Return to OR after Pain Fellowship?

[po_boy]

Anyone here return to the OR (permanently) after doing a pain fellowship?

If so, what were the reasons? Are you happy with your decision?

---

Members don't see this ad.

 

[aneftp]

Show me the money.

That’s what this is all about these days.

So yes. I know a few guys with pain fellowship whose pain practices didn’t launch successfully. Or who worked for hospitals or companies and didn’t get a cut of the profit sharing and left.

But with pain reimbursement lower and lower and gen Anesthesia rates higher and higher. It’s a brainer for specifically for those who don’t own their own practices

But those who have successful pain practices have no incentive to cut back on pain

So your question is are you making any money in pain? Compared to general Anesthesia money. That’s how you need to word it.

 

[painstop]

I did it completely 5 years ago (left full time pain clinic 10 years ago) and am quite happy. I started working at the tail end of the opioid bonanza days and the amount of mental health issues being (poorly) masked with pills and needles was getting to me. Trying to undo years of other clinician’s irresponsible behaviors in their search of the all mighty dollar was not worth it for me. In theory, it is an awesome field in a non-opioid practice and if it could focus on providing evidence-based interventional procedures and advancing that arena (basic procedures, endoscopy, advanced percutaneous procedures, etc). There is an entire thread in the pain forum that is about 100 pages deep on the opioid issues. I decided not to be a multimillionaire drug dealer and am content with that decision.

 

[Simba1711]

My friend went back to general anesthesia less than a year after pain fellowship. He makes a lot more money just doing locums 4 days a week right now. I had a colleague at my previous practice who quit pain for anesthesia after a few years. He didn’t like the patients and the ethics of his practice.

 

[Greenbayslacker]

Anesthesia $ is inflated because of locums and call coverage, both of which you can't find with pain. If you control for hours, nights, weekends, etc. an interventional-based practice sounds pretty good.

 

[TheLoneWolf]

Anyone here return to the OR (permanently) after doing a pain fellowship?

If so, what were the reasons? Are you happy with your decision?

Mods please forgive me if I'm not allowed to repost, but I wrote this in another thread and don't feel like rewriting.

Anesthesia and pain boarded. Probably the most interventional fellowship in a large state with several programs. Practice both pain and anesthesia and take all comers (not by choice but can still help 85-90% of who I work with if they aren't sad losers who refuse PT and only want surgery, procedures or narcs or some combination therof)

You will not find fulfillment doing pain management. Do you love unsolvable problems? How about annual falling reimbursement? Playing spine surgeon with one year training? Factory work of 30-40 procedures a day? How about paying someone fulltime to beg insurance to approve your procedures, many of which are now being classified as "experimental", and getting denied. How about doling out narcs to skeevy people who you either cannot trust or don't believe should be on the stuff long term; along with the DEA breathing down your back. Cut them off and your referrals dry up. Pain is saturated in essentially every city so your referrers will simply send their patients to someone "who will handle the patients pain (&opioids).

Sinking ship with a whole number of problems you haven't even considered or seen as an anesthesiologist. It's like a 6am to 10pm sorta job with lots of schmoozing. My phones autocorrect suggested the word schmucking... I'm talking about PP. Lots of hospitals have become quite smart and don't pay you and dont salary guarantee outside of the first 2 years while you get your practice off the ground. Nice guys with no business training find out they are making family doc money unless they heavily push RFA and implants. The grind is real. Just check out how much pain overhead is on their forum. Foreign concept to OR anesthesia.

The money you are making now and the vacation time you have far exceeds pain averages.


Long term pain guys are very money driven so they put up with the above. business degree mindset. Or the rare empathetic type who gets steamrolled by clinic owners and addicts alike.

Had young pain guys on this forum say I'm acting holier than thou or have some false piety because I expose the issues inherent to PP pain management. Yet not one can actually answer the substance of my argument or respond to my questions.

Academic pain management is, for the most part legit but the caveat is most of our literature is from a handful of PP pain guys directly paid by device reps. Academics view pain as heavy PT, non opioid med management and the occasional procedure. A far cry from day to day PP.

 

[chessknt]

Mods please forgive me if I'm not allowed to repost, but I wrote this in another thread and don't feel like rewriting.

Anesthesia and pain boarded. Probably the most interventional fellowship in a large state with several programs. Practice both pain and anesthesia and take all comers (not by choice but can still help 85-90% of who I work with if they aren't sad losers who refuse PT and only want surgery, procedures or narcs or some combination therof)

You will not find fulfillment doing pain management. Do you love unsolvable problems? How about annual falling reimbursement? Playing spine surgeon with one year training? Factory work of 30-40 procedures a day? How about paying someone fulltime to beg insurance to approve your procedures, many of which are now being classified as "experimental", and getting denied. How about doling out narcs to skeevy people who you either cannot trust or don't believe should be on the stuff long term; along with the DEA breathing down your back. Cut them off and your referrals dry up. Pain is saturated in essentially every city so your referrers will simply send their patients to someone "who will handle the patients pain (&opioids).

Sinking ship with a whole number of problems you haven't even considered or seen as an anesthesiologist. It's like a 6am to 10pm sorta job with lots of schmoozing. My phones autocorrect suggested the word schmucking... I'm talking about PP. Lots of hospitals have become quite smart and don't pay you and dont salary guarantee outside of the first 2 years while you get your practice off the ground. Nice guys with no business training find out they are making family doc money unless they heavily push RFA and implants. The grind is real. Just check out how much pain overhead is on their forum. Foreign concept to OR anesthesia.

