Anxiety

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callmeanesthesia said:
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.
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Your PMR partner does only basic lumbar procedures and makes 7 figures? Do you make 8 figures as a full fledged pain doc? Can I join your practice?

There are definitely decent jobs out there in ortho groups for PMR to EMG, joint injections, and bread and butter lumbar procedures, but usually they make far less money than pain docs who offer all major pain procedures including the ones that pay well like SCS, kypho, etc.
Generally PMR docs in ortho groups doing only basic procedures are making 250-300K.
 
bedrock said:
Your PMR partner does only basic lumbar procedures and makes 7 figures? Do you make 8 figures as a full fledged pain doc? Can I join your practice?

There are definitely decent jobs out there in ortho groups for PMR to EMG, joint injections, and bread and butter lumbar procedures, but usually they make far less money than pain docs who offer all major pain procedures including the ones that pay well like SCS, kypho, etc.
Generally PMR docs in ortho groups doing only basic procedures are making 250-300K.
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Well, he’s got a 14 year head start on me. I’m just now starting to do kypho and stim trials in office - was doing them at an ASC I don’t own shares in yet. Still, it makes sense that if you only do lumbar procedures and can fill your schedule with them you would make more than a “real” pain doc. They are lower risk, faster, less technical, and reimburse almost exactly the same. He gets to dump all the CESIs on me. I could easily do a couple caudals and a couple lumbar RFs in the time it takes to do a stim implant (and I’m not slow at either), once you include turnover time.
 
Private_MD said:
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.
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I have the book for you!

And actually, the book for everyone on this thread.
It will help you with anxiety and help you treat your patients.

BACK IN CONTROL by David Hanscom. Check it out.
 
bedrock said:
If all those cases happened at one facility then I shudder for the poor people who live in your city and I shudder for all other terrible and preventable complications happening all over the country!
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This is a 12 room surgical facility that is very busy and has one satellite asc as well
 
Agast said:
Have you considered therapy and a trial of propranolol for performance anxiety?
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I have low blood pressure as it is, so passing out on a patient would be insult to injury. I also have IBS, sorry I know TMI, so things worsen when I get anxious. It's also been a very difficult and emotionally painful year for me, my husband left me, I'm doing fellowship in a different city where I don't know anyone, etc. So lots of non-medical issues going on at the same time too. I guess I will finish and go from there.
 
Private_MD said:
I have low blood pressure as it is, so passing out on a patient would be insult to injury. I also have IBS, sorry I know TMI, so things worsen when I get anxious. It's also been a very difficult and emotionally painful year for me, my husband left me, I'm doing fellowship in a different city where I don't know anyone, etc. So lots of non-medical issues going on at the same time too. I guess I will finish and go from there.
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You are stressed out. Just work hard at fellowship, keep plugging away at anatomy, fluoro anatomy. When life settles down a little you can shadow or go to courses and get whatever you need built up skill wise.
 
you might want to consider initially joining an academic practice, to give yourself more training opportunities and experience before striking out on your own...
 
Private_MD said:
I have low blood pressure as it is, so passing out on a patient would be insult to injury. I also have IBS, sorry I know TMI, so things worsen when I get anxious. It's also been a very difficult and emotionally painful year for me, my husband left me, I'm doing fellowship in a different city where I don't know anyone, etc. So lots of non-medical issues going on at the same time too. I guess I will finish and go from there.
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I’m sorry, that is a lot to go through in one year and it’s been a bad year with everything else as well. I would consider taking up needlepoint, crocheting or knitting. It will help with fine motor skills, comfort around needles, occupy your mind and many people find it very therapeutic. Plus the pride of accomplishment with creating something beautiful.
 
