Pain Medicine is an Official Subspecialty of Emergency Medicine

[GatorCHOMPions]

In theory, I understand wanting to supplement one's income with ED shifts as a pain attending while your practice is ramping up in HOPD vs PP setting. But after the first year (max after the second year) out as a full-time pain attending doesn't it net more to one's bottom line to work more in a pain setting? Whether this is working an extra day, becoming more efficient, offering more advanced procedures. BTW my assumptions are made on non anesthesia-interventional pain MGMA avgs and how most jobs are advertised that share what they are paying.

It can be hard and take a while to get a full patient panel, especially if you're in a saturated market and/or starting from scratch. But yes once you're full or nearly full, more Pain = more gain$.

It's a misconception that EM has the best hourly comp. My colleague who has several years on me is bringing in like 1000 RVU/month working 35 hours per week including an hour lunch break each day for the staff. The typical RVU conversion for most jobs is like $60-70/RVU so you do the math. This is the hospital employed (HOPD) model. Private practice is paid on collections and is somewhat different. It's fairly easy to see 4 patients per hour in a well run clinic, he sees 5-6 per hour. Couple caveats, he is exceptionally productive and is faster/looser with opioids than I'd like to be but to each their own.

---

Members don't see this ad.

 

[Goodlife1119]

It can be hard and take a while to get a full patient panel, especially if you're in a saturated market and/or starting from scratch. But yes once you're full or nearly full, more Pain = more gain$.

It's a misconception that EM has the best hourly comp. My colleague who has several years on me is bringing in like 1000 RVU/month working 35 hours per week including an hour lunch break each day for the staff. The typical RVU conversion for most jobs is like $60-70/RVU so you do the math. This is the hospital employed (HOPD) model. Private practice is paid on collections and is somewhat different. It's fairly easy to see 4 patients per hour in a well run clinic, he sees 5-6 per hour. Couple caveats, he is exceptionally productive and is faster/looser with opioids than I'd like to be but to each their own.

Thanks for the detailed response.

 

[doctoroxygen]

It can be hard and take a while to get a full patient panel, especially if you're in a saturated market and/or starting from scratch. But yes once you're full or nearly full, more Pain = more gain$.

It's a misconception that EM has the best hourly comp. My colleague who has several years on me is bringing in like 1000 RVU/month working 35 hours per week including an hour lunch break each day for the staff. The typical RVU conversion for most jobs is like $60-70/RVU so you do the math. This is the hospital employed (HOPD) model. Private practice is paid on collections and is somewhat different. It's fairly easy to see 4 patients per hour in a well run clinic, he sees 5-6 per hour. Couple caveats, he is exceptionally productive and is faster/looser with opioids than I'd like to be but to each their own.

Patients per hour is incredibly dependent on major referral source. Spine surgeon referrals for procedure take 10 minutes for a 99204. Undifferentiated referrals from PCPs take much, much longer.

 

[Fox800]

Got this in a mass email from ABEM this morning. If I'm reading this correctly, only 36 ABEM-boarded docs are subspecialty boarded in pain medicine. It's a bold new frontier for EM & pain medicine.

 

[RustedFox]

What do these weird abbreviations stand for?

NCC?
BIM?
UHM?
CI?

 

[DeadCactus]

What do these weird abbreviations stand for?

NCC?
BIM?
UHM?
CI?

Neuro Critical Care
Brain Injury Medicine? (First time I've heard of it, looks like it's under PM&R.)
Undersea and Hyperbaric Medicine
Clinical Informatics

 

[Apollyon]

I thought BIM was bariatrics.

