Lines in the Sand

[AviatorDoc]

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So it seems that much of the "hot topic" debates on this board are dealing with marking ones territory, so it begs the question: Where do you draw the lines?

Let me make my case:

Is there some anatomical or technical barrier between the "interventional physiatrist" and "spine surgeon"? At what point does it really not make much sense for a physiatrist do be doing "procedures" and instead have a trained neuro or orthopedic surgeon operate?

To phrase it a bit differently, if a physiatrist is well-trained, is exposed to plenty of cases, is there (or should there be) a limit to what they can do from an interventional standpoint? Do you Spine guys do discectomies? Laminectomies? Fusions? Is anything fair game as long as its "percutaneous" and under fluoro? Could you go one step further and actually open the skin, again, assuming you have had plenty of supervised cases, and surgical back-up is immediately available?

Let me back away from the cord for a bit. Should a spasticity doc be able to implant their own pumps, even if they haven't had a full year of fellowship? A pump placement is a relatively easy procedure, right? Just an LP, some tunneling, a little pocket, hook it all up, and your good to go. Even general cardiologists put in their own pacemakers.

If you believe in "pushing the limit" of interventional, let's go to another extreme. Could an interventional physiatrist be trained to place their own DBS leads? (Again, with NS back-up.) After all, interventional neuroradiologists do their own coiling.

And if we collectively agree that you should do whatever you feel comfortable doing, and we should push the boundary of what we can justifiably do, would you not agree that each profession is in the right to do the same? Is it any different for PT to have direct patient access? Psychology to have prescription priveledges to a handful of psych meds? Doctors of pharmacy to have limited prescription rights? PTs doing EMGs? Isn't this all just about marking our own territories (assuming patient safety isn't compromised)?

Not that I'm against it.

 

[AviatorDoc]

Oh, one more "territory"

How aggressive should a physiatric resident be in reducing a nasty paraphimosis before calling Urology? Just a little personal experience from today's rounds.

 

[lobelsteve]

Once your an MD/DO, you can do anything you want. YOu won't be able to do it in a hospital because they have a credentialling committee to make sure you will be safe performing the procedures/surgeries you have requested to do. The hospital does not want the liability of an untrained/undertrained doctor doing what they ought not to be doing.

In states without certificates of need, you can open your own ASC and do many minor surgeries with little to no training as you will credential yourself to do them in your ASC.

At this time, it is starting to swimg past the point of medical malpractice. If you think you can just drop a pump into somebody without having had more than a weekend warrior course, you can. But if you experience a complication, it will not just be med-mal you will be facing. Criminal charges have and will continue to be filed against doctors practicing this far outside the standard of care. You will go to jail for such transgressions, and you will surrender your medical license to the state board. And I will be happy to testify against you. Patient safety above all else.

 

[drusso]

You are only as good as the complications *YOU* can personally handle. Do you like cleaning up other people's messes? Then, why should your "surgical back-up?"

As a physiatrist, when you get those late orthopedic polytrauma admissions to the Rehab Service--and its clear that no one with the knowledge, skills, and training of a "real doctor" has been looking after the patient for the last couple of weeks--don't you get a little miffed? Then just imagine how your "sugical back-up" is going to feel getting paged STAT to the OR to discover that you've been mucking around in someone's spine.

Pumps and Stims are straightforward surgical procedures and well within the reach of properly trained non-surgical specialists. But, you are not a surgeon. And, as lobelsteve alluded, that point will be made explicitly clear to the jury by the plantiff's counsel and there will be no shortage of expert witnesses available to testify against you.

 

[AviatorDoc]

i was throwing out this discussion in the role of devil's advocate. I agree that patient care comes first. That's my point. Are interventional physiatrists "pushing the limit" of what they should/should not be doing?

 

[lobelsteve]

i was throwing out this discussion in the role of devil's advocate. I agree that patient care comes first. That's my point. Are interventional physiatrists "pushing the limit" of what they should/should not be doing?

I now some who are doing more than they are capable of doing and some that are more capable than they give themselves credit for and who have pulled back from doing CESI, SCS, and sympathetic blocks.

When the plaintiff/prosecuting atty asks, " Who trained you?" you want to be able to answer appropriately.

