what to say

[AndyDufrane]

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k, so am interventional spine fellowship trained physiatrist, in my first gig as hospital based outpatient MSK/spine doc, been here a couple of months, my number of patients is still not where it should be in the outpatient clinic, I am being told the inpatient med director PMR doc would like for me to start seeing inpatient discharge outpatient follow ups now, not sure how to handle, I feel like if I say I am a MSK spine guy and not a general physiatrist, it could blow up in my face, any thoughts?

 

[Louisville04]

k, so am interventional spine fellowship trained physiatrist, in my first gig as hospital based outpatient MSK/spine doc, been here a couple of months, my number of patients is still not where it should be in the outpatient clinic, I am being told the inpatient med director PMR doc would like for me to start seeing inpatient discharge outpatient follow ups now, not sure how to handle, I feel like if I say I am a MSK spine guy and not a general physiatrist, it could blow up in my face, any thoughts?

You have expressed displeasure on another post about your job. I hope you are casually looking for other opportunities.

I would go ahead and see those patients. I am sure the bean counters don't like to see empty slots on your schedule. Once your practice pick ups, you won't have to see those patients . Plus, I am pretty sure reimbursement on follow ups on inpatient rehab is not comparable MSK/spine patients.

 

[AndyDufrane]

You have expressed displeasure on another post about your job. I hope you are casually looking for other opportunities.

I would go ahead and see those patients. I am sure the bean counters don't like to see empty slots on your schedule. Once your practice pick ups, you won't have to see those patients . Plus, I am pretty sure reimbursement on follow ups on inpatient rehab is not comparable MSK/spine patients.

Yes, I am casually lining up potential other opportunities, but thank you for the input,
I think it's a good life lesson coming out of training and finding out what hospital based
Employment really implies for an attending

 

[Louisville04]

Yeah, you might not like doing it, but just put up with it for now. If you do find another job, they usually want to speak with your former employer as a reference.

 

[Paddington]

Saying that you don't want to do it is exactly the wrong move. Maybe you could weasel out of it by claiming you're not qualified to see those kinds of patients. If your clinic slots are free, your best bet is probably just to see those patients.

You could change jobs but end up in the same position. Majority of pain doctors joining new practices that I've seen have ended up doing more inpatient work (including call, weekend rounds, etc.) than they initially expected. You're lucky if you're only being asked to see some inpatient to outpatient follow ups.

 

[RUOkie]

k, so am interventional spine fellowship trained physiatrist, in my first gig as hospital based outpatient MSK/spine doc, been here a couple of months, my number of patients is still not where it should be in the outpatient clinic, I am being told the inpatient med director PMR doc would like for me to start seeing inpatient discharge outpatient follow ups now, not sure how to handle, I feel like if I say I am a MSK spine guy and not a general physiatrist, it could blow up in my face, any thoughts?

FWIW, I am 15 yrs out of residency and still see some patients that I don't want to see. I see lots of "rehab" patients in my office (CVA, amputations, etc) despite the fact that I prefer MSK medicine.

Why do I do it? 2 reasons. 1) To make my referral sources happy. They don't know what to do with these people and they trust me. So I suck it up, and then I get to see their patients with shoulder pain, LBP and their EMG's. and 2) It helps to pay the bills.

If you were in solo practice, you would not be thinking twice, you'd just see them. An open spot in your schedule just means you make less money. Once you are booking out 2-3 weeks for patients, THEN you can start being choosy about what you see.

 

[lobelsteve]

If you have open slots, be happy to see those patients and help out your colleagues.

Just because you may not like to see/treat that type of disease process, does not mean you cannot be happy doing so.

Bigger question is this: Why are there spots on your schedule?

