anesthesia hates pain

[Jeff05]

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almost done with my pain fellowship and have noticed (i've worked in multiple institutions) that pain divisions are usually like the bastard step children of anesthesia departments.

support from anesthesia departments is rare. many in those departments do not hide either their disregard or downright contempt for what we do.

anesthesia leadership believes (for some reason) that pain is a losing proposition (even though solid pain practices can generate immense amounts of income for both the practitioners and the institution). many departments have policies that make it difficult for pain divisions to flourish.

most have NO clue what it is we actually do (most think all we do just fill oxycontin scripts and do epidural steroid injections).

i am just not sure why a specialty that is so marginalized and misunderstood by others (anesthesia) imparts the same treatment on its own members (just with more training).

 

[SleepIsGood]

I've heard that this is common. Typically because the anesthesiologists believe the pain physicians are just 'goofying' off in pain clinc.

The reality is that if one has a decent pain clinic, the pain physician can generate a lot more revenue (simply d/t to the more patients you are seeing).

This is also why Pain docs get pist off at the anesthesiologists. The anesthesiologists can run two rooms, essentially have residents run them, give them each a AM break, and a lunch break. They can 'lounge' more,while the Pain Physician is actively working more. Also wih Pain, you have followup and as a result more liability.

So...it's a toss up.

 

[2win]

almost done with my pain fellowship and have noticed (i've worked in multiple institutions) that pain divisions are usually like the bastard step children of anesthesia departments.

support from anesthesia departments is rare. many in those departments do not hide either their disregard or downright contempt for what we do.

anesthesia leadership believes (for some reason) that pain is a losing proposition (even though solid pain practices can generate immense amounts of income for both the practitioners and the institution). many departments have policies that make it difficult for pain divisions to flourish.

most have NO clue what it is we actually do (most think all we do just fill oxycontin scripts and do epidural steroid injections).

i am just not sure why a specialty that is so marginalized and misunderstood by others (anesthesia) imparts the same treatment on its own members (just with more training).

I do agree with some of your statements.
I do not agree that the " pain practices can generate immense amounts of income for both the practitioners and the institution". The future of pain medicine is dark...We do live in a sick society where at least 60% of people are on antidepressants and narcotics. The evidence for most of the pain procedures is lacking and finally most of the pain patient after the procedures use even higher amounts of narcotics. The "disability" business is a shame - an excuse used so often by the lazy people...Part of the pain business is psychiatry - and anesthesia people don't like it either.
Take a look to the gaswork openings in pain - see Florida clinics for pain medication "physicians"...
On the other side ask yourselves who are the academic pain docs- why they stayed in academics (with that lousy income) when they could make some nice profits doing private pain?
My friend - the future of pain is not bright IMO.
glty

 

[urge]

I hate the pain clinic. I don't want anything to do with it. If you want to be in your little world all the time, fine by me. Just don't get me involved. Fine by me if you don't take call.

 

[Jeff05]

I do agree with some of your statements.
I do not agree that the " pain practices can generate immense amounts of income for both the practitioners and the institution". The future of pain medicine is dark...We do live in a sick society where at least 60% of people are on antidepressants and narcotics. The evidence for most of the pain procedures is lacking and finally most of the pain patient after the procedures use even higher amounts of narcotics. The "disability" business is a shame - an excuse used so often by the lazy people...Part of the pain business is psychiatry - and anesthesia people don't like it either.
Take a look to the gaswork openings in pain - see Florida clinics for pain medication "physicians"...
On the other side ask yourselves who are the academic pain docs- why they stayed in academics (with that lousy income) when they could make some nice profits doing private pain?
My friend - the future of pain is not bright IMO.
glty

i'm not sure why you think academic pain docs stayed in academics.

 

[2win]

i'm not sure why you think academic pain docs stayed in academics.