 

[TrailRun]

How are the current fellows enjoying it? I'm finding I'm liking Pain more than I anticipated I would; helps that probably only 1% of our patients are on opiates and it's a highly procedurally driven fellowship. Fluoroscopic images are a bit challenging to learn (much like looking at ultrasound for the first time). I do miss some aspects of EM (thinking about all of the organ systems, etc) so am debating moonlighting or perhaps a 4 day pain 1 day EM split in the future, assuming I could pick my shift. In any case this definitely seems like a sustainable option for those coming from EM

 

[BoardingDoc]

How are the current fellows enjoying it? I'm finding I'm liking Pain more than I anticipated I would; helps that probably only 1% of our patients are on opiates and it's a highly procedurally driven fellowship. Fluoroscopic images are a bit challenging to learn (much like looking at ultrasound for the first time). I do miss some aspects of EM (thinking about all of the organ systems, etc) so am debating moonlighting or perhaps a 4 day pain 1 day EM split in the future, assuming I could pick my shift. In any case this definitely seems like a sustainable option for those coming from EM

Massively enjoying it. I would say that this fellowship is maybe 30% of the mental and physical effort as compared with my ED job. That's just an unexpected bonus though as I'm enjoying the work quite a bit. Definitely have more COT than you, but those patients honestly aren't that bad and we have a hard cap of 45 mme, so it isn't crazy doses. The procedures are also good and we get a lot of autonomy to more or less fly solo after you've done a few of them, with the attending around to give guidance if needed.

 

[painER]

How are the current fellows enjoying it? I'm finding I'm liking Pain more than I anticipated I would; helps that probably only 1% of our patients are on opiates and it's a highly procedurally driven fellowship. Fluoroscopic images are a bit challenging to learn (much like looking at ultrasound for the first time). I do miss some aspects of EM (thinking about all of the organ systems, etc) so am debating moonlighting or perhaps a 4 day pain 1 day EM split in the future, assuming I could pick my shift. In any case this definitely seems like a sustainable option for those coming from EM

Similar story here. Thought I would like pain and really enjoyed the first month of fellowship. We are also a highly procedural fellowship without much medical management so that may skew my opinion (although I honestly wish I had more med management exposure). Curious how feasible the 4/1 pain EM week is. That is appealing to me as well but not sure if it's possible without that one EM day being an undesirable shift.

 

[GatorCHOMPions]

Similar story here. Thought I would like pain and really enjoyed the first month of fellowship. We are also a highly procedural fellowship without much medical management so that may skew my opinion (although I honestly wish I had more med management exposure). Curious how feasible the 4/1 pain EM week is. That is appealing to me as well but not sure if it's possible without that one EM day being an undesirable shift.

I have that setup, not by design but that's how it's worked out as it's taken a bit to ramp up to having a 100% full pain practice. I'm in a hospital employed position with a pretty relaxed administration that lets me more or less pick my schedule as long as I'm productive. I've heard of some private practice jobs allowing less than a full 5 days too. It all depends on your boss. My EM shifts (other hospital system) are Fridays through Sundays 7a-11p, 2-3 per month, so not the best but not the worst ones.

 

[TrailRun]

Similar story here. Thought I would like pain and really enjoyed the first month of fellowship. We are also a highly procedural fellowship without much medical management so that may skew my opinion (although I honestly wish I had more med management exposure). Curious how feasible the 4/1 pain EM week is. That is appealing to me as well but not sure if it's possible without that one EM day being an undesirable shift.

I wonder as well, although anesthesia people do it.

I have that setup, not by design but that's how it's worked out as it's taken a bit to ramp up to having a 100% full pain practice. I'm in a hospital employed position with a pretty relaxed administration that lets me more or less pick my schedule as long as I'm productive. I've heard of some private practice jobs allowing less than a full 5 days too. It all depends on your boss. My EM shifts (other hospital system) are Fridays through Sundays 7a-11p, 2-3 per month, so not the best but not the worst ones.

and I guess you could potentially sell it as being a source for referrals 🙂

 

[Fox800]

Fellowship is good so far. Hospital call is very relaxed. Clinic days are very chill (we have residents that work with us that help carry the load). The staff have all been very nice and supportive.

It's been cool to be able to jump in and do procedures with little to no experience in week two (ILESI, MBBs, MILD, peripheral nerve stimulators).

So far, so good.

 

[Fox800]

I'm enjoying a sports medicine rotation a lot more than I thought. The non-operative orthopedics part is interesting, and the patient population is different enough to make it intriguing.

The sports medicine docs I'm working with are quite impressive with their MSK ultrasound skills and how they use it in real-time to make diagnoses. I'm very curious about incorporating some of this stuff into my practice.

