Interventional pain and acute/subacute rehab

[PMR2008]

I am currently a PGY4 in PM&R and will be starting a pain fellowship next summer. Considering all the reimbursement cuts recently and very likely more coming in the near future I was considering diversifying my practice. Is anyone on the board doing both interventional pain and inpatient/subacute rehab? If so what is your typical work week? How many beds do you cover? Do you have a mid-level helping out? Thanks.

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[101N]

I am currently a PGY4 in PM&R and will be starting a pain fellowship next summer. Considering all the reimbursement cuts recently and very likely more coming in the near future I was considering diversifying my practice. Is anyone on the board doing both interventional pain and inpatient/subacute rehab? If so what is your typical work week? How many beds do you cover? Do you have a mid-level helping out? Thanks.

I do both. How it's done depends upon your practice's details. For me it's 2mo inpt every 5 mo. In pt requires 2-3 hrs per day admitting, discharging. We split a 20 bed unit between 2 MDs. No mid level, 5 docs in practice.

It's a break from pain, but the environment is inherently inefficient.

(I happen to be at NAN'S as I write this. A convergence between Neuromodulation and rehab - motor impairments - is coming. Lots of excitement this yr about extending Neuromodulation well beyond 'pain'.)

 

[PMR2008]

Per hour of work is it financially worth it to do inpatient rehab vs pain? How often are you on call in your group?

 

[101N]

Per hour of work is it financially worth it to do inpatient rehab vs pain? How often are you on call in your group?

Currently 'pain' is more lucrative than Rehab, but times and reimbursement are changing. I am conservative with procedures and, bc of that, I make less on them than peers in my community. IMO the procedural-only model of pain is a bubble on the verge of deflating.

 

[emd123]

It all comes down to this: Is Pain a distinct specialty or not?

My feeling is: you pick a sub-specialty and do it full-time. Do you want to be a Pain "specialist" or do pain "part-time". There's definitely a point to be made for diversification and breaking up the monotony of a very narrowly focused sub-specialty, I will admit, but If you give up a years salary to do a fellowship in what is essentially a different specialty, despite some overlap, likely you think the sub-specialty (Pain) is better for you in some way, and worth pursuing. Does a cardiologist work as a general internist 2 days a week to keep up his internal medicine skills? I've never seen it, though it certainly could be done. Would you have your heart cath done by a cardiologist who really saw himself primarily as an internist, but just dabbled in heart caths a day or two per week to pad his salary a little bit? The same could be said for Pain.

I guess it depends whether you see yourself (and want the community to see you) primarily as a physiatrist who happens to do some Pain, or a Pain specialist who used to be a physiatrist (or anesthesiologist/neurologist/whatever).

Also, if you're that worried about Pain being decimated as a specialty, why waste your time on doing a fellowship?

I won't discount the potential doom and gloom on the horizon for Pain, but the likelihood of Pain ever paying LESS than non-procedure oriented specialties is very slim to zero. If procedures pay zero, then we're all billing evaluation and management codes making what non-procedure oriented specialties make (PMR, neuro, internal medicine, etc). They cant pay us zero dollars per year ( though they'd like too, I'm sure). Now, compared to a higher paid procedure oriented specialty like anesthesia, it's a different story, because Gas pays much more than PM&R or neuro, or psych. For that reason any drop in reimbursement makes it tougher to justify doing a fellowship, to then take a pay cut. Also, it can be brutal for someone used to a certain income that has to take a big pay cut.

So if you're PM&R, I say do Pain full time. I don't think Pain will ever pay less than PM&R.

Just one man's free opinion.

 

[jsaul]

It all comes down to this: Is Pain a distinct specialty or not?

My feeling is: you pick a sub-specialty and do it full-time. Do you want to be a Pain "specialist" or do pain "part-time". There's definitely a point to be made for diversification and breaking up the monotony of a very narrowly focused sub-specialty, I will admit, but If you give up a years salary to do a fellowship in what is essentially a different specialty, despite some overlap, likely you think the sub-specialty (Pain) is better for you in some way, and worth pursuing. Does a cardiologist work as a general internist 2 days a week to keep up his internal medicine skills? I've never seen it, though it certainly could be done. Would you have your heart cath done by a cardiologist who really saw himself primarily as an internist, but just dabbled in heart caths a day or two per week to pad his salary a little bit? The same could be said for Pain.

