Chronic pain practice without advanced procedures

[schmee90]

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Attendign for about two years pm&r background did a pain fellowhship. I was always intersted in more of a sports and spine practice with bread and butter spine procs ie ESI, RFA, peripheral joint injections. I obviously belive there is merit to neuromodulation and advanced procedures, but really have a goal of being a sports and spine practice. While I do have some experience with these procs during fellowship, I joined a practice that is very light on these types of procedures, and feel that the skills I have in fellowship are degrading a bit with SCS, vertifliex etc.

I have been considering doing some labs to keeps skills sharp but also questioning if I even want to keep these skills.

Any chronic pain doc have a practice were there are bascially sports and basic spine procs but dont really offer a whole lot of advanced procedures? DId you have any problems with finding jobs if you weren't intersted in advanced procs.

I feel like I would be fine in my current practice (salaried large medical system) just doing bread and butter procs for spine and peripheral joint stuff, but may have trouble in the future finding a job if I dont keep up skills in advanced procedures ie SCS,kypho, vertifliex, SIJ Fusion, etc.
As always thanks for any insight

 

[Taus]

Attendign for about two years pm&r background did a pain fellowhship. I was always intersted in more of a sports and spine practice with bread and butter spine procs ie ESI, RFA, peripheral joint injections. I obviously belive there is merit to neuromodulation and advanced procedures, but really have a goal of being a sports and spine practice. While I do have some experience with these procs during fellowship, I joined a practice that is very light on these types of procedures, and feel that the skills I have in fellowship are degrading a bit with SCS, vertifliex etc.

I have been considering doing some labs to keeps skills sharp but also questioning if I even want to keep these skills.

Any chronic pain doc have a practice were there are bascially sports and basic spine procs but dont really offer a whole lot of advanced procedures? DId you have any problems with finding jobs if you weren't intersted in advanced procs.

I feel like I would be fine in my current practice (salaried large medical system) just doing bread and butter procs for spine and peripheral joint stuff, but may have trouble in the future finding a job if I dont keep up skills in advanced procedures ie SCS,kypho, vertifliex, SIJ Fusion, etc.
As always thanks for any insight

does the practice forbid you from doing those procedures or your patients just don’t need them?

 

[schmee90]

does the practice forbid you from doing those procedures or your patients just don’t need them?

Historically sig difficulty in the state I practice in getting insurance approval, but most of it is the practice I am in has lots of peripheral joint mixed with the spine patients we see.

With so much peripheral joint mixed into our practice (which I like and feel comfortable with PM&R background) , it takes away from the amount of spine patients I see, which leads to less advanced procs.

 

[gaspasser127]

Depends on what you mean by advanced procedures. Peripheral joint practice could easily integrate PNS, percutaneous tenotomy (if your ortho overlords would ever be ok with it), and PRP if you want to consider that an advanced procedure.

DRG is also helpful for post surgical knee/hip pain.

Your joint patients are older and while your ortho surgeons are probably joint guys, it doesn’t mean there isn’t spinal pathology in those patients that wouldn’t be amenable to injections or even advanced procedures.

 

[runfastnow]

Attendign for about two years pm&r background did a pain fellowhship. I was always intersted in more of a sports and spine practice with bread and butter spine procs ie ESI, RFA, peripheral joint injections. I obviously belive there is merit to neuromodulation and advanced procedures, but really have a goal of being a sports and spine practice. While I do have some experience with these procs during fellowship, I joined a practice that is very light on these types of procedures, and feel that the skills I have in fellowship are degrading a bit with SCS, vertifliex etc.

I have been considering doing some labs to keeps skills sharp but also questioning if I even want to keep these skills.

Any chronic pain doc have a practice were there are bascially sports and basic spine procs but dont really offer a whole lot of advanced procedures? DId you have any problems with finding jobs if you weren't intersted in advanced procs.

