Brief rant...

[Piebaldi]

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Hey Pain forum,
I just need to rant for a second here. Please bear with me!
So I'm going to be doing a pain fellowship.

I noticed a few of the people in my program who graduated this year got - somehow- "pain/rehab" type of jobs? without fellowships. So curious how that works? How can some people practice without a pain fellowship? Given that they are not in desirable areas, and I don't know the extent of pain/spine that they are doing. But in general - howcan people practice pain without a fellowship? Granted I am in a very saturated area and no one can practice without a fellowship of any kind here but just curious.

Thanks!

 

[hyperalgesia]

Don't think about yourself. In areas that most pain trained guys won't go, these guys can potentially do some good. At least they're docs, probably accredited-residency-trained in a related specialty. When you start seeing nurses and chiros doing spinal procedures, then you can start to worry (for the pts).

 

[Piebaldi]

Don't think about yourself. In areas that most pain trained guys won't go, these guys can potentially do some good. At least they're docs, probably accredited-residency-trained in a related specialty. When you start seeing nurses and chiros doing spinal procedures, then you can start to worry (for the pts).

Do they get reimbursed by insurance though? If they have no training? Yes they are docs, but as someone who graduated from the same program I can attest that we don't get enough training to be able to do pain without a fellowship. I know one of the guys who went to TN for this hybrid type of pain/rehab job wanted to do pain but I am thinking he did not get the position. I just find it scary - doings RFs, cervical procedures, even more basic ones with NO training. Yikes!

 

[paindoc007]

Do they get reimbursed by insurance though? If they have no training? Yes they are docs, but as someone who graduated from the same program I can attest that we don't get enough training to be able to do pain without a fellowship. I know one of the guys who went to TN for this hybrid type of pain/rehab job wanted to do pain but I am thinking he did not get the position. I just find it scary - doings RFs, cervical procedures, even more basic ones with NO training. Yikes!

Happens all the time. I agree with hyperalgesia; I get far more concerned when I hear CRNA Mike doing scs trials then what you’re discussing.

 

[Biohazard685]

Depends on the location.

Some hospitals won't care who is doing the procedure as long as they real that fat site of service differenti.

Some hospitals won't let you get credentialed unless you are fellowship trained.

Some practices are run by surgeons that want a pain guy to feed them.

Focus on what you can get out of fellowship.

 

[SSdoc33]

Do they get reimbursed by insurance though? If they have no training? Yes they are docs, but as someone who graduated from the same program I can attest that we don't get enough training to be able to do pain without a fellowship. I know one of the guys who went to TN for this hybrid type of pain/rehab job wanted to do pain but I am thinking he did not get the position. I just find it scary - doings RFs, cervical procedures, even more basic ones with NO training. Yikes!

they bill the same codes. yes, they get reimbursed the same. some hospitals or other groups may not credential them, but there are family practice docs who do weekend courses doing these injections. get used to this sort of BS. just be good at what you do and do it well.

 

[drusso]

they bill the same codes. yes, they get reimbursed the same. some hospitals or other groups may not credential them, but there are family practice docs who do weekend courses doing these injections. get used to this sort of BS. just be good at what you do and do it well.

Contribute to your PainPACs and specialty societies that promote patient access to the most qualified and credentialed physicians. and protects patients from substandard care.

Asipp-Pac – Asipp-Pac

www.asipppac.org

 

[Agast]

The easy answer is they are not doing procedures. There are plenty of pain/rehab jobs that just want an MD/DO to sign off on things. Or medication management. I saw so many job postings looking for a “medical director” inviting new graduates to apply.

 

[Piebaldi]

The easy answer is they are not doing procedures. There are plenty of pain/rehab jobs that just want an MD/DO to sign off on things. Or medication management. I saw so many job postings looking for a “medical director” inviting new graduates to apply.

No no, these are actual practices and they are doing procedures. I just don't know how you can graduate (and this coming from someone who is PM&R trained = i just think I'd be crazy to do RFAs, cervicals, stim trials, etc without a fellowship) - particularly in a program that is not exposed to this. And particularly in an area where there is massive competition for these jobs where they are gone sooo quickly with top tier applicants.

 

[SSdoc33]

Contribute to your PainPACs and specialty societies that promote patient access to the most qualified and credentialed physicians. and protects patients from substandard care.