I guess it depends whether you see yourself (and want the community to see you) primarily as a physiatrist who happens to do some Pain, or a Pain specialist who used to be a physiatrist (or anesthesiologist/neurologist/whatever).

Also, if you're that worried about Pain being decimated as a specialty, why waste your time on doing a fellowship?

I won't discount the potential doom and gloom on the horizon for Pain, but the likelihood of Pain ever paying LESS than non-procedure oriented specialties is very slim to zero. If procedures pay zero, then we're all billing evaluation and management codes making what non-procedure oriented specialties make (PMR, neuro, internal medicine, etc). They cant pay us zero dollars per year ( though they'd like too, I'm sure). Now, compared to a higher paid procedure oriented specialty like anesthesia, it's a different story, because Gas pays much more than PM&R or neuro, or psych. For that reason any drop in reimbursement makes it tougher to justify doing a fellowship, to then take a pay cut. Also, it can be brutal for someone used to a certain income that has to take a big pay cut.

So if you're PM&R, I say do Pain full time. I don't think Pain will ever pay less than PM&R.Just one man's free opinion.

I know a PMR who is pain fellowship trained. After doing pain for 4 years he got burned out. he decided to go back and do general PMR and is happier and making 350,000. I know other private pracitve PMR docs making about the same in the city.

 

[PMR2008]

It all comes down to this: Is Pain a distinct specialty or not?

My feeling is: you pick a sub-specialty and do it full-time. Do you want to be a Pain "specialist" or do pain "part-time". There's definitely a point to be made for diversification and breaking up the monotony of a very narrowly focused sub-specialty, I will admit, but If you give up a years salary to do a fellowship in what is essentially a different specialty, despite some overlap, likely you think the sub-specialty (Pain) is better for you in some way, and worth pursuing. Does a cardiologist work as a general internist 2 days a week to keep up his internal medicine skills? I've never seen it, though it certainly could be done. Would you have your heart cath done by a cardiologist who really saw himself primarily as an internist, but just dabbled in heart caths a day or two per week to pad his salary a little bit? The same could be said for Pain.

I guess it depends whether you see yourself (and want the community to see you) primarily as a physiatrist who happens to do some Pain, or a Pain specialist who used to be a physiatrist (or anesthesiologist/neurologist/whatever).

Also, if you're that worried about Pain being decimated as a specialty, why waste your time on doing a fellowship?

I won't discount the potential doom and gloom on the horizon for Pain, but the likelihood of Pain ever paying LESS than non-procedure oriented specialties is very slim to zero. If procedures pay zero, then we're all billing evaluation and management codes making what non-procedure oriented specialties make (PMR, neuro, internal medicine, etc). They cant pay us zero dollars per year ( though they'd like too, I'm sure). Now, compared to a higher paid procedure oriented specialty like anesthesia, it's a different story, because Gas pays much more than PM&R or neuro, or psych. For that reason any drop in reimbursement makes it tougher to justify doing a fellowship, to then take a pay cut. Also, it can be brutal for someone used to a certain income that has to take a big pay cut.

So if you're PM&R, I say do Pain full time. I don't think Pain will ever pay less than PM&R.

Just one man's free opinion.

I don't think doing 2-3 hours a day of inpatient/subacute rehab will make you any less of a 'pain specialist'. I know a few of Interventional radiologist who do general radiology on the side and seem to be doing fine.
I personally do not think that Pain as a speciality will be decimated even with the cuts in reimbursements and there will always be a need for us in the future.
I am doing a pain fellowship to protect my self legally in the future, to learn advanced procedures and to make myself more marketable when looking for jobs. I want to practice "pain" on a full time bases because this is what I love to do but I don't want to lose the skills I have gained in residency including EMG, ultrasound, botox and general rehab. So diversifying my practice will hopefully help me in the long run.

 

[bedrock]

I know a PMR who is pain fellowship trained. After doing pain for 4 years he got burned out. he decided to go back and do general PMR and is happier and making 350,000. I know other private pracitve PMR docs making about the same in the city.

$350,000 for general PM&R in a major city.... Really?
That's a lot better than I hear from most general PMR docs in private practice in urban centers, but I've talked to a couple guys making that in rural areas.
I wonder if EMGs are half of your friend's practice?

The MGMA median for general PM&R is $241,000

 

[101N]

1+, this is a subspecialty, not a specialty.

However, I love spine and enjoy pain and I'm glad I did the fellowship.

