I want to do it all... Is that too much?

[Magnus Acus]

I'm an MS4 applying PM&R this cycle. My interests are mainly in the outpatient setting. I like MSK, injections, diagnostic/injection US, botox injections, pain management and love sports patients. I am very well read in chronic pain management (for an MS4) and I am 99% sure that I will pursue this fellowship after residency (and yes, I genuinely enjoy pain, I didn't just see the big $$$).

So my question is, can these different domains comingle in a PM&R practice? For example, could I have a 70% pain practice and 30% sports patients, or some variation thereof? To clarify, I have no interest in being associated with a sports team, only seeing sports related injuries. I definitely want to work within the full scope of ACGME pain, but if possible I would like to also see the athlete with complex MSK pathology that wont be surgical (eg- too complex for FM and no need for ortho). To further push the envelope, I could even see myself being involved in cancer related pain, regen (if research pans out), botox inj, placing/managing pumps, amputee care and even adding OMT to my practice. Intuitively I know this will be an uphill battle as it will be difficult for other providers to understand what/who to refer to me. But is this something that can be easily fixed by taking some PCPs out to dinner and providing a personal FAQ sheet?

Essentially- I want to do it all as a PM&R ACGME trained pain doc. I know that pain only is more lucrative, $ is not my main concern here, variety is. Is this logistically possible? *For reference- My family/target future practice area is in a fairly rual setting with the closest outpt PM&R doc being a 1h+ drive, area has large hospital that is primary hospital for 150K+ people, undesirable location for most in appalachia.

Thanks for the help!

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[j4pac]

If you want to do diagnostics/procedural ultrasound, Sports, Neurorehab/Botox, EMG, and stick needles in peoples spines…I’d try to do a Mayo residency followed by a Pain fellowship. You should be competent at all of that in the shortest amount of time possible going that route. If you don’t have to have the heavy ultrasound diagnostics/procedures, then I’d find a strong PM&R residency followed by Pain.

 

[drg123]

If you want to do diagnostics/procedural ultrasound, Sports, Neurorehab/Botox, EMG, and stick needles in peoples spines…I’d try to do a Mayo residency followed by a Pain fellowship. You should be competent at all of that in the shortest amount of time possible going that route. If you don’t have to have the heavy ultrasound diagnostics/procedures, then I’d find a strong PM&R residency followed by Pain.

This is sound advice. PM&R residency is the place to get the MSK and US fundamentals, so long as it is a program that prioritizes that, such as Mayo. There are others too. Then, ACGME Pain will expand the toolkit to have more spine and advanced procedures. You'd be very well rounded and capable of handling most anything.

 

[Magnus Acus]

If you want to do diagnostics/procedural ultrasound, Sports, Neurorehab/Botox, EMG, and stick needles in peoples spines…I’d try to do a Mayo residency followed by a Pain fellowship. You should be competent at all of that in the shortest amount of time possible going that route. If you don’t have to have the heavy ultrasound diagnostics/procedures, then I’d find a strong PM&R residency followed by Pain.

Thanks for this!
Unfortunately for me, Mayo is off the table. lol I'm a pretty good applicant, but I'm not a top 3% applicant. That being said, I do have some very solid residency options available to me at this point and I plan to take this advice!
Are there any other logistical issues that would prevent such a practice? I have heard that some attendings will say that "those patient populations are not compatible." How much do these other considerations factor into developing a practice?

 

[runfastnow]

If you want to maximize your potential for independent practice as an outpatient PM&R physician then do a pain/spine fellowship (or sports fellowship that offers spine training to at least offer lumbar injections). This would allow you to have as many options for you to offer patients. In terms of the "everything" you want to do - any above average PM&R residency can teach you how to do Botox, EMG, amputee, etc. and be competent enough to do this independently. Will anything be a bit scary your first time in practice? Yes - but you will be prepared.

The first 1-2 years out of training you will just be fighting to build referral sources and should be happy to see anything that walks in the door. Then over years 3-5 of your practice do everything you can to mold the practice into the patients/diagnoses that you find most enjoyable while also keeping the lights on at your practice.

 

[j4pac]

Thanks for this!
Unfortunately for me, Mayo is off the table. lol I'm a pretty good applicant, but I'm not a top 3% applicant. That being said, I do have some very solid residency options available to me at this point and I plan to take this advice!
Are there any other logistical issues that would prevent such a practice? I have heard that some attendings will say that "those patient populations are not compatible." How much do these other considerations factor into developing a practice?

