EtherBunny

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Has anyone on this board transitioned back to OR anesthesia after practicing 100% pain for a while? Any regrets in doing so?
 

Timeoutofmind

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I sent you a PM.
Would appreciate if someone could comment on this publicly instead of by pm's.

My question: if I do 100% pain for say three years after fellowship and want to get back in the OR, can I get credentialed? What would I need to do to get back in there? Is there some kind of refresher or proctorship?
 

Planktonmd

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I don't think you need anything to be credentialed as long as you are board certified/eligible.
Just on the first day you go back make sure they don't assign you to the heart room! :)
 

aneftp

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Would appreciate if someone could comment on this publicly instead of by pm's.

My question: if I do 100% pain for say three years after fellowship and want to get back in the OR, can I get credentialed? What would I need to do to get back in there? Is there some kind of refresher or proctorship?
Depends on the hospital system. Many are getting stricter and stricter (not just anesthesia but other specialities)

Even guys who do regular anesthesia but at ASC (not GI only but real ASC cases like ortho/peds). Some hospital system will want your case log and if they don't see "acute care" cases they will question your credentials

It depends on how anal the hospital system is. Obviously the more desperate they are they will let things slide.

My advice is if you find yourself having ur credendials questioned. Their are hospital especially more rural ones willing to let u slide by and credendial you for general anesthesia purposes.

My hospital system is pretty strict about the 5 year board certification process. And they do as for a case log. The final decision is up to the medical staff office. It's just weird this really good GI doc who couldn't practice inpatient locally for 2 years non compete with former patient. so he did all his scopes outpatient for 2 years. And he came back and they wouldn't let him do ERCPs until his was "proctored" 5 times.
 

ranvier

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I was roaming sdn and there is a similar post about going back to pain. So interesting how things shift back and forth. Best of luck.
 
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kazuma

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This could be an issue, I had to provide a case log to a couple new hospitals I'm being credentialed at and I'm only one year out of residency and board certified. One thing that would have been difficult to do had I not been practicing OR anesthesia is pediatric case credentialing. In order to do peds cases, they require that you have done 100 cases over the last year. Luckily I had done 150+ over my first 9 months in practice. I would assume you'd have to be proctored for 100 peds cases if you didn't meet their requirement.

I think it would be wise to do some locums on the side if you are considering doing OR anesthesia at some point after a pain fellowship.
 

zero0

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Is pain reimbursement that bad these days?
 

aneftp

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Is pain reimbursement that bad these days?
Unless u are workin for the "man" in pain. It's very hard to start your own pain practice from the bottom up.

Yes. It can be lucrative. But like any business it takes capital. It takes referrals.

Most of my successful anesthesia trained pain fellowship buddies took around 3 years to build capital and start own practice. In mean time they did general anesthesia. To buy equipment/lease office space/staff. You are talking at min 200-300k. Unless you are in an underserved area. It's hard to get someone to front you the money. Sure maybe you can take out a loan. But it's just massive debt to assume in addition to student loans.

So OP could have been workin for the man for 2 years. Obviously they shave a lot off the top in pain and require you to see a lot of patients. Nothing is given in this world for most people
 
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EtherBunny

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Is pain reimbursement that bad these days?
The compensation isn't the problem. You can make a lot of money in interventional pain, if you're in private practice. I know plenty of interventional pain physicians in private practice who make over $650,000/yr. The issue is HOW you make the money in this setting. The patients, with the notable exception of cancer patients and elderly/normal folks with isolated complaints (e.g., tennis elbow or lumbar radiculopathy), are absolutely draining. They suck the life out of you and are a source of burnout. Probably 50% of the patients have fibromyalgia or an undiagnosed central pain disorder, which is either overlooked or sub optimally treated. These patients are terrible candidates for interventional pain procedures. The majority of patients are on systemic opioids, even though 90% of these patients should NOT be on opioids. Good luck weaning them off. Many of the referring providers think it's a good idea to put patients on BOTH benzos AND opioids. It's a constant battle to get patients off the benzos and opioids, and annoying as hell to deal with. Imagine arguing with 10 patients a day about this very issue. It gets old quickly. You constantly have to worry about patients doing something stupid and overdosing, even if you take every reasonable precaution against this possibility. The failure rate for procedures in benign pain is unacceptably high, unlike the procedures for cancer pain. Dealing with third party payers is a royal pain in the ass. All of them have different local coverage determinations for procedures. Denials for care are commonplace and, in many cases, random. Documentation requirements are absurd. On top of all this joy is a systematic "milking" of the system by unethical physicians (obviously not everyone but more common than you might think), who are doing everything they possibly can to get rich off of patient care. It's basically the equivalent of being a glorified salesperson. Bad news.

It's just an absolute mess in private practice. Maybe it's different in integrated health care systems (I hope it is, anyways). Academia is definitely a different environment, but then you have the publish or perish dynamic.
 

