Should Pain Split into Surgical vs Interventional vs Medical Sub-Fields???

[drusso]

Each with their own KOL's, own programs, own specialty societies, etc?

Let's face it: If you're busy in the OR doing Vertiflexes and Stims all day and have your NP in the clinic doing your pre-and post-op, you don't have much in common with the pain doc who is trying to taper his patient on Vicosomaxanax. If busy you're with frying medial branches, genicular nerves, and pumping people full of corticosteroids until their joints crumble what you care about the guy doing PRP and BMAC?

Think of all the subspecialties that neurology has: Stroke, critical care, interventional, behavioral, neuro-psych, movement disorder, neuromuscular, etc.

Maybe it's time for pain doctors to break up:

Pain-Behavioral/addiction/Functional Restoration
Pain-Medical
Pain-Perioperative/Regional
Pain-Interventional
Pain-Regen
Pain-Surgical

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[Orin]

I would say no but not because of lobbying numbers. The clinical value is in the mixing. Patients don't need 6 specialists treating the same phenotype. They need some one with the time, skill, and desire to address things multifactorially, with appropriate referral when things needs something outside the scope.

 

[Ferrismonk]

I would say no but not because of lobbying numbers. The clinical value is in the mixing. Patients don't need 6 specialists treating the same phenotype. They need some one with the time, skill, and desire to address things multifactorially, with appropriate referral when things needs something outside the scope.

Pick two.

 

[Ferrismonk]

Each with their own KOL's, own programs, own specialty societies, etc?

Let's face it: If you're busy in the OR doing Vertiflexes and Stims all day and have your NP in the clinic doing your pre-and post-op, you don't have much in common with the pain doc who is trying to taper his patient on Vicosomaxanax. If busy you're with frying medial branches, genicular nerves, and pumping people full of corticosteroids until their joints crumble what you care about the guy doing PRP and BMAC?

Think of all the subspecialties that neurology has: Stroke, critical care, interventional, behavioral, neuro-psych, movement disorder, neuromuscular, etc.

Maybe it's time for pain doctors to break up:

Pain-Behavioral/addiction/Functional Restoration
Pain-Medical
Pain-Perioperative/Regional
Pain-Interventional
Pain-Regen
Pain-Surgical

Makes sense, but the real problem is too many different specialties "doing pain". We'd be better off not calling ourselves "Pain doctors" and instead calling ourselves interventional pain specialists.

We already have pain psych, and this isn't done by doctors.
We already have "medical" pain specialties. These are Rheum, Neuro, Endocrine, and PMR.
We already have perioperative/regional pain, this is under anesthesia (there even is a regional fellowship)
Pain Interventional - That's us
Pain Regen - Developing, but this is not yet ready for prime time. We're the best suited for this, but lack of regulation makes this primarily a minimally effective money-maker for quacks.
Pain Surgical - This is Ortho and Neurosurgery. We have just been poaching into their territory.

 

[hyperalgesia]

I don't think referring docs have a clue or recognize the difference. They just hear a pt who has intractable pain that surgeons can't "fix" and so they send to "pain management".

 

[deleted875186]

I like the mix, better for a patient to get care from one pack doctor.

already a lot of pain clinics do interventions only, won’t even prescribe gaba, which I think is unfair to the poor PCP who referred them. Interventions never cure people, i think all pain doctors have to be willing to do some med management, even if you don’t prescribe opioids.

 

[Disciple]

Each with their own KOL's, own programs, own specialty societies, etc?

Let's face it: If you're busy in the OR doing Vertiflexes and Stims all day and have your NP in the clinic doing your pre-and post-op, you don't have much in common with the pain doc who is trying to taper his patient on Vicosomaxanax. If busy you're with frying medial branches, genicular nerves, and pumping people full of corticosteroids until their joints crumble what you care about the guy doing PRP and BMAC?

Think of all the subspecialties that neurology has: Stroke, critical care, interventional, behavioral, neuro-psych, movement disorder, neuromuscular, etc.

Maybe it's time for pain doctors to break up:

Pain-Behavioral/addiction/Functional Restoration
Pain-Medical
Pain-Perioperative/Regional
Pain-Interventional
Pain-Regen
Pain-Surgical

Do you think there’s enough of a knowledge base for that many divisions?

Interventional and Medical might work, but Interventional should encompass full scale pump/SCS management
and Medical should primarily function as a subspecialty of Psychiatry.

 

[Laryngospasm]

Medical pain management= all the PCPs and NPs handing out oxycodone.

 

[SSdoc33]

Each with their own KOL's, own programs, own specialty societies, etc?

