RooAgg14

10+ Year Member
Jan 26, 2010
64
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Recently finished my fellowship (PMR trained) and started my first job at a private practice that has a large amount of ortho/neurosurgeons and a handful of interventional physiatrists. Heads up, this will be a long post, but these thoughts have been in my head all week -- I've read this forum for a while and am hoping to get some insight.

I did my fellowship at a single-specialty (PMR) PP w/ in-house fluoro where we did not use sedation for any MBB. About 65% of the time, we used just local for procedures (TFESIs, RFAs, intra-articular joints etc). I'd say about 30% of patients would get versed for TFESIs and RFAs and another 5% would get a combo of versed and fentanyl for RFAs (usually cervical). I'll now being doing my procedures at an ASC and have noticed a few things:

1.) I have privileges at a few ASCs. While getting a tour of one of the ASCs (A), I was told all patients at A get propofol (even for MBBs!). I guess there is an anesthesiology group that works there that provides the sedation. There are a few interventional spine guys (not from my practice) that do injections here at A and just go along with this. Getting propofol goes against everything I was taught...and just doesn't make sense to me, and I know isn't safe for the patient. I have privileges at another ASC (B) about 10 min down the road that does not have this requirement. I'm thinking I should have my patients just do their procedures at B? But there are some surgeons that work next to A that may expect me to do procedures at A. How should I navigate this situation?

2.) How do you schedule your follow-ups after performing a procedure at an ASC?
So in fellowship, when I did a diagnostic MBB (w/ lido) I would ask the patient right after the procedure how they felt, if positive schedule for the --> confirmatory MBB (w/ bupivicane). We didn't have the patient go home with a pain journal since the lido usually wore off after an hour or so. The confirmatory MBB was usually scheduled for the next week. I would wait about 20 min after performing the confirmatory and ask how the patient felt, if positive schedule --> RFA. If they needed a bilateral RFA, I'd do one side and then two weeks later do the other side. Then after two MBBs and the RFAs, I'd follow-up with the patient in clinic 6 weeks s/p RFA. I did not follow-up w/ the patient in clinic in between positive MBBs or prior/btwn RFAs. If the patient had a non-diagnostic MBB response, I would sched a f/u in clinic to reassess.

But now that I'll be doing procedures in an ASC, it seems like it'll be harder to do it how I did in fellowship. One of my colleagues told me to have patients follow-up in clinic after each inj (but he doesn't do MBB, he does facet injections w/ steroid and uses those as diagnostic/therapeutic inj). I feel like following up with the patient to see how a diagnostic MBB did, when all I used was anesthetic (which takes affect pretty quickly after the procedure) would be a waste of time and money for the patient. I'm on a guarantee salary for this first year, but someone else told me to just have them follow-up in clinic after each injection to increase revenue. I know I probably have an idealized view of how actual practice works, but it just doesn't seem right to me to have the patient follow-up the next day? for 5 min after an MBB so I can bill another level 2 or 3. Would love to hear how y'all do it! Help!

3.) On the same thought, what about after TFESIs? I use dex for all neuroaxial procedures, so often it seems like my patients may need more than 1 of these. In fellowship we used to schedule the patient for the second one 2 weeks after, and the patient could cancel if he/she was doing better and didn't need it. I feel like for this scenario, I could have them follow-up in two weeks in clinic after the 1st ESI to reassess. At least I can justify a visit since the ESI is supposed to be therapeutic.

4.) When you first started, how much time did you set aside for each procedure at an ASC? The other docs (who have been practicing for 15+ years) do q15 min. I know for sure my bilateral cervical MBB and unilateral cervical RFAs will take longer. 30 min for all RFAs and 15 min for TFESIs/other procedures? Keep it simple for the schedulers and do q20 min for all procedures? In fellowship, every procedure was scheduled for 15 min, and towards the end of fellowship, I was able to catch up with the hip/SIJ/easy lumbar TFESIs if I started to run behind -- but then again fluoro was in-house, so turnover was quick. I'd only have 1 fluoro suite running at the ASC.

5.) The other interventionalists in my practice don't do many/if any MBB. A lot of their patients come from surgeons within the practice who order things like BL C4-5, C5-6, C6-7 facet inj. So they go ahead and inject those levels with steroid (so it's diagnostic and therapeutic) and maybe 3 months later do the same thing (another diagnostic/therapeutic) and then do an RFA maybe another 3 mos later. I know the literature out there for RFA outcomes is after MBBs, and then there's that recent RCT saying facet inj are not very therapeutic...

