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ctts

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I apologize if this has been discussed already, but did not quite find a thread in our forum that directly addresses this.

Any thoughts on hiring NP v. PA for a private practice pain clinic? Perhaps there are different regulations depending on which state...I am in MA.

Also, I am under the impression that most here are against NPs or PAs doing procedures, especially if trying to operate independently, which is understandable, but what if the NP or PA is in your practice? I know a local ortho group with lots of PAs who do ultrasound guided shoulder/hip/knee injections. Could I consider training my NP or PA to do fluoro guided peripheral joint injections? I don't think I would feel comfortable training them to do facets or ESIs, but I think I would be ok with SI joints. Are these procedures reimbursable if done by NP or PA?
 

PinchandBurn

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I apologize if this has been discussed already, but did not quite find a thread in our forum that directly addresses this.

Any thoughts on hiring NP v. PA for a private practice pain clinic? Perhaps there are different regulations depending on which state...I am in MA.

Also, I am under the impression that most here are against NPs or PAs doing procedures, especially if trying to operate independently, which is understandable, but what if the NP or PA is in your practice? I know a local ortho group with lots of PAs who do ultrasound guided shoulder/hip/knee injections. Could I consider training my NP or PA to do fluoro guided peripheral joint injections? I don't think I would feel comfortable training them to do facets or ESIs, but I think I would be ok with SI joints. Are these procedures reimbursable if done by NP or PA?
Not a good idea.

Spine is outside of the scope of NP/PA
 
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RoloTomassi

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Def not SIJ. Other peripheral joints are such quick and easy procedures for us--do you benefit that much from the time savings to have a midlevel do it? I guess it depends on your procedure mix but my fluoro joint:spine ratio is like 1:30
 
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Agast

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When I visit the PCPs for my marketing tours, I always mention I don't have a midlevel so their patient is always getting 1:1 time with me.

I guess in the future I'll update that to "and I'll always be the one doing their procedures."

Are you really seeing enough SI joint pain-only patients that it makes it worth it? Sounds like your patients will see an uptake in unnecessary SI joint injections.
 
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Gnarvin

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I am strongly against midlevels doing any procedures outside TPI. It could be a recipe for disaster for our field to allow scope creep. First they do knees and shoulders, then they say hey if I can do those why not SI, then if I can do SI why not ESI, I can do an ESI why can’t I do a stim trial, etc.

There is a pain doc in a neighboring city that I used to send some of my patients to if they were looking to move to that city or whatever. I found out he is training a PA to do pain procedures and now I will never send a patient his way again.
 
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swamprat

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Have a CRNA - nice guy, only does anesthesia now. Anyway when he was in NJ he was doing Kypho etc under MD supervision. Ridiculous. He is older could be my dad but still...
 
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clubdeac

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I apologize if this has been discussed already, but did not quite find a thread in our forum that directly addresses this.

Any thoughts on hiring NP v. PA for a private practice pain clinic? Perhaps there are different regulations depending on which state...I am in MA.

Also, I am under the impression that most here are against NPs or PAs doing procedures, especially if trying to operate independently, which is understandable, but what if the NP or PA is in your practice? I know a local ortho group with lots of PAs who do ultrasound guided shoulder/hip/knee injections. Could I consider training my NP or PA to do fluoro guided peripheral joint injections? I don't think I would feel comfortable training them to do facets or ESIs, but I think I would be ok with SI joints. Are these procedures reimbursable if done by NP or PA?
you know ctts, I was wondering the same thing. And then I started thinking. Why hire an NP/PA to do my joint injections for $120k when I can just teach my medtech to do it? You know what I mean? They're easy enough and he knows his anatomy from dictating all my charts and watching me over the years. And he only costs me $30k a year. Once he gets the hang of that, I'll probably have him move to epidurals and hopefully stim.

Thanks for the ideas! 🤦‍♂️
 
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DrSpine

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Would you want a PA or NP injecting you, your parents, or loved ones? If the answer is no, then it's no for others. I don't trust an NP or PA, and typically when I am at an office and get them, I demand to see the Doctor or leave. Midlevels are only good for simple follow ups. Not for initial consult, not for procedures, etc.
 
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ctts

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In general, I agree with the above, that's why I have been doing everything myself the last 10 years. It's just getting hard to keep up with the volume, so just trying to explore ways to deal with it. Hiring another MD is not an option. I don't think I would have considered having an NP or PA do procedures, but the large ortho group here does that, and the local hospital even has a Radiology Assistant doing ultrasound guided musculoskeletal injections. I suppose just because others are doing it doesn't mean I should follow suit, but it just did make me wonder. (I have to admit the procedures notes from the PA performed injections at the ortho group are terrible...for example, it says "shoulder was injected" but I have no idea if they mean subacromial or glenohumeral, and likewise for hip, whether it was bursa or intraarticular.)

If NP or PA sees follow-ups for you, do you allow them to decide on the plan for the next procedure? And then you perform the procedure at the next visit based on your NP or PA's plan? Or do you reevaluate them again before deciding on the procedure? I would have a hard time trusting NP or PA to decide on the next procedure...and if I also cannot trust an NP or PA to do a simple injection procedure...what are they really good for? And if an NP or PA cannot do any procedures, then their job would be like my job, seeing pain patients all day, and talking about their pain, except without doing any procedures at all... Look, in general, I really do like my patients, and I spend a lot of time talking with them, making sure they are satisfied by the end of the visit, but if I had to do that non stop without procedures to break up the monotony of the day, I would really feel more burned out than I already do, so I cannot imagine why any NP or PA would want this kind of job, and if they took it, how can I expect them to want to stay? I guess it takes a special kind of person to truly be content in that kind of job. I figured if I let them do some basic procedures, they would be more likely to find the job more interesting and fulfilling, but I also understand the point about not wanting procedures done by non physicians.
 
