Pain medicine after neurology?

[Aldertonghen]

I’m a neurology residency applicant curious about pain medicine. If I do go this route I was planning on doing a neuromuscular fellowship first to pick up EMG expertise (is this worth it?). How common/difficult is it for a neuromuscular neurology trained pain physician to get a job in an ortho group (vs a pmr pain physician)? Is the compensation different from the latter (assuming similar practices)?

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[TIVAndy]

If u can do the same. Pay will be same

 

[Slowpoke]

Would consider just going through PM&R instead of neurology + neuromuscular fellowship. EMG is built into our curriculum (200 is required for graduation). However, we are not trained to do muscle or nerve biopsies.

 

[Agast]

I get the sense that people don’t love doing EMG and it isn’t much of a practice builder in terms of reimbursement. If you do the same accredited pain center fellowship as everyone else I don’t think the neurology background would be seen as a minus. Everyone sends their weird stuff to neurology anyway.

 

[Aldertonghen]

Would consider just going through PM&R instead of neurology + neuromuscular fellowship. EMG is built into our curriculum (200 is required for graduation). However, we are not trained to do muscle or nerve biopsies.

Yeah, that would’ve been an easier path for sure, but I already applied to neurology (match results next week).

 

[runfastnow]

I am ignorant to neurology electives/rotations but if you can get to 100+ EMGs in residency - especially if they are bread and butter carpal tunnel, cubital tunnel, radiculopathy studies - you could be good enough for that type of study for a practice.

I would not do neurology + neuromuscular + pain fellowship. Too much training and some major part of it would go to waste.

 

[Baron Samedi]

Only reason to do all the EMG training is if you really enjoy it. The only pain docs I know that maintain that skill are employed by the VA or DoD because they aren't production based.

I can also say the amount of times I've found an EMG to be helpful in clinical decision making in Pain Management is less than 10.

The bigger challenge will be finding a fellowship open to taking a Neurologist. I'm sure they exist, but some programs are less receptive to non-traditional primary specialties.

 

[Dr. Ice]

Emgs are a waste and don’t pay anymore along with much of everything else we do. Medicine is going in the waste basket. I talked to a hand surgeon yesterday who told me cms has slashed payment for CTS release almost to the point where it may not be worth it to do anymore

 

[SSdoc33]

Emgs are a waste and don’t pay anymore along with much of everything else we do. Medicine is going in the waste basket. I talked to a hand surgeon yesterday who told me cms has slashed payment for CTS release almost to the point where it may not be worth it to do anymore

there was a time when the electrodiagnostician would get paid more than the hand surgeon to do a CTR. not sure if thats still true.

dont do a neuomuscular fellowship then a pai nfellowship. choose one. there is little crossover.

neuromuscular is weird things like myopathies, SMA, GBS, mysathenia. very little crossover with pain medicine

i actually like doing EMGs. it breaks up the monotony of spine/pain all the time, and it does give you good continuity of care. but it doesnt pay all that well. you can get pretty quick at them, tho, so its not a loss-leader

 

[Orin]

I’m a neurology residency applicant curious about pain medicine. If I do go this route I was planning on doing a neuromuscular fellowship first to pick up EMG expertise (is this worth it?). How common/difficult is it for a neuromuscular neurology trained pain physician to get a job in an ortho group (vs a pmr pain physician)? Is the compensation different from the latter (assuming similar practices)?

A lot of this depends on your planned practice situation and what you decide to focus on in terms of tools. A neuromuscular fellowship/EMG will be useless for you if you're doing kyphos/stims/spacers, but could be great if you're an ortho group's diagnostic/injection person.

You get paid more for doing more. Procedures and implants are better than medications and tests, but all of this can change tomorrow.

You should figure out where you match, and when you do, reach out to the pain fellowship director there in your PGY1 year to ask about opportunities to rotate/explore that space. I would suspect you're best off going straight into a pain fellowship from neurology but figure out what you enjoy and what you can afford to do.

 

[Aldertonghen]

I am ignorant to neurology electives/rotations but if you can get to 100+ EMGs in residency - especially if they are bread and butter carpal tunnel, cubital tunnel, radiculopathy studies - you could be good enough for that type of study for a practice.

I would not do neurology + neuromuscular + pain fellowship. Too much training and some major part of it would go to waste.

I can certainly opt for EMG electives to easily do 100-200+ in residency- but then I would have less time for pain electives- which is very crucial as a neurology applicant. But what you’re saying makes sense and I’ll try my best to avoid an extra year.

