MSK Radiologist doing Pain Procedures

[Deucedano]

I am a third year med student in the process of trying to decide what I want to do. I really like the concept of diagnosis and the variation of diagnoses in radiology, but I also like the clinical aspect of pain medicine with the procedures and clinical care of chronic pain patients. Each specialty has its downsides (in my opinion), isolation/sitting all day/lack of human&patient contact with radiology and the paperwork/psych issues associated with clinical pain medicine.

I was reading about MSK fellowships in radiology and I was wondering how many of these graduates are practicing pain medicine? I would still like to practice general radiology also, so would it be possible to split my time between practicing radiology (reading msk and non-msk films, mri, ct, ect..) and msk pain management? Is there even a job market for this kind of person? Would it be beneficial for a pain practice to have an msk radiologist on staff? Thanks in advance for your input.

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[dc2md]

I was reading about MSK fellowships in radiology and I was wondering how many of these graduates are practicing pain medicine?

Do they train you in pain medicine during an MSK fellowship? I assume you're talking about interventional procedures.

 

[Mister Mxyzptlk]

I think there might be quite a few radiology "shot doctors", but few, if any, radiologists truly practicing pain medicine in the sense of evaluation and ongoing treatment, including medications, PT, etc. The ones I know just want to cherry-pick procedures.

 

[olafa]

for what my impression is as a person with a PMR background- the MSK fellowships are more for reading/ diagnostics whereas interventional radiologist may do the procedures do in pain. But they are limited in the types of procedures. One of the hospitals we rotated at as residents has IR - doing some of the over-flow procedures the pain consultant could fit into his schedule - they really only did SI and Interlaminar from what I remember. (yes the pain consult service included non-acute injections on patients admitted for other reasons, and consulted for these while the patient was admitted- PITA time-wise, really broke up the clinic schedule having to go to the hospital to do these procedures). They didn't do any diagnostic blocks, facet injection, evaluation or followup... Although, I think some IR at some institutions do vertebroplasty/kypho - I didn't see it where I was.

I am a third year med student in the process of trying to decide what I want to do. I really like the concept of diagnosis and the variation of diagnoses in radiology, but I also like the clinical aspect of pain medicine with the procedures and clinical care of chronic pain patients. Each specialty has its downsides (in my opinion), isolation/sitting all day/lack of human&patient contact with radiology and the paperwork/psych issues associated with clinical pain medicine.

I was reading about MSK fellowships in radiology and I was wondering how many of these graduates are practicing pain medicine? I would still like to practice general radiology also, so would it be possible to split my time between practicing radiology (reading msk and non-msk films, mri, ct, ect..) and msk pain management? Is there even a job market for this kind of person? Would it be beneficial for a pain practice to have an msk radiologist on staff? Thanks in advance for your input.

 

[Aether2000]

There are very few radiologists performing interventional pain full time. Most do not like to listen to patients whine and many lack the skills to make accurate diagnosis on physical exam and history. There are a few mercenary radiologists who advertise they read films then if they find something amenable to pain, will do the pain procedure for the referring physician. But fortunately, most are more ethical than that.

 

[PMR 4 MSK]

I've been to courses taught, at least in part, by interventional rads. At least one was full time interventional - no film reading. But he also did not do any E&M, was only a needle jockey. I'm guessing he was the highest paid doc in town. He just did whatever injection the ordering docs ordered - ESI, FJI, MBB, RFA, SGB, etc.

In some areas, the only ones doing vertebroplasties are IR. IR also does non-pain procedures - arteriograms, Greenfield filter placements, arthrograms, etc.

Also, just to clarify, radiology rarely diagnoses patients. They report what they see on films, US, etc. To give a diagnosis, one needs a full H&P, which they are universally lacking when the rad exam is done. Most rads do not do H&Ps or E&M (evaluation and management - assessing and diagnosing as well as treating medical conditions). That's probably a big part of what keeps the field in business - not having to listen to patient complaints all day.

One piece of advice you'll see frequently here is to not pick a specialty for it's sub-specialty. Sub-specialties come and go, more based on economics that science, and what is popular today may not exist in 10 years, but the parent specialty will. Figure out which parent field fits you better, and then, if you later decide to sub-specialize, do a fellowship.