 

[AviatorDoc]

And if someone puts you on the stand and says, "Where did you train?"
And you answer, "So-and-so Orthopedic Associates".
And they ask, "Is this a fellowship that is accredited by the American College of Graduate Medical Education?"
And you say, "No, but it is approved by the guidelines set by the Physiatric Association of Spine, Sports, and Occupational Rehabilitation."
Then they say, "Ah. An association of physiatrists?"
"Yes."
"So what you're saying is, collectively, an association of physiatrists has deemed themselves worthy of performing these procedures."

"Uh... yeah."

 

[lobelsteve]

And if someone puts you on the stand and says, "Where did you train?"
And you answer, "So-and-so Orthopedic Associates".
And they ask, "Is this a fellowship that is accredited by the American College of Graduate Medical Education?"
And you say, "No, but it is approved by the guidelines set by the Physiatric Association of Spine, Sports, and Occupational Rehabilitation."
Then they say, "Ah. An association of physiatrists?"
"Yes."
"So what you're saying is, collectively, an association of physiatrists has deemed themselves worthy of performing these procedures."

"Uh... yeah."

Some of us get to say how we trained in an ACGME certified program and our board certification in PM is secondary to our boards for PMR.

Of course some of us appear to be in DO school at the moment and may not be qualified to pose such questions without a fuller understanding of the dynamics and flux in the field of PM right now. But thats just a guess.😀

 

[drusso]

Avaitor,

The point is that the lines in the sand are shifting. You're safe doing what other similarly trained physicians in your community, state, or region are doing. The further away you get from what conventionally considered "within your scope of practice" the more risk and liability you incur should there be a bad outcome.

Just because a fellowship is ACGME-accredited does not protect you in and of itself. Being boarded (either by the ABMS via ACGME fellowships or ABPM via non-ACGME approved fellowships) helps. Participating in continuing medical education through groups like ASIPP, AAPM, PASSOR, ASRA, etc, helps. Keeping good records of how many procedures you done, how many proctored experiences you've had, etc helps.

At the end of the day, it's sort of a moot point. It's like moonlighting as a resident in small-town ED's. If you screw up and someone sues you, you will be held to the same standards of practice as a board certified ED physician. Similarly, if as an "interventional physiatrist," you screw up your "perc disc" procedure, you will be held to the same standards of practice as board certified spine surgeons or similarly trained physicians doing these procedures in your community. The lawyers won't be looking to PASSOR for guidance. They'll turn to NASS or the American Association of Neurological Surgeons!

 

[AviatorDoc]

Thanks for the input. Now its starting to make sense. 🙂

 

[axm397]

Here's an answer from a fellowship director:
From the most current issue of the resident newsletter
http://www.aapmr.org/resident/newslttr/060d.htm

So is ACGME accreditation really important?
Training at an ACGME accredited fellowship implies that your PROGRAM meets a given set of standards. The misinformation out there is that if you don't get trained at an ACGME-accredited program, you can't do procedures, and that is not accurate. Individual hospital credentialing committees are the ones who determine whether or not you can perform procedures. A lot of these committee members don't care about ACGME accreditation. They just want to know that you are well trained.

Another concern some residents have voiced is whether ACGME accreditation matters in a malpractice type situation.
First of all, you hopefully won't have a bad outcome, because in a fellowship, you'll get a lot of experience and learn how to avoid the common pitfalls. I think as long as you have the experience to do a procedure, and you trained in a fellowship, the accreditation status of the fellowship doesn't really matter. Where you will get in trouble is if you don't do a fellowship or you just go to a weekend course, and the first patient you perform a procedure on has a bad outcome.

 

[Disciple]

And if someone puts you on the stand and says, "Where did you train?"
And you answer, "So-and-so Orthopedic Associates".
And they ask, "Is this a fellowship that is accredited by the American College of Graduate Medical Education?"
And you say, "No, but it is approved by the guidelines set by the Physiatric Association of Spine, Sports, and Occupational Rehabilitation."
Then they say, "Ah. An association of physiatrists?"
"Yes."
"So what you're saying is, collectively, an association of physiatrists has deemed themselves worthy of performing these procedures."

"Uh... yeah."

The AAPMR crafted 3 documents (White Papers) outlining the role and scope of practice of Physiatrists, with specific guidelines regarding the performance of interventional pain management procedures. These can be found at www.aapmr.org

This is not just some random cowboy Physiatry club. If we wanted to do that we could form PSIS (Physiatric Spinal Intervention Society). These documents are official position statements put out by the professional organization that represents the entire profession, a profession whose board is a member of the ABMS.

