provide many diagnostic and treatment options...

the biggest advantage of marketing yourself that way is that you are no longer dependent on pleasing 3 spine surgeons.... instead your true referral base is 125 PCPs.... if you piss off one spine surgeon with them as your primary source of referrals/procedures, then you take a big hit... if you piss off one of the PCPs with them as your primary source of referrals/procedures, then you won't even notice the hit...

 

[tmh84]

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