Compensation for Pain Doctors

[Sandhumd]

Hello,
I have shadowed a couple of pain doctors and have found great interest in the field. My plan is to do an anesthesia residency followed by a pain managment fellowship. I would then like to do mainly a procedure-based private pain practice. I would like to know, from fellow sdners and pain doctors out there, what the compensation and lifestyle is like for a pain physician as these are important factors, however these are not the ultimate factors in deciding what I want to do with my life. Any info is much appreciated.

Thank you and Regards in advance

---

Members don't see this ad.

 

[Aether2000]

First of all, congrats on your decision. Secondly, don't carve your decision in stone at this very early time, since pain medicine will rapidly evolve over the next few years. The idea of being solely a proceduralist (ie. technician rather than a physician), is financially very lucrative at this time, but this type of practice is squarely in the gunsights of Medicare and insurers since there has been an enormous growth in the number of these procedures over the past 3 years. Medicare undoubtedly will attempt to cut the physician fees by 1/3 or more and other insurers are likely to follow. Thirdly, pain fellowships will begin to change rapidly this year due to new standardization adopted by the ABMS and ABA, and it is expected a number of anesthesia based fellowships will not survive the new site visits and drastically enhanced requirements over the next few years. Whatever your decision regarding pain medicine as a profession, rest assured the profession you see now will not be the profession of 5 years from now.

 

[Sandhumd]

thanks for your input. Just one comment though; would you rather have a technician or a trained pain physician undergo a spinal procedure on you to help reduce your pain? It seems that a lot of people talk about technicians taking over a wide array of physician-directed procedures. I'm not saying that this is not possible, just that people seem to worrying a little too much (however, this isn't surprising coming from medically-related scholars)

 

[Aether2000]

It matters little what I would want in terms of qualifications for performing technician procedures: what is important is what patients want or what they will accept. There are many CRNAs masquerading as physicians, waltzing in and introducing themselves as "first name-last name" or even worse, some are attempting to acquire a PhD or equivalent so they can introduce themselves as "doctor". There are radiology technicians performing interventional spine procedures under the "supervision" of a physician that may be in a different building, CRNAs performing both diagnostic and therapeutic spine procedures and spine surgery (RF, vertebroplasty, etc) that have a weekend warrior course behind them, and some nurse practitioners performing interventional spine procedures. Because we do not have a residency program in pain medicine, the profession is being infiltrated by these untrained uneducated charlatans that are paid the same as you, my friend for performing a technician's role. Pain medicine cannot market itself as a viable discipline that can be differentiated in the eye of the public from the ersatz injectionists until we have a residency, not a fellowship. Therefore acting solely as a technician in pain medicine is really no different than being a non-physician doing the same as far as the public and insurers are concerned.

 

[paz5559]

It matters little what I would want in terms of qualifications for performing technician procedures: what is important is what patients want or what they will accept. There are many CRNAs masquerading as physicians, waltzing in and introducing themselves as "first name-last name" or even worse, some are attempting to acquire a PhD or equivalent so they can introduce themselves as "doctor". There are radiology technicians performing interventional spine procedures under the "supervision" of a physician that may be in a different building, CRNAs performing both diagnostic and therapeutic spine procedures and spine surgery (RF, vertebroplasty, etc) that have a weekend warrior course behind them, and some nurse practitioners performing interventional spine procedures. Because we do not have a residency program in pain medicine, the profession is being infiltrated by these untrained uneducated charlatans that are paid the same as you, my friend for performing a technician's role. Pain medicine cannot market itself as a viable discipline that can be differentiated in the eye of the public from the ersatz injectionists until we have a residency, not a fellowship. Therefore acting solely as a technician in pain medicine is really no different than being a non-physician doing the same as far as the public and insurers are concerned.

Pejorative labels like "technician" or "block jock" are names academics use to disparage interventional pain physicians in the private sector, and need to be avoided.

It strikes me that anytime a spine surgeon sends you a patient and requests a discogram, you are functioning as a technician, yet I would doubt many of us would see that as abusive (which is what those names really imply).

The George Carlin routine that everyone going slower than you on the highway is an idiot, and everyone going faster than you is a *****, seems applicable here.

So long as you think, I see no reason why keeping the PCP, MSK PM&R, or IM involved for medication management of a stable patient, while you APPROPRIATELY select patients for procedures as the backbone of your practice.

The mantra of right patient, right doctor, and right procedure remains primary, but assuming all three of those components are in place, being an interventionist/proceduralist etc. to me is no different than being an interventional cardiologist; where handing off the pharmacotherapy to your non-interventional colleagues is not disparaged, but rather seen as a respected subspecialty in the field.

 

[drusso]

thanks for your input. Just one comment though; would you rather have a technician or a trained pain physician undergo a spinal procedure on you to help reduce your pain? It seems that a lot of people talk about technicians taking over a wide array of physician-directed procedures. I'm not saying that this is not possible, just that people seem to worrying a little too much (however, this isn't surprising coming from medically-related scholars)

Pain is complex. There are those situations where a simple procedure is all that a patient needs, but far more commonly patients require multi-modal treatments. Moreover, most painful conditions involves at least two organ systems (musculoskeletal and neurologic) and commonly psychiatric issues to boot.