 

[hopefulgasman]

I'm enjoying a sports medicine rotation a lot more than I thought. The non-operative orthopedics part is interesting, and the patient population is different enough to make it intriguing.

The sports medicine docs I'm working with are quite impressive with their MSK ultrasound skills and how they use it in real-time to make diagnoses. I'm very curious about incorporating some of this stuff into my practice.

Sure, if you don’t want to make any money.

 

[BoardingDoc]

Sure, if you don’t want to make any money.

Yeah, that's sorta the problem with a bunch of pain procedures, including lots of sports med US procedures. Some of it might be helpful for the patient, but are so poorly reimbursed as to make them rarely worthwhile.

 

[VA Hopeful Dr]

Yeah, that's sorta the problem with a bunch of pain procedures, including lots of sports med US procedures. Some of it might be helpful for the patient, but are so poorly reimbursed as to make them rarely worthwhile.

Expand that to outpatient procedures in general.

 

[TrailRun]

Are you cofellows applying for jobs already? Apparently it’s already time to start looking. Planning on doing full time pain or a hybrid of ER?

 

[Goodlife1119]

Are you cofellows applying for jobs already? Apparently it’s already time to start looking. Planning on doing full time pain or a hybrid of ER?

My co-fellow is currently applying. I've personally reached out to some jobs but usually for geographic reasons i've hesitated to interview. In the bigger cities in my state when I google jobs, I usually have to go through a recruiter-which I dislike going through. So i've been trying to find these practices online but then can't find contact information for them-it's a mess. Does anyone have any other ideas for finding jobs-i've tried google, practice link, gasworks, cold calling, reaching out to hospitals that I've been previously affiliated with, and some word of mouth from my program. In general, I am trying to be more thoughtful/more picky about picking a job then i've been in the past with my EM gigs.

 

[BoardingDoc]

Are you cofellows applying for jobs already? Apparently it’s already time to start looking. Planning on doing full time pain or a hybrid of ER?

I'm emailing a couple of connected people in my Rolodex next week to let them know I'm looking and see if they have any leads or can put me in touch with people who do (dept chairs, private offices, whatever).

 

[Franzd'Epinay]

So i've been trying to find these practices online but then can't find contact information for them-it's a mess.

I'm not in pain, but for larger hospital systems, try searching on LinkedIn for "[health system] recruiter". You can also search on google for other job postings in any specialty within that health system--often the recruiter will list their direct contact information and then they can direct you to the right person if it's not them. You could also try to find an email/phone for their HR department. Worst case scenario if it's a small place, you can just cold call the office, ask to speak with the practice manager, and then have them give you the information of their recruiting/HR person.

Basically, you just need a way to get a hold of one live person who knows enough to direct you in the right direction.

 

[Birdstrike]

I just heard Pain was a weak match this year with significant unfilled spots at good programs. It may not be so hard to get into, as it used to be.

Anyone looking to scramble into a spot, it’s time to act.

It looks like a hot anesthesia market is keeping anesthesia Pain applicant numbers down.

This is not first hand knowledge, just something I heard.

 

[sevo00]

I just heard Pain was a weak match this year with significant unfilled spots at good programs. It may not be so hard to get into, as it used to be.

That’s not something new. Same thing happened last year

 

[Fox800]

The time is now if you're thinking about a pain fellowship.

About 40 programs did not fill (out of ~108 total).

You can likely generate genuine interest with a thoughtfully worded e-mail + your CV sent out to...really, any program you'd entertain going to.

 

[Qambar Raza]

Yep, it's provocative and I said it. And I stand by it.

Last year ago, it was, "EM even applying to Pain is BANANALAND."

Now it's, "EM should apply to Pain. But saying EM applicants are better is BANANALAND."

That's perfect. I may convince no one, that EM applicants are better suited to a Pain fellowship. But if I even convince a few to go from, "EM can't do Pain," to, "EM should apply to Pain," then I've moved the needle of persuasion in the desired direction, by getting you to think past the sale. Then more EM applicants apply, more get in, more get on faculty, on fellowship admission committees, and the odds for the next round of EM applicants increase. Repeat.

