Anyone seen primarily pain with anesthesia on the side type of practice?

[cluelessmedstudent411]

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Curious about the feasibility of having a pain/anesthesia combo practice. I really enjoy aspects of anesthesia and have spent significant time/effort developing my skills/knowledge. I would love to continue to keep up with it. I was thinking something along the lines of 4 day pain/1-2 days anesthesia. I don't mind doing anesthesia over the weekend occasionally.

I understand that the cost here is possibly reduced revenue but if I was willing to accept that, is this possible? Have you seen anyone do it? What are the other downside Im not thinking of?

I have seen this in academia but never heard of it in PP.

 

[TIVAndy]

academics or kaiser.

 

[willabeast]

I did it for a long time. Gradually gave up the O.R., it was too difficult to keep up after 15 years. First years are easy but eventually you lose touch.

 

[cluelessmedstudent411]

I did it for a long time. Gradually gave up the O.R., it was too difficult to keep up after 15 years. First years are easy but eventually you lose touch.

How was your practice set up to manage this? Did you practice anesthesia in a hospital or surgery center?

 

[afob100]

It would be really easy to do full time pain during the week and moonlight/locums on the weekend (most/all anesthesia groups would be happy to have someone work their weekends). I moonlight 1 Saturday every 2-3 months at the hospital where I moonlit during fellowship...just to keep some anesthesia skills and in case covid worsens/shuts down my pain practice -> nice fall back to have. It would be easy to pick up more weekend shifts if I wanted to.

Outside of academics/kaiser, it would probably be very challenging to do both. One thing you could do is to just have 2 separate jobs. Find a 4 day a week pain job (I have seen 10 hr, 4 days a week full time pain jobs) and then locums on your day off.

Personally, it doesn't seem worth it, but then again I don't like OR anesthesia.

 

[willabeast]

How was your practice set up to manage this? Did you practice anesthesia in a hospital or surgery center?

Did OR anesthesia hospital or surgery center at first whenever not in pain clinic. Decided not to take call at night/weekends for anesthesia (easy to justify because i was always on call for pain and lots of docs wanted to take OR call as it is lucrative). After about 6 months was doing OR anesthesia once a week. After about ? 10 years once a month. This did not work well as i would miss department meetings and inservice on OR equipment. Then an odd thing happened. Chief of anesthesia wants me to take call at night. I had not taken OR anesthesia call for >15 years. He said it was not negotiable. So i gave up my OR anesthesia hospital privileges after 7 days of stressing about doing so. After i made my decision i felt it was a good one. In the meantime i was now in a PM and R department with a new chief and i was the only anesthesiologist. The chief did not want me taking PMR call. So i wound up working 5 days a week doing mostly spine in a PMR setting with no nights and no weekends and no call. Which was nice. And that is how it remained until i retired. It all worked out for me but i cannot stress how difficult it is to keep up in two specialties after 15 years or so in practice. It is easy first few years. Then it gets harder and harder.

 

[Asclepius186]

Have known several who did part time anesthesia and all of them except one gave it up to do only pain after a few years

 

[Ferrismonk]

I currently do both in private practice, but it's an unusual situation. In my experience, those who do both tend to either phase out anesthesia over time when they get sick of call, or they phase out pain when they get sick of insurance/authorizations/red tape.

In my experience, it is actually difficult to do full time pain with only weekend anesthesia. Most groups were not interested in basically a locum guy taking call who was not part of the group.

 

[Orin]

Yeah, it's a fun way to split it up but you're losing money/efficiency/skills as they're very different.

Academics or managed care settings like Kaiser or the VA are feasible options.
You could do anesthesia and acute pain/blocks easier in PP
You could do anesthesia and staff an inpatient pain service in a hospital affiliated practice

 

[cluelessmedstudent411]

I currently do both in private practice, but it's an unusual situation. In my experience, those who do both tend to either phase out anesthesia over time when they get sick of call, or they phase out pain when they get sick of insurance/authorizations/red tape.

