Pain versus cardiac fellowship?

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Mmmk. Since we cant just talk this out like reasonable people, here are some excerpts from the brick of a text above. Luckily I have a digital version. Try to call on your reading skills here sevo. Dig deep. Since SCS is the major topic under fire here lets start there. This is the chapter on SCS and PNS:
Excerpt 1.JPG

Excerpt 2.JPG

Excerpt 3.JPG


As for you, AK, maybe you just suck at it?
 
Haha yes. I am the worst SCS guy on this planet. I’m very horrible. Like the worst. It’s all me. Like 10000000% me me me.

It’s definitely not the industry driven manipulation, reps, device or evidence or ****ty technology. All 100k patients that complained to FDA and 450+ deaths are all implanted by me in a ****ty manner. Countries are banning SCS because of my poor technique. Me me me. Yup 100%.

Got it.
 
AKMD_1984 said:
Haha yes. I am the worst SCS guy on this planet. I’m very horrible. Like the worst. It’s all me. Like 10000000% me me me.

It’s definitely not the industry driven manipulation, reps, device or evidence or ****ty technology. All 100k patients that complained to FDA and 450+ deaths are all implanted by me in a ****ty manner. Countries are banning SCS because of my poor technique. Me me me. Yup 100%.

Got it.
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Patients who file complaints about SCS are the only patients filing device claims is that it? Shall we dig up how many claims are filed on fusion hardware? Like I said, in my clinic I have seen few complaints. Is it possible for leads to migrate? of course. Is it possible for them to short? of course. Many of these issues are problems with the technique. Are the leads anchored properly? If your patients are losing efficacy with perc leads, maybe its time you started referring to a neurosurgeon for a paddle lead. Those are shown in literature, to migrate less.
 
TeslaCoil said:
Mmmk. Since we cant just talk this out like reasonable people, here are some excerpts from the brick of a text above. Luckily I have a digital version. Try to call on your reading skills here sevo. Dig deep. Since SCS is the major topic under fire here lets start there. This is the chapter on SCS and PNS:
View attachment 397404
View attachment 397405
View attachment 397406

As for you, AK, maybe you just suck at it?
Click to expand...


I live in your head rent free haha. I love it. 🫵😹

You can post as much as you want. I’m not changing my mind.
 
TeslaCoil said:
And btw the military base and VA in my area refer to me almost exclusively.
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The rule was (and I'm sure still is) that pain referrals could only go out to the civilian network if the military pain clinic was full.

(Where "full" is a value consistent with government workload.)

There were certainly a lot of military patients who got referred to outside pain clinics, but our pain clinic was always booked solid. And so the salaried pain guys there had no incentive or need to cater to what the referring physician might have wanted. Their plate was always full. Consequently, opioids didn't get started or refilled for non-cancer pain, and their threshold for doing some of the lower yield procedures was high.

The culture was quite different than the other pain clinics I've had exposure to. I think their care was better.
 
pgg said:
The rule was (and I'm sure still is) that pain referrals could only go out to the civilian network if the military pain clinic was full.

(Where "full" is a value consistent with government workload.)

There were certainly a lot of military patients who got referred to outside pain clinics, but our pain clinic was always booked solid. And so the salaried pain guys there had no incentive or need to cater to what the referring physician might have wanted. Their plate was always full. Consequently, opioids didn't get started or refilled for non-cancer pain, and their threshold for doing some of the lower yield procedures was high.

The culture was quite different than the other pain clinics I've had exposure to. I think their care was better.
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The VA does have a pain physician who is very half-azzed here. And the military base here has no pain physician at all. I have a close relationship with both the VA and the base. Two of my PA's are retired combat medics who are well known on base. We provide 100% top notch care.
 
TeslaCoil said:
The VA does have a pain physician who is very half-azzed here. And the military base here has no pain physician at all. I have a close relationship with both the VA and the base. Two of my PA's are retired combat medics who are well known on base. We provide 100% top notch care.
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How many years have you been in practice?
 
TeslaCoil said:
The VA does have a pain physician who is very half-azzed here. And the military base here has no pain physician at all. I have a close relationship with both the VA and the base. Two of my PA's are retired combat medics who are well known on base. We provide 100% top notch care.
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What do you mean by half-azzed?

Sometimes the best delivery of medical care is to do as much nothing as possible. Don't just do something, stand there!

I'll grant you that the VA generally attracts doctors who don't necessarily want to see a lot of patients or work very hard (volume wise).
 
pgg said:
What do you mean by half-azzed?

Sometimes the best delivery of medical care is to do as much nothing as possible. Don't just do something, stand there!

I'll grant you that the VA generally attracts doctors who don't necessarily want to see a lot of patients or work very hard (volume wise).
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Ah, house of god. Great book. Well thats definitely this guys approach. Some med mgmt and minimal interventional procedures. Few pts overall. On his way to retirement. Nice guy though.
 