Hey I am a PGY-1 and want to persue PAIN after residency. I wanted to know what should be done to increase my chances to get in and there are most programs who haven’t mentioned EM residency in their requirements does that mean they dont hire EM for pain ?

 

[painER]

Do a pain rotation, find a pain mentor, try to get involved with a pain research project, show interest in the field. The more you can do of the above, the better you will be.

Just because they don't mention EM does not mean they won't take an EM grad. I'm the first EM fellow at my program, no mention of EM anywhere on their website.

 

[Birdstrike]

Hey I am a PGY-1 and want to persue PAIN after residency. I wanted to know what should be done to increase my chances to get in and there are most programs who haven’t mentioned EM residency in their requirements does that mean they dont hire EM for pain ?

Like @painER said above, the most important thing to do is to arrange a Pain rotation, at least one month, preferably two. If you do that, the gap between an Anesthesia and EM applicant is greatly narrowed.

Other than that, perform well as a resident, study for exams, and do as much things pain related as possible. There is more crossover between EM and Pain than you think. Research never hurts.

Whether a program mentions EM is irrelevant. They may not have updated their website. Some may not have gotten any EM applicants before. Also, the "EM friendliness" is iprossible to assess and even if it wasn't, it can change year to year based on who is interviewing, the strength of the application year and other factors.

Apply to all 110 ACGME programs, those in the Match and those not in the match. Use numbers and statistical probabilities to your advantage. Check what programs didn't fill. Sometimes good programs have an off year and you may sneak into a solid program that way.

 

[mancub]

Hey guys,

Second year EM attending heavily considering a pain. I'm currently ~2 years out in a great job for EM (location, hrs, pay, no nights, etc) but still considering a way out for all the same reasons discussed in the forum.

Background: prior to med school I was an OR/XR tech for an interventional pain clinic. Helped set up for all the procedures and then ran the C-arm during them. Injections/Ablations/Joint Injections/SCS trials. Helped run/put on regenerative medicine conferences for pain docs CME. Also functioned as an MA for the clinic side. In med school got swindled into EM instead of anesthesia or another specialty.

CV: county EM residency, above average boards, good research/pubs but not pain related, significant pain background but not as a provider. Could get letters from my PD, current ED director and maybe my old employer.

What is my best approach? What advice would you guys give to someone in my shoes? Setting up pain rotations might put my current job in jeopardy, could maybe swing a 1 week visit but beyond that would probably get hard.

Cheers!
Disillusioned Newish ED attending

 

[sevo00]

Hey guys,

Second year EM attending heavily considering a pain. I'm currently ~2 years out in a great job for EM (location, hrs, pay, no nights, etc) but still considering a way out for all the same reasons discussed in the forum.

Background: prior to med school I was an OR/XR tech for an interventional pain clinic. Helped set up for all the procedures and then ran the C-arm during them. Injections/Ablations/Joint Injections/SCS trials. Helped run/put on regenerative medicine conferences for pain docs CME. Also functioned as an MA for the clinic side. In med school got swindled into EM instead of anesthesia or another specialty.

CV: county EM residency, above average boards, good research/pubs but not pain related, significant pain background but not as a provider. Could get letters from my PD, current ED director and maybe my old employer.

What is my best approach? What advice would you guys give to someone in my shoes? Setting up pain rotations might put my current job in jeopardy, could maybe swing a 1 week visit but beyond that would probably get hard.

Cheers!
Disillusioned Newish ED attending

What do you mean swindled into EM?

 

[WhatJobDoIPick]

What do you mean swindled into EM?

Probably referring to how many of us were lied to by academic mentors about how great EM is.

 

[GatorCHOMPions]

Hey guys,

Second year EM attending heavily considering a pain. I'm currently ~2 years out in a great job for EM (location, hrs, pay, no nights, etc) but still considering a way out for all the same reasons discussed in the forum.

Background: prior to med school I was an OR/XR tech for an interventional pain clinic. Helped set up for all the procedures and then ran the C-arm during them. Injections/Ablations/Joint Injections/SCS trials. Helped run/put on regenerative medicine conferences for pain docs CME. Also functioned as an MA for the clinic side. In med school got swindled into EM instead of anesthesia or another specialty.

