Referral Source and Ortho Spine doing pain

[Pain Applicant1]

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Where do most of your referrals come from? Are they mainly from primary care or from ortho guys. I remember a thread like this previously posted and wanted to revisit it.

Also, anyone else coming across neuro or ortho spine guys doing pain procedures. What do you guys think about that?

 

[emd123]

Where I'm at, one of the neurosurgeons does a few ESIs here and there. Interventional rads does some ESIs, vertebros, and facets, and one of our neurologists (not fellowship trained) does about 5-10% pain.

 

[Tenesma]

i try to make sure that my referrals are primarily PCPs... they don't know what they are doing and need the most help, and are usually very appreciative...

i try to avoid receiving referrals from spine surgeons because
1) they think they know what is best for the patient, and that i am just a dumb anesthesiologist, who should do as I am told - except I don't work that way
2) they think they understand the spine better
3) they think that pain docs are really there just to write narcotics for their chronic post fusion pain patients
4) most spine surgeons will either do injections (or believe they can do injections better), or will have needle-jockeys in the office doing their series of 3 ESI

so focus on the PCPs as best as you can - it is a broader support base.

 

[Ligament]

100% agree with Tenesma, I greatly prefer PCP referrals as well.

 

[Pain Applicant1]

Nice. I'm glad to hear this. There's an ortho spine here who's doing about 50/50 (ortho and pain) including esi, mbb, facets, sij, scs, etc. I don't think she's well connected with the primary care folks and I think most of her referrals are from in house. I'd be happy to get most of my referrals from the PCPs and am really glad to hear that that's where most of your referrals come from.

 

[SSdoc33]

ortho spine or NS spine do injections mainly because they are not busy enough and cant get enough surgeries in. there was a dude at our practice who took a leave of absence, and when he returned, he couldnt book all of his OR time, s he did a 1/2 day of injections/week. a poked into the procedure room when he asked me a question. honestly, you dont even want to know what was going on in there. just let me say this: may god have mercy on his soul....

 

[drpainfree]

yup, there should be a ban on ortho/ns spine guys doing neuraxial pain procedures.

 

[olafa]

There are couple guys in our area doing injections- mix ortho and NS. Some blind caudals too. But personally I feel this is major conflict of interest and I can't beleive they are authorized to do them. If the injection fails (prob due to operation error and technique) then they are likely to procede to surgery. And if that fails then the surgeon says to the patient - "there's nothing we can do for you, we have already tried everything." Then trying to convince the pt otherwise from our standpoint is so futile becasue they feel the surgeon is the expert and they already laid the groundwork very poorly!

 

[clubdeac]

When I was in fellowship we did a two month neurosurgery rotation. The knowledge I gained about what was operable and what wasn't as well as having the opportunity to sit in on their decompressions and fusions was priceless. However they would also do ILESIs which now looking back, was hilarious. They would sit the patient on the edge of the examination table and place the c-arm around him horizontally so as to get a lateral. They would feel for their entry point and wing it using the xray only for depth perception. It was ridiculous. Looking back I think I saw as many false LORs and lumbar punctures as I did true epidurals. At the time, of course, I didn't know what was going on.... it's sad that trainees are actually exposed to that kind of crap. And these academic neurosurgeons were very well respected....

 

[mille125]

There is an ortho spine that has recently started doing pain procedures in my area as well. He is the least busiest of all of the spine surgeons in the area. I have seen some of his images because we practice in the same center. He does mainly transforaminals. 10% are in the neuroforamen and 90% are elsewhere mostly in the interspinous muscle. He claims that his patients get better which demonstrates the power of either the placebo effect or the trigger point injection or both. He has recently started cervical RF. I am scared for his patients. He has been fueled by the weekend warrior courses which are the main reason a lot of this exists. I have never understood why anyone can enroll in our interventional courses. What do you think would happen if you tried to enroll in our of their workshops?

 

[painstop]

There is an ortho spine that has recently started doing pain procedures in my area as well. He is the least busiest of all of the spine surgeons in the area. I have seen some of his images because we practice in the same center. He does mainly transforaminals. 10% are in the neuroforamen and 90% are elsewhere mostly in the interspinous muscle. He claims that his patients get better which demonstrates the power of either the placebo effect or the trigger point injection or both. He has recently started cervical RF. I am scared for his patients. He has been fueled by the weekend warrior courses which are the main reason a lot of this exists. I have never understood why anyone can enroll in our interventional courses. What do you think would happen if you tried to enroll in our of their workshops?

