How competative are Pain Management Fellowships?

[clc8503]

Out of curiosity, how competative are Pain Mangement Fellowships. I tried to do a search but I could not find what I was looking for. Do they work with there patients in clinics, similar to the way primary care physician do (I do realize the scope of practice IS DIFFERENT) I'm trying to get a mental picture of this.

Thanks

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[ThinkFast007]

Out of curiosity, how competative are Pain Mangement Fellowships. I tried to do a search but I could not find what I was looking for. Do they work with there patients in clinics, similar to the way primary care physician do (I do realize the scope of practice IS DIFFERENT) I'm trying to get a mental picture of this.

Thanks

never shadowed one. but from what i hear, yes, you do follow pts etc. Basically u are sorta like a PCP, cept you mk 6x as much.

from what i heard from the pain docs i talked to (but as i said i didnt shadow them or anything), most of the pts are drug seekers and druggies, etc. He told me that its a depressing site and infact was warning me against the whole field of pain mgt. But then again he drives a nice jag, lives in a phat house, etc.

I guess teh word 'drug seeker' isnt really used nowadays because there's that push for pain not being a able to objectively IDed and you should listen to the pt, etc. But....that was his take on it. He was like, "i'm glad i do pain only once a week".

 

[clc8503]

never shadowed one. but from what i hear, yes, you do follow pts etc. Basically u are sorta like a PCP, cept you mk 6x as much.

from what i heard from the pain docs i talked to (but as i said i didnt shadow them or anything), most of the pts are drug seekers and druggies, etc. He told me that its a depressing site and infact was warning me against the whole field of pain mgt. But then again he drives a nice jag, lives in a phat house, etc.

I guess teh word 'drug seeker' isnt really used nowadays because there's that push for pain not being a able to objectively IDed and you should listen to the pt, etc. But....that was his take on it. He was like, "i'm glad i do pain only once a week".

Thanks for your reply. I realize that any fellowship will be competative, but how competative is Pain Management compared to the other Anesthesiology fellowships? That's the main thing I'm curious about right now.

 

[VentdependenT]

Thanks for your reply. I realize that any fellowship will be competative, but how competative is Pain Management compared to the other Anesthesiology fellowships? That's the main thing I'm curious about right now.

Depends on what program you are interested in I guess. I think if you are even moderately motivated about gearing your CV towards pain (i.e. no insane pain research) then you should match somewhere. I know a few people who went into pain and they didn't express any concerns about it being ultra competitive.

The market seems good right now however and that is one of the major factors for the decline of competition in anes fellowships. I'll ask the fellows at my program when I'm on call next and find out the inside poop.

No more clinic for this guy. Interventional sounds tempting though.

 

[sevoflurane]

I've heard of pain doc's having 1-2 half day clinics a week... the rest of their time entails procedures, procedures, procedures.... +/- OR time running gas. Sounds varied and tempting.... but the chronic pain population can be demanding at times. Celiac plexus blocks are pretty cool and worth while in chronic abdominal pain, particularly pancreatic cancer pain.

 

[rexed]

In my class of 12 residents this year, 3 of us are going into pain, and 1 is planning on a regional fellowship followed by a pain fellowship....

Pain is getting a bit more popular these days...

 

[DrDre']

Some fellowship directors have spelling bees before choosing candidates...

 

[Aether2000]

Interventional pain as an isolated practice design will be dead in less than 5 years. You cannot cure anyone by sticking needles into their spine and the idea of walzing into a clinic, lining up 40 patients to administer epidurals, is fortunately becoming an anachronism. Pure interventionalists are simply technicians, much like an EKG technician. Eventually through pressure on physicians by Medicare and by private insurance, there will come a time when those practicing pure interventional pain will find themselves with significantly decreased reimbursement (yes, the procedures are vastly overvalued at this time). Only those who want to practice as physicians instead of technicians, with a balanced approach rather than an approach based on cherry picking and convenience to the physician, will eventually be involved with pain management. Therefore, it is my suggestion that those with a solely block jock mentality find another specialty since pain medicine is rapidly evolving into something they cannot tolerate.

 

[seaofred]

Sure, we all agree that using a multi-disciplinary approach is best when treating the patient in pain but why all of this doom and gloom. These procedures are going nowhere. There are a lot of modalities in medicine that don't have evidence based medicine behind them and these are still being used. I am just curious why you feel this way? Maybe I am just not following what you are saying? I do believe reimbursment might take a hit but I don't think you will go broke practicing pain management. What do you think?

 

[Aether2000]

Pain physicians can still make money doing pain management. Way too much money compared to other specialties including neurosurgery, anesthesiology, etc. This creates a bullseye effect for insurers trying to cut outlays and especially when the science behind what we do is so tenuous. Combine that with organizations that are hell-bent on obtaining even more reimbursement for pain management while printing pseudoscience of one individual as justification for such increased reimbursement, there is fostered a distrust of the specialty as being self-serving rather than scientific. There are already insurance carriers that will justifiably not consider any studies coming out of one location here in the US because of the self serving politics/financial gain promoted by one individual.
What must transpire in order to prevent the continuing collapse of the house of cards of interventional pain medicine (IDET, nucleoplasty, pulsed RF, dekompressor, APLD, LASE, disctrode, etc- all of which are no longer paid for by many carriers) is to elevate the ethics of research to the same level as other disciplines, and get a complete and unequivocal divorce from the placement of financial gain above that of science or patient care. But given the golden goose of pain medicine and its extreme reimbursement compared to other specialties, it is unlikely anyone from our specialty will want to stab the goose with the quaint and probably forgotten idea of ethics. Therefore, insurance carriers, Medicare, and ultimately high patient insurance deductables will make the case for a more humane and balanced approach than the block shop. Reimbursement will fall for pain physicians once this occurs. It is not gloom and doom...it is inevitable. But I think reinjecting (no pun intended) ethics and humanitarianism back into the business model of pain medicine is not necessarily a bad thing....

