FM doing pain procedures??

[NRAI2001]

I had an Attending in residency Who would do a lot of epidurals injections (he had a fluoroscopy lab ) in addition to shoulders, knee, hip injections.

What are your opinions on FM docs doing spinal pain procedures like epidural injections, facet injections… Etc. of course after training and certifications (not fellowship)?

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[lobelsteve]

Held to standard of ACGME.
Insurance should be biggest hold-up.
If medmal situation, easier for plaintiff, but not slam dunk.

 

[Ducttape]

what training and certification are you talking about?

a weekend course?




no. a resounding no.

 

[TheLoneWolf]

I had an Attending in residency Who would do a lot of epidurals injections (he had a fluoroscopy lab ) in addition to shoulders, knee, hip injections.

What are your opinions on FM docs doing spinal pain procedures like epidural injections, facet injections… Etc. of course after training and certifications (not fellowship)?

I worked at a practice with 8-9 family med docs doing interventional pain. None with any formal training accredited or nonaccredited fellowships. Did everything with fluoro and ultrasound and monthly trigger point injections that they billed as "nerve and plexus blocks". Would just youtube stuff before they did it....eg call themselves ultrasound experts and do USG trigeminal nerve blocks and cervical RFA. Always skating by what is legal and ethical. Have no understanding of the risks, optimal imaging, standards of care, sterility, treatment pathways.

They would do interlaminar epidurals, use a catheter to point to desired side and bill them as TFESI.

I have seen a guy perform ultrasound guided cervical RFA, patient goes to ED shortly after feeling unwell, found to have a "vertebral artery dissection", ED tells him it's most likely from the procedure, calls the "pain doc" to inform him on this and the "pain doc" spends the next 15 minutes on the phone trying to explain away and tell the patient that it absolutely couldn't have been the procedure to cause this complication.

I have seen a guy there put his hands across the patient room doorway to prevent a patient from leaving, begging the patient to try "just one more procedure" with the patient telling him "no, your procedures never worked" and shoving this guy out of the way so he can leave.

Trigger point causing pneumothorax and guy wondering weather to call an ambulance.

Guy causing a complication and getting blackmailed by the patient for $ so that they dont report the physician to the medical board.

All taught by one anesthesiologist with no pain training or fellowship. Starts them off on trigger points and opioid management then works them up to bigger procedures in a few months. He keeps almost 50ish percent of everyone's billings. Slimy fellow. Literally the person you meet who wants everyone to like him and look up to him but has literally zero scruples. Reptilian behavior.

Opioid prescription refills on high risk patients being done by an "assistant" with no medical training or background with the physicians login as he hangs out at his lakehouse...this happened with some frequency, not a one time event.

I was so backed up with work that I would occasionally send out periphreal joint and MSK stuff to a sports med trained guy who was also family med trained...gave one of my young patients CRPS from an injection for lateral epicondylitis.

Revolving door of mid-levels who would leave when they found out it was producing endless RVUs on anyone with a pulse. Demoralizing.

I was told off for recommending conservative treatments rather than pushing for procedures up front by the owner. Those family med guys billed way more and took home way more than I did.

I hated working there and knew that sooner or later I could find myself in trouble simply by association with these guys. I had little doubt the medical or other regulatory boards would step in and either pull the clinic or owners license. Higher up with association at the medical boards had vocalized they were well aware of what was going on but had trouble dislodging the owner.

Leaving there was probably the best decision I made career wise since residency.

 

[FrustratedFamDoc]

Bold, very very bold.

Unfortunately some of my FM peers really like to venture way off the reservation. $$ is almost the primary driver and you can't convince me otherwise.

 

[runfastnow]

Legal =/= Safe

 

[Baron Samedi]

I wouldn't let myself or a family member get injected by anyone who wasn't an ACGME fellowship graduate.

 

[paindoc007]

I’d rather have a fm doc with pain fellowship than an NP…

 

[buddababa]

I’d rather have a fm doc with pain fellowship than an NP…

key is fellowship.....

 

[MD87]

I wouldn't let myself or a family member get injected by anyone who wasn't an ACGME fellowship graduate.

I would (I myself completed an ACGME fellowship). There are plenty of unaccredited fellowships out there that provide better training than ACGME programs, though on average, I would agree that ACGME provides better/more complete training.

 

[Orin]

I value experience over training but there is way more variability and a way lower floor without a fellowship of some kind.

 

[Baron Samedi]

I would (I myself completed an ACGME fellowship). There are plenty of unaccredited fellowships out there that provide better training than ACGME programs, though on average, I would agree that ACGME provides better/more complete training.

That is undoubtedly true, but I have no way of knowing which nonaccredited programs are good and which are bad and there's no quality control system in place to help make that determination.

If Uncle Freddy in another state calls me and asks for my recommendation on who to see, I'm going to tell him to find an ACGME grad.

 

[MD87]

That is undoubtedly true, but I have no way of knowing which nonaccredited programs are good and which are bad and there's no quality control system in place to help make that determination.

If Uncle Freddy in another state calls me and asks for my recommendation on who to see, I'm going to tell him to find an ACGME grad.