Let's face it: If you're busy in the OR doing Vertiflexes and Stims all day and have your NP in the clinic doing your pre-and post-op, you don't have much in common with the pain doc who is trying to taper his patient on Vicosomaxanax. If busy you're with frying medial branches, genicular nerves, and pumping people full of corticosteroids until their joints crumble what you care about the guy doing PRP and BMAC?

Think of all the subspecialties that neurology has: Stroke, critical care, interventional, behavioral, neuro-psych, movement disorder, neuromuscular, etc.

Maybe it's time for pain doctors to break up:

Pain-Behavioral/addiction/Functional Restoration
Pain-Medical
Pain-Perioperative/Regional
Pain-Interventional
Pain-Regen
Pain-Surgical

"pain medicine" is not a primary specialty.

your neurology comparison is apples to oranges.

it would be like saying PM&R has pain, sports, SCI, TBI, neuromuscular, peds, etc.


but to answer your question, i dont think you need that many different subspecialties. just pick the niche you want and get to it. less need for oversight/specialty boards/MOC, etc

 

[drusso]

Makes sense, but the real problem is too many different specialties "doing pain". We'd be better off not calling ourselves "Pain doctors" and instead calling ourselves interventional pain specialists.

We already have pain psych, and this isn't done by doctors.
We already have "medical" pain specialties. These are Rheum, Neuro, Endocrine, and PMR.
We already have perioperative/regional pain, this is under anesthesia (there even is a regional fellowship)
Pain Interventional - That's us
Pain Regen - Developing, but this is not yet ready for prime time. We're the best suited for this, but lack of regulation makes this primarily a minimally effective money-maker for quacks.
Pain Surgical - This is Ortho and Neurosurgery. We have just been poaching into their territory.

Which regulations are impacting the effectiveness of Regen-Pain?

 

[drusso]

"pain medicine" is not a primary specialty.

your neurology comparison is apples to oranges.

it would be like saying PM&R has pain, sports, SCI, TBI, neuromuscular, peds, etc.


but to answer your question, i dont think you need that many different subspecialties. just pick the niche you want and get to it. less need for oversight/specialty boards/MOC, etc

Okay...change neurology to cardiology...Granny Smith vs Fuji...are you happy now?

 

[lobelsteve]

Good old days with Algos on forum. And Rinoo. We talked about Pain residency.

 

[drusso]

Good old days with Algos on forum. And Rinoo. We talked about Pain residency.

I forgot that Rinoo used to post here. It would be great to bring back his expertise...

 

[NJPAIN]

No need to subdivide pain medicine. Let’s face it, the terminology “ interventional pain medicine” did not even exist before we realized what a s**tshow opioid prescribing was. Take the opioids out of the practice that’s all you need. If you subdivide into surgical, regen, etc it will be a way for us to dump dump on one another in addition to other specialties already dumping on us.

 

[SommeRiver]

No need to subdivide pain medicine. Let’s face it, the terminology “ interventional pain medicine” did not even exist before we realized what a s**tshow opioid prescribing was. Take the opioids out of the practice that’s all you need. If you subdivide into surgical, regen, etc it will be a way for us to dump dump on one another in addition to other specialties already dumping on us.

Pain doctors talk BS about one another in ways I have to believe other specialites do not. We're set up for that bc there are no standards in our field and if I do something you don't do, you talk BS about me to your pts and our colleagues.

This happened to me...I did a procedure on a pt that gave 13 months of relief, and she ultimately had this bad pain flare but couldn't get in to see me so she saw this other NE GA pain guy who sat her down and filled her full of BS about me.

He told her I never did the procedure I claimed to have done; he told her I had committed fraud; he told her I had billed her for services I never performed.

Loser (him) goes and repeats the procedure I had done and it didn't help for 3 days. She follows back with me and tells me all of this.

He has a Hx of this behavior too. I was going to call him and confront him about it but decided not to do it.

I can't put myself in a fray...I have too much to lose and I am 100% positive everyone in the region knows him and cannot stand him.

 

[Ferrismonk]

Pain doctors talk BS about one another in ways I have to believe other specialites do not. We're set up for that bc there are no standards in our field and if I do something you don't do, you talk BS about me to your pts and our colleagues.

This happened to me...I did a procedure on a pt that gave 13 months of relief, and she ultimately had this bad pain flare but couldn't get in to see me so she saw this other NE GA pain guy who sat her down and filled her full of BS about me.

He told her I never did the procedure I claimed to have done; he told her I had committed fraud; he told her I had billed her for services I never performed.