The money you are making now and the vacation time you have far exceeds pain averages.


Long term pain guys are very money driven so they put up with the above. business degree mindset. Or the rare empathetic type who gets steamrolled by clinic owners and addicts alike.

Had young pain guys on this forum say I'm acting holier than thou or have some false piety because I expose the issues inherent to PP pain management. Yet not one can actually answer the substance of my argument or respond to my questions.

Academic pain management is, for the most part legit but the caveat is most of our literature is from a handful of PP pain guys directly paid by device reps. Academics view pain as heavy PT, non opioid med management and the occasional procedure. A far cry from day to day PP.

Dude you just described the entire field of outpatient medicine--insurance denials, unfixable pathology, poor reimbursement. When you aren't being massively subsidized by the hospital like the medical subspecialties this is what medicine is. This isnt special to pain at all.

 

[Hoya11]

Anyone here return to the OR (permanently) after doing a pain fellowship?

If so, what were the reasons? Are you happy with your decision?

I did the fellowship then PP for one year. I joined a bad group at the height of the opioid epidemic. Lots of shady business with borderline insurance fraud, drug rep dinners, lawyers, workers comp, opioid seekers. In PP I did not feel like this was what I wanted to do for my lifes work, especially with such a good alternative like anesthesia to fall back on. The system and the patients can drive you crazy. The OR in many ways is simpler and you are more free to do what you feel is right. Plus it feels like way more important work in the OR. If I had to do pain again I would probably do an easy academic job/anesthesia mix. But I have no plans to go back to pain

 

[TheLoneWolf]

Dude you just described the entire field of outpatient medicine--insurance denials, unfixable pathology, poor reimbursement. When you aren't being massively subsidized by the hospital like the medical subspecialties this is what medicine is. This isnt special to pain at all.

Your point is well taken but I would have serious pause comparing pain to cardiac, GI, EP, ortho, gen surg etc. Even something like rheumatology.

Perhaps they have falling reimbursement but that's the only contention of yours that holds. These fields don't have their technologies and established procedures rapidly called experimental and insurance puts a stop to it.CMS is not pushing annual proposed 9% cuts to them like to pain (across the board btw).

We dont have Cochrane, JAMA, NEJM putting out annual papers showing that other fields meds and procedures don't work with any frequency like that of pain. They go out of their way annually to roll on pain procedures, their questionable scientific underpinning, and their long term efficacy.

Furthermore, I don't believe fields like ortho cardio GI etc struggle to make payroll and are cornered into doing unnecessary procedures routinely to "make a good living". They don't have to undergo skeevy business practices and act against their best medical and moral judgments.

No, I argue that the problems of pain are unique to that field and not reflection of medicine in general.

 

[Centurion38]

Your point is well taken but I would have serious pause comparing pain to cardiac, GI, EP, ortho, gen surg etc. Even something like rheumatology.

Perhaps they have falling reimbursement but that's the only contention of yours that holds. These fields don't have their technologies and established procedures rapidly called experimental and insurance puts a stop to it.CMS is not pushing annual proposed 9% cuts to them like to pain (across the board btw).

We dont have Cochrane, JAMA, NEJM putting out annual papers showing that other fields meds and procedures don't work with any frequency like that of pain. They go out of their way annually to roll on pain procedures, their questionable scientific underpinning, and their long term efficacy.

Furthermore, I don't believe fields like ortho cardio GI etc struggle to make payroll and are cornered into doing unnecessary procedures routinely to "make a good living". They don't have to undergo skeevy business practices and act against their best medical and moral judgments.

No, I argue that the problems of pain are unique to that field and not reflection of medicine in general.

I've been doing pain for almost 8 years, full time. It can be the best job in medicine, or the worst job in medicine.

PP Pain, in my opinion, is mostly a cesspool. Either you are managing difficult, drug seeking, drug abusing patients or you farm this out to mid-levels and do procedures on them. Hint: you will be inherit these patients when your NP or PA quits, and you will stand tall before the Board or the DEA when they screw up as their "collaborating physician." Drug rep dinners, sleazy marketing, office managers dictating your practice templates and even practice style, payday loans for injections (!!??) in house UDS, insurance fraud, questionable procedures, in house DME, the list goes on. Hope you like 5 pm conversations in the parking lot "hey Doc, let me talk to you for a minute." Concealed carry permit or jiu-jitsu skills highly recommended.

Solo PP Pain in an opioid free practice can be idyllic. Takes a while to build. Better marry rich or inherit wealth or go into debt. But if you are willing to sacrifice and have a good business sense, this can be done.

Academic pain can be either very good, or very bad. Usually low-no opioid in each case.

Hospital pain can also be good or bad depending on your setup, compensation model, referral sources, admin expectations.

Many pain docs, especially PM&R, are working for large Ortho Spine groups. In this setup, you will generally be fed referrals, and there will be low expectations for opioid management. EMG skills are rarely valued. This can be a nice setup, especially if you have ASC buy in. In many practices though, the pain docs are bastard step children, have no true autonomy and are merely procedure monkeys for unscrupulous ortho spine surgeons. Hint: since all your referrals for procedures etc. are fed to you by a spine doc you are easily and inherently replaceable, no matter how good you think you are at 3 level TFESI's.