I agree...this field has been bastardized enough as it is. Remember the outcry on this board a few months ago when that guy on the east coast was offering a training course to CRNA's...time's are a changin and we need to start limiting these courses to the appropriate medical personnel as well...screw free trade...it's not like every physician is entitled to take a course on doing cardiac catheterizations or aneurysm coilings...we need to start putting our interventions in the same level of esteem or we'll have the same garbage results from people doing procedures incorrectly or for improper indications.

 

[geauxg8rs]

My problem, apart from what has been mentioned, is I think some surgeons don't want patients to get better with conservative treatments. If they send them to IR for an ESI (or do it themselves) and the patient fails to improve then they have more ease in getting auth on doing their surgery.
I have seen a patient sent to IR with a script for L4-5 ESI. Patient comes to me because I am closer to home.
The patient had several ESIs in the past with relief for only 3-4 days. Solely axial back pain, ttp over the facets on exam, inc pain with facet loading. Never been offered nor heard of MBB/RFA. I do the latter and patient has profound relief.
Patient states that the surgeon was going to go forward with "screws and rods" if she did not get better with ESI.

Just ridiculous.

 

[jsaul]

My problem, apart from what has been mentioned, is I think some surgeons don't want patients to get better with conservative treatments. If they send them to IR for an ESI (or do it themselves) and the patient fails to improve then they have more ease in getting auth on doing their surgery.
I have seen a patient sent to IR with a script for L4-5 ESI. Patient comes to me because I am closer to home.
The patient had several ESIs in the past with relief for only 3-4 days. Solely axial back pain, ttp over the facets on exam, inc pain with facet loading. Never been offered nor heard of MBB/RFA. I do the latter and patient has profound relief.
Patient states that the surgeon was going to go forward with "screws and rods" if she did not get better with ESI.

Just ridiculous.

this has been going on for nearly 8-10 years now. the numbers of fusions being done is just ridiculous. And the elevated numbers are soley the results of profit motive. I should say profit motive of gordan gekko proportions.

 

[Aether2000]

NASS is the organization that is promoting the weekend warrior training programs for OS and NS so they can get privilges to do these procedures. They are not an organization that is ultimately doing any favors for pain medicine. The OS and NS do the injections because 1. they can.... 2. they don't have to have the patient wait for the injection to be done by anyone else (scheduling referrals, etc), and 3. because per hour it is much more lucrative than operating room work.

 

[PMR 4 MSK]

NASS is the organization that is promoting the weekend warrior training programs for OS and NS so they can get privilges to do these procedures. They are not an organization that is ultimately doing any favors for pain medicine. The OS and NS do the injections because 1. they can.... 2. they don't have to have the patient wait for the injection to be done by anyone else (scheduling referrals, etc), and 3. because per hour it is much more lucrative than operating room work.

The funny thing is that at many hospitlas, NS and OS don't need to prove competence to do these. The thought is, they are Gods, they can do anything with a knife, so they must be able to do something as simple as poke a needle in the back. Admin assumes since they can remove bone from the spine, they can place a needle b/w the bones.

 

[SleepIsGood]

I agree...this field has been bastardized enough as it is. Remember the outcry on this board a few months ago when that guy on the east coast was offering a training course to CRNA's...time's are a changin and we need to start limiting these courses to the appropriate medical personnel as well...screw free trade...it's not like every physician is entitled to take a course on doing cardiac catheterizations or aneurysm coilings...we need to start putting our interventions in the same level of esteem or we'll have the same garbage results from people doing procedures incorrectly or for improper indications.

Agreed.

When OS and NS do these procedures, the conflict of interest is just soo profound.

Also, patients will have a bulging disc at L3/4, the OS tells the radiologist to do do a LESI at L5/s1. These guys then do b/l TFESI at L5/s1, when the pathology is much higher up!

 

[Ligament]

I'm OK with OS and NS doing pain injections. I think the majority are poorly done technically. However, I support this within their scope of practice.

 

[Jcm800]

I'm OK with OS and NS doing pain injections. I think the majority are poorly done technically. However, I support this within their scope of practice.

Should a heart surgeon put in a cardiac stent, most would say no. Sure they "can" but not as well as the cardiologist.

Should a general surgeon do a screening colonoscopy? Again just because it's in the same organ or body part doesn't make them experts to do all procedures in the vicinity. A general surgeon can scope, but about as well as an internist that learns it, neither are the best at it, so why would you go to someone when there is a trained speciality that can do things better...

I have no problem with ortho or nag doing these injections when they are part of their residency and fellowships...where i learned to do them...