Asipp-Pac – Asipp-Pac

www.asipppac.org

Ugh

Do you really want me to give money to Lax? I feel dirty just thinking about it

 

[MiddleOfNowherrr]

I am in an undesirable area, where my partner had been doing procedures as a non fellowship trained doc for years. He was therefore “grandfathered” into the pain world about a decade ago. HOWEVER the hospital system here is now giving new docs a hard time or blocking them altogether if not fellowship trained in pain (I have a feeling reimbursement was affected bc this hospital only thinks in terms of $$—well, they all do, dont they??)...
they carefully checked all my credentials (im anesthesia/pain) when i started and are now really pushing for board certification. They blocked another guy in the group from credentialing bc he wasnt fellowship trained so i dunno maybe it depends on the area and aggressiveness of the hospital u are considering working at.
I kind of like this approach bc a piece of me dies every time I see CRNAs/Chiros/NPs et al doing procedures....it scares me for the patients and frustrates me bc i have to clean up a lot of their messes bc they dont know what the F*** they are doing...

 

[drusso]

Ugh

Do you really want me to give money to Lax? I feel dirty just thinking about it

This is about something bigger more existential. Policy versus politics...

Separate the person from the policies.

You don’t have to like Trump as a person to still see that some of his policies are working.

I don’t agree with everything ASIPP does or promotes, but compared to other pain specialty societies, they’ve done more to help my family than others.

 

[Ducttape]

I assume you are not talking about “spine” fellowship docs.

I suspect some of these are med management, EMG, tpi and joint injection docs working in an ortho group.

 

[Piebaldi]

I assume you are not talking about “spine” fellowship docs.

I suspect some of these are med management, EMG, tpi and joint injection docs working in an ortho group.

Right, no I am not talking about spine fellowships, those are perfectly fine and many people get excellent training. I'm talking about people doing NO fellowship and somehow thinking they can do spine/int pain. I even had a colleague of mine say "well i had a lot of training in residency (different residency) I can do spine." I was like umm ok....

 

[VAthletics]

Is it illegal to advertise as a "pain" doc if you are not board certified? I also see a lot of PM&R docs proclaiming to be "sports" docs without a fellowship.

 

[blockstar]

Its not that easy to get credentialed to do these procedures AND get reimbursed. You can do auto and send a bill to the auto insurance company but real hospitals want people with real training. CRNAs/NPs might get paid by a chiro to do intrathecal stem cells or some cash based procedure but you wont find a normal hospital doing this.

 

[cowboydoc]

Its not that easy to get credentialed to do these procedures AND get reimbursed. You can do auto and send a bill to the auto insurance company but real hospitals want people with real training. CRNAs/NPs might get paid by a chiro to do intrathecal stem cells or some cash based procedure but you wont find a normal hospital doing this.

Credentialing and reimbursement is the crux of this discussion. All else is superfluous. I disagree with your assertion above based on who can and does these procedures in my region. There are more untrained physicians and mid-levels doing spine than fellowship-trained physicians in my area. In other parts of the country, well-trained docs have trouble getting on insurance panels. There are vast regional differences.

Most hospitals would hire an NP to do spine interventions in a heartbeat if there weren't a financial disincentive to do so. (lack of reimbursement, lawsuits, etc.)

 

[Piebaldi]

Credentialing and reimbursement is the crux of this discussion. All else is superfluous. I disagree with your assertion above based on who can and does these procedures in my region. There are more untrained physicians and mid-levels doing spine than fellowship-trained physicians in my area. In other parts of the country, well-trained docs have trouble getting on insurance panels. There are vast regional differences.

Most hospitals would hire an NP to do spine interventions in a heartbeat if there weren't a financial disincentive to do so. (lack of reimbursement, lawsuits, etc.)

right and this is my point. how cna someone without a fellowship of any kind do high end spine procedures? as a physician i would be terrified - and i'm not particularly looking forward to MORE training! but feel if i want to do spine it's needed.

 

[cowboydoc]

right and this is my point. how cna someone without a fellowship of any kind do high end spine procedures? as a physician i would be terrified - and i'm not particularly looking forward to MORE training! but feel if i want to do spine it's needed.