CV: county EM residency, above average boards, good research/pubs but not pain related, significant pain background but not as a provider. Could get letters from my PD, current ED director and maybe my old employer.

What is my best approach? What advice would you guys give to someone in my shoes? Setting up pain rotations might put my current job in jeopardy, could maybe swing a 1 week visit but beyond that would probably get hard.

Cheers!
Disillusioned Newish ED attending

Given the last couple Pain matches you should be good without doing much else to be honest. Many programs had difficulty filling. You have a better background than multiple EM hopefuls who matched that I've advised recently. The main thing I'd recommend is applying broadly. Sure do a week visit somewhere here and there if you think it could lead to a LOR. Maybe try networking at regional and/or national pain meetings.

 

[mancub]

What do you mean swindled into EM?

Love the culture, love the medicine, but nobody told me "I haven't seen my daughter in 3 days" or "workups and documentation to avoid litigation makes my soul hurt." I wish someone had said "We are fun, cool and sarcastic. You'll want to do this, but this work will burn you out."

Don't get me wrong. I have a spoiled life and live better than most the world. That being said as time passes this becomes more of a job and less a calling. Just want to explore other options before I'm too crispy.

Given the last couple Pain matches you should be good without doing much else to be honest. Many programs had difficulty filling. You have a better background than multiple EM hopefuls who matched that I've advised recently. The main thing I'd recommend is applying broadly. Sure do a week visit somewhere here and there if you think it could lead to a LOR. Maybe try networking at regional and/or national pain meetings.

Thanks for the advice!

 

[BoardingDoc]

Love the culture, love the medicine, but nobody told me "I haven't seen my daughter in 3 days" or "workups and documentation to avoid litigation makes my soul hurt." I wish someone had said "We are fun, cool and sarcastic. You'll want to do this, but this work will burn you out."

Don't get me wrong. I have a spoiled life and live better than most the world. That being said as time passes this becomes more of a job and less a calling. Just want to explore other options before I'm too crispy.


Thanks for the advice!

Something to bear in mind about pain.

1: It has become much easier to get into because so many fewer anesthesia grads are going into it because of how hot the anesthesia market is.

2: Getting a job as a pain doc is MUCH harder as an EM --> pain doc than as an anesthesia --> pain doc. My co-fellows are both anesthesia. Both have tons of job offers which involve doing some anesthesia time. Those same places have ghosted me because they don't care about me being able to do ER time, they just need anesthesiologists are are happy to use a part time pain job as the carrot that gets them one.

To be clear, you can still find work coming from EM. It just narrows your field and can make things tricky if you're geographically restricted. I don't say this to dissuade you from pain. I just want you to have all the details about pain that you wish you had about EM when choosing it.

If you have no geographic restrictions... ignore this.

 

[WhatJobDoIPick]

Something to bear in mind about pain.

1: It has become much easier to get into because so many fewer anesthesia grads are going into it because of how hot the anesthesia market is.

2: Getting a job as a pain doc is MUCH harder as an EM --> pain doc than as an anesthesia --> pain doc. My co-fellows are both anesthesia. Both have tons of job offers which involve doing some anesthesia time. Those same places have ghosted me because they don't care about me being able to do ER time, they just need anesthesiologists are are happy to use a part time pain job as the carrot that gets them one.

To be clear, you can still find work coming from EM. It just narrows your field and can make things tricky if you're geographically restricted. I don't say this to dissuade you from pain. I just want you to have all the details about pain that you wish you had about EM when choosing it.

If you have no geographic restrictions... ignore this.

This is a classic result of "grass is greener" phenomenon

 

[mancub]

This is a classic result of "grass is greener" phenomenon

Genuinely curious what you mean here? Being honest about the aspects of your job that are difficult or hard and exploring ways in how you may change them is just being proactive. I loved EM and still do enjoy most shifts.

Its not like I'm daydreaming about some dentist like job, rather just trying to make decisions that are best for me and mine.

 

[swamprat]

Something to bear in mind about pain.

