Degree of Surprise? Zero percent.

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I’m not a pain doctor but in my opinion, chronic pain management and anesthesiology are completely different jobs. They should have separate residencies.

Comments on that article by pain docs are also revealing.

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Some good jobs still exist but for the most part the pain docs did it to themselves. The ACGME went hog wild and let people from multiple paths into pain fellowships, pain docs started doing absurd numbers of procedures, and of course pain docs pushed opiates and other addictive medications. Insurance and Medicare/aid no longer want to pay for anything and it isn’t worth going through the approval process for diminishing returns.
 
GassYous said:
I think it's like rad onc. If you already have a job things are good but if you're just starting out it's tough. I know some people who are banking.
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You nailed it.

Just like the anesthesia job market. Those who were partners already by 1994 still did well between 1994-2000

Same with the early 2010s. The partners still did well. The newer people did not do well.

My pain friend (he’s 40) has a 20% soon to be 30% stake in surgery center. He’s making a killing working 4 days a week. 1.6 million last year. He covers some bs 100% supervision general/mac cases for lowly $250/hr just out of boredom and not be at home down the street from his house once in while for 6 hours.

But his in the south. He looked into moving to Miami and it’s bad prospects for him to setup shop in new location.

So pain is good for people already established
 
P

Thread 'Pain versus cardiac fellowship?'

I like both pain and cardiac, but can’t decide between the two. I know they are vastly different, but I would just like some extra training after residency and was wondering what attendings/people with more experience than me would advise? Thank you

Some interesting and contentious discussion about pain practice in that thread. Wherever you fall on that issue, I think everyone can probably agree that pain has an image problem at the very least. Between that and the burning hot market for generalist anesthesiologists, I'm not surprised pain fellowships aren't filling.
 
I'm years out from finishing residency, but I think sometimes how great it would be to do a fellowship in cardiac or regional for the extra skill set and level of personal comfort with cases. I would never do pain though hahaha
 
PainDrain said:
Some good jobs still exist but for the most part the pain docs did it to themselves. The ACGME went hog wild and let people from multiple paths into pain fellowships, pain docs started doing absurd numbers of procedures, and of course pain docs pushed opiates and other addictive medications. Insurance and Medicare/aid no longer want to pay for anything and it isn’t worth going through the approval process for diminishing returns.
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Agreed. Seems like any residency can now do a fellowship in Chronic Pain. Try getting into Cardiology or GI fellowships from outside IM. Not going to happen, door is closed. When you open the flood gates, this is what happens, market gets flooded. Our local fellowship rarely has anesthesia residents coming through their fellowship program (all PM&R, EM, Psych, and Neuro). Had a younger Psych-trained pain attending during residency that some of us rotated with. Watching them do procedures was ghastly.
 
PainDrain said:
Some good jobs still exist but for the most part the pain docs did it to themselves. The ACGME went hog wild and let people from multiple paths into pain fellowships, pain docs started doing absurd numbers of procedures, and of course pain docs pushed opiates and other addictive medications. Insurance and Medicare/aid no longer want to pay for anything and it isn’t worth going through the approval process for diminishing returns.
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Don't forget the nurses are operating their own pill mills, ketamine clinics, and "pain clinics". Such a joke.
 
coffeebythelake said:
I'm years out from finishing residency, but I think sometimes how great it would be to do a fellowship in cardiac or regional for the extra skill set and level of personal comfort with cases. I would never do pain though hahaha
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What extra skillset does a regional fellowship give you? We can all do blocks. A basic skill of anesthesia.
 
Maz777 said:
What extra skillset does a regional fellowship give you? We can all do blocks. A basic skill of anesthesia.
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U familiar, facile, and have high success rate, with SIFI, PENG, erector spinae, paravertebral, axillary, infraclav, ankle block, thoracic epidurals, QL blocks and others? I know about them, I've watched them on YouTube, I've done them with varying level of success. That isn't quite the level of competency I'm talking about
 
coffeebythelake said:
U familiar, facile, and have high success rate, with SIFI, PENG, erector spinae, paravertebral, axillary, infraclav, ankle block, thoracic epidurals, QL blocks and others? I know about them, I've watched them on YouTube, I've done them with varying level of success. That isn't quite the level of competency I'm talking about
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You don’t need a 1 year fellowship to learn them. You just need someone who knows how to do them well to show you the key highlights, tips, and tricks. If YouTube is not enough, a weekend course suffices. I was just at a course. One of the instructors joked that the difference between a regional anesthesiologist and a general anesthesiologist is about 10cc’s.
 
