PM&R vs. anesthesia trained pain doc differences

[stsa84]

Hey guys, MS3 here who is firmly committed to pursuing pain management. I had been tentatively thinking PM&R as the route, but a recent rotation in pain management (surrounded by anesthesia residents and anesthesia trained fellows) has begun to sway me towards anesthesiology. They speak strongly about how they'll be able to handle more invasive procedures, and will be more comfortable offering more variation in their procedures (i.e. STIM trials, cervical medial nerve blocks/RFA, kyphoplasty, etc.), based on their residency training. How true is this, in actuality? (They also comment on a higher earning power...I had one fellow who had a few $400k+ offers, which I don't think a PM&R doc could command straight out of fellowship).

I understand that a pain fellowship is far from guaranteed, and that if I end up practicing as a general PM&R or anesthesiology doc, I need to be satisfied with the scope of practice, salary, and lifestyle.

Can anyone offer additional insight into what the scope of practice could be for a PM&R vs. gas trained pain doc? Is there a tangible difference, and if so, what would it be? Thanks.

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[Papa Lou]

Either the residents you spoke with, or the way you interpreted their comments is very uncouth. It may be hard to get certain answers with that language.
Everyone who completes a fellowship has met certain minimum requirements of training.

IMO there's greats out of both fields. There's also crappy ones out of both fields. Why go by that?
I hope this helps.

 

[Ducttape]

do whichever specialty you feel you would be happy doing if you are not doing pain. if you cannot ever see yourself in the OR, then dont do anesthesiology, and if you find the rehab unit not in your plans at all, under any circumstance, dont do pmr.

the scope of your pain practice will be determined by what you, not the specialty field you choose...

 

[pmrmd]

Regardless of which track you take you will end up doing the same procedures, and with the same proficiency. If you go PMR, when the patient complains of hand pain worse at night or there is need for an EMG for their limb pain, you will actually do the EDX rather than refer for it. Many of us here do SCS implants, kyphos; CESIs and RFs are a given. I have never wished I was anesthesia trained. I point out to the medical students that an anesthesiology residency is spent putting people under daily, a surgical residency is spent doing surgery daily, but a PMR residency is spent doing a neuromusculoskeletal examination daily.

 

[drusso]

Pick your base-specialty based upon what you really enjoy doing. Many routes to pain now: FM, EM, Psych, Neuro, Pediatrics, OB/GYN, IM.

 

[Ducttape]

Regardless of which track you take you will end up doing the same procedures, and with the same proficiency. If you go PMR, when the patient complains of hand pain worse at night or there is need for an EMG for their limb pain, you will actually do the EDX rather than refer for it. Many of us here do SCS implants, kyphos; CESIs and RFs are a given. I have never wished I was anesthesia trained. I point out to the medical students that an anesthesiology residency is spent putting people under daily, a surgical residency is spent doing surgery daily, but a PMR residency is spent doing a neuromusculoskeletal examination daily.

now i went on the high road and said that there was no difference long term, but you had to go out and get a dig in about PMR...

why did you have to sink to that level? should us anesthesiologists respond?

 

[lobelsteve]

now i went on the high road and said that there was no difference long term, but you had to go out and get a dig in about PMR...

why did you have to sink to that level? should us anesthesiologists respond?

Pent, sux, tube.

 

[drusso]

PM&R: heat, ice, heat & ice, stretching, strengthening, and ROM...

 

[emd123]

The only difference is the anesthesia Pain guys pass a lot more gas than the others. Otherwise, we're all the same.

 

[Ligament]

Easier to get pain fellowship from Anesthetisia. However, pain fellowships may not exist by the time you are ready for fellowship, given how the government and insurance companies are trying to kill our subspecialty. Therefore I would not plan your residency based on a pain fellowship which may not exist...

 

[pmrmd]

I would add the anesthesiologists are better prepared for anything we don't want to happen. I hope I never wished I was an anesthesiologist.

 

[lonelobo]

No question PMR is absolutely the very most bestest at pain

 

[epidural man]

Lonelobo (and to the OP),

I know you were kidding - but I (as an anesthesiologist) tend to agree.

PM&R - because of their background, probably make a better pain physician after a year of fellowship. However, given a good pain practice after a few years, it is unlikely to matter where you trained initially.

I think starting out in fellowship, anesthesiologist are move comfortable procedurally, but what really matters is patient evaluation, pattern recognition, etc. A year fellowship is very short.

Procedures are picked up quickly in a good fellowship that offers a lot of experience. We have trained psychiatrists and neurologists - both very far from a needle before starting - and all of them have come out with flying colors procedurally.

Our (anesthesiologist's) claim to being better at pain because we are good and getting a needle tip exactly where we want it is probably because we know we suck at clinic (where the real important stuff happens). Pain is really about rehab, and that is the name of the game for PM&R.

Although I would say that anesthesiologist bring to the table stuff that is really important in pain that I doubt most fellowships teach (but pain physicians are probably thought to be "experts"). This is neuraxial information - like spread, pharmacokinetics and phamacodynamics of local anesthetics and opioids in the epidural/intrathecal space, acute pain management and post-surgical management, PCA management.

 

[lobelsteve]

Lonelobo (and to the OP),

I know you were kidding - but I (as an anesthesiologist) tend to agree.

