fluoro procedures after sports med fellowship?

[EM2Sportsmed]

Hey guys, I'm planning to pursue a primary care sports med fellowship. Most of the ones I would be eligible for unfortunately don't have any fluoro training but I really enjoy procedures. If a grad from a primary care sports med fellowship then joined a sports/pain practice and received on the job training in fluoro and spinal procedures, would this be an issue? I'm speaking more in terms of hospital privileges and and insurance reimbursement.

For any of you who own a pain clinic...in theory, would you hire a sports med trained physician who had experience in fluoro procedures?

For those who are thinking I should just apply to a pain fellowship, I considered it but would prefer the sports route for various reasons.

Thanks

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[gdub25]

Someone emailed this exact question to our fellowship director and it wasn't recieved very well.

These days it seems everyone is trying to limp in to pain management and understandably so as it is one of the highest reimbursing specialties right now. The average sports medicine Doctor could probably double their salary by doing pain management procedures. Personally, I hate to see family medicine, psychiatry, ER, etc doing pain. Not that I think these specialties aren't capable, but I worked really hard to get to where I am and feel my position is threatened by the ever increasing influx of back door pain doctors. I had to study a lot to score in the top percentiles of Steps 1, 2, and 3 and then again for the ITEs to earn a spot in a well respected anesthesia program and move on to ACGME pain fellowship. I want all that hard work and achievement to mean something and the opportunities it affords to be protected. I turned down a job in a hospital setting where two family medicine guys were doing injections and the hospital was wanting me to come in a "legitimize" their pain department. The docs were nice guys and they weren't practicing bad medicine but the job wasn't anything special and I wanted to do my part for the specialty and separate myself from such arrangements.

On the other hand I don't think you would have trouble getting hospital privileges or getting paid. Pain management is very profitable for a hospital and they would likely be very lenient with you if you were willing to work for them and show them you knew what you were doing.

Hope this hasn't come across as too harsh. It's hard to get the true feeling of what someone is saying when typing on an Internet forum.

 

[Dr. Ice]

Someone emailed this exact question to our fellowship director and it wasn't recieved very well.

These days it seems everyone is trying to limp in to pain management and understandably so as it is one of the highest reimbursing specialties right now. The average sports medicine Doctor could probably double their salary by doing pain management procedures. Personally, I hate to see family medicine, psychiatry, ER, etc doing pain. Not that I think these specialties aren't capable, but I worked really hard to get to where I am and feel my position is threatened by the ever increasing influx of back door pain doctors. I had to study a lot to score in the top percentiles of Steps 1, 2, and 3 and then again for the ITEs to earn a spot in a well respected anesthesia program and move on to ACGME pain fellowship. I want all that hard work and achievement to mean something and the opportunities it affords to be protected. I turned down a job in a hospital setting where two family medicine guys were doing injections and the hospital was wanting me to come in a "legitimize" their pain department. The docs were nice guys and they weren't practicing bad medicine but the job wasn't anything special and I wanted to do my part for the specialty and separate myself from such arrangements.

On the other hand I don't think you would have trouble getting hospital privileges or getting paid. Pain management is very profitable for a hospital and they would likely be very lenient with you if you were willing to work for them and show them you knew what you were doing.

Hope this hasn't come across as too harsh. It's hard to get the true feeling of what someone is saying when typing on an Internet forum.

Mostly agree. As long as hospitals are getting large sums of money through site of service differential and facility fees..they probably won't put a large road block in front on you doing procedures so long as you are able to provide a log or some documentation of number of completed procedures. The reality is that nothing is sacred anymore. Everything is about money and administrators don't really care whether or not a mid level or a highly trained Ivy League educated doc performs the procedure because the outcome isn't any less green for their bottom line. Medicine stopped becoming sacred in general once we put CEOs in charge of running the show.

To the origiginal poster..the reimbursement slash is coming and coming big as it already has started to happen with insurers dramatically dropping rates as compared to several years ago. Your better bet maybe to get well trained in regenerative medicine and work somewhere with a higher socioeconomic clientele and get paid cash for your treatments. Learn ultrasound and start doing prp on everything if you like procedures and are interested in money. I'm sure there a lot of sports docs out there doing really well on this model. Plus the sports population is generally better than the pain population. You aren't gonna see a lot of fibro or people seeking disability which is no picnic to deal with.

I have an ID friend who does really well for ID. Makes like 4-500k but has his own practice and works like a dog. Every weekend always on call. He keeps telling me that the writing is on the wall for procedure based specialities and I always shrug it off but cardiology and gi have taken hits and so has pain. The pendulum is constantly swinging and no one really knows where it is going.