KateFan

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I agree 100% with the above poster. I did anesthesia residency followed by pain fellowship, took a 100% pain job in a desirable locale for a lot of salary right out of training.
The patients, many of whom I had on my schedule, were on high dosages of narcotics. Having the same talk with them in various degrees day in and day out positvely drained my soul. Urine abberancies were routinely overlooked. Billing was often upcharged beyond the physician's control. Lots of shady practices all geared toward making more money for the man who decided he'd rather sit at home and pay himself to the tune of 150k q 2 weeks for essentially doing jack. To boot, the DEA was investigating him for the past 2 years prior to me joining, unbeknownst to me and another new hire when we signed.

Part of the problem too with pain reimbursement relates to the subjective nature of what we treat. There is no foolproof way to document improvement in something as subjective as pain. Thus, insurance companies, toeing the line of govt insurance, are quick to ax the reimbursement for esi, rftc, and scs- the core of what we do- due to lack of documented efficacy. The result is you are left with quite unscrupulous docs like the one I worked for who bilk and milk the system to maintain their desired level of affluence (God it must've been grand to be a pain doc or any doc in the 90's).
 
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zero0

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The compensation isn't the problem. You can make a lot of money in interventional pain, if you're in private practice. I know plenty of interventional pain physicians in private practice who make over $650,000/yr. The issue is HOW you make the money in this setting. The patients, with the notable exception of cancer patients and elderly/normal folks with isolated complaints (e.g., tennis elbow or lumbar radiculopathy), are absolutely draining. They suck the life out of you and are a source of burnout. Probably 50% of the patients have fibromyalgia or an undiagnosed central pain disorder, which is either overlooked or sub optimally treated. These patients are terrible candidates for interventional pain procedures. The majority of patients are on systemic opioids, even though 90% of these patients should NOT be on opioids. Good luck weaning them off. Many of the referring providers think it's a good idea to put patients on BOTH benzos AND opioids. It's a constant battle to get patients off the benzos and opioids, and annoying as hell to deal with. Imagine arguing with 10 patients a day about this very issue. It gets old quickly. You constantly have to worry about patients doing something stupid and overdosing, even if you take every reasonable precaution against this possibility. The failure rate for procedures in benign pain is unacceptably high, unlike the procedures for cancer pain. Dealing with third party payers is a royal pain in the ass. All of them have different local coverage determinations for procedures. Denials for care are commonplace and, in many cases, random. Documentation requirements are absurd. On top of all this joy is a systematic "milking" of the system by unethical physicians (obviously not everyone but more common than you might think), who are doing everything they possibly can to get rich off of patient care. It's basically the equivalent of being a glorified salesperson. Bad news.

It's just an absolute mess in private practice. Maybe it's different in integrated health care systems (I hope it is, anyways). Academia is definitely a different environment, but then you have the publish or perish dynamic.
Sounds rough. Here I was thinking pain was one of the last few havens in medicine, right up there with derm, GI, etc. Seems like the opioid epidemic has ruined the field. Handing that stuff out like candy for decades was bound to catch up to us eventually. Guess I'll stick to the OR if I even go the gas route at all. Still not sure.

I'm no veteran, but I've got enough sense to see that patient population is a big part of what makes practicing medicine bearable in the long run. Dealing with malignant and poorly managed patients pawned off on you by some second rate PCP would slowly suck my soul out. That's the biggest thing turning me off the ED. I guess pain is bound to suffer a lot of the same problems as EM in terms of patient population, albeit they might smell a little better when they come in. Maybe unconscious patients are the best kind after all.
 

d9sccr

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The compensation isn't the problem. You can make a lot of money in interventional pain, if you're in private practice. I know plenty of interventional pain physicians in private practice who make over $650,000/yr. The issue is HOW you make the money in this setting. The patients, with the notable exception of cancer patients and elderly/normal folks with isolated complaints (e.g., tennis elbow or lumbar radiculopathy), are absolutely draining. They suck the life out of you and are a source of burnout. Probably 50% of the patients have fibromyalgia or an undiagnosed central pain disorder, which is either overlooked or sub optimally treated. These patients are terrible candidates for interventional pain procedures. The majority of patients are on systemic opioids, even though 90% of these patients should NOT be on opioids. Good luck weaning them off. Many of the referring providers think it's a good idea to put patients on BOTH benzos AND opioids. It's a constant battle to get patients off the benzos and opioids, and annoying as hell to deal with. Imagine arguing with 10 patients a day about this very issue. It gets old quickly. You constantly have to worry about patients doing something stupid and overdosing, even if you take every reasonable precaution against this possibility. The failure rate for procedures in benign pain is unacceptably high, unlike the procedures for cancer pain. Dealing with third party payers is a royal pain in the ass. All of them have different local coverage determinations for procedures. Denials for care are commonplace and, in many cases, random. Documentation requirements are absurd. On top of all this joy is a systematic "milking" of the system by unethical physicians (obviously not everyone but more common than you might think), who are doing everything they possibly can to get rich off of patient care. It's basically the equivalent of being a glorified salesperson. Bad news.