Do pain because you like dealing longitudinally with patients. If you are good, capable, and patient your practice will eventually flourish and you will see fewer and fewer drug seekers and more and more LOL's with non surgical stenosis who benefit from MILD, young people with hot radics who do well with ESI's, and PLPS patients who really do well with SCS.

Finally- the problems pain faces are not unique to the specialty. There is also no shortage of unethical Physicians in other specialties. If I had a dime for every Ortho Spine, or GI doc or cardiologist doing completely unnecessary ALIF/TLIF/endoscopy/Watchman and procedures du jour I wouldn't be wasting my time posting on this forum.

I'd open my own practice with the capital and drive all my young employees into the ground while I profited off their labors and slept with their spouses.

 

[agolden1]

Sometimes, I think the biggest problem with pain medicine is a jobs problem.

If you follow the pain forum, there are some folks who have found some really great private practice/started their own practice/joined a hospital and are doing incredibly incredibly well for themselves controlling the substances they are writing and (typically) working through high to medium high volumes of procedures while relying on midlevels to some extent for clinic evaluations (but not always). They have in office c-arms or a good portion ownership of an ASC, understand billing and can crank and are happy to do so, similar to high volume orthopedics, GI or ophthalmology.

But then there's the rest of us who are tied to areas where these golden high volume jobs just don't exist for reasons (spouse, family, fear) we hang where we are and are left with an assortment of jobs that are less than desirable. High MME management, concurrent substances, poorly trained PAs churned as rapidly as new associates, and inappropriate procedures. Partnership a distant illusion which is often unequal and keeps the practice lead firmly in control without true equality. Clinic and procedural flow are poorly organized and not efficient.

Pain values entrepreneurship. Open your own practice and do it right while avoiding the bad jobs and lame offers out there.

But with student loans, dreams of home ownership, kids, just wanting to live a bit after residency, and not fully understanding how to open and develop a private practice, the idea of building your own can be beyond daunting.

Anesthesia jobs mentally are simpler. There are jobs all over the place and all of them need people. You aren't going to look at a random city like you could with pain and find there are no jobs or only terrible jobs with the local pill mill available. You won't be boxed out of the city where you grew up, or where your wife really badly wants to live. You'll work long hours and take care of sick folks in the middle of the night, but they money is almost a guarantee and there's a solid amount of time off for now.

And yes, I know people who have gone back to anesthesia from pain, but also know several people who escaped from anesthesia to pain and would never look back. People with a great financial cushion from working on their original field (anesthesia, EM, neuro) seem to have an easier time with making the transition.

 

[Agast]

Mods please forgive me if I'm not allowed to repost, but I wrote this in another thread and don't feel like rewriting.

Anesthesia and pain boarded. Probably the most interventional fellowship in a large state with several programs. Practice both pain and anesthesia and take all comers (not by choice but can still help 85-90% of who I work with if they aren't sad losers who refuse PT and only want surgery, procedures or narcs or some combination therof)

You will not find fulfillment doing pain management. Do you love unsolvable problems? How about annual falling reimbursement? Playing spine surgeon with one year training? Factory work of 30-40 procedures a day? How about paying someone fulltime to beg insurance to approve your procedures, many of which are now being classified as "experimental", and getting denied. How about doling out narcs to skeevy people who you either cannot trust or don't believe should be on the stuff long term; along with the DEA breathing down your back. Cut them off and your referrals dry up. Pain is saturated in essentially every city so your referrers will simply send their patients to someone "who will handle the patients pain (&opioids).

Sinking ship with a whole number of problems you haven't even considered or seen as an anesthesiologist. It's like a 6am to 10pm sorta job with lots of schmoozing. My phones autocorrect suggested the word schmucking... I'm talking about PP. Lots of hospitals have become quite smart and don't pay you and dont salary guarantee outside of the first 2 years while you get your practice off the ground. Nice guys with no business training find out they are making family doc money unless they heavily push RFA and implants. The grind is real. Just check out how much pain overhead is on their forum. Foreign concept to OR anesthesia.

The money you are making now and the vacation time you have far exceeds pain averages.


Long term pain guys are very money driven so they put up with the above. business degree mindset. Or the rare empathetic type who gets steamrolled by clinic owners and addicts alike.

Had young pain guys on this forum say I'm acting holier than thou or have some false piety because I expose the issues inherent to PP pain management. Yet not one can actually answer the substance of my argument or respond to my questions.

Academic pain management is, for the most part legit but the caveat is most of our literature is from a handful of PP pain guys directly paid by device reps. Academics view pain as heavy PT, non opioid med management and the occasional procedure. A far cry from day to day PP.

Not to detract from your essay, but “pushing” RFA isn’t a thing anymore, it’s now considered by insurance to be the mandatory therapeutic step as facet joint injections have become outlawed.

 

[GoBeers]

Do pain because you like dealing longitudinally with patients. If you are good, capable, and patient your practice will eventually flourish and you will see fewer and fewer drug seekers and more and more LOL's with non surgical stenosis who benefit from MILD, young people with hot radics who do well with ESI's, and PLPS patients who really do well with SCS.

Finally- the problems pain faces are not unique to the specialty. There is also no shortage of unethical Physicians in other specialties. If I had a dime for every Ortho Spine, or GI doc or cardiologist doing completely unnecessary ALIF/TLIF/endoscopy/Watchman and procedures du jour I wouldn't be wasting my time posting on this forum.

