Pain Surgeon?

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lobelsteve

lobelsteve

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  1. Attending Physician
It was an interesting read and certainly unfortunate interest in the field is decreasing. My fellowship PD always told us we were pain physicians, not interventional pain physicians, which I think is more relevant than ever.

Despite this, I still prefer to label and market myself an interventional pain doc. I still enjoy clinic and helping to diagnose and relieve suffering, but unfortunately there is a stigma behind being a “pain medicine doctor” (emphasis on medicine). Lay people think of two very different things when they hear “pain medicine doctor” and “interventional pain doctor.” I do not enjoy treating the specific patient population “pain medicine doctor” attracts, and I’m sure that likely plays a role in why interest of residents is also down.
 
The interventional portion is what attracts most applicants - I don’t think people really want to treat the whole person because that includes their neuroses….

Anesthesiology is suddenly very competitive and lucrative. When the doom and gloom of CRNA independence returns, everything will go back to normal.
 
Too many needles chasing too many spines.

It’s all about the $. This forum is filled with anecdotes of how much more pain docs got paid 10 years ago for everything. Epidurals, uds, botox, us guidance, Fluoro bundling, limiting levels to inject, pain pump refills, bracing, emgs. All the while practice costs have sky rocketed.

Not all doom and gloom though. The hospital based jobs seem 10x better than when I got out of fellowship.
 
The drop in interest is due to reimbursement decrease and anesthesia market. Chronic pain patients have sucked for decades, but if anything they're less pushy and average MMEs have gone down. Labeling, regardless of holistic vs surgical, does nothing, as the bottom line is the bottom line, has always been that way across all specialties.

In my opinion, pain surgeon labeling reeks of inferiority complex. If I started putting that on my business cards, my surgical partners would laugh.
 
@RoloTomassi very true. The opioid focused patients have gotten used to being told no and are not as pushy as they were when I started in 2015. The younger patients who are “scared of shots, don’t want/need surgery, and just need something for this pain, doc” are also more receptive of being told “No, that is a bad idea. Go to PT, and here is some diclofenac. Call me back if you would like to try a procedure.”
 
lobelsteve said:
www.linkedin.com

Pain Medicine Match: Are we in a Crisis? | Scott Pritzlaff MD posted on the topic | LinkedIn

🚨 Pain Medicine Match: Are We in a Crisis? 🚨 This Wednesday, the Pain Medicine Fellowship match results are set to be announced, and we’re anticipating the lowest recruitment in over a decade. Applications are down by 15% compared to last year, highlighting the need to reflect on where our...
www.linkedin.com www.linkedin.com

Kudos for Dr P to say it out loud.
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He was one of my attendings in fellowship, and he was a newer attending at the time. He’s a good guy. Former military.
 
I like the interventional term. Pain Medicine seems just too linked to pain medicine ie opiates. Pain management is a weird term because it’s really the patients job to manage with their pain. I’d be fine with pain surgeon too. I think any lay person would view a kypho or SCS as surgery for example. In any case, definitely not going to attract more applicants by de-emphasizing the procedural aspect.
 
MitchLevi said:
He was one of my attendings in fellowship, and he was a newer attending at the time. He’s a good guy. Former military.
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wasnt he also the guy that was claiming that we shouldnt be grandstanding and saying ' i was the first to do x procedure in the state of x" and chasing clout, when he was doing the exact same thing?
 
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lobelsteve said:
www.linkedin.com

Pain Medicine Match: Are we in a Crisis? | Scott Pritzlaff MD posted on the topic | LinkedIn

🚨 Pain Medicine Match: Are We in a Crisis? 🚨 This Wednesday, the Pain Medicine Fellowship match results are set to be announced, and we’re anticipating the lowest recruitment in over a decade. Applications are down by 15% compared to last year, highlighting the need to reflect on where our...
www.linkedin.com www.linkedin.com

Kudos for Dr P to say it out loud.
Click to expand...
It's cuz most pain docs were anesthesia.

Now you can mk a ton more doing anesthesia.

Thus no one from anesthesia is doing pain.


