"I could take a CRNA and do the same thing."--- Why Anesthesiology? Why are you heading into this?

Nov 3, 2013
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Yesterday, my colleague and I (both employees not partners) prepared to leave after a day of working our tails off. A surgeon who had a case on the board earlier, for which I had set up prepared and asked to send for the patient only to find the surgeon having disappeared somewhere comes to me at 1730 and tells me, "Come on.. do my case". I respond telling him I was ready for him earlier in the day, and that he was late to begin the morning off with. I tell him any other day I would stay late and do him the favor (which I often do even coming in on weekends sometimes) but that I had something set up for after work that I could not miss.

He responds saying, "I could take a CRNA and do the same thing". I tell him that he should go ahead and do that.

I left wondering… WTF… why is it that Anesthesiologists are always expected to NOT have a life outside of work? As if OUR time doesn't matter? Each year, the hospital expects more rooms to remain open while pay stays same (i.e., decrease).


And, more and more of our job entails supervision.. which sucks. I mean did we go into Anesthesiology to supervise?? And, more and more of those we supervise are dangerous, militant and half-baked.

So why Anesthesiology? Do those going into it know what it's really like out in the real world?

I would say it's an easier Residency and rotation than any of the other specialties… but life after training is a complete cluster.

Just wondering if people think about these things…. the life, how what we do is perceived etc? It's a constant battle.
 
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Consigliere

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It blows. I've been doing it for 15+ years and have seen it go from bad to worse. Welcome to your crummy future, new grads!
 

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Wiseguy
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"I don't get no respect!"

Honestly, until I started my residency, I never did realize how much of a surgeon's valet the anesthesiologist is (expected to be). For the surgeon, you are just a better-educated OR nurse/tech (fill in here with the legends about how appreciated certain hip-shooters from this forum are - good luck with your denial). That's the big negative of the specialty; one can live with it or leave (they'll find another body).

It's not an easier residency than Internal Medicine; I found it harder than my medical intern year. It's just addictively much more interesting for anybody who likes to think.

Just wait till they fill the OR with mostly 1:4 CRNA's, and will want the extra anesthesiologists to babysit perioperatively the surgical patients, 24 hours a day, in the new "patient-centered surgical home". So that the surgeons would do only "what they are best at": operate. We will be the surgical hospitalists/nocturnists. This is the "dream", and it's closer than you think. Enjoy your current life(style), while it lasts!

P.S. I don't do major favors for surgeons anymore. I find that their memory is very short.
 
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Consigliere

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Except for the fact that pain just underwent drastic cuts and they are predicting that many pain management practices will close.
 

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Wiseguy
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Sure. So is the primary care doc. :p
 
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ssmallz

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Except for the fact that pain just underwent drastic cuts and they are predicting that many pain management practices will close.
There's no point in going into pain from anesthesia b/c of $$. Starting salaries for pain docs are about 100k less then what general OR anesthesiologist but if you open your own clinic there is potential to make more. In terms of pure $$, I feel it's pretty neutral maybe even negative EV compared to just grinding it out in OR. The reason I say it's the best decision of my life is that I feel like more of a doc and less of a technician and my lifestyle is much better. You evaluate and treat the patients as you see fit, not as someone else does. They may refer to you for this and that but the bottom line is that most referring docs don't care what you do as long as the patient gets better. The add ons occur at your convenience, not someone else's. If a patient is late, it's your discretion to cancel/reschedule or see the patient. If the surgeon is late you suck it up and do the case even if it means missing plans. There are relatively few pain emergencies so it's basically clinic hours and call really isn't a big deal. Consults can wait so you do them at your convenience, unlike OR cases that done at the surgeons convenience. These are all things that just won't change not matter what happens with reimbursement. At the end of the day it's not a great fit for everyone but it was the right decision for me b/c all the things that OP mentioned were exactly what I disliked about OR anesthesia. Pain gives me a chance to be in the more traditional doctor role and I'm much happier for it.
 

Stank811

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Surgical home does not mean work more for less when playing the long game…people have historically have stated that CC was a waste bc you would make less and work more…there are CC jobs all over the place that pay 350-450 starting working 40hr/wk on average (shift work)…I know a lot of graduating residents wouldn't mind a PP anesthesia job that started with similar numbers…surgical home has a potential to create a lot of need which usually correlates to increased pay going forward….we just have to be smart/patient about the process and not rush it. The surgical home can not be run by mid-levels which I feel is currently happening and it has to be structured in a way that has multiple avenues of revenue for the anesthesia group. Or you could say F'it and sell to an AMC…which is unfortunately also happening. But as always we will see how this pans out…not going to worry about it to much.
 