Agast said:
I’m sorry, that is a lot to go through in one year and it’s been a bad year with everything else as well. I would consider taking up needlepoint, crocheting or knitting. It will help with fine motor skills, comfort around needles, occupy your mind and many people find it very therapeutic. Plus the pride of accomplishment with creating something beautiful.
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Thank you. I decided ultimately to take a bit of a hybrid position - 3 days gen/med and 2 days procedural - more lumbar/joint/botox/regen. i think it will help w confidence building and until the dust settles a bit. i also have a business that has been more successful than expected as well, so have to deal with that too.

i think my hybrid position might be a big blessing - financially it is well compensated, and it will allow some confidence building as dust finishes settling.

thanks for all the advice guys and gals! 🙂 appreciated!
 
callmeanesthesia said:
Well, he’s got a 14 year head start on me. I’m just now starting to do kypho and stim trials in office - was doing them at an ASC I don’t own shares in yet. Still, it makes sense that if you only do lumbar procedures and can fill your schedule with them you would make more than a “real” pain doc. They are lower risk, faster, less technical, and reimburse almost exactly the same. He gets to dump all the CESIs on me. I could easily do a couple caudals and a couple lumbar RFs in the time it takes to do a stim implant (and I’m not slow at either), once you include turnover time.
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There is definitely some truth to that. Cervical ESI and RF takes more time than lumbar procedures yet only pays about 2% more. Depending on how you get paid it is also true that stim takes far longer than cranking out several simple lumbar procedures in the same amount of time.
 
Private_MD said:
Thank you. I decided ultimately to take a bit of a hybrid position - 3 days gen/med and 2 days procedural - more lumbar/joint/botox/regen. i think it will help w confidence building and until the dust settles a bit. i also have a business that has been more successful than expected as well, so have to deal with that too.

i think my hybrid position might be a big blessing - financially it is well compensated, and it will allow some confidence building as dust finishes settling.

thanks for all the advice guys and gals! 🙂 appreciated!
Click to expand...

Good luck.
 
Private_MD said:
Thank you. I decided ultimately to take a bit of a hybrid position - 3 days gen/med and 2 days procedural - more lumbar/joint/botox/regen. i think it will help w confidence building and until the dust settles a bit. i also have a business that has been more successful than expected as well, so have to deal with that too.

i think my hybrid position might be a big blessing - financially it is well compensated, and it will allow some confidence building as dust finishes settling.

thanks for all the advice guys and gals! 🙂 appreciated!
Click to expand...

Congratulations, wish you the best luck.
 
Sorry you've had such a bad year. I remember my fellowship being very stressful. Confidence takes time and I certainly didn't have a lot of it even by the end of fellowship. You learn and gain so much in the first few years out of training. Trust that it'll get better and many of these procedures will become second nature. Maybe get on lexapro or Zoloft and take a propranolol 10mg on your procedure days. It won't drop your blood pressure much if any. (try it at home first though)
 
Not sure why everyone prefers TFESI. An ILESI with depomedrol will last much longer than the 10 mg decadron in your TFESI. You don’t need contrast for your ILESI, and it’s much faster and less radiation than a TFESI.

Am I missing something?
 
1) Every master starts as a disaster. I think my first day in fluoro I backed into the mayo stand and my attending bit my head off 🙂

2) I don't do kypho, SCS, pumps. I did do some SCS trials early in practice but did not have the volume in my small town to do regularly. I stay plenty busy with bread and butter and lots of USGI's. Get your basic procedures down cold and go to some SIS courses. Better to do fewer procedures well than spread yourself thin. I decided very deliberately how I wanted my practice to be. Make it what you want.

3) There are safer ways to do each procedure. e.g. you can do cerv MBB posterior approach or lateral approach. One is much safer. On CESI hit bone first, mark your depth on the Touhey, then do CLO. Take your time. PM me and happy to give some pearls prn or answer questions
 
dipriMAN said:
Not sure why everyone prefers TFESI. An ILESI with depomedrol will last much longer than the 10 mg decadron in your TFESI. You don’t need contrast for your ILESI, and it’s much faster and less radiation than a TFESI.

