cancer pain only practice

[Slowpoke]

Do you guys think there is enough volume to support an outpatient interventional cancer pain & cancer rehab practice?

I will be starting my PM&R residency training at one of the top programs in the country after this academic year (am an prelim medicine intern right now). And I ultimately want to help cancer survivors.

I think with the continuing improvements with cancer treatments (most recently with immunotherapy), cancer will be/is a chronic disease with debilitating side effects that I hope to target with my PM&R training and eventual interventional pain training.

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[willabeast]

Do you guys think there is enough volume to support an outpatient interventional cancer pain & cancer rehab practice?

I will be starting my PM&R residency training at one of the top programs in the country after this academic year (am an prelim medicine intern right now). And I ultimately want to help cancer survivors.

I think with the continuing improvements with cancer treatments (most recently with immunotherapy), cancer will be/is a chronic disease with debilitating side effects that I hope to target with my PM&R training and eventual interventional pain training.

There was a doc in Houston who did only cancer pain. He did a lot of neurolytic blocks as well as the usual stuff, was an attending at teaching hospitals there. The volume would probably be there in a large city but I have no idea if you could generate a decent income.

 

[callmeanesthesia]

Find out who does cancer rehab at your rehab program. Talk to them (email your program director, tell him/her your interest, and ask for a mentor you could talk to). They will probably have someone who does it, but if not they will know someone who does at another institution. I think you could do it as a career but you’d most likely have to be at an academic medical center or at least in a big city. You need a big cancer center to feed you referrals. Don’t worry about subspecializing at this point in your career though - you have years to learn what you really like, and remember it’s okay to change your mind.

 

[painfree23]

I’m not a huge fan of this “cancer pain” stuff. What is the difference between cancer pain and regular pain in terms of medication management ? Cancer pain is just OK for opiates and more aggressive nerve blocks. So it’s just opiate management which a lot of us have done for years plus more aggressive procedures.

 

[paindoc007]

I’m not a huge fan of this “cancer pain” stuff. What is the difference between cancer pain and regular pain in terms of medication management ? Cancer pain is just OK for opiates and more aggressive nerve blocks. So it’s just opiate management which a lot of us have done for years plus more aggressive procedures.

Maybe a large pump population also

 

[Slowpoke]

Find out who does cancer rehab at your rehab program. Talk to them (email your program director, tell him/her your interest, and ask for a mentor you could talk to). They will probably have someone who does it, but if not they will know someone who does at another institution. I think you could do it as a career but you’d most likely have to be at an academic medical center or at least in a big city. You need a big cancer center to feed you referrals. Don’t worry about subspecializing at this point in your career though - you have years to learn what you really like, and remember it’s okay to change your mind.

Thanks. I plan on reaching out to my PM&R PD when I start PGY2. The dream is to work at a cancer center. I think one of the referral basis could be how Hopkins has a cancer rehabilition program integrated into their cancer treatment - patient's meet the rehab team while in the hospital and f/up outpatient as needed. So I would just need to find a position at a place with a similar cancer treatment paradigm or set one up myself. I just wanted to figure out the feasibility of making a career out of it.

I went into PM&R solely for the cancer rehab route, for personal reasons. So I think if I ended up changing my mind on this, I would end up switching specialties.

 

[painfree23]

Maybe a large pump population also

Sounds lovely.

 

[callmeanesthesia]

Thanks. I plan on reaching out to my PM&R PD when I start PGY2. The dream is to work at a cancer center. I think one of the referral basis could be how Hopkins has a cancer rehabilition program integrated into their cancer treatment - patient's meet the rehab team while in the hospital and f/up outpatient as needed. So I would just need to find a position at a place with a similar cancer treatment paradigm or set one up myself. I just wanted to figure out the feasibility of making a career out of it.

I went into PM&R solely for the cancer rehab route, for personal reasons. So I think if I ended up changing my mind on this, I would end up switching specialties.