 

[seaofred]

Thanks for your reply. Tons of good info in there and it sure makes you think about the future of our specialty. There seems to be a bunch of golden geese in each specialty and a lot of these geese have no good studies backing up the practice of them.

 

[drusso]

So, Algos, what should be the solution?

Better ethics training, more science, what? Clearly, ONE very appealing aspect of the practice of pain medicine is the ability to make a good living. Highly compensated specialties attract highly qualified and ambitious candidates. If the bottom fell out of pain medicine, you could be certain that most applicants would not forego a year of "attending level salary" to pursue a fellowship.

I'm interested in hearing your thought's on the issue. How do you encourage the best in others and keep away the greedy influences and behavior that could ruin it for everyone?

 

[Aether2000]

The short answer is that physicians going into pain management can select the style of practice, the degree of ethical treatment of patients, and the organizations they support. Those who are interested in being doctors rather than technicians will insist on a balanced pain program that will deliver a very good salary, but will not be 3 times that of the average anesthesiologist. Organizations that have a mission of teaching and research are ultimately far more important to the specialty than those that emphasize buying a congressman in order to maximize pain reimbursement by Medicare.
The long answer is more complex. It involves the creation of a true specialty of pain medicine rather than the current bizarre mixture of pain fellowships from three completely different backgrounds teaching entirely different skills from one another. Even within the fellowship programs of anesthesiology, the variability in experiences and focus are so great that graduates of some programs cannot function at a basal level in the real world of pain management. Therefore, the only way to create a pain training program that imparts at least fundamental treatment skills is to scrap the fellowship concept altogether, and create pain residency programs.

 

[Disse]

The short answer is that physicians going into pain management can select the style of practice, the degree of ethical treatment of patients, and the organizations they support. Those who are interested in being doctors rather than technicians will insist on a balanced pain program that will deliver a very good salary, but will not be 3 times that of the average anesthesiologist. Organizations that have a mission of teaching and research are ultimately far more important to the specialty than those that emphasize buying a congressman in order to maximize pain reimbursement by Medicare.
The long answer is more complex. It involves the creation of a true specialty of pain medicine rather than the current bizarre mixture of pain fellowships from three completely different backgrounds teaching entirely different skills from one another. Even within the fellowship programs of anesthesiology, the variability in experiences and focus are so great that graduates of some programs cannot function at a basal level in the real world of pain management. Therefore, the only way to create a pain training program that imparts at least fundamental treatment skills is to scrap the fellowship concept altogether, and create pain residency programs.

What is particularly aggravating is that as an applicant it is almost IMPOSSIBLE to get any information regarding "balanced" programs and/or program information in general (especially unbiased information).

It seems as if fellowships (outside of a few extremely well-known programs) is simply a crap shoot. Guess it all comes down to location

 

[Aether2000]

I agree...and to add more confusion, the directors of the pain programs are constantly in flux. A great program one year may turn into a mediocre one the next year depending on the physicians teaching, internal politics, external politics (other departments limiting what pain physicians may do), etc. The best way to get an educated guess as to what programs are quality is to contact the current fellows in the program directly and ask them about the program.

 

[drrinoo]

I agree...and to add more confusion, the directors of the pain programs are constantly in flux. A great program one year may turn into a mediocre one the next year depending on the physicians teaching, internal politics, external politics (other departments limiting what pain physicians may do), etc. The best way to get an educated guess as to what programs are quality is to contact the current fellows in the program directly and ask them about the program.

Algos

You are presenting some common misconceptions about ASIPP and Dr. Manchikanti...personally, I believe the major reason that Dr. Manchikanti is criticized is simpe bigotry....

Indian physicians constitute well over 20-30% of standard ABMS specialities that feed pain medicine.....anesthesiology, physiatry...how many officers of any of these major organizations have physicians of indian origin or for that matter of foreign descent.

Dr. Manchikanti has single handedly saved the field of interventional pain medicine from the graveyard...ASIPP's membership is growing at an incredible rate will surpass ISISs, despite being around only half the time. You cannot slam this grass roots support of Dr. Manchikanti's efforts
Dr. Manchikanti never sleeps and all the meetings ASIPP organizes are about work....there is very little down time..ASIP meetings are never in luxury resort hotels and speakers are not paid to take first class tickets..Dr. M, on a personal level, has the ultimate characteristics of a leader..and is a simple and honest family man who doesn't drink or smoke...his staff have been loyal to him for years....

As far as I am concerned, he has given me a great deal of inspiration in terms of his life accomplishments

what did the ASA do...what did ISIS do...calling all the attendees at their conferences a bunch of 'feral practitioners'...NASS...is trying to kill vertebroplasty and pulsed RF...Heck, even the AAPMR could not block the American PT association from demanding that all PTAs are supervised by a PT...

at least ASIPP recognizes the hurdles pain physicians face and recognizes the things that need to be done, so that pain physicians do not lose further autonomy


ASIPP in its short life has done an incredible amount...being the first physician organization to pass a federal law...NASPER

AAPM is still supporting the Hurwitz case, even though this physician doled out huge bucketloads of narcotics and they couldn't even make up their mind about NASPER...the APS is opposed to NASPER, because it could interfere with patient access..the latter organizations are still using terms such as pseudoaddication...meaningless terms...even the DEA abandoned the support of some APS/AAPM guidelines for opioid prescribing.

Dr. Manchikanti has spearheaded efforts to educate and train physicians about regulatory issues in pain management from controlled substance use, to coding, to compliance...ASIPP has gotten a special designation for interventional pain, so that our practice expenses would be tallied by our peers...rather than use practice expenses from anesthesiology which would low ball practice expenses for interventionalists

He has also gotten interventional pain representation in CAC...the first new specialty in about 20 years...do you want neurosurgeons and anesthesiologists representing interventionalists?

