for pain pills pushers

[Machinery]

A few issues with some posts on this thread.

1. Chronic pain management involves more than steroid injections.
2. Pain doctors are trained to manage chronic pain and not just perform procedures.
3. The fact that SOME pain management modalities do not have strong evidence does not mean ALL pain management strategies/procedures are useless.
4. People do have chronic pain and someone has to manage it. I will put my money on a pain doctor doing it better than the crowd chanting "nothing works".

How many times have you heard the classic Neurology insult "You guys just work stuff up but can't actually do anything about it"? Well that might be true but they are the ones in the trenches which means they have a better shot at doing something about it than the sideline commentators.

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[powermd]

So the answer is that you have little to no credibility to make the absurd claims in your last post. And there may be more to the story than you're telling us, having "left" your ACGME-accredited pain fellowship after only 3 months.

You writing makes you sound like you have an axe to grind, bottom line.

If you're interested, come on over to the pain forum and have a read. We're all conscientious folks trying to do right for our patients in an increasingly hostile administrative environment. Do our procedures work for everyone? Of course not. Do they work when we select our patients well? Very much so, and you'll hear lots of these stories on our forum.

One I like to tell is about my brother-in-law. He had a pain in the ass for a full year before I had a chance to examine him. Looked to his caregivers like a muscle pull, but the pain would not resolve, and it didn't radiate down the leg, so no MRI. At first I thought he had piriformis syndrome, but the stretches and exercise didn't work. Eventually he got an MRI which showed a large L4-5 disc extrusion. Over a holiday I brought him in to my clinic and did a single interlaminar ESI at L5-S1, biased ipsilateral to his pain. Within 3 days the pain he had for the past year improved 60%, by 1 month he was 80% better. Now it only rarely bothers him, and it's been 3 years. I could go on for pages and pages with wonderful success stories that would be very hard to capture in a study.

I'm sorry if you had a bad experience early on in your career that caused you to drop out of your pain fellowship. Maybe you weren't right for the field to begin with, but you did miss out on potentially a very rewarding career helping improve the quality of life of others.

powermd would probably be interested to learn that I did just over three months in a ACGME-accredited Pain Fellowship before I realized what a wholesale scam it is (and left for private practice). Sure, that makes me both a slow learner (to have needed three months to see what most anesthesiologists realize with only a couple of weeks' exposure during residency) and a much faster learner than folks like powermd who have yet to figure it out.

That somebody else in medicine is just as bad or worse (What about chiropractors?! What about spine surgeons?! What about charlatans selling PRP or stem cell therapy?! or lasers?! or robots?! or...) doesn't mean that pain specialists get a pass.

If the steroid injections get people back to work or reduce opiate consumption it should be pretty easy to show, especially considering how many millions of dollars hang in the balance. The lack of good evidence (Almost twice as good as placebo? Really? Almost twice as good as nothing at all?? Or is it because the placebo injections still--as was once the apologists' theory--"flush away substance P?") is pretty damning.

When a pain interventionalist can make a go of it charging cash for his procedures and offering a money back guarantee if the patient is not satisfied, then I will agree there might be something to it. Show me that interventionalist who succeeds in selling his services directly to a patient without a third party picking up the tab, and then I'll do a recent literature search in hopes of "adding credibility."

 

[Orin]

I'm not sure if we're clear on this, but pain medicine practitioners aren't driving this opioid push. Opioid prescribing is mainly driven by family medicine and internal medicine providers in most studies. Pain/palliative folks definitely write some crazy and complex regimens, but there aren't enough of them to drive this poop show.

When a pain interventionalist can make a go of it charging cash for his procedures and offering a money back guarantee if the patient is not satisfied, then I will agree there might be something to it. Show me that interventionalist who succeeds in selling his services directly to a patient without a third party picking up the tab, and then I'll do a recent literature search in hopes of "adding credibility."

I'm very confused as to the seriousness of this or if you're trolling, as there are many lucrative practices that provide cash based care, both with pills and injections.
For example as you mentioned, laser therapy isn't covered by most insurances but the Laser Spine Institutes are doing great. PRP isn't covered but folks seem to love trying to save up for the Kobe Bryant/Andrew Luck/pick your athlete biologic treatments.

A money back guarantee would be great in medicine, but that's not at all realistic for pain medicine or any of our other specialties.
Would you pay back a patient if you couldn't ventilate them and decided to abort the case?
If you were an oncologist and your patient dies from their cancer, is that treatment regimen free?
Even a milder example, would you provide a money back guarantee for patients who have PONV or a sore throat despite your perfect anesthetic technique?