I’d definitely prioritize Fluoro over ultrasound in that case…I’d do a PM&R residency at the best, most well rounded program you can find…then do a Pain fellowship. You may not be competent at U/s but it’d rather omit that than spine procedures. There are also Sports/spine programs, that may be good enough for your needs depending on the program.

 

[DubVille]

I think that although this practice may be possible, its unlikely.

If you want botox for example (for spasticity) the neurologist they follow with will likely do this. Most dont want to add another cook to the kitchen for just your botox injections when they already see neurology.
For wheelchair/scs/brain injury/amputee you need to know vendors well and often try to coordinate appointments together. This would be hard to do in real practice (not impossible but difficult.)

I do outpatient pain and did a sports and spine fellowship at one of the NASS sites. It was probably 85% spine and fluoro with a small amount of US, peripheral joints, and pain meds(almost entirely non-narcotic).
Emg has been growing in the practice and is now almost 30-40%. Honestly it's probably bad for the bottom line compared to shots, but in enjoy it and it may be a way to "retire" early doing 2 or 3 days of emg a week. I usually just do the test and send them back to referring doc. If it's a spine thing I often take over depending on who sent it.

I think getting in with a hand surgery group is the way to go for emg, which thankfully I have over 4 years but before this it was mostly borderline useless emg referrals (80 yo "r/o" neuropathy) with edema. R/o radiculopathy when emg is not a sensitive test for that condition, etc. Plus the innervation of legs makes it less reliable for anything above L4 anyway as far as radics go.

 

[avalon10]

Join a big orthopedic group. You can likely do almost everything that you listed.
And most people do not want to manage pumps. Botox is often in the realm of neurology.

 

[cowboydoc]

Thanks for this!
Unfortunately for me, Mayo is off the table. lol I'm a pretty good applicant, but I'm not a top 3% applicant. That being said, I do have some very solid residency options available to me at this point and I plan to take this advice!
Are there any other logistical issues that would prevent such a practice? I have heard that some attendings will say that "those patient populations are not compatible." How much do these other considerations factor into developing a practice?

You received bad advice. This sounds like a great set up. You can definitely be a msk PM&R doc that does broader pain procedures. Not marketing yourself as a “pain” doctor is my best advice.

 

[RangerBob]

I’ve never actually met a neurologist who did Botox. Obviously some do as the above poster allude to, but I disagree Botox is the realm of neurology. PM&R is far better suited for it. Neurology rarely wants to follow SCI/brain injury/stroke patients even for a single follow up in clinic. Those are bread and butter PM&R patients.

 

[Magnus Acus]

You received bad advice. This sounds like a great set up. You can definitely be a msk PM&R doc that does broader pain procedures. Not marketing yourself as a “pain” doctor is my best advice.

Thank you all for the advice! I totally get not marketing myself as a "pain doc". I can see how that would preclude me from certain referals. Would doing a pain fellowship and then marketing myself as "Sports and Spine" or even "Interventional Physiatry" be the move? I like the idea of a sports/ sports and spine fellowhip, but I really want to be as well trained as possible for interventions. For example- I really love the idea of doing MILD, intracept, vertiflex, and all manor of future pain procedures. Maybe it's naivety, but I really think the future of pain and physiatry will be more procedural, with pain docs essentially doing more and more minimally invasive surgeries. BUT I love the bread and butter PM&R cases and want my practice to be more than just 30 low back pain encounters per day.

Anyone use "interventional physiatry" or other term? and if so- what does your practice look like?

 

[Magnus Acus]

Join a big orthopedic group. You can likely do almost everything that you listed.
And most people do not want to manage pumps. Botox is often in the realm of neurology.

I am from a rural area and I have recieved the same exact response when asking other pain docs about pump implantation and management. "I dont want the headache." And obviously my inexperience is showing- but is it really that bad? I am not really interested in pain pumps (maybe other than in palliative cases or something). It seems like there are probably a several patients who may do well in my area with a baclofen pump, would it really be that big of a headache for a solo doc to manage given EXCELLENT (highly exclusionary) pt selection? and yes- I guess I could refer to academics, but for the sake of argument, I would say at least 4/5 people in my target practice area would simply not have it done outside of a local doc for preference/financial reasons.