Weill Cornell Tri-Institutional Pain Fellowship | Department of Anesthesiology

Consider this fellowship. A good portion of it is spent at Memorial Sloan Kettering. My program director trained there, and is a total rockstar. There are a lot of great intervetional procedure for cancer pain. And don’t let the trash talk scare you on here. Intrathecal pumps for people with a long life ahead of them - probably a bad idea. Intrathecal pump for someone with stage 4 pancreatic cancer and uncontrolled abdominal pain - one of the most gratifying things I did in fellowship.

 

[Aether2000]

Most pain physicians find it is impossible to develop enough referral volume to support a cancer pain only or even a majority cancer pain population. Why? The oncologists liberally prescribe opioids to these patients, some long term, as they have effectively been granted a bye for societal restrictions on opioids, and because they have adopted an end-of-life care model to treat the patients when chemo/radiation/surgery have failed. Those patients entering hospice will find themselves treated by nurses>physicians and with the cheapest opioids available. RF and other neurolytic procedures, IT pumps, SCS, PNS, and short term local/steroid nerve blocks are all eschewed by most oncologists and hospice. Opioid medication management of malignancy by pain physicians, especially by those who have moved their non-cancer pain populations to lower doses of opioids or off opioids, is seemingly becoming less common.

 

[Ronin1]

Most pain physicians find it is impossible to develop enough referral volume to support a cancer pain only or even a majority cancer pain population. Why? The oncologists liberally prescribe opioids to these patients, some long term, as they have effectively been granted a bye for societal restrictions on opioids, and because they have adopted an end-of-life care model to treat the patients when chemo/radiation/surgery have failed. Those patients entering hospice will find themselves treated by nurses>physicians and with the cheapest opioids available. RF and other neurolytic procedures, IT pumps, SCS, PNS, and short term local/steroid nerve blocks are all eschewed by most oncologists and hospice. Opioid medication management of malignancy by pain physicians, especially by those who have moved their non-cancer pain populations to lower doses of opioids or off opioids, is seemingly becoming less common.

I echo his thoughts. I rarely see cancer referrals sent by local oncologists as they are confident in their ability to prescribe opioids. And the local hospices do not have pump programmers and in fact refused on multiple times to be trained on them for free.

 

[TheLoneWolf]

program I worked at had a very busy pain practice that dealt exclusively with cancer pain and surgical misadventure. Oncology referred to this clinic. High meqs way outside of CDC limits, mostly methadone and a short acting for btp. Procedures are mostly pump refills on legacy patients. Very rare SCS patient. Pain guy abandoned IPM a long time ago, says it doesn't work. High volume opiate prescribing all week long might be for others but I wouldn't work there for a kings ransom.

 

[SommeRiver]

Nope. Not in the real world.

 

[clubdeac]

Just met the oncologist who works down the hall from me. Her nurse told me they'll have a ton of patients for me. I had a nice discussion with her explaining that I will not be taking over opioid prescribing but I'm happy to offer interventions when necessary, i.e. neurolytics, celiacs, ICNBs for post lobectomy/thoracotomy pain, superior hypogastrics, ganglion impars etc.

 

[painfree23]

Just met the oncologist who works down the hall from me. Her nurse told me they'll have a ton of patients for me. I had a nice discussion with her explaining that I will not be taking over opioid prescribing but I'm happy to offer interventions when necessary, i.e. neurolytics, celiacs, ICNBs for post lobectomy/thoracotomy pain, superior hypogastrics, ganglion impars etc.

What neurololytic procedures were you considering?

 

[Timeoutofmind]

I had the same question as a resident.

I actually worked in a pain management clinic in a cancer center for several months during residency.

Ex cancer/palliative patients on ridiculous opioid doses. Now cancer free and disabled, hyperalgesic. Very difficult to wean. Were basically all of the clientele. Mostly actually dying of anything was getting opioids from the oncologists, so we rarely saw those people.

I am sure it can happen that there are rare practices like this that are meaningful...but it would take some outside the box networking/efforts and possibly geographic flexibility and you would want the fall back plan of non cancer pain training/practice.