Also, interventional pain specialists are not outpaid relative to other specialties..the financially successful interventionalists have invested a substantial amount of time and energy into their practices to become financially successful...most neurosurgeons, orthopods, radiologists simply have point to any random location in the USA and call up the local hospital...the hosptial will give them a huge high dollar salary/guarantee and all the equipment they need...not so for most pain guys

additionally, changes in compensation can occur for other reasons..cardiac surgeons are probably making less than interventional cardiologists...and the latter group control patients...this just represents a paradigm shift as medical technology advances.

because of lack of political activism the cardiac surgeons and vascular surgeons just got hosed....a little activism on a cardiac surgeons part would not have lowered reimbursements for CABG to 130% of a total knee....can you imaging spending 8+ years in residency training to face a future where you are paid a lump sum amount for the procedure and post-op management?
so, we need to engage payors and politicians for our fields

the current SGR and practice expense estimates suggests that we may could see a 40-50% reduction in reimbursements in 4-5 years....most interventionalists would not be able to treat medicare patients...at these rates

preserving reimbursements for pain procedures in offices/ASCs preserves patient access....ask any interventional pain guy to compete with a neurosurgeon or GI guy/radiologists in a hospital with regards to getting OR slots or Oupt procedure suite access in a hospital and they will lose....that is why interventionalists are trying to preserve reimbursement...

also any non-anesthesiology pain guys who try to apply for priviliges at a hospital may be blocked by the anesthesiology group...do you think the ASA would welcome phsyiatrists?

the list goes on....in fact ASIPP has done some work to mandate that fluoroscopy be the standard of care

as for ISIS...I heard two elite ISIS members testified against another ISIS member in a malpractice case and forced the guy into bankruptcy

In another example, a practitioner asked an elite ISIS guy..'what is the point of expending so much energy diagnosing a spinal pain generator, if there is no evidenced based treatment...what do I tell the patient?'...the elite ISIS guy told this practitioner that the patient 'should attend ISIS meetings on an annual basis until an evidenced based treatment arrives...and in the mean time, just wait'

and allow me to spread a misconception....I have heard that you teach non-physicians (CRNAs and NPs) pain procedures....don't you think that if we lower the bar any further by teaching non-physicians that this will affect our practice?

Finally, interventionalists probably cost health care only 5-15% of what spine surgeons cost society....there are a number of specialists that are trying to game the business of medicine....is a LASIK operation more effective than eyeglasses...is a pulsed RF facelift more efficacious in outcomes compared to a surgical facelift....is liposuction more effective than exercise....are brand name anti-hypertensives more cost effective than generics....are drug eluting stents that much better than balloon angioplasty....is a hysterectomy needed for any patient with abnormal bleeding...is scoping a 50+ adult with medial compartment OA justifiable?

a number of specialties operate on the fringes of evidence.

at the end of the day...a patient can get 150-200 epidurals for the price of one spinal fusion....aat 3/ years...it may buy them 20-25years

most interventionalists practice good medicine and most pain patients have legitimate complaints....

 

[Aether2000]

It would be difficult to find any single post by any pain physician that I disagree with more vehemently than yours.
First of all, your assertion of bigotry is the production of a pathetic lack of self confidence in yourself and your profession. Those who cannot withstand valid criticism turn to race as a scapegoat. You have not only demeaned yourself by such nonsensical comments about race and Indian physicians but also have also used non-sequitor logic to promote an extremist and unsupported view. There is no need to defend myself against such bizarre charges since such is so far off the mark and so far beneath my dignity that the only comment worthy of your incredibly stupid attempts to inject race into an argument is "get a life".
It is also absolute nonsense about a single individual "saving" pain management from the graveyard. Such adulation is an expected response from the minions of such but discounts continuing efforts of many individuals in other quite worthy and much older pain organizations. The accomplishments of all organizations who fight for pain management in whatever form should not be dismissed because they prefer to work behind the scenes instead of heaping mountains of self-praise on themselves everytime they have a meeting or participate in passing laws. And speaking of laws, one should examine NASPER closely. It is not a national drug tracking system...it is a federal grant with many restrictions to individual states who apply and are able to comply with the inevitable reams of paperwork that will be required by the feds in order to receive paltry sums of money in order to run these programs. In addition, NASPER is not only used to track patients but given its construct, can be used to track physician prescribing. Those who fall outside the "norms" may be subject to sanction by federal or state authorities. And by the way, congress passes laws, not pain organizations.
In case you hadn't noticed, the "special designations" for pain have absolutely no meaning legally, medically, or financially. Anesthesiology based pain physicians are paid the same rates as anesthesiologists doing the same work, not as any special reimbursement code would have you believe.
The coding issues are interesting in that if you read the contributions of certain individuals to CACs, you will find there is significant controversy in even the terminology selected to describe selective nerve root blocks, epidural steroid injections, transforaminals, etc., and there is certainly a significant degree of pontification on what is the "proper" and "accepted" method of performing these blocks. Now it appears the work done in regulatory issues, compliance, and certain interpretations of narcotic laws are being turned into moneymakers for the new board. It does make one consider the motivation for having such a fragmented approach to piecemeal "board certification" when $750 per topic is being charged to test the knowledge of each of these areas that the same organization worked to develop in their own interpretation.
Pain physicians generally make 1.5-3 times that of the average anesthesiologist and I know of several making more than $1,000,000 a year after expenses doing epidural steroid injections and blocks, lining patients up like an assembly line, failing to give patients information about the technical aspect of the blocks, informed consent as to possible complications, discussion of alternatives, and failing to tell the patient about the expected outcome of such blocks. These are mindless block jocks who have adopted wholesale the idea of increasing reimbursement at the expense of quality care for patients, even at a basally acceptable level. Increasing reimbursement by having Medicare accept questionable pain procedures whose main support comes from one journal that doesn't require any study oversight at all is disingenouous and dangerous. By having members of one organization actively attempting to stack the deck with their members on CAC committees by having an on-line application for such is even more alarming. If reimbursement does fall by 30-40%, which it should if there continues to be the mindless block jock model of pain management, then perhaps those who are not sincere about treating patients for a reasonable rate of return instead of the confiscatory rates now charged by some physicians would be better off out of the field of pain medicine altogether. One local pain doc charged $7,200 for a botox injection in his office and insurance paid $4,000. The visit took 15 minutes and he used 200 U Botox. Another routinely charges patients $1,500 for a sitting office epidural without fluoroscopy, that takes him all of 5 minutes to complete, and balance bills the patients for the total amount (no, he does not accept medicare). When an organization is hell-bent on increasing reimbursement for overpriced procedures and is attempting to have Medicare accept very questionable newly coded procedures at high reimbursement rates, one must consider carefully their motivations. It is the avarice promoted by organizations that see potential $$$$$ through political action committees that will ultimately backfire. You can pull the wool over the eyes of the HHS, especially if their leader is one of your buddies, but ultimately regulatory oversight by congressional committees, scrutiny by other organizations that do not share the goals of increasing reimbursement for an extremely well pain group of physicians and find their methods to acquire such increased reimbursement to be an anathema will dictate whether the motives are for enhanced patient care or enhanced physician pocketbooks.
As for teaching CRNAs, there are some low-level procedures that are taught by some pain organizations to CRNAs. However those of us who teach for pain organizations do not select the participants for such organizations but are working diligently from the inside to change the structure to that of a physician only group. We find it is better to work within organizations that are well established to change processes with which we disagree rather than to jump on board organizations that are philosophically repugnant. Some of these organizations are evolving into more exclusive organizations just as some organizations evolved in the opposite direction from a hyperexclusionary elitist club of anesthesiologists only. With respect to locations of the laboratories, for approximately the same price, many pain organizations feel it is better to have a little vision and not conduct the meetings repeatedly and exclusively in some hell-hole of a town that few physicians want to visit anyway.
Coming from the standpoint of an academician, it is understandable why you do not have a grasp on the financial realities of pain medicine compared with other specialties. The idea that neurosurgeons/orthopods do not have to build their practice and can exist in lassitude in the location of their choice drawing high salaries from the hospitals while the impoverished decrepit pain doctor languishes away is laughable. Thank you for the unintended humor in your post...it made my day.