I feel like I would be fine in my current practice (salaried large medical system) just doing bread and butter procs for spine and peripheral joint stuff, but may have trouble in the future finding a job if I dont keep up skills in advanced procedures ie SCS,kypho, vertifliex, SIJ Fusion, etc.
As always thanks for any insight

I'm in a nearly identical scenario as you are. Ortho practice historically based on sports + joints. Lots of Medicare aged people with your typical degenerative stuff all over. I've let SCS, kyphos go away; but do ESI, RF, MILD, Sprint, PRP, tenotomy, EMG, and USG stuff.

Any SCS I send to a pain colleague who does a great job. Any kyphos I send to IR colleague. Both get patients in right away and perform procedures as fast as I would if I kept the patient. All total its maybe 10-15 patients a year I send out to them. That isn't enough in my patient mix to go back and freshen up skills. If it creeps up to 40-50/year I would certainly consider to re-train as that would be enough volume to stay competent and financially worth the effort.

 

[Taus]

I'm in a nearly identical scenario as you are. Ortho practice historically based on sports + joints. Lots of Medicare aged people with your typical degenerative stuff all over. I've let SCS, kyphos go away; but do ESI, RF, MILD, Sprint, PRP, tenotomy, EMG, and USG stuff.

Any SCS I send to a pain colleague who does a great job. Any kyphos I send to IR colleague. Both get patients in right away and perform procedures as fast as I would if I kept the patient. In total it’s maybe 10-15 patients a year I send out to them. That isn't enough in my patient mix to go back and freshen up skills. If it creeps up to 40-50/year I would certainly consider to re-train as that would be enough volume to stay competent and financially worth the effort.

Ortho practice, all spine, some emg. I do 10-15 scs trials a year. Send out implants. I can do kypho, but send out the handful/year that need it. Those were business decisions…. Unless you own significant number shares in your asc, you lose a lot of money on each and every one of those cases vs B&B in office. Excellent local colleagues happy to get those in quickly and do a great job. Contemplating office kypho…. But not sure worth the hassle vs just send out.

No role for mild, as I have excellent surgical colleagues who can do an endoscopic lami. I send out 2-3/year for vertiflex or similar when they’re truly not a surgical candidate and it seems appropriate.

I see zero role for a pain doc doing any kind of arthrodesis for any reason.

Bread and butter is bread and butter for a reason…. Most people simply don’t need more than that. Some need surgery. Some need no more procedures.

 

[RoloTomassi]

I have excellent surgical colleagues who can do an endoscopic lami

Do you know what system they use?

 

[Taus]

Do you know what system they use?

No, I can ask

 

[bedrock]

No, I can ask

I’d like to know too. And, I’d like to know what kind of anesthesia is needed for the endoscopic lami?

The anesthesia is often the limiting factor

 

[MitchLevi]

GA Society Pain meeting this yr had a PMR guy who does endoscopic surgeries and there’s no way I’d start that process. Prob takes at least 3 yrs to get good at it, and his presentation was way outside of my comfort zone.

Wasted lecture IMO. Few ppl are going to basically restart their career, which is prob what it takes to incorporate that into your practice.

 

[bedrock]

GA Society Pain meeting this yr had a PMR guy who does endoscopic surgeries and there’s no way I’d start that process. Prob takes at least 3 yrs to get good at it, and his presentation was way outside of my comfort zone.

Wasted lecture IMO. Few ppl are going to basically restart their career, which is prob what it takes to incorporate that into your practice.

And who even pays for this , just PI? WC back in the day?

And how do you even get 3 years of experience to get good, when no one pays for it?

Did that PMR do endoscopics lami? I’ve seen a few. I can understand how they do endoscopic disectomies and facet ablations.

Less clear on endoscopic lamis

 

[MitchLevi]

And who even pays for this , just PI? WC back in the day?

And how do you even get 3 years of experience to get good, when no one pays for it?

Did that PMR do endoscopics lami? I’ve seen a few. I can understand how they do endoscopic disectomies and facet ablations.

Less clear on endoscopic lamis

TBH, I tuned him out after about 10 min bc I’m not restructuring my entire practice. Surgical anatomy in the spine is foreign to me. I have no idea what I’m looking at and there prob will be complications along the way that I’m just not in the mood to manage.

