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Anyone know the salaries of a PMR pain specialist?
lobelsteve said:180 to 1M+
Cannot even begin to discuss the compensation issues as it is so varied and should be based on productivity. Any thing less and you are selling yourself short.
peduncle said:Anyone know the salaries of a PMR pain specialist?
wonthurtabit1 said:What is a PMR pain specialist? If you are a self-anointed PMR pain specialist probably not a lot of money ... so be it. The bigger salaries come w/ acgme interventional physiatry or anesthesia pain fellowship training, ABA boards, etc. Lots of folks are calling themselves pain specialists just out of residency. There are also great non-acgme PMR fellowships w/ the kings/queens that you cannot shake a stick at: Slipman, Windsor, Derby/Yung Chen, April, Press, Prather, etc and probably some that I have missed.
I also think continuing education is key, run the PASSOR and ISIS series. Go hang out with the top folks and learn their tricks. Go to the ISIS, ASIPP, NASS courses.
lobelsteve said:I'm very offended.
Emory University PMR-Pain Fellowship- Georgia Pain Physicians. Robert Windsor is the Program Director and we are ACGME accredited and our fellows are ABPMR certified in PM via the ABMS. We are the cutting edge of PM and have been since Dr. Windsor became one of the founding fathers of PMR-Pain. Our fellows average starting base salary has been close to $250,000 and there are fellows who walk into practice with a one third partnership in an ASC based practice with a fixed overhead as their threshold.
wonthurtabit1 said:like I said, some that i missed: of course Windsor and the Emory pain group. geez
PainDr said:Of course, I suppose the real problem are the masses of untrained "pain specialists" doing procedures in their offices.
drusso said:AKA "Feral Injectionsists." An oldie, but a goodie...
What is Feral?
Nikolai Bogduk, BSC(Med) MB BS PhD MD Dip Anat FAFRM
A feral animal is one that was previously domestic but which has been released into the wild. Examples include, pigs, goats, and cats. Each of these is a problem in Australia.
Domestic pigs that escape into the wild become feral. In the wild they uproot native vegetation and disturb the native ecosystem; they become very aggressive; and subsequent generations revert to the behavior of
wild boars; but the difference is that feral pigs grow much bigger than native boars.
Goats have survived shipwrecks and inhabit islands around Australia. There they cause the same sort of problems as feral pigs - disrupting the natural environment.
Feral cats are probably the worst problem. The gentle domestic ***** becomes a fabulous survivor in the wild. They become fierce in the search of food; they become expert predators; they grow large as do their
offspring; they destroy native animals that are easy prey in a country with no more than a handful of carnivores, only the dingo (dog) being larger than a hand.
The key features of feral animals are that on the one hand, they were once domestic, in which environment they were relatively gentle, approachable, well behaved, and even trained; on the other hand, when they are released into the wild, they become aggressive survivors, and take advantage of the environment, which they disturb and destroy in their fight for survival.
I have on occasions used feral as a metaphor in Pain Medicine. There are practitioners that strike me as feral. They are ones who were once domestic (they went to medical school and were trained in the correct answers and correct behaviors) but once released into the wild (Pain Medicine) they become feral.
For reference, the features of feral practitioners are any of the following, alone or in combination.
§ They perform procedures without proper indications.
§ They perform procedures contrary to indications or contrary to best practice guidelines.
§ Incorrectly they call what they do by the same name as the legitimate procedure.
§ They charge the same CPT code even when they do the procedure wrongly or suboptimally.
§ They abuse the procedure by not assessing their results, i.e.
they perform diagnostic blocks but do not formulate a reliable or valid diagnosis; they perform therapeutic procedures but their outcomes are substandard or nil;
§ neither of which concerns them.
§ They misuse the literature, usually by quoting the legitimate literature to support what they do, even though what they do bears little resemblance to that literature.
§ They announce that what they do is better than what is reported in the literature, but never subject their techniques to scrutiny and evaluation.
