Who is best suited to do pain management?

[NRAI2001]

Anesthesiologists with pain fellowship? Neurologists? PMR?

Can the other neuro and PMR do the different types of blocks and epidural injections (1st year med student, so please correct me if I am wrong)?

Dont mean to start a war or anything. I just kinda interested in the field of pain and I didnt realize other specialties outside of Anesth. practiced pain management.

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[stim4u]

Workman's Comp Case Managers are the best pain doctors....

They know exactly what the patients need.

 

[PainDr]

Anesthesiologists with pain fellowship? Neurologists? PMR?

Can the other neuro and PMR do the different types of blocks and epidural injections (1st year med student, so please correct me if I am wrong)?

Dont mean to start a war or anything. I just kinda interested in the field of pain and I didnt realize other specialties outside of Anesth. practiced pain management.

Everyone has their own opinion, but personally, I think that no one specialty is better than the other. Each offers it's own unique knowledge base and skill set and if properly trained anyone can practice the full range of interventional techniques. Do a search and you'll find many past discussions/debates.

 

[Aether2000]

Since there is such a variety of training, certification, and educational backgrounds for those engaging in pain medicine, it may be more salient to consider what skill sets are needed, and that to a certain degree depends on the practice model.
There are some pain docs that operate as technician employees of surgeons that dutifully perform the ordered injections, never seeing the patients again thereafter unless the patient returns for the scheduled second and third block, and never using skills other than that required to stick needles into the spine.
Some pain docs prescribe medications and do acupuncture or physical therapy referrals.
Some pain docs specialize in surgical implantation of devices and minimally invasive spine.
Some pain docs are comprehensive, trying to be all things to all people.

So the skill sets needed depend on what type of pain practice you enter.

The skills needed for comprehensive pain include:
Administrative skills knowing how to set up and run an office
Finance skills
Clinical office based patient management skills
Emergency airway and resuscitation skills
Radiation safety and fluoroscopic interpretation skills
MRI and CT interpretation skills in addition to plain films specific to the spine
Diagnostic skill sets specific to pain medicine that are independent of anesthesiology, PM&R, neurology, etc.
Interventional injection skills of varying levels
Surgical skills for implantation, post operative patient management, and management of complications
Neurological diagnostic skills and interpretation of EMG/NCV results
Functional restoration modalities knowledge and resources for referral
Knowledge of pain syndromes that are medically, not surgically or injection treated.
Basic knowledge of rheumatology, neurosurgery, and OSS
Psychiatric and addiction medicine knowledge, esp when prescribing narcotics

Other than the above, there is really nothing to it

 

[drusso]

Algos hits the nail on the head...doing this Gig well requires being a Jack-of-All trades. It's a diverse skill set indeed.

 

[Disciple]

The skills needed for comprehensive pain include:
Administrative skills knowing how to set up and run an office
Finance skills
Clinical office based patient management skills
Emergency airway and resuscitation skills
Radiation safety and fluoroscopic interpretation skills
MRI and CT interpretation skills in addition to plain films specific to the spine
Diagnostic skill sets specific to pain medicine that are independent of anesthesiology, PM&R, neurology, etc.
Interventional injection skills of varying levels
Surgical skills for implantation, post operative patient management, and management of complications
Neurological diagnostic skills and interpretation of EMG/NCV results
Functional restoration modalities knowledge and resources for referral
Knowledge of pain syndromes that are medically, not surgically or injection treated.
Basic knowledge of rheumatology, neurosurgery, and OSS
Psychiatric and addiction medicine knowledge, esp when prescribing narcotics

I know of very few practicioners who even come close to having this complete skill set, and don't know how realistic it is unless someone is very, very highly motivated.

Which is why I think the current fellowship guildlines are a highly inadequate and poor attempt at what needs to be in place.

 

[Aether2000]

Agree absolutely and that is why I am such a proponent of a full blown pain medicine residency. We cannot achieve this skill set solely through a one year residency in pain medicine which is the case currently. Even after fellowship, there is simply too much to learn on the fly. But it is a political battle to breech the barriers currently erected to sustain the status quo. Pain fellows and those that have completed their fellowship can have the greatest influence by writing the ACGME and ABMS demanding a full residency be established to insure there will be adequate training available in pain medicine and to avoid wasting valuable years of your life pursuing the obligatory and perfunctory peripherally related training in other fields such as anesthesiology.

