PM&R Pain and ortho groups, EMGs

[premed67783]

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Are there any Pain-trained PM&R docs out there with experience working with private Ortho groups who want EMGs? I'm talking to one such group, and I was hoping to get some experienced input on whether this is generally a good idea, what that setting is like, what questions should I be asking, and any red flags I should look out for as I consider this practice. Any and all opinions/insights would be appreciated.

Some background info:
I'm a current fellow at an ACGME pain program. My background is PM&R. I'm finishing fellowship July 2022, and I'm talking to a couple practices in a Texas metro area.

One of the practices is a relatively large private Ortho spine group, ~15 surgeons, 4 physiatrists (2 pain-trained).

I was connected to them through a friend of a friend, and the practice seems to have a good reputation from what I gather. They say they're looking for "a great interventional pm&r physician who also does EMGs". I wouldn't mind doing EMGs early in my career, but ultimately I'm much more interested in building a practice focused on interventional pain procedures, implantable devices, and any new promising procedures that develop in the future.

I'm pretty new to this whole "job hunting" thing, especially the intricate workings of the private practice world, so I want to be aware of any potential pitfalls and questions I should be asking. I also wondering about a few potential concerns. In particular...

1. The fact that it's so surgeon heavy makes me wonder if the physiatrists end up being pushed around and having little say in how they practice. Is this a real problem? Am I being neurotic?

2. EMGs and compensation. From what I understand, EMGs don't pay nearly as well as spine injections, SCS, and all the other stuff you do a pain fellowship for. I'm wondering how much this would actually hurt my earnings. I'm also wondering if agreeing to do EMGs may somehow pidgeon-hole me into becoming the "EMG guy". I would want to transition away from them eventually.

3. New procedures. Are Ortho practices generally open to the PM&R/pain guy adopting new procedures? I definitely want to continue expanding my skills, and periodically adding new procedures throughout my career.

 

[Agast]

They’re not asking you to do only EMGs, they want the ease of having it done in house quickly to rule in radiculitis

 

[willabeast]

Are there any Pain-trained PM&R docs out there with experience working with private Ortho groups who want EMGs? I'm talking to one such group, and I was hoping to get some experienced input on whether this is generally a good idea, what that setting is like, what questions should I be asking, and any red flags I should look out for as I consider this practice. Any and all opinions/insights would be appreciated.

Some background info:
I'm a current fellow at an ACGME pain program. My background is PM&R. I'm finishing fellowship July 2022, and I'm talking to a couple practices in a Texas metro area.

One of the practices is a relatively large private Ortho spine group, ~15 surgeons, 4 physiatrists (2 pain-trained).

I was connected to them through a friend of a friend, and the practice seems to have a good reputation from what I gather. They say they're looking for "a great interventional pm&r physician who also does EMGs". I wouldn't mind doing EMGs early in my career, but ultimately I'm much more interested in building a practice focused on interventional pain procedures, implantable devices, and any new promising procedures that develop in the future.

I'm pretty new to this whole "job hunting" thing, especially the intricate workings of the private practice world, so I want to be aware of any potential pitfalls and questions I should be asking. I also wondering about a few potential concerns. In particular...

1. The fact that it's so surgeon heavy makes me wonder if the physiatrists end up being pushed around and having little say in how they practice. Is this a real problem? Am I being neurotic?

2. EMGs and compensation. From what I understand, EMGs don't pay nearly as well as spine injections, SCS, and all the other stuff you do a pain fellowship for. I'm wondering how much this would actually hurt my earnings. I'm also wondering if agreeing to do EMGs may somehow pidgeon-hole me into becoming the "EMG guy". I would want to transition away from them eventually.

3. New procedures. Are Ortho practices generally open to the PM&R/pain guy adopting new procedures? I definitely want to continue expanding my skills, and periodically adding new procedures throughout my career.

Are there any Pain-trained PM&R docs out there with experience working with private Ortho groups who want EMGs? I'm talking to one such group, and I was hoping to get some experienced input on whether this is generally a good idea, what that setting is like, what questions should I be asking, and any red flags I should look out for as I consider this practice. Any and all opinions/insights would be appreciated.