 

[Deucedano]

Thank for all the information. I have been doing a lot of reading and I agree that IR can do the interventional procedures, but neuro-rads and msk do interventional procedures also. However, several IR have posted that they aren't just needle jocky's, do injections and dump their patients off on another physician. Many have said they do H&P as well as follow up with their patients after the procedure. Apparently many interventional radiologists (neurorads, msk rads) believe the interventional aspect of the field is heading more in the clinical management direction. This is an example of what I am talking about http://drdouglasbeall.com/pages/current.html and http://www.ncbi.nlm.nih.gov/pubmed/7988173

As for choosing based a specialty based on specialization, I agree it is a bad idea. I was just trying to find a way where I could do two different fields that I like without doing two different residencies. That is my problem, I like too many specialties in medicine to choose just one. Anyways thanks again for the input.

 

[nvrsumr]

local IR guy by me doing pain procedures but with CT guidance at his private ASC. Curious how he bills. Any thoughts?

 

[hyperalgesia]

Many have said they do H&P as well as follow up with their patients after the procedure. Apparently many interventional radiologists (neurorads, msk rads) believe the interventional aspect of the field is heading more in the clinical management direction. This is an example of what I am talking about http://drdouglasbeall.com/pages/current.html and http://www.ncbi.nlm.nih.gov/pubmed/7988173

They may follow up with the pt after a procedure, but come up with a long term, comprehensive management plan - very unlikely. Most of them don't want to deal with the high maintenance and headaches that come with chronic pain management. If I were you, like MSK said, focus on which primary specialty best suits you. If you really don't like passing gas in the OR, I wouldn't go into anest. If you are miserable reading films, I'd probably stay away from rads. You always want to be able to fall back on your primary specialty and be content with it.

 

[Deucedano]

They may follow up with the pt after a procedure, but come up with a long term, comprehensive management plan - very unlikely. Most of them don't want to deal with the high maintenance and headaches that come with chronic pain management. If I were you, like MSK said, focus on which primary specialty best suits you. If you really don't like passing gas in the OR, I wouldn't go into anest. If you are miserable reading films, I'd probably stay away from rads. You always want to be able to fall back on your primary specialty and be content with it.

I can see what your getting at and I agree there would be no long term management. Like I said in my earlier post, I do like basic radiology and msk pm&r as core specialties, which is my problem. I want to split my time doing both, but it looks like it would be too much to handle. Oh well, just the thought of an ignorant third year medical student.

 

[dc2md]

If I were you, like MSK said, focus on which primary specialty best suits you. If you really don't like passing gas in the OR, I wouldn't go into anest. If you are miserable reading films, I'd probably stay away from rads. You always want to be able to fall back on your primary specialty and be content with it.

Or if you want a great MSK background and learn electrodiagnostics, PM&R will be great.

 

[Ligament]

Out here in Washington, there are far, far more radiologists (general, neurorads, MSK) doing basic pain procedures than actual Pain Medicine docs doing pain procedures. The usually do SIs, intraarticular facets, interlaminar ESIs, sometimes TFESIs (usually under CT). Almost nothing more than that. The usual pathway is for the PCP to send the patients for a bunch of injections with radiology (for example, ILESIs for facet pain x 3), then when those fail, the patient gets bumped up to the interventional pain docs.

When I was in Michigan, very few radiologists operating like this.

 

[Deucedano]

Out here in Washington, there are far, far more radiologists (general, neurorads, MSK) doing basic pain procedures than actual Pain Medicine docs doing pain procedures. The usually do SIs, intraarticular facets, interlaminar ESIs, sometimes TFESIs (usually under CT). Almost nothing more than that. The usual pathway is for the PCP to send the patients for a bunch of injections with radiology (for example, ILESIs for facet pain x 3), then when those fail, the patient gets bumped up to the interventional pain docs.

When I was in Michigan, very few radiologists operating like this.

Interesting. When you say when the interventions fail and the patients get bumped up to interventional pain docs is that because they patients arent getting the right treatment or lack of proper evaluation/follow up?