 

[lobelsteve]

This is good talk. I agree with Algos on many of these issues. I had an interview with Doris Cope at Pitt Anesthesia Pain Medicine and 2 years ago she was discussing the need for change in education. Is there a way to make pain it's own residency? Logistically it appears not too difficult to hammer out a schedule and get the ACGME to look. Politically- herding cats- and that is proven by this thread. I'm just starting my practice and came from PM&R to PM&R pain fellowship and there are lots of procedures I am uncomfortable with as my training was not geared towards regional. So how do we procede?

PGY1-surgical prelim
PGY2-3 mo IM, 3 mo neurology, 3 mo pscyhiatry, 3 mo Ortho
PGY3-3 mo neurosurgery, 6 month acute pain service 3 mo pain clinic
PGY4-mixed acute pain and clinic depending on what practice you will be going into.

THat is an easy enough 4 years and readily modifiable to be more useful.

So let's do this. Where can I send a letter? How can we get started?
Object: to benefit the patient by having a national standard in training for pain physicians as well as adding diversity to the training to allow pain physicians to better treat a broader spectrum of patients.

 

[drusso]

There does seem to be a number of professional groups in pain out of proportion to the number of practitioners compared to other fields. I think it be beneficial for pain physicians to stand together and not be splintered into increasingly smaller groups.

 

[Aether2000]

Perhaps we need Rodney King as a mediator for all the organizations...

 

[Disse]

Outside of political discussions (which are quite fascinating--will be interesting to try and dig through all the hearsay and find which organization is the "best" one to support) what are others feelings on the competitiveness of pain fellowships this year?

I'm sure everyone says this every year but it seems it has ramped up siginificantly this year when I compare my experiences so far with a friend of mines last year.

Also, is there anyway that this forum could be made so you can view it from the main SDN forums? No offense, but this topic was originally posted in the anesthesia forum and had multiple hits prior to being moved here (where most of the discussion became political). I've tried multiple times to access this forum from SDN but now just go to painrounds.com then to the forums.

Perhaps if this forum could be viewed from the SDN forums there would be more visitation and more discussion? Most of the time it is extremely dead here.

 

[Myotonia]

I heard that there are 3-4 residents of class of 18, 1 of them is a chief resident with super high board scores applying this year. They say that it will be a very competitive year. I donno.

 

[Doctodd]

Well.......to the original posters and follow ups, you guys are absolutley right. Dont go into pain. Stay where you are. ;-)

To the last few posts, i think the reason this forum isnt linked to the main board is to keep the traffic pertinent.

Good discussion otherwise....one of the reasons i went into medicine was because i hated politics. I have realized in the past few years that i have not escaped politics yet. Algos.....regarding those block jock docs who you mentioned highly overcharge, have you or anyone else attempted any "divine intervention"?

T

 

[Aether2000]

No intervention as of yet...the insurers are starting to do this for us to a certain degree. Anthem/Blue Cross implemented a policy effective July 2005 that cuts payment to anesthesiologists/ pain doctors by 2/3 for interlaminar ESI and caudal ESI and facet blocks performed in an ASC or hospital. Now the reimbursement is $80 in the OR for a LESI. Now if the insurers stop paying for these blocks without fluoroscopy, we will begin to see some real changes.
Part of the issue revolves around no common set of standards, and no one has a standard for performing LESI with or without fluoroscopy. One pain organization states in their "guidelines "that weekly administration of epidural steroids is acceptable in spite of the known adrenal suppression that lasts 2-4 weeks and in spite of the fact there is not one study that has demonstrated any greater long term outcome by stacking steroid injections in that manner. Such nonsensical "guidelines" are a disservice to the entire pain community and cause an increasingly jaundiced eye of the insurers when guidelines are based on whims or on "what-I-do-in-my-practice-therefore-it-must-be-a-standard".

 

[Hoya11]

Is anesthesiology the only route to becoming a pain doctor? What about nuerology to pain?

