Pre-requisites for Pain Consultation

[Michael Hammer]

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There appears to be a disparity among pain management specialists (who perform interventional as well as medical management) as to what information, if any, is required prior to consult.
The differences as to what is required prior to consultation ranges from:

a) Nothing
b) Patient brings available records in their possession when requesting an appointment.
c) A referring physician or not.
d) A primary care physician or not.
e) Physician referral
f) A "walk" in.
g) Medical records from referring physician that are current, from past 3-6 months, any imaging studies on disc, films, etc.
h) That the physician pre-screens the patients medical records for completeness, any history of previous pain management notes describing their care and are up to and including last note.
i) If PCP is not referring physician (say referral from podiatrist, chiropractor, cardiologist) then not only is PCP a mandatory requirement but recent office notes on that patient
j) Same as above but patient has no PCP
k) Any combination of the above or other scenario.

I would truly appreciate hearing from those in the forum as to how they accept new patients and what, if any pre-conditions are mandatory prior to accepting the patient for initial consultation. A brief explanation along with the answer would be greatly appreciated.

Thank you in advance for your input!!!

 

[PMR 4 MSK]

For chronic pain patients, I want any available records. If the records are minimal, as long as there are no red flags, I'll see them. Then we usually start playing the game of "it's in my records". Many patients seem to think there is one large virtual chart that is immediately available with everything ever done to them in it.

I don't require referrals except for Medicaid. I don't take self-referred Medicaid.

I get a lot of self-referred acute to subacute pain patients with little or no work up.

 

[Ducttape]

minimally, i require a referral, and that the patient has a primary care physician that is responsible for all other health issues. so no self-referrals.

beyond that, we ask for records, charts, etc but often dont get them until the patient comes here.

 

[lobelsteve]

As I am getting older,

I really don't require anything to get seen.

But I have a boatload of due diligence to get a controlled substance as well as a need for outside records depending on what the plan will include.

If there is no imaging that is recent and pertinent, my plan will include imaging before treatment.

 

[101N]

The only think I absolutely require prior to a consult or H&P is my intake questionnaire. I will see self-referrals with the understanding that there is no guarantee of ongoing care.

 

[Michael Hammer]

Would you mind describing the type of pain treatment center you operate from? I would be interested to know if your practice is more heavily weighted towards interventional procedures, medication, multidisciplinary, none of the above. Also I would be interested to know how you would characterize your demographic population, i.e.., middle class, working, higher than average Medicaid, that sort of thing. I should have incorporated that factor in the survey as different pain specialties operating out of different demographic environments practice differently. Thanks!

 

[Ducttape]

Would you mind describing the type of pain treatment center you operate from? I would be interested to know if your practice is more heavily weighted towards interventional procedures, medication, multidisciplinary, none of the above. Also I would be interested to know how you would characterize your demographic population, i.e.., middle class, working, higher than average Medicaid, that sort of thing. I should have incorporated that factor in the survey as different pain specialties operating out of different demographic environments practice differently. Thanks!

why do you ask?

and who exactly are you?

not to be too suspicious, but... im being suspicious. there have been some posters who clearly have ulterior motives.

 

[bedrock]

As his only two posts on the forum are in this thread, I'm thinking this guy is

1- a patient
2- journalist
3- troll


In any case, he's not a fellow health care provider, so I'd be very careful if you choose to post in this thread.

 

[Aether2000]

Michael Hammer is an outstanding pain physician, active in advancement of the field over the past few decades, and has written one of the best monographs on RF I have seen. He served well on some of the national organization committees and is an extraordinarily nice guy.

 

[Michael Hammer]

Michael Hammer is an outstanding pain physician, active in advancement of the field over the past few decades, and has written one of the best monographs on RF I have seen. He served well on some of the national organization committees and is an extraordinarily nice guy.

As his only two posts on the forum are in this thread, I'm thinking this guy is

1- a patient
2- journalist
3- troll

Thanks Mike!

But to be fair I have been called the "Troll Under the Bridge" by a girl I was hitting on in 6th grade!! LOL!!!

 

[Ducttape]

Michael Hammer is an outstanding pain physician, active in advancement of the field over the past few decades, and has written one of the best monographs on RF I have seen. He served well on some of the national organization committees and is an extraordinarily nice guy.

well, then, with that intro, welcome to the forums..

could i suggest that you get access to the physician's pain forums so that others - okay, i - feel more comfortable discussing specific details outside of the "public eye"...

