Intellectual Richness and Rigor of Pain Medicine Specialty

[drusso]

On a scale from 0-10 (Zero being none and Ten being the most you can imagine) rate the intellectual richness and rigor of our field today...

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[DrCommonSense]

On a scale from 0-10 (Zero being none and Ten being the most you can imagine) rate the intellectual richness and rigor of our field today...

I'd say its about the same as almost any procedural medical field in terms of intellectual rigor and evidence. It has about the same level of evidence as interventional cardiology, orthopedics and back surgeons (ortho and neuro).

Very difficult to compare to non procedural medicine considering most of that is just big pharma research in almost every field.

 

[lobelsteve]

I'd say an 8 if you are an SIS member and have a salary cap built in. I would also give you an 8 if you were a harm reductionist.

5 for ASIPP memberships.
2 for AAPMed
-11ty billion for AAPMgmt and interventional only.

 

[DrCommonSense]

I'd say an 8 if you are an SIS member and have a salary cap built in. I would also give you an 8 if you were a harm reductionist.

5 for ASIPP memberships.
2 for AAPMed
-11ty billion for AAPMgmt and interventional only.

Thats true of any field of medicine.

The highest paid interventional cardiologist is the one who stents the most people regardless of outcome

The highest paid back surgeon is the one who does the most fusions

The highest paid Orthopod does the most THR/TKRs

I think all fields of procedural medicine should be salaried to avoid conflicts of interest AFTER we control pharmaceutical costs, administrative costs, device costs, etc.

However, I don't recommend physician "caps" unless we eliminate all the non physician compensation costs that exceed physician pay by an order of 10.

 

[Ducttape]

Thats true of any field of medicine.

The highest paid interventional cardiologist is the one who stents the most people regardless of outcome

The highest paid back surgeon is the one who does the most fusions

The highest paid Orthopod does the most TKA/TKRs

I think all fields of procedural medicine should be salaried to avoid conflicts of interest AFTER we control pharmaceutical costs, administrative costs, device costs, etc.

However, I don't recommend physician "caps" unless we eliminate all the non physician compensation costs that exceed physician pay by an order of 10.

much as I find this challenging to admit... but I do agree with this concept. but it does fly in the face of capitalistic approach to medical care.

 

[Aether2000]

Those wascally wabbits! The AAPManagement changed their name to the Academy of Integrative Medicine, so now they can accommodate all the Reikis, Rolfers, Cuppers, Meridian Moguls, Moxibustion Montebanks, Crystal Charlatans, and the Not-Doctors (N.Ds).

 

[VA Hopeful Dr]

Thats true of any field of medicine.

The highest paid interventional cardiologist is the one who stents the most people regardless of outcome

The highest paid back surgeon is the one who does the most fusions

The highest paid Orthopod does the most THR/TKRs

I think all fields of procedural medicine should be salaried to avoid conflicts of interest AFTER we control pharmaceutical costs, administrative costs, device costs, etc.

However, I don't recommend physician "caps" unless we eliminate all the non physician compensation costs that exceed physician pay by an order of 10.

The problem with salaried docs is that we lose incentive to work hard. It does get trickier with procedural specialties as you pointed out. There has to be some middle way to reward working hard but not over-reward sticking a needle in every back that crosses your path.

 

[emd123]

On a scale from 0-10 (Zero being none and Ten being the most you can imagine) rate the intellectual richness and rigor of our field today...

20. Definitely 20.

 

[nvrsumr]

I think physicians minimize our cognitive labor. What we do as pain docs is a 9 which is an 11 for any other professional. Plus we have the added bonus of doing this with a smile while interacting with the general public

 

[drusso]

20. Definitely 20.

 

[clubdeac]

I think physicians minimize our cognitive labor. What we do as pain docs is a 9 which is an 11 for any other professional. Plus we have the added bonus of doing this with a smile while interacting with the general public

A 9-11? how? I'm going to play devil's advocate here. 80% of my patients are either axial lbp or neck pain. I basically have a 6 item menu to choose from. Facet interventions; epidurals (TFESI vs ILESI), PT referral, chiro referral, acupuncture referral, or Cymbalta. Assuming NSAIDs, tylenol and muscle relaxants have been tried. Personally I'm burnt out, if you couldn't tell

 

[nvrsumr]

Club make a list starting at the big toe and ending at the vertex of every procedure/pathology you have ever done/treated then add in systemic diseases ie. RA SLE etc. That is the differential dx that you go thru without realizing it. It is easy for you because you are a well trained expert.

I teach med students for fun and I think adding that to your practice might add a little perspective and remind you how far you have come.

Everyone is burned out. You are not alone in that feeling.

 

[Aether2000]

Pain medicine has the potential to be one of the most richly rewarding intellectual endeavors in all of medicine. However the way it is actually practiced in real pain practices is frequently quite different, being driven by insurance limitations and by the need to keep the doors open in an environment of ever-shrinking reimbursement for those procedures that are still covered. I have had the experience recently of visiting other pain practices and have found the mid-levels that frequently see the patients initially, have a very regimented approach that all lead to one of only a few injections, and they lack the fund of knowledge necessary to develop a differential diagnosis. Additionally they are bereft of the capacity to elucidate the various diagnosis in that differential by physical exam, laboratory or imaging studies. Referral to physical therapy is only performed as a means to ensure coverage of injections.

