need private practice attending input please

[Jeff05]

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hi,
i'm a ca2 applying for pain. have 2 choices - 1. my home program, big academic center, which is pretty good, getting better by the month. enough clinic and bread and butter procedures to go around vs 2. an academic powerhouse program that does lots of cancer pain and pumps/stims and other "hot" stuff...

i would like to go out into the community and, at least in the beginning, practice a mix of pain and anesthesia. with time i think i may transition to 100% pain...

so, which program would you recommend. when looking at potential employees, how important is it to have the "best" fellowship training?

 

[Pain_doc]

I'd recommend getting the best training available. Secondly, it is hard to practice "full-service" pain and perform OR anesthesia. You can't be slave to two masters.

 

[Mister Mxyzptlk]

It's easier to fall back to bread and butter things than try to learn the fancy stuff once you're out of training. As Gene Krantz, the flight director of Apollo 13 said, "Aim high!"

 

[Aether2000]

Anesthesiology and Pain Medicine are two dissimilar specialties that are not fungible, nor do they have the same character, flavor, or practice parameters. They are only vaguely related to one another. Being an excellent anesthesiologist does not in any way translate into being a good pain physician.
Select one or another early and save yourself the grief later.

This is exactly what nurse anesthetists do not understand- pain medicine /pain management of the chronic pain patient has little to do with their OR/OB practice.... That is why the errantly believe that chronic pain and especially interventional pain is simply an extension of the CRNA practice...they don't know enough to know what they should know.....

 

[Jeff05]

algosdoc, i disagree with you, a little bit.
i think anesthesiology and pain management are intimately related. my entire residency is spent managing acute pain (OR, PACU, ICU) pharmacologically, putting in epidurals, spinals, multiple nerve blocks (working with your hands nonstop - refining fine motor needle skills), acting as a consultant service, etc...an anesthesiologist has an almost visceral understanding of pain pathways and pharmacology of drugs before ever starting a pain fellowship.

but, anyway. what i'm hearing is - go for the gold and choose something and stick with it.

it's hard to do that though. i mean i've done a bunch of electives in pain - starting in med school. so i like it enough to do a fellowship in it and really explore it, but not sure i like it enough to do it, exclusively, for the rest of my life.

 

[Aether2000]

I could not possibly disagree more. The use of blind unguided techniques of local anesthetic delivery for the purpose of acute pain relief, whether in the OR or OB has virtually nothing to do with the skills required for fluoroscopic precision guided anatomically and pathology defined injections in the chronic pain patient. The vast majority of pain physicians do not treat post op pain, obstetrical pain, nor do we engage in regional or axial anesthesia for temporary anesthesia. These techniques are useless to us and to the chronic pain patients that have experienced pain for years. A 3 hour period of anesthesia does little to further the amelioration of nociceptive input, pain perception, or functional restoration in those that may experience chronic pain for the next 30 years. The diagnostic skills, surgical skills, clinical acumen, clinic operational and management skills, and focus on chronic patients that return monthly are virtually diametrical opposites to those skills needed for the administration of anesthesia in the OR or OB setting. The gulf between the practice of anesthesiology and pain medicine widens even more every year as pain medicine undergoes metamorphasis into its own residency program. That will be a significant improvement over the current fellowship training, that in itself is a monumental improvement over CRNA chronic and interventional pain non-training. Whereas 25 years ago, pain medicine was simply an extension of anesthesiology, it is today a separate entity, not better or superior than anesthesiology, but is a sui generis medical specialty.

 

[Jeff05]

ok, they're different.

 

[Mister Mxyzptlk]

ok, they're different.

C'mon Jeff, mix it up a little with him!

I don't see anything wrong with taking a taste of things to see what you want to do. I have practiced critical care, gas, hyperbaric medicine and pain management in a mix of academic and private settings.

For most of my career I wore two or more hats, being the sort of person who likes to do different things. It was very hard to be in the O.R. and run a pain clinic with an office. I also felt that I was only doing each specialty at 90% of my skill potential. Then there are the politics with the people in the group who are doing just gas - call, expenses, dividing the money, etc. I finally opted for full time pain. I know others who made the opposite decision.