 

[lobelsteve]

Interesting. When you say when the interventions fail and the patients get bumped up to interventional pain docs is that because they patients arent getting the right treatment or lack of proper evaluation/follow up?

Radiologists are requested to do procedures as ordered by a PCP with little to no training on the spine or pain. Wrong procedure gets ordered to start. IR has not talked to nor examined the patient.

Terrible for patient care, great for profits. Everyone gets series of LESI, then MBB, then SIJ. When they fail to get reilef- they get labeled drug seekers and get turfed to a Pain Specialist who performs the first spinal exam the patient has ever had and hopefully orders the correct treatment.

Kind of like the PCP writing a referral to the CT surgeon for LIMA to LAD because they think that is the blocked vessel.

 

[stim4u]

surgeons love sending to interventional radiologist. Their shots work for 1-2 weeks, and then all 'conservative measures' have failed. Time for surgery.....

most injections are interlaminar usually at the wrong spot, especially the patients you actually have to get a history from. have several patients with law suits against radiologist causing neurological damage after cervical TFESI's....

 

[dc2md]

...then when those fail, the patient gets bumped up to the interventional pain docs.

Seems they at least recognize the difference b/t a fellowship-trained pain doc, and a radiologist doing interventional pain procedures.

Are the referring physicians wising up?

 

[Tenesma]

when i trained at MGH - the spine surgeons would often send their patients to MSK radiology for all the spine procedures --- primarily because the IR/MSK guys would get the patient in within 24/48 hours and not second guess the surgeon....

we constantly had to fight to convince the spine surgeons that sending the spine patients to the pain clinic for eval and appropriate injection therapy (if even indicated) was better in the long run for the patients ---the spine surgeons disagreed...

until they found out that they could make money off procedures, and the spine surgeons just hired their own injectionists.... and then the IR/MSK guys got pissed off because they lost that part of the busines....

 

[geauxg8rs]

My fav was seeing a patient last week who took her "order for LESI at L4-5" for the IR dudes to perform (ordered from scalpel jockey). The diagnosis listed was lumbar facet arthropathy. The patient shows up with her order because our office is closer and wants her LESI. I tell her after reviewing films, doing H/P that her axial back pain that is particularly worse with exension would probably be better served with MBB. I am in total agreement with the assertion that IR guys serve the surgeons in their "conservative tx was exhausted" scheme.

 

[olafa]

That type of management described seems a bit inappropriate if not fraud-bound to increase the surgeon's revenues. I agree that IR definitely has something to contribute with their excellent image interpretation however functioning as a technician without clinical judgement does seem precarious. I would personally NOT want this treatment for myself. doesn't pass the sniff-test. I am sure there are exceptions, the exception would be obviously with the IR- msk who is trained in these types of patients with appropriate exam and judgement, they may be out there. It's not standard assuming that all IR trained docs would be capable of do the same procedures and I could see that it may be confusing to the referring physician.
vise versa-- you wouldn't send a patient to a pain doc to put a line in / coil an aneurysm that IR would normally do.
There is some cross-over but the primary training as a radiologist preemptively assumes no patient interaction - which does have allot to do pain management as whole.

My fav was seeing a patient last week who took her "order for LESI at L4-5" for the IR dudes to perform (ordered from scalpel jockey). The diagnosis listed was lumbar facet arthropathy. The patient shows up with her order because our office is closer and wants her LESI. I tell her after reviewing films, doing H/P that her axial back pain that is particularly worse with exension would probably be better served with MBB. I am in total agreement with the assertion that IR guys serve the surgeons in their "conservative tx was exhausted" scheme.

 

[Mister Mxyzptlk]

They may follow up with the pt after a procedure, but come up with a long term, comprehensive management plan - very unlikely. Most of them don't want to deal with the high maintenance and headaches that come with chronic pain management.

Exactly, and the only reason they do an H&P is to pad the bill.

I attended an IR pain course 6 years ago. They were absolutely shameless. There were lectures on how to steal referrals from IPM docs (marketing tip: tell referring docs that only radiologists know their way around the spine well enough to do these procedures). I went to the microphone during the question period and asked what they did if the patient didn't get better after their shots. I don't recall the exact response but it was basically, "I don't deal with that. I let them go to the pain doctors for Neurontin and all that crap."