 

[lobelsteve]

I would not hire you. My hospital would not credential you. Many insurers would not allow you on their panel.

That being said, there are plenty of folks who would hire you to do procedures.

 

[deleted472101]

I hear doing spine surgery makes money, you should try that after you sports medicine fellowship.

 

[Doctodd]

Not sure who said pain is well paid.....it used to be.

 

[Ducttape]

i would not be so bold as to say that it is easy to get credentialed. it depends on the system, and the situation.

hospitals do have services that hold onto, dearly, what they do best. you might run into a hospital that will not credential you because the pain clinic/ortho service/neuro/rads department feels an exclusivity with that procedure.

i have been asked multiple times about credentialling someone to do pain procedures. i refuse. not that i fear the competition, and i know most of those asking - but these other individuals want to use my fluoro suite and machine.

 

[A Witty Fool]

...That being said, there are plenty of folks who would hire you to do procedures.

El Chapo for one, even from prison or until he breaks free.

 

[cbest]

I'm a physiatrist currently doing a pain fellowship. I really like interventional spine and sports/MSK medicine, so I went back and forth for a while about which fellowship to pursue. Ultimately, I chose pain because I knew I wanted a large chunk of my future practice to be made up of spine and felt as though this would provide me with the proper training to become a comprehensive spine physician. One of my co-fellows, another physiatrist, made a smart comment one day when we were talking about how we both debated going into either pain or sports. He was talking it through with one of his attendings and was told coming from a PM&R background, you have the baseline knowledge and skills to always learn more sports medicine after training but that's not necessarily the case with interventional spine. I'm now halfway through my fellowship and couldn't imagine trying to learn these on the job or through weekend courses. I'm not trying to take anything away from the field of sports medicine; however, I personally had a much stronger foundation of sports/MSK medicine and peripheral joint intervention experience coming out of residency than I did with interventional spine and wanted to ensure I'd be able to perform interventional spine procedures skillfully and safely. Pain fellowships or some of the excellent non-ACGME interventional spine fellowships (Stanford, Michigan, Furman, etc) are your best bet to get good interventional spine training so that the procedures can be done precisely and safely.

 

[EM2Sportsmed]

Someone emailed this exact question to our fellowship director and it wasn't recieved very well.

These days it seems everyone is trying to limp in to pain management and understandably so as it is one of the highest reimbursing specialties right now. The average sports medicine Doctor could probably double their salary by doing pain management procedures. Personally, I hate to see family medicine, psychiatry, ER, etc doing pain. Not that I think these specialties aren't capable, but I worked really hard to get to where I am and feel my position is threatened by the ever increasing influx of back door pain doctors. I had to study a lot to score in the top percentiles of Steps 1, 2, and 3 and then again for the ITEs to earn a spot in a well respected anesthesia program and move on to ACGME pain fellowship. I want all that hard work and achievement to mean something and the opportunities it affords to be protected. I turned down a job in a hospital setting where two family medicine guys were doing injections and the hospital was wanting me to come in a "legitimize" their pain department. The docs were nice guys and they weren't practicing bad medicine but the job wasn't anything special and I wanted to do my part for the specialty and separate myself from such arrangements.

On the other hand I don't think you would have trouble getting hospital privileges or getting paid. Pain management is very profitable for a hospital and they would likely be very lenient with you if you were willing to work for them and show them you knew what you were doing.

Hope this hasn't come across as too harsh. It's hard to get the true feeling of what someone is saying when typing on an Internet forum.

I appreciate the response and honestly. I also completely understand how you feel about your job being threatened. More and more EM positions are being taken over by midlevels. There are still plenty of jobs to go around in EM but not sure how this will look in 5-10 years. I also worked very hard and had 99th percentile USMLE scores/graduated from a good US allopathic school and did residency at an ivy. The fact is that as I've been out a couple years in practice, the lifestyle can be tough with the scheduling and I really love procedures. Many people have commented on me doing this for the money (ie Jigsaw). I'm fairly certain I will be taking a pay cut if I go this route, as EM in my area pays extremely well. Pain medicine fellowships are also now open (in very limited supply) to EM graduates, as is sports medicine. I'm not trying to find an easy way to make lots of money here guys, I'm trying to find a path that I am happy with and allows me a more regular schedule.

 

[Mad Jack]

Someone emailed this exact question to our fellowship director and it wasn't recieved very well.