 

[lobelsteve]

powermd would probably be interested to learn that I did just over three months in a ACGME-accredited Pain Fellowship before I realized what a wholesale scam it is (and left for private practice). Sure, that makes me both a slow learner (to have needed three months to see what most anesthesiologists realize with only a couple of weeks' exposure during residency) and a much faster learner than folks like powermd who have yet to figure it out.

That somebody else in medicine is just as bad or worse (What about chiropractors?! What about spine surgeons?! What about charlatans selling PRP or stem cell therapy?! or lasers?! or robots?! or...) doesn't mean that pain specialists get a pass.

If the steroid injections get people back to work or reduce opiate consumption it should be pretty easy to show, especially considering how many millions of dollars hang in the balance. The lack of good evidence (Almost twice as good as placebo? Really? Almost twice as good as nothing at all?? Or is it because the placebo injections still--as was once the apologists' theory--"flush away substance P?") is pretty damning.

When a pain interventionalist can make a go of it charging cash for his procedures and offering a money back guarantee if the patient is not satisfied, then I will agree there might be something to it. Show me that interventionalist who succeeds in selling his services directly to a patient without a third party picking up the tab, and then I'll do a recent literature search in hopes of "adding credibility."

Hmm. Couldnt cut it so you are back at your nursing job giving gas?

😀

 

[Hoya11]

So the answer is that you have little to no credibility to make the absurd claims in your last post. And there may be more to the story than you're telling us, having "left" your ACGME-accredited pain fellowship after only 3 months.

You writing makes you sound like you have an axe to grind, bottom line.

If you're interested, come on over to the pain forum and have a read. We're all conscientious folks trying to do right for our patients in an increasingly hostile administrative environment. Do our procedures work for everyone? Of course not. Do they work when we select our patients well? Very much so, and you'll hear lots of these stories on our forum.

One I like to tell is about my brother-in-law. He had a pain in the ass for a full year before I had a chance to examine him. Looked to his caregivers like a muscle pull, but the pain would not resolve, and it didn't radiate down the leg, so no MRI. At first I thought he had piriformis syndrome, but the stretches and exercise didn't work. Eventually he got an MRI which showed a large L4-5 disc extrusion. Over a holiday I brought him in to my clinic and did a single interlaminar ESI at L5-S1, biased ipsilateral to his pain. Within 3 days the pain he had for the past year improved 60%, by 1 month he was 80% better. Now it only rarely bothers him, and it's been 3 years. I could go on for pages and pages with wonderful success stories that would be very hard to capture in a study.

I'm sorry if you had a bad experience early on in your career that caused you to drop out of your pain fellowship. Maybe you weren't right for the field to begin with, but you did miss out on potentially a very rewarding career helping improve the quality of life of others.

Yeah, I mean if you disagree with the conservative right why dont you just turn on fox news so you can better understand our point of view...come on over to the pain forum...

Why couldnt a neurosurgeon order an MRI and do the LESI? Not exactly cracking a medical mystery.

I do believe in LESIs. I do believe some pain doctors are ethical.

But I dont think their existence is necessary. Most are drug pushers, many have an altered idea of what success is given the cost. Cost in healthcare dollars, addicted patients, insurance company time, on and on... if the whole field went away no one would care. Get your LESI from the surgeon/regular anesthesiologist, and go get your heroin on the street..

I dont think pain has anywhere near the respect of a field like neurology to even be compared.

A good friend of mine is a neurosurgeon. He makes a LOOT of money and has asked me to join him several times. Its just not in me although it is tempting. In an honest conversation, he tells me, I dont care what the pain guys do with the patients as long as they eventually come back to me for surgery, thinks its completely comical what the pain guys are billing for. IPM is a middle man in the industrial machine of LBP treatment. Thats it.

The guys who are purely interventional are off the hook for the opioid epidemic, but not the extreme overconsumption of healthcare resources. Great that you dont give out percocet, but stop racking up a huge bill on the way to someone having inevitable surgery or inevitably getting better on their own. A successful injection is in the eyes of the beholder.

The idea that these genuine feelings of angst toward the field are unfounded by people who "couldnt cut it" is extremely short sighted. Time will tell , but I dont think the field will last as the microscope zooms in...

 

[Orin]

Why couldnt a neurosurgeon order an MRI and do the LESI? Not exactly cracking a medical mystery.

Yeah, and while we're at it, why couldn't a surgeon then see that patient they operated on for the rest of their life and follow up to manage the chronic pain that patient still has after the fusion from stem to stern?

