Pain vs anesthesia

[solomonliu]

For those who considered fellowship (specifically pain but can be any) but ultimately ended up doing private practice anesthesia, what were your reasons?

I am about to apply for fellowship and am torn between pain fellowship vs private practice anesthesia.

Thanks in advance!

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[Twiggidy]

For those who considered fellowship (specifically pain but can be any) but ultimately ended up doing private practice anesthesia, what were your reasons?

I am about to apply for fellowship and am torn between pain fellowship vs private practice anesthesia.

Thanks in advance!

When deciding on a fellowship, envision yourself doing it everyday. If you don’t like what you see then don’t do the fellowship. That applies to all
of them.

 

[Hoya11]

For those who considered fellowship (specifically pain but can be any) but ultimately ended up doing private practice anesthesia, what were your reasons?

I am about to apply for fellowship and am torn between pain fellowship vs private practice anesthesia.

Thanks in advance!

search my previous posts about this..

 

[Twiggidy]

For those who considered fellowship (specifically pain but can be any) but ultimately ended up doing private practice anesthesia, what were your reasons?

I am about to apply for fellowship and am torn between pain fellowship vs private practice anesthesia.

Thanks in advance!

Example. I did a CV fellowship which was doing hearts everyday for a year. If my practice was 2-4 hearts everyday for the rest of my career I’d love it and be satisfied regardless of how much a heart is reimbursed. In contrast if I had to do pain clinic everyday, I’d be better served working at the Apple Store instead.

 

[Aether2000]

This is what pain medicine in practice is all about: Part of the guys doing this hold patients hostage for drugs that are withheld if they do not agree to a continuous and never-ending series of epidurals, SI injections, facet injections, and RF neurotomies. Some are just drug dealers outright prescribing high dose opioids for extremely questionable reasons. Some are simply block jocks- offering only injections but find themselves squeezed by insurance carriers who place increasing restrictions on procedures and deem some standard procedures performed for the past 50 years to be "investigational". Pain doctors are slapping expensive bandaids on the nociceptive component of a multimodal etiology of pain, and repeating over and over again because there is no cure- just expensive treatments. Patients are epically dissatisfied, with a high percentage of obesity and smoking (much higher than the general population) and are passive about their treatments. Yes, you can hit a few home runs with long term improvement, but these are uncommon. Those receiving opioids are constantly spinning out of control or take risky changes by drinking alcohol with their meds, and if pain patients overdose, then you face criminal charges. So choose wisely.

 

[powermd]

This is what pain medicine in practice is all about: Part of the guys doing this hold patients hostage for drugs that are withheld if they do not agree to a continuous and never-ending series of epidurals, SI injections, facet injections, and RF neurotomies. Some are just drug dealers outright prescribing high dose opioids for extremely questionable reasons. Some are simply block jocks- offering only injections but find themselves squeezed by insurance carriers who place increasing restrictions on procedures and deem some standard procedures performed for the past 50 years to be "investigational". Pain doctors are slapping expensive bandaids on the nociceptive component of a multimodal etiology of pain, and repeating over and over again because there is no cure- just expensive treatments. Patients are epically dissatisfied, with a high percentage of obesity and smoking (much higher than the general population) and are passive about their treatments. Yes, you can hit a few home runs with long term improvement, but these are uncommon. Those receiving opioids are constantly spinning out of control or take risky changes by drinking alcohol with their meds, and if pain patients overdose, then you face criminal charges. So choose wisely.

There's no law stating you have to be a scum sucking d-bag if you practice pain medicine. I have a no-narc pain practice that is very satisfying professionally and economically. Just speaking of epidurals, I have a lot of patients who get several months or even years of pain relief from a single shot. No sensorium-altering meds, or body scarring surgery. $250 sounds like a great value proposition if you ask me.

I suffered with piriformis syndrome for 3 days before I figured out what it was and treated myself. On day two, I remember thinking I'd happily pay $5000 to make it go away. There's a lot of value in successfully treating someone's pain.

 

[Aether2000]

I would counter no epidural lasts for years. What happened was an acute flair up that resolved more quickly with an epidural, but would have resolved on its own accord with or without the epidural injection. Some may last for months, but many do not, and there is some evidence the more epidural steroids administered per patient, the less pain relief occurs. However you are correct in that you don't have to practice medicine in the gutter, even if many do. Pain patients are frequently directed to the gutter dwellers due to long standing relationships, kickbacks, or taking care of the opioid patients for the increasingly litigation and board of medicine action adverse family physicians. BTW it would have been interesting to see you doing your own US or fluoro or EMG guided piriformis injection. Hope you have some Charlie Aprill-worthy videos of that

 

[powermd]

I would counter no epidural lasts for years.

Anecdotes are anecdotes, but my brother in law suffered with butt pain for a whole year. Tried PT in earnest with no relief. I thought he had piriformis syndrome. Finally the pain started to radiate lower and someone got an MRI- large paracentral L4-5 HNP. One L5-S1 ILESI + 3 days later, 60% improved. 80% at 30 days. Intermittent complete relief vs minor symptoms for the past 3 1/2 years. I have many patients with stories like this one, so I believe it's real. When you eliminate the drug seekers, it's amazing how well interventional pain techniques work. And when it doesn't, I find a different approach that does.

And so sorry to disappoint the Charlie Aprill fans... my piriformis got better with 20 seconds of stretch.

 

[nimbus]

I had pyriformis syndrome too that was bothering me for a few months this year. Butt pain, numb toes, the whole picture. One day last month I noticed it was gone. Sometimes things just get better by themself.

