NANS 2023 -- Evolving Situation

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lobelsteve said:
My social media has local docs snd reps living it up. I don’t like fun that much.
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The night is young...

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Howly Cow.

NANS is right now?

I am in Vegas for unrelated reasons.

And I'm pissed - Abysinthe prices are through the roof! They were way cheaper the last time I went.

It's still probably worth it though.

Any thoughts on the best comedy club?
 
epidural man said:
Howly Cow.

NANS is right now?

I am in Vegas for unrelated reasons.

And I'm pissed - Abysinthe prices are through the roof! They were way cheaper the last time I went.

It's still probably worth it though.

Any thoughts on the best comedy club?
Click to expand...

Brad garrett

Absyinthe somewhat overrated
 
epidural man said:
Howly Cow.

NANS is right now?

I am in Vegas for unrelated reasons.

And I'm pissed - Abysinthe prices are through the roof! They were way cheaper the last time I went.

It's still probably worth it though.

Any thoughts on the best comedy club?
Click to expand...
I go at least once a year to see Bill Maher when he's in Vegas.
 
Update: Nevro is hitting hard. Abbott is in overdrive. Boston looks confused. Nalu got in a few sucker punches. Medtronic needs a nap. Reactiv8 and Sprint curb stomping Saluda.

New KOLs announced tonight.
 
As I get older, it's clear to me how much the "good" therapies always seem to be the ones with an industry behind them and that pays well.
 
Our field is a joke of pretend surgeons, KOLs, and I do it my way superstars.

Buy the SIS Guidelines.
Read the SIS Guidelines.
Do the SIS Guidelines.

If there is not an independent study on new devices/procedures, consider yourself a pioneer and doing human experimentation.
If you would not do the procedure on your mother, do not do it on your patients.
My salary cap was bumped up $100k this year.
Someone tell me what type of new shoes to get (beside the 1080s)
 
lobelsteve said:
Our field is a joke of pretend surgeons, KOLs, and I do it my way superstars.

Buy the SIS Guidelines.
Read the SIS Guidelines.
Do the SIS Guidelines.

If there is not an independent study on new devices/procedures, consider yourself a pioneer and doing human experimentation.
If you would not do the procedure on your mother, do not do it on your patients.
My salary cap was bumped up $100k this year.
Someone tell me what type of new shoes to get (beside the 1080s)
Click to expand...

I don't get it. Your employer raised the cap on how much money you can make?
 
lobelsteve said:
Our field is a joke of pretend surgeons, KOLs, and I do it my way superstars.

Buy the SIS Guidelines.
Read the SIS Guidelines.
Do the SIS Guidelines.

If there is not an independent study on new devices/procedures, consider yourself a pioneer and doing human experimentation.
If you would not do the procedure on your mother, do not do it on your patients.
My salary cap was bumped up $100k this year.
Someone tell me what type of new shoes to get (beside the 1080s)
Click to expand...
I was reading and nodding my head until you said, "If there IS not independent studies on new..."

Sabotaged the entire post.

...are...
 
lobelsteve said:
Our field is a joke of pretend surgeons, KOLs, and I do it my way superstars.

Buy the SIS Guidelines.
Read the SIS Guidelines.
Do the SIS Guidelines.

If there is not an independent study on new devices/procedures, consider yourself a pioneer and doing human experimentation.
If you would not do the procedure on your mother, do not do it on your patients.
My salary cap was bumped up $100k this year.
Someone tell me what type of new shoes to get (beside the 1080s)
Click to expand...

They raised your cap. Did they also raise your $/wRVU value?
 
MitchLevi said:
I was reading and nodding my head until you said, "If there IS not independent studies on new..."

Sabotaged the entire post.

...are...
Click to expand...
Actually it would be "were"
 
Are you walking around and pointing your phone to the ground and taking pictures?.no one is noticing your antics?

These wannabee surgeons and fake insta stars are hilarious
 
Serious question broadly speaking is it more of an ego thing or money thing for KOLs?