You understand the RVUs for doing a surgery. Why would they do a interventional procedure that might prevent them from capturing revenue? Why would they hire real pain docs that are interested in keeping patients off the table instead of the monkey that can make the insurance company happy for having tried "conservative therapies?"

There are folks looking for $$$ everywhere. Surgical/anesthesia/admin costs are driving a big share of healthcare utilization, so even if 5% of my patients get better, that's 5% which aren't going to see you or your surgeon friend in the OR.

I'm pretty confident the field will survive better than OR anesthesia because the majority of reasons a patient seeks medical care is pain, not the need for an anesthetic or a surgery.

It may not do as well as psychiatry, and it definitely won't do as well as the administrators.

 

[Measured_in_KG]

So the answer is that you have little to no credibility to make the absurd claims in your last post. And there may be more to the story than you're telling us, having "left" your ACGME-accredited pain fellowship after only 3 months.

You writing makes you sound like you have an axe to grind, bottom line.

Any chance you'd like to refute his points, rather than rely on ad hominem attacks? It shouldn't matter whether he's the president of SIS or a malpractice attorney feasting on your misdeeds. If he's saying something that's provably false, go ahead and prove it false without all the name calling.

 

[Measured_in_KG]

So the answer is that you have little to no credibility to make the absurd claims in your last post. And there may be more to the story than you're telling us, having "left" your ACGME-accredited pain fellowship after only 3 months.

You writing makes you sound like you have an axe to grind, bottom line.

Any chance you'd like to refute his points, rather than rely on ad hominem attacks? It shouldn't matter whether he's the president of SIS or a malpractice attorney feasting on your misdeeds. If he's saying something that's provably false, go ahead and prove it false without all the name calling.

 

[Machinery]

Why couldnt a neurosurgeon order an MRI and do the LESI? Not exactly cracking a medical mystery.

This is the same as asking why ENT couldn't do all the intubations in the hospital. They probably could but it will not make much sense.

But I dont think their existence is necessary. Most are drug pushers, many have an altered idea of what success is given the cost. Cost in healthcare dollars, addicted patients, insurance company time, on and on... if the whole field went away no one would care. Get your LESI from the surgeon/regular anesthesiologist, and go get your heroin on the street..

This is the exact issue I have with this thread. All the highlighted statements are just plain wrong mixed with unnecessary judgmental attacks. Again, let me remind everyone that chronic pain management involves more than LESIs. If I have a dollar for every time someone has predicted a field (including anesthesia) will disappear and no one will miss it .....

I dont think pain has anywhere near the respect of a field like neurology to even be compared.

Just like Anesthesia, pain is a Neurology sub-specialty. Obviously some people respect it enough to spend the extra time.

A good friend of mine is a neurosurgeon. He makes a LOOT of money and has asked me to join him several times. Its just not in me although it is tempting. In an honest conversation, he tells me, I dont care what the pain guys do with the patients as long as they eventually come back to me for surgery, thinks its completely comical what the pain guys are billing for. IPM is a middle man in the industrial machine of LBP treatment. Thats it.

This neurosurgeon friend of yours who makes a LOOT of money, does not care what the pain guys do to his patients, while acknowledging that they might be comically billing the same patients is probably not the best person to reference if you want to lend credibility to your argument. Why is he asking you to join him? If your comment above is correct, he can just order his own MRI and do the LESI.

The guys who are purely interventional are off the hook for the opioid epidemic, but not the extreme overconsumption of healthcare resources. Great that you dont give out percocet, but stop racking up a huge bill on the way to someone having inevitable surgery or inevitably getting better on their own. A successful injection is in the eyes of the beholder.

A significant portion of pain management referrals are from surgeons who have either done surgery or do not want to do surgery. The majority of the remaining referrals are from other doctors who have tried to manage patients' pain but have been unsuccessful which means the pain did not get better on it's own.

The idea that these genuine feelings of angst toward the field are unfounded by people who "couldnt cut it" is extremely short sighted. Time will tell , but I dont think the field will last as the microscope zooms in...

As the population ages, the volume of chronic pain patients will continue to increase. As the government continues to crack down on opioids, the number of casual pain treating providers (PCP, retired surgeon etc) will decline. Americans will not accept the "just deal with your pain" argument. This will almost guarantee increased business for the pain specialists. Pain doctors are actually in one of the best positions to grow. All they need to do is re-tool.

 

[powermd]

Any chance you'd like to refute his points, rather than rely on ad hominem attacks? It shouldn't matter whether he's the president of SIS or a malpractice attorney feasting on your misdeeds. If he's saying something that's provably false, go ahead and prove it false without all the name calling.