Pain is a fascinating field. There are some "rara avis" physicians that are dedicated in this field and the only opportunity for research is in academics. Some of them made the cash in pp and they returned to a more comfortable lifestyle. Some of them never had the taste of pp and it was more comfortable to stay in academics. There are others that left academics for pp in order to make some money. As you see the motives are different.
Keep in mind that the majority of anesthesia docs have marginal knowledge regarding pain medicine (physical exam, neuro , procedures, psych medication, abuse and treatment, pmr) . Guess why...
Before to start my practice I read few times a pmr textbook. And after that I continued with a neuro and a psych. How many of your fellow anesthesiologist did that?
On a final note I do believe that financially the field of pain management will have a serious hit in the next years. You really need to have a passion for pain medicine to stay in.

 

[urge]

On a final note I do believe that financially the field of pain management will have a serious hit in the next years. You really need to have a passion for pain medicine to stay in.

True that. I don't see too many people applying lately.

 

[Doctor4Life1769]

Pain is a fascinating field. There are some "rara avis" physicians that are dedicated in this field and the only opportunity for research is in academics. Some of them made the cash in pp and they returned to a more comfortable lifestyle. Some of them never had the taste of pp and it was more comfortable to stay in academics. There are others that left academics for pp in order to make some money. As you see the motives are different.
Keep in mind that the majority of anesthesia docs have marginal knowledge regarding pain medicine (physical exam, neuro , procedures, psych medication, abuse and treatment, pmr) . Guess why...
Before to start my practice I read few times a pmr textbook. And after that I continued with a neuro and a psych. How many of your fellow anesthesiologist did that?
On a final note I do believe that financially the field of pain management will have a serious hit in the next years. You really need to have a passion for pain medicine to stay in.

Could you please elaborate on the breadth of pain medicine from an anesthesia-perspective? Do most also prescribe narcotics or is that pretty much relegated to primary care, PMR, etc.? I ask because one anesthesiologist (PP) I rotated with refused to Rx narcotics and mainly did steroid injections, regional, epidurals, etc.

 

[ProRealDoc]

Could you please elaborate on the breadth of pain medicine from an anesthesia-perspective? Do most also prescribe narcotics or is that pretty much relegated to primary care, PMR, etc.? I ask because one anesthesiologist (PP) I rotated with refused to Rx narcotics and mainly did steroid injections, regional, epidurals, etc.

There's no money in writing scripts for narc. The money is in the procedures.

 

[ProRealDoc]

almost done with my pain fellowship and have noticed (i've worked in multiple institutions) that pain divisions are usually like the bastard step children of anesthesia departments.

support from anesthesia departments is rare. many in those departments do not hide either their disregard or downright contempt for what we do.

anesthesia leadership believes (for some reason) that pain is a losing proposition (even though solid pain practices can generate immense amounts of income for both the practitioners and the institution). many departments have policies that make it difficult for pain divisions to flourish.

most have NO clue what it is we actually do (most think all we do just fill oxycontin scripts and do epidural steroid injections).

i am just not sure why a specialty that is so marginalized and misunderstood by others (anesthesia) imparts the same treatment on its own members (just with more training).

Personally, I don't care what the pain docs are up to as long as they are generating revenue. If they are slick enough to read the newspaper all day and still keep the cash flowing then so be it. If their revenue helps to prop up the salaries of the rest of the group associates/partners, then all power to them.

 

[2win]

There's no money in writing scripts for narc. The money is in the procedures.

Pro - there is money...in writing scripts. I will stop here - this board is a public one and there is no need for more info.
Regarding the question - interventional only versus interventional with narcotics - any (BUT ANY) real pain doc will prescribe narcotics and other drugs in order to treat pain. Please guys don't listen to some stories with pain docs that get rich doing steroid injections. This isn't the case.
Far away from me to tell you to don't do pain medicine. Do it only if you like it - again you don't gonna get rich.

 

[2win]

Personally, I don't care what the pain docs are up to as long as they are generating revenue. If they are slick enough to read the newspaper all day and still keep the cash flowing then so be it. If their revenue helps to prop up the salaries of the rest of the group associates/partners, then all power to them.

How much is the revenue for an epidural transforaminal medicare?
What about a SI injection Blue cross?
Net revenue ASC for a spinal pump medicare? And so on...
Level 5 consult pain medicare?
What revenue????

