Anxiety

[Private_MD]

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I am completing a pain fellowship. I have some anxiety about some procedures and some i have decided altogether I don't think I will do - ever (examples - SCS, discectomies, etc).
I am interested in potentially doing more MSK type stuff vs spine - potentially fluoro guided large joints, a model which I have seen work very well by some groups.
Thoughts? Am I lame? I am having anxiety in terms of doing spine on my own when i'm done.

 

[thiswonthurtabit]

IMO anxiety is normal and natural. If you're able to adjust your practice so that you don't have to do the procedures that produce that anxiety you'll be a lot happier and healthier in the long run.

 

[lobelsteve]

I have anxiety doing SCS, kypho, and CESI.

If I did not, I wouldn't bother doing the procedure and would not be where I am currently.

These are scary procedures with potentially catastrophic outcomes. Take them seriously, know your anatomy.

Finished fellowship in 2005. Have done over 30,000 procedures since.

 

[Private_MD]

I have anxiety doing SCS, kypho, and CESI.

If I did not, I wouldn't bother doing the procedure and would not be where I am currently.

These are scary procedures with potentially catastrophic outcomes. Take them seriously, know your anatomy.

Finished fellowship in 2005. Have done over 30,000 procedures since.

Yeah some of them i dont think they are worth the risk - exactly because as you mention they can be catastrophic. i've heard of some really bad outcomes by various really good docs - and i'm nowhere near that level of skill - so it terrifies me.
one of my attendings recently told me how one of his atetndings with 30 years experience accidentally tore up the spine of a patient with CESI and patient either died or is paraplegic i forget. another one apparently had serious numbness and pain after epidural, etc

i'm like crap.

 

[clubdeac]

Yeah some of them i dont think they are worth the risk - exactly because as you mention they can be catastrophic. i've heard of some really bad outcomes by various really good docs - and i'm nowhere near that level of skill - so it terrifies me.
one of my attendings recently told me how one of his atetndings with 30 years experience accidentally tore up the spine of a patient with CESI and patient either died or is paraplegic i forget. another one apparently had serious numbness and pain after epidural, etc

i'm like crap.

I'm thinking the patient must've been sedated. I don't think you can "tear up a spine" in an awake patient. Anxiety though is normal. Like Steve, I have anxiety with all of those procedures and I've been doing this for 10 years. Plus I'm really good 😉

 

[Private_MD]

I'm thinking the patient must've been sedated. I don't think you can "tear up a spine" in an awake patient. Anxiety though is normal. Like Steve, I have anxiety with all of those procedures and I've been doing this for 10 years. Plus I'm really good 😉

Sometimes I wonder if I should have done a fellowship. So anxious. I'm sure you are.

 

[BobBarker]

You don’t have to do them. If you are pm&r, you can do a bunch of different minor injections and EMG’s as part of a ortho group and have a great career.

 

[Private_MD]

You don’t have to do them. If you are pm&r, you can do a bunch of different minor injections and EMG’s as part of a ortho group and have a great career.

Yeah but I feel I wasted a bunch of time and a whole year - a number of my attendings are actually dedicated and care about education - i would feel very stupid being like oh yeah never mind i'm going to inject knees and hips for the rest of my career (which actually i'm ok with!)

 

[hyperalgesia]

Yeah but I feel I wasted a bunch of time and a whole year - a number of my attendings are actually dedicated and care about education - i would feel very stupid being like oh yeah never mind i'm going to inject knees and hips for the rest of my career (which actually i'm ok with!)

You are better able to educate patients and perform even the procedures you will be doing. How much time do we waste in our 25 years of education? A lot more than one year!

On a side note, there is such a thing as "overly anxious". All procedures have risks, including knee and hip injections. The only way to avoid risk, is to do nothing. So there is a balance.

 

[SSdoc33]

Yeah but I feel I wasted a bunch of time and a whole year - a number of my attendings are actually dedicated and care about education - i would feel very stupid being like oh yeah never mind i'm going to inject knees and hips for the rest of my career (which actually i'm ok with!)

so you didnt know how something would be before you did it? nothing to be ashamed of. now you know. there are plenty of docs out there doing procedures they have no business doing.

i still cringe when i see all the CESIs on my schedule. hate them. done probably over 1500 of them but still hate them.

as a side note, although large joints dont pay all that well, you can do a lot of more of them in a similar time period. it could work, but i wouldnt plan a career around it.