His "points" are just troll-like accusations without expert credibility or evidence to support them.

Let him painstakingly list each procedure performed by interventional pain specialists, quote relevant and respected literature for each, and then explain how that justifies hyperbole like "snake oil".

Let him do a study of interventional pain specialists in which the hypothesis "every problem looks like a nail" is tested.

Let him provide data showing that the vast, vast, vast majority of chronic pain problems resolve on their own. Chronic pain is, by definition, chronic. It's not going away without DOING SOMETHING.

 

[nimbus]

He Took Opioids To Manage His Chronic Pain. When His Doctors Took Them Away, He Didn’t Want To Live Anymore.

 

[chocomorsel]

Hmm. Couldnt cut it so you are back at your nursing job giving gas?

😀

You are an ass hole. Find a nurse to do your anesthesia every time then since that’s what you equate us to.

 

[pgg]

We're all friends here, let's keep it civil.

 

[Arch Guillotti]

Find a nurse to do your anesthesia every time then since that’s what you equate us to.

Did you see the smiley emoji?

 

[DrCommonSense]

i have heard this argument before,

do you not think it is different to:

give anesthesia for a procedure suggested by a surgeon and agreed to by the patient

vs

actually suggest the procedure for the patient

i do. i think its more egregious to actually do the procedure and more forgiveable to simply provide the sedation for the procedure that has already been agreed upon/sold

tldr: i dont think that because we provide sedation for BS cases it makes us as fallable as those who suggest and book and do the BS procedure

Yeah because doing all those anesthesia for elective orthopedic and fusion surgeries who will inevitably go on HIGHER dosages of narcotics if so morally good right?

I mean its never like those post fusion patients aren't on high dosages of narcotics?

Oh wait, whats the evidence for any arthroscopy, most elective ortho surgeries, fusion surgeries in >90% of cases, etc?

Oh thats right exposing patients to anesthetics that can increased morbidity/mortality for large surgeries with dubious benefit evidence is so superior to those pain guys that do their placebo procedures right?

 

[DrCommonSense]

powermd would probably be interested to learn that I did just over three months in a ACGME-accredited Pain Fellowship before I realized what a wholesale scam it is (and left for private practice). Sure, that makes me both a slow learner (to have needed three months to see what most anesthesiologists realize with only a couple of weeks' exposure during residency) and a much faster learner than folks like powermd who have yet to figure it out.

That somebody else in medicine is just as bad or worse (What about chiropractors?! What about spine surgeons?! What about charlatans selling PRP or stem cell therapy?! or lasers?! or robots?! or...) doesn't mean that pain specialists get a pass.

If the steroid injections get people back to work or reduce opiate consumption it should be pretty easy to show, especially considering how many millions of dollars hang in the balance. The lack of good evidence (Almost twice as good as placebo? Really? Almost twice as good as nothing at all?? Or is it because the placebo injections still--as was once the apologists' theory--"flush away substance P?") is pretty damning.

When a pain interventionalist can make a go of it charging cash for his procedures and offering a money back guarantee if the patient is not satisfied, then I will agree there might be something to it. Show me that interventionalist who succeeds in selling his services directly to a patient without a third party picking up the tab, and then I'll do a recent literature search in hopes of "adding credibility."

When are all the patients that are getting fusion surgeries on their spine going to do the same thing about "money back" after surgery?

Also BMAC stem cells have more evidence even as Phase 3 trials than fusions do for discogenic pain that is a very common etiology for surgical indications for surgeons.

Please dont get me started on the lack of evidence for most elective Ortho surgeries, stents, fusions, prostate CA surgeries, etc that you routinely expose older patients to anesthesia.

 

[DrCommonSense]

Yeah, I mean if you disagree with the conservative right why dont you just turn on fox news so you can better understand our point of view...come on over to the pain forum...

Why couldnt a neurosurgeon order an MRI and do the LESI? Not exactly cracking a medical mystery.

I do believe in LESIs. I do believe some pain doctors are ethical.

But I dont think their existence is necessary. Most are drug pushers, many have an altered idea of what success is given the cost. Cost in healthcare dollars, addicted patients, insurance company time, on and on... if the whole field went away no one would care. Get your LESI from the surgeon/regular anesthesiologist, and go get your heroin on the street..

I dont think pain has anywhere near the respect of a field like neurology to even be compared.

A good friend of mine is a neurosurgeon. He makes a LOOT of money and has asked me to join him several times. Its just not in me although it is tempting. In an honest conversation, he tells me, I dont care what the pain guys do with the patients as long as they eventually come back to me for surgery, thinks its completely comical what the pain guys are billing for. IPM is a middle man in the industrial machine of LBP treatment. Thats it.