 

[bedrock]

Michael Hammer is an outstanding pain physician, active in advancement of the field over the past few decades, and has written one of the best monographs on RF I have seen. He served well on some of the national organization committees and is an extraordinarily nice guy.

apologies.

If algos vouches for you, that's good enough for me.

However, I do agree that this discussion should be in the physicians only forum

 

[ghost dog]

There appears to be a disparity among pain management specialists (who perform interventional as well as medical management) as to what information, if any, is required prior to consult.
The differences as to what is required prior to consultation ranges from:

a) Nothing
b) Patient brings available records in their possession when requesting an appointment.
c) A referring physician or not.
d) A primary care physician or not.
e) Physician referral
f) A "walk" in.
g) Medical records from referring physician that are current, from past 3-6 months, any imaging studies on disc, films, etc.
h) That the physician pre-screens the patients medical records for completeness, any history of previous pain management notes describing their care and are up to and including last note.
i) If PCP is not referring physician (say referral from podiatrist, chiropractor, cardiologist) then not only is PCP a mandatory requirement but recent office notes on that patient
j) Same as above but patient has no PCP
k) Any combination of the above or other scenario.

I would truly appreciate hearing from those in the forum as to how they accept new patients and what, if any pre-conditions are mandatory prior to accepting the patient for initial consultation. A brief explanation along with the answer would be greatly appreciated.

Thank you in advance for your input!!!

I am not based in the US, so take that for what it's worth.

The only absolute prerequisite for a consult in my clinic is that a patient must have a family physician for ongoing care. Not infrequently, I will have a patient call up the office to ask if we are " taking on new patients " to find out that they have been terminated by their primary care provider for violating their opioid contract.

Moreover, if you see " walk in " or unattached pts, you don't have access to their PMHx ( i.e. laundry list of meds, past Tx, imaging, etc.) Flying blind so to speak.

Thus the reason for this policy.

 

[Ligament]

Welcome to the forum Dr. Hammer. I've hired your wife in consultation in the past and she is wonderful.

 

[PinchandBurn]

Welcome to the forum Dr. Hammer. I've hired your wife in consultation in the past and she is wonderful.

is his wife "Marvel" ?

 

[Tenesma]

i require a referral from a doc - somebody i can send a report and recommendations to...

 

[Michael Hammer]

Thank you all for providing me with some guidance.

The geopolitical forces that drive demographic change for better or worse affect how we see our role in providing healthcare. Some communities have been ravaged by greedy, poorly trained physicians who sought only to addict, make steroid dependent, hose insurance companies for maximal allowable injections performed without effect. Those patients become so disabled and their co-morbidities so affected that such a "scorched earth" is fertile ground for addiction medicine only. Perhaps not too far away exists a community where folks believe their body is their temple, eat only organic food, exercise and practice yoga 3 times a day. The concept of pain management to them is not even in their vocabulary.

I have visited several practices in my journey to find a home, where I can practice as I see fit, treat patients with the best practice based on listening, observing, teaching, testing, and formulating a plan. I find it difficult to have a computer between myself and the patient, yet that appears to be a necessary evil. I can't type so without dictation I'm force to take my work home so that I can construct a meaningful note. Probably one that nobody will read.

Yet it is our duty to scramble to find, then crunch the pertinent data before a plan can be formulated. That is why I personally choose to review patients records before the encounter. So many red flags appear which calls for additional records. As a physician I'm needed to provide care yet the paperwork generated can be so overwhelming that the staff can easily point to me as the problem since "nobody has done this before". The fact is, I'm saving the staff from more paperwork and phone calls by throwing up this firewall.

In my quest to treat those who truly seek treatment, I've devised a plan which requires that each patient has a PCP. Each patient is referred by a physician. Each patient must agree to undergo baseline psychometric testing if on chronic opioids. Additionally, each patient must be assessed by a physiotherapist who performs baseline functional status. I do this not to to make it difficult for drug seekers to obtain opioids, but to determine how, longitudinally each patient is improving using several parameters by validated testing.

I want to see improvements, not just manage patients with chronic opioids. The business model has traditionally run counter-current to my plan, which is to yield the best and most durable improvements with the least amount of intervention, using the safest technique. My question pertained to how physicians are establishing patients in a system where so much is broken and we continually fight an uphill battle. Maybe I need to find a position in academia.