These days it seems everyone is trying to limp in to pain management and understandably so as it is one of the highest reimbursing specialties right now. The average sports medicine Doctor could probably double their salary by doing pain management procedures. Personally, I hate to see family medicine, psychiatry, ER, etc doing pain. Not that I think these specialties aren't capable, but I worked really hard to get to where I am and feel my position is threatened by the ever increasing influx of back door pain doctors. I had to study a lot to score in the top percentiles of Steps 1, 2, and 3 and then again for the ITEs to earn a spot in a well respected anesthesia program and move on to ACGME pain fellowship. I want all that hard work and achievement to mean something and the opportunities it affords to be protected. I turned down a job in a hospital setting where two family medicine guys were doing injections and the hospital was wanting me to come in a "legitimize" their pain department. The docs were nice guys and they weren't practicing bad medicine but the job wasn't anything special and I wanted to do my part for the specialty and separate myself from such arrangements.

On the other hand I don't think you would have trouble getting hospital privileges or getting paid. Pain management is very profitable for a hospital and they would likely be very lenient with you if you were willing to work for them and show them you knew what you were doing.

Hope this hasn't come across as too harsh. It's hard to get the true feeling of what someone is saying when typing on an Internet forum.

You have to work arguably harder to get into EM than anesthesia nowadays, so I wouldn't necessarily say that the "hard work" component of the argument holds up as well as it used to.

 

[Dr. Ice]

I would just like to add that working as a "pain doc" or "msk doc" or however you want to put it means a lot lot more than procedures. I can tell you that there is an enormous learning curve during your first few years as an attending and a lot of this has to do with managing patient expectation and your ability to read what a patient is expecting from you very quickly in your interview with them. Years ago we didn't have to deal with press ganey and social media. Now a days many physicians have taken on the models of car salesman and ask their patients to fill out health grades cards for positive reviews. I am by no means stating that your values as a physician should be compromised or that you pander to patients to receive positive reviews but a lot of your success will be based on how you are perceived. You cant be overtly aggressive or conservative. You have to listen, you have to spend time, you have to be clear and easy to understand. You have to be able to explain pathology in a way that is straightforward and without bias for what you want to do or what you want the patient to agree to do despite what your CEO or your practice leader wants you to do. These are the things that make being a "pain/msk doc" difficult and this is what the real art of the practice is. Coming from emergency medicine, these are generally not the things you would even pick up on during training because it's obviously not your real role as a provider so I can imagine the learning curve may even be slightly steeper. If you do 10k procedures you are gonna have the proficiency to be able to deal with complex anatomy and know where your comfort zone is. I cannot imagine having to learn this skill set AND having to learn how to deal with a difficult patient population at the same time. That is daunting. The spine fellowship gives you the skills so that you can spend the rest of the time in your first few years growing as a physician.

 

[gdub25]

You have to work arguably harder to get into EM than anesthesia nowadays, so I wouldn't necessarily say that the "hard work" component of the argument holds up as well as it used to.

I wasn't aware of this. The desireable specialties seem to change on a yearly basis it seems.

 

[Mad Jack]

I wasn't aware of this. The desireable specialties seem to change on a yearly basis it seems.

Anesthesia has been on a downward slide for many years. There were 1.5 positions per US MD applicant that ranked anesthesia as their primary or only specialty choice, and 0.9 anesthesia positions for all applicants that ranked anesthesia as their first or only choice. EM had 1.2 positions per US MD applicant that ranked it as their first or only choice, with 0.8 positions per all applicants ranking it as their first or only choice. The average anesthesia Step 1 score for the most recent charting outcomes was a 230 for both US MDs and independent applicants, which was the average for matched applicants in all specialties, while the Step 2 was 241, 2 points lower than the average for all specialties. Emergency medicine had equal US MD Step 1s (230), but higher Step 2s (242) when compared with their anesthesia counterparts. but perhaps what is more telling is that more qualified candidates were turned away from EM than anesthesia (the average EM reject had a Step 1 of 215, Step 2 225, while anesthesia's average US MD reject was a 208 Step 1, and a 223 Step 2). Anesthesia is somewhere near the middle of the pack in regard to competitiveness these days, largely because of CRNA encroachment, AMCs, and all the other fun things you guys have to deal with.

 

[SeniorWrangler]

It all depends on where and how you want to work, and what the competition is. Many bigger towns have the healthcare market divided up between a few big players these days.
If you go this path, I would strongly encourage you to consider some kind of organized training beyond weekend classes, even if it is short of a fellowship. The basic skills of fluoro procedures are not that hard but the knowledge and judgement required to use them effectively and safely are significant.
You also need to decide what your scope of practice is and what you'll refer out. Fluoro procedures range from pretty safe to terrifying in their level of risk.