I'd open my own practice with the capital and drive all my young employees into the ground while I profited off their labors and slept with their spouses.

I'm in my 4th year at a single specialty pain practice in big city market and so far so good. i love my job and feel like i'm making a difference while maintaining integrity, low dose opioids, and focusing on bread and butter procedures. I think you can make a strong living on MBB/RFA/ESI honestly. I don't make as much as colleagues in anesthesiology but honestly the no calls, weekends, and holidays is all i really care about now that i have a growing family.

if i were single then for sure i'd deal with anesthesia, but the pain lifestyle is perfect. i've received a total of 5 phone calls outside of work regarding patient care in my 4 years.

 

[Agast]

Before I went on maternity leave, I had so many patients give me baby gifts. It was honestly astounding to see how many people cared about me that way. And no, they weren’t all opioid patients. Pain management is sort of a weird made-up specialty that occupies a space no one else wants to deal with. But your patients really appreciate you.

 

[TheLoneWolf]

Not to detract from your essay, but “pushing” RFA isn’t a thing anymore, it’s now considered by insurance to be the mandatory therapeutic step as facet joint injections have become outlawed.

Outlawed? Is that a regional thing? We had no problems getting them approved, particularly for younger patients with facetogenic pain. Essentially holding off until the day they will need RFA

 

[TheLoneWolf]

I'm in my 4th year at a single specialty pain practice in big city market and so far so good. i love my job and feel like i'm making a difference while maintaining integrity, low dose opioids, and focusing on bread and butter procedures. I think you can make a strong living on MBB/RFA/ESI honestly. I don't make as much as colleagues in anesthesiology but honestly the no calls, weekends, and holidays is all i really care about now that i have a growing family.

if i were single then for sure i'd deal with anesthesia, but the pain lifestyle is perfect. i've received a total of 5 phone calls outside of work regarding patient care in my 4 years.

I mean...if avoiding call is the make or break between anesthesia and pain and all else being equal, why not be a day doc with fixed hours?

 

[Agast]

Outlawed? Is that a regional thing? We had no problems getting them approved, particularly for younger patients with facetogenic pain. Essentially holding off until the day they will need RFA

Medicare went to MBB/RFA only and the private payors followed. Really sucks because I thought results were pretty good, but officially they have no therapeutic benefit now.

 

[TheLoneWolf]

Medicare went to MBB/RFA only and the private payors followed. Really sucks because I thought results were pretty good, but officially they have no therapeutic benefit now.

Thanks for the info. Did not know that. We never had an issue with facet injections re insurance approvals. Billing lady in the clinic is on a first name basis with many in the insurance world. I doubt that any of the facet injections that I did were cash pay.

 

[chessknt]

Your point is well taken but I would have serious pause comparing pain to cardiac, GI, EP, ortho, gen surg etc. Even something like rheumatology.

Perhaps they have falling reimbursement but that's the only contention of yours that holds. These fields don't have their technologies and established procedures rapidly called experimental and insurance puts a stop to it.CMS is not pushing annual proposed 9% cuts to them like to pain (across the board btw).

We dont have Cochrane, JAMA, NEJM putting out annual papers showing that other fields meds and procedures don't work with any frequency like that of pain. They go out of their way annually to roll on pain procedures, their questionable scientific underpinning, and their long term efficacy.

Furthermore, I don't believe fields like ortho cardio GI etc struggle to make payroll and are cornered into doing unnecessary procedures routinely to "make a good living". They don't have to undergo skeevy business practices and act against their best medical and moral judgments.

No, I argue that the problems of pain are unique to that field and not reflection of medicine in general.

You realize endocrine, nephro, rheum basically only have e/m billing which is cut equally for all specialties right? Imagine if your only source of revenue was e/m billing then seeing another specialty bemoaning how unfair it is that spinal cord stimulator insertion will only pay the same as 3/4 day of seeing medicare patients instead of the whole day. If you don't think nephro or rheum have sick difficult patients I am thinking you must be out of touch with the issues they have to deal with.

I'm not saying you have it great but it isn't like seeing patients is some kind of special crucifix to bear, all of outpatient medicine is financially challenging and a lot of fields with no access to procedures (or legalized drug dealing) have it way worse. I declared someone dead with a bmi of 13 who was actively abusing meth yet the local drug dealer clinic put her on methadone (for cash of course) 150 mg bid that was dispensed on the regular for months. She had a hypercapnic arrest and died and that guy will make way more money than I ever dream of making. How anyone could look at someone with advanced lung disease and baseline hypoxia and respiratory cachexia who is actively using meth and think that is appropriate for long term methadone is beyond conprehensions to me. This is the world of outpatient medicine.

 

[TheLoneWolf]

You realize endocrine, nephro, rheum basically only have e/m billing which is cut equally for all specialties right? Imagine if your only source of revenue was e/m billing then seeing another specialty bemoaning how unfair it is that spinal cord stimulator insertion will only pay the same as 3/4 day of seeing medicare patients instead of the whole day. If you don't think nephro or rheum have sick difficult patients I am thinking you must be out of touch with the issues they have to deal with.

I'm not saying you have it great but it isn't like seeing patients is some kind of special crucifix to bear, all of outpatient medicine is financially challenging and a lot of fields with no access to procedures (or legalized drug dealing) have it way worse. I declared someone dead with a bmi of 13 who was actively abusing meth yet the local drug dealer clinic put her on methadone (for cash of course) 150 mg bid that was dispensed on the regular for months. She had a hypercapnic arrest and died and that guy will make way more money than I ever dream of making. How anyone could look at someone with advanced lung disease and baseline hypoxia and respiratory cachexia who is actively using meth and think that is appropriate for long term methadone is beyond conprehensions to me. This is the world of outpatient medicine.

