Pain Surgeon?

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Saw this gem today from another KOL

I can’t believe it didn’t work… He felt great after the test blocks that were done under mac with 3ml lido per level.
 

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Taus said:
Saw this gem today from another KOL

I can’t believe it didn’t work… He felt great after the test blocks that were done under mac with 3ml lido per level.
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That's ridiculous
 
TrailRun said:
Today was match day, sounds like there were some open spots again. Pain isn’t gonna have any better luck recruiting by de-emphasizing the procedural aspect. Do you really need a fellowship to be able to prescribe medicines? Opiates are a landmine no one wants to touch. The rest aren’t complicated. We do SCS, pumps, etc in the operating room. A kypho is definitely a surgical procedure. Patients definitely thought I was doing surgery doing sutures or chest tubes in the ER. I’m not trying to impress people at dinner parties, we don’t operate on babies hearts. Pain has to evolve and embrace the procedural aspect that we can uniquely offer. At a recent training they were talking about this stating in the setting of declining reimbursements one cannot make a career on ESI and MBB moving forward
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You should make a career taking the best care of patients. Fragmentation of care and cherry picking the lucrative procedures while deferring the other aspects is crappy. It leads to bad outcomes and ruins the entire field.
 
Taus said:
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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Are they tender to palpation over the iliac crest in the area near the distribution of the cluneal nerves?
 
drusso said:
Are they tender to palpation over the iliac crest in the area near the distribution of the cluneal nerves?
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Eureka!!

I knew something was missing from that picture… Couldn’t quite put my finger on it… But some nice PNS leads would really complete it
 
Office esi isn’t very good. If you are bad about policing your costs you might net less than an office visit. Mbb/rfa as a package remains very good. From initial consult to completion of the RFA is around $2200
 
Taus said:
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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What in the actual f*** is this?? More worried about the pendulous breasts causing cervicalgia than the double SCS implant covering who knows what?
 
CleanUp said:
I sprinkle in pain psych in easy to digest ways. Cymbalta. Desipramine. Take walks. Go out to eat with friends. Bring them in more frequently and just let them talk. It’s not much but it’s honest work.
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Bless you! You are doing god’s work. I just don’t have the time or patience.
 
Taus said:
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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To be fair, seems like they were as effective as the surgeon-surgeon in fixing her back pain.
 
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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and none of us cure any pain condition we see.


whats your point?

to completely ignore this aspect of pain management?

thats like doing an epidural and not giving a hoot what med you give through the epidural because you arent a pharmacologist. or giving exercises and pretending we are the actual physical therapists who spend an hour a session with each patient.



none of us said we are providing the actual pain psych. we are doctors, we diagnose problems, we come up with treatment plans, and then we refer to the appropriate people (OMG there are actual people who call themselves pain psychologists!!!) to go through the treatment.
 
#painsurgery

Endoscopic unilateral laminotomy and ligamentum flavectomy for lateral recess stenosis and bc.

To orient - 12 o’clock is medial , 6 is lateral 9 is cranial and 3 is caudal.

The cranial L4 lamina and IAP was drilled with a diamond burr and then undercut with a kerrison. The yellow ligament was then removed.

I think I make more doing an RFA in office though
 

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Maybe we should change our name to Spineologists… then we can take all the less complicated stuff and be as the cardiologist is to the CV surgeon lol
 
Ducttape said:
and none of us cure any pain condition we see.


whats your point?

to completely ignore this aspect of pain management?

thats like doing an epidural and not giving a hoot what med you give through the epidural because you arent a pharmacologist. or giving exercises and pretending we are the actual physical therapists who spend an hour a session with each patient.



none of us said we are providing the actual pain psych. we are doctors, we diagnose problems, we come up with treatment plans, and then we refer to the appropriate people (OMG there are actual people who call themselves pain psychologists!!!) to go through the treatment.
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This is a BS reply, and no one said anything about ignoring the psychological aspect of pain, and in fact I said the opposite in the very first sentence of the post you quoted. Unfortunately it doesn't work for the vast majority of people, and you are far better off ablating that 78 yo F with facet arthropathy.

To say that you're doing anything differently than any of the rest of us is my point.

We're all doing exactly the same thing, and no, you're not spending 45-60 minutes with patients and accomplishing anything that we're not accomplishing with 10 min visits that lead to PT, meds and shots.

Insurance, by and large does not cover pain psych, neither does Work Comp...Why? Because it has **** data.