In my experience, it is actually difficult to do full time pain with only weekend anesthesia. Most groups were not interested in basically a locum guy taking call who was not part of the group.

How do you split up your time?

 

[epidural man]

As mentioned, most give up one or the other.

However, I would try and hold onto both skills as long as possible (by moonlighting).

Right now, pain pay is dropping hard, anesthesia pay seems to be rising. I suspect this will continue.

I know several anesthesiologists who do 100% pain who are regretful they can't do anesthesia (or it would take considerable work to do it).

If you give up one after some years - good on you. But there is no reason to let go of the skill right out the gate because someone on SDN told you they gave it up after 15 years. They had good reason to do so. You do not (yet....).

I personally love doing both. Mostly, because when I am in the pain clinic, I long for the OR. When I am in the OR, I really miss the pain clinic.

Mostly, I hate working. I'd rather be skiing.

 

[Ferrismonk]

I do 3 days pain, 1 24-hour OB call per week.

 

[paindoctor2014]

I do 3 days pain, 1 24-hour OB call per week.

That’s a very interesting set up. Are the days fixed? Would you ever finish a call at 7 am and start a pain day?

 

[Ronin1]

Maintain your options. I’ve done both for over 20 years. Although I’m giving up anesthesia this year to get away from nights and weekends. You can keep a comfort level in anesthesia if you do your own cases imo. Supervision not so much.

 

[Dawkter]

I have a split practice (academics). What happens is you end up gravitating to bread and butter pain/anesthesia and are not particularly exceptional at either one. As much as I absolutely love the diversity of my schedule, I may end up phasing out anesthesia and moving toward pain.

The reimbursements are rapidly evolving with the money in anesthesia exceeding pain these days so that decision also needs to be factored in.

 

[PM&ARGHH]

I have a split practice (academics). What happens is you end up gravitating to bread and butter pain/anesthesia and are not particularly exceptional at either one. As much as I absolutely love the diversity of my schedule, I may end up phasing out anesthesia and moving toward pain.

The reimbursements are rapidly evolving with the money in anesthesia exceeding pain these days so that decision also needs to be factored in.

Is this because of anesthesia going up, pain going down, or both? It seems like pain is still holding fairly steady atleast on MGMA, even though I frequently hear about declining reimbursement. Not sure what’s going on in the general anesthesia side though.

 

[Ferrismonk]

That’s a very interesting set up. Are the days fixed? Would you ever finish a call at 7 am and start a pain day?

My group is very accommodating. I never work a post-call day and they usually try to get me the post-post call day off as well. I do work weekends and holidays though.

 

[TIVAndy]

from financial standpoint pain has many options for business expansion/options for revenue as opposed to anesthesia. it's not a simple - reimbursement is dropping and my income will drop. whereas anesthesia you are largely dependent on your labor and reimbursement. although i liked anesthesia - i have not touched it since fellowship.

 

[agolden1]

Is this because of anesthesia going up, pain going down, or both? It seems like pain is still holding fairly steady atleast on MGMA, even though I frequently hear about declining reimbursement. Not sure what’s going on in the general anesthesia side though.

PGY-4 anesthesia resident, but soon to be pain fellow...

Average anesthesia may be slightly higher, but again, these are people who are working longer hours including more nights, weekends, holidays with various late calls thrown in (sorry honey, I won't be there to tuck the kids in tonight). Not to mention stat/difficult airway management which always has the potential to go sideways, stat cesarian sections, etc. I can handle all of these situations, but I'm not sure that I NEED to continue to. Departmental respect in the hospital/OR is a very real problem as well. Not sure how bad I want to supervise CRNAs or resident long term and let someone else make mistakes under my license.

Pain to some of us represents a more controlled atmosphere where you're really the doctor and only your hands are responsible for what goes on under your license (minus supervising PAs/NPs I guess). Sure, there are some patient interactions which are going to be less than fun, but that's clinic medicine in a nutshell and I guess I'm more ok with those annoyances than those of the OR long term even if it (potentially) means a slightly lower salary.

