Chronic pain practice without advanced procedures

[schmee90]

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

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[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.