 

[ProRealDoc]

Pro - there is money...in writing scripts. I will stop here - this board is a public one and there is no need for more info.
Regarding the question - interventional only versus interventional with narcotics - any (BUT ANY) real pain doc will prescribe narcotics and other drugs in order to treat pain. Please guys don't listen to some stories with pain docs that get rich doing steroid injections. This isn't the case.
Far away from me to tell you to don't do pain medicine. Do it only if you like it - again you don't gonna get rich.

duplicate

 

[ProRealDoc]

Pro - there is money...in writing scripts. I will stop here - this board is a public one and there is no need for more info.
Regarding the question - interventional only versus interventional with narcotics - any (BUT ANY) real pain doc will prescribe narcotics and other drugs in order to treat pain. Please guys don't listen to some stories with pain docs that get rich doing steroid injections. This isn't the case.
Far away from me to tell you to don't do pain medicine. Do it only if you like it - again you don't gonna get rich.

If all you do is write scripts to folks who drive to Florida from out of state to buy a script for Oxicontin, then yeah, you will make cash.

 

[ProRealDoc]

How much is the revenue for an epidural transforaminal medicare?
What about a SI injection Blue cross?
Net revenue ASC for a spinal pump medicare? And so on...
Level 5 consult pain medicare?
What revenue????

Never done so I would not know. We all know medicare reimburses peanuts for anything you do. If all you are seeing is medicare patients then you're catering to the wrong crowd.

 

[2win]

Never done so I would not know. We all know medicare reimburses peanuts for anything you do. If all you are seeing is medicare patients then you're catering to the wrong crowd.

Pro - as you very well know the Medicare counts for the majority of pain patients. Besides that I do believe that the rates for the private ones will go down aiming at Medicare rates. If you have hospital privileges you have to see Medicare (at least this is my experience). If you are able to go cash - well congrats - me, I failed...How many are cash only???

 

[Arch Guillotti]

any (BUT ANY) real pain doc will prescribe narcotics and other drugs in order to treat pain.

This is nonsense. A number of very well respected pain docs on SDN will refute your statment.

 

[2win]

This is nonsense. A number of very well respected pain docs on SDN will refute your statment.

Really? Who?
I wanna see their argument for ONLY interventional pain and we can discuss. Is like being a surgeon - doing the procedure and you don't treat your post op pain. You send your patients to another surgeon to be treated.

 

[powermd]

Really? Who?
I wanna see their argument for ONLY interventional pain and we can discuss. Is like being a surgeon - doing the procedure and you don't treat your post op pain. You send your patients to another surgeon to be treated.

At least three of the most notable contributors to the pain forums run practices that involve minimal to no opiate prescribing. That doesn't mean they don't provide non-opioid medication management, or consults to other physicians on opioid management.

I think you're FOS if you equate a pain doc who doesn't prescribe opioids to a surgeon who doesn't treat post op pain. Only addicts 'need' 2 weeks of qid Percocet to treat the "pain" caused by an epidural injection. Even a discogram doesn't get you more than a few day's worth.

 

[Arch Guillotti]

What he said. Read the pain forums and you may obtain a different perspective on things. If you are really interested in discussing the matter with docs who do this every day for a living, try the pain forum.

At least three of the most notable contributors to the pain forums run practices that involve minimal to no opiate prescribing. That doesn't mean they don't provide non-opioid medication management, or consults to other physicians on opioid management.

I think you're FOS if you equate a pain doc who doesn't prescribe opioids to a surgeon who doesn't treat post op pain. Only addicts 'need' 2 weeks of qid Percocet to treat the "pain" caused by an epidural injection. Even a discogram doesn't get you more than a few day's worth.

 

[2win]

What he said. Read the pain forums and you may obtain a different perspective on things. If you are really interested in discussing the matter with docs who do this every day for a living, try the pain forum.