I think it’s ego but I could be wrong. Not sure how much they get paid or how much upside there is with stock. I imagine it’s a very small amount of equity but again I could be wrong.

From the looks of it some act like they’re raking in > 3 M yearly from it all. Maybe they are?
 
lobelsteve said:
Our field is a joke of pretend surgeons, KOLs, and I do it my way superstars.

Buy the SIS Guidelines.
Read the SIS Guidelines.
Do the SIS Guidelines.

If there is not an independent study on new devices/procedures, consider yourself a pioneer and doing human experimentation.
If you would not do the procedure on your mother, do not do it on your patients.
My salary cap was bumped up $100k this year.
Someone tell me what type of new shoes to get (beside the 1080s)
Click to expand...
I Hope it’s not a bother to ask. I’m a pain applicant and I’m trying to justify my decision. I know I will feel hard pressed to push advanced procedures or any procedure lacking solid literature support on my future patients. I read through the SIS guidelines you mentioned and their sponsored meta analysis and it seems like even a large portion BB procedures have scarce evidence supporting their use. RFA, esi beyond lumbar region, etc. Even the more interesting/promising? stuff like DRG has crappy evidence. What gives? Is your practice really just MBB and esi? Do I really need to have a loose moral compass to practice pain med?

Appreciate your input if you’re willing to share.

 
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22yis said:
I Hope it’s not a bother to ask. I’m a pain applicant and I’m trying to justify my decision. I know I will feel hard pressed to push advanced procedures or any procedure lacking solid literature support on my future patients. I read through the SIS guidelines you mentioned and their sponsored meta analysis and it seems like even a large portion BB procedures have scarce evidence supporting their use. RFA, esi beyond lumbar region, etc. Even the more interesting/promising? stuff like DRG has crappy evidence. What gives? Is your practice really just MBB and esi? Do I really need to have a loose moral compass to practice pain med?

Appreciate your input if you’re willing to share.

Click to expand...
99% of care is new patients, follow ups, ESI, joint, MBB/RF, peripheral nerve block/RF, kypho, SCS.
 
22yis said:
I Hope it’s not a bother to ask. I’m a pain applicant and I’m trying to justify my decision. I know I will feel hard pressed to push advanced procedures or any procedure lacking solid literature support on my future patients. I read through the SIS guidelines you mentioned and their sponsored meta analysis and it seems like even a large portion BB procedures have scarce evidence supporting their use. RFA, esi beyond lumbar region, etc. Even the more interesting/promising? stuff like DRG has crappy evidence. What gives? Is your practice really just MBB and esi? Do I really need to have a loose moral compass to practice pain med?

Appreciate your input if you’re willing to share.

Click to expand...
Being in a field that is just MBB/ESI as you say - is actually very comforting. It’s nice to live in a finite world. Can you imagine living in the infinite universe of primary care? Ugh.

We do a lot of stuff that doesn’t seem to work in the literature world, but if you actually practice it, it clearly works. I can’t explain why literature can’t capture it - others have tried though.
 
Also, our world has improved vastly now that we only give a rare opioid.

I swear my time spent with patients have dropped probably an average 15 min per patient since I don’t have to spend so much time telling them all the ways that opioids are horrible and why they shouldn’t take them and why I won’t give them any. Such a time suck that was - and I’m not sure it ever worked anyway. I still had to do it though.
 
22yis said:
I Hope it’s not a bother to ask. I’m a pain applicant and I’m trying to justify my decision. I know I will feel hard pressed to push advanced procedures or any procedure lacking solid literature support on my future patients. I read through the SIS guidelines you mentioned and their sponsored meta analysis and it seems like even a large portion BB procedures have scarce evidence supporting their use. RFA, esi beyond lumbar region, etc. Even the more interesting/promising? stuff like DRG has crappy evidence. What gives? Is your practice really just MBB and esi? Do I really need to have a loose moral compass to practice pain med?

Appreciate your input if you’re willing to share.