It's just an absolute mess in private practice. Maybe it's different in integrated health care systems (I hope it is, anyways). Academia is definitely a different environment, but then you have the publish or perish dynamic.
Something I've been wondering about. I'm seriously considering a pain fellowship but I'm wondering if it's a "grass is greener" situation. My program has a significant portion that goes into pain every year (20-30%) and subsequently it looks like a great route, especially after some of our residency issues.

As an intern, I had a private practice pain rotation that was almost purely interventional. Of course there was some medication management, but the vast majority of clinic was either diagnosing patients and setting up a procedure or follow-up appointments. Patient's that broke their pain contracts were discharged, no questions asked. Patients that wouldn't follow recommendations as far as cutting back on narcotics while trying procedures and PT were often sent back to their PCP. (I know how that sounds, but what more can you do for a patient that doesn't agree w/ your plan?). Is this sort of practice not commonplace?
 

PainDrain

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The definition of pain medicine: Patients come to see you and let you stick needles in them in the hope that you will refill their Oxycontin prescription.
Every practicing pain doctor knows this simple fact but some are living in denial and won't admit it.
This is so true.

In my experience most of the patients would gladly have a needle stuck in their back/neck every few months so they can keep their candy coming in. I had some great patients who weren't on narcs, but for every one like that I had a dozen who were simply "chemical copers", treating their emotional pain and social dysfunction with mind altering substances.
 
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EtherBunny

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Something I've been wondering about. I'm seriously considering a pain fellowship but I'm wondering if it's a "grass is greener" situation. My program has a significant portion that goes into pain every year (20-30%) and subsequently it looks like a great route, especially after some of our residency issues.

As an intern, I had a private practice pain rotation that was almost purely interventional. Of course there was some medication management, but the vast majority of clinic was either diagnosing patients and setting up a procedure or follow-up appointments. Patient's that broke their pain contracts were discharged, no questions asked. Patients that wouldn't follow recommendations as far as cutting back on narcotics while trying procedures and PT were often sent back to their PCP. (I know how that sounds, but what more can you do for a patient that doesn't agree w/ your plan?). Is this sort of practice not commonplace?
You should definitely be cautious when it comes the "grass is greener" phenomenon. In principle, interventional pain medicine should be an amazing subspecialty.

If you could somehow start or join a practice that is:
1. truly multidisciplinary (physical therapists with expertise and experience treating chronic pain patients, a well-trained and ethical chiropractor, a talented acupuncturist, massage therapy, and pain psychology)
2. highly selective in terms of what patients the practice takes on long term, filtering out all drug seekers, "chemical copers," and patients with centralized pain disorders and/or axis II disorders, only leaving "normal" chronic pain patients who just want to become more functional and contribute positively to society
3. highly restrictive vis-a-vis systemic opioid prescriptions, limiting them to cancer pain, acute/subacute postoperative pain, and the occasional 70+ year old elderly person with particularly severe, NSAID refractory degenerative joint disease all over the place that you can't realistically treat with interventional pain procedures effectively
4. divorced from third party payers, who increasingly view interventional pain procedures as "investigational" and are trigger happy when it comes to denials of care, even if care is pre-authorized
5. profitable despite being ethical, multidisciplinary, and (highly) opioid restrictive

then, yes, interventional pain would be a dream. Highly predictable schedule. No weekends, no nights, no in house call. No emergencies. High income. Fun procedures and satisfied patients.

The problem is that reality is a far cry from the ideal in interventional pain. Truly multidisciplinary practices are not that common, except in a few high end private practices and academia. For the most part, private practice is the polar opposite of multidisciplinary, simply because of the high cost of maintaining all of the ancillary services such as PT, pain psych, massage, etc. It eats into the bottom line and requires a very high volume of interventional pain procedures to maintain. In addition, the selectivity on the front end is a double-edged sword. In the long term, it will result in a great patient population that you not only can help but also enjoy treating. However, it's a recipe for pissing off referring providers. If you reject half the referrals from a PCP (or whomever), don't be surprised when your referrals from that doc mysteriously disappear. It's ridiculous, but it's reality. With respect to highly restrictive opioid prescribing habits...plan on arguing with patients every day, multiple times a day about why opioids are bad for them long term (dependence, tolerance, addiction, hyperalgesia, endocrine disturbances, societal consequences, activity restrictions, etc. etc.) and that, believe it or not, the doctor who was previously prescribing them oxycontin, oxycodone, AND benzos for benign pain was doing the WRONG thing. It's draining. After you do it a few hundred times, it gets old. "Chemical copers" are EXTREMELY common in pain medicine and, unfortunately, many doctors outside (and inside) the field of pain medicine have fostered this mentality over the years.

Finally, it would be amazing to be divorced from third party payers for reimbursement. There are so many enormous advantages to it: more face time with patients, far less time devoted to extraneous documentation requirements, higher profit margins because you can run a much leaner operation overall without staff devoted to billing, more freedom in procedural options, etc. The list goes on and on. The problem is that this model of care, which is known as concierge medicine or direct pay, is not being done routinely in interventional pain. Primary care, orthopedics, derm...yeah, but not interventional pain. It's hard to venture into this territory when you have a wife, children, and $250,000 of educational debt.