 

[clubdeac]

so you didnt know how something would be before you did it? nothing to be ashamed of. now you know. there are plenty of docs out there doing procedures they have no business doing.

i still cringe when i see all the CESIs on my schedule. hate them. done probably over 1500 of them but still hate them.

as a side note, although large joints dont pay all that well, you can do a lot of more of them in a similar time period. it could work, but i wouldnt plan a career around it.

sadly a CESI doesn't pay all that much more than a large joint injection

 

[DOctorJay]

I commend you for recognizing this about yourself. There's no reason to do anything you don't want to do or aren't comfortable with for the rest of your career. I agree these procedures still provoke some anxiety for me 7 years into practice without any major complications. I think if you aren't nervous about them it's time to give them up before you harm someone.

There are plenty of physiatrists out there working in ortho groups doing only lumbar spine procedures along with joints and they send cervical stuff elsewhere. Do what you want!

 

[PainRehabMD]

I know docs who are not doing any procedures after completing a pain fellowship. The fellowship should have also trained you on how to better diagnose your patients and decide which procedures would be appropriate even if you're not the one doing them. It's entirely up to you what you want to do.

 

[SommeRiver]

There are a lot of procedures that you can do comfortably without subjecting yourself and the pt to a ton of risk.

TBH, you can do all clinic and send your shots to someone and be busy all day...You may not get the same bonuses as those doctors and you won't make as much money, but you can justify your salary and place in the world with a nonoperative and minimal procedure practice.

 

[Private_MD]

I commend you for recognizing this about yourself. There's no reason to do anything you don't want to do or aren't comfortable with for the rest of your career. I agree these procedures still provoke some anxiety for me 7 years into practice without any major complications. I think if you aren't nervous about them it's time to give them up before you harm someone.

There are plenty of physiatrists out there working in ortho groups doing only lumbar spine procedures along with joints and they send cervical stuff elsewhere. Do what you want!

Yeah this is something I would consider - lumbar I think I am ok with for the most part minus SCS - cervical gives me the creeps

 

[Laryngospasm]

Certain procedures are simply not worth the anxiety and risk for what they pay. There are some guys that love that stuff so I send it to them. No harm in that. I simply don’t do cervical discography or tfesi for those reasons.

 

[Orin]

Fear is the mindkiller.

It's okay to bow out if you are not comfortable with X/Y/Z. Pain medicine allows you to build your practice in a way that you're comfortable with, but not all paths are remunerated as well as others.

I agree though, anxiety lets you know you're at the edge of your comfort zone. That allows you to grow. If you can't imagine growing into a specific procedure without supervision, then reconsider your trajectory/practice parameters, or figure out how you can have supervision/backup nearby.

 

[Private_MD]

It's okay to bow out if you are not comfortable with X/Y/Z. Pain medicine allows you to build your practice in a way that you're comfortable with, but not all paths are remunerated as well as others.

I agree though, anxiety lets you know you're at the edge of your comfort zone. That allows you to grow. If you can't imagine growing into a specific procedure without supervision, then reconsider your trajectory/practice parameters, or

Fear is the mindkiller.

It's okay to bow out if you are not comfortable with X/Y/Z. Pain medicine allows you to build your practice in a way that you're comfortable with, but not all paths are remunerated as well as others.

I agree though, anxiety lets you know you're at the edge of your comfort zone. That allows you to grow. If you can't imagine growing into a specific procedure without supervision, then reconsider your trajectory/practice parameters, or figure out how you can have supervision/backup nearby.

Well I do know a number of attendings that have built extremely profitable practices with just bread and butter - ESI, MBB, RFA, etc etc. No high level stuff. I don't want to stroke out every time I'm going to do a procedure though.

 

[pain_doc_]

I hope that things get better for you after fellowship. I know they did for me. A lot of it depends on the environment you trained in. Who knows, you may grow into enjoying more procedures than you would think! Takes time.

 

[MD87]

In fellowship, whenever a patient had a lumbar TFESI, it was a 2-level TFESI. For every 1 patient who got an ILESI, 8 or 9 got TFESI. As a result, I felt confident in TFESI, but lumbar ILESI made me anxious when I graduated. Initially, I scheduled a lot of my patients for TFESI rather than ILESI. As I became more comfortable, I started scheduling more ILESI. Now, I'm 2 years out, and ILESI are my favorite procedure because they are quick, easy, and you pretty much always get great contrast flow.

I echo what everyone is saying. Anxiety is normal, especially when you are first starting, but even later on. If the anxiety becomes a major point of stress for you and doesn't decrease over time, then it may be worthwhile sending those procedures elsewhere. Some of the anxiety will decrease as your procedure volume increases. Anxiety means you likely won't hurt a patient. Being overly confident at this point in your training would be a problem.