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This thread is wild.



I’m a pain doc in a big southern city. On a day to day basis I would say that it’s a job. I don’t love it and don’t hate it. Regular hours and 6 weeks vacay can get time off on short notice. We’re 4 days a week which is pretty nice. I have a buddy who is at one of the major hospital systems who does 15%gas and 85% pain. He gets 12 weeks but has trouble making last minute changes in his schedule.

Will say that our group is nice in that there’s no production pressure and I can do what I think is best for the patients. If they have a radic will try ESI if it doesn’t work I won’t repeat and never push patients to get procedures. I see a lot of patients that have been to other practices that are basically if you want meds you have to get injected. RFAs seem to be about 60-70% successful for facet arthropathy in my practice with a good portion lasting >1year.

I would chime in that you have to be okay with people complaining all day. I usually interject some jokes to try and lighten the mood. Sometimes I feel like a counselor and for some older patients I might be their only human interaction for that week. I get to have relationships with patients, which I find to be the most rewarding part of the job. I felt that I didn’t get that in anesthesia.

The competition in our city is insane though. We have a few offices and the busiest ones are an hour outside the city. If you want to be in the city you have to market like crazy and then still not get as busy as you’d like.

My biggest problem with pain was the documentation and we just got ai scribe and it’s made that aspect a whole lot better.

All of that said, I think anesthesia market is nuts right now. You can easily find GA jobs in the 6-700k range w/ 12 weeks off. You will never find that in pain and especially not in major metro. Only way to make that work would be to open a practice yourself and hire other doctors that will bring in money.

If I could do it again I would probably choose anesthesia over pain TBH. I would say that most pain docs are reasonably happy but so are most anesthesiologists.

Just my 2 cents
 
gasmanmd2020 said:
RFAs seem to be about 60-70% successful for facet arthropathy in my practice with a good portion lasting >1year.
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Sounds like it's "The Panther" of procedures.

If that's the bar for "success" it says a lot about interventional pain.
 
pgg said:
Sounds like it's "The Panther" of procedures.

If that's the bar for "success" it says a lot about interventional pain.
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That's about standard for any of our treatments for chronic pain: PT, NSAIDs, muscle relaxers, gabapentin, lidocaine patches, and so on.

Modern medicine isn't great at chronic pain on any front.
 
You can do both if you can afford the delay in gratification. Especially if you and to do academics.
 
One of the things I truly despise about pain mgt is that there are multiple routes to be a “pain physician”.

Credentials and training matters. Too many competing societies, ASIPP, American Pain society, SIS, ASRA, NANS, ASPN etc

An anesthesiology residency and its rigor, stress and call burden is not equivalent to PMR or psychiatry. Yet they’re practicing it. Many FP docs too.

I look at pain mgt as just an extension of anesthesiology and practice as such.

But since we live in a society where skipping the line is accepted - we think it’s ok for pain mgt too.
 
AKMD_1984 said:
One of the things I truly despise about pain mgt is that there are multiple routes to be a “pain physician”.

Credentials and training matters. Too many competing societies, ASIPP, American Pain society, SIS, ASRA, NANS, ASPN etc

An anesthesiology residency and its rigor, stress and call burden is not equivalent to PMR or psychiatry. Yet they’re practicing it. Many FP docs too.

I look at pain mgt as just an extension of anesthesiology and practice as such.

But since we live in a society where skipping the line is accepted - we think it’s ok for pain mgt too.
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Don’t forget aana actively promotes learn on the job weekend certificates for crnas to do interventional pain as well.
 
aneftp said:
Don’t forget aana actively promotes learn on the job weekend certificates for crnas to do interventional pain as well.
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Yeah well I don’t take AANA seriously
We are talking about legitimate intellectually organized authorities - physician led/ managed

There’s too many of those

In contrast we only have one ASA
 
AKMD_1984 said:
Yeah well I don’t take AANA seriously
We are talking about legitimate intellectually organized authorities - physician led/ managed

There’s too many of those

In contrast we only have one ASA
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There are quite a few crna doing interventional pain in Florida. The only requirement to be successful in Florida is how motivated you are.

That’s the problem with pain. Too many people can do it and learn on the jon

Same thing with plastic surgeons. The real ones went through either 6 years or more of training yet so many wanna be plastic surgeons without the full credentials do various plastic surgeries.
 
aneftp said:
You can do both if you can afford the delay in gratification. Especially if you and to do academics.
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You just can't. Not well anyway. Complex cardiac requires full timers. Im sure pain is the same...
Sure maybe rinky dink operations are fine but high level stuff, no way
 
PpfSuxTube said:
You just can't. Not well anyway. Complex cardiac requires full timers. Im sure pain is the same...
Sure maybe rinky dink operations are fine but high level stuff, no way
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Some docs did mutiple fellowships this way. My good friend in North Carolina did this for years. Small town hospitals helped him build his pain practice plus he did the hybrid general/cardiac

There are docs who do peds fellowship and than cardiac as well and pain! Call them crazy

First dude I met on locums market 20 years ago was quadruple board certified (pain, im/peds, icu) plus army reserve. Simply amazing doc. Real fellowship train in pain and cardiac annes and critical care medicine. Plus has his IM/peds (4 years ) primary training. Than he did anesthesia (3 years)
 
aneftp said:
There are quite a few crna doing interventional pain in Florida. The only requirement to be successful in Florida is how motivated you are.