For feral practitioners the consequences are clear - like feral animals they survive in the wild; some survive well. Some get elevated to positions of prestige, and teach courses (showing their offspring how to survive in the wild).
For others the behavior of feral practitioners can be as offensive as the behavior of feral animals. Feral medical practice gives a bad name to the procedures; it gives a bad name to responsible practitioners.
It is for this reason that I have introduced the metaphor - feral, in the context of Pain Medicine.
The objectives of ISIS are not so much to stamp out feral practice, but to represent cogent and responsible practice that stands in contrast to feral behavior. It is to lead by example.
It has been for this reason that ISIS sponsored research to provide a legitimate scientific base for the procedures that we promote. It is for this reason that the Standards Committee is nearing completion of
comprehensive descriptions of what is good behavior; that is not destructive to our environment - respected medical practice.
My own tragedies in this arena, and why I use the descriptor - feral, have arisen when I have published good work, only to have it decried by critics, not because it is scientifically unsound but because the procedure, now legitimized, will be abused by the ferals. I estimate, perhaps incorrectly, that for every good operator there are 9 feral exponents. I, and the reputation of good practice, are outnumbered by the ferals, and it is the ferals, not the good practitioners, that the critics see day to day. It is no wonder that they
are not impressed with needle procedures.
I look to ISIS for support, through its programs of research and Standards, I seek allies and growing numbers of responsible practitioners, who lead by example.
You can live comfortably with domestic pigs, domestic goats, and domestic cats; they can even be fun to live with; and even insurers might be tempted to feed the young at an animal farm. No-one wants to feed
cat food to feral cats.
In case you missed the depth of the metaphor, the innocent native animals who get eaten or have their habitat destroyed by feral animals are the patients.
drusso said:AKA "Feral Injectionsists." An oldie, but a goodie...
What is Feral?
Nikolai Bogduk, BSC(Med) MB BS PhD MD Dip Anat FAFRM
A feral animal is one that was previously domestic but which has been released into the wild. Examples include, pigs, goats, and cats. Each of these is a problem in Australia.
Domestic pigs that escape into the wild become feral. In the wild they uproot native vegetation and disturb the native ecosystem; they become very aggressive; and subsequent generations revert to the behavior of
wild boars; but the difference is that feral pigs grow much bigger than native boars.
Goats have survived shipwrecks and inhabit islands around Australia. There they cause the same sort of problems as feral pigs - disrupting the natural environment.
Feral cats are probably the worst problem. The gentle domestic ***** becomes a fabulous survivor in the wild. They become fierce in the search of food; they become expert predators; they grow large as do their
offspring; they destroy native animals that are easy prey in a country with no more than a handful of carnivores, only the dingo (dog) being larger than a hand.
The key features of feral animals are that on the one hand, they were once domestic, in which environment they were relatively gentle, approachable, well behaved, and even trained; on the other hand, when they are released into the wild, they become aggressive survivors, and take advantage of the environment, which they disturb and destroy in their fight for survival.
I have on occasions used feral as a metaphor in Pain Medicine. There are practitioners that strike me as feral. They are ones who were once domestic (they went to medical school and were trained in the correct answers and correct behaviors) but once released into the wild (Pain Medicine) they become feral.
For reference, the features of feral practitioners are any of the following, alone or in combination.
§ They perform procedures without proper indications.
§ They perform procedures contrary to indications or contrary to best practice guidelines.
§ Incorrectly they call what they do by the same name as the legitimate procedure.
§ They charge the same CPT code even when they do the procedure wrongly or suboptimally.
§ They abuse the procedure by not assessing their results, i.e.
they perform diagnostic blocks but do not formulate a reliable or valid diagnosis; they perform therapeutic procedures but their outcomes are substandard or nil;
§ neither of which concerns them.
§ They misuse the literature, usually by quoting the legitimate literature to support what they do, even though what they do bears little resemblance to that literature.
§ They announce that what they do is better than what is reported in the literature, but never subject their techniques to scrutiny and evaluation.