 

[Private_MD]

In fellowship, whenever a patient had a lumbar TFESI, it was a 2-level TFESI. For every 1 patient who got an ILESI, 8 or 9 got TFESI. As a result, I felt confident in TFESI, but lumbar ILESI made me anxious when I graduated. Initially, I scheduled a lot of my patients for TFESI rather than ILESI. As I became more comfortable, I started scheduling more ILESI. Now, I'm 2 years out, and ILESI are my favorite procedure because they are quick, easy, and you pretty much always get great contrast flow.

I echo what everyone is saying. Anxiety is normal, especially when you are first starting, but even later on. If the anxiety becomes a major point of stress for you and doesn't decrease over time, then it may be worthwhile sending those procedures elsewhere. Some of the anxiety will decrease as your procedure volume increases. Anxiety means you likely won't hurt a patient. Being overly confident at this point in your training would be a problem.

I actually like ILESI! TFESI those are challenging

 

[jsaul]

a neurosurgeon who has been doing pain procedures for 20 plus years had last year one cervical esi that resulted in a cord injection. and had one cervical tf esi that had cord injury when he went too medial.

another neurosurgeon who has been doing pain for 4 years now RF'ed a lumbar spinal nerve pretty good this year;

a non fellowship trained anesthesia doc who had a cord infarct from cervical esi procedure this year and last year had PTX from a thoracic RF and 2-3 years ago had a patient brown sequard after a cervical procedure

a fellowship trained pain doc last year inadvertently inject cement into spinal canal ; had vertiflex misadventure this year

 

[Ferrismonk]

It's completely normal to have some anxiety, especially right after residency, but don't let that paralyze you. I still stay that every grey hair I have is because of a CESI.

If I had to guess, you feel more comfortable with joints and ILESI because you've mostly done those. Bigger things will give you less anxiety when you've done more of them, especially out in the real world. During training, I only did one TFESI, now I do mostly TFESI. I only did one hip injection, but now it's a piece of cake. I've discovered that I love the challenge of stim, but I don't like the operative part so I don't do my own implants anymore. Not a big deal.

However, as others have said, you're options are wide open when you graduate and your fellowship won't be wasted. There are a ton of jobs out there for people who just want to do office, inpatient rounding, simple joints, and lumbar procedures. They're usually the larger PMR groups or attached to Ortho. No shame in that if that's what you like. I know several groups who like hiring those docs, just don't expect to be paid the same.

 

[Ferrismonk]

And yes, most of the bad outcomes you have seen are probably from those who either oversedated their patients, didn't know what the hell they were doing (happens a LOT more than you'd imagine), or just got sloppy.

Also, learn what is not appropriate. Discograms are no longer indicated. Cervical TFESI not indicated. Do most procedures with no sedation. Use small needles and inject slowly. There is no way my 25G quinke advanced under CLO with clear contrast in and out of the epidural space with saline and dex only is going to "tear up the spine". The 18G touhy hanging drop CESI in office with no flouro injecting local and depo I saw while a rotating medical student, maybe.

 

[Aether2000]

There are many procedures that have inherently high risk, but you probably never saw or heard of them in your pain fellowship: neurolytic spinal blocks, neurolytic epidurals, cordotomy, and several others of that ilk. SCS does have some risk associated, but using some risk avoidance techniques (saline for the LOR, always enter the epidural space below L2 for thoracic lead placement, slow advancement) these are commonly performed procedures with relatively few disastrous outcomes. As with any procedure, the more you do, the more tricks you learn, and the more comfortable you become. Intracordal injection of even tiny amounts of liquid of any kind can cause catastrophic results, but using the CLO technique makes it extremely unlikely you will ever enter the cord. Check out the advanced courses of SIS or some of the ASIPP courses for lots of pearls.

 

[au bon pain]

SCS does have some risk associated, but using some risk avoidance techniques (saline for the LOR, always enter the epidural space below L2 for thoracic lead placement, slow advancement) these are commonly performed procedures with relatively few disastrous outcomes.

Can you explain saline for LOR for scs? I'm being taught air for LOR is preferred for this to not impact electrode impedance and better detect any whisp of csf.

