Outpatient PM&R

[DOstudent22]

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What kinds of procedures do 100% outpatient PM&R docs perform, besides EMG and trigger point injections?? I'm curious because ideally I would like to practice outpatient PM&R, but what does a practice like that entail?

Also, if anyone in practice knows, how much do physiatrists make off of procedures like EMG and trigger point injections??

And is it difficult to have an outpatient practice if neurologists can do EMG, PCP's and anaesthesoloigists do injections?

 

[Finally M3]

Other injections include:

Occipital nerve blocks
Joint injections (steroid mostly, some hyaluronic acid for knees & possibly shoulders), from major such as knees, shoulders, to minor such as AC joint
Bursae injections (trochanteric, subacromial)
Epidondyle injections
Tendonosis/itis injections
All the lovely fluoro-guided procedures

I don't know what the RVUs are, but in general, trigger points don't pay for a whole lot (about a level 4 F/U I think), but EMGs + NCV pay a lot (think 3-4 figures depending on how many limbs/nerves you do).

Not difficult as long as you settle in the right referral pocket. Lots of PCPs will ship out all MSK problems, for some reason, they don' like to deal with them.

 

[PMR 4 MSK]

A good rule of thumb is - if it can be reached by a needle without fluoro, PM&R can do it most of the time (joints, nerves, tendons, ligaments, muscles, etc). For the fluoro procedures, you may get to do enough to get credentialled at some residency programs, not at others. To do the major procedures (pumps, stims, IDET, discograms) you should have a fellowship in pain.

EMGs depend on the payor - If you did a single limb with, say 2 motors and 3 sensories with aneedle exam - Medicaid pays virtually nothing, Medicare might pay about $300/limb, HMO's might be a little more, PPO's upwards of $500 - $750/limb, and work comp could be a little more.

My average in-office procedure pays around $100, fluoro around $350 in a surgery center. You'll get more if you get your own flouro in-office.

We have turf battles with many other professions, but we fill a unique niche - we can do many things that would take several other doctors to do.😀

 

[stretch210]

Instead of starting a new thread, I thought I would ask on this thread titled outpatient PM&R...

which residency programs are notorious for strong outpatient MSK PM&R reputations and experience? What does this include exactly with regards to the training?

Thanks.

 

[ampaphb]

A good rule of thumb is - if it can be reached by a needle without fluoro, PM&R can do it most of the time (joints, nerves, tendons, ligaments, muscles, etc). For the fluoro procedures, you may get to do enough to get credentialled at some residency programs, not at others. To do the major procedures (pumps, stims, IDET, discograms) you should have a fellowship in pain.

While I know I am gonna get flamed for this, I do not believe a PM&R or anesthesia physician should be doing ANY interventional spine procedures (and yes, I include lumbar interlaminars in this list) without a fellowship.

Yes, lots of people do them with just weekend courses, but it is indefensible in court when something goes awry.

You say you did 200 in residency? Well, let's start with how many did you actually do, as opposed to watch, or assist. And of those you actually did, I'm sure some were transforaminal, and others were caudal. How many were S1, L5, or L4? How many had instrumentation in the way, or large osteophytes you had to work your way around? And lets not even get started about doing cervical procedures.

Worse still, how many had things go wrong? and did you figure out how to avoid those in future with the benefit of a mentor in the room to get you out of trouble? How many were taught to you by staff who barely knew what THEY were doing?

In short, these are procedures that are easy when they go well, and can be fraught with difficulty when they don't. The groups who tell you they will train you, or worse still, the ones who just let you lose on their patients are just in it for the money.

You might let a general orthopod do your carpal tunnel release, but I would rather have a hand surgeon do mine. I would also rather have a fellowship-trained interventionist do my Mom's caudal, even if you did do a few in residency

 

[Disciple]

To do the major procedures (pumps, stims, IDET, discograms) you should have a fellowship in pain.

Anybody else find transforaminals just as difficult if not more than discograms?

 

[Disciple]

While I know I am gonna get flamed for this, I do not believe a PM&R or anesthesia physician should be doing ANY interventional spine procedures (and yes, I include lumbar interlaminars in this list) without a fellowship.

Yes, lots of people do them with just weekend courses, but it is indefensible in court when something goes awry.

So, would you say that our standard for residency training is too low?

Is the standard for training in interventional procedures the fellowship model only because it is the current accepted model?

A comparison can be made with our EMG training vs. Neurology EMG training. 20+ years ago when PM&R residencies ended upon completion of PGY-3, I'm sure many programs had sub-standard EMG training. The bar has since been raised and a Physiatrist performing EMGs would be defensible in court. During an expected transition period when programs are brought up to snuff, I would propose a pathway either through residency or fellowship, given that the proper standards are met.

E.g. Neurology-Neurophys fellowship PM&R-No EMG fellowship
Ortho-Spine fellowship Neurosurg-No fellowship
Anesthesia-Pain fellowship PM&R-Pain fellowship/Spine fellowship or No fellowship (given that training stardards
are uplifted)

 

[ampaphb]

Anybody else find transforaminals just as difficult if not more than discograms?

I did not say that.

 

[Disciple]

I did not say that.

I was referring to myself.

 

[lobelsteve]

While I know I am gonna get flamed for this, I do not believe a PM&R or anesthesia physician should be doing ANY interventional spine procedures (and yes, I include lumbar interlaminars in this list) without a fellowship.

Yes, lots of people do them with just weekend courses, but it is indefensible in court when something goes awry.

You say you did 200 in residency? Well, let's start with how many did you actually do, as opposed to watch, or assist. And of those you actually did, I'm sure some were transforaminal, and others were caudal. How many were S1, L5, or L4? How many had instrumentation in the way, or large osteophytes you had to work your way around? And lets not even get started about doing cervical procedures.

Worse still, how many had things go wrong? How many were taught to you by staff who barely knew what THEY were doing?

In short, these are procedures that are easy when they go well, and can be fraught with difficulty when they don't. The groups who tell you they will train you, or worse still, the ones who just let you lose on their patients are just in it for the money.

You might let a general orthopod do your carpal tunnel release, but I would rather have a hand surgeon do mine. I would also rather have a fellowship-trained interventionist do my Mom's caudal, even if you did do a few in residency

Hope your mom is feeling better. 😀