Payers I’m not sure man.

The 3 year statement is just my opinion, and I got that number from SCS. I believe it takes about 50 solo trials and around the same number of implants to be good at SCS. That takes 3 years or so when you first introduce stim to your practice IMO.

The presenter at GSIPP was a super nice guy and it was an impressive PPT presentation, but no one in that audience truly GAF bc he really wasn’t speaking to us. Maybe I misread the situation, and maybe there will be ppl who do it but def not me.

Let the surgeon do surgery.

 

[swamprat]

And who even pays for this , just PI? WC back in the day?

And how do you even get 3 years of experience to get good, when no one pays for it?

Did that PMR do endoscopics lami? I’ve seen a few. I can understand how they do endoscopic disectomies and facet ablations.

Less clear on endoscopic lamis

I do them. They are hard. Results are good and it takes a long time to do so its more of a passion than anything else if you want to get into them. From a cognitive perspective its simple - you dock on the facet, clear off all the soft tissue debris until you see bone, use a drill of some sorta to shave down the IAP into the cranial lamina and then use endoscopic kerrisons to undercut the thin lamina left and take out the ligament. The nice thing about endoscopic is once you traverse the yellow ligament the water pressure pushes the dura and traversing nerve root away and essentially as a retractor.

 

[giddyup]

I have multiple colleagues I am close with who work at an ortho practice in my town and only do bread and butter and are making 1 - 1.3 a year. Definitely possible. Half clinic half procedures every day and they have half partnership within the ortho group which includes surgery center and PT and MRI revenue.

 

[Dr. Ice]

I have multiple colleagues I am close with who work at an ortho practice in my town and only do bread and butter and are making 1 - 1.3 a year. Definitely possible. Half clinic half procedures every day and they have half partnership within the ortho group which includes surgery center and PT and MRI revenue.

Geographic location?

 

[giddyup]

Geographic location?

Midwest larger city not Chicago

 

[Dr. Ice]

There to

Midwest larger city not Chicago

There you go

 

[knoxdoc]

Regarding OP - you are describing my practice to a T. I'm with an ortho group and do all B&B. No kypho (spine surgeon wants those), no stim (local pain doc wants those), no pumps (does anyone want those?), no mild (just send to spine surgery). I have no desire to push any boundaries at this point. I do a ton of EMG and that's what sets me apart in the group (I'm the only one doing them). I previously did a lot of sports (got the certification), but don't even bother with much of that now. So to answer your question - Yes to pure B&B. I wouldn't have it any other way.

 

[MitchLevi]

A busy pain doctor doing basic pain management can make a lot of money and positively impact their community. It is a very good gig.

 

[Dr. Ice]

A busy pain doctor doing basic pain management can make a lot of money and positively impact their community. It is a very good gig.

Geography geography and contracts contracts…

If all my mostly unwanted posts on here mean anything to youngins and/or new grads. If you don’t have some absurd political dogmatic belief, don’t work in the northeast. If your spouse needs to be there, show he, she, it, the math and they will sing another tune. The northeast will rob your soul of everything just so you can say you aristocratically live there

 

[BobBarker]

If the most advanced thing you do is a cervical RFA but you do a great job at them and everything else then you will do well in your career in any setting.

 

[klumpke]

Just wanted to bump this thread- any new grads have any insight on findings jobs with no expectations of advanced procedures? I would like a primarily B&B and peripheral joint practice and just want to get more data points on how feasible this is.

Thanks in advance!

 

[clubdeac]

Just wanted to bump this thread- any new grads have any insight on findings jobs with no expectations of advanced procedures? I would like a primarily B&B and peripheral joint practice and just want to get more data points on how feasible this is.

Thanks in advance!

I haven’t been in the job market for a bit but I would assume you’d be fine in any large orthopedic or neurosurgery practice. Typically they aren’t all that interested in stim or any of the minor surgical procedures that could be seen as encroaching on their turf. Bread and butter is where it’s at

 

[BobBarker]

Yes, that is fine. Many private pain docs would love to have you as well.