Am I missing something?
Click to expand...
The literature.
 
specepic said:
1) Every master starts as a disaster. I think my first day in fluoro I backed into the mayo stand and my attending bit my head off 🙂

2) I don't do kypho, SCS, pumps. I did do some SCS trials early in practice but did not have the volume in my small town to do regularly. I stay plenty busy with bread and butter and lots of USGI's. Get your basic procedures down cold and go to some SIS courses. Better to do fewer procedures well than spread yourself thin. I decided very deliberately how I wanted my practice to be. Make it what you want.

3) There are safer ways to do each procedure. e.g. you can do cerv MBB posterior approach or lateral approach. One is much safer. On CESI hit bone first, mark your depth on the Touhey, then do CLO. Take your time. PM me and happy to give some pearls prn or answer questions
Click to expand...

haha i like this one! "every master starts as a disaster" i feel like i am constantly preoccupied all the time unfortunately - my former spouse did a number on a number of things, and the litigation is still ongoing - exhausting. now also comes board studying and a new level of stress. hopefully since they are oral boards it wont be too bad. i am hoping that in a number of months things will calm down, litigation will end, fellowship will be done, i'll be back home with loved ones, i'll have a nice job that will allow me to build up my skills, and things can hopefully calm themselves. i appreciate all the support guys!
 
dipriMAN said:
Not sure why everyone prefers TFESI. An ILESI with depomedrol will last much longer than the 10 mg decadron in your TFESI. You don’t need contrast for your ILESI, and it’s much faster and less radiation than a TFESI.

Am I missing something?
Click to expand...
Isn't it fraudulent to bill for a fluoro-guided ILESI if you don't use contrast, unless you document very clearly that the patient has a severe allergy to contrast? Also, why not use contrast? Admittedly, for lumbar ILESI, it's pretty rare that I think I'm in the epidural space and the contrast shows I'm not, but every so often I'm in a vein and none of the contrast stays in the epidural space (I don't use live fluoro routinely for ILESI - I only use live if after I inject contrast I don't see anything). I may be biased since I work in a city known for being particularly litigious, but from a CYA perspective I think it wouldn't be a good idea to not use contrast.

My 2 cents on ILESI vs. TFESI (anecdotal) - my experience is pretty consistent with the literature. Usually, I do TFESI with dex for discs and foraminal stenosis (unless terribly severe and I think it would be too painful or impossible to access the foramen) and ILESI with particulate for canal stenosis. All I know is that when I do a TFESI, if it doesn't work, I try an ILESI, and vice versa. Typically, if the first injection doesn't help significantly, the second one doesn't either. Sure, I have a handful of cases where a TEFSI didn't help but an ILESI does, but those are relatively few and far between.
 
MD87 said:
Isn't it fraudulent to bill for a fluoro-guided ILESI if you don't use contrast, unless you document very clearly that the patient has a severe allergy to contrast? Also, why not use contrast? Admittedly, for lumbar ILESI, it's pretty rare that I think I'm in the epidural space and the contrast shows I'm not, but every so often I'm in a vein and none of the contrast stays in the epidural space (I don't use live fluoro routinely for ILESI - I only use live if after I inject contrast I don't see anything). I may be biased since I work in a city known for being particularly litigious, but from a CYA perspective I think it wouldn't be a good idea to not use contrast.

My 2 cents on ILESI vs. TFESI (anecdotal) - my experience is pretty consistent with the literature. Usually, I do TFESI with dex for discs and foraminal stenosis (unless terribly severe and I think it would be too painful or impossible to access the foramen) and ILESI with particulate for canal stenosis. All I know is that when I do a TFESI, if it doesn't work, I try an ILESI, and vice versa. Typically, if the first injection doesn't help significantly, the second one doesn't either. Sure, I have a handful of cases where a TEFSI didn't help but an ILESI does, but those are relatively few and far between.
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Why would it be fraudulent to not use contrast for ILESI, the Fluoro is bundled in the code anyway, you still used an image showing fluoro guidance to direct the needle. It’s analogous to not using contrast for an MBB, can’t do an MBB without fluoro.
 