Laws don't exist to define a moral high ground, but to set a minimum standard.

 

[Ducttape]

a lot of the "rules" that are put in place by CMMS are specifically to limit the number of unscrupulous proceduralists.

you might not remember, but even 10 years ago, many family docs would do "facet injections" or epidurals without fluoro.

 

[hyperalgesia]

Credentialing and reimbursement is the crux of this discussion. All else is superfluous. I disagree with your assertion above based on who can and does these procedures in my region. There are more untrained physicians and mid-levels doing spine than fellowship-trained physicians in my area. In other parts of the country, well-trained docs have trouble getting on insurance panels. There are vast regional differences.

Most hospitals would hire an NP to do spine interventions in a heartbeat if there weren't a financial disincentive to do so. (lack of reimbursement, lawsuits, etc.)

Most hospitals would probably prefer an NP who is "pain certified" by the board respected by NPs, than an MD who is not "pain certified". All they care about is the CYA and the $$.

 

[Ronin1]

You will find that hospitals do what is in their financial benefit. For example in my facility. Rated the best hospital in a major metro area they asked me to review a pmr guy they employed who wanted interventional privileges based on a 6 month non accredited sports fellowship. When I declined to approve the request based on lack of training they simply had another employed doc sign off on them. Then they had the gall to advertise him as an interventional spine physician. Lol

 

[emd123]

Hey Pain forum,
I just need to rant for a second here. Please bear with me!
So I'm going to be doing a pain fellowship.

I noticed a few of the people in my program who graduated this year got - somehow- "pain/rehab" type of jobs? without fellowships. So curious how that works? How can some people practice without a pain fellowship? Given that they are not in desirable areas, and I don't know the extent of pain/spine that they are doing. But in general - howcan people practice pain without a fellowship? Granted I am in a very saturated area and no one can practice without a fellowship of any kind here but just curious.

Thanks!

They're not going to have any clue what they're doing with interventions. They'll probably be scripts monkeys. Pain is hard to learn even a year, let alone while in the 1 or 2 months of rotations they've done in residency.

 

[RM38]

I know several people whom said they were taking jobs like the ones described and they are doing a variety of interventions. Set up is they are usually doing mostly inpatient PM&R stuff and the facility has an outpatient clinic with a flouro suite for them to do injections and see patients on the side. They will also do some med management and get most of their patients by having the inpatients follow up with them and then start addressing their other issues. I met a guy whom had signed to a practice like this in DFW and had never done an injection before. He was about to do a couple of months of spine in residency and said he would probably do about 75-100 procedures. Ultimately people whom are doing these injections (especially cervical) without being nervous after minimal training is because they don't have the knowledge to be nervous. Some just don't understand what could actually happen to the patient if procedures were done inappropriately. The people in the above situation are probably also working for a lot less than what most pain docs would and they are trying to keep the volume in house. I also know somebody whom is now doing regenerative med with a pain group/regenexx and they are having him learn spinal procedures now apparently even though the others guys are fellowship trained and pain boarded, so it is not uncommon. It is better than having CRNAs doing this stuff though. The hospital in the area where I grew up (rural hospital, but big metro area only about 30 min farther south) had CRNAs doing pain procedures in the ASC there until recently. My dad used to operate there and said they now had to stop because the liability was now too high for them, which I take as code for they had some major complications and had to shut it down. I believe they now hired a Fellowship trained Pain doc to run things.

 

[hyperalgesia]

Don't forget the founding fathers of pain were not "fellowship trained".

I think most of the bad pain docs are not bad because they are poorly trained. They are poorly/not trained because they are bad docs.

A good doc knows his limitations. So it's conceivable for a guy, who is a quality physician, who may not have a formal pain fellowship, to do good work. I'm sure there are many on this board who are here to learn what they can and do what they are comfortable with and the needs of their community.

Then there are the cowboys, those with or without training, who just don't know their limitations or only care about money.

I agree that pain training is important but my point is it is equally a marker of a good physician, as it is a MAKER of a good physician.

 

[Ferrismonk]

From my observations, as long as pain procedures pay more than office visits and allows people do not work weekends or holidays, every unscrupulous "provider" who is chasing a buck and can legally stab someone will.