May I be the first to say...I don't know the day to day of outpatient nephro and rheum and am unsure what they deal with; though I have no doubt it is both difficult and frustrating...and probably reimburses little just to add to it.

I'm sorry to hear about your methadone patient. I frequently deal with the same. Every whackadoo and midlevel and their elderly grandmother thinks that they can safely prescribe long term opiates to drug abusers and chemical copers. Financial incentive is strong. Frustrating to no end that the standard of care really depends on which clinic you walk into.

 

[Agast]

I declared someone dead with a bmi of 13 who was actively abusing meth yet the local drug dealer clinic put her on methadone (for cash of course) 150 mg bid that was dispensed on the regular for months. She had a hypercapnic arrest and died and that guy will make way more money than I ever dream of making. How anyone could look at someone with advanced lung disease and baseline hypoxia and respiratory cachexia who is actively using meth and think that is appropriate for long term methadone is beyond conprehensions to me. This is the world of outpatient medicine.

150mg methadone BID is addiction management dosing. It’s to prevent patients from abusing heroin. Your patient could have died from OD’ing on heroin instead - would that make you feel better? Now I think everyone has moved towards suboxone for addiction. Methadone for pain shouldn’t have to go higher than 40mg in a day.

 

[TheLoneWolf]

150mg methadone BID is addiction management dosing. It’s to prevent patients from abusing heroin. Your patient could have died from OD’ing on heroin instead - would that make you feel better? Now I think everyone has moved towards suboxone for addiction. Methadone for pain shouldn’t have to go higher than 40mg in a day.

Highest I've ever seen is 175 mg daily, one dose. Lady was so zonked, I don't think she knew where she was. Borderline conscious.

 

[Agast]

Highest I've ever seen is 175 mg daily, one dose. Lady was so zonked, I don't think she knew where she was. Borderline conscious.

During fellowship I had an inpatient pain consult on a patient who was on 400mg methadone daily. That’s when I learned about methadone clinics with specialty compounded wafers to get the really high doses. Except in the hospital we only had 10mg tabs, so I had to write for 40 tabs daily. Oh and whatever he needed for postop pain on top of that. Surprisingly had an uneventful stay.

 

[TheLoneWolf]

During fellowship I had an inpatient pain consult on a patient who was on 400mg methadone daily. That’s when I learned about methadone clinics with specialty compounded wafers to get the really high doses. Except in the hospital we only had 10mg tabs, so I had to write for 40 tabs daily. Oh and whatever he needed for postop pain on top of that. Surprisingly had an uneventful stay.

Just wow. All these years, I have never heard of compounded wafers. I would ask, why not just use liquid methadone, quite common where I am 10mg/ml. Cheap too

 

[Ronin1]

Thanks for the info. Did not know that. We never had an issue with facet injections re insurance approvals. Billing lady in the clinic is on a first name basis with many in the insurance world. I doubt that any of the facet injections that I did were cash pay.

It seems like my whole practice is MBB/RFA/ follow up for authorization visits.

 

[GoBeers]

I mean...if avoiding call is the make or break between anesthesia and pain and all else being equal, why not be a day doc with fixed hours?

I think ultimately it comes down to the amount of autonomy allowed too.
I'm not familiar with anesthesia scheduling for "day doc" but in pain medicine, ultimately you can clock in and out whenever you want, lunch whenever you want, choose who you want to see, choose how many people you want to see, choose how you want to manage patients. Things you mentioned in original post are all true but I just don't see it personally... or maybe I just don't care as much about it?

-falling reimbursements ... sure.. annoying
-prior auths... sure annoying (although when you and your staff know the rules and template notes to fit all necessary requirements for approval, it really isn't that hard). If things are not covered, then oh well too bad, not going to fight it.
-skeezy patients.... then don't see them. or take 2 minutes to say you don't prescribe opioids and refer them somewhere else (as you say, plenty of pain docs to choose from)
-DEA breathing down our necks... that's why prescribe no opioids or keep it minimal

There's plenty of pain patients to go around. Everyone has back and joint issues. I used to worry about "referrals drying up" when I didn't continue someone's lousy 1990s med mgmt regimen but it doesn't seem to be a big deal. 1) TONS of PCPs out there, 2) seems like most pain physicians in my area are all practicing similarly anyway... no or low opioids, so there isn't a pill mill for a PCP to lean on these days, 3) I would assume most PCPs aren't there to screw you , they just need help, 4) eventually your good , ethical reputation will be known.

Just the other day I got a grievance from an HMO patient because I refused to take over PCP's oxycontin and dilaudid Rx for patient's treatment of sinus headaches (LOL). The ENT surgeon actually referred him to pain mgmt to manage his post op sinus surgery pain and suggested that I can continue his current regimen (in essence, this false expectation was the set up for the consultation visit to go no where). The guy was so shocked when I told him I wasn't going to prescribe opioids and that I felt the surgeon should take responsibility for his own work. He literally said "NO! the surgeon can't prescribe opioids. he said you MUST prescribe opioids." I literally laughed and said "ok, there seems to be a disconnect between reality and expectation here, I'll be happy to send second opinion pain mgmt referral, and I suggest you ask surgeon for post op opioids if needed or see a different surgeon" and I left the room. No sweat off my back. I could care less about the grievance.