 

[EM2Sportsmed]

I would not hire you. My hospital would not credential you. Many insurers would not allow you on their panel.

That being said, there are plenty of folks who would hire you to do procedures.

When I first started to look into this I had considered applying to a nonACGME pain program since there are many more available to apply for. In the end, I had assumed this would be a worse route to go for insurance and hospital privileges, since they often look for something "ACGME approved", especially if I could get some procedural training in a sports program.. Out of curiosity, would you be more likely to hire someone from a nonACGME pain fellowship?

 

[lobelsteve]

I have run a non ACGME fellowship and will do so again in the next year or two. I am not hiring anyone, but I will train folks to be the best pain doc that they can be.

 

[specepic]

My hosp would not hire or credential you. BC/BE only and it is a small comm hosp

It really comes down to knowing what you dont know. I thought I was pretty good at fluoro procedures b/f fellowship and had a lot of cases under my belt for a resident. Prob as many cases as some graduating fellows. Then I hit fellowship and realized I had more to learn. Then I went into practice and know much more know and every year fine tune.

There is no substitute for solid training and I dont think it can be had on the job IMHO

Best of luck

 

[Gastrapathy]

"My hospital won't credential you" just means "I will find any justification to block local competition." This is a sign of saturation. Seen it in the advanced procedures realm in GI after I got in under the wire.

 

[specepic]

+-9****++++++++++++++++++++++++++++++++++++

"My hospital won't credential you" just means "I will find any justification to block local competition." This is a sign of saturation. Seen it in the advanced procedures realm in GI after I got in under the wire.

It may mean that to you but not to me. In fact the market around here has capacity. This was a hosp admin decision for all providers/all specialties.

 

[Ducttape]

When I first started to look into this I had considered applying to a nonACGME pain program since there are many more available to apply for. In the end, I had assumed this would be a worse route to go for insurance and hospital privileges, since they often look for something "ACGME approved", especially if I could get some procedural training in a sports program.. Out of curiosity, would you be more likely to hire someone from a nonACGME pain fellowship?

yes. without hesitancy.

but i am a worker bee, not a boss, so take that for what its worth.

 

[melancholy]

I'm a physiatrist currently doing a pain fellowship. I really like interventional spine and sports/MSK medicine, so I went back and forth for a while about which fellowship to pursue. Ultimately, I chose pain because I knew I wanted a large chunk of my future practice to be made up of spine and felt as though this would provide me with the proper training to become a comprehensive spine physician. One of my co-fellows, another physiatrist, made a smart comment one day when we were talking about how we both debated going into either pain or sports. He was talking it through with one of his attendings and was told coming from a PM&R background, you have the baseline knowledge and skills to always learn more sports medicine after training but that's not necessarily the case with interventional spine. I'm now halfway through my fellowship and couldn't imagine trying to learn these on the job or through weekend courses. I'm not trying to take anything away from the field of sports medicine; however, I personally had a much stronger foundation of sports/MSK medicine and peripheral joint intervention experience coming out of residency than I did with interventional spine and wanted to ensure I'd be able to perform interventional spine procedures skillfully and safely. Pain fellowships or some of the excellent non-ACGME interventional spine fellowships (Stanford, Michigan, Furman, etc) are your best bet to get good interventional spine training so that the procedures can be done precisely and safely.

this is the same thought process i went through in PM&R residency as my training program was strong with sports/msk, Edx, spine and I had personal interests in msk from prior experiences, thus I felt that the part I needed to add was at least bread and butter interventional procedures (fluoro and even ultrasound) as well as more background on medical management and other intricacies of pain management to do the best job possible in a safe and responsible manner. I believe i made the right choice going into a pain fellowship rather than trying to go for a sports med fellowship and the diagnostic skills have certainly helped in practice now. i do feel interested in getting more education in sports medicine but there seem to be plenty of educational opportunities that are quite appropriate if you have the baseline knowledge and understanding to build upon (which one would with a solid PM&R residency). I do not think it is a necessity however to have to learn the most advanced interventional procedures, so i do think that most just need to be solid with bread and butter interventional procedures and have enough knowledge to branch out from there.

All that being said, I am also not confident I would hire someone for procedures without some sort of interventional or pain fellowship. YMMV out in the community though.