Pain psych is the least efficient treatment for pain that I've ever seen. It is expensive and never reaches an end point. The data on it are BS, as are those individuals who peddle it as being reliably beneficial.

I'd looooooove for one of my local competitors to roll out a diverse pain psych program so I can take all of his/her patients.

I've sat in multidisciplinary meetings on complicated patients and had nationally-recognized and broadly-published pain psychologists say the most asinine things you've ever heard. I got into an argument with one (whose name you definitely know) because she said there's no evidence for spinal cord stimulation in failed back, and then recommended we wean opiates by one pill per month on a patient taking #180 Percocet 10/325mg for the last decade or so.

The ego in some of these people is incredible.

Edit - Recommend your pt read these books, and you've done all you can do for that pt from the pain psych approach, and you will save them TONS of money:

1727368316300.png
1727368386240.png
 
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MitchLevi said:
This is a BS reply, and no one said anything about ignoring the psychological aspect of pain, and in fact I said the opposite in the very first sentence of the post you quoted. Unfortunately it doesn't work for the vast majority of people, and you are far better off ablating that 78 yo F with facet arthropathy.

To say that you're doing anything differently than any of the rest of us is my point.

We're all doing exactly the same thing, and no, you're not spending 45-60 minutes with patients and accomplishing anything that we're not accomplishing with 10 min visits that lead to PT, meds and shots.

Insurance, by and large does not cover pain psych, neither does Work Comp...Why? Because it has **** data.

Pain psych is the least efficient treatment for pain that I've ever seen. It is expensive and never reaches an end point. The data on it are BS, as are those individuals who peddle it as being reliably beneficial.

I'd looooooove for one of my local competitors to roll out a diverse pain psych program so I can take all of his/her patients.

I've sat in multidisciplinary meetings on complicated patients and had nationally-recognized and broadly-published pain psychologists say the most asinine things you've ever heard. I got into an argument with one (whose name you definitely know) because she said there's no evidence for spinal cord stimulation in failed back, and then recommended we wean opiates by one pill per month on a patient taking #180 Percocet 10/325mg for the last decade or so.

The ego in some of these people is incredible.
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I think certain patients that are not axis II could benefit from CBT - but the problem is they are never on board with it and no one does it except high cash pay psych. In my opinion pain catastrophizing is a serious issue - not that everyone has it like your example of the 78 year old facet lady but you know what I mean when you see that patient and they are always "terrible" this and that. Just my 2 cents. Overall that doesn't mean we shouldn't try to treat them with what we have in our toolbox but if they can get CBT and actually run the program and practice I think it could help them long term.
 
swamprat said:
I think certain patients that are not axis II could benefit from CBT - but the problem is they are never on board with it and no one does it except high cash pay psych. In my opinion pain catastrophizing is a serious issue - not that everyone has it like your example of the 78 year old facet lady but you know what I mean when you see that patient and they are always "terrible" this and that. Just my 2 cents. Overall that doesn't mean we shouldn't try to treat them with what we have in our toolbox but if they can get CBT and actually run the program and practice I think it could help them long term.
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Definitely agree, but like you said...It's way too expensive for virtually all but a few pts, and you're better off just recommending they buy a few books to read.

The idea I need a pain psych referral prior to stimulation, when thoracic to sacral fusions do not is unbelievable.
 
some state WC do cover pain psychology. NY does. or at least they profess that they do.

i dont think we are all doing the exact same thing. i spend a lot more than 5 min with the chronic patients, there is always a discussion on mood and depression and how to improve these factors, including discussion about benefits of pain psychology and the benefits of seeing the pain psychologist.

it took me years but through close communication with the psychiatry department and psychology professor and with incorporation of a NYS grant regarding mental health, here is an embedded pain psychologist who will see these patients and bills through OMH. she also does SCS evals.


i usually recommend these:
www.google.com

Managing Pain Before It Manages You

Join the hundreds of thousands of readers who have found help and hope for getting their lives back from chronic pain in this empowering workbook. Top pain specialist and physician Margaret A. Caudill spells out 10 steps that can radically change the way you feel--both physically and...
www.google.com

amazon link didnt work. here is hte author site. i have audiobook.

Pain Management

www.vidyamala-burch.com www.vidyamala-burch.com
 
cowboydoc said:
Not a terrible plan. All could be retired by the time the MME gets problematically low.
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I did hasty math at that time and came up with something like an 8 year wean or something insane like that.
 
lobelsteve said:
Bladder stim w s3 lead
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Patient told me it was “for the nerve pain in her feet“ … I presume DRG.