For feral practitioners the consequences are clear - like feral animals they survive in the wild; some survive well. Some get elevated to positions of prestige, and teach courses (showing their offspring how to survive in the wild).
For others the behavior of feral practitioners can be as offensive as the behavior of feral animals. Feral medical practice gives a bad name to the procedures; it gives a bad name to responsible practitioners.
It is for this reason that I have introduced the metaphor - feral, in the context of Pain Medicine.
The objectives of ISIS are not so much to stamp out feral practice, but to represent cogent and responsible practice that stands in contrast to feral behavior. It is to lead by example.
It has been for this reason that ISIS sponsored research to provide a legitimate scientific base for the procedures that we promote. It is for this reason that the Standards Committee is nearing completion of
comprehensive descriptions of what is good behavior; that is not destructive to our environment - respected medical practice.
My own tragedies in this arena, and why I use the descriptor - feral, have arisen when I have published good work, only to have it decried by critics, not because it is scientifically unsound but because the procedure, now legitimized, will be abused by the ferals. I estimate, perhaps incorrectly, that for every good operator there are 9 feral exponents. I, and the reputation of good practice, are outnumbered by the ferals, and it is the ferals, not the good practitioners, that the critics see day to day. It is no wonder that they
are not impressed with needle procedures.
I look to ISIS for support, through its programs of research and Standards, I seek allies and growing numbers of responsible practitioners, who lead by example.
You can live comfortably with domestic pigs, domestic goats, and domestic cats; they can even be fun to live with; and even insurers might be tempted to feed the young at an animal farm. No-one wants to feed
cat food to feral cats.
In case you missed the depth of the metaphor, the innocent native animals who get eaten or have their habitat destroyed by feral animals are the patients.
algosdoc said:Wow...good point! Perhaps Dr B can aim his guns with a broader swath. It was fascinating seeing Dr Bogduk and Dr Racz on the same stage together with their academic jousting. Both are respected leaders of the field and both had valid points. I think it is that type of interaction that benefits us mere mortals the most.
paz5559 said:Maybe it was just my innate ISIS bias, but to me Dr. Racz came off as a doddering old man, shilling for ASIPP and Epimed, while Drs. Bogduk and Aprill stood their ground and did not let him ramble off touting the virtues of blunt needles without a shred of evidence.
paz5559 said:Maybe it was just my innate ISIS bias, but to me Dr. Racz came off as a doddering old man, shilling for ASIPP and Epimed, while Drs. Bogduk and Aprill stood their ground and did not let him ramble off touting the virtues of blunt needles without a shred of evidence.
paz5559 said:Maybe it was just my innate ISIS bias, but to me Dr. Racz came off as a doddering old man, shilling for ASIPP and Epimed, while Drs. Bogduk and Aprill stood their ground and did not let him ramble off touting the virtues of blunt needles without a shred of evidence.
md2k said:Yes, it was your ISIS bias. And yes there is some evidence that Pauza conveniatly forgot to mention or he just didn't do his homework. Look up the Atkins paper in 89, bergers paper and heavners paper in relation to artery punctures. No one ever said you cant puncture veins!!!!
Personally I have used them hundreds of times and have yet to get an arterial puncture.
paz5559 said:Care to give us any citations so we can look these articles up (or perhaps even post the abstracts so they can be discussed in this forum?)
Ditto, respect papa raczwonthurtabit1 said:We should all hope to have achieved all that "doddering"... give the guy a break. How many of us will be invited to the big table in 40 years? show some respect for the forefathers
nuff said
paz5559 said:Care to give us any citations so we can look these articles up (or perhaps even post the abstracts so they can be discussed in this forum?)
paz5559 said:Care to give us any citations so we can look these articles up (or perhaps even post the abstracts so they can be discussed in this forum?)
pazpaz5559 said:Care to give us any citations so we can look these articles up (or perhaps even post the abstracts so they can be discussed in this forum?)
md2k said:*******************
I found you two of the articles. Hopefully this helps you understand blunt needles and the concept behind them my freindly biased ISIS member.