 

[Agast]

Just summon up the confidence of a CRNA who has done two proctored injections and wrote an essay about it and is now ready to move on to the real world unsupervised

 

[epidural man]

Couple of comments about some things mentioned above - sorry didn’t multiquote.
I know everyone is going Gaga on this board about 25gauge cutting needle in the cervical spine - but I don’t think there is any evidence this is safer, and I just can’t imagine that it is. I think a large, dull scooped needle (18guage tuohy) is safer. I can do the same CLO approach, but in a space where often there is no space, I just can’t see why a very small, piercing, cutting needle is better.

Next - those mentioning cervical injury - were those from needle piercing the cord or from particulate steroid?

Finally - there is saline everywhere in the body. The epidural space isn’t dry. Not sure why people are against LOR with saline. Plus, the lead is a long way from entry. I like saline for LOR.

 

[Laradd]

I know how Anxiety sucks to get along with things but I'm hoping that you'll do better.

 

[Ducttape]

your anxiety level will rise the closer you get to the day you actually are on your own.

if you were not anxious, even with your first trigger point injection, then you didn't learn anything in fellowship.

but anxiety will decrease as you become familiar with doing these procedures on your own. and there will always be procedures that you will be anxious about, no matter how many times you do them (see algosdoc's note above)


---------------
one thing that can help, if you aren't doing them - see if your attendings can go through some mock injection disaster situations, with a stimulator, such as a LA OD or some other injection complication.

they are fun and terrifying and can reinforce that you know what to do in case of an emergency...

 

[paindoctor2014]

I used to use saline for LOR. Switched to air. Don’t like not knowing if there is a possible csf puncture.

 

[Baron Samedi]

Lots of strategies you can use to mitigate risk in pain procedures:

- Early on schedule longer procedure slots so you don't feel rushed
- Use multiple views to ensure the correct needle placement
- Avoid sedating patients
- Counsel patients if they get parasthesias that they need to tell you
- Avoid using particulate steroids
- Don't do cervical transforaminals
- Avoid putting LA in the cervical spine
- Early lateral view to confirm depth
- Check placement with contrast to ensure yourself even if you know you're posterior
- If the view or contrast spread is questionable, don't inject
- Review imaging prior to procedure, measure depth to epidural space to get an idea of where LOR should be
- In older/sicker patients look for a recent platelet count/coag panel
- Avoid doing procedures in patients who are unlikely to benefit from them

And most importantly:
- Remember that every aspect of Pain Management is elective care and that any procedure or treatment plan can be aborted at any time

 

[Baron Samedi]

Risk of pneumocephalus with air LOR.

I use air because I always make a mess with the saline and I know the feel of it better.

 

[Orin]

Anxiety isn't the problem as much as it is the reaction to it.

Do you get panicked?
Do you start making bad decisions/movements?
Does the patient/team notice?
Will you quit after one bad outcome?

I would counsel some CBT/therapy while you're still malleable. Fear really screws you up and even doing safe things, bad stuff happens.

 

[SommeRiver]

I don’t use LOR (air or saline) during SCS.

 

[callmeanesthesia]

Back to the OPs original question, yes you can build a practice doing low risk procedures. I have a PMR partner who does only lumbar procedures - SI, ESI, MBB/RF. Doesn’t even do interlam ESI, and rakes in 7 figures. But you will need somewhere to send those procedures you aren’t comfortable doing.

 

[thiswonthurtabit]

I commend you for recognizing this about yourself. There's no reason to do anything you don't want to do or aren't comfortable with for the rest of your career. I agree these procedures still provoke some anxiety for me 7 years into practice without any major complications. I think if you aren't nervous about them it's time to give them up before you harm someone.

There are plenty of physiatrists out there working in ortho groups doing only lumbar spine procedures along with joints and they send cervical stuff elsewhere. Do what you want!

How does one track down a gig like this? Where I'm working now I don't really feel like I have any control over what I offer and there are some procedures (like CESI) that give me so much anxiety sometimes I think I'd be better off just being an uber driver or something and not worrying about the risks and liabilities.

 

[DOctorJay]

one of our competing networks is like this. they have an interventional spine group that doesn't do anything cervical. they don't do stims either. usually these are jobs associated with ortho groups so they're out there you just have to search.

 

[thiswonthurtabit]

I actually like ILESI! TFESI those are challenging

Interesting, I'm the exact opposite. I probably did 250-300 TFESI in fellowship as opposed to ~10 lumbar ILESI. I feel way more comfortable with needle placement and contrast spread etc with TFESI than ILESI.

On that subject does anyone have a good place improving knowledge about interlaminar contrast spreads? I want to look at a few hundred pictures of various spreads (epidural, subdural, etc) to improve my recognition.