In short, patients with pain complaints need technically-skilled DOCTORS. Patients can also tell if a physician is just out to make money off them by doing procedures: They don't perceive a 20 minute H&P, a procedure, and a $900 bill as good value for their health care.

 

[Mister Mxyzptlk]

The mantra of right patient, right doctor, and right procedure remains primary, but assuming all three of those components are in place, being an interventionist/proceduralist etc. to me is no different than being an interventional cardiologist; where handing off the pharmacotherapy to your non-interventional colleagues is not disparaged, but rather seen as a respected subspecialty in the field.

If you tried that approach in my area you'd have zero referrals. All the pain docs here do comprehensive pain management. If you have compassion for your patients and want them to have the best possible pain management you have to do it yourself. The typical internist/FP is either too clueless or too afraid to properly do opioid management.

[rant mode on]

The root post asked about compensation. I know it's a factor but I am sick of the predators out there who exploit patients for monetary gain. If you lust after money and have a sociopathic disregard for the suffering of others - seeing them only as meat on the hoof - please go into something like pathology where you can't directly harm someone with your greed. Pain management is already "full". So is spine surgery, for that matter. Radiology is an excellent field for people who want to do procedures without getting into messy things like writing prescriptions.

Procedures are just a piece of pain management. The chronic sufferers have complex psychosocial problems that often take years to unravel, and you cannot alleviate their pain until you get them through those issues. I see a lot of patients far more than their FP. I might work on someone for 5+ years to put them back together.

The relationships that have developed over the years are priceless. I have plenty of patients going back 10 or more years. On a regular basis someone will ask me to please never leave the area, or they will say they include me in their prayers, or send a thank-you note. After almost 28 years I still get a charge when I see a pain scale of zero, or a patient tells me they have gone back to work for the first time in 3 years. You will not get this experience with a few weeks of rotations or a year of fellowship. Besides, it's boring isn't it? Everyone wants to see a trigeminal ablation but nobody really cares about how you treat concurrent pain and depression.

If I hit the lottery I'd still go to work every day. Some of the docs in my area are well past retirement age but they keep practicing because they love it. One of the FPs is 71, reads the literature voraciously and still has med students rounding with him. I'd like to think doctors are still being cranked out who feel that way, but since the Michael Milken years of the 80s it seems to be all about the money and who cares who gets hurt.

[rant mode off]

 

[Disciple]

The mantra of right patient, right doctor, and right procedure remains primary, but assuming all three of those components are in place, being an interventionist/proceduralist etc. to me is no different than being an interventional cardiologist; where handing off the pharmacotherapy to your non-interventional colleagues is not disparaged, but rather seen as a respected subspecialty in the field.

I can only see this being feasible in a rural or underserved area. I have limited experience, but the geographic region I'm in is full or interventional pain docs. The PCPs refer patients when the opiate dosages start getting out of their comfort zone or if they don't want to do the opiate management in the first place. If I do a bunch of procedures on their patients, that's fine with them so long as I take care of the opiates and the pain complaints in general, so they don't have to hear about it when the patient's go to seem them. If I don't feel like doing this, they just start referring to the guy across the street.

 

[Disciple]

So long as you think, I see no reason why keeping the PCP, MSK PM&R, or IM involved for medication management of a stable patient, while you APPROPRIATELY select patients for procedures as the backbone of your practice.

Last time I checked MSK Physiatrists were even less inclined to manage opiates than interventional pain docs.

 

[Spine Specialist]

The relationships that have developed over the years are priceless. I have plenty of patients going back 10 or more years. On a regular basis someone will ask me to please never leave the area, or they will say they include me in their prayers, or send a thank-you note. After almost 28 years I still get a charge when I see a pain scale of zero, or a patient tells me they have gone back to work for the first time in 3 years. You will not get this experience with a few weeks of rotations or a year of fellowship. Besides, it's boring isn't it? Everyone wants to see a trigeminal ablation but nobody really cares about how you treat concurrent pain and depression.

If I hit the lottery I'd still go to work every day. Some of the docs in my area are well past retirement age but they keep practicing because they love it. One of the FPs is 71, reads the literature voraciously and still has med students rounding with him. I'd like to think doctors are still being cranked out who feel that way, but since the Michael Milken years of the 80s it seems to be all about the money and who cares who gets hurt.

Awww..gorback i wanna be just like you + algos when i grow up!

 

[Mister Mxyzptlk]

Awww..gorback i wanna be just like you + algos when i grow up!

Shouldn't that be "if"?

 

[Aether2000]

It is very likely gorback and I will both die in office....

 

[PainDr]

I can only see this being feasible in a rural or underserved area. I have limited experience, but the geographic region I'm in is full or interventional pain docs.