 

[Machinery]

This is what pain medicine in practice is all about: Part of the guys doing this hold patients hostage for drugs that are withheld if they do not agree to a continuous and never-ending series of epidurals, SI injections, facet injections, and RF neurotomies. Some are just drug dealers outright prescribing high dose opioids for extremely questionable reasons. Some are simply block jocks- offering only injections but find themselves squeezed by insurance carriers who place increasing restrictions on procedures and deem some standard procedures performed for the past 50 years to be "investigational". Pain doctors are slapping expensive bandaids on the nociceptive component of a multimodal etiology of pain, and repeating over and over again because there is no cure- just expensive treatments. Patients are epically dissatisfied, with a high percentage of obesity and smoking (much higher than the general population) and are passive about their treatments. Yes, you can hit a few home runs with long term improvement, but these are uncommon. Those receiving opioids are constantly spinning out of control or take risky changes by drinking alcohol with their meds, and if pain patients overdose, then you face criminal charges. So choose wisely.

Generalizations are rarely accurate.

1. Most high dose opiods come from PCPs and research now shows patients under the care of pain management clinics end up on less opiods with better outcomes.
2. Not all injections work but some do for specific patients. Most of the returning patients come back because they got relief from said procedure, not because they are held 'hostage'. The VA has some data on this.
3. Insurance is in fact squeezing everyone doing procedures in medicine, and they should. Folks are exploiting the system like crazy. This is not unique to pain.
4. You are correct about the multimodal etiology of pain. This is the exact reason why you need pain centers and doctors who know how to identify those different aspects of pain. What are you suggesting? We throw our hands up and give up on the patients?
5. You talk about a few home runs? Open your eyes dude! Look at the bulk of cases we are providing anesthesia for. Only a few end up with better outcomes. "A few home runs" is the name of the game in our reactionary healthcare system. Not a problem specific to pain.
6. The bulk of criminal charges related to opioid meds involve non pain doctors practicing pain management. Not all patients on opioids spin out of control drinking alcohol as you stated.

Pain management is an evolving field and it should be. Opioids will take a lesser role as will those dabbling in pain management using opiods. This will lead to a need for real pain management physicians. The population is aging and chronic pain patients are increasing. Pain doctors will do great, and as is the case with all the doomsayers for all specialties, they will be wrong.

On a more personal note, my inlaw had knee pain. She does not take any opioids. She is not a surgical candidate. She got a knee ablation done and she has a vast improvement in her pain and quality of life. That might be a rare home run by a pain specialist, but it is our homerun and he did a lot more for us than the random pain doctor bashing comments I sometimes see on SDN.

 

[Aether2000]

I suppose i might be a bit jaded but of the 25 pain docs in my region, 20 of them were engaged in the behaviors described including many who told patients they had to have the injections in order to obtain opioids. No bashing, just facts. The stats from 2015 showed pain docs prescribed the highest dosages of opioids while PCPs prescribed opioids to more individuals. There is nothing wrong with interventional treatments for pain if you realize that the psychological, social, financial, and neuroplasticity aspects of pain are not improved significantly by a pure noceceptive approach (pain generators). This was shown by Loeser back in the early 1980s. What we lack are the tools to attack these entrenching aspects of chronic pain or to do so at an affordable cost.

 

[neutro]

current pain medicine practice needs to be renamed as addiction psychiatry...thats like 70-80% of our new patients in clinic.

"My FP wont write my 3 percocets a day because I dont have a second lumbar fusion. He said as a PCP, I am "not allowed" to write for pain medications anymore. He said I need to see "pain management". I took my last pill today".

I got tired of dealing with this non sense every day, so I am taking a break from pain.

 

[244913]

Interventional psychiatry

 

[Twiggidy]

And this is what's slowly being realized......even in private practice pain management, you're still a service industry.

 

[neutro]

And this is what's slowly being realized......even in private practice pain management, you're still a service industry.

Its more than that, read algosdoc's posts here and on pain forums to get an honest understanding of current pain practice.

I practiced hospital based pain for 2 years straight after fellowship - solo practice in a small community hospital. PP pain management is another beast and full of unethical choices.

My practice was extremely busy. Lots of medicaid patients. Mix of interventional and med mgt (cancer pain, palliative, totally refractory pain, vascular patients on anticoagulation and refractory ischemic pain, etc). The problem isn't the pain diagnosis or our skill or whether a physician writes for opioids or not - that is a debatable issue, most pain physicians would agree that there are certain painful conditions where opioids do help the patient esp. when there are no other options left, i.e. in a compliant patient with a truly refractory painful condition with demonstratable functional limitation and QOL, ability to work, and mood changes if pain is not controlled. The problem is that there is no end point to "pain management". What happens two years down the road with that patient? What about 5? Do you wean? If so, when? What happens if the wean fails.

Many interventional pain modalities have moderate to weak evidence behind them. Stims have a 30-40% lead migration rate 2-3 years after implantation. Intrathecal pumps have not been shown to be effective for CNMP. Recent study by Steve Cohen showed MBB neurotomy may not be as effective as previously shown. Cervical medial branch RFAs tend to help for 5-6 months only. ESIs have been controversial since day 1 but we still do them for palliation and temporary pain relief.

So, if you look at it from a cost-effective standpoint, to an observer and a non pain doc , these procedures also do not have much value (value = benefit/cost). Infact, you talk to many internists, they dont even believe in these procedures by saying "we send the patient to pain mgt, they do a block and send the patient back - patient didnt improve, now what."
Thats just the tip of the iceberg. I would call the current landscape in pain as simply, 'complicated'.