And how often do you here that an anesthesiology resident wants to go into pain but cannot because it is too competitive? Is there something you can do if you are not in that elite 3 of 12 residents like take an extra year? Is it possible that these 3 are not the highest ranked residents, but really the only three residents interested in pain?

THanks for any help

 

[Aether2000]

A list of neurology based pain fellowships may be found at:
http://algosresearch.org/Education/NeurologyPainFellowships.html

Obviously, neurology has significant weaknesses with respect to pain management...often being relegated to interlaminar steroid injections and botox injections, and have deficits with respect to use of sedative/hypnotic IV agents and resuscitation protocols. However, the diagnostic skills may be very useful in certain areas of pain medicine. Some programs may offer corrections of such deficits when combined with other disciplines such as PM&R.

 

[Disse]

Well.......to the original posters and follow ups, you guys are absolutley right. Dont go into pain. Stay where you are. ;-)

To the last few posts, i think the reason this forum isnt linked to the main board is to keep the traffic pertinent.

Good discussion otherwise....one of the reasons i went into medicine was because i hated politics. I have realized in the past few years that i have not escaped politics yet. Algos.....regarding those block jock docs who you mentioned highly overcharge, have you or anyone else attempted any "divine intervention"?

T

Not sure if I agree about why this forum isn't linked to the main board. "Pertinence" is somewhat dependent on who is reading the forum. If this forum is strictly for pain clinicians I can see why some would not want it to be seen from the main forum. However, since attendings post on the other subspecialty forums there I'm not sure if that is truly an issue. Similarly, I think it is useful for both those interested in the specialty as well as those practicing the specialty to be able to access the forum easily (also, there may be some possibly interested who do not even know about this forum).

BUT if this forum is to remain "semi-secret" then it stands to reason that posts in the anesthesia, pm&r, psych, neuro, etc. sub-forums on SDN shouldn't be moved here (like they are).

This forum gets significantly less volume and has much less activity than the main forums. When trying to get information it is most useful to have a large volume of "lookers" to provide it.

 

[PAINISGOOD]

I also vote for this forum to be linked to the main forums!!!! We need more people contributing....I suggest putting the pain medicine forum under anesthesiology as a "sub-forum" .

Who do we contact for such a change? I can try asking the anesthesiology forum moderator.

 

[DigableCat]

I also vote for this forum to be linked to the main forums!!!! We need more people contributing....I suggest putting the pain medicine forum under anesthesiology as a "sub-forum" .

Who do we contact for such a change? I can try asking the anesthesiology forum moderator.

Given that this forum was created by a "PM&R physician", I don't think that it should be added under an anesthesiology "sub-forum". PainRounds.org, also the brainchild of a PM&R physician. We're not all anesthesiologist you know.

My .02c.

 

[Disse]

Given that this forum was created by a "PM&R physician", I don't think that it should be added under an anesthesiology "sub-forum". PainRounds.org, also the brainchild of a PM&R physician. We're not all anesthesiologist you know.

My .02c.

Should just be listed under the specialty forums on its own just like Anethesia, PM&R, Radiology, etc.

 

[lobelsteve]

Keep it hidden. If people are interested and intelligent, they will talk to someone who knows we are here. I've referred a few lurkers here.

 

[Doctodd]

This forum is not linked for a reason, and a moderator gave me the reason i gave you. If you choose not to believe it, then that is ok.

Maybe this thread is a perfect example of why. I for one am glad this forum isnt cluttered with anyone and everyone because the posts are/were relevant to the pain field. To have a bunch of "non-pain" guys begin threads that arent relevant to the pain field would take away from the purpose of this forum in the first place.

T

 

[Disse]

This forum is not linked for a reason, and a moderator gave me the reason i gave you. If you choose not to believe it, then that is ok.

Maybe this thread is a perfect example of why. I for one am glad this forum isnt cluttered with anyone and everyone because the posts are/were relevant to the pain field. To have a bunch of "non-pain" guys begin threads that arent relevant to the pain field would take away from the purpose of this forum in the first place.

T

And what is that perfect example of why? People interested in pain asking about how competitive it is to match, good programs, etc. or long political diatribes on how awful one specialty society is compared to another?

IF this forum is to strictly be clinical pain that is fine (I can see how some would want things limited to discussions of overhead expenses and payer mixes). BUT if so then pain discussions started at other forums should then stay at those forums--obviously those posting in those threads are "non-pain" guys and shouldn't have their non-relevant posts regarding the pain field cluttering up this forum.

Funny, though, I bet many "non-pain" clinical folks have a pretty good idea of payer mixes, practice management and basic overhead expenses that some just staring practice may find useful.

 

[drrinoo]

Algos,

Go take a Protonix for your bilious spats....I never expected an individual to engage in personal tirades. So be it.

First off, Rodney King was beaten by the LAPD...their actions and the consequent local jury verdict offended the sensibilities of all Americans and unfortunately led to some terrible race riots...even George Bush, Sr. at the time sympathesized with Rodney King, as did the federal courts....so by poking fun at Rodney King, you just align yourself with some extremist groups in the USA...

Perhaps you are confusing Rodney King with Rev. Al Sharpton...who did a hugely important service to NYC by protesting the brutal rape of Abner Louima (rape with a police stick) and the tragic death of an East African food vendor by the police....

Either way, you have just solidified my opinions about you, as posted in my earlier post....and if you still want to re-consider my opinion...take a flight out of rural Indiana and attend any South Asian (or Asian) party in a downtown club in NYC, LA, SF, or Boston (they are 2nd generation expats from the South, Midwest, and the suburbs)...and see what they say about your efforts to single out one individual in all of pain medicine.

In any case, your opinions about ASIPP and the practice of interventional pain are inconsistent with your practice.


A practice with a 23% overhead is closer to a surgical practice, whereas a practice with a 50% overhead is closer to an internal medicine or family practice clinic.

Why is this important....because it suggests that your practice is more along the lines of a 'block jock with fancy equipment (i.e., fluoro)' as opposed to a multidisciplinary comprehensive pain center.