nimbus said:
You don’t need a 1 year fellowship to learn them. You just need someone who knows how to do them well to show you the key highlights, tips, and tricks. If YouTube is not enough, a weekend course suffices. I was just at a course. One of the instructors joked that the difference between a regional anesthesiologist and a general anesthesiologist is about 10cc’s.
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CRNAs do the Maverick course for a weekend and are regional fellowship trained
 
nimbus said:
You don’t need a 1 year fellowship to learn them. You just need someone who knows how to do them well to show you the key highlights, tips, and tricks. If YouTube is not enough, a weekend course suffices. I was just at a course. One of the instructors joked that the difference between a regional anesthesiologist and a general anesthesiologist is about 10cc’s.
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I'm not at all saying they're right (far from it so don't misinterpret this), but isn't this analogous to CRNAs claiming equivalence with physician anesthesiologists? I'm not regional fellowship trained, and know my limits, despite feeling pretty confident in my skills.

I feel minimizing the value of a year at a robust regional training program is similarly insulting as a nurse saying their clinical time makes them as proficient as a physician anesthesiologist. I'm not arguing that its necessary to become a successful anesthesiologist out in the real world, but don't try and tell me learning some "tips and tricks", YouTube and a weekend course puts you on par with the likes of Dr. Hernandez and other regional gurus.
 
SRYSPAC said:
I'm not at all saying they're right (far from it so don't misinterpret this), but isn't this analogous to CRNAs claiming equivalence with physician anesthesiologists? I'm not regional fellowship trained, and know my limits, despite feeling pretty confident in my skills.

I feel minimizing the value of a year at a robust regional training program is similarly insulting as a nurse saying their clinical time makes them as proficient as a physician anesthesiologist. I'm not arguing that its necessary to become a successful anesthesiologist out in the real world, but don't try and tell me learning some "tips and tricks", YouTube and a weekend course puts you on par with the likes of Dr. Hernandez and other regional gurus.
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The thing is I don’t need to be Dr. Hernandez. The weekend course was organized by an academic department where a dedicated block team does PVBs for most of their breast cases. The instructor told me they get a couple of pneumothaxes every year. Because I’m in PP and not academics, that just wouldn’t fly. I’d never do a PVB for a case that wasn’t already get a chest tube. We have several regional fellowship grads in our department, one from this program. Nobody does PVBs for breast cases. Everyone does the same basic blocks whether they did a fellowship or not.
 
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nimbus said:
The thing is I don’t need to be Dr. Hernandez. The weekend course was organized by an academic department where a dedicated block team does PVBs for most of their breast cases. The instructor told me they get a couple of pneumothaxes every year. Because I’m in PP and not academics, that just wouldn’t fly. I’d never do a PVB for a case that wasn’t already get a chest tube. We have several regional fellowship grads in our department, one from this program. Nobody does PVBs for breast cases. Everyone does the same basic blocks whether they did a fellowship or not.
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That's the whole point of my post; you don't need the fellowship to be competent at blocks and it's not necessary for everybody out in practice; your comments suggest you are just as good as someone that did a fellowship, but maybe that's just my misinterpretation if you weren't saying you know the ins and outs of all the blocks mentioned above.

On the flip side, it's kind of sad the instructor minimized their own "expertise," so maybe you're right :shrug:
 
SRYSPAC said:
That's the whole point of my post; you don't need the fellowship to be competent at blocks and it's not necessary for everybody out in practice; your comments suggest you are just as good as someone that did a fellowship, but maybe that's just my misinterpretation if you weren't saying you know the ins and outs of all the blocks mentioned above.

On the flip side, it's kind of sad the instructor minimized their own "expertise," so maybe you're right :shrug:
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I specifically took the course because I wanted to learn a methodical approach and to demystify QLB and PENG in my own head. One afternoon got the job done.

Also got some helpful advice to angle the probe to make the costotransverse ligament light up for PVB. Still will reserve for thoracic cases.
 
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nimbus said:
You don’t need a 1 year fellowship to learn them. You just need someone who knows how to do them well to show you the key highlights, tips, and tricks. If YouTube is not enough, a weekend course suffices. I was just at a course. One of the instructors joked that the difference between a regional anesthesiologist and a general anesthesiologist is about 10cc’s.
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Could you link the course if you don’t mind. Thanks in advance
 
coffeebythelake said:
U familiar, facile, and have high success rate, with SIFI, PENG, erector spinae, paravertebral, axillary, infraclav, ankle block, thoracic epidurals, QL blocks and others? I know about them, I've watched them on YouTube, I've done them with varying level of success. That isn't quite the level of competency I'm talking about
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Thanks for checking. Yes, perfectly facile.

Did you just really list an ankle block as an advanced "block"? You do understand that podiatrists do ankle infiltrations routinely in practice? And ESPs, QLs, SIFIs, and PENGs? Blocks that were literally "invented" because they are incredibly easy to do. Most of practicing regional isn't in learning how to do blocks. Blocks are very easy in the ultrasound era.