I’ll look through some prior images of other similar cases, hopefully find one I’ve seen similar to this, but instead of pedicle screws, an interspinous spacer.
 
callmeanesthesia said:
Why is there a lone quotation mark at the end of the title?? And why is that alone in red? Did he self-publish this or something?
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Is this one of those low budget ‘Who’s Who’ or Southwest Airlines type publications in which you pay them money to feature you?
 
swamprat said:
I think certain patients that are not axis II could benefit from CBT - but the problem is they are never on board with it and no one does it except high cash pay psych. In my opinion pain catastrophizing is a serious issue - not that everyone has it like your example of the 78 year old facet lady but you know what I mean when you see that patient and they are always "terrible" this and that. Just my 2 cents. Overall that doesn't mean we shouldn't try to treat them with what we have in our toolbox but if they can get CBT and actually run the program and practice I think it could help them long term.
Click to expand...
moodgym.com.au
Clinically validated, online CBT, cheap.
 
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Ducttape said:
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.
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So, as a pain doc - you believe that there is no such thing as severe chronic pain?

I feel like I have to be misunderstanding this. Please tell me I'm misunderstanding this.
 
hippieskippy said:
So, as a pain doc - you believe that there is no such thing as severe chronic pain?

I feel like I have to be misunderstanding this. Please tell me I'm misunderstanding this.
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That’s not what he said at all. When the affective component is far greater than the nociceptive component the treatment that should work will not. At least until we address the psychological component.
 
hippieskippy said:
So, as a pain doc - you believe that there is no such thing as severe chronic pain?

I feel like I have to be misunderstanding this. Please tell me I'm misunderstanding this.
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there is absolutely severe chronic pain.


but ofttimes there is severe pain in the setting of mild findings. and often patients have severe injury with low perceived pain.

pain itself can also be psychological not purely physical.



i had a unique experience early in my ER days. i saw a patient who cut his finger at work, did not tolerate local lidocaine for suture, and screamed to high heaven with the digital block. 1 simple interrupted. he requested morphine and a week off of work and was angry when he got neither.

a couple of hours later, a construction worker came in still nailed to a board. nailgun disintegrated the patients 3rd and fractured 4th metacarpals. they could not pull his hand off, so they brought him in still attached to the wood.

he asked me to pull the nail out. i said i couldnt, he needed to be transferred to somewhere that had hand surgery. he asked if i could just bandage it up so the blood would stop dripping on the homeowners floors because he could go finish the job, then he'd be willing to drive himself to MUSC, 2 hours away. did not request anything for pain. just had to go back and finish the job and it didnt hurt bad enough to stop working.
 
Guy requesting morphine was likely just looking to get high and wanting a vacation.. probably had nothing to do with his pain perception. sorry but one of the worst things about pain is we never really know who is really hurting vs desiring the euphoria opioids provide.
 
Agast said:
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.
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CRNAs can also do a "pain fellowship." That doom and gloom will always be there but the anesthesia market is hot regardless.
 
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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Psychosocial issues, pain anxiety, fear of pain, provocation, catastrophizing, etc..

If I palpate a patient’s lumbar paraspinals and she jumps or gasps, I’m going palpate the contralateral side. If I get the same response, I’m going palpate the contralateral forearm. If I get the same response there, I’m almost certainly looking at fibromyalgia, superimposed on whatever anatomic lumbar spine issue the patient has. Whatever you wanna call it, I can’t use palpation to tell me anything about the location or severity of the patient’s pain. In probably 75% of these cases the patients will also have exaggerated guarding/fearful responses to physical examination requiring significant muscle effort and/or muscle stretch. In these cases the diagnostic utility of my physical exam is further diminished.

Does this mean that none of these patients would benefit from injection? No. However, I am willing to bet that many of these patients who have “failed” multiple injections (selected based upon imaging review and provocative physical examination) were examined without the performing physician noticing that the exaggerated responses were generalized.

I taught a patient a wall sit the other day. Despite having been in and out of 2 different pain physicians’ offices and through multiple courses of physical therapy over the last five years, she was absolutely terrified to step her 2nd foot away from the wall just to get into the wall sit starting position. It was almost like watching someone stand on the ledge of a building thinking if she took one step too far, she would fall off. She was eventually able to work towards performing 2 sets of 5 dynamic wall sits per day. I’m seeing her for follow up this week. Do we really believe that a patient like this would benefit more from a procedure than just learning how to not be afraid to do very basic exercise?