Some background info:
I'm a current fellow at an ACGME pain program. My background is PM&R. I'm finishing fellowship July 2022, and I'm talking to a couple practices in a Texas metro area.

One of the practices is a relatively large private Ortho spine group, ~15 surgeons, 4 physiatrists (2 pain-trained).

I was connected to them through a friend of a friend, and the practice seems to have a good reputation from what I gather. They say they're looking for "a great interventional pm&r physician who also does EMGs". I wouldn't mind doing EMGs early in my career, but ultimately I'm much more interested in building a practice focused on interventional pain procedures, implantable devices, and any new promising procedures that develop in the future.

I'm pretty new to this whole "job hunting" thing, especially the intricate workings of the private practice world, so I want to be aware of any potential pitfalls and questions I should be asking. I also wondering about a few potential concerns. In particular...

1. The fact that it's so surgeon heavy makes me wonder if the physiatrists end up being pushed around and having little say in how they practice. Is this a real problem? Am I being neurotic?

2. EMGs and compensation. From what I understand, EMGs don't pay nearly as well as spine injections, SCS, and all the other stuff you do a pain fellowship for. I'm wondering how much this would actually hurt my earnings. I'm also wondering if agreeing to do EMGs may somehow pidgeon-hole me into becoming the "EMG guy". I would want to transition away from them eventually.

3. New procedures. Are Ortho practices generally open to the PM&R/pain guy adopting new procedures? I definitely want to continue expanding my skills, and periodically adding new procedures throughout my career.

I am not Physiatrist but i worked amongst them for 25 years. Seems to me reading/doing EMGs was not considered status - y. Suspect it had to do with reimbursement. When you are new you get the worst jobs. Always. Regarding getting pushed around. Who owns the business? Whomever that is (there could also be limited partners as well) gets to do the pushing. If you take the job, and they offer a limited partnership, go for it. My two cents.

 

[Taus]

Are there any Pain-trained PM&R docs out there with experience working with private Ortho groups who want EMGs?

I am. 6 years in.

I'm talking to one such group, and I was hoping to get some experienced input on whether this is generally a good idea, what that setting is like, what questions should I be asking, and any red flags I should look out for as I consider this practice. Any and all opinions/insights would be appreciated.

Don’t know best way to ask, but make sure you’re not used as a dumping ground for post op failures and opioid management.

It can be a great fit in the right group for pmr/pain. I am very happy.

Some background info:
I'm a current fellow at an ACGME pain program. My background is PM&R. I'm finishing fellowship July 2022, and I'm talking to a couple practices in a Texas metro area.

One of the practices is a relatively large private Ortho spine group, ~15 surgeons, 4 physiatrists (2 pain-trained).

I was connected to them through a friend of a friend, and the practice seems to have a good reputation from what I gather. They say they're looking for "a great interventional pm&r physician who also does EMGs

I wouldn't mind doing EMGs early in my career, but ultimately I'm much more interested in building a practice focused on interventional pain procedures, implantable devices, and any new promising procedures that develop in the future.

If the emgs are mostly from hand surgeons it’s generally easy and useful studies. I don’t mind doing them, but don’t love doing them. However as time has gone on my half days of emg are a nice mental break from the routine of clinic and essentially a change of pace. If you are ok doing some, but don’t want to be inundated, then just set limits on how many/week you’re willing to do. IMO anything more than a half day/week will detract too much from your spine/pain practice.

I'm pretty new to this whole "job hunting" thing, especially the intricate workings of the private practice world, so I want to be aware of any potential pitfalls and questions I should be asking. I also wondering about a few potential concerns. In particular...

1. The fact that it's so surgeon heavy makes me wonder if the physiatrists end up being pushed around and having little say in how they practice. Is this a real problem? Am I being neurotic?

Say In how the practice is run? Highly Doubtful. But I’d think that’s true of any large established group that you join, Ortho or not. Say in how you practice and treat patients?- no way. I’d look elsewhere if the latter was taking place. You’ll need to ask the current pmr docs.

2. EMGs and compensation. From what I understand, EMGs don't pay nearly as well as spine injections, SCS, and all the other stuff you do a pain fellowship for. I'm wondering how much this would actually hurt my earnings. I'm also wondering if agreeing to do EMGs may somehow pidgeon-hole me into becoming the "EMG guy". I would want to transition away from them eventually.