The few people whose med mgmt I take on, either they agree to wean down or they are already on low dose reasonable therapy that I'm comfortable continuing after appropriate evaluation. Otherwise the chronic opioid patient complains for a few minutes and then they leave with a second opinion referral in hand.

 

[TheLoneWolf]

It seems like my whole practice is MBB/RFA/ follow up for authorization visits.

I agree. >95% of my facet interventions are MBB or RFA. That other 5 percent is facet injections, aspirations, aspirating facet cysts etc

 

[TheLoneWolf]

I think ultimately it comes down to the amount of autonomy allowed too.
I'm not familiar with anesthesia scheduling for "day doc" but in pain medicine, ultimately you can clock in and out whenever you want, lunch whenever you want, choose who you want to see, choose how many people you want to see, choose how you want to manage patients. Things you mentioned in original post are all true but I just don't see it personally... or maybe I just don't care as much about it?

-falling reimbursements ... sure.. annoying
-prior auths... sure annoying (although when you and your staff know the rules and template notes to fit all necessary requirements for approval, it really isn't that hard). If things are not covered, then oh well too bad, not going to fight it.
-skeezy patients.... then don't see them. or take 2 minutes to say you don't prescribe opioids and refer them somewhere else (as you say, plenty of pain docs to choose from)
-DEA breathing down our necks... that's why prescribe no opioids or keep it minimal

There's plenty of pain patients to go around. Everyone has back and joint issues. I used to worry about "referrals drying up" when I didn't continue someone's lousy 1990s med mgmt regimen but it doesn't seem to be a big deal. 1) TONS of PCPs out there, 2) seems like most pain physicians in my area are all practicing similarly anyway... no or low opioids, so there isn't a pill mill for a PCP to lean on these days, 3) I would assume most PCPs aren't there to screw you , they just need help, 4) eventually your good , ethical reputation will be known.

Just the other day I got a grievance from an HMO patient because I refused to take over PCP's oxycontin and dilaudid Rx for patient's treatment of sinus headaches (LOL). The ENT surgeon actually referred him to pain mgmt to manage his post op sinus surgery pain and suggested that I can continue his current regimen (in essence, this false expectation was the set up for the consultation visit to go no where). The guy was so shocked when I told him I wasn't going to prescribe opioids and that I felt the surgeon should take responsibility for his own work. He literally said "NO! the surgeon can't prescribe opioids. he said you MUST prescribe opioids." I literally laughed and said "ok, there seems to be a disconnect between reality and expectation here, I'll be happy to send second opinion pain mgmt referral, and I suggest you ask surgeon for post op opioids if needed or see a different surgeon" and I left the room. No sweat off my back. I could care less about the grievance.

The few people whose med mgmt I take on, either they agree to wean down or they are already on low dose reasonable therapy that I'm comfortable continuing after appropriate evaluation. Otherwise the chronic opioid patient complains for a few minutes and then they leave with a second opinion referral in hand.

As I said in my earlier post, I don't have the choice to screen patients and must take on all comers. Bad for business, money should walk out the door mentality of our clinic owner.

I've never had a complaint or problem lodged against me but it's draining having to talk to long term opioid abusers all day about deescalation. I won't prescribe, save a few very select cases. I'm sure you can attest, the situation can escalate quickly to verbal or physical altercation and I just don't need that.

I hope you are right about the unicorn practices where it's nonopioid PP, screen all patients and only take the ones I believe I can help, with some med mgmt and primarily interventional in nature. I haven't seen it. Closest thing to academic university pain management. From my experience, they also can't screen patients and take all comers. So that same issue becomes a near daily occurrence.

 

[GoBeers]

As I said in my earlier post, I don't have the choice to screen patients and must take on all comers. Bad for business, money should walk out the door mentality of our clinic owner.

I've never had a complaint or problem lodged against me but it's draining having to talk to long term opioid abusers all day about deescalation. I won't prescribe, save a few very select cases. I'm sure you can attest, the situation can escalate quickly to verbal or physical altercation and I just don't need that.

I hope you are right about the unicorn practices where it's nonopioid PP, screen all patients and only take the ones I believe I can help, with some med mgmt and primarily interventional in nature. I haven't seen it. Closest thing to academic university pain management. From my experience, they also can't screen patients and take all comers. So that same issue becomes a near daily occurrence.

No I see all comers as well... including the chronic pancreatitis consult from GI, scrotal pain from urology , and endometriosis from gyn.
What I'm saying is... I happily recommend against opioids and follow the guidelines even suggested by their own academies, and whoever else is giving them opioids can continue it. These patients never come back.

Maybe it's more a state of mind. I let them complain for a few sentences and then I continue to shrug my shoulders reiterating that opioid benefits don't outweigh risks or that I'm not the appropriate specialist who should be handling opioids for their problems. They are welcome to come back if they want non-opioid options.

If you are at a practice where there is a little bit of pressure to prescribe opioids to keep patients, then that's a whole different difficult circumstance that would be stressful for sure.

 

[fathead88]

There are many different practice types in pain. I’m hospital-employed, went straight into pain from anesthesia residency. 4 days/week, no nights, no call, no weekends. Low dose/risk med management only (think <30 MME, no concurrent benzos/ambien), screen new patient referrals, mostly interventional. Steady good referrals from PCPs and spine surgery. 6 weeks off, I’ll make about 650-700 this year. Can’t complain about much. Sure some patients suck. But that’s medicine.