I feel like these patients would be better off by having MBBs (save them from the steroid in case they need an SIJ or TFESI in the future) and going straight to an RFA if they have diagnostic responses. That way while they may need to be put through uncomfortable cervical MBBs, the hope is that they will have longer lasting relief with the RFAs vs short-term w/ facet inj. But me telling the surgeons this as someone just coming out of fellowship may not go over well... For those who work in groups similar to mine, what would you do in a situation like this? Just suck it up and do it since that's what they've ordered? Send an appropriately worded email to all the physicians in the practice letting them know of how you've been trained to perform injections and attach the literature? I don't mind doing a single level unilateral/bilateral or double level unilateral facet inj in the right patient (a younger patient/someone w/ clear facet synovitis/facet cyst, etc), but bilateral three level facet injections -- that's too much IMO. Not only am I the youngest, but I'm also 1 of 2 female physicians (the other is a surgeon) in the entire practice (20+ docs), so there is another layer to this. I want to assert myself, but not look demanding...) I've been asking my marketing team to take me to more family practice/IM groups, so that hopefully at least some of my patient census will be where I am in charge of the plan.

If you made it through all that word vomit, thank you! I just want to be able to provide the best care for my patients in an ethical and evidence-based manner, but right now feel like an outlier.
 

nvrsumr

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Apr 25, 2002
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1. I wouldn’t go up against your employers vested economic interests day one.

2. Just have the post op nurse at asc do pain diary and if + schedule round 2 or rf. scheduling fu will get u busier faster....

3. Your MA can do follow up call and schedule or just do the fu

4. 30 and 15 is fine. U won’t be that busy to start.

5. U are hired by an ortho group. U will do the requested injections or you will be let go. With time you may be able to educate some of them but...
 

Agast

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Sep 14, 2009
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the river lethe
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You can book your MBB under local anesthesia, no one can demand you use sedation if you do not think it is indicated. I’m assuming you don’t have in-house fluoro.

Do not come in carrying loads of papers to back up your practice unless you want the other pain doctors there to think you are criticizing their method of practice. Now that you are an attending “this is how I want to do my procedure” should be good enough.

Because you are doing all your procedures at an ASC you are losing out big time on professional fees. You will need to hustle a little more in order to make up for it in terms of clinic and procedure volume.
 
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Aether2000

algosdoc
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May 3, 2005
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You are in a practice that carries increased risk of injury and medical-legal risk to you by doing all procedures with patient unconscious. You are in a practice that is not standard of care. You are in a practice that penalizes you financially for any Anthem or Medicare patient with procedures performed in an ASC where you are not an owner. You are in an injection mill.
 
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NJPAIN

7+ Year Member
Nov 28, 2011
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The sedation issue should be easy. I don’t envision that anyone will force you to have patients sedated if that is not your practice. You should not have to go to a different facility. You may just struggle a bit with fighting the local culture of patients wanting sedation.
With regard to the practice of doing a follow up visit vs not, it’s not a matter of what is good medicine vs bad. It’s logistics and economics. The academic and PP models are very different. If you get crazy busy and need to minimize follow ups in order to see more new patients THEN you can go back to your fellowship model of practice.


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Agast

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Sep 14, 2009
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the river lethe
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Start quietly looking for another job.

That is unnecessary. ASC-only is not unusual for pain docs hired by surgical groups. It doesn’t mean they want you to be a block jock or run a pill mill. They just don’t know how interventional pain works because they can’t do their procedures in an office setting. Demonstrate value and establish your practice and push for an in-house fluoro suite. The other interventional physiatrists should be able to use it too so upfront costs of building one is lower.
 

RooAgg14

10+ Year Member
Jan 26, 2010
64
20
Texas
Status
  1. Attending Physician
I appreciate all the input! My initial post came off very negatively. I think I just feel a little overwhelmed starting my first job and having to change my practice from what I'm used to for the past year. Millennials, right ;)

I actually do really like the organization -- they aren't considered an "ortho group" or injection/pill mill. More of a long-standing multi-disciplinary spine group with ortho, neurosurgery, PMR, psych, PT. The two physiatrists love the place and are full partners. The organization as a whole seems to respect the conservative care docs. We don't do chronic opioid meds. In re: ASCs, I'll be doing procedures at 3 different ASCs. I'm only at ASC A (propofol for all) 1/2 day week. That ASC is not part of the group I work for, I only have privileges there as a convenience for those patients/surgeons in the area. After two years, I am eligible for partnership and able to buy in at ASC B and C. Those are the ASCs where I'll be doing the majority of procedures and have a much stronger say on what I want to do. There are talks to having a fluoro suite in the next couple of years, so I will definitely continue to push for that.

I'm on a first year guarantee, so I have a little time to build my practice. I'll take the advice and schedule the follow-ups to get me busier faster. I'll also be doing NCS/EMG studies to bring up patient volume. And like someone said, once I get busy, I can go back to the fellowship model to make room for new patients.

Thank you again for all the advice -- it's nice to be able to talk these things out with others.
 
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