Actually, it's not feasible in these situations either. I'm in a fairly rural area and all the PCPs fully expect me to manage meds (which I'm happy to do). If I refused to practce comprehensive care, they'd just send patients to "the city", about 50 miles away, which is what they did before I arrived.

 

[Spine Specialist]

If I hit the lottery I'd still go to work every day.

If algos hit the lotto i know for sure he would still be coming to painrounds every single day and answering all the silly questions from kidos.

 

[mille125]

Actually, it's not feasible in these situations either. I'm in a fairly rural area and all the PCPs fully expect me to manage meds (which I'm happy to do). If I refused to practce comprehensive care, they'd just send patients to "the city", about 50 miles away, which is what they did before I arrived.

ditto

 

[lobelsteve]

BTW, opioids work pretty good for pain.
Not using opioids as your blanket statement towards care is reprehensible and I think malpractice for a pain physician. Kind of like writing for Darvocet.
You should know better.

Given, opioids pose a unique risk not sen in other branches of medicine- abuse, addiction, diversion. But you didn't choose another branch of medicine. Imagine the cardiologist who refuses to Rx beta blockers because may slow the heart rate too much (or whatever the crazy anti-drug people are saying bad about beta blockes- remeber when they caused or ruined diabetic FBS control?).

It's a tool in your toolbox, and you better use it.

 

[Alpamayo]

Sandhumd -
Let's face it ... you won't be poor if you go into pain medicine. You'll likely be better compensated than most anesthesiologists. But as algosdoc indicated in his thread, there is going to be a lot of change coming in reimbursement...and you've got a ways to go. Go into pain medicine because you're going to enjoy it. But first, focus on being an outstanding physician, whether it's in anesthesiology, pmr...etc. I'm only two years into practicing on my own, I come from an anesthesiology background, and I'm pain fellowship trained. I chose to go into pain medicine because it afforded me more autonomy than being an anesthesiologist in an OR, and interventional pain because I love doing procedures. But with that comes a great deal of responsibility - you better be aware of what the complications are of every procedure you do, how to avoid them, and what to do emergently if they occur. Furthemore, injections are only part of the game - they compliment physical therapy, counselling, and medication management. I'm not so sure a "techician" can is facile in all these aspects of care. Also, recognize that the specialty of pain medicine is exploding with new techniques, treatments and just overall knowledge. You need to be well versed in PMR, psychology, spine surgery, oncology, ortho...for these will be your peers. Your patients [and colleagues] will be able to tell the difference between a "technician" vs a physician quickly. Medication management is part of the deal as well, although, working closely with nurses / PA's can help manage your time more efficiently, especially with tough patients. As you go through your training, focus on creating an enormous skill set in as many areas as possible [it's tought to compete with a doc who can do it all, and you have that many more options to treat patients]. Trust me, injections get routine after a while, so don't look at it as being a technician vs a physician....Strive to be a great physician with extraordinary technical skill...this will set you apart from the pack, your peers will refer to you because you can handle anything that comes your way. Good luck to you in your pursuit....

 

[peduncle]

so everyone anticipates that pain physicians will be especially hit when reimbursements are cut?

 

[Spine Specialist]

Sandhumd -
Let's face it ... you won't be poor if you go into pain medicine. You'll likely be better compensated than most anesthesiologists. But as algosdoc indicated in his thread, there is going to be a lot of change coming in reimbursement...and you've got a ways to go. Go into pain medicine because you're going to enjoy it. But first, focus on being an outstanding physician, whether it's in anesthesiology, pmr...etc. I'm only two years into practicing on my own, I come from an anesthesiology background, and I'm pain fellowship trained. I chose to go into pain medicine because it afforded me more autonomy than being an anesthesiologist in an OR, and interventional pain because I love doing procedures. But with that comes a great deal of responsibility - you better be aware of what the complications are of every procedure you do, how to avoid them, and what to do emergently if they occur. Furthemore, injections are only part of the game - they compliment physical therapy, counselling, and medication management. I'm not so sure a "techician" can is facile in all these aspects of care. Also, recognize that the specialty of pain medicine is exploding with new techniques, treatments and just overall knowledge. You need to be well versed in PMR, psychology, spine surgery, oncology, ortho...for these will be your peers. Your patients [and colleagues] will be able to tell the difference between a "technician" vs a physician quickly. Medication management is part of the deal as well, although, working closely with nurses / PA's can help manage your time more efficiently, especially with tough patients. As you go through your training, focus on creating an enormous skill set in as many areas as possible [it's tought to compete with a doc who can do it all, and you have that many more options to treat patients]. Trust me, injections get routine after a while, so don't look at it as being a technician vs a physician....Strive to be a great physician with extraordinary technical skill...this will set you apart from the pack, your peers will refer to you because you can handle anything that comes your way. Good luck to you in your pursuit....

awesome.... you guys inspire me...great first post to read today....

 

[Doctodd]

great post but sobering......cuz i want to open up an ASC. Well.....the plan is still to have a multispecialty ASC, but the task of learning how and then undertaking the whole process is daunting. Then id probably get blacklisted by the hospital. So much politics.

T