The actual interventional lectures were pathetic. Lumbar ESI lecture discussed how much volume you need via caudal entry to reach the lumbar space. CESI lecture made no mention of catheters at all and they discussed the dangers of CTFESI as if the news broke the day before.

 

[Tenesma]

i remember as a fellow moonlighting in anesthesia --- MSK/IR had a case that required MAC and i was assigned to do the MAC for a TFESI (which took literally 25 minutes and 5 minutes of fluoro - before the contrast)...

the IR fellow found out i was a pain fellow and was all excited: "we could go into practice together, I can do the injections and you can do the prescriptions"....
my stomach churned...

 

[nvrsumr]

i remember as a fellow moonlighting in anesthesia --- MSK/IR had a case that required MAC and i was assigned to do the MAC for a TFESI (which took literally 25 minutes and 5 minutes of fluoro - before the contrast)...

the IR fellow found out i was a pain fellow and was all excited: "we could go into practice together, I can do the injections and you can do the prescriptions"....
my stomach churned...

Had similar experience at a kyphoplasty course as a fellow. Me and 6 IR fellows from a "top" north east program. I literally had to stand in the corner because how slow and heavy on the pedal these guys were. No idea how to line up the endplates, even with the tech's help. Super basic stuff and it was in January so no excuses.

Now in PP I never get kypho referrals because the PCPs want to send them to IR because their training is so much better than mine or whatever.....

 

[Tenesma]

why would anybody in their right mind want to do kypho/vertebroplasties...

the reimbursement stinks for medicare patients (most are medicare)
the patients are usually sick as dogs with all kinds of other crazy stuff going on
it has to be done with anesthesia --- and based on the OR schedule, a 30 minute kyphoe could consume 2 hours of your time
the patients will get micro-emboli and code right there on the table...

yuck....

this is one procedure I will gladly say: "yup, everybody else is better than me at Kypho/vertebroplasty"...

 

[SleepIsGood]

At MGH almsot all the KYpho/Vplast are done by radiology...same thing that people onhere have said. They take 3 times as much time and after their injection they have no idea how to manage the patients (meds,etc).

Ithink the key is that we all need to work on PMDs realizing that a pain specialist should be sought first, not a surgeon.

 

[lobelsteve]

why would anybody in their right mind want to do kypho/vertebroplasties...

the reimbursement stinks for medicare patients (most are medicare)
the patients are usually sick as dogs with all kinds of other crazy stuff going on
it has to be done with anesthesia --- and based on the OR schedule, a 30 minute kyphoe could consume 2 hours of your time
the patients will get micro-emboli and code right there on the table...

yuck....

this is one procedure I will gladly say: "yup, everybody else is better than me at Kypho/vertebroplasty"...

I do them in the office with local or light fent/versed. Reimbursement for MC is posted elsewhere but it is very good, and the kit costs half of the reimbursement. It takes 30 min from door to door.

 

[Tenesma]

the PMDs/PCPs don't understand that we are superior to a surgeon ---

in their minds, a surgeon is the penultimate word on spine mgmt...

the way to catch them is to convince them that you can see/evaluate pt sooner and you will then decide if surgical eval is necessary

timefactor is IMPORTANT - PMDs like knowing they can get patient in with you within a few days so that they don't have to field complaints of pain all day long

 

[Jcm800]

why would anybody in their right mind want to do kypho/vertebroplasties...

the reimbursement stinks for medicare patients (most are medicare)
the patients are usually sick as dogs with all kinds of other crazy stuff going on
it has to be done with anesthesia --- and based on the OR schedule, a 30 minute kyphoe could consume 2 hours of your time
the patients will get micro-emboli and code right there on the table...

yuck....

this is one procedure I will gladly say: "yup, everybody else is better than me at Kypho/vertebroplasty"...

i love it. I will take it over dealing with a 45 year old male with "3 bad discs" who doesnt want to work anymore at the mill, but only has 22 years in but needs 25 to get a full pension, but disabilty help...

i think vertebral augmentation is my favorit procedure. I cant really think of anything i like better...