Procedure Numbers

[blockerdoctor]

Hello fellow pain docs. I am 16 months into private practice. I want to get a sense from other pain docs how many do you think is too many procedures in one day.

I am currently doing 40 procedures 3 days a week. Some say that will wear out a doctor but I am fine with this. I don't feel worn out. In fact, I am considering adding another day to make it 4 days a week due to demand.

What do others think?

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[Ducttape]

i guess if you want to be a needle jockey, an injection every 15 minutes for 10 hours is a good pace.

im not that fast... i guess because i talk to patients.

 

[Louisville04]

Hello fellow pain docs. I am 16 months into private practice. I want to get a sense from other pain docs how many do you think is too many procedures in one day.

I am currently doing 40 procedures 3 days a week. Some say that will wear out a doctor but I am fine with this. I don't feel worn out. In fact, I am considering adding another day to make it 4 days a week due to demand.

What do others think?

What part of the country are you located....rural area? What is your referral base? You've been in practice for 16 months and you are doing 120 procedures/week with still more demand

 

[PinchandBurn]

Hello fellow pain docs. I am 16 months into private practice. I want to get a sense from other pain docs how many do you think is too many procedures in one day.

I am currently doing 40 procedures 3 days a week. Some say that will wear out a doctor but I am fine with this. I don't feel worn out. In fact, I am considering adding another day to make it 4 days a week due to demand.

What do others think?

you mean total of 40 procedures in a week right? Or are you talking about 120 a week?

40 a week is pretty reasonable I think. If you are considering things like great occ nerve injections and TPIs in the mix of that 40.

 

[101N]

i guess if you want to be a needle jockey, an injection every 15 minutes for 10 hours is a good pace.

im not that fast... i guess because i talk to patients.

1+

Appropriate handle "blockerdoctor".

 

[blockerdoctor]

What part of the country are you located....rural area? What is your referral base? You've been in practice for 16 months and you are doing 120 procedures/week with still more demand

i am not in a rural area. I am in a city ranked in the top 10 in terms of population... yes, there is more demand for me to do more procedures. That is my question. do you think 40 a day 3 days a week is too many? Or should I add the 4 th procedure day

 

[blockerdoctor]

you mean total of 40 procedures in a week right? Or are you talking about 120 a week?

40 a week is pretty reasonable I think. If you are considering things like great occ nerve injections and TPIs in the mix of that 40.

I do 40 spinal procedures with flouro a day. That includes ESIs, facets, si, rfa, discograms etc.

 

[Pain Applicant1]

40/day 3 days/week is absolute madness for anyone, especially after only 16 months in PP. It is also nearly impossible.

How do you generate the procedures? When do you see patients to schedule for procedures? Do you work solo or are you in a group where you just get referred to to perform procedures? Something's not right here.

 

[Louisville04]

i am not in a rural area. I am in a city ranked in the top 10 in terms of population... yes, there is more demand for me to do more procedures. That is my question. do you think 40 a day 3 days a week is too many? Or should I add the 4 th procedure day

There is no thing as too many or too little. It is what ever is your comfort level.

 

[powermd]

There is no thing as too many or too little. It is what ever is your comfort level.

A better question is how are his patients doing? Do they get well such that they don't need additional injections q4-8 weeks? Does everyone get a series of 3 regardless of how well the first injection worked?

Our office is very busy, but I can honestly say we have high standards for treatment efficacy. Our repeat business usually comes from this situation: "Great, you fixed by back... now let me tell you about this shoulder problem I've been having."

 

[stim4u]

you should add another physician if you are truly over 120 procedures a week. Too much radiation and you will see a complication in 2-3 years, so be prepared. furthermore, your ulnar nerve, plantar facitis, and knee will not sustain this level of productivity. Take it from me.
Finally for the procedural hatters on this forum, make sure you are doing the ethical and medically necessary procedures for your patients or you will be audited and targeted by CMS.

 

[Jcm800]

if you are doing a 120 procedures a week, and you dont feel worn out, then you better be driving a ferrari to work, or it is too many procedures. meaning if you work for someone and you arent making a bajillion dollars they are stealing from you.

but back in non-crazy town, that is an insane number and a terrible idea.

 

[lobelsteve]

That doe not appear to be legitimate care based on hrs in a day and time spent doing a procedure. Also, there is not a demographic that supports the need for such aggressive interventional care.