 

[hyperalgesia]

Thanks. I plan on reaching out to my PM&R PD when I start PGY2. The dream is to work at a cancer center. I think one of the referral basis could be how Hopkins has a cancer rehabilition program integrated into their cancer treatment - patient's meet the rehab team while in the hospital and f/up outpatient as needed. So I would just need to find a position at a place with a similar cancer treatment paradigm or set one up myself. I just wanted to figure out the feasibility of making a career out of it.

I went into PM&R solely for the cancer rehab route, for personal reasons. So I think if I ended up changing my mind on this, I would end up switching specialties.

If you set up a practice that incorporates PT and OT and marketed it as a unique, structured, cancer rehab program, I think you could do well. Minimal need for pain interventions here.

OTOH, you could set up a program as a sort of advanced hospice, where your people take over opioids and offer blocks, rhizotomies, pumps.

The main thing is to market whatever you do as a structured package that makes it easy for referring docs and pts to stop coordinating everything.

I think either model could be very successful if marketed correctly and not in a super saturated area.

 

[clubdeac]

What neurololytic procedures were you considering?

Well when I was working at the VA I had no qualms doing neurolytic splanchnics, ganglion impars, intercostals and superior hypogastrics. Now that I'm in the private world I'm honestly not sure how many of those I'll be wanting to do. We'll see

 

[Slowpoke]

If you set up a practice that incorporates PT and OT and marketed it as a unique, structured, cancer rehab program, I think you could do well. Minimal need for pain interventions here.

OTOH, you could set up a program as a sort of advanced hospice, where your people take over opioids and offer blocks, rhizotomies, pumps.

The main thing is to market whatever you do as a structured package that makes it easy for referring docs and pts to stop coordinating everything.

I think either model could be very successful if marketed correctly and not in a super saturated area.

Thanks, this is the sort of angle that I was referring to in the hopkin's model. The pitch would be organizing a structured "Cancer Rehabiliation" program at said cancer center (if there isn't a structured program set up yet -- I suspect a majority of cancer centers will already have a program like this when I graduate residency though) and being able to offer interventions on a PRN basis. I know I won't make as much as a well oiled PP office that has dedicated days for procedures, but (and I may sound naive right now), money isn't as strong of a motivator for me as career fulfillment.

 

[callmeanesthesia]

Thanks, this is the sort of angle that I was referring to in the hopkin's model. The pitch would be organizing a structured "Cancer Rehabiliation" program at said cancer center (if there isn't a structured program set up yet -- I suspect a majority of cancer centers will already have a program like this when I graduate residency though) and being able to offer interventions on a PRN basis. I know I won't make as much as a well oiled PP office that has dedicated days for procedures, but (and I may sound naive right now), money isn't as strong of a motivator for me as career fulfillment.

You sound like a good fit for academia, which is good because that is likely the only place the kind of practice you have in mind will be feasible. Get into research now, if you aren’t already. Hit it hard, take extra classes on stats and methodology. Try to get a bunch of first author publications under your belt before your graduate residency. That said, speaking from personal experience, try not to let your absolute certainty in what you want to do blind you to other experiences and options that may an even better fit for you.

 

[Slowpoke]

You sound like a good fit for academia, which is good because that is likely the only place the kind of practice you have in mind will be feasible. Get into research now, if you aren’t already. Hit it hard, take extra classes on stats and methodology. Try to get a bunch of first author publications under your belt before your graduate residency. That said, speaking from personal experience, try not to let your absolute certainty in what you want to do blind you to other experiences and options that may an even better fit for you.

Thank you, I will commit to memory the last sentence of your post. I appreciate it. I have a strong research background going into residency (multiple co-author publications in high impact journals) and also took a year off from med school to do cancer research at a top cancer center and I plan on carrying this momentum into the rest of residency and beyond.