For my first few years out though I may try and do some locums work if there's something reasonable around. If there's not, I'm not sure my heart will be broken. Maybe I'll feel differently a few years into practice...

 

[afob100]

PGY-4 anesthesia resident, but soon to be pain fellow...

Average anesthesia may be slightly higher, but again, these are people who are working longer hours including more nights, weekends, holidays with various late calls thrown in (sorry honey, I won't be there to tuck the kids in tonight). Not to mention stat/difficult airway management which always has the potential to go sideways, stat cesarian sections, etc. I can handle all of these situations, but I'm not sure that I NEED to continue to. Departmental respect in the hospital/OR is a very real problem as well. Not sure how bad I want to supervise CRNAs or resident long term and let someone else make mistakes under my license.

Pain to some of us represents a more controlled atmosphere where you're really the doctor and only your hands are responsible for what goes on under your license (minus supervising PAs/NPs I guess). Sure, there are some patient interactions which are going to be less than fun, but that's clinic medicine in a nutshell and I guess I'm more ok with those annoyances than those of the OR long term even if it (potentially) means a slightly lower salary.

For my first few years out though I may try and do some locums work if there's something reasonable around. If there's not, I'm not sure my heart will be broken. Maybe I'll feel differently a few years into practice...

100% agree with this. I get referrals from other docs for patients to see ME - as a pain specialist. If you take great care of patients, word will spread and you will get more referrals to see YOU. I find this aspect of pain to be immensely rewarding...you have much more control of your life in pain than anesthesia.

 

[epidural man]

PGY-4 anesthesia resident, but soon to be pain fellow...

Average anesthesia may be slightly higher, but again, these are people who are working longer hours including more nights, weekends, holidays with various late calls thrown in (sorry honey, I won't be there to tuck the kids in tonight). Not to mention stat/difficult airway management which always has the potential to go sideways, stat cesarian sections, etc. I can handle all of these situations, but I'm not sure that I NEED to continue to. Departmental respect in the hospital/OR is a very real problem as well. Not sure how bad I want to supervise CRNAs or resident long term and let someone else make mistakes under my license.

Pain to some of us represents a more controlled atmosphere where you're really the doctor and only your hands are responsible for what goes on under your license (minus supervising PAs/NPs I guess). Sure, there are some patient interactions which are going to be less than fun, but that's clinic medicine in a nutshell and I guess I'm more ok with those annoyances than those of the OR long term even if it (potentially) means a slightly lower salary.

For my first few years out though I may try and do some locums work if there's something reasonable around. If there's not, I'm not sure my heart will be broken. Maybe I'll feel differently a few years into practice...

RE: hospital respect.
I currently work in 5 locations and it isn’t the case anywhere that anesthesia has no respect.
In fact, in one small community hospital, anesthesia has maybe the MOST respect because they stepped up and took charge of the COVID situation. They now basically run the place. It was disorienting to me (an occasional worker) to have the ICU doc calling me for suggestions and advice.

I find that those that don’t respect you likely don’t respect ANYONE and the problem is them, not a surgeon/anesthesia dynamic.

 

[cluelessmedstudent411]

RE: hospital respect.
I currently work in 5 locations and it isn’t the case anywhere that anesthesia has no respect.
In fact, in one small community hospital, anesthesia has maybe the MOST respect because they stepped up and took charge of the COVID situation. They now basically run the place. It was disorienting to me (an occasional worker) to have the ICU doc calling me for suggestions and advice.

I find that those that don’t respect you likely don’t respect ANYONE and the problem is them, not a surgeon/anesthesia dynamic.

This is really enlighting to hear as a resident but my experience from shadowing, med student, and resident has been that most of the time there is very little respect. I do think that you tend to have more respect in a rural areas than urban areas this may just be due to the difficulties of getting a physician to those hospitals.