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dipriMAN said:
Why would it be fraudulent to not use contrast for ILESI, the Fluoro is bundled in the code anyway, you saved an image showing fluoro guidance to direct the needle. It’s analogous to not using contrast for an MBB, can’t do an MBB without fluoro.
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“Contrast is just a crutch. You don’t need it and costs too much.”

My first boss. I put in notice after only 6 months.

Contrast proves you are in the epidural space.
Contrast proves you are not in a.........
Vein
Artery
Disc
Thecal sac
Ligament
Paraspinal muscle

Don’t be this guy:

DD52300C-BB13-43E4-B57A-F9CEF0F8B86E.jpeg
2842F5E6-C29C-450C-ABA7-BEC86C619BBF.jpeg
 
Every insurance likely has different definitions. I don't know about you, but I can't keep all of their different protocols straight. I quickly did a google search, and Evicore defines an ILESI as:
Interlaminar epidural steroid injection (ILESI) is an injection of contrast (absent allergy to contrast), followed by the introduction of a corticosteroid and possibly a local anesthetic into the epidural space of the spine either through a paramedian or midline interlaminar approach under fluoroscopic guidance.
So, if you aren't injecting contrast (in the absence of an allergy) you aren't doing what they are paying you to do. Aside from the potentially fraudulent aspect of things, contrast is also fairly universally considered to be standard of care for these injections.
 
lobelsteve said:
“Contrast is just a crutch. You don’t need it and costs too much.”

My first boss. I put in notice after only 6 months.

Contrast proves you are in the epidural space.
Contrast proves you are not in a.........
Vein
Artery
Disc
Thecal sac
Ligament
Paraspinal muscle

Don’t be this guy:

View attachment 319658View attachment 319659
Click to expand...
Ha! What is the story behind this MRI?
 
lobelsteve said:
The literature.
Click to expand...

The literature has only been done on ACUTE lumbar disc hernations. In that specific diagnosis/procedure, which represents less than 10% of my lumbar epidurals, I agree that a TFESI with dex has more literature support than ILESI with depo.

There is no good literature on recurrent lumbar radiculopathy from small/recurrent disc bulges and no good literature on lumbar stenosis. Anecdotally, I think ILESI with depo or S1 TFESI with depo lasts far longer in these patients (lumbar stenosis and recurrent lumbar radiculopathy represent 90% of the diagnoses for which most of us perform lumbar epidurals as a pain physician) .
I can't tell you how many hundreds of unnecessary surgeries I've prevented by not just doing TFESI with dex like a robot. It actually annoyed the first orthopedic group I worked with, because they suddenly had so many less operations to do, because I didn't do things like the other pain physicians they had worked with previously.

The pathophysiology of stenosis is not the same as acute radiculopathy and it is narrow minded to think that we can apply the results from studies on a small subset of patients and think it applies to all of them.
 
lobelsteve said:
The literature.
Click to expand...
That's weird, when I look the reviews suggest no statistically significant long term difference in outcomes between the two. They're possibly better for acute radics and short term efficacy but I don't push to do them.

Europe PMC

Europe PMC is an archive of life sciences journal literature.
europepmc.org europepmc.org

If they removed the financial incentive for multilevel or bilateral TF approaches, I would expect people would do more ILESIs with the same general outcomes
 
bedrock said:
The literature has only been done on ACUTE lumbar disc hernations. In that specific diagnosis/procedure, which represents less than 10% of my lumbar epidurals, I agree that a TFESI with dex has more literature support than ILESI with depo.

There is no good literature on recurrent lumbar radiculopathy from small/recurrent disc bulges and no good literature on lumbar stenosis. Anecdotally, I think ILESI with depo or S1 TFESI with depo lasts far longer in these patients (lumbar stenosis and recurrent lumbar radiculopathy represent 90% of the diagnoses for which most of us perform lumbar epidurals as a pain physician) .
I can't tell you how many hundreds of unnecessary surgeries I've prevented by not just doing TFESI with dex like a robot. It actually annoyed the first orthopedic group I worked with, because they suddenly had so many less operations to do, because I didn't do things like the other pain physicians they had worked with previously.

