Pain Medicine Fellowships & EMGs

[JBM16BYU]

I'm a current PM&R resident interested in pain medicine. I am also interested in the ABEM board certification in electrodiagnostic medicine. To y'all's knowledge, which pain fellowships allow the PM&R fellows to continue to practice EMG's, as to prevent skill loss? Thanks in advance.

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[Peterluger]

Probably all of them. Anesthesiologists are such weak people that they sold out Pain years ago to other specialties decades ago. Thats why anesthesiology-run Pain fellowships are now chock full of PM&R fellows

 

[SommeRiver]

Probably all of them. Anesthesiologists are such weak people that they sold out Pain years ago to other specialties decades ago. Thats why anesthesiology-run Pain fellowships are now chock full of PM&R fellows

LOL

 

[paindoc007]

Errrr. Anesthesiologists are weak bc they sold out ANESTHESIA decades ago, and now crna’s do all of it. Pain has been and should always be multi-disciplinary. We all bring something to the table.

 

[Peterluger]

Errrr. Anesthesiologists are weak bc they sold out ANESTHESIA decades ago, and now crna’s do all of it. Pain has been and should always be multi-disciplinary. We all bring something to the table.

Pain is part and parcel of anesthesiology. anesthesiologists sold off the whole package. They sold off anesthesia, which by definition includes interventional pain.

Other specialties, especially surgical specialties, have much larger genitals than Anesthesiology physicians. Surgeons only interaction with nurses is to tell them what to do (unlike many anesthesiologists who let circulator nurses and scrub nurses insult them all day) and on top of that, have been much more successful in NOT farming things out to other specialties. IR is not doing any breast or penis implants as far as i know

 

[SommeRiver]

Pain is part and parcel of anesthesiology. anesthesiologists sold off the whole package. They sold off anesthesia, which by definition includes interventional pain.

Other specialties, especially surgical specialties, have much larger genitals than Anesthesiology physicians. Surgeons only interaction with nurses is to tell them what to do (unlike many anesthesiologists who let circulator nurses and scrub nurses insult them all day) and on top of that, have been much more successful in NOT farming things out to other specialties. IR is not doing any breast or penis implants as far as i know

You have a very uneducated opinion and must be a fellow running an acute pain service for the week.

 

[Peterluger]

You have a very uneducated opinion and must be a fellow running an acute pain service for the week.

Possibly

 

[Baron Samedi]

Pain is part and parcel of anesthesiology. anesthesiologists sold off the whole package. They sold off anesthesia, which by definition includes interventional pain.

Other specialties, especially surgical specialties, have much larger genitals than Anesthesiology physicians. Surgeons only interaction with nurses is to tell them what to do (unlike many anesthesiologists who let circulator nurses and scrub nurses insult them all day) and on top of that, have been much more successful in NOT farming things out to other specialties. IR is not doing any breast or penis implants as far as i know

For someone so obsessed with large genitals you sure seem to have some SDE going on.

 

[JBM16BYU]

So all that being said, serious question. Are there particular pain fellowships that allow you to continue to do EMG's throughout your fellowship training?

 

[PainRehabMD]

So all that being said, serious question. Are there particular pain fellowships that allow you to continue to do EMG's throughout your fellowship training?

West LA VA/UCLA will have you do EMG for some rotations. This is a different program from the UCLA one.

A year without EMG shouldn't make you lose your skills. You'll just be a little rough getting back into it.

 

[nvrsumr]

BWH bought an emg machine for their pmr fellow and had a neurologist on staff in the pain clinic who did a lot of Emg guided Botox. Was a long time ago though.

 

[Ronin1]

So do any of you guys actually do EMGs in practice? As an anesthesia trained guy I just don’t see much utility on a regular basis for this exam.

 

[BobBarker]

I refer out all the time on carpal tunnels for EMG. If you can do it yourself then more power to you.

 

[nynydoc]

PMR Here in Practice and future pain fellow (despite the comments, it was an uphill battle and many of my mentors are great leaders in the field)

EMGs have a good utility when performed correctly. Sadly, most of the time there is something wrong and having been in private practice, you realize medicine docs family docs PTs and Chiropractors perform these and even some neurologist and PMR docs pretty much over call a lot of pathology. Specifically for pain, I used it for ruling in and ruling out nerve entrapments, combining it occasional blocks, and overall gives the patient a concrete diagnosis when imaging, correctly done EMG, and interventions weigh in on it. In addition, I love using the needle examination to look for active denervations. It gives me a better picture on how much the radic is causing potential nerve breakdown and this gives patients informed decisions as to surgical options vs staying conservative.

Just my 2 cents.