 

[klumpke]

Awesome thanks guys!

 

[MitchLevi]

Awesome thanks guys!

Standard pain management is a homerun in the majority of cases. Safe, predictable and prints money if you can keep the line moving. It allows surgeons to do surgery and more specifically, you give them the ability to leave the room and move to the next patient. Don't forget that.

 

[swamprat]

This thread is atrocious - unless you are boomers or close to retirement you are doing the field a disservice. Or you have terrible hands and prob shouldn't even be placing needles anywhere near anyones spine. Good luck - CMS will chop peripheral blocks and RFA. Your anti opioid and pharmacies won't fill it anyway because now your a pill mill. You have what? Epidurals, rfa? Joints ortho wants anyway - can bill for that arthrogram after all. Glad it is not the case amongst my circle of pain docs and spine surgeons.

 

[oneforfighting]

If you do rural med you can practice however you like

 

[lobelsteve]

This thread is atrocious - unless you are boomers or close to retirement you are doing the field a disservice. Or you have terrible hands and prob shouldn't even be placing needles anywhere near anyones spine. Good luck - CMS will chop peripheral blocks and RFA. Your anti opioid and pharmacies won't fill it anyway because now your a pill mill. You have what? Epidurals, rfa? Joints ortho wants anyway - can bill for that arthrogram after all. Glad it is not the case amongst my circle of pain docs and spine surgeons.

Tell us how you feel...

 

[clubdeac]

This thread is atrocious - unless you are boomers or close to retirement you are doing the field a disservice. Or you have terrible hands and prob shouldn't even be placing needles anywhere near anyones spine. Good luck - CMS will chop peripheral blocks and RFA. Your anti opioid and pharmacies won't fill it anyway because now your a pill mill. You have what? Epidurals, rfa? Joints ortho wants anyway - can bill for that arthrogram after all. Glad it is not the case amongst my circle of pain docs and spine surgeons.

Actually, I can name four or five docs off the top of my head who are really big into all the new shiny toys and “pain surgery” procedures. They are also known to have some of the worst hands in the field so I’m not sure technical skill has anything to do with it. Probably has more to do with ones belief that all pain can be cured with a procedure, risk aversion and comfort and satisfaction in ones current situation.

 

[lobelsteve]

Actually, I can name four or five docs off the top of my head who are really big into all the new shiny toys and “pain surgery” procedures. They are also known to have some of the worst hands in the field so I’m not sure technical skill has anything to do with it. Probably has more to do with ones belief that all pain can be cured with a procedure, risk of aversiveness and comfort and satisfaction in ones current situation.

Pain Surgeons will separate from pain doctors.

 

[Magnus Acus]

My question is regarding standard of care.

Clearly, offering patients every pain surgeon gadget/toy/bone juice/whatever at cash pay prices is wrong and an issue that this field has to contend with. However, is it below the standard of care to offer excellent intracept candidates (a procedure i think with very good evidence) oxy 5s or PT only? What about offering RFA candidates PT, bracing and mindfullness?

It seems that unless the totally non-interventional pain doc heavily refers all candidates for procedures to a partner, they are at risk of allowing excess suffering. I (unfortunately) know many patients suffering at this very moment from seeing non-interventional pain docs who tell patients to their face that "there's nothing we can do for your facetogenic LBP since therapy and bracing didn't work".

 

[Dr. Ice]

My question is regarding standard of care.

Clearly, offering patients every pain surgeon gadget/toy/bone juice/whatever at cash pay prices is wrong and an issue that this field has to contend with. However, is it below the standard of care to offer excellent intracept candidates (a procedure i think with very good evidence) oxy 5s or PT only? What about offering RFA candidates PT, bracing and mindfullness?

It seems that unless the totally non-interventional pain doc heavily refers all candidates for procedures to a partner, they are at risk of allowing excess suffering. I (unfortunately) know many patients suffering at this very moment from seeing non-interventional pain docs who tell patients to their face that "there's nothing we can do for your facetogenic LBP since therapy and bracing didn't work".