Fair, there’s obviously a big difference between an unaccredited Stanford program or Furman versus a random small private practice program.

I think we would all prefer to send a family member to someone that we personally know is good or know the reputation of, regardless of training.

 

[lobelsteve]

Fair, there’s obviously a big difference between an unaccredited Stanford program or Furman versus a random small private practice program.

I think we would all prefer to send a family member to someone that we personally know is good or know the reputation of, regardless of training.

I think we have a pretty good network here and I know I’ve seen several of the other doctors patients. Hopefully someone is taking care of my folks when they leave Georgia.

 

[clubdeac]

Need ACGME training. if you don't think so then why do you think any doc needs any sort of ACGME training for anything or why does a doc need med school for that matter. That's the logic NPs and PAs use. Without some sort of standardization you just have a bunch of cowboys doing whatever whenever they want. That's kinda where we're headed though. It's unfortunate insurance doesn't help police this. instead of limiting pain procedures to those that are appropriately trained they just cut reimbursement across the board punishing everyone. Baby out with the bathwater mentality

 

[cowboydoc]

I think we have a pretty good network here and I know I’ve seen several of the other doctors patients. Hopefully someone is taking care of my folks when they leave Georgia.

I have 2! 86, 84 and still reasonably active. Had to give up tennis at 81, though.

 

[MD87]

Need ACGME training. if you don't think so then why do you think any doc needs any sort of ACGME training for anything or why does a doc need med school for that matter. That's the logic NPs and PAs use. Without some sort of standardization you just have a bunch of cowboys doing whatever whenever they want. That's kinda where we're headed though. It's unfortunate insurance doesn't help police this. instead of limiting pain procedures to those that are appropriately trained they just cut reimbursement across the board punishing everyone. Baby out with the bathwater mentality

I agree with this in theory. But the ACGME needs to do a better job providing training that is actually representative of the types of practices that fellows want to work in. For PM&R, most ACGME fellowships provide no or minimal EMG training, which is something that a lot of employers want. It can be intimidating coming out of a fellowship having not done an EMG for 1-2 years and then being asked to perform them. I did an ACGME fellowship, and I got great training. I’m very risk averse, and I didn’t want to have training that might limit me in anyway based on ACGME/no ACGME, but at times I wonder if I would have been better off doing what is now one of the NASS fellowships. I haven’t done a second of inpatient pain since finishing fellowship, and I don’t plan on it either. And, while I was doing those rotations during fellowship, I tried to not think of them as a complete waste, but…

 

[MitchLevi]

Opiate management is a big part of ACGME training, whereas the nonaccredited fellowships are largely interventional and with minimal exposure to medications. At least, that's how many of them are run, not all. ACGME will put you in the hospital occasionally, and you'll do a lot of BS none of us do in the real world like IV lidocaine for example (it doesn't work) or 3-4 day continuous ketamine infusions (dumb).

Many are "boutique." It's one or two attendings and they hire fellows for a year and that's a hedge for clinic volume management. You're cheap labor and you're willing to work hard and smile and dip out 12 months later. You won't bother them with discussions about partnership or have similarly annoying conversations. There have been no shortage of horror stories coming from programs like that.

Conversely, there are several nonaccredited programs putting out fantastic pain doctors. We had one interview with us 3 or 4 years ago. He was great, but also expecting guaranteed partnership and equity and all types of BS that ain't gonna happen just because you decided to come work with us.

You probably won't get exposure to pain psych without ACGME. My fellowship program is probably the top pain psych facility in the nation, and I'm still trying to figure out the role of pain psych other than weighing in on stimulators.

 

[Baron Samedi]

You probably won't get exposure to pain psych without ACGME. My fellowship program is probably the top pain psych facility in the nation, and I'm still trying to figure out the role of pain psych other than weighing in on stimulators.

Bit off topic but does anyone have any quality resources for what a psych SCS eval needs to entail exactly and who is qualified to do them?

 

[sloh]

I agree with this in theory. But the ACGME needs to do a better job providing training that is actually representative of the types of practices that fellows want to work in. For PM&R, most ACGME fellowships provide no or minimal EMG training, which is something that a lot of employers want. It can be intimidating coming out of a fellowship having not done an EMG for 1-2 years and then being asked to perform them. I did an ACGME fellowship, and I got great training. I’m very risk averse, and I didn’t want to have training that might limit me in anyway based on ACGME/no ACGME, but at times I wonder if I would have been better off doing what is now one of the NASS fellowships. I haven’t done a second of inpatient pain since finishing fellowship, and I don’t plan on it either. And, while I was doing those rotations during fellowship, I tried to not think of them as a complete waste, but…

It’s very rare pain docs need EMG to inform them of what procedures to perform. The clinical exam and history are often sufficient. Probably not a good ROI for any pain fellowship to make EMG a significant part of their training.

 

[cowboydoc]

It’s very rare pain docs need EMG to inform them of what procedures to perform. The clinical exam and history are often sufficient. Probably not a good ROI for any pain fellowship to make EMG a significant part of their training.