gasdoc77

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There's no point in going into pain from anesthesia b/c of $$. Starting salaries for pain docs are about 100k less then what general OR anesthesiologist but if you open your own clinic there is potential to make more. In terms of pure $$, I feel it's pretty neutral maybe even negative EV compared to just grinding it out in OR. The reason I say it's the best decision of my life is that I feel like more of a doc and less of a technician and my lifestyle is much better. You evaluate and treat the patients as you see fit, not as someone else does. They may refer to you for this and that but the bottom line is that most referring docs don't care what you do as long as the patient gets better. The add ons occur at your convenience, not someone else's. If a patient is late, it's your discretion to cancel/reschedule or see the patient. If the surgeon is late you suck it up and do the case even if it means missing plans. There are relatively few pain emergencies so it's basically clinic hours and call really isn't a big deal. Consults can wait so you do them at your convenience, unlike OR cases that done at the surgeons convenience. These are all things that just won't change not matter what happens with reimbursement. At the end of the day it's not a great fit for everyone but it was the right decision for me b/c all the things that OP mentioned were exactly what I disliked about OR anesthesia. Pain gives me a chance to be in the more traditional doctor role and I'm much happier for it.
I am very interested in your opinion. I have practiced in academics, private practice, I'm echo boarded, and everywhere I go I find that we are treated no different than the nursing staff. I have considered pain, yet I am reasonably settled geographically with a wife, infant children, a house, etc. and family nearby (which has been huge!) I am with a very large anesthesia group on an aggressive partnership track that is more than fair, yet I hate the day to day injustices. I've often said I get paid to NOT kick people's a%$, which is about what it comes down to. You seem happy with your decision and I admire that.
 
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Outrigger

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When I was a medical student, an anesthesiology resident warned me that they get absolutely no respect in their job. I see every day just how correct they were. I laughed when I heard the guy say that he wasn't going to do the case because the surgeon came late. If I tried that, I would be out of a job within the hour. The surgeons where I work want to do all their add-on cases after work starting in the 6 to 630 range guaranteeing you rarely get home for a nice dinner with the family. The cases could just as easily be done the next morning before their clinics start but that would mean the surgeon having to get up as early as the anesthesiologist which is a nonstarter. Another surgeon takes a 3 hour lunch break everyday and ends up starting his cases in the late afternoon (Guess it beats 6:30 PM) Administration can't kiss a surgeon's butt fast enough but the presence of the anesthesiologist is merely tolerated. Pain seems like a nice way to go even if you make less.
 
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Mman

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I don't understand these sort of situations. In my ACT model practice, I never have to stay late to ruin plans. We have a schedule. We have MDs supervising CRNAs and AAs. We work 24/7. Elective stuff during the day and urgent add ons on evenings and nights and weekends. If a surgeon is busy and shows up hours late, his case is going to probably be waiting for some other surgeon to finish since we don't have a bunch of empty rooms staffed and ready to go at all times. It's block scheduling. If you can't finish within your block, you go on the add on list and duke it out for space with every other surgeon.

Now I do have to work late, but it's when I'm scheduled to work late.

I like the surgeons I work with and it's not personal if their case can't get done if they or the patient is late.
 

chmd

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If AMCs control a large portion of the anesthesia services will anesthesia reimbursement be better protected? The ASA is too weak to protect us but I can't imagine Wall Street investors having the same problem.
 

ssmallz

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I am very interested in your opinion. I have practiced in academics, private practice, I'm echo boarded, and everywhere I go I find that we are treated no different than the nursing staff. I have considered pain, yet I am reasonably settled geographically with a wife, infant children, a house, etc. and family nearby (which has been huge!) I am with a very large anesthesia group on an aggressive partnership track that is more than fair, yet I hate the day to day injustices. I've often said I get paid to NOT kick people's a%$, which is about what it comes down to. You seem happy with your decision and I admire that.
My opinion on what? Are you thinking about going back to do a pain fellowship or just unhappy with your current gig?

If AMCs control a large portion of the anesthesia services will anesthesia reimbursement be better protected? The ASA is too weak to protect us but I can't imagine Wall Street investors having the same problem.
They will certainly be more aggressive about protecting reimbursement but that doesn't mean you will get a piece of the pie. Walmart and McDonalds are very profitable companies that still pay minimum wage. You need to understand that when you are not a partner in a group, the group's interests may not always align with yours. When working for a large group like an AMC, salaries will continue to ebb and flow based mostly on supply and demand economics for each geographic area. The AMCs will provide you with stability and being part of a group but you won't end up making top dollar. This isn't necessarily a bad thing however because having stability in a job can be very comforting and lead to more negotiating power with a hospital. There are plenty of happy docs working for Kaiser
 
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DermViser

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"I don't get no respect!"

Honestly, until I started my residency, I never did realize how much of a surgeon's valet the anesthesiologist is (expected to be). For the surgeon, you are just a better-educated OR nurse/tech (fill in here with the legends about how appreciated certain hip-shooters from this forum are - good luck with your denial). That's the big negative of the specialty; one can live with it or leave (they'll find another body).

It's not an easier residency than Internal Medicine; I found it harder than my medical intern year. It's just addictively much more interesting for anybody who likes to think.