 

[Disciple]

Hey guys, I'm planning to pursue a primary care sports med fellowship. Most of the ones I would be eligible for unfortunately don't have any fluoro training but I really enjoy procedures. If a grad from a primary care sports med fellowship then joined a sports/pain practice and received on the job training in fluoro and spinal procedures, would this be an issue? I'm speaking more in terms of hospital privileges and and insurance reimbursement.

For any of you who own a pain clinic...in theory, would you hire a sports med trained physician who had experience in fluoro procedures?

For those who are thinking I should just apply to a pain fellowship, I considered it but would prefer the sports route for various reasons.

Thanks

Here's a fairly recent article on the topic:

https://www.researchgate.net/public...icians_interested_in_musculoskeletal_medicine

Interesting that the same issue has been going on for 20 years.

 

[melancholy]

Here's a fairly recent article on the topic:

https://www.researchgate.net/public...icians_interested_in_musculoskeletal_medicine

Interesting that the same issue has been going on for 20 years.

Thanks for finding that article. Yes interesting how this has continued on for several years. I had previously considered some of these hybrid MSK fellowships which seemed very attractive and colleagues who have done them seem to be able to find jobs without significant difficulty either doing sports or more spine interventional work. I actually think the best scenario would be doing a well rounded acgme accredited pain fellowship with pre-existing interest and strong training in sports/spine/neuro as well as electrodiagnostics through residency. The background is important as these skills would be difficult to gain in fellowship, but fellowship will focus on developing other tools (interventional, medical management, etc) to care for these patients from the acute to chronic phases of their conditions.

 

[ampaphb]

Get the best possible training you can. If the guy you are learning from is well respected, terrific. There are *****s who run ACGME accredited fellowships I wouldn't let do procedures on my dog. There are folks out there who have trained with Dreyfuss, Aprill, and Derby. None of them are ACGME. accredited, yet they are exceedingly well trained.

My point is, the devil is in the details. Sure, it would be nice to do a fellowship. But if you are going for a preceptor ship instead, make sure it isn't cursory and haphazard. Make sure it is structured. Make sure you know not only the basics, but the nuances of our field; how to do an epidural 5 different ways, so you know what to do when the first 4 don't work. K low when to not do a procedure, when to abandon one, and when to press forward.

Oh, and for goodness sake, ignore everything Dr. Ice said above. You have to be the adult in the room. Be the bad guy. Recognize that pain is NOT about Press Gainey ratings. You want to be perceived as the guy who does the right thing, who is able to tell patients no (politely), who DOESN'T compromise. Not an absolutist, but not someone willing to negotiate. It takes a delicate, firm approach. That can often vary from patient to patient, but at the end of the day, you need to be able to put your head on the pillow comfortable in the notion that every move you made that day abided by your Hypocratic responsibility to 'first do no harm'.

 

[Dr. Ice]

Yes ignore everything I said...unless you want to practice in NY/NJ/PA where the NYT prints an article everyday about what horrible people doctors are...I wish I didnt have to worry about press gainey.

 

[ampaphb]

Sorry dude, but advice like "worry about how you are perceived" "dont be overtly conservative" and "don't bias your explanations so as to influence what you want the patient to do" is simply wrong.

You are a consultant. As such you are paid for your opinion. If all the patient came to you for was data, no value would be placed on your education, training, experience, or insight.

 

[Dr. Ice]

I respectfully agree to disagree. Maybe I should move out of the northeast

 

[Disciple]

Thanks for finding that article. Yes interesting how this has continued on for several years. I had previously considered some of these hybrid MSK fellowships which seemed very attractive and colleagues who have done them seem to be able to find jobs without significant difficulty either doing sports or more spine interventional work. I actually think the best scenario would be doing a well rounded acgme accredited pain fellowship with pre-existing interest and strong training in sports/spine/neuro as well as electrodiagnostics through residency. The background is important as these skills would be difficult to gain in fellowship, but fellowship will focus on developing other tools (interventional, medical management, etc) to care for these patients from the acute to chronic phases of their conditions.

The article brings to light some of the negatives of the PMR specialty, at least the way it's run.

20 years is a long time.

The deeper issue, is why, in 2016 should you still have to make this all important "choice" during PGY-3/PGY-4 year.

1995-2005 Progression
2006-2016 Regression

When I previously read that article, I wrote a piece but didn't publish it. Comparison I used was Ortho. Ortho has only 2 CAQs (Sports Medicine/Hand), yet trains in Spine, shoulder/elbow, foot/ankle, total joint, trauma, etc., and provides quality assurance for all those subspecialties.