Click to expand...
I think where we can truly help patients is by being excellent spinal diagnosticians, and in a sense, gatekeepers of surgical need. This is especially the case if you have overly aggressive local surgeons that will fuse anyone with a disc bulge.
RFAs really help, for sure. MBB/RFA for old people with arthritis pain is probably at least 2/3 of my practice.
Kyphoplasties, appropriately used, can prevent older patients from declining into severe deconditioning.
SCS for sure has a role in certain intractable pain states.
Unfortunately, there’s a disconnect between what pays well and taking the time to evaluate a patient appropriately.
Counseling the CRPS patient that their pain won’t get better until they quit smoking and start using the limb, evaluating a patient with severe cervical stenosis and early myelopathy, and sending them to the surgeon, or telling the fibro patient that their disc bulges are normal for age, and they need yoga and water aerobics, and to drop 50 lbs. None of those reimburse well (just the office visit) but are part of good pain care.
I’m in private practice but still try to make time for those sorts of things. I spend most of my time doing injections and have mid-levels seeing new and f/u patients for me. However, I also review imaging before an injection and talk to the patient. Probably at least once a day I’ll change the injection.
Long story short, I think there are ways to practice pain ethically and really help patients.
 
epidural man said:
Also, our world has improved vastly now that we only give a rare opioid.

I swear my time spent with patients have dropped probably an average 15 min per patient since I don’t have to spend so much time telling them all the ways that opioids are horrible and why they shouldn’t take them and why I won’t give them any. Such a time suck that was - and I’m not sure it ever worked anyway. I still had to do it though.
Click to expand...
I'm a PM&R resident going pain and I feel like I speak to this topic all the time to different attendings and they stare at me like I just asked them what oxycodone is.

My future practice goals are no opioids unless palliative/cancer pain, very acute injury (surgery, compression Fx, ect), or some other RARE occurrance. I feel like when I tell people this, their response is "So what do you do for the 50yo w/ severe OA?" or "How does pain management not give opioids?" Which to me, is a dated take on opioids and out of touch with the opioid epidemic we are currently in. I think they expect pain to just be addiction med without the counselling.

Seem accurate or am I off base?
 
Magnus Acus said:
I'm a PM&R resident going pain and I feel like I speak to this topic all the time to different attendings and they stare at me like I just asked them what oxycodone is.

My future practice goals are no opioids unless palliative/cancer pain, very acute injury (surgery, compression Fx, ect), or some other RARE occurrance. I feel like when I tell people this, their response is "So what do you do for the 50yo w/ severe OA?" or "How does pain management not give opioids?" Which to me, is a dated take on opioids and out of touch with the opioid epidemic we are currently in. I think they expect pain to just be addiction med without the counselling.

Seem accurate or am I off base?
Click to expand...
Depends on your area. I’ve been practicing like that for the last 5 years. Opioids only for acute injuries - compression fractures, acute disc herniation, acute post-procedural pain. Cancer pain is handled by their oncologist.
“I don’t recommend or prescribe opiates for chronic pain” is what I tell them. If they push it, I have a premade handout with all the discussion points on it, that I can hand to them to read at their leisure.
 
Magnus Acus said:
I'm a PM&R resident going pain and I feel like I speak to this topic all the time to different attendings and they stare at me like I just asked them what oxycodone is.

My future practice goals are no opioids unless palliative/cancer pain, very acute injury (surgery, compression Fx, ect), or some other RARE occurrance. I feel like when I tell people this, their response is "So what do you do for the 50yo w/ severe OA?" or "How does pain management not give opioids?" Which to me, is a dated take on opioids and out of touch with the opioid epidemic we are currently in. I think they expect pain to just be addiction med without the counselling.

Seem accurate or am I off base?
Click to expand...
22yis said:
I Hope it’s not a bother to ask. I’m a pain applicant and I’m trying to justify my decision. I know I will feel hard pressed to push advanced procedures or any procedure lacking solid literature support on my future patients. I read through the SIS guidelines you mentioned and their sponsored meta analysis and it seems like even a large portion BB procedures have scarce evidence supporting their use. RFA, esi beyond lumbar region, etc. Even the more interesting/promising? stuff like DRG has crappy evidence. What gives? Is your practice really just MBB and esi? Do I really need to have a loose moral compass to practice pain med?