As above. Last time I ran the numbers it was kinda neutral vs clinic. Def less than a half day of procedures. However, if you’re in a group with spine surgeons and they are directly referring injections to you, this negates the loss of clinic time for emg, ie where you're not generating spine procedures

3. New procedures. Are Ortho practices generally open to the PM&R/pain guy adopting new procedures? I definitely want to continue expanding my skills, and periodically adding new procedures throughout my career.

New? Sure…. As long as not encroaching on traditionally spine surgical procedures.

Hope that helps.

 

[Taus]

They’re not asking you to do only EMGs, they want the ease of having it done in house quickly to rule in radiculitis

Emg is really not very useful for this. Only 60-70% sensitive for radic….

 

[callmeanesthesia]

My partner is PM&R and does EMGs as part of a very busy interventional practice. Seems quite lucrative for him. He does 4-6 EMGs per day. He has a tech who does the NCS, then he comes over in between procedures to do the EMG. Dictates the interpretations at the end of the day. I think if you have a nurse or tech to do most of the time-consuming work it can be highly lucrative. (Caveat - I’m anesthesia-trained so i don’t have direct experience).

 

[deleted875186]

I would question why they need so many EMGs done, don’t typically need it in straightforward radic. Are they doing it gor surgical planning? Perhaps a lot for carpal tunnel if there’s someone that does hand surgery.

 

[Dr. Ice]

EMGs are not great for radic..there are false negatives and positives. I did a bunch for Rothman institute, when I worked there. Some of their “esteemed hand surgeons” used to send a bunch to me back in the day. I found it really important to read the orthos note prior to doing the study. Often times they are convinced of a diagnosis and want you to validate it. Or they don’t want to operate, and are looking for you to find something else. If you are ethical, and call it like you see it, you would see your referrals go down. I usually called a spade a spade,
but at one of the offices I worked at, I was the only one who did it, so they were stuck. These guys used to send me the EMGs on the day before they were scheduled for surgery to validate. Not sure if there was an insurance pre-requisite at the time.
I didn’t mind doing it back then because it actually reimbursed better. Now it’s not worth it at all in my opinion. You can see more patients in the amount of time it would take to do EMGs which might have more value..

 

[RoloTomassi]

1. The fact that it's so surgeon heavy makes me wonder if the physiatrists end up being pushed around and having little say in how they practice. Is this a real problem? Am I being neurotic?

It may or may not be, depending on the docs/practice culture. Ask the PM&R guys. Can PM&R become equal partners? Is there high turnover?

I'm also wondering if agreeing to do EMGs may somehow pidgeon-hole me into becoming the "EMG guy". I would want to transition away from them eventually.

Probably best not to refuse to do them. I doubt the other guys like to do them either, so that makes you, the fresh out of training guy, look pretty entitled. I would be firm that you only want to take on an equal share and the other PM&R don't dump them on you. If you get busy enough that doing then is not the most valuable use of your time, they shouldn't object to outsourcing them. Definitely find out how many the others do weekly.

Are Ortho practices generally open to the PM&R/pain guy adopting new procedures

As long as they are profitable ones and don't cannibalize their business. May be tricky with regen med, genicular RFA, etc

 

[vadim1980]

Are there any Pain-trained PM&R docs out there with experience working with private Ortho groups who want EMGs? I'm talking to one such group, and I was hoping to get some experienced input on whether this is generally a good idea, what that setting is like, what questions should I be asking, and any red flags I should look out for as I consider this practice. Any and all opinions/insights would be appreciated.

Some background info:
I'm a current fellow at an ACGME pain program. My background is PM&R. I'm finishing fellowship July 2022, and I'm talking to a couple practices in a Texas metro area.

One of the practices is a relatively large private Ortho spine group, ~15 surgeons, 4 physiatrists (2 pain-trained).

I was connected to them through a friend of a friend, and the practice seems to have a good reputation from what I gather. They say they're looking for "a great interventional pm&r physician who also does EMGs". I wouldn't mind doing EMGs early in my career, but ultimately I'm much more interested in building a practice focused on interventional pain procedures, implantable devices, and any new promising procedures that develop in the future.