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clubdeac

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In general, I agree with the above, that's why I have been doing everything myself the last 10 years. It's just getting hard to keep up with the volume, so just trying to explore ways to deal with it. Hiring another MD is not an option. I don't think I would have considered having an NP or PA do procedures, but the large ortho group here does that, and the local hospital even has a Radiology Assistant doing ultrasound guided musculoskeletal injections. I suppose just because others are doing it doesn't mean I should follow suit, but it just did make me wonder. (I have to admit the procedures notes from the PA performed injections at the ortho group are terrible...for example, it says "shoulder was injected" but I have no idea if they mean subacromial or glenohumeral, and likewise for hip, whether it was bursa or intraarticular.)

If NP or PA sees follow-ups for you, do you allow them to decide on the plan for the next procedure? And then you perform the procedure at the next visit based on your NP or PA's plan? Or do you reevaluate them again before deciding on the procedure? I would have a hard time trusting NP or PA to decide on the next procedure...and if I also cannot trust an NP or PA to do a simple injection procedure...what are they really good for? And if an NP or PA cannot do any procedures, then their job would be like my job, seeing pain patients all day, and talking about their pain, except without doing any procedures at all... Look, in general, I really do like my patients, and I spend a lot of time talking with them, making sure they are satisfied by the end of the visit, but if I had to do that non stop without procedures to break up the monotony of the day, I would really feel more burned out than I already do, so I cannot imagine why any NP or PA would want this kind of job, and if they took it, how can I expect them to want to stay? I guess it takes a special kind of person to truly be content in that kind of job. I figured if I let them do some basic procedures, they would be more likely to find the job more interesting and fulfilling, but I also understand the point about not wanting procedures done by non physicians.
Your logic is baffling. You're deliberating over how a PA/NP could stand to do pain without actually doing procedures? Well you've got two solutions. A) They could go to med school or B) you can train your replacement.
 
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nvrsumr

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I can empathize with ctts’s conondrum. He is held to a higher standard the the hospital down the street that is reimbursed 5x his clinic. It’s a business.
 

RoloTomassi

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I don't have a midlevel because I don't really trust them to do injections or make decisions on what type of injection for me to do. Stable, chronic med mx with close supervision is really the only thing I see them doing. If you work on your efficiency and have good scribes, MAs, scheduler, secretary, you can just be the doctor and be productive.

For your joint injections, if they are positioned, prepped, draped, ultrasound sterilized and ready, injections and gloves laid out, you can walk in the room, inject and be out in few minutes.
 
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Ducttape

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there are benefits towards having a midlevel.

the primary benefit is so that they can decompress your volume of those patients that are "regular" who do not require a lot of insight or aggressive treatment.

best example are those patients that you do an SI injection 2-3 times a year, someone that you RFA every 8 months or so, or those patients that you may follow long term on a neuromodulator or NSAID, for example someone that you cannot get the PCP to take over meds.

there is a huge range as to what NPs and PAs want to do. many are happy with just seeing patients, and do not find the injections themselves "fun". that might be a construct that we as pain doctors are uniquely blessed to not only be able to perform but also have an interest in.

in my career, the only NPs i had clamoring to do procedures were those that worked with me in the ER. only about 1/3 of ER midlevels really loved doing procedures.

i know that almost every single ortho clinic in the area allows PA/NPs to do extremity injections. that appears to be the local standard of care. i have suggested to NPs i have worked with that they could get certified by myself, but would have to have me directly supervise 25 separate injections. (or 50, if they are very eager.)

no one has taken me up on that offer.
 

GandalfTheWhite

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Your logic is baffling. You're deliberating over how a PA/NP could stand to do pain without actually doing procedures? Well you've got two solutions. A) They could go to med school or B) you can train your replacement.

there are benefits towards having a midlevel.

the primary benefit is so that they can decompress your volume of those patients that are "regular" who do not require a lot of insight or aggressive treatment.

best example are those patients that you do an SI injection 2-3 times a year, someone that you RFA every 8 months or so, or those patients that you may follow long term on a neuromodulator or NSAID, for example someone that you cannot get the PCP to take over meds.

there is a huge range as to what NPs and PAs want to do. many are happy with just seeing patients, and do not find the injections themselves "fun". that might be a construct that we as pain doctors are uniquely blessed to not only be able to perform but also have an interest in.

in my career, the only NPs i had clamoring to do procedures were those that worked with me in the ER. only about 1/3 of ER midlevels really loved doing procedures.

i know that almost every single ortho clinic in the area allows PA/NPs to do extremity injections. that appears to be the local standard of care. i have suggested to NPs i have worked with that they could get certified by myself, but would have to have me directly supervise 25 separate injections. (or 50, if they are very eager.)

no one has taken me up on that offer.

isnt the main point of having NPs/PAs to see the follow-ups/med refills/ and patients that need a lot of TLC? No idea why you would want to supervise a PA/NP doing a procedure when you can do it yourself faster.
 
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