If we removed all competition for 100 miles in a suburban metro, you'd have it.

40 procedures divided by 8 hrs, no lunch. Doable as long as you do not do RF or have any slow down or complications or talk to patients or do anything other than stab and run.

If being audited by CMS, good luck. That looks to be 99.9th percentile.

 

[PMR 4 MSK]

Add a 4th day, even a fifth. Make the money while you can. Retire early and get out before the cumulative radiation or lawsuits get you.

But be aware, since you are not personally doing E&Ms on all these patients, that you are relying on the referring doc's diagnosis and treatment being correct and appropriate. When/if a case goes to court, you will be asked what you did to assess the patient. At 40 pts/day, it is not possible for you to asses each pt, get informed consent consisting of alternatives, risks and benefits, do a procedure and document all that, unless youare working 20 hours per day.

 

[Pain Applicant1]

I'm interested to see where this post goes. I'm not sure the OP is truly a pain doc. S/he just joined the board and then posts something like this. Hmmm....

 

[Jcm800]

I'm interested to see where this post goes. I'm not sure the OP is truly a pain doc. S/he just joined the board and then posts something like this. Hmmm....

i agree. Probably someone fishing for data. Lets lynch them. I vote we kill this thread. or move it the private forum. If they are legit, they can follow it into there. but we are also the dummies that are answering.

 

[stim4u]

the consensus is that 40 procedures a day is not feasible or reasonable, unless he is counting every level and trigger point.......

 

[bedrock]

i agree. Probably someone fishing for data. Lets lynch them. I vote we kill this thread. or move it the private forum. If they are legit, they can follow it into there. but we are also the dummies that are answering.

Agree. Let's move this to private forum and see if this guy is really a pain physician and not a lawyer or insurance ex.

 

[blockerdoctor]

you should add another physician if you are truly over 120 procedures a week. Too much radiation and you will see a complication in 2-3 years, so be prepared. furthermore, your ulnar nerve, plantar facitis, and knee will not sustain this level of productivity. Take it from me.
Finally for the procedural hatters on this forum, make sure you are doing the ethical and medically necessary procedures for your patients or you will be audited and targeted by CMS.

thank you sir. This is what I was wondering about. the toll on the body. And yes it truly is 40 per day. Mostly esi's but facets, si jts, some rfa's and some discograms. they have very efficient set up with 2 rooms and multiple recovery rooms. I mostly do not use iv sedation.

 

[blockerdoctor]

I walked into a situation where I get 90 percent of the procedures from a spine surgeon who is very busy. He has several associates working with him that sees patients. the number of patients in the practice is huge

 

[docnyc]

40/day is a very high number in my opinion. I also would be concerned about radiation exposure. Not sure how these patients are getting adequate follow up unless you are strictly an injectionist and all E/M is from spine surgery. I find the pure injectionist model (no clinic or E/M time with pts) leaves patients dissatisfied as no one is explaining why the procedure is being done. With 40 pts in a day I doubt you would have adequate time to explain the reason behind the procedure you are doing.

As an aside, on what basis does CMS audit people. Is it the number of procedures they are doing in relation to average numbers?

That doe not appear to be legitimate care based on hrs in a day and time spent doing a procedure. Also, there is not a demographic that supports the need for such aggressive interventional care.

If we removed all competition for 100 miles in a suburban metro, you'd have it.

40 procedures divided by 8 hrs, no lunch. Doable as long as you do not do RF or have any slow down or complications or talk to patients or do anything other than stab and run.

If being audited by CMS, good luck. That looks to be 99.9th percentile.

 

[lobelsteve]

40/day is a very high number in my opinion. I also would be concerned about radiation exposure. Not sure how these patients are getting adequate follow up unless you are strictly an injectionist and all E/M is from spine surgery. I find the pure injectionist model (no clinic or E/M time with pts) leaves patients dissatisfied as no one is explaining why the procedure is being done. With 40 pts in a day I doubt you would have adequate time to explain the reason behind the procedure you are doing.

As an aside, on what basis does CMS audit people. Is it the number of procedures they are doing in relation to average numbers?

Number of CPT submitted claims compared to same taxonomy in same region is first trigger.