I only consider PVBs, IC caths, and thoracic epidurals as blocks that require any degree of technical expertise. But, again, you can learn any of these in practice if you have the appropriate volume and join the right practice. I've seen many a graduated regional fellows from "top-notch" programs who can't achieve a simple surgical block with a routine single-shot sciatic or brachial plexus, catheters threaded intravascular without recognition, large pneumothoraces needing chest tubes, etc. Very basic stuff. All from graduated regional fellows.
 
CubsDynasty said:
CRNAs do the Maverick course for a weekend and are regional fellowship trained
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I thought u meant Tom cruise maverick top gun character maverick.

Cowboy style anesthesia.
 
Maz777 said:
Thanks for checking. Yes, perfectly facile.

Did you just really list an ankle block as an advanced "block"? You do understand that podiatrists do ankle infiltrations routinely in practice? And ESPs, QLs, SIFIs, and PENGs? Blocks that were literally "invented" because they are incredibly easy to do. Most of practicing regional isn't in learning how to do blocks. Blocks are very easy in the ultrasound era.

I only consider PVBs, IC caths, and thoracic epidurals as blocks that require any degree of technical expertise. But, again, you can learn any of these in practice if you have the appropriate volume and join the right practice. I've seen many a graduated regional fellows from "top-notch" programs who can't achieve a simple surgical block with a routine single-shot sciatic or brachial plexus, catheters threaded intravascular without recognition, large pneumothoraces needing chest tubes, etc. Very basic stuff. All from graduated regional fellows.
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Yes. 100%.
It’s more about knowing which patient should get which block and why. And more importantly why they shouldn’t and how you manage them.

Same with pain medicine.

Putting a needle isn’t the hard part. Anyone with some concept of anatomy, good eye hand coordination can learn that.

Also, in my opinion the bread and butter regional anesthesia blocks:
(IC/SC/Ax/ACB/femoral/pop/saph/TAP/ PVB) will get you through > 95% of what’s required day to day. For my current setup I haven’t really had to do many fancy things. Once in a while I’ll do a thoracic epidural but it’s not that bad…

The major issue with catheters is as you all know is:

A) who’s going to manage post op issues and if there is dedicated staff for that
B) anti coagulation

So my personal preference is single shot.

My first two months of pain fellowship was me being fluoro tech for every other injection to get the view first.
 
AKMD_1984 said:
Yes. 100%.
It’s more about knowing which patient should get which block and why. And more importantly why they shouldn’t and how you manage them.

Same with pain medicine.

Putting a needle isn’t the hard part. Anyone with some concept of anatomy, good eye hand coordination can learn that.

Also, in my opinion the bread and butter regional anesthesia blocks:
(IC/SC/Ax/ACB/femoral/pop/saph/TAP/ PVB) will get you through > 95% of what’s required day to day. For my current setup I haven’t really had to do many fancy things. Once in a while I’ll do a thoracic epidural but it’s not that bad…

The major issue with catheters is as you all know is:

A) who’s going to manage post op issues and if there is dedicated staff for that
B) anti coagulation

So my personal preference is single shot.

My first two months of pain fellowship was me being fluoro tech for every other injection to get the view first.
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Do any beeper calls docs even do catheters any more? It’s simply not worth your time if you are covering the calls from the patient.
 
aneftp said:
Do any beeper calls docs even do catheters any more? It’s simply not worth your time if you are covering the calls from the patient.
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There’s a few surgeons at an ASC that I work at who demand catheters with on Q pump so they won’t have to take post op calls.
That practice is going away slowly too after people are realizing that there is liability with local anesthetics in unattended hands. I hope it goes away altogether.
In my opinion the risk/liability/headaches compared to benefits - do not justify PB infusions unless the patient truly needs it and is admitted and monitored.
 
AKMD_1984 said:
There’s a few surgeons at an ASC that I work at who demand catheters with on Q pump so they won’t have to take post op calls.
That practice is going away slowly too after people are realizing that there is liability with local anesthetics in unattended hands. I hope it goes away altogether.
In my opinion the risk/liability/headaches compared to benefits - do not justify PB infusions unless the patient truly needs it and is admitted and monitored.
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I haven’t done an outpatient cath on Q since 2018. So yes. It’s a practice going away.
 
aneftp said:
Do any beeper calls docs even do catheters any more? It’s simply not worth your time if you are covering the calls from the patient.
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Assuming you have exparel available, I don’t see any reason to placing catheters. They work maybe 50% of the time. Otherwise they leak or fall out. No need to wake me up at 3am to inform me the catheter came out
 
Maz777 said:
What extra skillset does a regional fellowship give you? We can all do blocks. A basic skill of anesthesia.
Click to expand...
I dont think you need a fellowship to be good @ regional but residency doesn't cover it either. It's one thing having the staff man over your shoulder positioning the patient, choosing the right block for that surgeon and patient, navigating anatomical hurdles and literally telling you where to put the local, to being solo facile. It's taken me years honestly as staff granted I'm cardiac mostly, to be approaching confidence in my blocks.