PM&R - because of their background, probably make a better pain physician after a year of fellowship. However, given a good pain practice after a few years, it is unlikely to matter where you trained initially.

I think starting out in fellowship, anesthesiologist are move comfortable procedurally, but what really matters is patient evaluation, pattern recognition, etc. A year fellowship is very short.

Procedures are picked up quickly in a good fellowship that offers a lot of experience. We have trained psychiatrists and neurologists - both very far from a needle before starting - and all of them have come out with flying colors procedurally.

Our (anesthesiologist's) claim to being better at pain because we are good and getting a needle tip exactly where we want it is probably because we know we suck at clinic (where the real important stuff happens). Pain is really about rehab, and that is the name of the game for PM&R.

Although I would say that anesthesiologist bring to the table stuff that is really important in pain that I doubt most fellowships teach (but pain physicians are probably thought to be "experts"). This is neuraxial information - like spread, pharmacokinetics and phamacodynamics of local anesthetics and opioids in the epidural/intrathecal space, acute pain management and post-surgical management, PCA management.

What's a PCA?

 

[drusso]

Lonelobo (and to the OP),

I know you were kidding - but I (as an anesthesiologist) tend to agree.

PM&R - because of their background, probably make a better pain physician after a year of fellowship. However, given a good pain practice after a few years, it is unlikely to matter where you trained initially.

I think starting out in fellowship, anesthesiologist are move comfortable procedurally, but what really matters is patient evaluation, pattern recognition, etc. A year fellowship is very short.

Procedures are picked up quickly in a good fellowship that offers a lot of experience. We have trained psychiatrists and neurologists - both very far from a needle before starting - and all of them have come out with flying colors procedurally.

Our (anesthesiologist's) claim to being better at pain because we are good and getting a needle tip exactly where we want it is probably because we know we suck at clinic (where the real important stuff happens). Pain is really about rehab, and that is the name of the game for PM&R.

Although I would say that anesthesiologist bring to the table stuff that is really important in pain that I doubt most fellowships teach (but pain physicians are probably thought to be "experts"). This is neuraxial information - like spread, pharmacokinetics and phamacodynamics of local anesthetics and opioids in the epidural/intrathecal space, acute pain management and post-surgical management, PCA management.

Here's an observation:

1) Anesthesia trained guys and gals get attracted to pain because they want to feel like "real doctors" again and not glorified technicians or robots (ie "Hey, Anesthesia, table up; table down.")

2) PM&R trained guys and gals get attracted to pain because they want to feel like "real doctors" again and not glorified medical social workers or interns (ie Mrs. Smith in 304 needs an order for a bedside commode, compression stockings, and a walker. Oh, and she's hasn't pooped in three days, can you do something about that?)

You may now return to your regularly scheduled inter-speciality mud-slinging...

 

[SSdoc33]

if i had to do inpatient PMR, i would quit. seriously. torture.

also, is there a rule that ward clerks need to weigh 300 pounds, and never stand up? the nursing station feel like the george washington bridge at rush hour. i get the chills just thinking about it

 

[powermd]

also, is there a rule that ward clerks need to weigh 300 pounds, and never stand up?

Had a greatest generation patient refer to this as "secretary spread". I thought it was funny this observation is multi-generational.

 

[drusso]

Had a greatest generation patient refer to this as "secretary spread". I thought it was funny this observation is multi-generational.

Oh, God: That's funny! See references to "Office Space" in other thread. And, remember, please attach cover sheets to your TPS reports.

 

[ampaphb]

GIGO applies here. The specialty is not important. The specific people you learn from make all the difference. The question is not if you are anesthesia or PM&R. The question is not whether you are AMBS fellowship trained, or non-ABMS.

The only question that matters to me when I am assessing whether I need to redo the injections already done by another pain doc in the community is does he/she know what they are doing, or are they *****s. Many of the local *****s have excellent credentials (one is a Mayo trained anesthesiologist who I wouldn't let do procedures on my dog, much less anyone I cared about).

Do some digging, and find out who does good work, and is well respected by those who should know. Who does Dave turn to when he has a question? Who does Lig trust? Does Lobel think highly of them? Some are good but dinguses, so make sure you can put up with their BS for a whole year (Slipman comes to mind, as do a number of his progeny).

That is not to say that you should just trust my opinions. Get a consensus. There are Mount Rushmore guys in our field. Dreyfus, Bogduk, Aprill, Derby, etc. Really nice people who are really good at what they do. Make a point of learning from people like them. If you are trained by a *****, the best you can hope for is to be as good he or she is. (BTW, as a pain snob, I think there are way more *****s and blowhards in our field than there are reasonable folks).

If they do series of three epidurals, if they do blind injections, if they let their mid-levels do procedures, you should run away. If they do ultrasound-guided spine procedures, write high dose narcs (120 MEDs routinely), or seem more concerned about their business than about the patients, I would run, and you might consider running too.

As always do your homework. Afterall, I could be a ***** too!

 

[Ducttape]

one last comment -

Pain as a profession has been defined by all of you above as chronic outpatient pain. not all pain management is outpatient/chronic.

while we often forget about inpatient pain/postsurgical pain, etc., the area in which anesthesiology is preferentially better prepared is in the inpatient side of things. so treatment options such as thoracic epidurals, PCAs, neuraxial blocks, etc. which have almost no role for chronic outpatient pain are key treatment options for inpatient service.