Just my $0.02 as a burnt out interventional pain physician (who initially was very excited about a career in pain medicine).
 

aneftp

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You should definitely be cautious when it comes the "grass is greener" phenomenon. In principle, interventional pain medicine should be an amazing subspecialty.

If you could somehow start or join a practice that is:
1. truly multidisciplinary (physical therapists with expertise and experience treating chronic pain patients, a well-trained and ethical chiropractor, a talented acupuncturist, massage therapy, and pain psychology)
2. highly selective in terms of what patients the practice takes on long term, filtering out all drug seekers, "chemical copers," and patients with centralized pain disorders and/or axis II disorders, only leaving "normal" chronic pain patients who just want to become more functional and contribute positively to society
3. highly restrictive vis-a-vis systemic opioid prescriptions, limiting them to cancer pain, acute/subacute postoperative pain, and the occasional 70+ year old elderly person with particularly severe, NSAID refractory degenerative joint disease all over the place that you can't realistically treat with interventional pain procedures effectively
4. divorced from third party payers, who increasingly view interventional pain procedures as "investigational" and are trigger happy when it comes to denials of care, even if care is pre-authorized
5. profitable despite being ethical, multidisciplinary, and (highly) opioid restrictive

then, yes, interventional pain would be a dream. Highly predictable schedule. No weekends, no nights, no in house call. No emergencies. High income. Fun procedures and satisfied patients.

The problem is that reality is a far cry from the ideal in interventional pain. Truly multidisciplinary practices are not that common, except in a few high end private practices and academia. For the most part, private practice is the polar opposite of multidisciplinary, simply because of the high cost of maintaining all of the ancillary services such as PT, pain psych, massage, etc. It eats into the bottom line and requires a very high volume of interventional pain procedures to maintain. In addition, the selectivity on the front end is a double-edged sword. In the long term, it will result in a great patient population that you not only can help but also enjoy treating. However, it's a recipe for pissing off referring providers. If you reject half the referrals from a PCP (or whomever), don't be surprised when your referrals from that doc mysteriously disappear. It's ridiculous, but it's reality. With respect to highly restrictive opioid prescribing habits...plan on arguing with patients every day, multiple times a day about why opioids are bad for them long term (dependence, tolerance, addiction, hyperalgesia, endocrine disturbances, societal consequences, activity restrictions, etc. etc.) and that, believe it or not, the doctor who was previously prescribing them oxycontin, oxycodone, AND benzos for benign pain was doing the WRONG thing. It's draining. After you do it a few hundred times, it gets old. "Chemical copers" are EXTREMELY common in pain medicine and, unfortunately, many doctors outside (and inside) the field of pain medicine have fostered this mentality over the years.

Finally, it would be amazing to be divorced from third party payers for reimbursement. There are so many enormous advantages to it: more face time with patients, far less time devoted to extraneous documentation requirements, higher profit margins because you can run a much leaner operation overall without staff devoted to billing, more freedom in procedural options, etc. The list goes on and on. The problem is that this model of care, which is known as concierge medicine or direct pay, is not being done routinely in interventional pain. Primary care, orthopedics, derm...yeah, but not interventional pain. It's hard to venture into this territory when you have a wife, children, and $250,000 of educational debt.

Just my $0.02 as a burnt out interventional pain physician (who initially was very excited about a career in pain medicine).
Let me ask you something.

1. Do you own your own pain practice?

My middle age (38-44 years old) pain friends who own their own pain practice love it

My young pain friends (less than 35 years old) who don't own their own pain practice hate it
 

aneftp

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Of course my pain friends. The ones who are successful take Friday's and even some Monday's off as well now.

So a lot of the job satisfaction has to do with time off as well.

Maybe that's why many of the crnas are happy. Most only work 3 maybe 4 days a week and no weekends or nights!
 
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EtherBunny

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I've thought about starting my own practice on several occasions. Although it would be great to have absolute control over the practice, I'm not too keen on the idea of solo practice nowadays for a variety of reasons.

#1: It's becoming increasingly difficult to get paid for interventional pain services. Most practices have to hire a fair number of staff to handle prior authorizations and appeals. This is an unavoidable expense that really cuts into the bottom line. Group practices and integrated health care systems can defray these costs more than a solo practitioner because multiple providers can use the same billing staff. It's a more favorable provider to billing staff ratio.

#2: I'm not convinced that solo practice is really the best for patients. I'm a huge advocate for multidisciplinary care for chronic pain patients. As a solo practitioner I would have to refer patients to multiple providers in various disciplines, all of whom are spread out. The care becomes fragmented, onerous for patients, and communication is almost unavoidably poor among the various clinicians. Team based care is the new norm, and integrated health care systems are FAR better at this than a bunch of solo docs in the community.