 

[Ronin1]

Is EMG actually reimbursements at a reasonable rate for you guys that do it? It would seem to be not as good financial use of your time if you are a busy interventionalist

 

[nynydoc]

If you’re a busy interventionalist, I would assume not financially worth it unless you pack your schedule with it. A good study (I’m quick), is about 20-30 minutes but often if you start getting a neuropathy work up- geez that sucks and it takes a while to do (a good study). If you have a good tech that does NCS well, you can do the needle study and run two rooms at the same time.

As far as reimbursement- depends on the carrier but I usually calculate around 175-250 for an upper limb, possibly towards 300 with bilateral studies? Don’t quote me on this.

There’s another thread on this but I saw OON reimbursement return with over 1K.

Pack up your day with at least 10 studies and probably can see $1500-2000 for the day.

I personally hope to continue EMGs in my future practice for the above reasons but we’ll see how it goes then. For the OP- I personally don’t see the benefit of the added board certification. You’re already way more qualified out of residency than general neurologists coming out to do them. The other specialists that are amazing with EMG are neuromuscular trained neurologists. They are a great resource to have.

 

[Taus]

I was very comfortable doing emg after Pm&r residency. I had the same goal of not being too rusty on them after a year in pain fellowship. I used 2 weeks of my elective time towards the end fellowship to brush up on them before going into a practice. I looked into spending that time with the neurology or pmr dept at my fellowship. I ended up going back to my residency program for this. Way more independence with my old attendings then being an outsider with brand new attendings.

 

[PainApp2021]

So do any of you guys actually do EMGs in practice? As an anesthesia trained guy I just don’t see much utility on a regular basis for this exam.

A question opposite to this thread: I'm a PMR PGY3 and actively do not want to do EMGs in future practice assuming I get accepted into a pain fellowship. Is it safe to say that most programs don't focus on these? Would an ortho private practice expect a PMR pain grad to do EMGs plus interventions?

 

[bedrock]

A question opposite to this thread: I'm a PMR PGY3 and actively do not want to do EMGs in future practice assuming I get accepted into a pain fellowship. Is it safe to say that most programs don't focus on these? Would an ortho private practice expect a PMR pain grad to do EMGs plus interventions?

Safe to say that 99% of pain fellowships do not require EMGs during the fellowship.

You don’t need to do EMGS in two of three main types of pain positions in america, hospital employee, or part of a pain group.

The third main type of pain position is to work for an orthopedic group and the vast majority of ortho groups hire a PMR/Pain physician, not a anesthesia/pain physician, specifically because they want a pain physician who also does EMGs.

 

[DubVille]

I do about 6-10 EMGs a week, basically block 1 day off for it. Never planned on doing emg but there is very little offered in my location. Key for PMR folk is hand surgeon groups, they can keep you busy with bread and butter cases (mostly).

I rarely order EMG myself. Partner orders them constantly as a "nonsense pain rule out" which I discuss over and over isnt what it's for. Usually I think he is hoping I will take them over. Also get alot of 80-90 year old, chf with edema, lower extremity, morbidly obese, etc cases from PCPs. I usually do extremely limited study or state it's not going to be helpful.

Great thing about them can be new patient visits plus EMG. If its Normal I usually say I need to look over and FU with referring doc and that's it. May transition over time to doing more if I can and doing 2 days a week part time as I phase out of practice and patient continuity (it will be a long way). I dont have a tech, may consider it but NCV can be tricky at times and I dont trust anyone else yet, sometimes I question myself.

 

[Bostonspine]

Safe to say that 99% of pain fellowships do not require EMGs during the fellowship.

You don’t need to do EMGS in two of three main types of pain positions in america, hospital employee, or part of a pain group.

The third main type of pain position is to work for an orthopedic group and the vast majority of ortho groups hire a PMR/Pain physician, not a anesthesia/pain physician, specifically because they want a pain physician who also does EMGs.

I just took a job like this will most likely limit it to internal referrals from hand and spine. In our area the wait for an EMG is 6-8 weeks

 

[Baron Samedi]

Honestly I just don't know how EMG contributes specifically to Pain Medicine. I don't do them because I don't think they contribute much to my aspect of patient care. Almost all my clinical decision making is based on symptomology, imaging, and physical exam.

 

[Bostonspine]

Honestly I just don't know how EMG contributes specifically to Pain Medicine. I don't do them because I don't think they contribute much to my aspect of patient care. Almost all my clinical decision making is based on symptomology, imaging, and physical exam.

Mostly if your concern for peripheral compression or neuropathy, but otherwise not needed. As alluded above in an ortho group where your seeing more than Spine it can be complementary

 

[Baron Samedi]

Mostly if your concern for peripheral compression or neuropathy, but otherwise not needed. As alluded above in an ortho group where your seeing more than Spine it can be complementary

Yeah, in which case it's helping others make decision and not myself. I agree in an ortho group it may be helpful.