 

[Disciple]

So it seems that much of the "hot topic" debates on this board are dealing with marking ones territory, so it begs the question: Where do you draw the lines?

Let me make my case:

Is there some anatomical or technical barrier between the "interventional physiatrist" and "spine surgeon"? At what point does it really not make much sense for a physiatrist do be doing "procedures" and instead have a trained neuro or orthopedic surgeon operate?

To phrase it a bit differently, if a physiatrist is well-trained, is exposed to plenty of cases, is there (or should there be) a limit to what they can do from an interventional standpoint? Do you Spine guys do discectomies? Laminectomies? Fusions? Is anything fair game as long as its "percutaneous" and under fluoro? Could you go one step further and actually open the skin, again, assuming you have had plenty of supervised cases, and surgical back-up is immediately available?

Let me back away from the cord for a bit. Should a spasticity doc be able to implant their own pumps, even if they haven't had a full year of fellowship? A pump placement is a relatively easy procedure, right? Just an LP, some tunneling, a little pocket, hook it all up, and your good to go. Even general cardiologists put in their own pacemakers.

If you believe in "pushing the limit" of interventional, let's go to another extreme. Could an interventional physiatrist be trained to place their own DBS leads? (Again, with NS back-up.) After all, interventional neuroradiologists do their own coiling.

And if we collectively agree that you should do whatever you feel comfortable doing, and we should push the boundary of what we can justifiably do, would you not agree that each profession is in the right to do the same? Is it any different for PT to have direct patient access? Psychology to have prescription priveledges to a handful of psych meds? Doctors of pharmacy to have limited prescription rights? PTs doing EMGs? Isn't this all just about marking our own territories (assuming patient safety isn't compromised)?

Not that I'm against it.

Physiatrists may perform any interventional pain procedures with which they are properly trained and feel comfortable that is within the scope of practice of Interventional Pain Physicians. And, thanks to ASIPP, Interventional Pain Management is an official specialty designation with CMS.

And yes, there are Physiatrists that are pushing the envelope. One PASSOR fellowship includes percutaneous placement of pedicle screws under the supervision of a neurosurgeon. There are some Physiatrists who are shaving menisci. If you want to take the legal risk and your surgeon colleagues are willing to back you up, more power to you. In the area I reside, there are no surgeons who would be happy about bailing me out and many who would be happy to crucify me in court should I mess one of these surgical procedures up.

All procedures have known/accepted complications. What will get you into trouble is either having a complication you shouldn't have had because you don't know what you're doing or having a known complication that you blow off or don't manage properly.

The second part of your post doesn't quite fit with the first. You've mixed scope of practice for procedures (large technical component) to things that require practicing medicine (diagnosis and management). For example, it's called "Electrodiagnostic Medicine" for a reason. A competent electromyographer is expected to take the patient's history/PE, perform the electrodiagnostic study, and then clinically correlate the two to make a medical diagnosis, whether it be something as simple as carpal tunnel syndrome or something as complex as lumbar radic superimposed on a rare form of peripheral neuropathy.

Self referral for PT? What if a patient has back pain and wants some to go straight to PT for massage and ultrasound. What if he/she doesn't know they have a tumor in their spine or a pathologic fracture. What if they have an annular tear at a single level and shouldn't be doing flexion based lumbar stabilization exercises. What if they have undiagnosed CRPS and desensitization therapy would be more helpful instead of ab crunches and body weight squats. What if they have a disease like Ankylosing Spondylitis causing their back pain?

 

[AviatorDoc]

Again, I appreciate all the feedback. I apologize for coming across as confrontational, but i felt that my point was being missed. Right now, Im just an educated idiot in the world of finding a fellowship, and in need of a little direction.


I agree that the second part of my original post was slightly off topic. I guess staying within the medical profession would have made for better analogies. Would you rather have your EGD & Colonoscopy from a gastroenterologist or a GI surgeon? Would you rather have your aneurysm coiled from a NS or interventional rads? Would you rather have your face lift by plastics or dermatology?

In the end, i guess it really doesnt matter what the original background is... go with the doc who's the best. I know that PASSOR fellows are very well-trained and extremely competent. As long as Medicare, malpractice lawyers, Senators and patients know that and are ok with that, then there's no problem.