I'm pretty new to this whole "job hunting" thing, especially the intricate workings of the private practice world, so I want to be aware of any potential pitfalls and questions I should be asking. I also wondering about a few potential concerns. In particular...

1. The fact that it's so surgeon heavy makes me wonder if the physiatrists end up being pushed around and having little say in how they practice. Is this a real problem? Am I being neurotic?

2. EMGs and compensation. From what I understand, EMGs don't pay nearly as well as spine injections, SCS, and all the other stuff you do a pain fellowship for. I'm wondering how much this would actually hurt my earnings. I'm also wondering if agreeing to do EMGs may somehow pidgeon-hole me into becoming the "EMG guy". I would want to transition away from them eventually.

3. New procedures. Are Ortho practices generally open to the PM&R/pain guy adopting new procedures? I definitely want to continue expanding my skills, and periodically adding new procedures throughout my career.

I was in the same boat when I started in the ortho practice right after fellowship. I just made it known to them that I will do EMGs with the understanding that the majority of my practice will be interventional pain management. As long as they get that and are agreeable, then that may be a good idea

Depending on the payer mix, the EMGs can reimburse pretty well and most of the studies you get from the ortho group our pretty straightforward, like carpal tunnel vs radic. Also EMGs can be a good way to build up your schedule when you first start and can result in injections as well. If you have a tech for the NCS part, it may make it easy for you to see clinic patients while a big portion of the study is done

Ultimately I stopped doing EMGs after the first three years, but that’s because I got pretty busy with the other stuff. I still have friends that aren’t as busy and use the EMGs to supplement

 

[premed67783]

Thank you all for your insight! It's all very helpful.

Regarding emerging pain procedures - A number of established and emerging pain interventions sort of blur the line between "pain management" and "spine surgery". I'm thinking SCS/pump implants, MILD, kyphos, vertiflex, SI fusion, etc. I'm sure more will emerge in the future.

I've been wondering how spine surgeons generally feel about pain docs doing these procedures, especially within their own group. Do they generally see this as a threat to their turf? Or are they getting enough business from lamis, fusions, etc that they don't mind?

I haven't seen lot of grumbling or opposition, but I imagine this is the kind of thing that wouldn't be expressed publicly. Does anyone here have a sense of this from working with Ortho/neurosurgeons?

 

[Agast]

I haven't seen lot of grumbling or opposition, but I imagine this is the kind of thing that wouldn't be expressed publicly. Does anyone here have a sense of this from working with Ortho/neurosurgeons?

This practice already has 2 pain doctors. Why don't you ask them what it's like?

 

[deleted875186]

Thank you all for your insight! It's all very helpful.

Regarding emerging pain procedures - A number of established and emerging pain interventions sort of blur the line between "pain management" and "spine surgery". I'm thinking SCS/pump implants, MILD, kyphos, vertiflex, SI fusion, etc. I'm sure more will emerge in the future.

I've been wondering how spine surgeons generally feel about pain docs doing these procedures, especially within their own group. Do they generally see this as a threat to their turf? Or are they getting enough business from lamis, fusions, etc that they don't mind?

I haven't seen lot of grumbling or opposition, but I imagine this is the kind of thing that wouldn't be expressed publicly. Does anyone here have a sense of this from working with Ortho/neurosurgeons?

SCS and MILD are not replacing laminectomies, spine volume is not going anywhere for appropriate patients that need decompressions. I would probably rather get a lami than a MILD if I was in good health.

I don’t think any percutaneous fusion devices will stand the test of time.

The rise in spinal fusions is a problem and is unethical in my opinion, rather than Medicare repeatedly cutting IPM they should put stricter guidelines in place for these surgeons doing multilevel fusions on unknowing patients.

 

[bedrock]

This practice already has 2 pain doctors. Why don't you ask them what it's like?

That was my thought as well.

 

[Taus]

SCS and MILD are not replacing laminectomies, spine volume is not going anywhere for appropriate patients that need decompressions. I would probably rather get a lami than a MILD if I was in good health.

I don’t think any percutaneous fusion devices will stand the test of time.

The rise in spinal fusions is a problem and is unethical in my opinion, rather than Medicare repeatedly cutting IPM they should put stricter guidelines in place for these surgeons doing multilevel fusions on unknowing patients.