Just wait till they fill the OR with mostly 1:4 CRNA's, and will want the extra anesthesiologists to babysit perioperatively the surgical patients, 24 hours a day, in the new "patient-centered surgical home". So that the surgeons would do only "what they are best at": operate. We will be the surgical hospitalists/nocturnists. This is the "dream", and it's closer than you think. Enjoy your current life(style), while it lasts!

P.S. I don't do major favors for surgeons anymore. I find that their memory is very short.
Thought you were joking about the Patient Centered Surgical Homes: https://www.google.com/#q=patient+centered+surgical+home
WTF!?!?!
 
Dec 21, 2013
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http://www.biomedcentral.com/content/pdf/1471-2253-13-6.pdf

I find the surgical home model to be a great move. Anesthesiologist have to adapt to the changing times, and I think this is a great idea. Granted I like Critical Care, not everyone does, but we have to evolve and become intertwined with in the hospital with a greater footprint. Otherwise, we will be seen as replaceable by some. I believe Anesthesiologists skill set and knowledge is being underutilized. The larger the footprint is, the more valuable become.

This makes sense. Is it more work for the same pay? Probably sad to say, but yes.
 

Gas you down

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When I was a medical student, an anesthesiology resident warned me that they get absolutely no respect in their job. I see every day just how correct they were. I laughed when I heard the guy say that he wasn't going to do the case because the surgeon came late. If I tried that, I would be out of a job within the hour. The surgeons where I work want to do all their add-on cases after work starting in the 6 to 630 range guaranteeing you rarely get home for a nice dinner with the family. The cases could just as easily be done the next morning before their clinics start but that would mean the surgeon having to get up as early as the anesthesiologist which is a nonstarter. Another surgeon takes a 3 hour lunch break everyday and ends up starting his cases in the late afternoon (Guess it beats 6:30 PM) Administration can't kiss a surgeon's butt fast enough but the presence of the anesthesiologist is merely tolerated. Pain seems like a nice way to go even if you make less.
I've had plenty of surgeons show up extremely late, then jump up and down when they're told about being moved to the supplemental list. they call administration and my response to admin is something like "yes we were ready for his case, but then he shows up 2 hrs late. this pushes every other surg back. we are paying an entire OR staff to sit on their ass. then when the surg finally shows up we gave to pay them time and a half. this is not the way to run a business."
you have to talk dollars to the admin. they don't understand anything else
 
Apr 18, 2014
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It's not a constant battle. Who would you want to put you to sleep? Or your kids? You might be answering your own question: Look and the back ground, training, experience, and medical decision making. You can't predict when a case will become more complicated and small decisions pre-op or early in case can have big consequences later on... Just a few thoughts.
 
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EtherBunny

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I am very interested in your opinion. I have practiced in academics, private practice, I'm echo boarded, and everywhere I go I find that we are treated no different than the nursing staff. I have considered pain, yet I am reasonably settled geographically with a wife, infant children, a house, etc. and family nearby (which has been huge!) I am with a very large anesthesia group on an aggressive partnership track that is more than fair, yet I hate the day to day injustices. I've often said I get paid to NOT kick people's a%$, which is about what it comes down to. You seem happy with your decision and I admire that.
No regrets on my end either. I'm an interventional pain physician (I focus exclusively on cancer pain patients though). There's no way I would ever go back to the OR as an anesthesiologist. Yes, interventional pain is facing some reimbursement issues, but the truth of the matter is that ALL specialists are on the chopping block now. Cost containment will affect every highly paid specialist at some point. This has been the general trend in the last 20+ years--the statistical outliers in terms of income are getting cut. It's a "reversion to the mean" phenomenon. Yes, there are still some outliers statistically (spine surgery, ortho, etc.), but I guarantee you these folks will face huge cuts in the future. It's inevitable.

In addition, even with the cuts in interventional pain, you can still make plenty of money and live very comfortably. At some point the "doom and gloom" about income on SDN needs to stop. Even if income dropped to $200,000 per year (which is highly unlikely by the way), you would still be in the top 10% of income in the United States, which is already the richest country in the world (this would probably translate into the top 0.01% income percentile worldwide). With the cuts, most interventional pain physicians are still making in the high 300s to low 400s on average (and many are making far more)--not bad, considering that most of these physicians work 40 hrs/week and have no weekend, holiday, or overnight patient encounters. There are still many interventionalists in pain who make far more (i.e., high six figures or even in the millions), especially physicians who own practices and are gifted businessmen.

There are so many upsides to interventional pain. It's a great field in my opinion. Sure it has its own set of issues just like any specialty in medicine, but on balance it's tough to beat. My wife and child certainly appreciate the fact that I'm always home in time for dinner, I'm always present for special events, and I always spend the weekends and holidays with them. You can't put a price on that. (Plus, I get to sleep in my own bed every night). For me, time with my family is essential, and a career in pain medicine is very compatible with this, on par with a career in dermatology in many respects. In fact, I often joke that pain medicine is the "derm of anesthesia," because it kinda is.