#3: I'm not a huge fan of the "business" of medicine. I used to be very interested in it, as I'm somewhat entrepreneurial by nature. But there's something fundamentally unethical and sleazy (to me anyways) about mixing business and medicine. It makes me feel like a glorified salesman, not a physician. Being a private practice owner absolutely requires very close attention to the business side of things. In many respects, solo pain practices are businesses first rather than clinical practices (if that makes any sense). It's all about milking as much money out of the system as humanly possible, without going to jail, pissing off referring providers, or overtly harming patients (even though plenty of medically unnecessary services may be rendered in the process). That's the "business" of medicine and I hate it.

#4: I don't particularly like the wining and dining aspects of being a specialist. I don't like taking referring docs out to dinner in order to earn their "business." I don't like the wining and dining nonsense with pharmaceutical reps and device reps. I just want to focus on patient care and maybe do some research. Plain and simple. I was always told that if you take great care of your patients--if you're truly excellent at what you do clinically--the money will naturally follow and your practice will grow. I was told that you don't have to be a great businessman to succeed professionally, you just have to be a great doctor. Unfortunately, what I've observed in private practice is the polar opposite. It's the unethical, greedy, and slick businessmen in pain medicine who are thriving financially. The truly ethical docs are the ones who are struggling. Sad but true in my neck of the woods.
 

Planktonmd

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2. highly selective in terms of what patients the practice takes on long term, filtering out all drug seekers, "chemical copers," and patients with centralized pain disorders and/or axis II disorders, only leaving "normal" chronic pain patients who just want to become more functional and contribute positively to society
You just excluded 95% of all chronic pain patients!
 
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nvrsumr

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I have a solo pain practice. Desirable location. Dog comes to work everyday. Own the building. Zero narcotics. 8-5 m-thurs. No nights. No weekends. Never see the inside of a hospital. Haven't been to a work dinner in a decade. Good pay. 100% autonomy.

Just another point of view.
 

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I have a solo pain practice. Desirable location. Dog comes to work everyday. Own the building. Zero narcotics. 8-5 m-thurs. No nights. No weekends. Never see the inside of a hospital. Haven't been to a work dinner in a decade. Good pay. 100% autonomy.

Just another point of view.
Awesome.
 

NightNight

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I have a solo pain practice. Desirable location. Dog comes to work everyday. Own the building. Zero narcotics. 8-5 m-thurs. No nights. No weekends. Never see the inside of a hospital. Haven't been to a work dinner in a decade. Good pay. 100% autonomy.

Just another point of view.
Yeah that's legit.


Sent from my iPhone using SDN mobile
 

PainDrain

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I have a solo pain practice. Desirable location. Dog comes to work everyday. Own the building. Zero narcotics. 8-5 m-thurs. No nights. No weekends. Never see the inside of a hospital. Haven't been to a work dinner in a decade. Good pay. 100% autonomy.

Just another point of view.
Only difference though is that you clearly started during the "good times" for pain. Starting a practice from scratch today takes atleast 300k, as stated above and you can't do it in desirable locations.
 

aneftp

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Only difference though is that you clearly started during the "good times" for pain. Starting a practice from scratch today takes atleast 300k, as stated above and you can't do it in desirable locations.
Yes u can. The millennia generation wants everything NOW. Generally those born after 1980 are the millennia generation.

My friend spent 3 years working hard in general anesthesia before building capital to start successful pain in a major top 5-6 population highly desirable area.

Nothing is a given in life. Sure luck can be involved. But it's hard work sterting a small business.

Like I said before. Those working for someone in pain are generally very unhappy because they are required to hit a certain amount of patients and revenue. And of course you know someone is shaving 20-40% off the top of your billing.
 

GravelRider

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Yes u can. The millennia generation wants everything NOW. Generally those born after 1980 are the millennia generation.
.
Oh please. Cliche much? Are you a news anchor for CNN or write fluff pieces for the local paper? These damn whippersnapper millennials...

Every generation thinks they handled their set of circumstances better than the subsequent generation. I walked uphill both ways to school in blizzards with shoes 2 sizes too small....
 

lord_jeebus

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It is possible to start a pain practice on a low budget. Unless you're hanging a shingle in an area with no established pain doctor, I don't think that the initial volume justifies the expense of a procedure suite with C-arm.

I started with a sublease on unused medical office space from another doctor, free EMR, and one medical assistant. Fluoro procedures can be done in an ASC (or hospital when required by specific insurance). Billing outsourced for 5% of collections. Made my own website with Wordpress, printed up some brochures. Use my personal laptop and bought a cheap computer and a printer/fax for the MA. The other doctor had an ultrasound machine that I borrowed, otherwise this would be the most significant initial expense. About $400/mo on Google Adwords, no other paid marketing. Wrote a few medical articles for the local newspaper for free publicity. I did some lunches for local PCP's in the first year. Also met the local surgeons, but in my experience all they care about is how many patients you send them. The spine surgeons near me are like clockwork; if I refer them a patient who gets scheduled for surgery, the next week they send a referral back. They don't care how good or ethical you are.