For those of us in pain. The future maybe bright in 10 to 15 years as there will be a shortage. Assuming CrNA don't step in
 
RoloTomassi said:
The drop in interest is due to reimbursement decrease and anesthesia market. Chronic pain patients have sucked for decades, but if anything they're less pushy and average MMEs have gone down. Labeling, regardless of holistic vs surgical, does nothing, as the bottom line is the bottom line, has always been that way across all specialties.

In my opinion, pain surgeon labeling reeks of inferiority complex. If I started putting that on my business cards, my surgical partners would laugh.
Click to expand...

If a Neurosurgeon does an SCS implant- perc or paddle- would anyone try to clip his wings at the scrub sink and dispute the fact that he just performed a surgery?

Pain physicians are not general surgeons, neurosurgeons, or vascular surgeons but certainly the high volume implanters are more than just "proceduralists" (a favorite backhand comment usually from fellow anesthesiologists). They are surgeons, who perform surgery, and many do it quite capably.

Anyone who has ever done a complex IT pump revision/replacement, or a complicated SCS revision/replacement especially in a patient with poor body habitus instinctively recognizes that this is fundamentally "surgery" in the most basic sense and so would any objective observer, medical or otherwise.
 
Centurion38 said:
If a Neurosurgeon does an SCS implant- perc or paddle- would anyone try to clip his wings at the scrub sink and dispute the fact that he just performed a surgery?

Pain physicians are not general surgeons, neurosurgeons, or vascular surgeons but certainly the high volume implanters are more than just "proceduralists" (a favorite backhand comment usually from fellow anesthesiologists). They are surgeons, who perform surgery, and many do it quite capably.

Anyone who has ever done a complex IT pump revision/replacement, or a complicated SCS revision/replacement especially in a patient with poor body habitus instinctively recognizes that this is fundamentally "surgery" in the most basic sense and so would any objective observer, medical or otherwise.
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No. We are still not surgeons. Just like interventional cardiology and radiologists are still proceduralists. You do not see cardiologists who place pacemakers and clips, TAVRS, or stents call themselves surgeons and they do a ton more procedures than CT surgeons do.
The term proceduralist is not backhanded... its an accurate description: you are a physician who performs a variety and plethora of procedures.

Placing a SCS implant is minor surgery. Removing an epidural hematoma with a decompression is the real surgery. Lets stay in our lane and not pretend to be something we are not. Its embarrassing.
 
My evaluations and care are multidisciplinary, but I still present as an interventional pain physician since it seems disingenuous to preach about true comprehensive care when I do not typically take over opioid prescription responsibilities. UC Davis has a great program, but like many academic institutions, it focuses on interventions over longitudinal comprehensive management of pain (which should certainly include opioids).
 
Tboned said:
Jonathan Hagedorn did that. I think @lobelsteve posted it.
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The list of doctors on LinkedIn who make impassioned posts like that are legion.

The term Pain Surgeon is embarrassing, almost as embarrassing as the chair of my PMR residency saying he could envision a day PMR doctors administer tPA instead of neurologists.

Edit - We have great job yall. Procedures, clinic and some surgical options. Can really make a difference in your community. Make more money than the vast majority of our physician colleagues. Be cool…
 
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i for one prefer the term "pain management physician".

as i tell anyone who critiques me by saying "arent you a pain medicine doc?", i say "no, i am a pain management doctor. we are not going to cure your chronic pain. we are going to help and teach you how to manage your chronic pain in a way that is safe, effective and can hopefully prevent the bad outcomes of chronic pain."


and yes, some of us possess unique surgical skills; however, that is not the majority. for those pain docs who do complex procedures, they do have the capacity of calling themselves interventional spine surgeons.
 
I identify as a pain sturgeon
IMG_2765.jpeg
 
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lobelsteve said:
www.linkedin.com

Pain Medicine Match: Are we in a Crisis? | Scott Pritzlaff MD posted on the topic | LinkedIn

🚨 Pain Medicine Match: Are We in a Crisis? 🚨 This Wednesday, the Pain Medicine Fellowship match results are set to be announced, and we’re anticipating the lowest recruitment in over a decade. Applications are down by 15% compared to last year, highlighting the need to reflect on where our...
www.linkedin.com www.linkedin.com

Kudos for Dr P to say it out loud.
Click to expand...
Scott is a GREAT guy.