If anyone out there has come up with a model that works both for the patient and the staff I would love to hear about it!

Thank you all for your responses, they were truly enlightening!

Mike


(

 

[lobelsteve]

Thank you all for providing me with some guidance.

The geopolitical forces that drive demographic change for better or worse affect how we see our role in providing healthcare. Some communities have been ravaged by greedy, poorly trained physicians who sought only to addict, make steroid dependent, hose insurance companies for maximal allowable injections performed without effect. Those patients become so disabled and their co-morbidities so affected that such a "scorched earth" is fertile ground for addiction medicine only. Perhaps not too far away exists a community where folks believe their body is their temple, eat only organic food, exercise and practice yoga 3 times a day. The concept of pain management to them is not even in their vocabulary.

I have visited several practices in my journey to find a home, where I can practice as I see fit, treat patients with the best practice based on listening, observing, teaching, testing, and formulating a plan. I find it difficult to have a computer between myself and the patient, yet that appears to be a necessary evil. I can't type so without dictation I'm force to take my work home so that I can construct a meaningful note. Probably one that nobody will read.

Yet it is our duty to scramble to find, then crunch the pertinent data before a plan can be formulated. That is why I personally choose to review patients records before the encounter. So many red flags appear which calls for additional records. As a physician I'm needed to provide care yet the paperwork generated can be so overwhelming that the staff can easily point to me as the problem since "nobody has done this before". The fact is, I'm saving the staff from more paperwork and phone calls by throwing up this firewall.

In my quest to treat those who truly seek treatment, I've devised a plan which requires that each patient has a PCP. Each patient is referred by a physician. Each patient must agree to undergo baseline psychometric testing if on chronic opioids. Additionally, each patient must be assessed by a physiotherapist who performs baseline functional status. I do this not to to make it difficult for drug seekers to obtain opioids, but to determine how, longitudinally each patient is improving using several parameters by validated testing.

I want to see improvements, not just manage patients with chronic opioids. The business model has traditionally run counter-current to my plan, which is to yield the best and most durable improvements with the least amount of intervention, using the safest technique. My question pertained to how physicians are establishing patients in a system where so much is broken and we continually fight an uphill battle. Maybe I need to find a position in academia.

If anyone out there has come up with a model that works both for the patient and the staff I would love to hear about it!

Thank you all for your responses, they were truly enlightening!

Mike


(

Socialize pain medicine and make Pain a govt position.

1. sovereign immunity.
2. Salary at 60% MGMA with COLA
3. Only Pain can perform certain CPT.
4. Only Pain can Rx opiates outside of 2 weeks post-op or acute.

 

[Ducttape]

unfortunately, i do think you would enjoy academia. there is still, however the pressure to perform and to produce, just not as "in your face". and the push to use EHR is much greater at academic centers.

 

[Michael Hammer]

Almost from its inception the good old boys in corporate took the interventional pain ball into the "Evil Parallel Universe" and Mr. Spock was sporting a goatee.

I hate when that happens.

 

[Jitter Bug]

Prereqs for referrals depend how hungry you are 🙂

We are private practice so we accept self referrals and doc referrals. All I require is an intake form, the initial Oswestries and a patient who can mentally hold it together until the exam room.

However, I won't start any meds at all until I have a med list from their prescribing docs, and I won't order imaging until I have seen what they already have out there. For work comp case I won't do any paperwork until I have records back to the initial contact with occ med, ED, urgent care etc to clarify the details.

My office tries to get me full records before the initial visit but I won't send the patient away if it's not complete. Often the patients themselves won't tell anyone but me about the CD in their purse of the CT spine they had done last week. Weird but true.

 

[ghost dog]

Thank you all for providing me with some guidance.

The geopolitical forces that drive demographic change for better or worse affect how we see our role in providing healthcare. Some communities have been ravaged by greedy, poorly trained physicians who sought only to addict, make steroid dependent, hose insurance companies for maximal allowable injections performed without effect. Those patients become so disabled and their co-morbidities so affected that such a "scorched earth" is fertile ground for addiction medicine only. Perhaps not too far away exists a community where folks believe their body is their temple, eat only organic food, exercise and practice yoga 3 times a day. The concept of pain management to them is not even in their vocabulary.

I have visited several practices in my journey to find a home, where I can practice as I see fit, treat patients with the best practice based on listening, observing, teaching, testing, and formulating a plan. I find it difficult to have a computer between myself and the patient, yet that appears to be a necessary evil. I can't type so without dictation I'm force to take my work home so that I can construct a meaningful note. Probably one that nobody will read.