The many differential diagnosis possible are discounted or simply ignored by any pain practices are paid 5 times as much per hour for injections than for thoughtful history with confirmatory physical exams for all the elements in the differential. It seems the state of the profession is to rule out one of three or four major diagnosis by performing injections sequentially then if there are more obscure or secondary causes of pain, these are treated with medications or by referral back to the family physician rather than looking deeper.

If all you have is a hammer everything looks like a nail, and increasingly pain medicine is constricted to only three or four different types of nails. In these cases the intellectualism has evaporated and has been supplanted by financial survival.

 

[oreosandsake]

I'd say an 8 if you are an SIS member and have a salary cap built in. I would also give you an 8 if you were a harm reductionist.

5 for ASIPP memberships.
2 for AAPMed
-11ty billion for AAPMgmt and interventional only.

8 + 8 + 2 + 5 >> 10 !

 

[Ducttape]

The problem with salaried docs is that we lose incentive to work hard. It does get trickier with procedural specialties as you pointed out. There has to be some middle way to reward working hard but not over-reward sticking a needle in every back that crosses your path.

No offense but as a salaried doc (who has a small incentive bonus) I have not lost incentive.

It’s easy to stick needles in ppl. It’s hard to convince people that they themselves hold the key to getting better.

FYI add to your armament pain psych, cbt, catastrophizing, rfa, neuro modulation.

Get to know your patients personally. See what really is bothering them - ofttimes it’s not something seen on an MRI (sorry freddypt) - it’s an anniversary of an event, death of a friend, an injury, an assault, a bad relationship....

 

[lobelsteve]

8 + 8 + 2 + 5 >> 10 !

÷4=5.75

 

[oreosandsake]

don't stop learning. try to look outside the box.

your fluoro eyes have caused you to be myopic.

if your differential diagnoses for back pain stop after facet, disc, myofascial, SIJ then you aren't giving the complexity of the human body enough credit. and you have shoehorned your brain into a static algorithm

but we all know docs that perform ILESI, TFESI, bilateral 2 level TFESI, MBB x2, RFA, SIJ, SIJ RFA, bilateral TFESI, RFA, RFA RFA SCS trial, SCS implant, 2nd SCS implant, PNS, in that order, regardless of the primary diagnosis, along with UDS every month...

 

[VA Hopeful Dr]

No offense but as a salaried doc (who has a small incentive bonus) I have not lost incentive.

It’s easy to stick needles in ppl. It’s hard to convince people that they themselves hold the key to getting better.

FYI add to your armament pain psych, cbt, catastrophizing, rfa, neuro modulation.

Get to know your patients personally. See what really is bothering them - ofttimes it’s not something seen on an MRI (sorry freddypt) - it’s an anniversary of an event, death of a friend, an injury, an assault, a bad relationship....

And not everyone does - lots of people do well being salaried.

But lots of people don't.

 

[DrCommonSense]

Pain medicine has the potential to be one of the most richly rewarding intellectual endeavors in all of medicine. However the way it is actually practiced in real pain practices is frequently quite different, being driven by insurance limitations and by the need to keep the doors open in an environment of ever-shrinking reimbursement for those procedures that are still covered. I have had the experience recently of visiting other pain practices and have found the mid-levels that frequently see the patients initially, have a very regimented approach that all lead to one of only a few injections, and they lack the fund of knowledge necessary to develop a differential diagnosis. Additionally they are bereft of the capacity to elucidate the various diagnosis in that differential by physical exam, laboratory or imaging studies. Referral to physical therapy is only performed as a means to ensure coverage of injections.

The many differential diagnosis possible are discounted or simply ignored by any pain practices are paid 5 times as much per hour for injections than for thoughtful history with confirmatory physical exams for all the elements in the differential. It seems the state of the profession is to rule out one of three or four major diagnosis by performing injections sequentially then if there are more obscure or secondary causes of pain, these are treated with medications or by referral back to the family physician rather than looking deeper.

If all you have is a hammer everything looks like a nail, and increasingly pain medicine is constricted to only three or four different types of nails. In these cases the intellectualism has evaporated and has been supplanted by financial survival.

Once again, this is an issue for all of medicine between procedural vs intellectual payment systems.

Whenever one goes to an Ortho surgeon, they only send you for PT to get approval for hip/knee/back surgery.

Whenever one goes to an interventional cardiologist, they give medications only to get to the point of placing the stent.

Incentives matter in life. Since physicians aren't rewarded for cognitive medicine, they will increase their procedure volume to keep the lights on.

 

[SeniorWrangler]

There's a striking disconnect between pain medicine as an academic field, which is fascinating and evolving rapidly, and pain medicine as a clinical practice, which is pretty much as Clubdeac described it.
But I think the same disconnect between theory and practice exists in lots of fields.

 

[emd123]

There's a striking disconnect between pain medicine as an academic field, which is fascinating and evolving rapidly, and pain medicine as a clinical practice, which is pretty much as Clubdeac described it.
But I think the same disconnect between theory and practice exists in lots of fields.

Agree.