 

[jsaul]

$350,000 for general PM&R in a major city.... Really?
That's a lot better than I hear from most general PMR docs in private practice in urban centers, but I've talked to a couple guys making that in rural areas.
I wonder if EMGs are half of your friend's practice?

The MGMA median for general PM&R is $241,000

yes that's about what they are making in a top 4 city in terms of pop. they see patients in the hospital and as an outpatient and they admit patients to their rehab unit. They do some emgs as well.
The guy I know that did full time pain has now done full time PMR for nearly 2 years and is making that kind of money. he said he is making the same if not more then when he was doing pain and with a lot less headaches and pain for him.

 

[SSdoc33]

I don't think doing 2-3 hours a day of inpatient/subacute rehab will make you any less of a 'pain specialist'. I know a few of Interventional radiologist who do general radiology on the side and seem to be doing fine.
I personally do not think that Pain as a speciality will be decimated even with the cuts in reimbursements and there will always be a need for us in the future.
I am doing a pain fellowship to protect my self legally in the future, to learn advanced procedures and to make myself more marketable when looking for jobs. I want to practice "pain" on a full time bases because this is what I love to do but I don't want to lose the skills I have gained in residency including EMG, ultrasound, botox and general rehab. So diversifying my practice will hopefully help me in the long run.

inpatient rehab. pain. EMGs. ultrasound. botox.

cant all be done. i dont care who you are. it cant all be done well, and to be honest, you are not gonna want to spread yourself so thin. "jack of
all trades, master of none"

 

[PMR 4 MSK]

I tried it in my first job, but dropped rehab after a couple years. Pain paid better and had no call.

 

[PMR2008]

inpatient rehab. pain. EMGs. ultrasound. botox.

cant all be done. i dont care who you are. it cant all be done well, and to be honest, you are not gonna want to spread yourself so thin. "jack of
all trades, master of none"

Maybe it can't be done by you. But I have worked with people who do all the above and do it well.

 

[bedrock]

Maybe it can't be done by you. But I have worked with people who do all the above and do it well.

Not all of those people do it all well, it just may appear that way.

Particularly in PM&R. I know quite a few guys that do rehab, MSK/sports and pain (spine mainly). Most do only the basic bread and butter spine procedures. A lot of them just do lumbar epidurals, SIJ, facet, and hip injections.
Many don't do RF anywhere, let alone cervical or thoracic.

Almost all of those general "do everything" physiatrists don't do advanced interventional procedures such as SCS, pumps, discos, verts, sympathetic blocks, etc.

I think there is a definitely a role for those physiatrists, and I support them as most of them help a lot of people, but not all of them "do everything well".

I've seen patients downstream who never got their RF but needed it for years, or had their pain markedly improved from a long-delayed SCS, or that finally got from me their referral to addiction rehab, etc that someone specializing in pain would do.

 

[SSdoc33]

Maybe it can't be done by you. But I have worked with people who do all the above and do it well.

ok, RESIDENT, more power to ya. but when you get out into the real world, you will know that it is impossible to coordinate all of these things, let alone find a job that permits this, let alone fighting traffic to get from one site to another, let alone getting the PCPs who refer to you to know what the hell you actually are, let alone be profient in all these areas, let alone checking INRs on every patient who gets an EMG (see PM&R thread if interested). so please, before you get high and mighty, listen to those who are trying to help you.

 

[PMR2008]

Not all of those people do it all well, it just may appear that way.

Particularly in PM&R. I know quite a few guys that do rehab, MSK/sports and pain (spine mainly). Most do only the basic bread and butter spine procedures. A lot of them just do lumbar epidurals, SIJ, facet, and hip injections.
Many don't do RF anywhere, let alone cervical or thoracic.

Almost all of those general "do everything" physiatrists don't do advanced interventional procedures such as SCS, pumps, discos, verts, sympathetic blocks, etc.

I think there is a definitely a role for those physiatrists, and I support them as most of them help a lot of people, but not all of them "do everything well".

I've seen patients downstream who never got their RF but needed it for years, or had their pain markedly improved from a long-delayed SCS, or that finally got from me their referral to addiction rehab, etc that someone specializing in pain would do.

You are right. Now that I think about it what you said makes sense. Thanks for explaining. I do know 1 person who does all the advanced procedures you mentioned and does subacute rehab but I doubt he does either as well as someone who only does one.
Is there anything else you want to add to the conversation 101N?
SSdoc33 I apologize for my rude comment.