Additionally, the fact that you teach CRNAs and NPs, while freely offering your thoughts on the pros/cons of ABMS specialties entering into pain management, e.g, neurology, is laughable....so it is ok to teach a nurse practitioner a facet block, but a neurologist would not be qualified to do this block?

As far as income....some CRNAs make 200 to 250,000+ dollars a year...about 2 times the average starting salary of a physiatrist....why would a CRNA need to learn how to do a facet block...patient access? or is it so that they can have an additional source of revenue....or is it so you can block any local competion in your community and the communities of like minded pain physicians...you can hire a CRNA or NP...and reduce your waitlist time..just so that your referring physicians won't send patients elsewhere

is it so bad that a physiatrist or anesthesiologist learn a few of these entry level procedures in order to treat their patients...or do you want to drop the floor further and force them to do advanced procedures with whcih they might not be comfortable?

And if you are so upset about some interventionalists making >1000000, why don't you go after them....or better yet increase the penetration of medicare, medicaid, indigent patients into your practice....you can have a good life on 100-150,000/dollars a year and truly help the disenfranchised poor and uninsured.

As for ASC reimbursement....it is imperative to preserve patient access. At HOPDs...the nurses are burdened by excessive and unnecessary paper work (like asking a patient if they like to read)...this leads to gross inefficiencies...1-1.5 hour turnarounds for a 5 minute procedure....

The CMS and HHS cannot and never will be influenced by any physician organization to raise rates....the CMS will exercise its right to reduce costs and introduce measures to reduce costs.

The ESI recommendations you suggest are not tenable in your state...there is Local Coverage Designation in your state that is posted by Administar that outlines how frequently ESIs should be performed..Administar Federal

As for the guy who bills insurers 7000 for 200 units of Botox..that sounds like what a dermatologist would charge

Look, any physician who egregiously charges their patients for useless services should be condemned....but you should voice your opinions to other specialties that do the same thing...

..should we be practicing medicine according to community standards or should we as interventionalists set the motto for the highest form of ethical and moral care....and require all other physicians in all disciplines follow suit....

In any case, if you are going to present yourself as holier than thou, you should practice accordingly before you start to point fingers....

It would be difficult to find any single post by any pain physician that I disagree with more vehemently than yours.
First of all, your assertion of bigotry is the production of a pathetic lack of self confidence in yourself and your profession. Those who cannot withstand valid criticism turn to race as a scapegoat. You have not only demeaned yourself by such nonsensical comments about race and Indian physicians but

 

[Aether2000]

No one would have ever bring up race in a battle of ethics unless they have an axe to grind which you clearly do. It is unfortunate injection of race as an attempt to divert attention from the ethics of the leadership of an organization has brought such antipathy...I suggest that your alignment with Al Sharpton has solidified our views of your extremist political expressions. Thank you for the confirmation. The quote about Rodney King (who was a drug abusing alcoholic violent offender who subsequently was arrested several more times) who you obviously revere for some reason, was meant as a humorous remark based on his now infamous comment "Why can't we all just get along". Not surprisingly you don't get it.
The lack of financial aptitude in pain management is demonstrated by some individuals who haven't a clue regarding overhead percentages in the real world. Physicians who are involved in non-academic pain practices (the vast majority of pain physicians) realize there are methods of manipulating the percentages to suit their practice, their expectations, their need for glitz, and the staffing needs. Ignorance of real world pain practice finance is endemic in academic programs where there is little or no time spent on this important aspect of running a practice. Residents matriculate from academic pain programs without the necessary tools in business, coding, finance, and clinic setup options with which to start a successful practice. Subsequently, many newly graduating fellows join groups already in business because they haven't been given enough information by their academic instructors (many of which have never run a successful pain practice themselves), in order to survive. Some hire expensive consultants to set up a practice, others dabble in pain medicine for years after a fellowship being involved in a part time pain practice while maintaining their base income from the safe predictability of OR anesthesia that has virtually no overhead. Many residents with significant medical school debts, are terrified of the startup costs of initiating their own practice in pain medicine. Some will succumb to the sales tactics and advertisements in journals touting new expensive equipment when a used or refurbished piece of equipment will do just fine. These are all vital pieces of information left out of academic pain fellowships and therefore it is understandable how attendings in academic institutions who have not ever had to operate outside the rarefied air of such places and have never had to deal with real world financial issues would be clueless as to overhead percentages and how one can adjust these.