Smart and humble. An enthusiastic educator who takes time post clinic and weekends to make sure his fellows get a balanced education. the curriculum at Davis is well-structured. Charles De Mesa is also an absolutely fantastic guy.

yes, the field, is increasingly procedure/device driven.

in a lot of ways, it makes sense. not because industry is driving the field, but because anyone can fill a rx.
hardly any other specialty knows how to troubleshoot a faulty ITP or patient going into IT baclofen withdrawal. pain rehab programs are expensive. a lot of patients don't want the counseling, bio-psycho-social, mindfullness, biofeedback, physical therapy, meditation, etc
 
RoloTomassi said:
The drop in interest is due to reimbursement decrease and anesthesia market. Chronic pain patients have sucked for decades, but if anything they're less pushy and average MMEs have gone down. Labeling, regardless of holistic vs surgical, does nothing, as the bottom line is the bottom line, has always been that way across all specialties.

In my opinion, pain surgeon labeling reeks of inferiority complex. If I started putting that on my business cards, my surgical partners would laugh.
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It’s the physician equivalent of nurse anesthesiologist.
 
drusso said:
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I’m not following what the end game is here in this article. I understand that we shouldn’t be posting pics on LinkedIn of minute man implants or whichever unproven therapy is on the menu that day, but does that mean we stop doing procedures and go back to writing opioids when PT is exhausted? It’s impossible to address the psychosocial issues involved in pain medicine in private practice. If I suggest a patient sees a psychiatrist, then they get angry that I think their pain isn’t ’real.’ Furthermore, it’s impossible to refer any of these patients in my region to a behavior health therapist when all of them are out-of-network, preferring to see cash-paying soccer moms lamenting about their depressing days of staying at home and drinking Pinot.
 
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gaseous_clay said:
I’m not following what the end game is here in this article. I understand that we shouldn’t be posting pics on LinkedIn of minute man implants or whichever unproven therapy is on the menu that day, but does that mean we stop doing procedures and go back to writing opioids when PT is exhausted. Furthermore it’s impossible to address the psychosocial issues involved in pain medicine in private practice. If I suggest a patient sees a psychiatrist, then they get angry that I think their pain isn’t ’real.’ Furthermore it’s impossible to refer any of these patients in my region to a behavior health therapist when all of them are out-of-network, preferring to see cash-paying soccer moms lamenting about their depressing days of staying at home and drinking Pinot.
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Well written


In PP. No one has the bandwidth to do this. Also there's the real world where patients can't afford it.

Finally. How much does psych actually work. Have you seen the med list of people tht have gone to see a psych...
 
I think you guys had poor training. Addressing the psychosocial issues is more important than the shot or the pill. Until you realize that and make the patient realize that, you have failed in your job.
 
lobelsteve said:
I think you guys had poor training. Addressing the psychosocial issues is more important than the shot or the pill. Until you realize that and make the patient realize that, you have failed in your job.
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That’s true for nearly every aspect of medicine - heart health, depression/anxiety, diabetes, etc.

How often are private practice cardiologists, endocrinologists, psych etc addressing psychosocial issues?

I’m not disagreeing with you - but the reality of medicine in the US makes addressing these issues near impossible.
 
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lobelsteve said:
I think you guys had poor training. Addressing the psychosocial issues is more important than the shot or the pill. Until you realize that and make the patient realize that, you have failed in your job.
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I think you are generalizing and are in a bubble.

I don't disagree that chronic patients require psych. People on COT, etc. Particularly if on disability, not working etc.

Then there's patients in the real world. People like you and I and most on here. If you hurt, you don't want me to tell you it's psychological. You would want a shot to get back to work and function. You don't have time..
 
lobelsteve said:
I think you guys had poor training. Addressing the psychosocial issues is more important than the shot or the pill. Until you realize that and make the patient realize that, you have failed in your job.
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We clearly don’t have as much time on our hands as you do. What you’re saying in typical judgmental Lobel fashion is not wrong, but it simply cannot be done in non-hospital based settings where we are responsible for paying the bills.
 