 

[Slowpoke]

Resurrecting this thread that I made 2 years ago. I am now am a PGY3, who is a bit more weathered (completed a 2 month stint with COVID19 here in NYC), and mostly unwavered in my career goal aspirations. My question to the board is:

With the advent of changing societal norms dictating migration away from chronic opioid use, to some degree even in the cancer population, which pain interventions (in your experience) seem to be under-utilized/most effective in the treatment of malignant pain?

 

[willabeast]

Resurrecting this thread that I made 2 years ago. I am now am a PGY3, who is a bit more weathered (completed a 2 month stint with COVID19 here in NYC), and mostly unwavered in my career goal aspirations. My question to the board is:

With the advent of changing societal norms dictating migration away from chronic opioid use, to some degree even in the cancer population, which pain interventions (in your experience) seem to be under-utilized/most effective in the treatment of malignant pain?

i used to get sent patients for neurolytic celiac p.b. who almost always needed a simple adjustment in their oral meds rather than a procedure. usually referred by surgeons rather than oncologists. very few patients were ever told about the 1% incidence of paraplegia before seeing me. may be related? referrals are often done for all sorts of reasons unrelated to what is stated.

 

[painfree23]

Have a patient who was getting IV meds at home thru a TPN line from a cancer doctor. Then patient was referred to me for wean now that cancer improved but still with serious pain issue.

 

[drusso]

Thanks, this is the sort of angle that I was referring to in the hopkin's model. The pitch would be organizing a structured "Cancer Rehabiliation" program at said cancer center (if there isn't a structured program set up yet -- I suspect a majority of cancer centers will already have a program like this when I graduate residency though) and being able to offer interventions on a PRN basis. I know I won't make as much as a well oiled PP office that has dedicated days for procedures, but (and I may sound naive right now), money isn't as strong of a motivator for me as career fulfillment.

Unless you're employed by a large hospital system or tertiary care center, you'll starve in the private practice world with this idea. The model you describe is correct in theory but a non-starter on its business merits. You would need a capitated model or medical directorship.

If I were you, I'd just offer some 1099 work for a cancer center on the side. Recognize that you'll be ordering scans, ancillaries, etc. Your enterprise value will be very attractive to them so negotiate with that in mind.

 

[bedrock]

Resurrecting this thread that I made 2 years ago. I am now am a PGY3, who is a bit more weathered (completed a 2 month stint with COVID19 here in NYC), and mostly unwavered in my career goal aspirations. My question to the board is:

With the advent of changing societal norms dictating migration away from chronic opioid use, to some degree even in the cancer population, which pain interventions (in your experience) seem to be under-utilized/most effective in the treatment of malignant pain?

You can definitely do this. You just have to plan on a career in academic pain medicine. There are many pain physicians that focus on cancer pain, but 90% of them work in an academic center, and the other 10% work in a large private hospital with a major cancer center.

 

[Orin]

If you're in NYYC, go talk to the people at Sloan Kettering.
Cancer pain works there as they're outside the regular prior-auth system, have good leadership, a good brand, and are aggressive about doing things.

 

[gaseous_clay]

I’m not a huge fan of this “cancer pain” stuff. What is the difference between cancer pain and regular pain in terms of medication management ? Cancer pain is just OK for opiates and more aggressive nerve blocks. So it’s just opiate management which a lot of us have done for years plus more aggressive procedures.

With potentially higher MMEs

 

[deleted993114]

Do you guys think there is enough volume to support an outpatient interventional cancer pain & cancer rehab practice?

I will be starting my PM&R residency training at one of the top programs in the country after this academic year (am an prelim medicine intern right now). And I ultimately want to help cancer survivors.

I think with the continuing improvements with cancer treatments (most recently with immunotherapy), cancer will be/is a chronic disease with debilitating side effects that I hope to target with my PM&R training and eventual interventional pain training.

No

 

[myrandom2003]

If you did cancer pain and adhesive arachnoiditis, plenty of volume for opioids

 

[Laryngospasm]

Just what everyone wants these days. A practice full of ridiculously high doses of opioids.