Just my $0.02
 
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EtherBunny

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Pain is the "psych of anesthesia". ;)
Fortunately this isn't a significant issue in my practice since I focus exclusively on cancer pain, but there's no question that (in general) pain physicians have to pay attention to potential untreated or suboptimally treated mood disorders and personality disorders. You can't be a good interventional pain physician if you completely ignore comorbid conditions, especially psychiatric disorders. This is why it's harder for CRNAs to really make significant inroads into interventional pain. It's much more than just sticking needles in patients. You need to bring a fairly broad skill set and knowledge base to the table to provide excellent care to chronic pain patients. Personally, I like that aspect of pain medicine, but it's not for everybody.
 

nimbus

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Haha. Crystal healers. Lol. That was funny. You forgot Witches and Warlocks. LMBO.
Sad part is people spend REAL MONEY on crystal healers, shamans, naturopaths, etc. I used to date a gal........
 

EtherBunny

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Anesthesia, neurology, pm&r, OB, CRNAs, NPs, Family Medicine, chiropractors, naturopaths, crystal healers, acupuncturist, etc. the all want a piece

Yes, many specialties can (in principle) become interventional pain specialists, a fact that reflects the multidisciplinary nature of the field in general. But in reality, there are limited fellowship spots around the country, which are very competitive to attain, and the vast majority of these spots are taken by grads from PM&R or anesthesiology. There is a very strong bias for grads from PM&R and anesthesiology residencies, especially the latter. Other specialties have an uphill battle gaining a spot in any decent pain medicine fellowship. Since employment is more often than not predicated on having completed an ACGME accredited pain fellowship, PM&R and anesthesiology will continue to have nearly all of the market share around the country, particularly as the trend toward hospital employment increases.

Yes, there are shady pain practices out in the community started by internists, chiropractors, and god knows who else. But the days are numbered for these practices. The Feds are cracking down on pill mills nationwide. Insurance companies are also becoming much more restrictive in their coverage of interventional pain procedures, making it more difficult for block shops to maintain absurdly high revenue by cranking out procedures on anything with two legs. High quality, multidisciplinary care for chronic pain patients is being gradually enforced nationwide by a variety of agencies, making it increasingly difficult for various greedy scam artists to make any inroads into the field.

I, for one, am not worried. There's no substitute for a fellowship trained interventional pain physician. The fact that the vast majority of hospitals will only employ interventional pain physicians who have completed a pain fellowship underscores this point.
 

Hoya11

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Yes, many specialties can (in principle) become interventional pain specialists, a fact that reflects the multidisciplinary nature of the field in general. But in reality, there are limited fellowship spots around the country, which are very competitive to attain, and the vast majority of these spots are taken by grads from PM&R or anesthesiology. There is a very strong bias for grads from PM&R and anesthesiology residencies, especially the latter. Other specialties have an uphill battle gaining a spot in any decent pain medicine fellowship. Since employment is more often than not predicated on having completed an ACGME accredited pain fellowship, PM&R and anesthesiology will continue to have nearly all of the market share around the country, particularly as the trend toward hospital employment increases.

Yes, there are shady pain practices out in the community started by internists, chiropractors, and god knows who else. But the days are numbered for these practices. The Feds are cracking down on pill mills nationwide. Insurance companies are also becoming much more restrictive in their coverage of interventional pain procedures, making it more difficult for block shops to maintain absurdly high revenue by cranking out procedures on anything with two legs. High quality, multidisciplinary care for chronic pain patients is being gradually enforced nationwide by a variety of agencies, making it increasingly difficult for various greedy scam artists to make any inroads into the field.

I, for one, am not worried. There's no substitute for a fellowship trained interventional pain physician. The fact that the vast majority of hospitals will only employ interventional pain physicians who have completed a pain fellowship underscores this point.
I have the opposite take on pain. I am BC in Pain and was the chief fellow in a large well-known program. I was, like you are, very enthusiastic about pain. I went back to anesthesia in the OR and do not miss pain one bit. You can see from my posts in the pain forum that my attitude really took a 180 from when I was a fellow and early in my career as a PP pain attg.

The downside of pain is what you actually are doing day to day. Which, I now understand to believe, NOT helping people (in most cases) and exacerbating an opiate epidemic (in most cases) Yes you get weekends off (except for phone calls) and nights (except for sleazy marketing dinners/phone calls). But you get most of those off anyway in anesthesia. Like the above poster mentioned, even in a 1:4 model, you are still working only when scheduled which is 2-3 calls per month. I am out before 3pm in anesthesia 20% of the time, and am out before 6pm 95% of the time.

At least in anesthesia I am doing real good for real good people. Pain management is a man-made field. Keep the patients happy with opiates, keep the doctors/ascs happy with the procedures that they reluctantly agree to for secondary gain. Meanwhile your thousands of dollars of procedures and god knows how many opiate prescriptions are not helping the world. Insurance companies are paying those huge bills and premiums come back on GENUINELY sick people. "I lost my percocet" get out of here, I dont want to deal with those people. And yes you'll tell me your patient population is all angels, but when you do pain long enough you realize you are just handing out opiates, generating revenue with procedures, nobody gets better, and people end up getting in trouble or hurt from the opiates.