Where is there a lack of interventional docs? Where I’m at there is someone in every street corner and within a block of me. Someone is being recommended some type of procedure here invariably whether they need it or not. Maybe this is a geographic thing

 

[Magnus Acus]

I mostly bring this up since the conversation in this thread is essentially describing how to thrive as a non-interventional or minimally interventional pain doc. Having seen a lot of this done very poorly, I wanted to give my perspective.

Though to answer your question, while seeing patients in my hometown, internship, and residency it was not as easy as you may suspect to get patients appropriate care- even a reliable pipeline for B&B pain procedures. Residency done at household name university hospital in northeast and would have absolutely no clue how to get patients an advanced pain procedure of any kind (PNS, SCS, intracept, mild). Major spine surgery or deal with it, such places exist.

 

[Ducttape]

My question is regarding standard of care.

Clearly, offering patients every pain surgeon gadget/toy/bone juice/whatever at cash pay prices is wrong and an issue that this field has to contend with. However, is it below the standard of care to offer excellent intracept candidates (a procedure i think with very good evidence) oxy 5s or PT only? What about offering RFA candidates PT, bracing and mindfullness?

It seems that unless the totally non-interventional pain doc heavily refers all candidates for procedures to a partner, they are at risk of allowing excess suffering. I (unfortunately) know many patients suffering at this very moment from seeing non-interventional pain docs who tell patients to their face that "there's nothing we can do for your facetogenic LBP since therapy and bracing didn't work".

yes.

standard of care does not include elective procedural treatment. injections are an adjunct and a component of comprehensive care management, not the end all.



your view on pain treatment seems awfully focused on interventional therapy as the cure to "excess suffering".


one can argue that focusing on non-interventional treatment could provide the patient with better long term outcomes; i am unaware of any studies that show that interventional therapy improves long term pain outcomes, where as there are indications that lifestyle modifications, weight loss, behavioral health activities can do so.

 

[Magnus Acus]

I'm not sure why my perspective was seen as adversarial, i think it's fairly conservative really. I specifically mentioned not abusing procedures for all but excellent candidates. Also, you used the words "cure" and "long term", not me. Preventing excess suffering would be involve reducing the patient's current suffering, which yes, some interventions can do - especially over the short term. Also, I never mentioned not adhering to lifestyle modifications, weight loss and behavioral health activities, of course this would be the primary intervention. It feels that you are trying to view me in a box that I am not in.

All I wanted to say was that some advanced procedures may help patients who are excellent candidates and have failed conservative options. Therefore, in my view, it would behoove an excellent pain physician to not extricate themselves from all advanced or new procedures in order to best serve our patients (the topic of this thread).

 

[clubdeac]

My question is regarding standard of care.

Clearly, offering patients every pain surgeon gadget/toy/bone juice/whatever at cash pay prices is wrong and an issue that this field has to contend with. However, is it below the standard of care to offer excellent intracept candidates (a procedure i think with very good evidence) oxy 5s or PT only? What about offering RFA candidates PT, bracing and mindfullness?

It seems that unless the totally non-interventional pain doc heavily refers all candidates for procedures to a partner, they are at risk of allowing excess suffering. I (unfortunately) know many patients suffering at this very moment from seeing non-interventional pain docs who tell patients to their face that "there's nothing we can do for your facetogenic LBP since therapy and bracing didn't work".

I think procedures are fine after failing 6 weeks of conservative care

 

[lobelsteve]

Gentlemen, a new KOL is born before our eyes.

 

[Ducttape]

you equate using interventional procedures as the way to get rid of excess suffering. you wonder if it is standard of care to provide interventional procedures, a statement that seems to suggest is mandatory to offer. you then state that someone only offering noninterventional care is a risk of allowing excess suffering and imply that injections are "appropriate care".

you are talking out both sides of your mouth.


injections can help. injections can be part of a comprehensive management program. but not offering a specific procedure is not outside the standard of care.

 

[Magnus Acus]

Well, I really respect you and Steve, I won’t say anything more on the topic.

 

[lobelsteve]

Well, I really respect you and Steve, I won’t say anything more on the topic.