Yet it is our duty to scramble to find, then crunch the pertinent data before a plan can be formulated. That is why I personally choose to review patients records before the encounter. So many red flags appear which calls for additional records. As a physician I'm needed to provide care yet the paperwork generated can be so overwhelming that the staff can easily point to me as the problem since "nobody has done this before". The fact is, I'm saving the staff from more paperwork and phone calls by throwing up this firewall.

In my quest to treat those who truly seek treatment, I've devised a plan which requires that each patient has a PCP. Each patient is referred by a physician. Each patient must agree to undergo baseline psychometric testing if on chronic opioids. Additionally, each patient must be assessed by a physiotherapist who performs baseline functional status. I do this not to to make it difficult for drug seekers to obtain opioids, but to determine how, longitudinally each patient is improving using several parameters by validated testing.

I want to see improvements, not just manage patients with chronic opioids. The business model has traditionally run counter-current to my plan, which is to yield the best and most durable improvements with the least amount of intervention, using the safest technique. My question pertained to how physicians are establishing patients in a system where so much is broken and we continually fight an uphill battle. Maybe I need to find a position in academia.

If anyone out there has come up with a model that works both for the patient and the staff I would love to hear about it!

Thank you all for your responses, they were truly enlightening!

Mike


(

Hi Mike,

Your approach sounds very interesting. What psychometric tests do you use in evaluating patients ?

Cheers.

 

[mille125]

There appears to be a disparity among pain management specialists (who perform interventional as well as medical management) as to what information, if any, is required prior to consult.
The differences as to what is required prior to consultation ranges from:

a) Nothing
b) Patient brings available records in their possession when requesting an appointment.
c) A referring physician or not.
d) A primary care physician or not.
e) Physician referral
f) A "walk" in.
g) Medical records from referring physician that are current, from past 3-6 months, any imaging studies on disc, films, etc.
h) That the physician pre-screens the patients medical records for completeness, any history of previous pain management notes describing their care and are up to and including last note.
i) If PCP is not referring physician (say referral from podiatrist, chiropractor, cardiologist) then not only is PCP a mandatory requirement but recent office notes on that patient
j) Same as above but patient has no PCP
k) Any combination of the above or other scenario.

I would truly appreciate hearing from those in the forum as to how they accept new patients and what, if any pre-conditions are mandatory prior to accepting the patient for initial consultation. A brief explanation along with the answer would be greatly appreciated.

Thank you in advance for your input!!!

Welcome Mike

I require referral (no walk in). It can be from PCP or other (neuro,ortho). If they do not have a PCP, I will arrange for them to get one after they see me. I feel that it is essential that one has a PCP. I require imaging if done and like to get notes.

 

[pjuer]

hi Mike, Greetings from Marion and Paducah

 

[Michael Hammer]

Then it sounds like you have passed the sobriety test!

 

[Michael Hammer]

Hi Mike,

Your approach sounds very interesting. What psychometric tests do you use in evaluating patients ?

Cheers.

Sorry for the delay in answering "GHOST DOG"!

We use the Center for Epidemiological Studies Depression Scale (CES-D) as baseline to determine the overall level of depression. Based on the score we make recommendations if further treatment or assessment is warranted. It's a rough estimate and perhaps not validated in directing treatment but the easiest to administer. If there is a better one out there it would be great to know about it!

Mike

 

[ghost dog]

Sorry for the delay in answering "GHOST DOG"!

We use the Center for Epidemiological Studies Depression Scale (CES-D) as baseline to determine the overall level of depression. Based on the score we make recommendations if further treatment or assessment is warranted. It's a rough estimate and perhaps not validated in directing treatment but the easiest to administer. If there is a better one out there it would be great to know about it!

Mike

This scale seems a tad unwieldy.


I like the PHQ 9 questionnaire for depression as it is i) validated, ii) useful for both initially confirming a diagnosis of major depressive disorder ( in conjunction with a history, of course ) and then iii) subsequently following a patient's response to management of this issue ( yes, I manage a patient's depression in addition to their pain issues ). A drop of 5 points or more ( in comparison to their baseline score ) is said to be clinically significant in respect to this scale.

I prefer this scoring system over the Beck depressioninventory as it is quicker for the patient to fill out.