I think pain is in a boom right now due to ASCs. Anesthesiologists can suddenly be owners and get a piece of the facility fee by doing procedures at an ASC. Then generate huge revenue by seeing the patients in the office q2months for new opiates. All I can say is, it just cant continue. The people in the know will soon wise up to the sleazy street patients on their 12th injection on workers comp and oxycodone 30 q6h. We will stop paying for these losers and the "doctors" who are getting rich by enabling these parasites.

I think I could only tolerate a career in pain in a unique model like in academics or cancer only, even then though, why not just go to your PCP/Oncologist for meds? Because the blocks are going to make such a difference? OMG and this business with the stimulators and pumps makes me want to throw up - almostl completely useless are the stimulators, and pumps ARE completely useless. Total money makers for industry that is controlling the pain field, which if it were to go away completely, would be a good thing for medicine. No more enabled crazy opiate people, No more 20 cases in a day at an ASC for 1k/epidural, and just let guys like me (trained but no financial motivation to do procedures) do the procedures for healthy people who are actually good candidates, and let the PT guy do PT, the ortho guy and PMR guy diagnose and intervene. The only unique skillset pain fellowship brings is procedures. All the other stuff is just learning the nuts and bolts of other specialties and piecing it together.

So have fun writing your scripts and talking patients into procedures for your own benefit (again most of the time). Take that pretty fluoro picture and show your friends. Then fill out the disability paperwork and talk to the workers comp case worker and oh yeah how about CPS for the mom that ODd on her oxycodone while driving her son around. Maybe one day pain physicians will wake up to what they truly are: opportunists capitalizing and worsening a broken medical system. UGH - it just cant last, its a ridiculous field.
 
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nolagas

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I have the opposite take on pain. I am BC in Pain and was the chief fellow in a large well-known program. I was, like you are, very enthusiastic about pain. I went back to anesthesia in the OR and do not miss pain one bit. You can see from my posts in the pain forum that my attitude really took a 180 from when I was a fellow and early in my career as a PP pain attg.

The downside of pain is what you actually are doing day to day. Which, I now understand to believe, NOT helping people (in most cases) and exacerbating an opiate epidemic (in most cases) Yes you get weekends off (except for phone calls) and nights (except for sleazy marketing dinners/phone calls). But you get most of those off anyway in anesthesia. Like the above poster mentioned, even in a 1:4 model, you are still working only when scheduled which is 2-3 calls per month. I am out before 3pm in anesthesia 20% of the time, and am out before 6pm 95% of the time.

At least in anesthesia I am doing real good for real good people. Pain management is a man-made field. Keep the patients happy with opiates, keep the doctors/ascs happy with the procedures that they reluctantly agree to for secondary gain. Meanwhile your thousands of dollars of procedures and god knows how many opiate prescriptions are not helping the world. Insurance companies are paying those huge bills and premiums come back on GENUINELY sick people. "I lost my percocet" get out of here, I dont want to deal with those people. And yes you'll tell me your patient population is all angels, but when you do pain long enough you realize you are just handing out opiates, generating revenue with procedures, nobody gets better, and people end up getting in trouble or hurt from the opiates.

I think pain is in a boom right now due to ASCs. Anesthesiologists can suddenly be owners and get a piece of the facility fee by doing procedures at an ASC. Then generate huge revenue by seeing the patients in the office q2months for new opiates. All I can say is, it just cant continue. The people in the know will soon wise up to the sleazy street patients on their 12th injection on workers comp and oxycodone 30 q6h. We will stop paying for these losers and the "doctors" who are getting rich by enabling these parasites.

I think I could only tolerate a career in pain in a unique model like in academics or cancer only, even then though, why not just go to your PCP/Oncologist for meds? Because the blocks are going to make such a difference? OMG and this business with the stimulators and pumps makes me want to throw up - almostl completely useless are the stimulators, and pumps ARE completely useless. Total money makers for industry that is controlling the pain field, which if it were to go away completely, would be a good thing for medicine. No more enabled crazy opiate people, No more 20 cases in a day at an ASC for 1k/epidural, and just let guys like me (trained but no financial motivation to do procedures) do the procedures for healthy people who are actually good candidates, and let the PT guy do PT, the ortho guy and PMR guy diagnose and intervene. The only unique skillset pain fellowship brings is procedures. All the other stuff is just learning the nuts and bolts of other specialties and piecing it together.

So have fun writing your scripts and talking patients into procedures for your own benefit (again most of the time). Take that pretty fluoro picture and show your friends. Then fill out the disability paperwork and talk to the workers comp case worker and oh yeah how about CPS for the mom that ODd on her oxycodone while driving her son around. Maybe one day pain physicians will wake up to what they truly are: opportunists capitalizing and worsening a broken medical system. UGH - it just cant last, its a ridiculous field.
daaammnn!
 