That’s the problem with pain. Too many people can do it and learn on the jon

Same thing with plastic surgeons. The real ones went through either 6 years or more of training yet so many wanna be plastic surgeons without the full credentials do various plastic surgeries.
Click to expand...

aneftp said:
Some docs did mutiple fellowships this way. My good friend in North Carolina did this for years. Small town hospitals helped him build his pain practice plus he did the hybrid general/cardiac

There are docs who do peds fellowship and than cardiac as well and pain! Call them crazy

First dude I met on locums market 20 years ago was quadruple board certified (pain, im/peds, icu) plus army reserve. Simply amazing doc. Real fellowship train in pain and cardiac annes and critical care medicine. Plus has his IM/peds (4 years ) primary training. Than he did anesthesia (3 years)
Click to expand...

Where I went to med school, there was an anesthesia attending who had done pediatrics residency, then peds ICU fellowship, then realized what he actually wanted was that degree of complexity but in the OR, so he went on to do anesthesia residency, peds anesthesia fellowship, and lastly peds cardiac anesthesia fellowship. One of the most medically intelligent guys I’ve ever met. Probably going to be working forever after spending 12 years in training.
 
aneftp said:
Some docs did mutiple fellowships this way. My good friend in North Carolina did this for years. Small town hospitals helped him build his pain practice plus he did the hybrid general/cardiac

There are docs who do peds fellowship and than cardiac as well and pain! Call them crazy

First dude I met on locums market 20 years ago was quadruple board certified (pain, im/peds, icu) plus army reserve. Simply amazing doc. Real fellowship train in pain and cardiac annes and critical care medicine. Plus has his IM/peds (4 years ) primary training. Than he did anesthesia (3 years)
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With respect. I dont mean racking up fellowship.
I meant being an actual cardiac anesthesiologist that can do any case well and help the surgeon and patient.

Obtaining a fellowship means very little in terms of competence. All you have to do is show up. And even the best fellowship can't prepare you for real life doing solo complex cases with demanding surgeons and structural heart proceduralists...

Can a fellow tell the surgeon what size mitral ring to place within 2mm? How many neocords and where? You got maybe 15 mins before theyre calling for heparin and want to know how to fix this valve. Can a fellow guide a cardiac proceduralist thru mitralclip on tee from septal puncture and take severe complex regurg down to trivial? 4 times a day and be done by 6pm with everyone extubated?

Can anyone @ the end of fellowship/start of staff do that? If they can theyre different gravy to me and I was a solid enough fellow. Not amazing but not terrible. And we did tonnes of cases

I assume pain has complex procedures too? But idk honestly
 
PpfSuxTube said:
With respect. I dont mean racking up fellowship.
I meant being an actual cardiac anesthesiologist that can do any case well and help the surgeon and patient.

Obtaining a fellowship means very little in terms of competence. All you have to do is show up. And even the best fellowship can't prepare you for real life doing solo complex cases with demanding surgeons and structural heart proceduralists...

Can a fellow tell the surgeon what size mitral ring to place within 2mm? How many neocords and where? You got maybe 15 mins before theyre calling for heparin and want to know how to fix this valve. Can a fellow guide a cardiac proceduralist thru mitralclip on tee from septal puncture and take severe complex regurg down to trivial? 4 times a day and be done by 6pm with everyone extubated?

Can anyone @ the end of fellowship/start of staff do that? If they can theyre different gravy to me and I was a solid enough fellow. Not amazing but not terrible. And we did tonnes of cases

I assume pain has complex procedures too? But idk honestly
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And I agree with you. The complex stuff

But remember 95% of stuff community placed do at the basic stuff. Even many cardiac surgeons at smaller hospitals leave their complex valve surgery for bigger hospitals, because they know bigger places have better round a clock care than smaller places.
 
aneftp said:
And I agree with you. The complex stuff

But remember 95% of stuff community placed do at the basic stuff. Even many cardiac surgeons at smaller hospitals leave their complex valve surgery for bigger hospitals, because they know bigger places have better round a clock care than smaller places.
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For sure. There just aren't enough bodies to demand everyone specialises to the nth degree but I also believe you can't pick and choose when a ruptured pap comes in or something.

We even offer an out of hours mitraclip rescue service with some great results...

Our cardiac dept doesn't allow ppl pick and choose their lists. Everyone has to do everything
 
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