Appreciate your input if you’re willing to share.

Click to expand...
There is hope for both of you. I almost didn't do pain because of the opioids I saw in academics (particularly 15 years ago). You both definitely need to spend time with some private practice pain docs.

You can still have a very good and productive practice with minimal opioids. Of course you rarely need to give a 2 weeks of opioids to patients with a spine fracture or a truly hot radic. But that is far far different from doing chronic monthly standard opioid fills.

To 22yis. The only thing in pain medicine that has level one evidence is MBB/RFA. Otherwise, you need to take studies with a grain of salt as some things just haven't yet been studied optimally. That doesn't mean they don't help patients.
ESI can be very helpful outside of the lumbar spine, but there are far fewer patients for whom you can do a standardized study regarding thoracic ESI compared to lumbar ESI. Kyphoplasty has some mixed studies but praticing pain physicians all see what this does for the right patients. Similar with SCS/DRG.
 
epidural man said:
Also, our world has improved vastly now that we only give a rare opioid.

I swear my time spent with patients have dropped probably an average 15 min per patient since I don’t have to spend so much time telling them all the ways that opioids are horrible and why they shouldn’t take them and why I won’t give them any. Such a time suck that was - and I’m not sure it ever worked anyway. I still had to do it though.
Click to expand...
I agree with you.
Since you’re more experienced than I am how do you recommend dealing with hot radiculopathy? Seems like a handful of opioids until the epidural is reasonable. Of course Gabapentin/Lyrica as the mainstay.

Feel free to chime in others with more experience
 
DrMDAware said:
I agree with you.
Since you’re more experienced than I am how do you recommend dealing with hot radiculopathy? Seems like a handful of opioids until the epidural is reasonable. Of course Gabapentin/Lyrica as the mainstay.

Feel free to chime in others with more experience
Click to expand...
ESI. No opioids for this usually. Maybe Tramadol or Nucynta.
 
epidural man said:
ESI. No opioids for this usually. Maybe Tramadol or Nucynta.
Click to expand...

DrMDAware said:
I agree with you.
Since you’re more experienced than I am how do you recommend dealing with hot radiculopathy? Seems like a handful of opioids until the epidural is reasonable. Of course Gabapentin/Lyrica as the mainstay.

Feel free to chime in others with more experience
Click to expand...

yep.

It should be rare for you to give opioids for a radic. You will notice over time that the patients who didn't get opioids, will show up promptly for their procedure, while those that did get opioids are more likely to reschedule their ESI and/or ask for opioid refill before/after their ESI.

One thing you might consider for patients who appear particularly bad off is to do a quick TPI with 30mg of toradol (15 if petite/certain medical issues). The patient feels like you are doing something for them now and more likely to accept no opioids and just TPI+gaba/lyrica until their ESI. If you have 3 rooms and your staff is properly trained, it should only take you 90 seconds to do the TPI, which is quicker than arguing about opioids. Also many commercial insurances pay as much for a TPI as they do for a joint injection, which takes more time for you and the staff than a TPI.
 
bedrock said:
yep.

It should be rare for you to give opioids for a radic. You will notice over time that the patients who didn't get opioids, will show up promptly for their procedure, while those that did get opioids are more likely to reschedule their ESI and/or ask for opioid refill before/after their ESI.

One thing you might consider for patients who appear particularly bad off is to do a quick TPI with 30mg of toradol (15 if petite/certain medical issues). The patient feels like you are doing something for them now and more likely to accept no opioids and just TPI+gaba/lyrica until their ESI. If you have 3 rooms and your staff is properly trained, it should only take you 90 seconds to do the TPI, which is quicker than arguing about opioids. Also many commercial insurances pay as much for a TPI as they do for a joint injection, which takes more time for you and the staff than a TPI.
Click to expand...
Practical. Thanks.

Just so I’m clear are you recommending an IM toradol injection or a TPI?

If a TPI you’re putting it lumbar?

Throw in some B12 because no real downside?