EtherBunny

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I'm
I have the opposite take on pain. I am BC in Pain and was the chief fellow in a large well-known program. I was, like you are, very enthusiastic about pain. I went back to anesthesia in the OR and do not miss pain one bit. You can see from my posts in the pain forum that my attitude really took a 180 from when I was a fellow and early in my career as a PP pain attg.

The downside of pain is what you actually are doing day to day. Which, I now understand to believe, NOT helping people (in most cases) and exacerbating an opiate epidemic (in most cases) Yes you get weekends off (except for phone calls) and nights (except for sleazy marketing dinners/phone calls). But you get most of those off anyway in anesthesia. Like the above poster mentioned, even in a 1:4 model, you are still working only when scheduled which is 2-3 calls per month. I am out before 3pm in anesthesia 20% of the time, and am out before 6pm 95% of the time.

At least in anesthesia I am doing real good for real good people. Pain management is a man-made field. Keep the patients happy with opiates, keep the doctors/ascs happy with the procedures that they reluctantly agree to for secondary gain. Meanwhile your thousands of dollars of procedures and god knows how many opiate prescriptions are not helping the world. Insurance companies are paying those huge bills and premiums come back on GENUINELY sick people. "I lost my percocet" get out of here, I dont want to deal with those people. And yes you'll tell me your patient population is all angels, but when you do pain long enough you realize you are just handing out opiates, generating revenue with procedures, nobody gets better, and people end up getting in trouble or hurt from the opiates.

I think pain is in a boom right now due to ASCs. Anesthesiologists can suddenly be owners and get a piece of the facility fee by doing procedures at an ASC. Then generate huge revenue by seeing the patients in the office q2months for new opiates. All I can say is, it just cant continue. The people in the know will soon wise up to the sleazy street patients on their 12th injection on workers comp and oxycodone 30 q6h. We will stop paying for these losers and the "doctors" who are getting rich by enabling these parasites.

I think I could only tolerate a career in pain in a unique model like in academics or cancer only, even then though, why not just go to your PCP/Oncologist for meds? Because the blocks are going to make such a difference? OMG and this business with the stimulators and pumps makes me want to throw up - almostl completely useless are the stimulators, and pumps ARE completely useless. Total money makers for industry that is controlling the pain field, which if it were to go away completely, would be a good thing for medicine. No more enabled crazy opiate people, No more 20 cases in a day at an ASC for 1k/epidural, and just let guys like me (trained but no financial motivation to do procedures) do the procedures for healthy people who are actually good candidates, and let the PT guy do PT, the ortho guy and PMR guy diagnose and intervene. The only unique skillset pain fellowship brings is procedures. All the other stuff is just learning the nuts and bolts of other specialties and piecing it together.

So have fun writing your scripts and talking patients into procedures for your own benefit (again most of the time). Take that pretty fluoro picture and show your friends. Then fill out the disability paperwork and talk to the workers comp case worker and oh yeah how about CPS for the mom that ODd on her oxycodone while driving her son around. Maybe one day pain physicians will wake up to what they truly are: opportunists capitalizing and worsening a broken medical system. UGH - it just cant last, its a ridiculous field.
I'm gonna have to respectfully disagree with you on this one. I know several former pain physicians who decided to leave pain after a few years and transition into anesthesia. One did so because the compensation for pain in California was relatively crappy when compared to OR anesthesia. He was a very good doc. I would trust him with my family members. However, the other docs, without exception, were relatively bad physicians. Subpar bedside manner, questionable technical ability, poor diagnostic acumen, burnt out. They were very unhappy in interventional pain and I suspect it was because they just weren't particularly good at it.

Interventional pain isn't an easy field. You can't apply simple protocols, which is why it's hard for CRNAs to compete in any meaningful way with fellowship-trained interventional pain physicians. It doesn't rely very heavily on any of the skills acquired in anesthesiology residency. It has a skill set that straddles multiple specialty lines, which requires an enormous knowledge base that (frankly) only physicians possess. Every patient is unique and patient selection is absolutely essential for success with any intervention.

The notion that interventional pain procedures don't work is absurd. They do work, provided that you select patients correctly. Bad physicians do a sloppy evaluation and exercise poor judgment when they select particular patients for interventions. Obviously I wasn't in your practice. I never met your patients or observed your patient encounters. But if you noticed that the vast majority of your procedures didn't work, as your post would suggest, then you need to take a close look in the mirror before blaming the field as a whole. It wasn't because of the inherent lack of efficacy from interventional pain procedures, it's because of the patient selection (or your technique).