 

[SSdoc33]

You are right. Now that I think about it what you said makes sense. Thanks for explaining. I do know 1 person who does all the advanced procedures you mentioned and does subacute rehab but I doubt he does either as well as someone who only does one.
Is there anything else you want to add to the conversation 101N?
SSdoc33 I apologize for my rude comment.

accepted.

although i think i probably apologize as well. good luck.

 

[101N]

ok, RESIDENT, more power to ya. but when you get out into the real world, you will know that it is impossible to coordinate all of these things, let alone find a job that permits this, let alone fighting traffic to get from one site to another, let alone getting the PCPs who refer to you to know what the hell you actually are, let alone be profient in all these areas, let alone checking INRs on every patient who gets an EMG (see PM&R thread if interested). so please, before you get high and mighty, listen to those who are trying to help you.

1+

You can't be a master of everything. But, you can do part-time inpatient and have a spine/pain practice. Staying abreast of the changes in inpatient rehab isn't difficult.The bigger issue I've run into is 'branding'. Is my practice spine/pain or PM&R. Some referring docs - & institutions - only see my one hat.

For the OP. The only way you will end up with a hybrid practice is if you join a traditional PM&R group and bring your spine/pain skills, or if a hospital is looking for someone for one roll - inpatient - and you can talk them into giving you the other as well. The later could be a very good thing just out of fellowship.

And now for some politics: I do not think it is wise for our specialty to lose it's connection with the truly disabled.

 

[Jcm800]

accepted.

although i think i probably apologize as well. good luck.

i feel i should apologize as well...

wait, i never made any comments... im just trained now that if i hear an apology that means i am suppose to apologize for something also . Means i have been married to long...

 

[101N]

i feel i should apologize as well...

wait, i never made any comments... im just trained now that if i hear an apology that means i am suppose to apologize for something also . Means i have been married to long...

I'm married as well, so I will also apologize prophylacticly.

 

[facets]

SSdoc33 I apologize for my rude comment.[/QUOTE]

You are overreacting, SS doc is from New York, you can't offend him

 

[SSdoc33]

SSdoc33 I apologize for my rude comment.

You are overreacting, SS doc is from New York, you can't offend him[/QUOTE]

behind this tough facade is....... not very much actually....

 

[PMR 4 MSK]

I'm married as well, so I will also apologize prophylacticly.

I try that sometimes, but it just pisses my wife off further.

 

[painfre]

I got an offer to do In patient rehab on 1-2 weekends/ month . This is the same hospital where i got an offer to do part time out patient Pain. When I came to know about the census which is 38-44 on an average per weekend, I said NO. They offered me to see 20 Saturday amd other 20 on Sunday.
They did not discuss about the reimbursement but it might be a flat fee/day. No RVU syatem in the hospital. Any thoughts ??

 

[PMR 4 MSK]

I got an offer to do In patient rehab on 1-2 weekends/ month . This is the same hospital where i got an offer to do part time out patient Pain. When I came to know about the census which is 38-44 on an average per weekend, I said NO. They offered me to see 20 Saturday amd other 20 on Sunday.
They did not discuss about the reimbursement but it might be a flat fee/day. No RVU syatem in the hospital. Any thoughts ??

You need the money bad enough to give up 2 weekends a month? Like working 12 days on, 2 off, then 12 on and 2 off again? (assuming you are working your day job 5 d/wk)

They would have a really hard time paying me enough to do that.

 

[bedrock]

painfre must be saving up for that newest Ferrari?

 

[pmrrmp]

While interviewing for jobs (currently in fellowship now), I've noticed that most "part-time" pain offerings appear to be for clinic/med refills rather than time for procedures.

Could anybody with more experience chime in? Is it realistic to find a "part-time pain" position that allows for more procedures? How about more invasive procedures like MILD and stim implants? Or is part-time procedure pain a pipe dream?

 

[PMR 4 MSK]

Pain pts and their referrers do not want a part-time doc. They want availability.

But it depends on your competition. If you have a go-getter down the street, aggressively marketing, seeing anything that comes his way, doing late hospitals rounds, etc, you'll starve to death.

If you you don't ave much competition, you can set your own rules. I work less than 30 hours per work on average. I make less than if I worked more, but I am happier.

 

[painfre]

I work for Government. My clinical work is about 4 days a week. 8:30 to 4 pm. only. No calls. Though I got offer to work for 2 weekends in IN Pt rehab, I am considering for 1 weekend. I want to have a feel of private practice keeping my current job as it is.