As for CRNAs performing blocks, with or without the education provided by organizations they have and will continue to do so. Because of their years of experience with regional anesthesia and epidural injections, they are eminently more qualified than a neurologist without such experience or training to perform certain low level pain injections. It is not a matter of what degree they have by their name- it is the experience and training that matters. For those of us who have substantial first hand experience with both groups in the real world of medicine, I am superbly qualified to make comparisons. Touting ABMS neurologists technical skills over that of seasoned CRNAs is laughable...the CRNAs are far more proficient. However you confuse board certification with skills in which there may have been little or no training in residency. ABMS certification absolutely unequivically does not certify a physician is technically skilled, especially when the residency does not teach such skills. The organizations with which I am affiliated in a teaching capacity have widely varying rules about membership and those who are permitted in low or high level courses. My personal philosophies are that CRNAs should not be engaged in any advanced procedures and NP, PA, radiology techs should not be engaged in any invasive pain interventional procedure. In an ideal world, physicians and CRNAs would be offered the appropriate training in separate tracks. All but one of the organizations with which I am affiliated are physician only, and the outlier teaches CRNAs low level techniques only, which we the instructors are attempting to change. Even your boss taught for organizations that teach CRNAs for many years so undoubtedly you have the same turpitude towards him. It is clear you have a disdain for CRNAs doing any pain management procedures but in the real world of non-academic pain, there are reasons why some CRNAs engage in pain management which would not be apparent to the academics. Some CRNAs perform pain procedures because there are no physicians (anesthesiologists/physiatrists) close to their town. Others engage in low level pain procedures because believe it or not, in the non-academic world there are actually anesthesiologists and PM&R docs that loath pain patients and the treatment of chronic pain. Other CRNAs are hired by neurosurgical groups as their employee to perform on-site diagnostic injections when they need them and not subject to the whims of the million dollar a year pain docs in their town.
Your hostility towards CRNAs performing pain interventional procedures is clear. But are you consistent in your philosophies and hold that DVMs should not be practicing medicine as they do in your institution? Is it ethical for a veternarian to be supervising residents without an attending MD in the room during extremely invasive procedures?
The million dollar pain doctors are indeed an anathema to pain medicine and will meet their demise without my direct intervention as long as medicare and the insurers have sufficient knowledge regarding fair pricing of procedures. We have an enormous variation in the quality of care being delivered in pain medicine ranging from those practices that perform 40 sitting blind epidural injections a day and no medical decision-making to those that are diligent and conscientious, performing only a small fraction of that number of blocks, yet take the time to assess the patient and to treat them long term. I have grave concerns CAC committees being stacked with members of an organization that has as their primary goal to obtain higher reimbursement for the already highly paid pain physicians.
Access to ASCs should be maintained only for procedures that make sense to be performed in an ASC. It is ludicrous for an ASC to charge a patient $1500 for an epidural injection that could be done for less than $100 physician's cost in an office. I agree most pain procedures have no place in the hospital due to absurd turnover times and indeed except for intrathecal infusion pump implantation, I have pulled all procedures out of the hospital setting.
The Administar guidelines do not promote weekly epidural steroids as do some organizations. They promote epidural injections followed by reassessment then by another injection if need be. There is no scientific study that supports weekly injections but some organizations promote that view.
I never claimed to be holier than anyone...I simply point out that there are pain organizations that have unethical practices, period. My critiques are of the leadership of such organizations and not those who participate as members that often are unaware of legal, ethical, and medical questionable judgements by such organizational leadership. I don't care if their leadership is Indian, Indianan, Pakistani, or Iranian. But I care deeply that others know about the direction their organization is taking especially when there may be legal issues involved.

 

[paindefender]

Algos:
It is unbelievable and pathetic how some so called “academicians” and “professors??” can stand with a straight face behind an individual who is obviously fabricating data. A large number of pain physicians support your views. As for Rinoo, disregard his comments. His inferiority complex is derived from the denigration and rejection of his abilities and attitudes as a physician. Calling him an academician is an overstatement, he is more like the Mini-Me of Mr. M.

 

[PainDr]

I must disagree with some of the previous comments. Neurology is actually an excellent route to interventional pain. I am a neurologist currently completing an interventional fellowship at a top program. My fellowship group consists of anesthesiologists, a physiatrist and myself. We have found that having a multidisciplinary group is beneficial for all.

Also, just because one has completed a neurology residency does not necessarily mean they have no interventional skills. During internship and residency, I spent all of my elective time in interventional pain, so I was not starting at square one. At the beginning of fellowship, all of us had some interventional experience, mainly EPIs and somatic and sympathetic blocks, but none of us (including the anesthesiologists) had done pumps, stimulators or vertebroplasties. None of us (including the anesthesiologists) had much experience with RF. But now we all have and we are all becoming equally proficient.

Regarding "correction of deficits", that is certainly an issue for all specialties, including anesthesiology. As a neurology resident I often encountered patients referred by anesthesiologists from "comprehensive pain clincs"...including one individual quite well known in the field of interventional pain. It was not uncommon for these "experts" to subject their patients to inadequate or unnecessary workups followed by inappropriate or unnecessary interventions.

The best pain physicians are those with superior diagnostic skills and a large repetoire of interventional and medical treatment options. Many fellowships are starting to recognize the importance of having faculty and fellows from varied fields. Each of us has a unique knowledge base from which we all can benefit.

 

[Aether2000]

I cannot agree more that a true multispecialty approach is superior to a single specialty and that anesthesiology based physicians are at a disadvantage with respect to diagnostic skills compared to neurologists. Neurology is indeed an excellent background for pain management but in and of itself, the vast majority of those with such training have few interventional skills and have not been exposed to interventional pain medicine. Only during fellowship is there any significant exposure to interventional pain for most neurologists, therefore in general their skills in interventional pain are quite inferior to that of anesthesiologists or CRNAs. Your experience with interventional pain training during base neurlogy residency (I assume this was hands on training of facet blocks, SI blocks, transforaminal and interlaminar ESI....simply watching someone else perform these procedures is worthless) is quite uncommon but is laudable. Eventually we will have a pain residency program so the extensive unnecessary training physicians currently receive in their base residencies can be culled into a rational focused program. For instance, it is not necessary to intubate 3,000 people in order to learn how to intubate in an emergency situation as one would encounter in pain medicine. Much of the training time in all three base disciplines could very easily be focused towards pain syndromes, their diagnosis and treatment, saving years of extraneous training. Hopefully we will arrive at such a residency before we retire, but of course then our training will be deemed obsolete. So be it.

 

[PainDr]

Agree with all of the above. My experience was unique in that I was interested in pain before choosing my residency, so I purposely designed my elective time to maximize interventional exposure...which involved doing procedures, not simply observing (which is pretty much a worthless endeavor). Fortunately, my program included well trained, forward thinking anesthesiologists who welcomed and encouraged me.

 

[Aether2000]

Which program? We are always looking for the great programs such as yours.

 

[PainDr]

I sent you a PM.

 

[pjuer]

I have been running a multidisciplinary interventional pain practice for 13 years.
With reimbursements for pain procedures gradually going down, I would be happy making 75% of the average anesthesiologist take-home pay.I don't know how these guys are supposedly making three to six times the average anesthesiologist salary.

 

[Aether2000]

They are block jocks....simple minded technicians who are interested in performing primarily or solely injections. Multidisciplinary physicians make less but usually not less than anesthesiologists (average 260K).