 

[specepic]

thank you sir. This is what I was wondering about. the toll on the body. And yes it truly is 40 per day. Mostly esi's but facets, si jts, some rfa's and some discograms. they have very efficient set up with 2 rooms and multiple recovery rooms. I mostly do not use iv sedation.

They should be paying you VERY well, esp if they own the ACS, they are doing v. well with all those cases.

 

[blockerdoctor]

these are done in the office not an ASC

 

[clubdeac]

The only way this is feasible is if you have at least two rooms like you say and everything is set up and ready the minute you walk into the room. You put on your gloves, tech shoots pic and you stick and inject. You bid them adieu and on to the next room. Same song second verse.... You must have an exceptionally efficient and experienced staff. You've walked into a dream situation. From what I understand, for those that want this, it takes years to build such a machine. I agree though, you need some days for f/u's and new consult evals, right?? Do you even evaluate these patients before injecting??

 

[PinchandBurn]

these are done in the office not an ASC

Also what are you considering to be a 'procedure'.

If you were to do MBBs at L2,3,4,5. Are you considering this as "1" injection or "3" (as three facets are blocked?


I know guys that do the latter and consider it three injections, which is very different.

 

[jsaul]

I think he means one procedure equals one procedure no matter how many shots or levels

 

[blockerdoctor]

Also what are you considering to be a 'procedure'.

If you were to do MBBs at L3,4,5,s1. Are you considering this as "1" injection or "3" (as three facets are blocked?


I know guys that do the latter and consider it three injections, which is very different.

THe above mentioned situation is one procedure. I don't know why anyone would count that as 3 procedures. I am counting One procedure per patient no matter how many sticks or injections-- whether that is IL ESI at L5-S1; or a 2 level TF ESI, or a 2 level facet joint injection or a 3 level discogram.
I do not do official follow up visits. I rarely bill E and M codes. Like I said the procedures are sent to me. I breifly look at the chart and if I object for whatever reason I cancel or change the procedure. For example one was sent for bilateral TON, C3 RFA. I of course only did one side.

 

[Ducttape]

So yes, he is a needle jockey. In that case, 40 procedures per day is probably not that atypical.

The needle jockey in my area schedules q10-15 min TF...

 

[pmrmd]

Insane numbers. If you want to make someone better, it starts at a history and a physical exam. That can't be bypassed to treat an MRI image or do what someone tells you to do instead. I am not impressed but rather nauseous. Congrats blocker, you have lowered yourself to that of a technician.

 

[painstop]

I don't think I would be too fulfilled with this setup (although if you're working three days a week that is pretty sweet). I like more control as to deciding the next course of treatment.,,it goes hand in hand with being a physician and not a tech (although I'm sure there are plenty of IR guys that follow this model and are content...to each their own). The cancer risk is real so I hope you're using appropriate precautions (pulsed, low-dose, etc).

On a completely separate note, I believe the L3,L4,L5 medial branch block and S1 dorsal rami block is actually TWO facet joints, not three (L3 and L4 for the L4/5 facet joint, L4 and L5 as well as S1 for the L5/S1 facet joint...the triple innervation of the L5/S1 joint has basically been disproven so I wouldn't bother with S1 unless you are doing a sacroiliac RF, which is a completely separate topic.

 

[Pain Applicant1]

It may be me and I could be wrong but I don't trust ortho spine or neuorsurg's eval anymore. Now that I'm in private practice, I find that the surgeons don't really evaluate the H and P. They tend to base things almost exclusively on image findings. I've been asked to do TFESI for axial back pain with no signs of radic pattern because of some periph stenosis noted on MRI. I've also been told that the S1 nerve root mainly controls EHL. At this point, I will never rely on someone else's exam, especially that of a surgeon.

With that said, I've spent a lot of time training with an ortho spine surgeon during residency who helped me land my fellowship and I still have a great deal of respect for both spine and neurosurgeons. I also rely on them a lot, especially when I'm concerned about neuro defiict issues.

 

[powermd]

Insane numbers. If you want to make someone better, it starts at a history and a physical exam. That can't be bypassed to treat an MRI image or do what someone tells you to do instead. I am not impressed but rather nauseous. Congrats blocker, you have lowered yourself to that of a technician.

The majority of his patients come from a spine surgeon. The whole point is to ram as many patients as possible through injection therapy so the surgeon can cherry pick the failures as operative candidates.