 

[Barleycorn]

Anyone here return to the OR (permanently) after doing a pain fellowship?

If so, what were the reasons? Are you happy with your decision?

There are many different practice types in pain. I’m hospital-employed, went straight into pain from anesthesia residency. 4 days/week, no nights, no call, no weekends. Low dose/risk med management only (think <30 MME, no concurrent benzos/ambien), screen new patient referrals, mostly interventional. Steady good referrals from PCPs and spine surgery. 6 weeks off, I’ll make about 650-700 this year. Can’t complain about much. Sure some patients suck. But that’s medicine.

What geographic area?

 

[neutro]

There are many different practice types in pain. I’m hospital-employed, went straight into pain from anesthesia residency. 4 days/week, no nights, no call, no weekends. Low dose/risk med management only (think <30 MME, no concurrent benzos/ambien), screen new patient referrals, mostly interventional. Steady good referrals from PCPs and spine surgery. 6 weeks off, I’ll make about 650-700 this year. Can’t complain about much. Sure some patients suck. But that’s medicine.

this seems like a very good setup

 

[mdo1738]

There are many different practice types in pain. I’m hospital-employed, went straight into pain from anesthesia residency. 4 days/week, no nights, no call, no weekends. Low dose/risk med management only (think <30 MME, no concurrent benzos/ambien), screen new patient referrals, mostly interventional. Steady good referrals from PCPs and spine surgery. 6 weeks off, I’ll make about 650-700 this year. Can’t complain about much. Sure some patients suck. But that’s medicine.

We have a very similar set up. HOPD pain in the right setting can be tremendous.

I get the logic behind why PP doesn't screen referrals, and of course academics is just a dumping ground where it would be soooo unethical to refuse a new patient. But I came out of the gate screening all my referrals and it has saved many headaches. You can't detect all the mines before entering the minefield, but usually it takes about 15 seconds of looking through the referral paperwork to pick up on the messes. Much better for your sanity to just say no then and there instead of letting that patient into your office. I don't turn down a ton, probably 1-2 a week, and have absolutely no problem getting a very full schedule. And I continue to get (more appropriate) referrals from the folks who have sent me ones I've declined.

 

[sloh]

There are many different practice types in pain. I’m hospital-employed, went straight into pain from anesthesia residency. 4 days/week, no nights, no call, no weekends. Low dose/risk med management only (think ambien), screen new patient referrals, mostly interventional. Steady good referrals from PCPs and spine surgery. 6 weeks off, I’ll make about 650-700 this year. Can’t complain about much. Sure some patients suck. But that’s medicine.

Location?

 

[fathead88]

Midwest- top 30-ish metropolitan city.

If pain ever fell completely through I would go back to the OR in heartbeat. Sure I would need refreshing and wouldn’t be comfortable with peds or cardiac, but I genuinely enjoy anesthesia and would be happy to doing it.

 

[Timeoutofmind]

There are many different practice types in pain. I’m hospital-employed, went straight into pain from anesthesia residency. 4 days/week, no nights, no call, no weekends. Low dose/risk med management only (think <30 MME, no concurrent benzos/ambien), screen new patient referrals, mostly interventional. Steady good referrals from PCPs and spine surgery. 6 weeks off, I’ll make about 650-700 this year. Can’t complain about much. Sure some patients suck. But that’s medicine.

That is very impressive.

Congratulations!

Can I ask…

1. $/RVU?
2. Number of patient encounters in a clinic day?
3. Number of procedures in a procedure day?

 

[fathead88]

That is very impressive.

Congratulations!

Can I ask…

1. $/RVU?
2. Number of patient encounters in a clinic day?
3. Number of procedures in a procedure day?

$69.5/wrvu, no tiers.
25-30 patients in a 7-3 clinic day
“basic” injections days are 30-35, including ESI, facets, MBB/RFA, SCS trials
Also have OR time for SCS implants and kyphos

 

[po_boy]

$69.5/wrvu, no tiers.
25-30 patients in a 7-3 clinic day
“basic” injections days are 30-35, including ESI, facets, MBB/RFA, SCS trials
Also have OR time for SCS implants and kyphos

Sounds like a great gig

 

[addoncase]

I hope you are right about the unicorn practices where it's nonopioid PP, screen all patients and only take the ones I believe I can help, with some med mgmt and primarily interventional in nature.

They exist very rare indeed. I am in a small private group that does both pain and Anes, I do both. The pain part is as you described I have at most 15 patients I have given opioids when I felt it was warranted. We don’t do any fancy things like verriflex or mild just bread and butter cases and the patients are all shared, I don’t own my own pool of
Patients however.

Have never felt pressured to rx opioids, and we have a an excellent referral base and get only referrals 95% of the time for interventions from surrounding surgeons (mostly epidurals, MBB, SIJ etc)

This is a stark contrast from what I saw in fellowship being part of a “heath network” that had a centralized phone service for “pain” let the flood gates from all the other specialties shunt patients to you so they don’t have to rx meds.

 

[blockstar]

There are many different practice types in pain. I’m hospital-employed, went straight into pain from anesthesia residency. 4 days/week, no nights, no call, no weekends. Low dose/risk med management only (think <30 MME, no concurrent benzos/ambien), screen new patient referrals, mostly interventional. Steady good referrals from PCPs and spine surgery. 6 weeks off, I’ll make about 650-700 this year. Can’t complain about much. Sure some patients suck. But that’s medicine.