 

[Gauss]

he's only a few months into a new job - he can't be full yet. Takes time. Lots of bumps in the road and politics that you run into without realizing it.
I'd rather see rehab followups than opiate/med management followups

 

[SSdoc33]

If you can't bill a 99204 or 99243, then it is a crappy deal. I don't think you can bill it if another pm and r in your group has already seen them? Inpatient may be different

 

[AndyDufrane]

he's only a few months into a new job - he can't be full yet. Takes time. Lots of bumps in the road and politics that you run into without realizing it.
I'd rather see rehab followups than opiate/med management followups

yeah, its only been 5-6 months since I started, but I thought that if I did an interventional spine fellowship, signed up for job title that specifically says MSK/spine physiatrist, and landed a hospital based job, that it would be a safe bet that I would avoid the usual general physiatry duties , but lesson learned, that I have to extra careful when looking at possible career oppties, as far as the other question, not sure why I still have open slots, have been meeting w/ local pcps over the last several months, but I have heard it can take some time to build up a practice

 

[AndyDufrane]

the other kicker is I have done 3 Lumbar TESI, 1 caudal, and maybe 10 lumbar MBB in the last 6 months, but seen plenty of chronic pain/fibro types

 

[PMR2008]

the other kicker is I have done 3 Lumbar TESI, 1 caudal, and maybe 10 lumbar MBB in the last 6 months, but seen plenty of chronic pain/fibro types

WTF!!! 😱

 

[AndyDufrane]

WTF!!! 😱

My sentiments exactly

 

[AndyDufrane]

The real question is how long do I give this opportunity a chance, is a year too long?i am beginning to think so

 

[RUOkie]

the other kicker is I have done 3 Lumbar TESI, 1 caudal, and maybe 10 lumbar MBB in the last 6 months, but seen plenty of chronic pain/fibro types

Do you have a person doing marketing with you? Who are the spine surgeons sending their patients to? Hell, I don't do interventional spine, and I generate more spine procedures than that.

 

[AndyDufrane]

Do you have a person doing marketing with you? Who are the spine surgeons sending their patients to? Hell, I don't do interventional spine, and I generate more spine procedures than that.

I have a whole marketing department promoting me,

 

[RUOkie]

I have a whole marketing department promoting me,

so when you speak with the spine guys, what do they say? What about the primary care docs in your community. Where do they send their back pain/radiculopathy patients? Ask them!

 

[AndyDufrane]

so when you speak with the spine guys, what do they say? What about the primary care docs in your community. Where do they send their back pain/radiculopathy patients? Ask them!

the pcps say that if I don't give the patient what they want (pain pill, or injection right away), then they will send them to those docs who do, because I tell them I will try other things like PT and non opioids meds before injections, but the pcps say that the patient wants the quick fix pain pill or injection, plus I am located in a not so great neigborhood, and the other docs are in nicer area in the burbs

 

[bedrock]

The real question is how long do I give this opportunity a chance, is a year too long?i am beginning to think so

Get the hell out of there. That job obviously bites.

However, you don't want to end up in the same situation with your next job, so you do need to be thorough when picking your next job.

FYI- Easiest to get screwed in hospital employed positions, so I would avoid those if possible.

 

[lobelsteve]

the pcps say that if I don't give the patient what they want (pain pill, or injection right away), then they will send them to those docs who do, because I tell them I will try other things like PT and non opioids meds before injections, but the pcps say that the patient wants the quick fix pain pill or injection, plus I am located in a not so great neigborhood, and the other docs are in nicer area in the burbs

So do you just see patients and then tell them they need PT?

If I were a PCP hearing this I'd avoid you as well.

If PT has direct access then who needs you?

What's wrong with seeing them for an injection while they get PT or home exercise program started?

No one says you have to write opiates if you do not want to, but how about Flexeril, Ultram, Savella, Lyrica, and a TENS unit?

 

[Gauss]

in his defense- all HMO's and most of the blues won't auth any spinal injection prior to PT, some want you to use nsaids, and still others want "radiological evidence"

next I'll burst your bubble that somehow you'd end up full in under a year with predominantly interventional spine cases. 1st 6 months your case log doesn't surprise me at all. You're not in an established pain or spine group and you're clearly competing against several others. What you're describing is not unusual. In a competitive, desirable market building such a practice can take years.