What's the financial relationship between the surgeon and the injection billing? Does he get a big piece of that too? I swear if I could function on minimal sleep and work well at night I would have done neurosurgery or orthopedics... these guys have it made in the shade.

As it happens though, I did not, and I'm very happy in my role as pain healer. On a typical day I'll inject 12-20 people, but spend plenty of time doing thorough E&Ms on the folks that need it. Our NPs crank through the bread and butter stuff (and grab me for consult if there's an issue). It's a very rewarding way to practice.

 

[PinchandBurn]

I don't think I would be too fulfilled with this setup (although if you're working three days a week that is pretty sweet). I like more control as to deciding the next course of treatment.,,it goes hand in hand with being a physician and not a tech (although I'm sure there are plenty of IR guys that follow this model and are content...to each their own). The cancer risk is real so I hope you're using appropriate precautions (pulsed, low-dose, etc).

On a completely separate note, I believe the L3,L4,L5 medial branch block and S1 dorsal rami block is actually TWO facet joints, not three (L3 and L4 for the L4/5 facet joint, L4 and L5 as well as S1 for the L5/S1 facet joint...the triple innervation of the L5/S1 joint has basically been disproven so I wouldn't bother with S1 unless you are doing a sacroiliac RF, which is a completely separate topic.

yes, but if you do L2, 3,4,5 then that's 3 facets. I almost never do s1.

 

[Jcm800]

It may be me and I could be wrong but I don't trust ortho spine or neuorsurg's eval anymore. Now that I'm in private practice, I find that the surgeons don't really evaluate the H and P. They tend to base things almost exclusively on image findings. I've been asked to do TFESI for axial back pain with no signs of radic pattern because of some periph stenosis noted on MRI. I've also been told that the S1 nerve root mainly controls EHL. At this point, I will never rely on someone else's exam, especially that of a surgeon.

With that said, I've spent a lot of time training with an ortho spine surgeon during residency who helped me land my fellowship and I still have a great deal of respect for both spine and neurosurgeons. I also rely on them a lot, especially when I'm concerned about neuro defiict issues.

I agree.cant trust nobody no where. I am shocked at how poorly patients are examined, but more than that how bad they are interviewed. If you just listen to them,most of the clues are there,but the knee jerk is as long as there is SOMETHING on the MRI, the answer is always ESI, regardless of the pathology. Rarely do I get asked for a facet injection or SI injection. I finally got the surgeons used to just sending them for EVALUATION and nothing else.

 

[Ducttape]

he is a technician. im not trying to denigrate him, but he is probably all not that interested in how they do, or the end results.

there are many other practitioners who also work this way .. think pathologists, radiologists, the aforementioned needle jockeys.

on the other hand - great pay, many days off, no business worries, dont worry about having to satisfy referrals. not bad if you think of it that way.

 

[Jcm800]

he is a technician. im not trying to denigrate him, but he is probably all not that interested in how they do, or the end results.

there are many other practitioners who also work this way .. think pathologists, radiologists, the aforementioned needle jockeys.

on the other hand - great pay, many days off, no business worries, dont worry about having to satisfy referrals. not bad if you think of it that way.

We are ALL secretly jealous. No patient bull****, just put needle here...sign me up

 

[drf]

I don't think I would be too fulfilled with this setup (although if you're working three days a week that is pretty sweet). I like more control as to deciding the next course of treatment.,,it goes hand in hand with being a physician and not a tech (although I'm sure there are plenty of IR guys that follow this model and are content...to each their own). The cancer risk is real so I hope you're using appropriate precautions (pulsed, low-dose, etc).

On a completely separate note, I believe the L3,L4,L5 medial branch block and S1 dorsal rami block is actually TWO facet joints, not three (L3 and L4 for the L4/5 facet joint, L4 and L5 as well as S1 for the L5/S1 facet joint...the triple innervation of the L5/S1 joint has basically been disproven so I wouldn't bother with S1 unless you are doing a sacroiliac RF, which is a completely separate topic.

I believe I read this at some point but does anyone have a nice reference that led them to stop blocking/RFing S1?

 

[emd123]

120 procedure per week? WTF? Add a day? Hell no. Are you paid on production? If so, take every Friday off, and Monday too!

 

[mille125]

Hello fellow pain docs. I am 16 months into private practice. I want to get a sense from other pain docs how many do you think is too many procedures in one day.