 

[RangerBob]

I am from a rural area and I have recieved the same exact response when asking other pain docs about pump implantation and management. "I dont want the headache." And obviously my inexperience is showing- but is it really that bad? I am not really interested in pain pumps (maybe other than in palliative cases or something). It seems like there are probably a several patients who may do well in my area with a baclofen pump, would it really be that big of a headache for a solo doc to manage given EXCELLENT (highly exclusionary) pt selection? and yes- I guess I could refer to academics, but for the sake of argument, I would say at least 4/5 people in my target practice area would simply not have it done outside of a local doc for preference/financial reasons.

The main issues with pumps are volume and pump call. Most rural areas don't have much volume. Which is fine if it's just a small part of your practice. The bigger issue is call--someone has to be available 24/7 to help these patients because literally (and I use that word with about 98% accuracy here) no one knows how to manage a pump. And baclofen withdrawal is potentially lethal. So you need to have a back up if you're on vacation. Obviously you give the patient oral baclofen if they ever think their pump is malfunctioning, but at a certain point someone needs to assess that patient. Neurosurgery is happy to help if it's concerns regarding possible infection or it needs to be removed, but otherwise it's 100% on you.

On the the other hand, the patients are very grateful, keep coming back every few months for a refill (which pays well I believe), and you get some quality time to chat with them while you refill their pump.

While headaches for us, can be profoundly life-altering for some patients with refractory spasticity (or just poor tolerance to oral meds). We saw a lot of pump patients in residency and I only met one who regretted the decision. And we saw so many chronic TBI/SCI/strokes in clinic I don't think it was just self-selection--we basically covered the whole state with regards to spasticity management.

Pain pumps on the other hand... I didn't work with many in training, but I have met a lot of patients with pain pumps as an inpatient attending. I swear somewhere around 80% or so have had their pumps turned off. Probably great for palliative patients, but as you know pain is so multifafactorial, and as one surgeon told me, "never operate on crazy." Hyperbole obviously, but I find one thing more pain doctors need to learn is how to not just keep throwing more and more interventions at a patient and instead sit down and have a heart-to-heart talk. Most patients with chronic pain do much better with 6 months of progressive low-impact aerobic exercise, but so many have learned helplessness or an external locus of control that they just can't adhere to the program.

 

[avalon10]

Thank you all for the advice! I totally get not marketing myself as a "pain doc". I can see how that would preclude me from certain referals. Would doing a pain fellowship and then marketing myself as "Sports and Spine" or even "Interventional Physiatry" be the move? I like the idea of a sports/ sports and spine fellowhip, but I really want to be as well trained as possible for interventions. For example- I really love the idea of doing MILD, intracept, vertiflex, and all manor of future pain procedures. Maybe it's naivety, but I really think the future of pain and physiatry will be more procedural, with pain docs essentially doing more and more minimally invasive surgeries. BUT I love the bread and butter PM&R cases and want my practice to be more than just 30 low back pain encounters per day.

Anyone use "interventional physiatry" or other term? and if so- what does your practice look like?

The problem with calling yourself "pain management" isn't referrals, it's that you'll be completely flooded with opioid-seeking patients.

 

[Magnus Acus]

The problem with calling yourself "pain management" isn't referrals, it's that you'll be completely flooded with opioid-seeking patients.

Ah.. This makes more sense. lol

 

[Iamnew2]

I am from a rural area and I have recieved the same exact response when asking other pain docs about pump implantation and management. "I dont want the headache." And obviously my inexperience is showing- but is it really that bad? I am not really interested in pain pumps (maybe other than in palliative cases or something). It seems like there are probably a several patients who may do well in my area with a baclofen pump, would it really be that big of a headache for a solo doc to manage given EXCELLENT (highly exclusionary) pt selection? and yes- I guess I could refer to academics, but for the sake of argument, I would say at least 4/5 people in my target practice area would simply not have it done outside of a local doc for preference/financial reasons.

you are naive - for one, vertiflex, MILD, etc and all that type of rather invasive pain procedures are not that frequent - you may get a handful of patients here and there, but patients who truly are good candidates are not that frequent, many insurances don't pay for them, etc. Many people who talk about these procedures have actually never done them or have much experience with them but are under the impression that they pay big bucks - also keep in mind what they COST. implants I despised - don't know how others feel about them, but one of the thigns that drove me to just do plain rehab as opposed to pain. hated pumps so much. Bread and butter pain is what ultimately makes the bucks. Pain pumps are a pain - for the pain physician managing them, reason why few pain docs want to do them and they also have high liability. Baclofen pumps are not that high paying and can be a pain - particularly if thye malfunction, if patients are not compliant, etc.