What the pcp's are saying isn't very different from what you'd hear anywhere else. Don't expect that to change much.

What I do think you're lacking is guidance from someone with experience and doesn't perceive you as a threat

 

[AndyDufrane]

in his defense- all HMO's and most of the blues won't auth any spinal injection prior to PT, some want you to use nsaids, and still others want "radiological evidence"

next I'll burst your bubble that somehow you'd end up full in under a year with predominantly interventional spine cases. 1st 6 months your case log doesn't surprise me at all. You're not in an established pain or spine group and you're clearly competing against several others. What you're describing is not unusual. In a competitive, desirable market building such a practice can take years.

What the pcp's are saying isn't very different from what you'd hear anywhere else. Don't expect that to change much.

What I do think you're lacking is guidance from someone with experience and doesn't perceive you as a threat

I think you nailed it on the head, I am basically flying solo in a group that primarily is inpatient general physiatry oriented, and I don't have an experienced interventionalist that is guiding me, the other senior interventionalist left right as I got here, and yes, there is alot of ortho groups in the area that have there own spine physiatrist, I think I may be up the creek w/o paddle in regards to the set up here, and yes, the HMOs, insurances in my area will deny injections if you don't at least try other things like PT or NSAIDs before trying the injections

 

[AndyDufrane]

So do you just see patients and then tell them they need PT?

If I were a PCP hearing this I'd avoid you as well.

If PT has direct access then who needs you?

What's wrong with seeing them for an injection while they get PT or home exercise program started?

No one says you have to write opiates if you do not want to, but how about Flexeril, Ultram, Savella, Lyrica, and a TENS unit?

No I do not just tell them they need PT, I tell them I will spend time in the H&P trying to figure out where the pain generator is, then address it in a comprehensive way with possible PT, injections, and both non-opioid and if appropriate opioid meds, but I think you are right, from a marketing perspective, I might as well be talking to a brick wall, I don't think they get it, so I have to work on my marketing message

 

[lobelsteve]

No I do not just tell them they need PT, I tell them I will spend time in the H&P trying to figure out where the pain generator is, then address it in a comprehensive way with possible PT, injections, and both non-opioid and if appropriate opioid meds, but I think you are right, from a marketing perspective, I might as well be talking to a brick wall, I don't think they get it, so I have to work on my marketing message

Bingo.

Use your resources at AAPMR or through the pain forums and you'll get a ton of advice. And ridicule. 😛

 

[Xardas]

Relax.. its your first job out. You are learning things that you couldn't have learned in residency or either fellowship. Stay at least a full year and then figure out what you want to do. Don't get a reputation as someone who jumps around jobs too much.

Also, to answer your original post, like others hve said since you're not that busy just see the patients that come your way.

Saying no too often early hurts you. When you get mroe established and busy then you can say no.

 

[AndyDufrane]

thanks everyone for the input, its been good, its nice to be able to vent

 

[specepic]

I was pretty hard core on opioids right out of the gate (post-fellowship). Now COT does not stress me out.

- urine test
- med agreement
- frequent follow ups to assess compliance
- Rfs at OV only
- stick to your rules

Some pts do fine on opioids, many do not. Sort through them, you have time anyway. The PCPs dont want you to take over narcs they want your help with the pain issues. How you accompish this is up to you.

Btw-many/most of those opioid pts may need inj's, but you cant have your cake and eat it too

What is probably happening is you dont really like pain pts and dont like opioids. So your bedside manner with these folks (whether you are conscious of it or not) is not what it could be which is what gets back to the PCPs. If you have some strong people skills you can taper or d/c opioids while maintining a good pt relationship.

If I recall you did sports/spine, not pain fellowship? Hate to say but in the 'real-world', there are very few 'sports-spine' pts and a **** load of people with chronic pain, fibro, head to toe pain ,etc.

Much luck, it can be fun

 

[PhysiatristDoc]

If you wanted primarily interventional cases, you would have served yourself better working for surgeons. They don't want the chronics coming back to the office. They will not want you doing their surgical follow ups. They will not expect you to entertain fibromyalgia in an endless fashion. They will pay you better. In a practice with inpatient generalists, they will be upset if you don't pick up your share of general stuff.