There are some good online articles about medical micro-practices, which tend do be primary care practices, but the model works with Pain also.

The challenge is growing the practice in an ethical way. I know all the local pain doctors and volume is directly proportional to sleeziness. Accordingly my growth has been slow and I don't have much advice in this department. The ratio of patients to pain doctors in my area is too high for anyone to maintain a full-time non-narcotic practice. If you're in a saturated area, the best way to practice pain, both financially and for your sanity, is probably part-time in combination with part-time work in an OR.
 

zero0

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The challenge is growing the practice in an ethical way. I know all the local pain doctors and volume is directly proportional to sleeziness.
So how is the DEA not on these guys' arses?
 

PainDrain

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Bc it's not just opiate scripts that he's referring to. BS blocks to maximize billing w/o any improvement in patient care

Or how about forming a separate anesthesia company and hiring a Crna to give propofol for all your cases then keeping 50% of the anesthesia collections.

Or forming a seperate Utox company and performing UToxs at every visit?

There is no shortage of sleeve.
 

craigkes

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It is possible to start a pain practice on a low budget. Unless you're hanging a shingle in an area with no established pain doctor, I don't think that the initial volume justifies the expense of a procedure suite with C-arm.

I started with a sublease on unused medical office space from another doctor, free EMR, and one medical assistant. Fluoro procedures can be done in an ASC (or hospital when required by specific insurance). Billing outsourced for 5% of collections. Made my own website with Wordpress, printed up some brochures. Use my personal laptop and bought a cheap computer and a printer/fax for the MA. The other doctor had an ultrasound machine that I borrowed, otherwise this would be the most significant initial expense. About $400/mo on Google Adwords, no other paid marketing. Wrote a few medical articles for the local newspaper for free publicity. I did some lunches for local PCP's in the first year. Also met the local surgeons, but in my experience all they care about is how many patients you send them. The spine surgeons near me are like clockwork; if I refer them a patient who gets scheduled for surgery, the next week they send a referral back. They don't care how good or ethical you are.

There are some good online articles about medical micro-practices, which tend do be primary care practices, but the model works with Pain also.

The challenge is growing the practice in an ethical way. I know all the local pain doctors and volume is directly proportional to sleeziness. Accordingly my growth has been slow and I don't have much advice in this department. The ratio of patients to pain doctors in my area is too high for anyone to maintain a full-time non-narcotic practice. If you're in a saturated area, the best way to practice pain, both financially and for your sanity, is probably part-time in combination with part-time work in an OR.

I agree with what is said....for the most part. Yes, volume can be related to sleeziness but not always. Having moved to a slightly underserved area myself with little in the direction of non-opioid pain management at the time I can tell you someone that doesn't just write opioids can be a welcome addition. You question yourself the first 6 months-1 year but it works in a lot of situations. In my practice I am booked out several weeks (not a great thing but again.....slightly underserved and this will change in several months) and the opioids that I take over are the ones that come off (for the most part). If they don't want to come off....non-opioid management only....works well. If the PCP feels like writing the meds then they can continue the meds. Yep, I am sure I lost referrals at first but it is working out...for now. I do opioid management as mentioned above....elderly with no other options in order to clean their house, bathe themselves etc.. I am fortunate that I get to do both anesthesia and pain management in my practice. It's been that way since day one at my request. One of the reasons I took this job. I wouldn't change it. If I had to do straight OR anesthesia I would likely not enjoy it long (and the same for pain). I have a lot of friends doing straight anesthesia and their life isn't all gold for sure. They have stress and concerns as well. Just look at this message board about the future of anesthesia. I sleep in my own bed, have had two patient calls in two years, no nights/weekends/etc. Any time I get upset by it I think about how much fun I am having fishing. Just my two cents.
 
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lord_jeebus

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So how is the DEA not on these guys' arses?
One of the pain doctors in my area lost his DEA license and now does injections only. He's already at retirement age so he seems to be happy with his 1 day/week practice. I actually think that he was not intentionally breaking the rules but was careless regarding documentation.

The DEA recently revoked the DEA license of an IM doctor who was prescribing opioids also. His former patients have been scrambling to find new pain doctors, but from what I've seen of their records, this doctor was dirty.

Right before I moved to this area, the former president of the county medical society was sent to prison for crimes related to opioids, along with a pharmacist co-conspirator.

So the DEA is definitely watching things. But with the right documentation, it is possible to get away with a lot of questionable things regarding opioids, and there is a wide grey area between prescribing opioids to a dying cancer patient and prescribing opioids to a known drug dealer.
 
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lord_jeebus

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Or how about forming a separate anesthesia company and hiring a Crna to give propofol for all your cases then keeping 50% of the anesthesia collections.
The popular version of this scam around here is to have a pair of anesthesiologists taking turns with the injections and the "MAC," which in some cases is not propofol but just monitoring of vital signs, +/- a little Versed. Of course this is done at the out-of-network ASC that shares a wall with the in-network pain clinic.
 