1: It has become much easier to get into because so many fewer anesthesia grads are going into it because of how hot the anesthesia market is.

2: Getting a job as a pain doc is MUCH harder as an EM --> pain doc than as an anesthesia --> pain doc. My co-fellows are both anesthesia. Both have tons of job offers which involve doing some anesthesia time. Those same places have ghosted me because they don't care about me being able to do ER time, they just need anesthesiologists are are happy to use a part time pain job as the carrot that gets them one.

To be clear, you can still find work coming from EM. It just narrows your field and can make things tricky if you're geographically restricted. I don't say this to dissuade you from pain. I just want you to have all the details about pain that you wish you had about EM when choosing it.

If you have no geographic restrictions... ignore this.

I respectfully diagree with #2. Maybe you just were unlucky - I've been a pain MD for 7 years now, had several jobs and during the job hunt(s) had multiple interviews - all 100% pain only. Most pain practices seem to advertise "100% pain" because a lot of pain docs hate anesthesia or don't want to do it anymore. A lot of anesthesia also has turned into PE like envision and team health (prob market dependent but is similar to EM) so these small groups don't even have contracts with hospitals to provide anesthesia services.

 

[Birdstrike]

I’m only one person, but for me, the grass has been much greener on the Pain side. It’s not even close. I’ve been doing Pain for 13 years now, longer than the 11 years I spent in EM.

I’ve kept my EM board certification current this whole time, but I’ve never felt the need to use it. I could have easily anytime along the way. I still could, but have no need, no desire.

People often make the mistake of thinking “EM or Pain” and they’re too afraid to replace one with the other. You don’t have to look at it and and “either/or” proposition. A Pain fellowship adds another specialty to your skillset. It doesn’t take one away from you.

 

[swamprat]

I’m only one person, but for me, the grass has been much greener on the Pain side. It’s not even close. I’ve been doing Pain for 13 years now, longer than the 11 years I spent in EM.

I’ve kept my EM board certification current this whole time, but I’ve never felt the need to use it. I could have easily anytime along the way. I still could, but have no need, no desire.

People often make the mistake of thinking “EM or Pain” and they’re too afraid to replace one with the other. You don’t have to look at it and and “either/or” proposition. A Pain fellowship adds another specialty to your skillset. It doesn’t take one away from you.

Yep agree - I will say you will make more $ and have a much better lifestyle in pain. I, however still work a shift a month - I just can't fully get away I still like the general medicine which pain is lacking. With that being said, it is very powerful to decide you don't want to do shifts or not pick up any shifts given your subspecialty.

 

[Birdstrike]

Recently switched from my original Pain job with a primary care group to a physician owned Orthopedics group. I'm much busier, doing more procedures (especially advanced procedures, SpStim/Kypho/PNS) and have 2-3 times the staffing help. The referrals seem to flop into my lap with little to no effort whereas at the other job it got harder and harder every year to get them in, due to encroaching competition. Happy with the decision.

 

[BoardingDoc]

Recently switched from my original Pain job with a primary care group to a physician owned Orthopedics group. I'm much busier, doing more procedures (especially advanced procedures, SpStim/Kypho/PNS) and have 2-3 times the staffing help. The referrals seem to flop into my lap with little to no effort whereas at the other job it got harder and harder every year to get them in, due to encroaching competition. Happy with the decision.

Are you doing any sprint multifidus stim either after "failed" RFA or in lieu of RFA entirely? I've had what I feel is enough training in scs and Kypho (and pumps unfortunately) but I've had none with pns except at cadaver labs. Definitely curious about sprint in particular.

 

[Birdstrike]

Are you doing any sprint multifidus stim either after "failed" RFA or in lieu of RFA entirely? I've had what I feel is enough training in scs and Kypho (and pumps unfortunately) but I've had none with pns except at cadaver labs. Definitely curious about sprint in particular.

I haven't done multifidus but I've done genicular and superior cluneal (working with NALU, right now). So far, both of those feel easier that spinal cord stims, which often aren't challenging, but can be if someone has a particularly bad spine. If you're already adept at SCS, Kypho and pumps, it's not a big leap to PNS, from my limited experience. The skill set seems very similar.