I could put the needle anywhere on the uss screen but that may not be the correct target, or might miss some important nerve proximal for example pop fossa im sure ive been too distal a few times and isb I think missed a root. Very deflating to have to convert to GA
 
PpfSuxTube said:
I dont think you need a fellowship to be good @ regional but residency doesn't cover it either. It's one thing having the staff man over your shoulder positioning the patient, choosing the right block for that surgeon and patient, navigating anatomical hurdles and literally telling you where to put the local, to being solo facile. It's taken me years honestly as staff granted I'm cardiac mostly, to be approaching confidence in my blocks.

I could put the needle anywhere on the uss screen but that may not be the correct target, or might miss some important nerve proximal for example pop fossa im sure ive been too distal a few times and isb I think missed a root. Very deflating to have to convert to GA
Click to expand...
My residency did a pretty good job teaching us blocks, risks/benefits/indications, what to do when they fail, etc. I was pretty self sufficient with regional by the time CA-3 rolled around...then I went into PP and watching some of the older attendings do blocks was painful!
 
Haha sounds controversial, but never thought about the fact patients willing undergo procedures that likely didn't do much just so they can get prescribed more opioids.
 
GravelRider said:
Pain is a fake specialty. The reason why the specialty is tanking is because of crackdown on narcotic prescriptions. The only reason that people underwent those procedures was to get their oxy re-up.
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Aren't you over-generalizing? I've benefited from several interventional procedures that have enhanced my quality of life, including the treatment of saphenous CRPS. I've also never been prescribed a schedule II pain med outside the post-operative period. Never been offered one, never requested one. I don't want opioids. I take pregabalin and duloxetine and function pretty well with these. I'd try more surgery or even an SCS before agreeing to chronic pain management. Maybe I'm the exception, maybe I'm higher functioning, but I've known other people who've had interventional procedures that are not on opioids. I don't think you describe the majority of pain practices.
 
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psycho-matic said:
Aren't you over-generalizing? I've benefited from several interventional procedures that have enhanced my quality of life, including the treatment of saphenous CRPS. I've also never been prescribed a schedule II pain med outside the post-operative period. Never been offered one, never requested one. I don't want opioids. I take pregabalin and duloxetine and function pretty well with these. I'd try more surgery or even an SCS before agreeing to chronic pain management. Maybe I'm the exception, maybe I'm higher functioning, but I've known other people who've had interventional procedures that are not on opioids. I don't think you describe the majority of pain practices.
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Nope. I am describing the overwhelming vast majority of pain practices.
 
I have had 100k patient visits without prescribing a single opioid. Just your average solo pain doc.

bit of schandnfreude on this thread for the docs finally catching up. Glad you made it.
 
nvrsumr said:
I have had 100k patient visits without prescribing a single opioid. Just your average solo pain doc.

bit of schandnfreude on this thread for the docs finally catching up. Glad you made it.
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Don’t worry, those patients eventually shopped their way to someone who did prescribe them opioids. You got a few procedures in that process…everyone wins!

You would think that with increasing stigma on opioid prescribing and increased scrutiny that the demand for pain management physicians to do procedures that provide alternatives would be booming. However, the opposite has happened. The decreased demand for pain management physicians has coincided with the increased opioid prescribing scrutiny. Alternatively, the heyday of the pain management specialty coincides directly with the heyday of Purdue Pharma and the opioid prescribing boom times. Interesting, huh? 🤔
 
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GravelRider said:
Don’t worry, those patients eventually shopped their way to someone who did prescribe them opioids. You got a few procedures in that process…everyone wins!

You would think that with increasing stigma on opioid prescribing and increased scrutiny that the demand for pain management physicians to do procedures that provide alternatives would be booming. However, the opposite has happened. The decreased demand for pain management physicians has coincided with the increased opioid prescribing scrutiny. Alternatively, the heyday of the pain management specialty coincides directly with the heyday of Purdue Pharma and the opioid prescribing boom times. Interesting, huh? 🤔
Click to expand...

There are many reasons for the decrease in the number of pain procedures being performed, one of which is stricter insurance guidelines and increased pushback on all interventions. There has also been push in the literature away from doing "series of 3 injections" which is also likely responsible for decreased numbers as opposed to what was done 10 years ago.

At least in my community, there aren't a lot of people prescribing opioids these days and defintatly nothing in high dose. I haven't seen a patient in oxycontin at any level in at least 4 years. There has been a real push away from opioids in the chronic pain world, it's a really nice place to practice now
 
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