Loser (him) goes and repeats the procedure I had done and it didn't help for 3 days. She follows back with me and tells me all of this.

He has a Hx of this behavior too. I was going to call him and confront him about it but decided not to do it.

I can't put myself in a fray...I have too much to lose and I am 100% positive everyone in the region knows him and cannot stand him.

Never wrestle a pig. You''ll both get dirty and the pig enjoys it.

 

[Ferrismonk]

I like the mix, better for a patient to get care from one pack doctor.

already a lot of pain clinics do interventions only, won’t even prescribe gaba, which I think is unfair to the poor PCP who referred them. Interventions never cure people, i think all pain doctors have to be willing to do some med management, even if you don’t prescribe opioids.

Do you think that a cardiologist is needed to write metoprolol?

but to answer your question, i dont think you need that many different subspecialties. just pick the niche you want and get to it. less need for oversight/specialty boards/MOC, etc

Agree, but it would be useful if the patient/referring provider knew what to expect when they were looking into specialists. We've all seen patients who went to a "pain doctor" who didn't do interventions, or doesn't do cervical, or doesn't do stim, or writes obscene amount of opiates, etc.

 

[Ferrismonk]

Which regulations are impacting the effectiveness of Regen-Pain?

You know the answer here. There's a major lack of regulation in this field, although the biggest issue in my book is non-physicians injecting patients.

 

[deleted472101]

Musculoskeletal PMR in office
=cardiology

Interventional-pain(intervention/NM)
=interventional cardiology/EP

Ortho/neurosurgery=CT surgery

 

[drusso]

You know the answer here. There's a major lack of regulation in this field, although the biggest issue in my book is non-physicians injecting patients.

I'm just trying to understand WHAT you think should be regulated. Regulation is used when you want LESS of some thing or some activity. What do you want less of?

 

[Rocuronium18]

Canadian here. We do two year pain fellowships where we go through medical, interventional, and multidisciplinary pain management. Now, within my first five years of practice, the nuances required to manage cancer pain pumps or stim complications or performing ultrasound guided procedures we might not have done in fellowship makes me think that rather than a further sub specialized area, pain medicine might need its own entry level residency.

 

[Agast]

Canadian here. We do two year pain fellowships where we go through medical, interventional, and multidisciplinary pain management. Now, within my first five years of practice, the nuances required to manage cancer pain pumps or stim complications or performing ultrasound guided procedures we might not have done in fellowship makes me think that rather than a further sub specialized area, pain medicine might need its own entry level residency.

I have a Canadian patient who's spent the year here for work. She’s anxious about returning because she says she’d have to wait months before getting a pain doc referral. What’s it like over there for establishing care and being seen on a timely basis?

 

[NJPAIN]

Canadian here. We do two year pain fellowships where we go through medical, interventional, and multidisciplinary pain management. Now, within my first five years of practice, the nuances required to manage cancer pain pumps or stim complications or performing ultrasound guided procedures we might not have done in fellowship makes me think that rather than a further sub specialized area, pain medicine might need its own entry level residency.

Excellent point. UK, AU,NZ all 2 years. US training not long enough to qualify

 

[Orin]

I would be more supportive of a stand-alone 3 - 4 year pain residency program that started as a PGY-2, with anesthesia/medicine/surgical base year. Then you can differentiate into whatever per the original post.

 

[lobelsteve]

Pain doctors talk BS about one another in ways I have to believe other specialites do not. We're set up for that bc there are no standards in our field and if I do something you don't do, you talk BS about me to your pts and our colleagues.

This happened to me...I did a procedure on a pt that gave 13 months of relief, and she ultimately had this bad pain flare but couldn't get in to see me so she saw this other NE GA pain guy who sat her down and filled her full of BS about me.

He told her I never did the procedure I claimed to have done; he told her I had committed fraud; he told her I had billed her for services I never performed.

Loser (him) goes and repeats the procedure I had done and it didn't help for 3 days. She follows back with me and tells me all of this.

He has a Hx of this behavior too. I was going to call him and confront him about it but decided not to do it.

I can't put myself in a fray...I have too much to lose and I am 100% positive everyone in the region knows him and cannot stand him.

For the board: Canton is not NE GA.

We do have a lot of folks who do lousy work. The "Bend over the table, you can have your scripts after the shot" kind of bad.
PM me details please.

 

[TheLoneWolf]

Never wrestle a pig. You''ll both get dirty and the pig enjoys it.

Pigs bite

 

[Rocuronium18]

I have a Canadian patient who's spent the year here for work. She’s anxious about returning because she says she’d have to wait months before getting a pain doc referral. What’s it like over there for establishing care and being seen on a timely basis?