I am more of a generalist. I would be ok with what you are describing.

You need to look elsewhere. I disagree with the one year comment, find what you want and move on swiftly, you need to keep your skills sharp.

 

[Louisville04]

If you wanted primarily interventional cases, you would have served yourself better working for surgeons. They don't want the chronics coming back to the office. They will not want you doing their surgical follow ups. They will not expect you to entertain fibromyalgia in an endless fashion. They will pay you better. In a practice with inpatient generalists, they will be upset if you don't pick up your share of general stuff.

I am more of a generalist. I would be ok with what you are describing.

You need to look elsewhere. I disagree with the one year comment, find what you want and move on swiftly, you need to keep your skills sharp.

If they patient fails to improve with surgery, they will want you to handle the follow ups which is most likely chronic opioid meds.

 

[bedrock]

If they patient fails to improve with surgery, they will want you to handle the follow ups which is most likely chronic opioid meds.

depends on the group. Many groups have the surgical follow-ups see the PAs, and PAs also do most of the med management.

You just have to ask the specific questions. I know PMR pain docs in ortho/NS groups who 1-do 5% narc management, just acute cases, nothing else.
In other groups they 2-do 20-25% narc management, acutes, and some of the patients you're working on with interventions, and the occasional consult for a tough case.
In other groups you 3- do 70% med management, and that is their expectation. You handle everyone who fails surgery, even if they shouldn't have fused them. Avoid the last situation like the plague. You have to be very clear on that when you check out jobs.

Options 1 and 2 aren't bad. Option 1 is rare, but option 2 is out there if you look around. There are lots of option 3s out there, so ask before accepting any ortho/NS job.

 

[AndyDufrane]

yeah, its dawning on me this organization is a mess, inpatient providers are dropping like flies, in the couple of months that I have been here, a few inpatient providers have left and I can tell their inpatient population is very sick, medically complex, and strong hints are dropping for me about whether I could help out by picking up an inpatient census or call or follow ups, so when the inevitable "can you help us out comes", I will not be surprised, but it makes sense since its mostly a generalist practice, but its dawning on me that private practice is still a very viable option despite all these crazy healthcare changes, most private practice physiatrists I know are pretty happy, and if I want the interventional spine cases, I should go work in a surgeon's practice or primarily interventional focused practice, the biggest issue is I think that I am not getting enough interventional spine procedure volume to maintain skills that I learned during my fellowship, and instead am getting pushed into seeing general PMR patients, which is not OK with me, so I am trying to think of the best exit strategy, the best way to do it without burning bridges, and I agree with the above comments about not waiting for a year, cause that is enough time to lose your skills

 

[AndyDufrane]

If you wanted primarily interventional cases, you would have served yourself better working for surgeons. They don't want the chronics coming back to the office. They will not want you doing their surgical follow ups. They will not expect you to entertain fibromyalgia in an endless fashion. They will pay you better. In a practice with inpatient generalists, they will be upset if you don't pick up your share of general stuff.

I am more of a generalist. I would be ok with what you are describing.

You need to look elsewhere. I disagree with the one year comment, find what you want and move on swiftly, you need to keep your skills sharp.

I guess I might be fine doing a general inpatient discharge follow up for patients that are primarily ortho-gen rehabs once in awhile if the other general PMR are really tied up, but no SCI, TBI, CVAs, and if they ask to carry an inpatient census and do call I will say that I don't feel comfortable taking care of inpatients and doing call and don't want to jeopordize patient care, and if they don't take my polite hint, then I think that will be my trigger to resign sooner, I mean, I hate to sound like a spoiled brat, but this was not talked about during the interview, and I don't think its fair, and I think I could fine another suitable gig

 

[Xardas]

To follow up on my one year comment.. if it is ideal to not jump too soon but if you are absolutely miserable like it sounds like you are then leave. I mean if its at the cost of your personal mental or physical health then don't stay