In the final analysis I agree with algos. I really don't recommend a mix of pain and gas as a long term plan, but if you have to do it to see what you really want then go for it.

 

[lobelsteve]

Algos is spot on.

As for the flip side:

PMR and Pain- as the lurkers are out there...

Inpatient rehab is akin to watching paint dry. TBI, CVA, Peds rehab, Prosthetics/Orthotics, Burn, Cardiopulm are useless for Pain.

EMG, Msk, SCI, Modalities, Ortho/Rheumm and Physical Diagnosis have been invaluable in correlating the history, physical, and imaging into a treatment plan that best benefits the patient. Needle skills are program dependent and surgical skills are taught in Pain fellowships and surgical internships. The weakness in PMR training is more program dependnent. The folks comingout of Mayo know how to read their own MRI's, where some others think it is just a piece of paper with what the radiologist tells you. None of the PMR docs are worth their salt in a code without further training.

Pain is Pain. We are not the bastard stepchild of Neurology, Anesthesiology, Physiatry, or Nursing. The income generated by the departments in academic centers with chairmen that sit in lofty positions with the ABMS, ACGME, ABA, etc will attempt to politically destroy necessary changes like the creation of a Pain residency as it would not financially benefit their departments. For some folks, it all comes down to money.

 

[Aether2000]

Jeff, my point is not to discourage you from pursuing anesthesiology then pain medicine if you find it interesting, but is to demonstrate the dichotomy between the professions that were amalgamated 3 decades ago. The CRNAs performing OR and OB anesthesia are self deluded into thinking interventional pain or comprehensive pain is merely a weekend course away from their CRNA schooling, that has in itself no interventional pain training and very little comprehensive training. Having observe CRNAs with reasonably good regional anesthesia skills pith the spinal cord of cadavers repeatedly under fluoroscopic guidance gives one great trepidation about the translation of blind skills into that of those of an interventional pain physician. The specialty of pain medicine has little to do with anesthesiology and is far removed from CRNAs that pay $2200 and spend one weekend to learn an entirely new specialty.

 

[drusso]

I would agree that there is no single best "path" or base specialty. You have to do the specialty you enjoy. Once you're competent in that domain, you need to "mix it up" and get as much elective experience and multi-disciplinary training as possilbe.

Coming from a strong physiatry background, an anesthesia-based pain fellowship was very valuable to me. If you come from an anesthesia background with strong regional skills, you might try to look for a more multidisciplinary fellowship.

I think what is *REALLY* lacking from all of the traditional base specialities is more meaningful exposure to surgical management of pain. I wish that I had more electives and time to work with spine surgeons and neurosurgeons...Sometimes I wish I had a better understanding of how they think or don't think about pain...

 

[Jeff05]

how important is placement of pumps and stims to a successful pain management practice?

 

[Ligament]

For financial success, probably low importance. For patient care, of variable importance. It really depends on what type of overall armamentarium you have for pain treatment.

how important is placement of pumps and stims to a successful pain management practice?

 

[ParaVert]

For financial success, probably low importance.

I really have to disagree with you there. As narcopushers and depopushers become more commonplace, it is increasingly important to distinguish yourself from the other quacks on the block. Take my situation for example. There are four guys in my town (population ~ 40k "city", 100k county/outskirts) doing pain. One guy is fellowship trained (but not really invasive), one guy is a Neurologist doing blind ESI's, and one guy is a burned-out FP running a script clinic.

In a typical month (eg: January, 2008), I did 2 kyphoplasties, 2 vertebroplasties, 3 stim trials, one implant (one referred to NSG, one fail), and a Gasserian RF. That is in addition to the transforaminals, cervicals, hips, knee Synvisc and other bread and butter that kept me busy.

Even though I make more $$ per month on boring spine than on fancy stuff, my ability to market myself as a hard-core interventionalist has really paid off by winning large PCP group referrals over the other pain docs who have been practicing in this town for many years.


Go for the gold, Jeff! Nobody who went to Harvard ever regretted not going to community college.

 

[Disciple]

What if you're in a major metropolitan area with an abundance of "hardcore interventionalists"?