PainDrain

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I forgot two more sleeze bag moves.

The sleezebag Doctor gets a speaking honorarium from a drug company of 2k per engagement. That Doctor then becomes the largest prescriber of drug X. Doctor collects honorarium every time the drug rep comes to the office and brings lunch. Doctor collects honorarium fee for every dinner and lunch they give in community. Now drug X costs ten times what a generic drug of similar efficacy costs but who cares.

Another sleezebag move is to open your own "In house" pharmacy and say patients can fill scripts in office for cash.
 

San Marzano

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Is board certification a job requirement for some places? My residency program happily employs many non boarded anesthesiologists.
 

kazuma

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Is board certification a job requirement for some places? My residency program happily employs many non boarded anesthesiologists.
No, we had a non-boarded CT guy who had been out for 5 yrs at my program. After 9 months and a number of serious clinical and interpersonal issues he was told to either leave or get fired. We also had a number of young staff who hadn't taken or successfully passed the written or oral exam within a few years of graduation. I became board certified before a couple of the new staff I had as a CA1.
 

drrosenrosen

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I know that these threads can get long and hard to read, so if the op or anyone else has specific questions, I'd be happy to try to answer.

I did two years in private physician owned pain practice after fellowship. Got back into anesthesia by spending 3 years at an academic center where I did one day per week in the or. Now doing private employed practice, one week in clinic, one week in or. I love it.

Sent from my SM-N920V using Tapatalk
 

aneftp

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No, we had a non-boarded CT guy who had been out for 5 yrs at my program. After 9 months and a number of serious clinical and interpersonal issues he was told to either leave or get fired. We also had a number of young staff who hadn't taken or successfully passed the written or oral exam within a few years of graduation. I became board certified before a couple of the new staff I had as a CA1.
Must be a lenient academic program. Most major universities give non boarded (even from own program around 3 years and they are gone).
 

nycitygas

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Must be a lenient academic program. Most major universities give non boarded (even from own program around 3 years and they are gone).
That is very lenient. My community hospital will toss out anybody not BC in their primary specialty within 5 years.
 

kazuma

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That is very lenient. My community hospital will toss out anybody not BC in their primary specialty within 5 years.
Yeah I'm pretty sure the hospitals I'm credentialed at have the same 5 yr rule.
 

BCM

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Has anyone on this board transitioned back to OR anesthesia after practicing 100% pain for a while? Any regrets in doing so?
No regrets at all. PM if you have specific questions.
 

SeniorWrangler

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I forgot two more sleeze bag moves.

The sleezebag Doctor gets a speaking honorarium from a drug company of 2k per engagement. That Doctor then becomes the largest prescriber of drug X. Doctor collects honorarium every time the drug rep comes to the office and brings lunch. Doctor collects honorarium fee for every dinner and lunch they give in community. Now drug X costs ten times what a generic drug of similar efficacy costs but who cares.

Another sleezebag move is to open your own "In house" pharmacy and say patients can fill scripts in office for cash.
The first one is shady but legal; the second one is putting a target on your back for a DEA raid or worse. Same thing with maxing out urine drug screens for all your patients and taking a cut of the lab fee; this seems like a money making machine but the government and insurance companies watch for these scams and will go after providers aggressively to get their money back. Now that everything is electronic, they are investing some serious money in fraud detection.
 

yancantcook

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I know that these threads can get long and hard to read, so if the op or anyone else has specific questions, I'd be happy to try to answer.

I did two years in private physician owned pain practice after fellowship. Got back into anesthesia by spending 3 years at an academic center where I did one day per week in the or. Now doing private employed practice, one week in clinic, one week in or. I love it.

Sent from my SM-N920V using Tapatalk
If I may ask, how did you find a OR/pain job, it seems like they are extremely difficult to find. I did a pain fellowship in CA but did not want to go back to the east coast and took an academic anesthesia/acute pain job. However, my ideal is to be able to do some chronic pain as well in addition to OR. i like the combination however have not been able to find any combo positions even listed.
 