I have plenty of patients who do extremely well after interventional pain procedures. Pancreatic cancer patients with intractable pain despite being on high doses of systemic opioids...Guess what? I can eliminate their abdominal pain entirely with ONE procedure and get them off opioids. I've done it several hundred times. The patients think it's magical and they are VERY appreciative. Try telling one of them that pain procedures "never work." They would laugh out loud. Or what about patients with severe pain due to compression fractures to the point that they can't stand up or walk? Guess what? I can eliminate their pain with ONE procedure, too. I have TONS of these patients. The list goes on and on. I'm not sure how you left interventional pain with the idea that procedures don't work. I have hundreds of patients on my panel who would beg to differ. Are there treatment failures? Absolutely, but they are in the minority. Patient selection is key. My dad, who is a doctor, gets a transforaminal epidural steroid injection every year. He wasn't able to function before he starting getting the injections. If you told him that interventional pain procedures "never work" he would laugh in your face.

Do yourself a favor and don't spread so much venom and misinformation about interventional pain. The field accomplishes a tremendous amount of good, when it is performed by well trained, ethical, and competent physicians who actually give a crap about their patients. For all the jackasses out there injecting everything with two legs or distributing pills like a glorified drug dealer, I have zero respect for them. Their days are numbered and the color orange is in the not-so-distant future for many of them.

OR anesthesia is a great field, but don't fool yourself into thinking it's all peaches and cream. There are drawbacks to a career in interventional pain, but there are enormous problems on the horizon for OR anesthesia. One search on SDN is proof of that. The rise of mega-groups a that use and abuse new grads, lack of genuine respect (being called "anesthesia" instead of "doctor"), lack of ultimate control, in house overnight call, increasingly prevalent "independent" practice by CRNAs, no patients of your own, projected HUGE decrease in income if Medicare rates become commonplace with Obamacare, etc. I get to avoid all that crap in interventional pain. Not a bad gig, in my opinion. But one man's treasure is another's trash...
 
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FFP

Wiseguy
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I'm gonna have to respectfully disagree with you on this one. I know several former pain physicians who decided to leave pain after a few years and transition into anesthesia. One did so because the compensation for pain in California was relatively crappy when compared to OR anesthesia. He was a very good doc. I would trust him with my family members. However, the other docs, without exception, were relatively bad physicians. Subpar bedside manner, questionable technical ability, poor diagnostic acumen, burnt out. They were very unhappy in interventional pain and I suspect it was because they just weren't particularly good at it.

Interventional pain isn't an easy field. You can't apply simple protocols, which is why it's hard for CRNAs to compete in any meaningful way with fellowship-trained interventional pain physicians. It doesn't rely very heavily on any of the skills acquired in anesthesiology residency. It has a skill set that straddles multiple specialty lines, which requires an enormous knowledge base that (frankly) only physicians possess. Every patient is unique and patient selection is absolutely essential for success with any intervention.

The notion that interventional pain procedures don't work is absurd. They do work, provided that you select patients correctly. Bad physicians do a sloppy evaluation and exercise poor judgment when they select particular patients for interventions. Obviously I wasn't in your practice. I never met your patients or observed your patient encounters. But if you noticed that the vast majority of your procedures didn't work, as your post would suggest, then you need to take a close look in the mirror before blaming the field as a whole. It wasn't because of the inherent lack of efficacy from interventional pain procedures, it's because of the patient selection (or your technique).

I have plenty of patients who do extremely well after interventional pain procedures. Pancreatic cancer patients with intractable pain despite being on high doses of systemic opioids...Guess what? I can eliminate their abdominal pain entirely with ONE procedure and get them off opioids. I've done it several hundred times. The patients think it's magical and they are VERY appreciative. Try telling one of them that pain procedures "never work." They would laugh out loud. Or what about patients with severe pain due to compression fractures to the point that they can't stand up or walk? Guess what? I can eliminate their pain with ONE procedure, too. I have TONS of these patients. The list goes on and on. I'm not sure how you left interventional pain with the idea that procedures don't work. I have hundreds of patients on my panel who would beg to differ. Are there treatment failures? Absolutely, but they are in the minority. Patient selection is key. My dad, who is a doctor, gets a transforaminal epidural steroid injection every year. He wasn't able to function before he starting getting the injections. If you told him that interventional pain procedures "never work" he would laugh in your face.

Do yourself a favor and don't spread so much venom and misinformation about interventional pain. The field accomplishes a tremendous amount of good, when it is performed by well trained, ethical, and competent physicians who actually give a crap about their patients. For all the jackasses out there injecting everything with two legs or distributing pills like a glorified drug dealer, I have zero respect for them. Their days are numbered and the color orange is in the not-so-distant future for many of them.

OR anesthesia is a great field, but don't fool yourself into thinking it's all peaches and cream. There are drawbacks to a career in interventional pain, but there are enormous problems on the horizon for OR anesthesia. One search on SDN is proof of that. The rise of mega-groups a that use and abuse new grads, lack of genuine respect (being called "anesthesia" instead of "doctor"), lack of ultimate control, in house overnight call, increasingly prevalent "independent" practice by CRNAs, no patients of your own, projected HUGE decrease in income if Medicare rates become commonplace with Obamacare, etc. I get to avoid all that crap in interventional pain. Not a bad gig, in my opinion. But one man's treasure is another's trash...
You might be talking about something different than Hoya11. You seem to have a lot of cancer patients, while most docs I see in PP tend to focus on back pain.