 

[Taus]

Exactly. Ortho group. I rarely order my own emg. History physical and imaging generally all that’s needed in spine. Occasionally sent to me by pcp for spine eval and I suspect carpal or cubital tunnel. Or a rare parsonage turner. I’ll send out peripheral neuropathy, myopathy, motor neuron etc workups to neurology. otherwise mainly internal referrals from hand surgeons, some spine, an occasional traumatic peripheral nerve injury or other rare entrapment. I don’t mind doing them. A mental break/change of pace from clinic. I think pays somewhere in the middle between clinic and fluoro procedures.

 

[Crybaby]

So do any of you guys actually do EMGs in practice? As an anesthesia trained guy I just don’t see much utility on a regular basis for this exam.

I do EMG's. I did not plan on it, but it was great as it kept me busy while ramping my own practice up. The problem is- it keeps me too busy and typically do not help me fill my schedule for injections. I have continued to do them as a way to keep a few neurosurgeons and ortho guys pleased.

It has been good to keep up anatomy, innervation, functions as well. I have had a few weird cases lately, which can really drain time.

 

[SSdoc33]

i find i look forward to my EMG 1/2 days more than my spine days. it really is nice to mix things up a bit. if you get good at them and can be fast, they are a money maker -- not on the order of spine injections, but like was previously stated, more $$$ than clinic

 

[cbest]

Don’t worry about not doing EMGs for your fellowship year. If your job out of fellowship requires you to do EMGs, spend a little time brushing up and start with a few easy CTS cases then build back from there. It’ll come back to you pretty quickly.

 

[bedrock]

i find i look forward to my EMG 1/2 days more than my spine days. it really is nice to mix things up a bit. if you get good at them and can be fast, they are a money maker -- not on the order of spine injections, but like was previously stated, more $$$ than clinic

Exactly. Ortho group. I rarely order my own emg. History physical and imaging generally all that’s needed in spine. Occasionally sent to me by pcp for spine eval and I suspect carpal or cubital tunnel. Or a rare parsonage turner. I’ll send out peripheral neuropathy, myopathy, motor neuron etc workups to neurology. otherwise mainly internal referrals from hand surgeons, some spine, an occasional traumatic peripheral nerve injury or other rare entrapment. I don’t mind doing them. A mental break/change of pace from clinic. I think pays somewhere in the middle between clinic and fluoro procedures.

You guys must be fasting than me with EMGs. Ever since the big EMG rate cute in 2012, I find that I am paid about as much for an EMG as I am for an office visit (and office visits also generate procedures)

How fast on average ( not on the ideal patient) do you guys do a carpal/cubital tunnel EMG? Or a full unilateral UE EMG for carpal, cubital, radiculopathy? (I typically don't do a needle exam on patients without any neck symptoms)

 

[DubVille]

For a new patient level 3 (sometimes level 4) and unilateral full emg ncs with 5 ncs and full needle testing it takes 45 min. Maybe 1 hr.

I tend to combine exam and some history as I do the procedure.

 

[Crybaby]

For a new patient level 3 (sometimes level 4) and unilateral full emg ncs with 5 ncs and full needle testing it takes 45 min. Maybe 1 hr.

I tend to combine exam and some history as I do the procedure.

Do you bill for new patient and NCS/EMG, I just usually bill the latter

 

[Taus]

I do 40 mins for all. Some unilateral take less, some bilateral
or complex take longer. Balances out. I bill emg/ncs only. No E&M.

 

[DubVille]

I bill an e&m especially if I order a brace, imaging, etc. Its always paid out.
I do the ncv and needle, and a history to start/physical. Usually get more details as I do the study and talk to them. If I had to stop billing e/m that would hurt.

 

[SSdoc33]

30 minutes / study. needle on everyone. you would be surprised how many radiculopathies can masquerade as CTS. there is nearly always a case for the needle, IMHO.

ill bill an e/m if it is a f/u patient of mine and i do some management, or if a separate consult is ordered at the same time. maybe 25% of the time

 

[jonnylingo]

bilat or single limb EMG, 30 min.
Generally all NCS get EMG as well for reasons SSdoc33 outlined.
40-50 studies/week.
I have a tech performing NCS.
Bill E/M if it's my patient (rare, I may order a study on one of my patietns 1-2x/mo) or consultation is requested. ~10% of time.

 

[SSdoc33]

bilat or single limb EMG, 30 min.
Generally all NCS get EMG as well for reasons SSdoc33 outlined.
40-50 studies/week.
I have a tech performing NCS.
Bill E/M if it's my patient (rare, I may order a study on one of my patietns 1-2x/mo) or consultation is requested. ~10% of time.

You mean 40 to 50 studies/ month?