Unfortunately, the broader scope of pain medicine limits our ability to see patients in a timely manner. As most clinics are multidisciplinary pain programs in academic centres, the wait times to get in can be quite long - I have a primarily neuromodulation-focused practice, and am booking new consults into October (I also work half time pain, half time anesthesia, so that‘s part of the reason why). Certainly, for urgent cancer pain consults for consideration of IT pump, we expedite those to be seen within a few weeks. For routine low back pain consults, these patients have two main options here: they can wait 9-12 months for more thorough and multidisciplinary consults, or could wait only 1 month for an interventional radiologist to inject a facet joint without any physical exam or assessment (or evidence, heyoooo!)

 

[Rocuronium18]

I have a Canadian patient who's spent the year here for work. She’s anxious about returning because she says she’d have to wait months before getting a pain doc referral. What’s it like over there for establishing care and being seen on a timely basis?

Another thing - pain medicine, as an academic subspecialty, is relatively new in Canada. Our formal 2 year fellowship program, accredited by the Royal College of Physicians and Surgeons of Canada, only started in 2014, and we have 10 fellowship spots TOTAL across the country (aka, less than the number of pain fellows that train each year in the Chicago area!). High quality pain medicine practiced by physicians that have done fellowships or have some obligation to maintain CME (so, not these yahoos - Chronic pain management is big business in Ontario – and these four private clinic chains dominate the industry) is not very prevalent, unfortunately.

 

[Ducttape]

absolutely not.

there is no value in elevating the self worth of needle jockeys in to thinking what they are doing is the essence of pain medicine.

we already have interventional spine as a separate track that some people go, and a sports medicine track for others.

first, there will be no market for any track other than the interventional. you do not have to go a pain doctor to discuss chronic pain with a physician. in fact, a pain psychologist is probably preferable for patients inclined. or a PMR doctor for functional restoration. or an addictionologist.

second, the problem you will see is that this version of pain medicine with various tracks will quite possibly boil down in to 2 groups:
- those who do injections and make tons of money, get to tell patients to get lost if their expensive injections and implants dont work - which will entice every resident with loans
- those who dont, and would be under constant pressure to just prescribe narcotics.

who is going to do the second track?

 

[SommeRiver]

I like the idea of an IM intern year followed by a 3 year Pain Medicine residency.

IM intern yr is invaluable on multiple levels, and 3 yrs of Pain Medicine focusing on multidisciplinary care.

 

[SSdoc33]

pain residency is the best option, but that isnt going to happen anytime soon.

personally, i think 13 years of post high-school education is enough.no need to make the pain fellowship longer. we are going to have to trust some of the docs out there to learn on their own and try to do the right thing.

our efforts should be focused on keeping all the midlevels away from doing interventions

 

[Ferrismonk]

I'm just trying to understand WHAT you think should be regulated. Regulation is used when you want LESS of some thing or some activity. What do you want less of?

If I'm dreaming...

1. Only physicians (MD/DO) can inject PRP/BMAC/SVF.
2. Preferably, only physicians (MD/DO) with proper training, whether that be IOF certified or whatever. At minimum keep it to Ortho, PMR, and Pain only.
3. No allografts.
4. I think there is enough evidence out there now that insurances should cover joint/tendon injections with PRP. I would be fine with the standard steroid injection reimbursement, with the allowance that the patient can pay an out-of-pocket premium to have the PRP made and used instead of steroid.

 

[deleted875186]

If I'm dreaming...

1. Only physicians (MD/DO) can inject PRP/BMAC/SVF.
2. Preferably, only physicians (MD/DO) with proper training, whether that be IOF certified or whatever. At minimum keep it to Ortho, PMR, and Pain only.
3. No allografts.
4. I think there is enough evidence out there now that insurances should cover joint/tendon injections with PRP. I would be fine with the standard steroid injection reimbursement, with the allowance that the patient can pay an out-of-pocket premium to have the PRP made and used instead of steroid.

It’s insane that all insurrances have PRP as a non covered service .... but someone can go get a knee, hip, shoulder scope and clean out which is covered, more expensive, and has been shown not to be helpful.

 

[cowboydoc]

It’s insane that all insurrances have PRP as a non covered service .... but someone can go get a knee, hip, shoulder scope and clean out which is covered, more expensive, and has been shown not to be helpful.

Ortho is way better at unifying and lobbying.

 

[NJPAIN]

Ortho is way better at unifying and lobbying.

Bingo.

 

[drusso]

Ortho is way better at unifying and lobbying.

Pain needs to mimic ortho.