@lobelsteve I don’t think you really are doing what you say either. You schedule 34 patients per day routinely and probably flex up to 44 at times. So you aren’t addressing any psychosocial concerns other than quit smoking, quit drinking, go for a walk, just like we all do.
 
PinchandBurn said:
I think you are generalizing and are in a bubble.

I don't disagree that chronic patients require psych. People on COT, etc. Particularly if on disability, not working etc.

Then there's patients in the real world. People like you and I and most on here. If you hurt, you don't want me to tell you it's psychological. You would want a shot to get back to work and function. You don't have time..
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The truth is that we don't want to tell them what should be obvious - that if there was no psychological component, there is no severe pain, only an annoyance or irritation.

Now for an acute process, such as a herniation, deferring this discussion is appropriate. But for chronic pain, without introducing this, we are misleading patients in to thinking the next big injection or surgery will cure their problem.

I tell all people that there is a role for pain psychology and tell them to ask and I'll refer and talk to them.

The sole advantage of being HOPD.
 
BobBarker said:
@lobelsteve I don’t think you really are doing what you say either. You schedule 34 patients per day routinely and probably flex up to 44 at times. So you aren’t addressing any psychosocial concerns other than quit smoking, quit drinking, go for a walk, just like we all do.
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Never been over 37. Working to get under 30 most days. I don’t bother. Tell people to quit smoking quit drinking and lose weight. Everybody knows this. I check in on their stressors and figure out what are their failures to doing the best things for their health. Prescribing a drug and ordering a procedure takes 10 seconds.
 
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Every day I will have 2 or 3 people that get an extra 5-10 min out of me where I delve into pain psych. I also refer people to google YouTube lectures by Sean Mackey, Beth Darnell and Heather P King.

My fellowship program is probably the most in depth pain psych hub in the USA (Stanford Pain).

NONE of you are able to help those problems because you're not good enough at it, you don't have time and you're not trained in it.

NONE of you are teaching biofeedback or providing CBT, mindfulness or guided imagery.

If you're not doing 45-60 min and teaching those management skills I just mentioned you're not providing pain psych management, and until you are please STFU about it.

Edit: Here's what is annoying in our field - Dr. X sees 20-23 pts per day, and cannot understand how Dr. Y can see 30 or more, so automatically X accuses Y of providing poor care or throws out the term "needle jockey." Dr. X then tries to pretend like he/she is well rounded and provides comprehensive care that is interdisciplinary and mentions pain psych and psychosocial counseling, etc...It's complete BS.

NONE of you provide ACTUAL pain psych management.
 
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drusso said:
Are they tender to palpation near the iliac crest in the distribution of the territory of the cluneal nerves?
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I've seen epidemic levels of this in the last few yrs.
 
drusso said:
Are they tender to palpation near the iliac crest in the distribution of the territory of the cluneal nerves?
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1727282122201.png


Only when I palpate with my right hand.
 
As long as there is no payment this will remain the same pipe dream that it has always been unless you are wealthy.
 
MitchLevi said:
Every day I will have 2 or 3 people that get an extra 5-10 min out of me where I delve into pain psych. I also refer people to google YouTube lectures by Sean Mackey, Beth Darnell and Heather P King.

My fellowship program is probably the most in depth pain psych hub in the USA (Stanford Pain).

NONE of you are able to help those problems because you're not good enough at it, you don't have time and you're not trained in it.

NONE of you are teaching biofeedback or providing CBT, mindfulness or guided imagery.

If you're not doing 45-60 min and teaching those management skills I just mentioned you're not providing pain psych management, and until you are please STFU about it.

Edit: Here's what is annoying in our field - Dr. X sees 20-23 pts per day, and cannot understand how Dr. Y can see 30 or more, so automatically X accuses Y of providing poor care or throws out the term "needle jockey." Dr. X then tries to pretend like he/she is well rounded and provides comprehensive care that is interdisciplinary and mentions pain psych and psychosocial counseling, etc...It's complete BS.

NONE of you provide ACTUAL pain psych management.
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Dr X is also getting paid by RVUs
 
Sent to me last week for a second opinion. Has seen a local world’s greatest pain surgeon. Hard to believe still in 10 out of 10 pain with this and the opioids.
 

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