 

[Aldertonghen]

A lot of this depends on your planned practice situation and what you decide to focus on in terms of tools. A neuromuscular fellowship/EMG will be useless for you if you're doing kyphos/stims/spacers, but could be great if you're an ortho group's diagnostic/injection person.

You get paid more for doing more. Procedures and implants are better than medications and tests, but all of this can change tomorrow.

You should figure out where you match, and when you do, reach out to the pain fellowship director there in your PGY1 year to ask about opportunities to rotate/explore that space. I would suspect you're best off going straight into a pain fellowship from neurology but figure out what you enjoy and what you can afford to do.

Thank you for your advice! It would definitely be good to explore this space further in PGY1/ as early as possible. Most of the people I’ve asked regarding neurology->pain do their pain fellowship straight out of residency, and it certainly makes a lot of sense.

 

[Dr. Ice]

Unless you wanna do something academic, spending days diagnosing parsonage turner, I fail to see how EMGs make much sense to do anymore for someone interested in a pain practice. The test is not even reliable for radiculopathy and I’ve known plenty of hand surgeons who are now bypassing emg as pre-requisite to do carpal tunnel release. I’ll do it every now and then to keep skill set, cause as the other poster said, who knows..but I can’t see the reimbursement changing to be favorable. Why would it? It’s unreliable, and over utilized.

 

[Agast]

Unless you wanna do something academic, spending days diagnosing parsonage turner, I fail to see how EMGs make much sense to do anymore for someone interested in a pain practice. The test is not even reliable for radiculopathy and I’ve known plenty of hand surgeons who are now bypassing emg as pre-requisite to do carpal tunnel release. I’ll do it every now and then to keep skill set, cause as the other poster said, who knows..but I can’t see the reimbursement changing to be favorable. Why would it? It’s unreliable, and over utilized.

You’re going to miss out on that sweet sweet diabetic peripheral neuropathy stimulator money

 

[Dr. Ice]

You’re going to miss out on that sweet sweet diabetic peripheral neuropathy stimulator money

Lol..I’ll let someone take an hour to do a 3 limb study to diagnose it (aanem criteria to dx PPN) and then I’ll throw in the stim

 

[Ducttape]

forget the neuromuscular fellowship.

ingratiate yourself with the pain program at your institution. do pain medicine rotations as much as possible.

go right to pain fellowship. someone doing a different fellowship will appear to be a less viable candidate (they cant make up their minds about what they want to do etc.)

 

[mid|ine]

In PP you will definitely get paid more with a neurology specialty then PM&R from the private payers. Agree with above, no need for the neuromuscular fellowship.

 

[Aldertonghen]

In PP you will definitely get paid more with a neurology specialty then PM&R from the private payers. Agree with above, no need for the neuromuscular fellowship.

Is there any reason why a neuro trained pain physician would make more than pmr? I always thought neuro pain made the least (anesthesia the most, and pmr in the middle).

 

[Dr. Ice]

Is there any reason why a neuro trained pain physician would make more than pmr? I always thought neuro pain made the least (anesthesia the most, and pmr in the middle).

There is no standardization to this. Much of it depends on practice set up, hopd vs pp, demographics/geography, contracts etc. From a pain practice standpoint, once you have been through fellowship, you have entered the workforce, and there won’t be constant questions about your background as long as you are well trained and can provide a service. Short answer is, there shouldn’t be “a specific reason”…

 

[Orin]

Is there any reason why a neuro trained pain physician would make more than pmr? I always thought neuro pain made the least (anesthesia the most, and pmr in the middle).

You're paid what you think you accept for your services. There are variations based on how your contract is structured, what you do, and how your system makes money from your services. I would hope it to be rare that two providers from different base specialties would bill the exact same services/volumes and make dramatically different amounts at the same site of service.

Anesthesia tends towards a higher base and lower production bonuses
Physiatry tends towards a lower base and more production bonuses
Neurology I have no clue about but I assume trends towards physiatry.

Some of the trends are based on comfort with higher compensating procedures as compared to time consuming tests/interactions that don't pay.

If you enjoy talking to patients and dissecting out pathology from an exam or history, E&M doesn't pay you as much as just plugging them into a diagnostic injection algorithm. If you enjoy figuring out how to justify wires, screws, or cement in your patients, then you'll make a lot more bank for yourself or a health system.

 

[mid|ine]

Private payers reimburse different primary specialties differently. Typically they need/want neurologists on their panel more and will pay more, even though the end service (pain), may be the same.