You obviously did not read the articles are are just speaking out of your ass. Read them first and learn.lobelsteve said:Spoken like a fellow in Racz's program....
Puncturing dog kidneys is not analogous to arterial puncture.
Bias from Racz's article cannot be ignored.
The debate rolls on.
Ad hominim attacks attest to your character.md2k said:You obviously did not read the articles are are just speaking out of your ass. Read them first and learn.
lobelsteve said:Ad hominim attacks attest to your character.
"Results: All attempts to directly puncture the kidney and liver with sharp needles were successful. All but one attempt to puncture a spinal nerve/nerve root with 20-, 22-, and 25-gauge sharp needles were successful but half or less attempts to puncture the intestines were successful. All attempts to puncture the renal artery with sharp needles were successful. Blunt needles never punctured the renal artery, spinal nerve/nerve root and intestines and rarely penetrated the kidney (22- and 25-gauge one time each). All attempts to puncture the liver with blunt needles were successful. Bleeding scores for kidney punctures were generally higher for larger sharp needles than for smaller ones. Bleeding scores for blunt needle punctures of the liver were generally smaller than for sharp needle puncture.
Conclusion: Blunt needles are less likely than sharp ones to enter vital structures and/or produce hemorrhage. Thus, blunt needles may be preferable to sharp ones for performing interventional pain procedures."
So explain how this translates to spinal procedures in humans. Really, please.
Get some real data or better yet just look at Pauza's data. Blunt over sharp makes intuitive sense and in PM that is close enough for most folks. The added cost without known added benefit makes the debate plausible but not worth wasting time over.
Your attitude is unprofessional at best and does nothing to support your stance onm the issue. A little decorum if not respect even in this forum is still appropriate.
md2k said:Ditto, respect papa racz
md2k said:Heavner study: All attempts to puncture the renal artery with sharp needles were successful. Blunt needles never punctured the renal artery, spinal nerve/nerve root and intestines and rarely penetrated the kidney (22- and 25-gauge one time each).
Akins study:In four dogs, we could not force the blunt needle to enter a barium-filled renal artery despite at least 100 direct forceful attempts.
Yes they are dog studies. However, they did show that they couldn't penetrate the renal arteries with blunts and with sharps they could. What else do you want?? So it wasn't done in the spine. Do you want a study where you attempt to inject in the vertebral artery, or the artery of adamkewicz? Pauza's study?? All he showed is that you can get in a vein. Big deal, thats not a complication. He has no data regarding arterial puncture. As you said, Blunt over sharp makes intuitive sense.
I agree, the needles cost much, much more. Probably 3 to 5 times more and thats unfortunate.
This was not an attack Ad hominim. I am not trying to kill the messenger. I was merely replying to your comment and was not trying to affend you. In the future I will atone my responses in respect to you
drusso said:For those of us who didn't have the opportunity to attend, can you please elaborate...paint a picture if you will? What was the setting and what were the major points??
wonthurtabit1 said:What is a PMR pain specialist? If you are a self-anointed PMR pain specialist probably not a lot of money ... so be it. The bigger salaries come w/ acgme interventional physiatry or anesthesia pain fellowship training, ABA boards, etc. Lots of folks are calling themselves pain specialists just out of residency. There are also great non-acgme PMR fellowships w/ the kings/queens that you cannot shake a stick at: Slipman, Windsor, Derby/Yung Chen, April, Press, Prather, etc and probably some that I have missed.
I also think continuing education is key, run the PASSOR and ISIS series. Go hang out with the top folks and learn their tricks. Go to the ISIS, ASIPP, NASS courses.
Disciple said:What does the quality of your training have to do with billing?
I would argue that better training makes one more knowledgeable and conservative, therefore making less money.
Secondly, some of the fellowships you listed are "Musculoskeletal" or "Spine/Sports Medicine" fellowships. I wouldn't even call them "pain" fellowships. Not that they do not offer great training, because they do, but they lead someone down a different type of practice entirely.