This is the 🐐 of all pain jobs lol.

Im considering going back to OR.

I worked 12 hour days made 600 for a year and a half seeing 50 patients a day. MMEs thru the roof no screening 4 weeks off.

Now doing locums gas making 350 an hour much better drinking coffee posting on sdn zero concerns after hours.

 

[Sriddymopboi]

This is the 🐐 of all pain jobs lol.

Im considering going back to OR.

I worked 12 hour days made 600 for a year and a half seeing 50 patients a day. MMEs thru the roof no screening 4 weeks off.

Now doing locums gas making 350 an hour much better drinking coffee posting on sdn zero concerns after hours.

How long were you away from main OR and how was the adjustment period after going back? Would you recommend locums to a new grad?

 

[blockstar]

How long were you away from main OR and how was the adjustment period after going back? Would you recommend locums to a new grad?

I did a month after fellowship in the OR before starting my pain job.

Its an adjustment like going on a new rotation in residency.

Doing locums imo is fine for a new grad. Most places are happy for the help.

 

[Status Sciaticus]

where and how are yall finding HOPD jobs? I am looking all over Texas and WA and cannot find any listings for HOPDs. Is there someone to cold-call in administration or a department?

 

[agolden1]

where and how are yall finding HOPD jobs? I am looking all over Texas and WA and cannot find any listings for HOPDs. Is there someone to cold-call in administration or a department?

Call the main number for the hospital, get an operator on the phone and ask to speak to someone with physician recruitment.

I was always able to speak or leave a message with someone.

That being said, this technique also netted me 0 interviews. Often was just told the department was full.

 

[GassYous]

where and how are yall finding HOPD jobs? I am looking all over Texas and WA and cannot find any listings for HOPDs. Is there someone to cold-call in administration or a department?

Just build your own ambulatory surgery center along 635 or something
Get in close with the nearby doctors, do 25 cases a week and you're in the money

 

[Status Sciaticus]

Just build your own ambulatory surgery center along 635 or something
Get in close with the nearby doctors, do 25 cases a week and you're in the money

Hard to come up with $5M to build out an asc. makes sense to do when you have 4-5 MDs together so you can always keep it running.

 

[jsammi245]

Just wanted to throw in my experience for anyone also thinking of going back to anesthesia after doing chronic pain. I ended up going back to the OR from pain after 2 years. Something I thought I would never do but.... here I am. As much as I loved my chronic pain patients I was also getting burnt out. A huge part of me leaving was dealing with opioid management. Granted I was only managing 30-40 MME and patients were screened, it was still tiring having that conversation. Checking the PDMP/ UDS, having constant conversations about negative UDS or trying to wean off opioids was exhausting. I also live in an area where it is pretty much impossible to run a non-opioid practice. We needed to keep our VIP referral sources happy which means if you want your straightforward ESI/MBNB/RFA you bet you are also taking over opioid medications. I did many injections from bread and butter (RFA/ESI) to advanced MILD, SCS implants, vertiflex, intracept etc. but found I rarely hit home runs on my injections. Many would still be on chronic opioid therapy despite these interventions. I managed to only wean down a few patients off opioids but unfortunately most would stay on the same medication regimen while supplementing with injections (and no we didn't trade injections for medications). You do feel rusty going back to the OR but it's like riding a bike and it comes back quick. I also managed to get an anesthesia job where I did not have to take any calls, weekends or holidays and was a 7-3 job. I definitely miss the clinic hours and my patients, but it feels great going back home not worrying about what you had prescribed or patients complaining that their TFESI only lasted a day or if that stimulator you implanted was infected. Once I am done in the ORs well... I am done. I also can take longer vacations without worrying about patients being front loaded into my clinic when I come back. I think if I were to pursue pain again, I would probably lean towards an orthopedic/neuro spine group or academics where you get straight forward referrals (again not promised) and are better protected.

 

[gaschicago]

Looking for opinion from group:

Currently in an orthopedic group. Work 4.5 days/week. No opioid management, mostly interventional. Great internal referral source. Have some patients on neuropathics/muscle relaxants coming for refills every now and then.

New contract given which has some changes notably limited ability to moonlight and expansive non compete for few years (would have to leave the metropolitan area).

Would you stay or leave?

 

[chessknt]

Looking for opinion from group:

Currently in an orthopedic group. Work 4.5 days/week. No opioid management, mostly interventional. Great internal referral source. Have some patients on neuropathics/muscle relaxants coming for refills every now and then.

New contract given which has some changes notably limited ability to moonlight and expansive non compete for few years (would have to leave the metropolitan area).

Would you stay or leave?

In exchange for what? Did your pay go up substantially? Could always tell them to take noncompete out or restrict it to pain only or create a small buyout clause like 5-10k penalty or something....

 

[Status Sciaticus]

Looking for opinion from group:

Currently in an orthopedic group. Work 4.5 days/week. No opioid management, mostly interventional. Great internal referral source. Have some patients on neuropathics/muscle relaxants coming for refills every now and then.

New contract given which has some changes notably limited ability to moonlight and expansive non compete for few years (would have to leave the metropolitan area).

Would you stay or leave?

No favorable changes in your court? Could you ask for increased comp since they are kneecapping your ability to moonlight?