What about an ultrasound guided caudal if it’s below L4?
 
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I forget, are you salaried Steve? Just curious since you brought up your pay
 
Just got home from NANS! One of the main DRG stim utilizers told me that “there’s people who can perform DRG stim, and those who unfairly question its efficacy” and that if I can’t perform DRG stim, send my focal neuropathic pain patients to someone who can.

Where do you all stand on DRG stim? I saw too many procedural issues in my fellowship that I vowed to wait until the procedure and it’s complications improved. But am I missing something with DRG stim? Have not done it myself post-fellowship.
 
cameroncarter said:
Just got home from NANS! One of the main DRG stim utilizers told me that “there’s people who can perform DRG stim, and those who unfairly question its efficacy” and that if I can’t perform DRG stim, send my focal neuropathic pain patients to someone who can.

Where do you all stand on DRG stim? I saw too many procedural issues in my fellowship that I vowed to wait until the procedure and it’s complications improved. But am I missing something with DRG stim? Have not done it myself post-fellowship.
Click to expand...
:laugh:
Haven’t done any since I got out of fellowship. Did a few in fellowship and hated them. Now I just do dorsal column, and thus far I have not run into anyone where I’ve said “the only thing that will help you is a DRG.”
 
lobelsteve said:
99% of care is new patients, follow ups, ESI, joint, MBB/RF, peripheral nerve block/RF, kypho, SCS.
Click to expand...
and 95% of that is New patients, Office visits, ESI, MBB/RF. Many many docs only do these procedures and nothing "advanced" or non-spine. Some don't even do necks.

Magnus Acus said:
I'm a PM&R resident going pain and I feel like I speak to this topic all the time to different attendings and they stare at me like I just asked them what oxycodone is.

My future practice goals are no opioids unless palliative/cancer pain, very acute injury (surgery, compression Fx, ect), or some other RARE occurrance. I feel like when I tell people this, their response is "So what do you do for the 50yo w/ severe OA?" or "How does pain management not give opioids?" Which to me, is a dated take on opioids and out of touch with the opioid epidemic we are currently in. I think they expect pain to just be addiction med without the counselling.

Seem accurate or am I off base?
Click to expand...
That's because your attendings are old. Get through fellowship then practice evidence-based medicine. Opioids aren't just a time suck, they aren't effective for chronic pain.

What do you do for the 50 y/o with severe OA? Recommend physical therapy, topicals, intermittent injections, surgery, nerve blocks/RF.

cameroncarter said:
Just got home from NANS! One of the main DRG stim utilizers told me that “there’s people who can perform DRG stim, and those who unfairly question its efficacy” and that if I can’t perform DRG stim, send my focal neuropathic pain patients to someone who can.

Where do you all stand on DRG stim? I saw too many procedural issues in my fellowship that I vowed to wait until the procedure and it’s complications improved. But am I missing something with DRG stim? Have not done it myself post-fellowship.
Click to expand...
I didn't do DRG in fellowship, but do in private practice. It's been great for focal neuropathic pain. I don't think it works any better than dorsal column overall, but it is more precise and you can avoid unintended sensations easier.
 
I've gotten really decent at DRG revisions. Done far more of them than any trials/implants. I'm just not seeing as much CRPS in the knee secondary to osteoarthritis as everybody else, I suppose.

It's also amazing how they say it's for "focal neuropathic pain" yet most of these patients have 4 leads in their back.
 
lobelsteve said:
Our field is a joke of pretend surgeons, KOLs, and I do it my way superstars.

Buy the SIS Guidelines.
Read the SIS Guidelines.
Do the SIS Guidelines.

If there is not an independent study on new devices/procedures, consider yourself a pioneer and doing human experimentation.
If you would not do the procedure on your mother, do not do it on your patients.
My salary cap was bumped up $100k this year.
Someone tell me what type of new shoes to get (beside the 1080s)
Click to expand...
1883 Luccheses
 
DRG-S is not for everyone. I mean both patients and docs. But it absolutely is indicated for the crps patient in the right hands. Follow the evidence…
 
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