 

[epidural man]

This is really enlighting to hear as a resident but my experience from shadowing, med student, and resident has been that most of the time there is very little respect. I do think that you tend to have more respect in a rural areas than urban areas this may just be due to the difficulties of getting a physician to those hospitals.

Don’t confuse “no respect for residents” with “no respect for Anesthesiologists”....big difference.

 

[Asclepius186]

I wouldn’t say there is no respect, but at the end of the day the surgeons and the OR staff know that the surgeon is the man (or woman) in charge and the anesthesiologist is just another piece of the puzzle to make the machine go.

 

[Peterluger]

I wouldn’t say there is no respect, but at the end of the day the surgeons and the OR staff know that the surgeon is the man (or woman) in charge and the anesthesiologist is just another piece of the puzzle to make the machine go.

If there IS respect, why are anesthesiologists pushing beds to PACU? Why can’t the circulator push the bed and the anesthesiologist watches the patient?

 

[Asclepius186]

If there IS respect, why are anesthesiologists pushing beds to PACU? Why can’t the circulator push the bed and the anesthesiologist watches the patient?

Agreed. Granted most ACT model practices CRNA or resident pushes bed. But I will say by the end of CA3 year when I was still pushing that bed with the obese patient down the hall while the circulator and surgical resident walked and watched, I felt like a real putz.

 

[Ducttape]

no offense, but the anesthesiologist needs to be at the head of the bed for airway management. if you are anywhere other than the head of the bed, you cant act in an emergency without difficulty.

 

[Peterluger]

no offense, but the anesthesiologist needs to be at the head of the bed for airway management. if you are anywhere other than the head of the bed, you cant act in an emergency without difficulty.

Right, so you can walk with the circulator while she pushes the bed bro, and more adequately monitor the patient rather than being the bed pusher. Not sure what part didnt make sense

 

[Ducttape]

hard to do a jaw thrust, or adjust oxygen or nasal cannula, or look at the monitor on the patient bed, when walking 2 feet in front of the stretcher strutting your stuff.

get over it. the anesthesiologist is the only person who is responsible for the patient and their wellbeing, not "the case" or the procedure.


if its any consolation, I polled the 3 board certified attending anesthesiologists working at the surgical center today, and none of them would have it any other way.

 

[Peterluger]

hard to do a jaw thrust, or adjust oxygen or nasal cannula, or look at the monitor on the patient bed, when walking 2 feet in front of the stretcher strutting your stuff.

get over it. the anesthesiologist is the only person who is responsible for the patient and their wellbeing, not "the case" or the procedure.


if its any consolation, I polled the 3 board certified attending anesthesiologists working at the surgical center today, and none of them would have it any other way.

WALK NEXT TO THE STRETCHER THEN, AT THE HEAD OF THE BED. WALK BEHIND THE CIRCULATOR WHO SHOULD BE PUSHING THE BED

 

[Status Sciaticus]

WALK NEXT TO THE STRETCHER THEN, AT THE HEAD OF THE BED. WALK BEHIND THE CIRCULATOR WHO SHOULD BE PUSHING THE BED

why have the circulator pushing the bed if youre just going to have to move them out of the way to get to the head of the bed?

Its not that hard to push a bed. Plus, I can get them to the PACU faster than the little old circulator who is driving slow.
I'm not saying that anesthesiologists are appropriately respected; they're not. But pushing the bed is not a manifestation of that.
I would say, putting monitors on in PACU or waiting to sign out while the PACU nurses take their sweet ass time is a bigger sign of disrespect than wheeling the patient there.