 

[Orin]

I don’t use LOR (air or saline) during SCS.

LOR to the lead, keep it simple.

 

[lobelsteve]

LOR to air, but often in lateral view so when I insert lead I can see it curl posteriorly before going AP to run it up.

 

[Private_MD]

Anxiety isn't the problem as much as it is the reaction to it.

Do you get panicked?
Do you start making bad decisions/movements?
Does the patient/team notice?
Will you quit after one bad outcome?

I would counsel some CBT/therapy while you're still malleable. Fear really screws you up and even doing safe things, bad stuff happens.

Yes I panic, and yes if i had a really bad outcome I'd definitely quit. To be honest, if I could find a gig doing lumbar stuff I'd be happy as a clam. Right now i have an offer that involves some rehab, that is really well paid, very close to where i'm at geographically and in an area that is saturated, with a potential for a med directorship in the near future, where i can work 4 or so days a week and thinking of finding a growing group that wants me 1-2 days a week where i can maybe do mostly lumbar and peripheral. i think that would be a good thing. i dont want to do stims, pumps, or risky cervical stuff

 

[SommeRiver]

I use the lead in CLO with a flat trajectory.

OP, there are tons of jobs out there...You can do only lumbar if you want, and only RFA or epidurals if that's what you want to do.

 

[Private_MD]

I use the lead in CLO with a flat trajectory.

OP, there are tons of jobs out there...You can do only lumbar if you want, and only RFA or epidurals if that's what you want to do.

Thank you. Yeah I think I will likely focus on that. I think I would be too anxious to do high end stuff. Thanks for the advice all!
Very helpful! 🙂

 

[Ronin1]

Most of your anxiety is probably due to lack of volume. I’m sure most anesthesia trained guys have little to no anxiety with epidural injections due to pre fellowship experience. But in any event you can dictate how your practice will develop. Just don’t tell you’re potential employers/partners that you can do everything then change it up when you get there.

 

[Orin]

Yes I panic, and yes if i had a really bad outcome I'd definitely quit.

I'm not okay with that. I would really ask you to address that with some therapy or talk to your mentors about how to handle that.
Even doing easy/safe stuff, bad things happen. It's just probability.

 

[Private_MD]

I'm not okay with that. I would really ask you to address that with some therapy or talk to your mentors about how to handle that.
Even doing easy/safe stuff, bad things happen. It's just probability.

Yes but if I hit someone's cervical cord and they become a quad, it's very different than if maybe i cause some paresthesias from hitting a nerve in the lumbar spine or something. So "bad things happen' but some are catastrophic.

 

[BobBarker]

Anesthesia guys have less anxiety due to the other anesthesia procedures. I intubated a 300lb man who was dying of hypovolemic shock my first night on call as an intern. I think it was July 3rd.

also, lining out a patient as they exsanguinate, caring for a baby during surgery, etc.

 

[bedrock]

a neurosurgeon who has been doing pain procedures for 20 plus years had last year one cervical esi that resulted in a cord injection. and had one cervical tf esi that had cord injury when he went too medial.

another neurosurgeon who has been doing pain for 4 years now RF'ed a lumbar spinal nerve pretty good this year;

a non fellowship trained anesthesia doc who had a cord infarct from cervical esi procedure this year and last year had PTX from a thoracic RF and 2-3 years ago had a patient brown sequard after a cervical procedure

a fellowship trained pain doc last year inadvertently inject cement into spinal canal ; had vertiflex misadventure this year

Damn. Where you hear/learn about all these bad pain procedural outcomes?

 

[au bon pain]

Yes but if I hit someone's cervical cord and they become a quad, it's very different than if maybe i cause some paresthesias from hitting a nerve in the lumbar spine or something. So "bad things happen' but some are catastrophic.

Yup this is an important distinction. Nobody can really know how they'll react unless they're unfortunate/unlucky enough to be the doc in such a case.

I don't think it's uncommon for a diligent doc to be very aware of the worst possible outcomes from a procedure. Definitely use it as a protective mechanism to keep patients safe. At the same time, consider how often these concerning thoughts actually come to fruition. Look up some adverse event stats to help frame your concerns. There's a paper on AEs from 10,000 epidurals from Manchikanti. IIRC, no major AEs. That's not to say that data is the final word, but if it's anywhere close to reality then it's unlikely anything super bad will happen in your career from the bread and butter procedures. And while our procedures are elective, many patient would turn to surgery if they didn't exist...and pain procedure AE rates are nothing compared to spine surgery AE rates.