 

[avalon10]

you are naive - for one, vertiflex, MILD, etc and all that type of rather invasive pain procedures are not that frequent - you may get a handful of patients here and there, but patients who truly are good candidates are not that frequent, many insurances don't pay for them, etc. Many people who talk about these procedures have actually never done them or have much experience with them but are under the impression that they pay big bucks - also keep in mind what they COST. implants I despised - don't know how others feel about them, but one of the thigns that drove me to just do plain rehab as opposed to pain. hated pumps so much. Bread and butter pain is what ultimately makes the bucks. Pain pumps are a pain - for the pain physician managing them, reason why few pain docs want to do them and they also have high liability. Baclofen pumps are not that high paying and can be a pain - particularly if thye malfunction, if patients are not compliant, etc.

Agreed with Iamnew2. Most of these new things like vertiflex, MILD etc are hyped up by the companies that make them but generally turn out to be useless, and getting paid for them isn't worth the effort of doing them. Bread and butter for spine is ESI, MBB/RFA, SIJ etc. Stims are also pains. If you're lucky you'll get busy enough that you can do B&B stuff and not have to deal with stims (and pain pumps).

 

[avalon10]

And if you're extra lucky you won't have to do EMGs

 

[Iamnew2]

And if you're extra lucky you won't have to do EMGs

I have only met a handful of PM&R doctorswho did EMGs in private practice. How common are they these days? I never felt they were that helpful - if I were a surgeon I would never base a surgical intervention on an EMG. They are simply not that reliable with tons of proneness for error depending on who does them.

 

[avalon10]

I have only met a handful of PM&R doctorswho did EMGs in private practice. How common are they these days? I never felt they were that helpful - if I were a surgeon I would never base a surgical intervention on an EMG. They are simply not that reliable with tons of proneness for error depending on who does them.

Tons of people do them. Surgeons use them all the time. Personally I hate doing them and have stopped. Hopefully won't ever do another one.

 

[Iamnew2]

Tons of people do them. Surgeons use them all the time. Personally I hate doing them and have stopped. Hopefully won't ever do another one.

I'm with you on that - I hate doing them and haven't done one since residency. Here in the Midwest very few people do them.

 

[Magnus Acus]

you are naive - for one, vertiflex, MILD, etc and all that type of rather invasive pain procedures are not that frequent - you may get a handful of patients here and there, but patients who truly are good candidates are not that frequent, many insurances don't pay for them, etc. Many people who talk about these procedures have actually never done them or have much experience with them but are under the impression that they pay big bucks - also keep in mind what they COST. implants I despised - don't know how others feel about them, but one of the thigns that drove me to just do plain rehab as opposed to pain. hated pumps so much. Bread and butter pain is what ultimately makes the bucks. Pain pumps are a pain - for the pain physician managing them, reason why few pain docs want to do them and they also have high liability. Baclofen pumps are not that high paying and can be a pain - particularly if thye malfunction, if patients are not compliant, etc.

Thank you for this response. It looks like pump management is unpopular throughout this thread, so I imagine I will also feel this way after residency and so I won’t worry about that too much.. lol

As far as the other invasive procedures- MILD/vertiflex/Intracept/SCS/Kypho/PNS/etc, do you really believe that all of this will turn out to be all marketing/hype? To me it seems likely that at least some of these will be efficacious, although I certainly believe that many developing procedures will flop. I feel like all of medicine is advancing and inevitably becoming more procedural. PM&R and Pain not excluded. I think there will be variations of progress in both fields within my career. I obviously don’t know what the members of this forum know though (hence why I posted). So do you disagree with this take?

Additionally, back to the crux of the OP, is there a reason you went straight back to rehab only? Why not merge the aspects of pain and rehab you enjoy rather than picking one or the other? For me, ideally I would have a sort of Frankenstein practice.