In a poll I conducted in 2004 of anesthesiologists now practicing full time pain medicine, note the results with respect to how relevant the residency in anesthesiology is to pain medicine:

69% believed they did not have sufficient training in fluoroscopically guided injections, 81% had insufficient training in MRI/CT/X ray interpretation, 88% had insufficient training in functional rehabilitation, 62% had insufficient training in clinic medicine, 50% had insufficient training in neurological assessment, 44% had insufficient training in oral medication management, 100% had insufficient training in practice finance and practice operations, 88% had insufficient training in posture/gait analysis, 56% had insufficient training in chronic return patient management, 25% believed they had inadequate training in primary disease diagnosis, 81% had insufficient training in rheumatological diagnosis and management. On the other hand, 100% believed they had sufficient training in basic airway management (manual airway manipulation maneuvers, oral airway use, oxygen therapy). Also, 100% had sufficient training in emergency IV access. 94% believed they had adequate training in advanced airway management and in running code situations. Of the non-anesthesiology trained respondents, the vast majority felt they had sufficient training in rheumatological disease, neurological assessment, MRI/xray interpretation. Half believed they had adequate training in oral medication management, 83% had adequate training in basic airway management, and 67% had adequate training in advanced airway management. Half believed they had adequate emergency IV access training and 33% had adequate training in running code situations. While this is a preliminary study which will be followed by a much larger study in several practice situations, it appears the following conclusions may be made: 1. Anesthesiology provides better training than non-anesthesiology in airway management, emergency IV access, and running code situations, however more than 2/3 of non anesthesiologists have acquired sufficient training in both basic and advanced airway management through their primary residencies. 2. Anesthesiology residency training is inadequate in nearly every other area of medicine and skills important to the conduct of pain management. While this survey does not address fellowship training as a means of procuring the skills necessary in a pain management practice, it does point out that either a reconfiguration of the anesthesiology residency would be highly desirable in order to provide sufficient skills in areas of importance to pain management or that a pain management residency program per se would avoid wasting valuable years of training by not attempting to compact the majority of skills necessary into a single year of training

 

[Ligament]

Silly Algos, you forgot the most important skills of all: nunchuck and bo staff skills.

So the skill sets needed depend on what type of pain practice you enter.

The skills needed for comprehensive pain include:
Administrative skills knowing how to set up and run an office
Finance skills
Clinical office based patient management skills
Emergency airway and resuscitation skills
Radiation safety and fluoroscopic interpretation skills
MRI and CT interpretation skills in addition to plain films specific to the spine
Diagnostic skill sets specific to pain medicine that are independent of anesthesiology, PM&R, neurology, etc.
Interventional injection skills of varying levels
Surgical skills for implantation, post operative patient management, and management of complications
Neurological diagnostic skills and interpretation of EMG/NCV results
Functional restoration modalities knowledge and resources for referral
Knowledge of pain syndromes that are medically, not surgically or injection treated.
Basic knowledge of rheumatology, neurosurgery, and OSS
Psychiatric and addiction medicine knowledge, esp when prescribing narcotics

Other than the above, there is really nothing to it

 

[Aether2000]

lol...I am sure there are a few others that escaped me...some of which are not printable...

 

[NRAI2001]

Silly Algos, you forgot the most important skills of all: nunchuck and bo staff skills.

Hahahah

you forgot .......Computer hacking skills. Girls only want boyfriends who have great skills.

 

[drusso]

You know, there's like a butt-load of gangs in pain medicine. This one gang kept wanting me to join because you know I'm pretty good with a bo staff...

 

[NRAI2001]

don't be jealous that I've been chatting online with babes all day. Besides, we both know that I'm training to be a cage fighter.

 

[MossPoh]

Napoleon Dynamite overload.

 

[Mister Mxyzptlk]

Hahahah

you forgot .......Computer hacking skills. Girls only want boyfriends who have great skills.

I believe you mean "l33t haxor 5killz"

 

[NRAI2001]

I believe you mean "l33t haxor 5killz"

?

 

[Mister Mxyzptlk]

08V10U5LY 4 n00b WH0 D032'n7 UND3r574nD L337 5p33k.

go to http://www.jayssite.com/stuff/l33t/l33t_translator.html

type in the phrase "L337 haxor 5killz" and press the "translate to English" button. Also try the above sentence.