You're at best hilarious ---
I don't know what pain business you ran so far or whatever knowledge you have about that - so your opinion so far is totally ignored. And I cannot stop to remember mmd...
Powermd - just stepped out in real world so .. he has to learn a lot. You two guys and other "pain medicine" forum posters ( and I can come with some respectable names though...) believe that you can have an honest and profitable practice doing discograms and steroid injections. Oh - I forgot and also advise "stupid" PCP- s about medication changes (this is the "consult") - you are out of your mind...And why not do not prescribe narcotics if the patient needed ? Ah - I know because you only tell others to do it...Don't you see the flaws in your logic? Who has ears to hear ...
I'm done with this thread. You guys go in PP - do discograms and facets and please, please DO NOT prescribe narcotics ....And you two smarties - show me a randomized trial (no bias) to see a decreased in opioid use after a spinal stim or pump (long term). And it will look like Mobama numbers (your favorite Archie) - "we created a lot of jobs but the rate of unemployment is the same". MEANS BS

 

[Jeff05]

You're at best hilarious ---
I don't know what pain business you ran so far or whatever knowledge you have about that - so your opinion so far is totally ignored. And I cannot stop to remember mmd...
Powermd - just stepped out in real world so .. he has to learn a lot. You two guys and other "pain medicine" forum posters ( and I can come with some respectable names though...) believe that you can have an honest and profitable practice doing discograms and steroid injections. Oh - I forgot and also advise "stupid" PCP- s about medication changes (this is the "consult") - you are out of your mind...And why not do not prescribe narcotics if the patient needed ? Ah - I know because you only tell others to do it...Don't you see the flaws in your logic? Who has ears to hear ...
I'm done with this thread. You guys go in PP - do discograms and facets and please, please DO NOT prescribe narcotics ....And you two smarties - show me a randomized trial (no bias) to see a decreased in opioid use after a spinal stim or pump (long term). And it will look like Mobama numbers (your favorite Archie) - "we created a lot of jobs but the rate of unemployment is the same". MEANS BS

ok, ok, you're doing a great job underlining the title of this thread. you're one of the anesthesia guys who thinks pain is a bunch of BS.

i don't want this thread to turn into a discussion of the merits of pain management, that is a very complex and emotional discussion that i just don't have the energy to have at this time.

i must say, however, many things in medicine have NO long term data, i'll leave it at that.

 

[Doctor4Life1769]

I'm only a medical student, so I'm not up to par so much about the business side of medicine. However, I would have imagined that the only source of reimbursement/income from Rx'ing narcs would be that you're "guaranteed" a monthly supply of patients who come for the refills of the narcs for whatever reason (not going into that). Besides that, I'd think you wouldn't get paid for actually writing a script for a narc (however, maybe I'm wrong and the doc does get paid for "script padding"?) I'd imagine the biggest bang for your buck would be interventional; however, I suppose one could say that by also writing scripts for supplemental narcs on a monthly basis keeps the patient volume steady and high. My only beef with interventional + narcs is the patient population it tends to invite and carry around ... versus those who come simply for the injections (after having an MRI, having shown evidence of rehab, etc.)

 

[2win]

ok, ok, you're doing a great job underlining the title of this thread. you're one of the anesthesia guys who thinks pain is a bunch of BS.

i don't want this thread to turn into a discussion of the merits of pain management, that is a very complex and emotional discussion that i just don't have the energy to have at this time.

i must say, however, many things in medicine have NO long term data, i'll leave it at that.

Jeff - I am sorry that I deviated form your question. I am doing anesthesia and pain and I don't hate at all pain medicine - it is an amazing field.
Regarding the long term data - I am satisfied to obtain a temporary improvement in quality of life with an interventional procedure. The problem is that they don't last too long and a lot of them return to the narcotics. If you want to have a thriving practice I would say to do both - procedures and medication.

 

[IlDestriero]

Jeff - I am sorry that I deviated form your question. I am doing anesthesia and pain and I don't hate at all pain medicine - it is an amazing field.
Regarding the long term data - I am satisfied to obtain a temporary improvement in quality of life with an interventional procedure. The problem is that they don't last too long and a lot of them return to the narcotics. If you want to have a thriving practice I would say to do both - procedures and medication.