I think when we stop trying to call anyone who cares for the spine or musculoskeletal system a "pain" doctor, perhaps there can be more uniform standards for those who wish to practice comprehensive pain medicine.
Disciple said:Secondly, some of the fellowships you listed are "Musculoskeletal" or "Spine/Sports Medicine" fellowships. I wouldn't even call them "pain" fellowships. Not that they do not offer great training, because they do, but they lead someone down a different type of practice entirely.
I think when we stop trying to call anyone who cares for the spine or musculoskeletal system a "pain" doctor, perhaps there can be more uniform standards for those who wish to practice comprehensive pain medicine.
paz5559 said:Semantics, but in this case, with a core of misunderstanding beneath mere verbiage
I agree that some fellowships are non-interventional. But to suggest that preeminent ones like those run by Drs Press and Prather do not address pain demonstrates a fundamental disconnect in our field.
Injections are not, nor were they ever designed to, be the silver bullet that solves patients' symptomatology. Those with that belief are doomed to have the revolving door practice that makes a good deal more money, but ultimately doesnt get patients better long term.
Injections and other spinal interventions are a means to an end. They enable patients to experience a pain-free window pf opportunity. What we encourage them to DO during that period is the key. Drs. Press, Weinstein, Herring, and Prather view injections as the START of the therapeutic mélange, but then take a more active role in the specifics of the physical therapy that follows.
To draw a bright line distinction between fellowships is a mistake. Clearly, some do more injections than others. Clearly some do no cervical interventions at all. But to say I am different from those trained by some of our thought leaders, and to distinguish their training as a different subset altogether misses the point - we all treat pain. Pain is a dirty word, cause at it's root, it implies we treat it with narcotics, and thus no one wants to be a pain doctor anymore. But in this forum, where narcotics are not our focus, whether we treat with injections, therapy, or both, we are ultimately treating the same entity.
lobelsteve said:Bingo. I think Rathmell and the boys have all that sorted out and the ACGME will implement the changes next year. There will be great change in PM&R Pain programs or they will go away from trying for ACGME accred. I'm revieing the PIF right now and it looks doable, buth the gas bias the boys put on it is overpowering. If you look at the edits- only the anes section did not get a full rewrite.
Does qanybody have the list of the PMR docs that went to the table with Rathmell? I need to discuss this....
Disciple said:Personally, I don't think there will be anymore newly accredited PM&R pain programs.
If I remember correctly, Barry Smith MD was one of the Physiatrists at the table. Perhaps we should have had the PM&R pain/spine guys doing the negotiating.
Maybe it's too late.
paz5559 said:Semantics, but in this case, with a core of misunderstanding beneath mere verbiage
I agree that some fellowships are non-interventional. But to suggest that preeminent ones like those run by Drs Press and Prather do not address pain demonstrates a fundamental disconnect in our field.
Injections are not, nor were they ever designed to, be the silver bullet that solves patients' symptomatology. Those with that belief are doomed to have the revolving door practice that makes a good deal more money, but ultimately doesnt get patients better long term.
Injections and other spinal interventions are a means to an end. They enable patients to experience a pain-free window pf opportunity. What we encourage them to DO during that period is the key. Drs. Press, Weinstein, Herring, and Prather view injections as the START of the therapeutic mélange, but then take a more active role in the specifics of the physical therapy that follows.
To draw a bright line distinction between fellowships is a mistake. Clearly, some do more injections than others. Clearly some do no cervical interventions at all. But to say I am different from those trained by some of our thought leaders, and to distinguish their training as a different subset altogether misses the point - we all treat pain. Pain is a dirty word, cause at it's root, it implies we treat it with narcotics, and thus no one wants to be a pain doctor anymore. But in this forum, where narcotics are not our focus, whether we treat with injections, therapy, or both, we are ultimately treating the same entity.
peduncle said:Anyone know the salaries of a PMR pain specialist?