 

[lobelsteve]

If anyone is interested in sparring, martial arts, cage fighting, knife fighting, etc; I can arrange a few minutes for you to test your skills with my boss.
He is an accomplished PM doc, former ISIS instructor, and definitely the strongest Pain Doc in the world. Go ahead, make his day. When I trained in his program, I often felt like Clouseau walking around a corner into Kato.

 

[paz5559]

If anyone is interested in sparring, martial arts, cage fighting, knife fighting, etc; I can arrange a few minutes for you to test your skills with my boss.
He is an accomplished PM doc, former ISIS instructor, and definitely the strongest Pain Doc in the world. Go ahead, make his day. When I trained in his program, I often felt like Clouseau walking around a corner into Kato.

Kato was the Green Latern, genius!

 

[Mister Mxyzptlk]

Kato was the Green Latern, genius!

That was the Green Hornet. ("Hornet gun... check. Hornet sting... check. Let's roll, Kato!")

In the Pink Panther movies Clouseau's manservant was Kato. One of his duties was to try to do sneak attacks on Clouseau. Hence the reference by lobelsteve. ("Kato, what is going on in that little yellow brain of yours?")

And let's not forget that other famous sidekick, Kato Kaelin, who I believe is still helping O.J. search America's golf courses for the real killer. ("Survivor in the Outback--I mean how hard can it be to actually survive in a steak house?")

 

[lobelsteve]

Kato was the Green Latern, genius!

Posting when its over your head leaves egg on your face. And corn on the floor. (Inside joke- video to follow).

 

[Josh L.Ac.]

Alright, I'll probably get properly flamed for this, but along the lines of the original topic:


How about a MSA [acupuncture] + CRNA doing pain management? Obviously with the CRNA training, there would be no surgery implants, so we're talking trigger point injections, epidurals, and the like. Plus, practicing in KS or MO would probably require the "supervision" of a MD/DO.


Thoughts?


For clarification, CRNA school would require a RN + 1+ years of ICU experience.

 

[Disciple]

You would still need someone to make diagnoses, manage medication and institute the proper rehabilitation.

 

[paz5559]

Alright, I'll probably get properly flamed for this, but along the lines of the original topic:


How about a MSA [acupuncture] + CRNA doing pain management? Obviously with the CRNA training, there would be no surgery implants, so we're talking trigger point injections, epidurals, and the like. Plus, practicing in KS or MO would probably require the "supervision" of a MD/DO.


Thoughts?


For clarification, CRNA school would require a RN + 1+ years of ICU experience.

IMHO, you would be practicing medicine without a license.

 

[Josh L.Ac.]

So even if the patient is properly diagnosed by a physician and given a treatment protocol, it would be improper for a CRNA to perform the treatment?


Let me spin it another way: if you were a pain management doc and had your own practice, would you see it as a benefit to hire a CRNA + LAc to help with pain management, or would it be too much of a hassle / liability? Would it be a benefit to hire the CRNA + LAc or would a pain management RN + LAc suffice [meaning no difference between what the two could offer in your practice model].

 

[lobelsteve]

A CRNA and an accupuncturist have no business in a practice without a supervising physician.

Agree with PAZ- to practice medicine, you should have a medical degree.

However,


Getting back to PAZ and corn....

PAZ hunts for lunch

Just a typical day in the office when PAZ drops his lunch onto the front desk staff, her computer, the hallway, the walls.......excuse the video- taken with a RAZR.

 

[Aether2000]

CRNAs are attempting to compete with MDs in the pain management arena, yet they have in general insufficient training, are poorly educated in pain management, have few diagnostic skills in pain management, have virtually no training in their CRNA programs in pain management, and are attempting to leapfrog the necessary prerequisites for interventional pain medicine. If they want to perform the surgical and non-surgical procedures that a physician would perform, they should drop out of being a CRNA, and do the responsible thing by going to medical school and engage in a full residency program. ISIS and several other organizations have strongly worded position statements on this very subject, and it is my opinion that there is no need to introduce a separate ersatz branch of medicine due to the avarice and extreme overconfidence of poorly trained, poorly educated non-physicians.

 

[Ligament]

The BIG problem with pain medicine as it is is that we have way too many technician block-jocks and not nearly enough physicians with clinical and diagnostic skills. Having CRNAs do these procedures would just be adding to the technician dogpile.