The problem with trying to dump med management back on the referring PCP is that one of the reasons that they sent the patient to you in the first place was to avoid med management. If you drop a few ESIs, facets, etc and make recs and send them back for management of his/her chronic pain, the next referral from that office will probably go to your competition across town.

 

[2win]

The problem with trying to dump med management back on the referring PCP is that one of the reasons that they sent the patient to you in the first place was to avoid med management. If you drop a few ESIs, facets, etc and make recs and send them back for management of his/her chronic pain, the next referral from that office will probably go to your competition across town.

A word of wisdom - finally. Again future pain docs or fellows - do not believe all the stupid fantasies about pain medicine getting you rich and fast...
You have to work hard, smart and humble.

 

[powermd]

2win is right. While writing only non-opiates may be something they are trying to hammer home in certain fellowhip programs, I want to see how many people can run a successful practice prescribing only lyrica, cymbalta, and effexor, and "educating" PCPs on opiate-writing practices. You are not going to have a very large practice for many years, especially if your competition is willing to take over the opiate managing duties.

A fellowship buddy of mine just started practice in Salt Lake City, and he uses a tri-lateral opiate agreement in which the PMD does the prescribing. Why? Because that's how they roll in SLC.

If you are still incredulous, PM tenesma and ask how he gets away with it. If you're a good pain doc in the right community, you can.

I agree that you will have a lot more patient referrals if you write narcotics- the practice I joined works this way. Guess what? We have a practice full of junkies with go-nowhere pain problems because the real problem none of the patients want to address is chemical coping/addiction. They sure get plenty of injections though... I'd lose my mind and quit if these folks accounted for >50% of the practice.

What I disagree with was 2win's stated logic equating a no-opioid pain doc with a no-opioid surgeon. Surgeon's create acute pain that deserves treatment with opioids. Pain docs do not.

 

[2win]

A fellowship buddy of mine just started practice in Salt Lake City, and he uses a tri-lateral opiate agreement in which the PMD does the prescribing. Why? Because that's how they roll in SLC.

If you are still incredulous, PM tenesma and ask how he gets away with it. If you're a good pain doc in the right community, you can.

I agree that you will have a lot more patient referrals if you write narcotics- the practice I joined works this way. Guess what? We have a practice full of junkies with go-nowhere pain problems because the real problem none of the patients want to address is chemical coping/addiction. They sure get plenty of injections though... I'd lose my mind and quit if these folks accounted for >50% of the practice.

What I disagree with was 2win's stated logic equating a no-opioid pain doc with a no-opioid surgeon. Surgeon's create acute pain that deserves treatment with opioids. Pain docs do not.

Powerdoc - it was my least intention to create a debate opioids practice versus non opioids...
There isn't a pain business without a complete treatment an this includes the freaking opioids. Tenesma is a great doc imo - and he's lucky (maybe she) if he(she) can have a successful practice WITHOUT to prescribe them...Look - if you're private if you wanna have a biz you have to prescribe them. How is it if you have a cancer patient and you don't prescribe opioids? Look to the previous posts - even in a stim trial you prescribe narcotics - don't you? I understand very well the desire to DON'T do it but doesn't work like that - by professional and moral standards.

"What I disagree with was 2win's stated logic equating a no-opioid pain doc with a no-opioid surgeon. Surgeon's create acute pain that deserves treatment with opioids. Pain docs do not."
No, no , no - I am sorry if I was misunderstood - I said that there is no complete practice of pain medicine without to treat with EVERY tool that you have the symptom (or the cause)...I know that there are practices that use only interventional pain and SOME drugs (but not narcotics). I know also that the docs chose to do that because of the headache associated with the narcotic prescription. And also I don't blame them at all - is their business and I congratulate them if they do good. My point is that for the new grads I will don't recommend to do that.
That's all ....
Salt Lake City - a special place. Cannot be compared with the rest of the USA. Although when you look at the USA narcotic map they don't stay very well either...For me was a surprise.