I am currently doing 40 procedures 3 days a week. Some say that will wear out a doctor but I am fine with this. I don't feel worn out. In fact, I am considering adding another day to make it 4 days a week due to demand.

What do others think?

I am not even going to respond to this mess

 

[lobelsteve]

I am not even going to respond to this mess

Are you trying To say somethings afoul?

For the low low price of $2m per year you can stab all the people you want. Just hand in the MD and don't pretend like you are trying to help anyone.

 

[mille125]

Hello fellow pain docs. I am 16 months into private practice. I want to get a sense from other pain docs how many do you think is too many procedures in one day.

I am currently doing 40 procedures 3 days a week. Some say that will wear out a doctor but I am fine with this. I don't feel worn out. In fact, I am considering adding another day to make it 4 days a week due to demand.

What do others think?

Do you do a series of three?

 

[Pain Applicant1]

Do you do a series of three?

Series of 3, I don't think think so. Series of 10, more likely. You never know, the 10th one just might work.

Seriously though, do you have an opening for me

 

[PMR 4 MSK]

The main problem I have with this sort of approach is that it is a top-down approach with capitalist bias. Instead of a patient with back pain trying OTC meds, activity modification, followed by Rx meds and PT, then injection therapy if that fails, and if all else fails, consider surgery, this method often starts with "can we do surgery?". If no, "where can we inject?" then work your way down to PT and meds.

To be fair, it may be the case that most patients that are referred have already failed meds and PT.

But who is deciding on what injection, and what is the point of them? Is it diagnostic work or therapeutic? If therapeutic, who is doing the follow ups and deciding on the next course of action? Who prescribes meds and monitors response?

Being a needle monkey can be easy, high-paying work, but high-volume = more patients = more risk. Not doing the E&M yourself may put you at higher risk. And it tends to be very, very costly to the system. Good for the docs, not so good for society, possibly.

 

[powermd]

To be fair, it may be the case that most patients that are referred have already failed meds and PT.

Something that bugs the hell out of me is the importance of having a pain-competent clinician manage medication trials and PT. Almost universally when I see a patient who has "failed" these modalities, they never really had a fair trial of properly directed care. I can understand how a PMD might not understand all the nuances of med management, but it's inexcusable when a patient with shoulder or upper back pain "fails" PT, only to tell me "they just worked on my neck". The same can be said for failing injection therapy or anything else I guess.

 

[Tenesma]

40/day 3 days/week after 16 months of practice... it sounds like an efficient/sweet neuro-radiology set-up without any real competition in the area...

personally, I don't think it is doable - nor is it sustainable - for many reasons...

 

[ghost dog]

Something that bugs the hell out of me is the importance of having a pain-competent clinician manage medication trials and PT. Almost universally when I see a patient who has "failed" these modalities, they never really had a fair trial of properly directed care. I can understand how a PMD might not understand all the nuances of med management, but it's inexcusable when a patient with shoulder or upper back pain "fails" PT, only to tell me "they just worked on my neck". The same can be said for failing injection therapy or anything else I guess.

I frequently see patients who have received in excess of 1 - 2 years of physiotherapy predominantly focused on passive modalities. Unsurprisingly, the patient is no better. Also unsurprisingly: paid for by MVA insurance with involvement of a lawyer.

 

[specepic]

I would only trust another BC pain doc, who I knew WELL, to directly order an injection that I would be asked to perform. Currently, no injection w/o a consult and MRI review is my norm. I get requests from respected surgeons all the time for procedures that could harm the pt based on their anatomy.

 

[emd123]

I get requests from respected surgeons all the time for procedures that could harm the pt based on their anatomy.

Give us an example...

 

[bedrock]

I would only trust another BC pain doc, who I knew WELL, to directly order an injection that I would be asked to perform. Currently, no injection w/o a consult and MRI review is my norm. I get requests from respected surgeons all the time for procedures that could harm the pt based on their anatomy.

I have surgeons ask for interlaminar ESI at C3-C4, interlaminar ESI at levels where they previous did a lami.
Had them request a C1-C2 RF, and C4-C5 TFESI with kenalog....
a SCS on patients with moderate to severe thoracic stenosis..........etc..

I wouldn't do any specific procedure based on what a surgeon is asking for