Thanks for the insight!

 

[Magnus Acus]

And if you're extra lucky you won't have to do EMGs

Haha as of now I am ambivalent to EMG. The occasional diagnostic challenge seems interesting, but I have heard of the abundant inappropriate tests ordered and low reimbursement rates as reasons to not do them.

 

[avalon10]

Thank you for this response. It looks like pump management is unpopular throughout this thread, so I imagine I will also feel this way after residency and so I won’t worry about that too much.. lol

As far as the other invasive procedures- MILD/vertiflex/Intracept/SCS/Kypho/PNS/etc, do you really believe that all of this will turn out to be all marketing/hype? To me it seems likely that at least some of these will be efficacious, although I certainly believe that many developing procedures will flop. I feel like all of medicine is advancing and inevitably becoming more procedural. PM&R and Pain not excluded. I think there will be variations of progress in both fields within my career. I obviously don’t know what the members of this forum know though (hence why I posted). So do you disagree with this take?

Additionally, back to the crux of the OP, is there a reason you went straight back to rehab only? Why not merge the aspects of pain and rehab you enjoy rather than picking one or the other? For me, ideally I would have a sort of Frankenstein practice.

Thanks for the insight!

Kypho is a great procedure. Works very well for acute fracture. MILD might be helpful for some non-surgical stenosis patients, but it’s probably way over-used.
Stims are very common, I just choose not to get involved with them anymore.
Every new procedure is hyped by the manufacturer and their KOLs as a real “game-changer” or a major “innovation.” The latest seems to be Intracept. The manufacturer wants to make as much money as quickly as possible.
After a while you’ll see a lot of these products come and go. In general, don’t believe the hype.

 

[sloh]

drove me to just do plain rehab as opposed to pain

Such a discrepancy between what med students and residents get excited about in residency/fellowships and what actually pays well (accounting for all the logistics, business aspects of medicine, RVU’s, volume) once they are out as attendings haha

 

[drg123]

Thoughts on peripheral nerve stim like SPR? Seems low risk, possibly high efficacy, not much aftercare, and not too hard to deliver (ultrasound or fluoro, nothign implanted in central neuraxis).

 

[Iamnew2]

Thank you for this response. It looks like pump management is unpopular throughout this thread, so I imagine I will also feel this way after residency and so I won’t worry about that too much.. lol

As far as the other invasive procedures- MILD/vertiflex/Intracept/SCS/Kypho/PNS/etc, do you really believe that all of this will turn out to be all marketing/hype? To me it seems likely that at least some of these will be efficacious, although I certainly believe that many developing procedures will flop. I feel like all of medicine is advancing and inevitably becoming more procedural. PM&R and Pain not excluded. I think there will be variations of progress in both fields within my career. I obviously don’t know what the members of this forum know though (hence why I posted). So do you disagree with this take?

Additionally, back to the crux of the OP, is there a reason you went straight back to rehab only? Why not merge the aspects of pain and rehab you enjoy rather than picking one or the other? For me, ideally I would have a sort of Frankenstein practice.

Thanks for the insight!

As mentioned the vertiflex/MILD, etc - it's not that they are not effective, it's that there is only a small subset of patients that are true appropriate candidates, they are very $$$$ (I think one of the above which I can't recall - maybe vertiflex or mild? costs thousands of dollars to get the actual hardware from the company - (residency teaches you essentially nothing about running a practice which is in and out of itself a bad thing - residencies should teach residents how to be successful in this regard - at the end of the day if you can't run a practice, it doesn't matter how good you are), and so it's not always worth the trouble nor is it cost effective, it's potentially high risk particularly for pumps, it takes a bunch of time to do certain procedures, and very importantly there are many many many patients who will say "no" to these type of invasive procedures.

very few people in my experience want pumps/mild/vertiflex.

As far as me goes, it was really a personal decision. I'm a gal aka, "lady doctor" so I had concerns re: radiation and child bearing in part, most of the practices here wanted everything including pumps which is not what I wanted to do, and at the end of the day I wanted in due time to move up the exec physician ladder, not to mention that I was in a very litigious state - so for me straight rehab was the better choice. I am able to make the same if likely not more than pain, have a leisurely pace of work, can take off when I want, I'm a director which will lead to more leadership options, don't have to worry about radiation, etc.