 

[Jcm800]

I'm OK with OS and NS doing pain injections. I think the majority are poorly done technically. However, I support this within their scope of practice.

Should a heart surgeon put in a cardiac stent, most would say no. Sure they "can" but not as well as the cardiologist.

Should a general surgeon do a screening colonoscopy? Again just because it's in the same organ or body part doesn't make them experts to do all procedures in the vicinity. A general surgeon can scope, but about as well as an internist that learns it, neither are the best at it, so why would you go to someone when there is a trained speciality that can do things better...

I have no problem with ortho or NSg doing these injections when they are learned as part of their residency and fellowships...where i learned to do them...

 

[Aether2000]

However, many NS or OS will not at all support pain physicians engaging in spine surgery procedures such as minimally invasive fusion, tube discectomy, or hemilaminotomy after completing a weekend course offered by NASS.

 

[clubdeac]

I'm OK with OS and NS doing pain injections. I think the majority are poorly done technically. However, I support this within their scope of practice.

Ligament!!! Blasphemy!! Can't believe you. I'm somewhat joking but seriously, what gets me is the unfairness. They want to shut down vplasties, limit perc disks and MILD procedures. If that's the case they shouldn't be allowed to stick a needle anywhere. They need to learn to play fair. And btw, I've met some real ******* neurosurgeons in my day. Why does everyone think they're all brilliant, can do no wrong Gods??? It's ridiculous!! Sorry, I'm blaming my poor mood on my post coital morning HA..

 

[SSdoc33]

Ligament!!! Blasphemy!! Can't believe you. I'm somewhat joking but seriously, what gets me is the unfairness. They want to shut down vplasties, limit perc disks and MILD procedures. If that's the case they shouldn't be allowed to stick a needle anywhere. They need to learn to play fair. And btw, I've met some real ******* neurosurgeons in my day. Why does everyone think they're all brilliant, can do no wrong Gods??? It's ridiculous!! Sorry, I'm blaming my poor mood on my post coital morning HA..

neurologists know everything and do nothing.
neurosurgeons know nothing and do everything.
psychiatrists know nothing and do nothing.


i'm blaming my poor mood on "lack-of-post-coital-morning-HA"

 

[bedrock]

I'm blaming my poor mood on my post coital morning HA..

I'm never have a headache or a bad mood the morning after coitus......unless I had to get someone real drunk to get laid 😀

 

[Aether2000]

SS, you left one out....
Pathologists know everything and do everything, but too late!

 

[clubdeac]

neurologists know everything and do nothing.
neurosurgeons know nothing and do everything.
psychiatrists know nothing and do nothing.


i'm blaming my poor mood on "lack-of-post-coital-morning-HA"

haha, that's good stuff... I'm gonna start using that.

And I know we're no neurologists (bc we do ****) but seriously, isn't a post coital HA a real thing? I'm joking around but not really... hehe

 

[PMR 4 MSK]

Should a heart surgeon put in a cardiac stent, most would say no. Sure they "can" but not as well as the cardiologist.

Should a general surgeon do a screening colonoscopy? Again just because it's in the same organ or body part doesn't make them experts to do all procedures in the vicinity. A general surgeon can scope, but about as well as an internist that learns it, neither are the best at it, so why would you go to someone when there is a trained speciality that can do things better...

I have no problem with ortho or nag doing these injections when they are part of their residency and fellowships...where i learned to do them...

My first surgery rotation as a med student was with Colon and Rectal surgery. They did lots of flex sigs and colonoscopies.

 

[Jcm800]

My first surgery rotation as a med student was with Colon and Rectal surgery. They did lots of flex sigs and colonoscopies.

yes but everybody agrees that flex sigs are not worth the scope they use...they are not even recommended anymore. this was a push by FPs to do scopes, to scope for dollars. im no expert in GI medicine, but i believe they found that it was cost-ineffective and dangerous as a screening tool, since patients did not want to get a routine screening colon when they just got a flex sig, and things were missed.

second of all, there was a push at universities to do surgical endoscopy. when i was a general surgery resident, this was the big thing...
guess what, only rarely do they do them now, and only at some random university places...especially since reimbursement is slashed.

and the rationale for doing them was, "well we can" but they knew, and even admitted to me,that they were not very good at it, since they were "cutters" not GI docs...

 

[PMR 4 MSK]

yes but everybody agrees that flex sigs are not worth the scope they use...they are not even recommended anymore.

Yeah, but I forgot to add in that I trained last century. Lap Cholys were revolutionary at the time. MRIs existed, but we weren't really sure what to do with them. We ordered tomograms (not CT) for kidney stones.