I honestly wish the federal government would define the "practice of medicine". Nurses fall under the board of nursing, chiropractors fall under the chiropractic board, etc and can define what is within their "scope of practice". I further wish that doctors could not legally practice in fields outside their residency training. If you're a general surgeon, you should be doing surgery, no interventional pain procedures. If you're a neurosurgeon, stick to neurosurgery. If you're an interventional pain doctor, you shouldn't do plastics. It's ridiculous and patient's have no idea what the hell is going on in medicine or what kind of training their "provider" has.

 

[Ducttape]

Then there are the cowboys, those with or without training, who just don't know their limitations or only care about money

what you say is all well and good until the "good doc" realizes that they can make boat... as in a boatload of money. then, that weekend course becomes, by default, "an excellent and completely thorough review of the intervention and makes me qualified to do that procedure in real life"...

 

[DoYouEvenLiftBro]

Right, no I am not talking about spine fellowships, those are perfectly fine and many people get excellent training. I'm talking about people doing NO fellowship and somehow thinking they can do spine/int pain. I even had a colleague of mine say "well i had a lot of training in residency (different residency) I can do spine." I was like umm ok....

Our residency (pmr) if you want can end with 400-600 fluoro injections... Many go straight into pain w/o procedural issues but hospital employment is a different story

 

[Piebaldi]

Our residency (pmr) if you want can end with 400-600 fluoro injections... Many go straight into pain w/o procedural issues but hospital employment is a different story

Who hires these people? Just curious (I am not trying to sound snippy, just curious). Here where I'm at it's rather competitive. Don't know of anyone who has gotten hired without some sort of fellowship - ACGME/non ACGME pain, spine, sports, etc. In our program we did not get anywhere near 400-600 injections

 

[Ligament]

I think with a strong PM&R residency, one can go into sports and spine type stuff rather safely and well. My residency gave me a lot of exposure to fluoro guided spine procedures. I could have gone into a sports and spine situation. Could have busted my ass and gone into real pain medicine too, with a lot of extra ISIS and ASIPP classes. Would not have been ideal...but would have been ethical and reasonable,

 

[drusso]

I think with a strong PM&R residency, one can go into sports and spine type stuff rather safely and well. My residency gave me a lot of exposure to fluoro guided spine procedures. I could have gone into a sports and spine situation. Could have busted my ass and gone into real pain medicine too, with a lot of extra ISIS and ASIPP classes. Would not have been ideal...but would have been ethical and reasonable,

This is basically what most PM&R grads did before we were commonly accepted into ACGME-accredited programs. We "rolled our own." My partner spent a year doing mini-fellowships/preceptorships around the country "back in the day." Spent time with the Saal brothers, and ISIS luminaries, etc...

But, in this day and age that seems a little too cavalier. I review cases for my medical board and I hold non-fellowship trained doctors practicing pain medicine to the same standard as an ACGME-trained Pain Medicine specialist.

 

[Piebaldi]

This is basically what most PM&R grads did before we were commonly accepted into ACGME-accredited programs. We "rolled our own." My partner spent a year doing mini-fellowships/preceptorships around the country "back in the day." Spent time with the Saal brothers, and ISIS luminaries, etc...

But, in this day and age that seems a little too cavalier. I review cases for my medical board and I hold non-fellowship trained doctors practicing pain medicine to the same standard as an ACGME-trained Pain Medicine specialist.

I am not saying it is wrong to do spine stuff with training. I am saying that coming out of a PM&R residency where you haven't been exposed or done enough of this stuff is not safe.

 

[hyperalgesia]

What about the pmr or anesthesia doc who doesn't get into a fellowship but takes a job with an experienced group? He gradually starts adding procs to his toolbox. I see no issue with this.

I agree with fighting for patient safety. And absolutely agree the same standard applies with or without fellowship. These guys don't get any sort of pass.

I just don't support protectionism.

 

[Ducttape]

in your above example, what is to prevent the same experienced group from hiring a PA or NP who then gradually adds procedures to his toolbox?

imo, its a slippery slope when we do not insist on a standard of educational training.

those PAs/NPs who are smart enough will go back to med school and do residencies. if they are non boarded doctors then they, like myself, can go back and do a completely different residency and then fellowship to become a board certified pain doctor.