Agreed.

Anything that doesn’t involve decompression and/or fusion should be fine. Re mild/vertiflex, in this setup you’ll likely need a clear understanding with your spine surgeons that patients being offered these procedures have been declared by them as not surgical candidates. Frankly, politics with Ortho aside, that’s who should be getting these procedures. Not everyone who comes in the door and fails PT and esi which is what I now see in the private practice community .

 

[wendalltwolf]

Seems like most stop doing EMG’s eventually for better reimbursement with clinic/procedures (me included). I’d ask for a new machine and not something off eBay. Keep it running well for the next new guy who you’ll most likely hand off EMG duties to.

 

[bedrock]

Taus and Agast gave good advice.

1- Definitely ask the current PMR guys re volume of EMGs (and how they are distributed)
2-I would stipulate in your contract that you do a similar percentage of EMGs, and not get saddled with all of them.
3-Agree that anything more than 1/2 clinic day per week, or 2 clinic days per month is too much and will definitely cut into your revenue. 5 PMR docs for 14 orthos is a high ratio, you shouldn't have to do more EMGs than 1/2 day week.

4- that said, the ability to do EMGs is a major reason why ortho groups hire PMR/Pain physicians instead of anesthesia pain. It will greatly reduce your employment options if you complete refuse to do EMGs, particularly as a new PMR/Pain grad.

5- At some point in the future (not now as a job applicant), I would try to get an EMG tech which would greatly increase your productively and revenue. My current job requires EMGs. I'm not a fan of EMGs, and they definitely pay less than procedures, however with tech helping me a few days a month, (had to teach them myself), I saved myself an extra 1.5 days per month to generate spine procedures and the tech makes EMGs much more lucrative.

 

[Dr. Ice]

I told my group I don’t feel like doing them. There’s another non interventional pmr doc in my group who gladly does them now. I’ll throw a bone every now and then and do like one half day a month if it’s convenient just to keep the skill set. There’s a ton of neurologists in the area that the hand guys can send their cts screens to if they want. Not sure the reimbursement now makes anyone care to “keep it in house.”

I always thought the reason ortho hired us over anesthesia was because we are cheaper labor 😝

 

[drusso]

Are there any Pain-trained PM&R docs out there with experience working with private Ortho groups who want EMGs? I'm talking to one such group, and I was hoping to get some experienced input on whether this is generally a good idea, what that setting is like, what questions should I be asking, and any red flags I should look out for as I consider this practice. Any and all opinions/insights would be appreciated.

Some background info:
I'm a current fellow at an ACGME pain program. My background is PM&R. I'm finishing fellowship July 2022, and I'm talking to a couple practices in a Texas metro area.

One of the practices is a relatively large private Ortho spine group, ~15 surgeons, 4 physiatrists (2 pain-trained).

I was connected to them through a friend of a friend, and the practice seems to have a good reputation from what I gather. They say they're looking for "a great interventional pm&r physician who also does EMGs". I wouldn't mind doing EMGs early in my career, but ultimately I'm much more interested in building a practice focused on interventional pain procedures, implantable devices, and any new promising procedures that develop in the future.

I'm pretty new to this whole "job hunting" thing, especially the intricate workings of the private practice world, so I want to be aware of any potential pitfalls and questions I should be asking. I also wondering about a few potential concerns. In particular...

1. The fact that it's so surgeon heavy makes me wonder if the physiatrists end up being pushed around and having little say in how they practice. Is this a real problem? Am I being neurotic?

2. EMGs and compensation. From what I understand, EMGs don't pay nearly as well as spine injections, SCS, and all the other stuff you do a pain fellowship for. I'm wondering how much this would actually hurt my earnings. I'm also wondering if agreeing to do EMGs may somehow pidgeon-hole me into becoming the "EMG guy". I would want to transition away from them eventually.

3. New procedures. Are Ortho practices generally open to the PM&R/pain guy adopting new procedures? I definitely want to continue expanding my skills, and periodically adding new procedures throughout my career.

EMG's are the Costco Rotisserie Chicken of PM&R/Pain. You might break even, but every so often you'll sell a TV at the check-out counter. There's your margin.

Did you hear that SCS is FDA-approved for diabetic polyneuropathy? Imagine that...