 

[lobelsteve]

1. Get into a group of 10 spine surgeons.
2. Make sure you do 3 ESI's and none of them help the patient
3. PLIF
4. Dual octrode SCS
5. Refer them back to PCP for opioid management


I had a patient referred to me this past week who underwent the exact scenario. The SCS didn't help, his primary was overwhelmed, and this poor 78 y/o man was left in worse pain then he started.

 

[paz5559]

1. Get into a group of 10 spine surgeons.
2. Make sure you do 3 ESI's and none of them help the patient
3. PLIF
4. Dual octrode SCS
5. Refer them back to PCP for opioid management


I had a patient referred to me this past week who underwent the exact scenario. The SCS didn't help, his primary was overwhelmed, and this poor 78 y/o man was left in worse pain then he started.

Steve, you missed opportunity for several additional hundred thousand of our healthcare dollars to be spent:
1) 4 extremity EMG/NCS
2) Diagnostic SNRB, THEN TF ESI x3
3) Pulsed RF of the DRG
4) Facet block, MBB, RF neurotomy
5) ADR, +/- revision ADR
6) 360 degree interbody fusion
7) AB DCS x2
8) PNS
9) Refer back to PCP for opioid management
10) Intrathecal pump

 

[drusso]

Steve, you missed oportunity for several additional hundred thousand of our healthcare dollars to be spent:
1) 4 extremity EMG/NCS
2) Diagnostic SNRB, THEN ESI x3
3) Pulsed RF of the DRG
4) Facet block, MBB, RF neurotomy
5) ADR, +/- revision ADR
6) 360 degree interbody fusion
7) AB DCS x2
8) PNS
9) Refer back to PCP for opioid management
10) Intrathecal pump

I vote we increase the E&M reimbursement for opioid management and/or create a separate code for dealing with medically complex pain related issues. I think that the medical oncologists were able to do this for cancer related discussions of treatment, prognosis, and risk/benefit analysis of care. This may help create a positive economic incentive for proceduralists to actually talk to patients.

 

[Aether2000]

Excellent idea! I am perpetually disgusted by attitudes of pure interventional pain proceduralists (as are family docs, patients, etc). The course director of a course I taught this weekend spoke at length about how opiates have no place in his practice and that instead he will "fix their problem". I am not sure if he was just pompous and arrogant or completely naive despite his years of practice. He said he refers patients for medical management back to "someone else", in effect anyone but him. The idea of fixing chronic spinal disorders with needles is absurd when the issues long ago surpassed the peripheral nociceptive stage. Perhaps we need a certification for physicians that patients can depend on...eg. a Total Pain Specialist certification that would mean all modalities of therapy are included.

 

[bec1]

I'm considering getting back into medicine after a 5 1/2-year hiatus, and am looking for ideas. I started a solo practice fresh out of orthopaedic surgery residency in a small town in central Illinois, bent on being a different kind of surgeon, and basically burned out after 5 years. I was board certified and a fellow of the American Academy of Orthopaedic Surgeons.

I very much enjoyed doing surgery, but I also took a special interest in the "difficult" patients, the ones with psychological overlay that weren't going to be good candidates for surgery. I ended up spending a lot of time with them, treating them nonsurgically (intensively monitored exercise programs, education, judicious diagnostic workups, injections, and at times, pain medication).

For an assortment of reasons that I won't detail here, I quit medicine rather than simply move to a new location when my practice failed to live up to my hopes and aspirations. I've been successfully doing computer programming at a thriving Internet security software company in the SF Bay Area ever since then, and am only now healed enough from my first practice experience to consider returning to medicine. The question is, what kind of medicine? I'm not really interested in *chronic* pain management, but musculoskeletal rehabilitation and related pain issues are certainly within my area of competency and interest.

I let my AAOS membership, and my Illinois license, lapse. My orthopaedic board certification has certainly expired by now, as well. I've been completely out of the medical profession while I've been out here in California. Any thoughts appreciated regarding career options and paths to get there. Licensing process, appropriate fellowships given my background, where to direct my search for an appropriate practice location (I'm not looking to open another solo practice), etc.

Thanks.

 

[lobelsteve]

As for ASC reimbursement....it is imperative to preserve patient access. At HOPDs...the nurses are burdened by excessive and unnecessary paper work (like asking a patient if they like to read)...this leads to gross inefficiencies...1-1.5 hour turnarounds for a 5 minute procedure....


Hmm, I know a doc doing 20 ESI's from 7-11:30 in the hospital setting.
Granted, he doesn't know the patient's name or perform an actual exam, but he is getting paid $78 (Medicare) per pop. I was disgusted when I learned about this, fortunately, it is a few states away from me.


BTW, in regards to the list of $$$ procedure, I apologize for not including the diagnostic cash cow, and then lets not forget to add PT, clinical psychology, and chiropractic care under our EIN. 1 tax id and it shouldn't violoate stark.

(Please understand that I am being sarcastic and have no desire to practice in jail, that is, while in jail!)

 

[DigableCat]

For all the anger placed on the "block jocks", it seems rather interesting that no one seems to vent on the surgeons who sometimes cause these issues in the first place. Is it maybe because without them, many of your consultations would fade away?

Dear Dr. Ortho/Neurosurg/etc:

Thank you for this interesting patient that you have referred to me for chronic pain management. On review of his history, It's interesting that you did not request any electrodiagnostic procedures, physical therapy, or diagnostic injections prior to your <insert procedure here>. I am sure your procedure provided you with a considerable reimbursement, but now I have the unfortunate situation of having to deal with a post-procedural patient who is now possibly worse than before the surgery and now has a general distrust of doctors which makes my job slightly more difficult. I hope in the future you will allow patients to have the option of seeing me PRIOR to your invasive/non reversible procedures. That way they can feel that if they still proceed with surgery, they've exhausted every possible conservative route.

PS. Lets keep those patients coming shall we. Their insurance hasn't run out yet.<wink>

I'm just saying...

Needless to say, I've always liked the concept of "You break, you buy."