 

[BobLoblaw78]

Hmmm. I think it is fairly easy to tell people who think they are more important and those who don't. If someone is arrogant, they immediately lose respect. I never respect someone more b/c they don't have to push a bed. I do respect a person more who is willing to help out someone else even if it isn't there job. I think you are getting stuck on the respect part more than you need to. You do get some less respect at first, but can earn more with time. You may get confused with a CRNA or something else. With time, the people that know you (and matter) will know who you are and how much to respect you. They will know whether you are the person to go to when things go crazy regardless of whether you push a bed. Frankly, it is a double edged sword. I find myself wishing people would come to me less with issues b/c I have other things I need to be taking care of. Don't sweat the small stuff. I can promise you my life is not affected by what someone thought of me when I was pushing a bed 10 years ago or yesterday. To be honest, they were probably worried about what they were having for lunch and don't even remember me or anyone else that day.

 

[BobLoblaw78]

It is hard to maintain superior knowledge in both. Reminds me of that general surgeon saying they had "I specialize in all of it (but master none of it)"

 

[Peterluger]

Hmmm. I think it is fairly easy to tell people who think they are more important and those who don't. If someone is arrogant, they immediately lose respect. I never respect someone more b/c they don't have to push a bed. I do respect a person more who is willing to help out someone else even if it isn't there job. I think you are getting stuck on the respect part more than you need to. You do get some less respect at first, but can earn more with time. You may get confused with a CRNA or something else. With time, the people that know you (and matter) will know who you are and how much to respect you. They will know whether you are the person to go to when things go crazy regardless of whether you push a bed. Frankly, it is a double edged sword. I find myself wishing people would come to me less with issues b/c I have other things I need to be taking care of. Don't sweat the small stuff. I can promise you my life is not affected by what someone thought of me when I was pushing a bed 10 years ago or yesterday. To be honest, they were probably worried about what they were having for lunch and don't even remember me or anyone else that day.

I think you’re kind of missing the point. The question is, WHY are you pushing the bed, and not the circulator? It reflects a fundamental lack or respect for our profession

 

[BobLoblaw78]

Maybe. Or maybe you are missing the point. My dad is a janitor. Does that mean I shouldn't respect him? The biggest jerk I know is head of anesthesia department and never pushes a bed or does a case while making more money. Should he get more respect than me?

Guess what. I think every circulator would push the bed for me if I asked them to, but not b/c I am an anesthesiologist. I don't want them to. There is literally no where else I need to be than right there and I don't find it demeaning.

 

[Ducttape]

again, I respectfully disagree.

it has nothing to do with respect. it has to do with efficiency in patient care. you the anesthesiologist knows when it is okay to go, when to stop. you the anesthesiologist knows that the patient may need help with airway, or you gotta run, fast to recovery, or turn around to go back to the OR.

if the circulator is pushing, you have ceded at least part of your responsibility and control and given it to someone who frankly doesn't care about the patient, only getting them to recovery so she can go back and set up the room for the next case to please the surgeon.

 

[Tramadeezy]

The most respected/smartest attending at my program routinely pushed the bed when transporting patients to and from icu.

 

[Peterluger]

Maybe. Or maybe you are missing the point. My dad is a janitor. Does that mean I shouldn't respect him? The biggest jerk I know is head of anesthesia department and never pushes a bed or does a case while making more money. Should he get more respect than me?

Guess what. I think every circulator would push the bed for me if I asked them to, but not b/c I am an anesthesiologist. I don't want them to. There is literally no where else I need to be than right there and I don't find it demeaning.

Again, you arent getting the point. The person who is pushing the bed doesnt deserve any less respect. The point is, you need to ask yourself WHY YOU SPECIFICALLY are the one pushing the bed. You really should be at the head constantly observing the patient, not focusing on pushing the bed

 

[BobLoblaw78]

We just have different opinions.

I don't need to focus on pushing the bed any more than I need to focus on chewing gum. But you could make the same case for changing OR table height, fluids, drawing up medications, turning knobs, etc. Who needs to do those? We should be constantly observing the patient.

Plus, you contradict yourself. You said the reason we are pushing it is a fundamental lack of respect. Now you say it isn't a respect issue on who pushes the bed.