Treat as aggressively as you desire. As you move on in your career, you realize how little a difference we make. Especially compared to diet and exercises and mental health.

 

[Agast]

we can talk a good game about all the sexy new advanced procedures that exist for interventional pain management, but it’s not a great look when many of them can only be done on primary Medicare patients

 

[nvrsumr]

Before the midlevel boom but during peak pills it was pretty common to have noninterventional docs feed the interventionist.

For @swamprat xstop, spine endoscopy, scs and pns were being done 20 years ago. Barely any advancement in the field despite years of earnest PI docs doing their best for humanity.

It’s bread and butter for a reason

 

[jsaul]

Before the midlevel boom but during peak pills it was pretty common to have noninterventional docs feed the interventionist.

For @swamprat xstop, spine endoscopy, scs and pns were being done 20 years ago. Barely any advancement in the field despite years of earnest PI docs doing their best for humanity.

It’s bread and butter for a reason

Also Stryker disc dekompressor, IDET, etc. Remember those

 

[cowboydoc]

Pour out some methylene blue for our homies!

 

[Laryngospasm]

Treat as aggressively as you desire. As you move on in your career, you realize how little a difference we make. Especially compared to diet and exercises and mental health.

Yes if 90% of our patients had spent more time on these things they would never see us in the first place. The unfortunate irony is that by the time many of them do they are so far gone there is nothing we can really do realistically for any significant relief. The new gen glps will provide far more than we ever did.

 

[Dr. Ice]

Ah yes the GLPs..no one to get an emergent surgery because anesthesia will block for fear of that undigested piece of chicken hanging around in there..,

 

[specepic]

To answer the OP:

I don't do 'advanced' procedures: i.e. SCS, kypho, pumps

I'm in an ortho group so do A LOT of USGI, and plenty of bread and butter fluoro. I'm PM&R/DO so also do a lot of OMT, acup, etc. Also do opioid management in a sparing/controlled manner

Frankly I am so busy I don't have the bandwidth to add more stuff. I try to be as sharp as possible with the simpler procedures

Fortunate to be at a hosiptal and group where I can shape my own practice w/o being micromanaged.

Just be productive, run on time (mostly), care about your craft, and have a good bedside manner and you will be very busy and enjoy your work

 

[Dr. Ice]

To answer the OP:

I don't do 'advanced' procedures: i.e. SCS, kypho, pumps

I'm in an ortho group so do A LOT of USGI, and plenty of bread and butter fluoro. I'm PM&R/DO so also do a lot of OMT, acup, etc. Also do opioid management in a sparing/controlled manner

Frankly I am so busy I don't have the bandwidth to add more stuff. I try to be as sharp as possible with the simpler procedures

Fortunate to be at a hosiptal and group where I can shape my own practice w/o being micromanaged.

Just be productive, run on time (mostly), care about your craft, and have a good bedside manner and you will be very busy and enjoy your work

Are you RVU based? Do you do regen? If so, does it make sense to do it in that set up? I have been debating adding it, but I’m already booking out a few weeks and I’ve only been working since July. It’s also a little bit of a turf issues, as the sports guys already do it

 

[cowboydoc]

Are you RVU based? Do you do regen? If so, does it make sense to do it in that set up? I have been debating adding it, but I’m already booking out a few weeks and I’ve only been working since July. It’s also a little bit of a turf issues, as the sports guys already do it

See other thread, where he’s the OP discussing adding it. Based on what you’ve described and the “turf issues,” I would consider punting regen to the docs who do it frequently if you have a decent working relationship and there is not a significant incentive for you to do it.

If you’re already busy, you will be looking to narrow your focus soon. Don’t add something that you’re not really in to.

If you are really interested in regen, and the option is not readily available for your patients, then I would certainly not discourage you from pursuing it.

I have added PRP to my services offered, but in the RVU model it’s not particularly lucrative. There are several other procedures that I readily punt to colleagues in different situations. I sent kyphos to a private practice doc. He does them in office, takes good care of people. Same goes for many of the newer “advanced“ procedures.