 

[powermd]

You sound angry. It's Friday, have a drink, relax.

PMR MSK doesn't prescribe opioids routinely either. I have no problem with prescribing opioids to, or recommending opioids for patients who I feel will do well on the therapy. This is a very small number of patients however.

One reason I like the idea of a no-opioid practice is that it eliminates the major dysfunction in the PMD-pain doc relationship. That dysfunction being "If you take over my annoying drug seekers and keep them quiet, I'll keep sending you patients you can pick over for injections." This creates a huge incentive to overprescribe opioids to bad candidates. If the PMD must continue prescribing, they will thank you for helping them stop opioids on patients for whom the drugs are inappropriate. This is basically what Tenesma does.

Powerdoc - it was my least intention to create a debate opioids practice versus non opioids...
There isn't a pain business without a complete treatment an this includes the freaking opioids. Tenesma is a great doc imo - and he's lucky (maybe she) if he(she) can have a successful practice WITHOUT to prescribe them...Look - if you're private if you wanna have a biz you have to prescribe them. How is it if you have a cancer patient and you don't prescribe opioids? Look to the previous posts - even in a stim trial you prescribe narcotics - don't you? I understand very well the desire to DON'T do it but doesn't work like that - by professional and moral standards.

"What I disagree with was 2win's stated logic equating a no-opioid pain doc with a no-opioid surgeon. Surgeon's create acute pain that deserves treatment with opioids. Pain docs do not."
No, no , no - I am sorry if I was misunderstood - I said that there is no complete practice of pain medicine without to treat with EVERY tool that you have the symptom (or the cause)...I know that there are practices that use only interventional pain and SOME drugs (but not narcotics). I know also that the docs chose to do that because of the headache associated with the narcotic prescription. And also I don't blame them at all - is their business and I congratulate them if they do good. My point is that for the new grads I will don't recommend to do that.
That's all ....
Salt Lake City - a special place. Cannot be compared with the rest of the USA. Although when you look at the USA narcotic map they don't stay very well either...For me was a surprise.

 

[2win]

You sound angry. It's Friday, have a drink, relax.

PMR MSK doesn't prescribe opioids routinely either. I have no problem with prescribing opioids to, or recommending opioids for patients who I feel will do well on the therapy. This is a very small number of patients however.

One reason I like the idea of a no-opioid practice is that it eliminates the major dysfunction in the PMD-pain doc relationship. That dysfunction being "If you take over my annoying drug seekers and keep them quiet, I'll keep sending you patients you can pick over for injections." This creates a huge incentive to overprescribe opioids to bad candidates. If the PMD must continue prescribing, they will thank you for helping them stop opioids on patients for whom the drugs are inappropriate. This is basically what Tenesma does.

1) ready for a drink - I would love to have one with you
2) Now you came up straight - ". I have no problem with prescribing opioids to, or recommending opioids for patients who I feel will do well on the therapy." This is what I said also.
I am on call buddy - and judging by the number of posts - it wasn't a busy one- so far - finger crossed...
Have a great weekend- stay close for the drink - is on me
2win

 

[InductionAgent]

i am just not sure why a specialty that is so marginalized and misunderstood by others (anesthesia) imparts the same treatment on its own members (just with more training).

I personally did not enjoy my pain rotations and had no desire to do pain medicine. However, I thought the pain faculty at my residency were solid physicians and anesthesiologists. They all spent time in the OR as well and were very good at regional anesthesia. Most of them, as well as our pain fellows, seemed very happy. So I am finding it difficult to feel very sympathetic toward you.

 

[Ligament]

The future is bleak for all physicians, not just pain. Thank you Obama and you Democrats out there!

 

[IN2B8R]

The future is bleak for all physicians, not just pain. Thank you Obama and you Democrats out there!

Pssst, Ligament: if you need another consultant in your little gig there, gimme a hollar 😉

 

[2win]

The future is bleak for all physicians, not just pain. Thank you Obama and you Democrats out there!

Right!!!
The future is bright for stupid organizations like JACHO and other "regulatory" boards.