 

[Status Sciaticus]

Again, you arent getting the point. The person who is pushing the bed doesnt deserve any less respect. The point is, you need to ask yourself WHY YOU SPECIFICALLY are the one pushing the bed. You really should be at the head constantly observing the patient, not focusing on pushing the bed

LOL you cant push the bed and observe the patient at the same time??

 

[Peterluger]

LOL you cant push the bed and observe the patient at the same time??

Well, you can technically observe the patient while smoking crack too, but it doesn’t mean it’s a good idea and is conducive to observing the patient as closely as possible

 

[Status Sciaticus]

Well, you can technically observe the patient while smoking crack too, but it doesn’t mean it’s a good idea and is conducive to observing the patient as closely as possible

Crack is for the poors.
If pushing the bed is altering your brain chemistry, you're definitely doing something wrong.

 

[Peterluger]

Crack is for the poors.
If pushing the bed is altering your brain chemistry, you're definitely doing something wrong.

Don’t smoke crack, your Bronx pain program doesn’t approve. They won’t want you in their program with that attitude

 

[deleted875186]

We just have different opinions.

I don't need to focus on pushing the bed any more than I need to focus on chewing gum. But you could make the same case for changing OR table height, fluids, drawing up medications, turning knobs, etc. Who needs to do those? We should be constantly observing the patient.

Plus, you contradict yourself. You said the reason we are pushing it is a fundamental lack of respect. Now you say it isn't a respect issue on who pushes the bed.

I don’t mind pushing the bed to PACU, as stated above you need to be at the head.

I do agree that pushing the bed in general is a sign of less respect. At my residency we had to go “pick up” any ICU patient, when they could just as easily be delivered to the ICU by the ICU nurse or circulator, just like they leave the ICU for a scan or something. In residency I was also the lone person pushing the patient from preop to the OR, nurses wouldn’t even come hold the OR door open, wouldn’t even help if it was a giant patient getting bariatric surgeon, so I do think it is a sign of disrespect in some sense.

Than again, I now moonlite at a community hosptial and will go pick people up from the ED, don’t feel disrespected at all, more of a “team effort” trying to expedite things. Hard to get a feel unless you know the culture in the hospital I guess.

 

[Ducttape]

the more I read this thread, the more I realize that the problem with respect is that the one who does not think he should be pushing the bed either doesn't respect himself or is fixated on the impression they are getting disrespected, and that gets projected to others.

people respect doctors who have respect for themselves and others. I saw this all the time as a 2 time resident, 1 time fellow, and long time academic doc.

those who think too highly of themselves are looked down upon. they usually have a condescending attitude and nurses go out of their way to tear that down.
otoh, anyone who think too little of themselves are ignored.

those who are respectful to othersand to themselves - they are the ones that other healthcare professionals respect and go out of their way to help, and are the ones that get to sleep all night during ICU shifts...

 

[deleted875186]

the more I read this thread, the more I realize that the problem with respect is that the one who does not think he should be pushing the bed either doesn't respect himself or is fixated on the impression they are getting disrespected, and that gets projected to others.

people respect doctors who have respect for themselves and others. I saw this all the time as a 2 time resident, 1 time fellow, and long time academic doc.

those who think too highly of themselves are looked down upon. they usually have a condescending attitude and nurses go out of their way to tear that down.
otoh, anyone who think too little of themselves are ignored.

those who are respectful to othersand to themselves - they are the ones that other healthcare professionals respect and go out of their way to help, and are the ones that get to sleep all night during ICU shifts...

I agree with the sentiment.

I do think there are hospitals were the anesthesiology department in general is not treated with respect like any other medical or surgical service would be. In general, the issue is the attitude not the bed pushing

 

[Nodolor]

Not anesthesiology but PM&R, I do half my procedures at an ASC. I actually wheel my patients from pre-op to procedure suite.
Could I ask a nurse to do ? sure but I guess I am not that hung up on being "disrespected" and it really makes it more efficient for me and patients
seem to like it.