I am not a pain specialist, but I have provided anesthesia for a few (and most of them are smart people with good training), and suggesting that procedures don't work just because of pain doc incompetence sounds simplistic and overoptimistic.

If pain medicine were as efficient as you describe it (the patient needs only to find the right doc), people would FLOCK to those outstanding pain specialists, like they do to great surgeons. There would be minimal need for serious pain medications, and people would not get personality changes because of their daily torture.

In residency, I was told more than once to go into pain during my respective rotation. I chose to do critical care exactly because I felt like Hoya11: sometimes it works, mostly it doesn't, and the world is full of BC pain quacks. Cheers to Hoya11, and all great docs who recognize the(ir) limits and put their patients first!
Hoya11 said:
I think I could only tolerate a career in pain in a unique model like in academics or cancer only, even then though, why not just go to your PCP/Oncologist for meds? Because the blocks are going to make such a difference? OMG and this business with the stimulators and pumps makes me want to throw up - almostl completely useless are the stimulators, and pumps ARE completely useless. Total money makers for industry that is controlling the pain field, which if it were to go away completely, would be a good thing for medicine. No more enabled crazy opiate people, No more 20 cases in a day at an ASC for 1k/epidural, and just let guys like me (trained but no financial motivation to do procedures) do the procedures for healthy people who are actually good candidates, and let the PT guy do PT, the ortho guy and PMR guy diagnose and intervene. The only unique skillset pain fellowship brings is procedures. All the other stuff is just learning the nuts and bolts of other specialties and piecing it together.
 
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Twiggidy

Manny Rivers Cuomo
2+ Year Member
Jan 13, 2015
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I have the opposite take on pain. I am BC in Pain and was the chief fellow in a large well-known program. I was, like you are, very enthusiastic about pain. I went back to anesthesia in the OR and do not miss pain one bit. You can see from my posts in the pain forum that my attitude really took a 180 from when I was a fellow and early in my career as a PP pain attg.

The downside of pain is what you actually are doing day to day. Which, I now understand to believe, NOT helping people (in most cases) and exacerbating an opiate epidemic (in most cases) Yes you get weekends off (except for phone calls) and nights (except for sleazy marketing dinners/phone calls). But you get most of those off anyway in anesthesia. Like the above poster mentioned, even in a 1:4 model, you are still working only when scheduled which is 2-3 calls per month. I am out before 3pm in anesthesia 20% of the time, and am out before 6pm 95% of the time.

At least in anesthesia I am doing real good for real good people. Pain management is a man-made field. Keep the patients happy with opiates, keep the doctors/ascs happy with the procedures that they reluctantly agree to for secondary gain. Meanwhile your thousands of dollars of procedures and god knows how many opiate prescriptions are not helping the world. Insurance companies are paying those huge bills and premiums come back on GENUINELY sick people. "I lost my percocet" get out of here, I dont want to deal with those people. And yes you'll tell me your patient population is all angels, but when you do pain long enough you realize you are just handing out opiates, generating revenue with procedures, nobody gets better, and people end up getting in trouble or hurt from the opiates.

I think pain is in a boom right now due to ASCs. Anesthesiologists can suddenly be owners and get a piece of the facility fee by doing procedures at an ASC. Then generate huge revenue by seeing the patients in the office q2months for new opiates. All I can say is, it just cant continue. The people in the know will soon wise up to the sleazy street patients on their 12th injection on workers comp and oxycodone 30 q6h. We will stop paying for these losers and the "doctors" who are getting rich by enabling these parasites.

I think I could only tolerate a career in pain in a unique model like in academics or cancer only, even then though, why not just go to your PCP/Oncologist for meds? Because the blocks are going to make such a difference? OMG and this business with the stimulators and pumps makes me want to throw up - almostl completely useless are the stimulators, and pumps ARE completely useless. Total money makers for industry that is controlling the pain field, which if it were to go away completely, would be a good thing for medicine. No more enabled crazy opiate people, No more 20 cases in a day at an ASC for 1k/epidural, and just let guys like me (trained but no financial motivation to do procedures) do the procedures for healthy people who are actually good candidates, and let the PT guy do PT, the ortho guy and PMR guy diagnose and intervene. The only unique skillset pain fellowship brings is procedures. All the other stuff is just learning the nuts and bolts of other specialties and piecing it together.

So have fun writing your scripts and talking patients into procedures for your own benefit (again most of the time). Take that pretty fluoro picture and show your friends. Then fill out the disability paperwork and talk to the workers comp case worker and oh yeah how about CPS for the mom that ODd on her oxycodone while driving her son around. Maybe one day pain physicians will wake up to what they truly are: opportunists capitalizing and worsening a broken medical system. UGH - it just cant last, its a ridiculous field.