More from Physicians Online (POL:
www.pol.net) about this very topic. Apparently, we've generated some discussion among our attending/staff colleagues:
Anon_746515 on 03/05/04 11:13 AM
I am physiatrist, doing 100% non-surgical spine practice. I did a two-year fellowship in musculoskeletal, spine and sports medicine and is pain boarded through ABA. I work with a renowned conservative spine surgeon. We read X-rays, MRIs ourselves and often discuss with the radiologists about their readings.
I have seen many anesthesiologists doing pain management who are big on needles but have no clues to their diagnoses. Most of their impressions after a very poor hitory and physical examination is 'multifactorial low back pain'. These are the pain specialists that end up doing one dozen facet joint injections on one patient at one sitting and then go ahead with RF abaltion of bilateral MBBs for all those levels.
Or, they do series of epidurals irrespective of outcome. To me they may be excellent in maneuvering their needles, but by putting needles where it was not needed, make themselves and others, including the patients, more confused. It is like having weapon in your hand and you know how to kill, but do not know who is your friend or foe.
I do not want to generalize. There are good docs and not so good docs in every specialty and as Dr. Soriano mentioned, every specialty, by virtue of their training have their strength and weakness at certain faculties. We should not look down upon other specialties based on their weakness, rather look into ourselves and see what we are lacking in managing our patients and try to gather skills from other specialties for a more gratifying practice.
If you are a good doc, know what you are doing and your patients like you, you do not need to fear other docs taking your practice.
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Anon_18ed41b on 03/06/04 07:12 AM
Anon 746515:
I have a similar background as a PM&R residency followed by an orthopedic fellowship performed in an Orthopedic Dept with Spine Surgeons - and practice as you. My clinical interests are pretty much limited to spine and EDX and I'll be sitting for the EDX boards next month. I am a member of NASS, ISIS, and the AAEM.
I do not consider myself a pain physician, but an interventional physiatrist. I do not want to bear the pain moniker as, more often than not, my observation has been that chronic pain is a much more psychosocial than biological phenomenon and I am still not convinced even after having worked in an internationally recognized multidisciplinary chronic pain clinic- that specialty physicians have a meaningful role in its management let alone treatment. Moreover, as I eluded earlier, interested observers - insurance companies, health epidemiologists, occupational health clinics, etc. - are coming to equate the "interventional pain management designation" with a practice pattern - expensive and anecdotal - that I do not want to be associated with.
However, as a concession to the 'turf' war I plan to sit for the ABPM&R sponsored pain boards. This is not due to the salience of the material to my practice or my interest in "pain" but merely out of recognition of the turf wars between a small specialty - PM&R - and a much larger specialty - Anesthesia. I do not buy the Spine = Pain argument put forward by the pain tribe; why not chest pain? Pain for me is a symptom, not a disease, and as a physician my focus will always be on the treatment of the underlying disease.
For the studentdoctor.net residents: in the end, evidence, outcomes, and continued education should be your guiding principles. Those practioners who are trying to take an evidence-based, nosological approach, to spine and musculoskeletal problems will be more familiar with the etiology and natural history of the diseases they treat and this will lead to measurably better outcomes.(1, 2) With that in mind, you need to think about your fellowship training carefully.
1. Klein, Ben J. PhD. Radecki, Richard T. MD. Foris, Michael P. MBA. Feil, Edward I. MD. Hickey, Martin E. MD. Bridging the Gap Between Science and Practice in Managing Low Back Pain: A Comprehensive Spine Care System in a Health Maintenance Organization Setting. Spine. 25(6):738-740, March 15, 2000.
2. Saal, Jeffrey A. MD, FACP. 1996 North American Spine Society Presidential Address. Spine. 22(14):1545-1552, July 15, 1997.
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Rinoo Shah on 03/06/04 04:39 PM
anon 18e..or shall we call you p.c, ....which BTW stands for politically correct [medicine] and does not represent the initials of an individual on the p.o.l. discussion boards with a portuguese namesake
your arrogance in these matters is stifling and what is particularly appalling is the stark dichotomy between some of your posts on the ISIS web site and on p.o.l.
in one recent ISIS post you describe a transdural L5-S1 discogram for a patient with a posterolateral fusion to help the referring physician decide if the patient is a candidate for an anterior interbody fusion or is 'nuts'..i.e., a candidate for psychological counseling.
I truly wonder how you can ethically convince a patient that this discogram is in the patient's best interest as well as an ALIF if positive...and tell the patient (based on your posts on p.o.l.) that SCS, lysis, intrathecal opioid, oral opioids, neurontin and other AEDs do not have sufficient evidence and are not in the patient's best interest..
there is no such thing as a spinal diagnostician nor interventional physiatrist...
diagnose what? if a patient doesn't have an analgesic or provocative response to your repertoire of 'spinal interventions'..which based on your posts are limited to your interpretation of evidence to discos, transforaminals and may be SIJs, or medial branch blocks...so if a patients pain cannot be reproduced or blocked with these interventions...then they would only benefit from psych...or if their pain is reproduced or blocked...and they don't reach a therapeutic endpoint..then they go to your REFERRING spine surgeon?
additionally, according to your ISIS posts percentage-wise you see a larger number of run-of-the-mill disc herniations...how did you develop such a cozy practice...do you turn a blind eye (selection bias) to patients you cannot help and dissuade them from seeing pain physicians in your community
this latter practice generates the scorn and ire of cadde5 against physiatrists...you see the easy to treat patients and dump the waste baskets on the pain physicians and then crib about there approach to treating them
you call interventional pain physicians 'goats'.....but as a 'spinal diagnostician' you appear to be a greater goat...fueling the spinal surgery business
In Merrill's article in Reg Anesth in 12/03...the estimated cost to medicare from interventional pain in 2001(excluding implants: SCS and IT pumps)...was about 370 million...he estimated that since medicare' share of physician fees was 21% then the costs to the USA overall, could be as high as 1.8 billion
...but take a look at his TABLE 3...out of this 370 million to Medicare...translaminar ESIs accounted for 130 million, transforaminals for 36 million, medial branch blocks 60 million, medial branch RFTC 13 million, and sympathetic 3 million,, there were extra dollars and cents for fluoroscopic guidance, epiduraography....but all in all the vast majority of costs were by spine interventions...very familiar to p.c.
now look at the spinal surgery business that p.c. is helping promote...according to Mirza and Deyo...implants alone for spine surgery generate 2 billion in revenue...the implants alone! cost health care more than most interventional pain procedures
now look at Figure 1...250,000 spinal fusion surgeries were performed in 2001 and that rising trend may outstrip total knees and hips...according to DEyo the average inpatient hospitalization (EXCLUDING THE SPINE SURGEON's FEES) is 34,000
250, 000 x 34,000 = 8.5 billion dollars...and with physician fees it may top 10-12 billion
I feel your relentless criticism of interventional pain is in the hopes of keeping your spinal diagnostic business alive...the last thing you would want is an interventional pain physician to spoil your cozy party with your spinal surgery colleagues...here is your motto
'lets keep the spinal diagnostic and spinal surgery business alive...shall we?'
your acceptance of chronic pain as less of a biological problem and your lack of respect of interventional pain physicians and the premier clinic founded by JJ Bonica and subsequently headed by J. Loeser further underscores your ulterior motives not to mention your ignorance in recognizing the vast achievements in our understanding of chronic pain over the past 50 years...you have no interest in the psychological aspects of pain apart from trying to protect your turf
p.c....doesn't stand for politically correct medicine but paul...it stands for...
pork chop for me (spinal diagnostician and spine surgeon) and nay for you (pain physician and pain patients)