I don’t usually post stuff like this. It takes too much mental energy that I don’t have after clinic. I’ve been sick for the last few days though and am still a little delirious haha.

What’s the point? I don’t know. I just see so many patients like this and wonder if all the people seeing them before me really thought that they could help the patient by just continuing to perform injections. Is it insufficient knowledge depth? Lack of curiosity? The need to see patients so quickly that this type of education is impossible?

I guess there are some patients you shouldn’t pretend like you are going to be able to help when you schedule initial consults for 15-20 minutes.
 
Kissmyabjj said:
Psychosocial issues, pain anxiety, fear of pain, provocation, catastrophizing, etc..

If I palpate a patient’s lumbar paraspinals and she jumps or gasps, I’m going palpate the contralateral side. If I get the same response, I’m going palpate the contralateral forearm. If I get the same response there, I’m almost certainly looking at fibromyalgia, superimposed on whatever anatomic lumbar spine issue the patient has. Whatever you wanna call it, I can’t use palpation to tell me anything about the location or severity of the patient’s pain. In probably 75% of these cases the patients will also have exaggerated guarding/fearful responses to physical examination requiring significant muscle effort and/or muscle stretch. In these cases the diagnostic utility of my physical exam is further diminished.

Does this mean that none of these patients would benefit from injection? No. However, I am willing to bet that many of these patients who have “failed” multiple injections (selected based upon imaging review and provocative physical examination) were examined without the performing physician noticing that the exaggerated responses were generalized.

I taught a patient a wall sit the other day. Despite having been in and out of 2 different pain physicians’ offices and through multiple courses of physical therapy over the last five years, she was absolutely terrified to step her 2nd foot away from the wall just to get into the wall sit starting position. It was almost like watching someone stand on the ledge of a building thinking if she took one step too far, she would fall off. She was eventually able to work towards performing 2 sets of 5 dynamic wall sits per day. I’m seeing her for follow up this week. Do we really believe that a patient like this would benefit more from a procedure than just learning how to not be afraid to do very basic exercise?


I don’t usually post stuff like this. It takes too much mental energy that I don’t have after clinic. I’ve been sick for the last few days though and am still a little delirious haha.

What’s the point? I don’t know. I just see so many patients like this and wonder if all the people seeing them before me really thought that they could help the patient by just continuing to perform injections. Is it insufficient knowledge depth? Lack of curiosity? The need to see patients so quickly that this type of education is impossible?

I guess there are some patients you shouldn’t pretend like you are going to be able to help when you schedule initial consults for 15-20 minutes.
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It’s probably a combination of a busy schedule, overload, $$$, and lack of training or desire to address the biopsychosocial aspects of pain and explain central sensitization and pain catastrophizing with the patient. It’s the rare person who enjoys or wants to take the time to engage in these types of conversations. In my experience they often aren’t well received
 
no where in our current system are there incentives to incorporate this kind of treatment.


move people in and out, see them so quickly they cant catch a breath, set them up for the next injection or procedure, in the remote hope that that will be the miracle.

its all about the $$$.

and yes, part of it is the patients' expectations that they are so focused on a cure because that is what society tells them is out there. which is one reason why therapy is not well recieved.


because of this, people wont get better.
 
PinchandBurn said:
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
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Bad assumption. They’re moving in rapidly
 
lobelsteve said:
www.linkedin.com

🚨 Pain Medicine Match: Are We in a Crisis? | Scott Pritzlaff MD

🚨 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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Is this the same guy who thinks we should extend pain fellowships to 2 and 3 years? 🤣

Talk about cratering the applicants
 
Sometimes I think there should be two specialties, procedural pain medicine and everything else, so people know what they’re getting.
 
masterPain said:
Is this the same guy who thinks we should extend pain fellowships to 2 and 3 years? 🤣

Talk about cratering the applicants
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His former boss constantly pumped a 24 month pain fellowship plan, and if you sat down at a table with him (Sean Mackey) he’d utterly destroy you in that debate.
 
MitchLevi said:
His former boss constantly pumped a 24 month pain fellowship plan, and if you sat down at a table with him (Sean Mackey) he’d utterly destroy you in that debate.
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Lol typical academic. I wouldn’t waste my time. 2 years is preposterous
 
That would be good if you wanted to go into academics and do research, which virtually no one ACTUALLY wants to do in the real world. It's good to say that when you're a trainee, but you're gonna be grossly stunted in your growth as an MD if you go that route.
 
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