Agree, but it would be good for pain physicians (and neurosurgeons) to have a basic understanding of EMG, what it can and can’t do and how it should affect clinical decision making.

(I have no idea how to perform an MRI, but I know how to read it and how it affects my clinical decisions.

 

[sloh]

Agree, but it would be good for pain physicians (and neurosurgeons) to have a basic understanding of EMG, what it can and can’t do and how it should affect clinical decision making.

(I have no idea how to perform an MRI, but I know how to read it and how it affects my clinical decisions.

Isn’t that what PM&R residency was for?

 

[Baron Samedi]

I've done exactly zero EMGs since residency and plan on keeping it that way. Let the general PM&R and Neuro nerds do that kind of stuff. I send maybe 1-2 patients/year for one.

 

[nvrsumr]

My Anesthesia pain fellowship bought me an EMG machine and I did them one afternoon a week during fellowship

 

[cowboydoc]

Isn’t that what PM&R residency was for?

I’m saying teaching anesthesiologists EMGs in pain fellowship is a waste of time, but understanding the basics of results is fairly important.

 

[Welcome123]

In NYC, we have NPs doing pain procedures.

I was asked to testify against a complication that occurred following ESI by the NP. The NP has a very successful pain/sports practice in manhattan.
Since the np is also a chiropractor- He markets himself as a DR.

The first concern I had on reviewing the case was the nurse practitioner training was inappropriate for this type of procedure. The attorney didn’t seem to think that was a point he could even use and was irrelevant.
In this setting, it is hard to think that a family practice doctor doing epidurals is an issue

 

[bedrock]

In NYC, we have NPs doing pain procedures.

I was asked to testify against a complication that occurred following ESI by the NP. The NP has a very successful pain/sports practice in manhattan.
Since the np is also a chiropractor- He markets himself as a DR.

The first concern I had on reviewing the case was the nurse practitioner training was inappropriate for this type of procedure. The attorney didn’t seem to think that was a point he could even use and was irrelevant.
In this setting, it is hard to think that a family practice doctor doing epidurals is an issue

OMG
That is sad. I still wonder if that attorney is correct. If an NP has vastly inferior training compares to a board certified pain physician then the complication is due to that terrible training. If the NP just went to a couple weekend courses, he should be sued into oblivion.

BTW, without naming names, what was the complication?

 

[clubdeac]

In NYC, we have NPs doing pain procedures.

I was asked to testify against a complication that occurred following ESI by the NP. The NP has a very successful pain/sports practice in manhattan.
Since the np is also a chiropractor- He markets himself as a DR.

The first concern I had on reviewing the case was the nurse practitioner training was inappropriate for this type of procedure. The attorney didn’t seem to think that was a point he could even use and was irrelevant.
In this setting, it is hard to think that a family practice doctor doing epidurals is an issue

Disgusting and sad the attorney doesn’t know the difference bw a doctor and NP. You should’ve told him it’s akin to having a paralegal represent you instead of him and then losing the case. Probably not irrelevant the paralegal represented you

 

[Ducttape]

In NYC, we have NPs doing pain procedures.

I was asked to testify against a complication that occurred following ESI by the NP. The NP has a very successful pain/sports practice in manhattan.
Since the np is also a chiropractor- He markets himself as a DR.

The first concern I had on reviewing the case was the nurse practitioner training was inappropriate for this type of procedure. The attorney didn’t seem to think that was a point he could even use and was irrelevant.
In this setting, it is hard to think that a family practice doctor doing epidurals is an issue

he is probably correct. the NP standards as set by nursing organizations is woefully simplistic. that attorney recognizes that fact.

in the end, nursing credentialing societies are in the business of furthering nursing scope of practice and will do very little to censure a nurse.

 

[TheLoneWolf]

he is probably correct. the NP standards as set by nursing organizations is woefully simplistic. that attorney recognizes that fact.

in the end, nursing credentialing societies are in the business of furthering nursing scope of practice and will do very little to censure a nurse.

As duct has said, legal precedent that physicians weighing in on nursing standards is inappropriate, which I think is a mistake, particularly if I am asked to supervise them and hold legal liability for their problems. Some jobs I've come across dont even pay anything for supervising NPs l. It's part of the package, so to speak. Physicians can fully comment on other physicians.

 

[clubdeac]

As duct has said, legal precedent that physicians weighing in on nursing standards is inappropriate, which I think is a mistake, particularly if I am asked to supervise them and hold legal liabilityfor this problems. Some jobs ive come across dont even pay anything for supervising NPs l, its part of the package so to speak. Physicians can fully comment on other physicians.

At our hospital we’re forced annually to sign an agreement that says we’ll agree to supervise mid levels

 

[TheLoneWolf]

At our hospital we’re forced annually to sign an agreement that says we’ll agree to supervise mid levels

I have literally turned down job offers >90-99% MGMA in the Midwest because my partner had to supervise NPs for 50% of MGMA in their fields.

Even with heavy negotiating, I found out hospitals won't budge on opting out of midlevel supervision, even at the risk of losing 2 specialists or even potentially taking a decrease in pay.