neutro

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I felt the same way. After finishing my fellowship in pain last year, i was employed by a private practice.
I lasted 7 months and then I resigned.
The issue was, being employed in a PP was a complete disaster. No control over who you want to see. no integrated system, so no history/physical frm referring docs available. Every other week, I was asked to take donuts to some PCPs at 10 AM to advertise myself to family docs that could care less about another "pain doctor" in town. It was disgusting.
At that time, Pennsylvania did not have a state narcotic registry also. My first week of practice was nuts.
I survived and infact was doing well to build the practice, but in my heart, I knew this was not for me. I gave a two month notice in november of last year. Hugged all my patients before their last visit and took a hospital job locally. I was very picky in taking on patients. The minute I felt I could not have a therapeutic relationship with the patient, I did not accept them in my practice. So the ones that stayed were great patients and knew the boundaries. ofcourse the bosses were not happy since everything was $$$.
Leaving PP was probably the best move I ever made. Perhaps a higher power was on my side. I did it because in my heart, I did not feel good.
Now I do 4 days of pain (10 hours each day, 8 am to 6 pm - I leave work by 7 ish). 1.5 days procedures - I do upto 15 a day for full day. 2.5 days clinic. I have access to the hospital's ASC, sedation, nurses.
One day a week I do general anesthesia.
I am earning more than I did in PP. Everything has to be MGMA based.
I am eligible for 403b, 457 b which I max out. My employer puts money towards my 457f. my healthcare insurance is paid, as the only pain doc for the hospital, I set the rules for my practice. I get to choose how I wish to practice. I practice bread and butter pain medicine, addiction medicine, cancer pain medicine, orthopedic pain with bread and butter fluoro procedures. The hospital bought me a new RFA machine, and has backed me since day 1. I take on train wrecks - but I don't mind. I communicate with PCPs, surgeons, neurologists and come up with a plan. We all respect each other's stance. I take over difficult patients for them. Just this week I was able to wean off a 32 year old patient s/p surgery for GIST tumor that I inherited on fentanyl patch 200 mcg/ hr x 72 hour plus 24 mg po dilaudid to MS Contin 30 bid plus 2-3 tabs of tramadol 50 a day. We tried reducing further, but she had recurrence of pain, so I left her at that. It was very rewarding and this was a 6 week long process. She had my cell phone number for the past month. She called me whenever she wanted to. She is truly grateful.
I participate in pain meetings and designed protocols for inpatient pain control. I plan to lead the multidisciplinary pain committee. Care is integrated. I see who is doing what. If I dont agree with the PCP, I call them immediately and we re-evaluate. Drfirst med hx was made available to me - which was a god send. PA got the state narcotic registry up and running as of two weeks ago, and I love the system. It saves all my patients so I dont have to type their info again every visit.
On my anesthesia day, I get paid locums rate and after 6 months, I will start taking call for 1.25 x the rate.
My practice is clean. It has to be. I have 40 doctors that I work with. Its no non sense and its shared decision making.
In addition, also have some commitments towards a local addiction-rehab outpatient facility (part time work - signing charts and some on site work) where I meet with recovering addicts and alcoholics once every two weeks and do a powerpoint presentation. Its the closest you can get to CBT I suppose. We have these patients on suboxone and naltrexone that are being treated for substance use disorder. This practice is not cash based, rather a subsidiary of one of the largest healthcare systems in the country.

I rescued my career by leaving PP. I am earning more. I am far happier. I am trying my best to clean up my community's ridiculous drug problem and doing my part. I blame the sleazy doctors 100% for creating this mess. Just last week I discharged a patient from my practice on his second visit when he was supposed to transition his opiate care from me. His UTOX was + for 6 MAM. Out of curiosity, I look at his narcotic registry, he went down the road and was prescribed oxycontin 27 mg (Xtampza) which he refilled in a different state. The physician did not do their due diligence or check any records or find out. That physician is also known to be a pill pusher - and I am not sure why, as that particular physician is not even a pain physician, rather a general neurologist.

I reported both the patient and the doctor to the DEA.

Of course you're going to have those intense conversations and need to educate, but if you're not going to educate, then no one else is.
Its certainly not that PCP who is rx'ing 30 mg oxycodone for LBP on a 45 year old without even getting a goddamn xray or examining the patient (or a UTOX - like ever!) and having the audacity to send you the patient on last day of his refill. Yes it is nonsense.

My plan is to be an independent physician 5-6 years down the road, but I want to build my brand and be the best in everything first. I only care about being the best I can be. I plan to obtain a few more certifications, esp. the new headache management board (AIHS)
I have learned to be happy. I have a $ number in my mind that I will be happy with and that is not too far from what I am earning at this time. After that, all I care about is my sanity, my wife, my parents, my cat and my health. Life cannot be just about money.

You can do anesthesia, and also start your practice on the side. Perhaps you can do ASC work, and see pain patients 3-5 pm (or 3-8 some days plus saturdays) everyday by forming your own corporation. You can outsource your billing. Use practicefusion as the EMR - its free. there are firms that will do insurance credentialing for you. Take procedures to the same ASC - I am sure they will love it because they get to charge the facility fees. You can choose which insurances you par with. Once you get busy, maybe in 1 years time, hire a PA. Continue doing anesthesia. Then transition to a clinic. All you need is a 800 office visits a month and you will do quite well.
I had thought about all that when I was out of work for 2 months. I filed for my own corporation (Anesthesia and Pain Medicine Consultants of PA), and was on my way. I still have a domain for my website. I paid sybe medical 300 bux to get me credentialed with BC/BS and medicare to start with....Plus 3% billing. I was going to use practicefusion which is web based and free. I was going to lease office space for 1000 bux a month.

I was down to do it.

But the hospital liked me and the rest is history. I liked them too and that helped. But I learned a lot and next time when I want to go solo on my own terms, I will be far better prepared.

I will never EVER be an employee of a PP pain group.

My two cents.

Keep your head up.