The guys who are purely interventional are off the hook for the opioid epidemic, but not the extreme overconsumption of healthcare resources. Great that you dont give out percocet, but stop racking up a huge bill on the way to someone having inevitable surgery or inevitably getting better on their own. A successful injection is in the eyes of the beholder.

The idea that these genuine feelings of angst toward the field are unfounded by people who "couldnt cut it" is extremely short sighted. Time will tell , but I dont think the field will last as the microscope zooms in...

Does your neurosurgeon friend who "makes alot of money" have "evidence" for all the fusion surgeries (or any back surgeries he does) outside of the very small minority that have myelopathy?

http://ard.bmj.com/content/annrheumdis/69/9/1643.full.pdf

So by your logic, if neurosurgeons/ortho surgeons just stopped doing 99% of their back surgeries, there would be no loss to the system and benefits in terms of their extreme overconsumption of healthcare resources.

Also, how many of those post fusion patients are on narcotic medications? Do they get better after surgery to become more functional or use less narcotic medications?

Workman comp studies out of Ohio show worse outcomes after fusion surgeries with increased narcotic usage.

Spinal Fusion Surgery Provides Worse Outcomes in Workers' Compensation Patients

So why is surgery "inevitable" when it hasn't shown to be superior to conservative care for the VAST majority of patients outside of the very few with actually severe weakness due to a surgical lesion again?

BMJ studies show exercise and CBT are equal to surgery at four years out for the vast majority of patients. IPM that allows people to continue to exercise with no surgical involvement has a better track records than your surgical friend.

And why are you doing anesthesia for such things?

 

[Hoya11]

Does your neurosurgeon friend who "makes alot of money" have "evidence" for all the fusion surgeries (or any back surgeries he does) outside of the very small minority that have myelopathy?

http://ard.bmj.com/content/annrheumdis/69/9/1643.full.pdf

So by your logic, if neurosurgeons/ortho surgeons just stopped doing 99% of their back surgeries, there would be no loss to the system and benefits in terms of their extreme overconsumption of healthcare resources.

Also, how many of those post fusion patients are on narcotic medications? Do they get better after surgery to become more functional or use less narcotic medications?

Workman comp studies out of Ohio show worse outcomes after fusion surgeries with increased narcotic usage.

Spinal Fusion Surgery Provides Worse Outcomes in Workers' Compensation Patients

So why is surgery "inevitable" when it hasn't shown to be superior to conservative care for the VAST majority of patients outside of the very few with actually severe weakness due to a surgical lesion again?

BMJ studies show exercise and CBT are equal to surgery at four years out for the vast majority of patients. IPM that allows people to continue to exercise with no surgical involvement has a better tack records than your surgical friend.

And why are you doing anesthesia for such things?

lol at this dudes posts, its like someone gave speed to a nonenglish speaking person in front of a translator

 

[DrCommonSense]

lol at this dudes posts, its like someone gave speed to a nonenglish speaking person in front of a translator

Have you read your illiterate posts before including this idiotic refutation? Maybe you shouldn't speak about anyone's English skills.

Also notice how you can't refute my argument and just attempt ad homs despite showing both a BMJ study and Ohio workman's comp study confirming that you are FOS about the "inevitability" of surgery or its actual benefit for the vast majority of patients.

 

[DrCommonSense]

lol at this dudes posts, its like someone gave speed to a nonenglish speaking person in front of a translator

Oh maybe you should worry about OR anesthesiologists more considering they are on the chopping block due to high costs compared to nurses.

Where's your "studies" to confirm that anesthesiologists aren't overpaid and clinically superior to nurses? According to RAND and health care "consultant" groups, you are way overpaid and should be receiving nurse wages due to "studies" confirming nurses are just as good as docs.

Anesthesiologists could be considered glorified "middle men" whose loss wouldn't be missed by patients if replaced by nurses. See how that works?

Nurse practitioners: Good for patients but a bitter pill for doctors

 

[Psai]

wtf is going on in this thread...

 

[Man o War]

Jesus. The Donald got an SDN account too.
We have been legitimized ladies and gents

 

[DrCommonSense]

wtf is going on in this thread...

Some tool came on to drop ad-hom attacks with zero evidence. Tool whines about lack of sufficient English skills while writing using disjointed sentence construction when responding to quickly written statements by another anonymous poster that gives him study after study refuting his *****ic claims.

Normal internet stuff.