The pathophysiology of stenosis is not the same as acute radiculopathy and it is narrow minded to think that we can apply the results from studies on a small subset of patients and think it applies to all of them.
Click to expand...

So just do what you do cuz it works for you. Nonscience. And clearly doing way too many ESIs.
 
Why is that image taken, and when?
 
dipriMAN said:
Not sure why everyone prefers TFESI. An ILESI with depomedrol will last much longer than the 10 mg decadron in your TFESI. You don’t need contrast for your ILESI, and it’s much faster and less radiation than a TFESI.

Am I missing something?
Click to expand...
Why are you doing fluoride guided ILESI without contrast? What’s the point?
 
MD87 said:
Every insurance likely has different definitions. I don't know about you, but I can't keep all of their different protocols straight. I quickly did a google search, and Evicore defines an ILESI as:
Interlaminar epidural steroid injection (ILESI) is an injection of contrast (absent allergy to contrast), followed by the introduction of a corticosteroid and possibly a local anesthetic into the epidural space of the spine either through a paramedian or midline interlaminar approach under fluoroscopic guidance.
So, if you aren't injecting contrast (in the absence of an allergy) you aren't doing what they are paying you to do. Aside from the potentially fraudulent aspect of things, contrast is also fairly universally considered to be standard of care for these injections.
Click to expand...
from the evicore guidelines
62323
Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (i.e., fluoroscopy or CT)
 
lobelsteve said:
New patient. Worse back pain after esi 1 week prior at other docs. Got mri to rule out infection/hematoma and found the med collected in a ball/cyst outside flavum at L4-5.
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What did you tell the patient
 
lobelsteve said:
So just do what you do cuz it works for you. Nonscience. And clearly doing way too many ESIs.
Click to expand...

I was discussing ESI for radiculopathy and spinal stenosis, not axial pain.

From where exactly do you infer that I’m doing too many ESI?

Because I’m doing enough to prevent/delay spine surgery?
 
lobelsteve said:
90% of your esi are not for acute radic from hnp. Not good support in the literature for whom you are injecting.
Click to expand...

You don't perform epidurals for lumbar stenosis?

All the sweet old ladies in their 80s with an L4-L5 spondylolisthesis and leg pain preventing them from walking in the park with their grandkids, you just tell them to suck it up or have an L4-L5 PLIF at age 85?

Really excellent literature support for that approach....
 
lobelsteve said:
90% of your esi are not for acute radic from hnp. Not good support in the literature for whom you are injecting.
Click to expand...
What do you do for your chronic radic people from facet hypertrophy / osteophytes / disc bulg / formainal stenosis etc.
 
ED50 said:
You are using topamax for elderly patients with neuropathic pain? Curious what your dosing and success looks like?
Click to expand...

25 bid, increase to 50 bid after a week if needed. I have younger folks go to 100 bid if no side effects.

pubmed.ncbi.nlm.nih.gov

Topiramate in chronic lumbar radicular pain - PubMed

The anticonvulsant topiramate might reduce chronic lumbar nerve root pain through effects such as blockade of voltage-gated sodium channels and AMPA/kainite glutamate receptors, modulation of voltage-gated calcium channels, and gamma-aminobutyric acid agonist-like effects.
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov

pubmed.ncbi.nlm.nih.gov

The rationale and use of topiramate for treating neuropathic pain - PubMed

Topiramate acts on neuronal transmission in at least five ways: by modulating voltage-gated sodium ion channels, potentiating gamma-aminobutyric acid inhibition, blocking excitatory glutamate neurotransmission, modulating voltage-gated calcium ion channels, and by inhibiting carbonic anhydrase...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov
 
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