 

[paz5559]

The BIG problem with pain medicine as it is is that we have way too many technician block-jocks and not nearly enough physicians with clinical and diagnostic skills. Having CRNAs do these procedures would just be adding to the technician dogpile.

No, the BIG problem with pain medicine is that we have no ability to see that there is more than one way to skin a cat.

George Carlin, in describing his fellow drivers, "Everyone going slower than me is an idiot, everyone going faster is a maniac."

In fact, just cause you do more or fewer injections than the next guy does NOT mean that you are the only one who does things the right way. "Block jock" is a phrase that ought to be banned from this board, or acknowledged that all of us, to one degree or another, are block jocks.

I dare you to define the term and not use a fuzzy word like "excessive" or "indiscriminate" that could describe any of our algorithms when viewed by a fellow practitioner.

So lighten up on your judgmental terminology.

Are there folks who do way too many blocks in our field? Absolutely. But look to orthopaedics, where there are certainly an equal number of surgeons who operate on patients with less than clear cut indications. If they address the issue at all, they keep it in house. Ours is a field that is already too disparate, and clearly too fractious. “Why can’t we all just get along?”

Rather than casting aspersions, let me recommend that what we really need to do is present a united face to the outside world, and perhaps address the outliers in our profession from within.

The issue of CRNAs doing procedures is one ISIS, ASIPP, AAPM, et al can all agree upon, and it would be nice to see them all working together for a change.

There are lots of guys who do three bilateral transforaminals when one caudal will do. Clearly they do it for the money. That being said, I don't feel the need to call them block jocks. I just roll my eyes, and suggest that they are outliers. Maybe I am fooling myself, but I believe that eventually referral sources or the OIG will recognize they are practicing outside of the usual and customary practice parameters, address the issue, and that practicing legitimate interventional pain medicine will ultimately carry the day.

 

[drusso]

There are lots of guys who do three bilateral transforaminals when one caudal will do. Clearly they do it for the money. That being said, I don't feel the need to call them block jocks. I just roll my eyes, and suggest that they are outliers. Maybe I am fooling myself, but I believe that eventually referral sources or the OIG will recognize they are practicing outside of the usual and customary practice parameters, address the issue, and that practicing legitimate interventional pain medicine will ultimately carry the day.

I'm going to play devil's advocate: The hallmark of any profession is its ability to self-regulate. *WE* as highly trained and knowledgable sub-specialist medical practitioners know the difference between a "block-jock" and a "comprehensive pain physician." *WE* know what "churning" and "fiscal abuse" is when we see it. These are necessarily vague and non-specific terms because they are solely dependent upon professional judgment. The lay person, no matter how intelligent and insightful, cannot make these judgments because they don't know what we know.

If we don't clean our house others will. So, an ethical pain physician should be a zealous advocate for responsible practice patterns. This does not mean that you don't do things that aren't supported by 5 RCT's, 2 meta-analyses, and 3 professional group practices guidelines. The very nature of pain medicine, at this time, does not have this level of rigor for anything it does.

Waiting for the feds to identify and remediate the bad apples is a bad idea. The pressure should come from within the field. Perhaps someone should study and elucidate the risk factors for the feral practice of pain medicine...

From Professor Bogduk:

I have on occasions used “feral” as a metaphor in Pain Medicine. There are practitioners that strike me as feral. They are ones who were once domestic (they went to medical school and were trained in the correct answers and correct behaviors) but once released into the wild (Pain Medicine) they become feral.

For reference, the features of feral practitioners are any of the following, alone or in combination.

§ They perform procedures without proper indications.
§ They perform procedures contrary to indications or contrary to best practice guidelines.
§ Incorrectly they call what they do by the same name as the legitimate procedure.
§ They charge the same CPT code even when they do the procedure wrongly or suboptimally.
§ They abuse the procedure by not assessing their results, i.e.
they perform diagnostic blocks but do not formulate a reliable or valid diagnosis; they perform therapeutic procedures but their outcomes are substandard or nil;
§ neither of which concerns them.
§ They misuse the literature, usually by quoting the legitimate literature to support what they do, even though what they do bears little resemblance to that literature.
§ They announce that what they do is better than what is reported in the literature, but never subject their techniques to scrutiny and evaluation.

 

[paz5559]

I'm going to play devil's advocate: The hallmark of any profession is its ability to self-regulate. *WE* as highly trained and knowledgable sub-specialist medical practitioners know the difference between a "block-jock" and a "comprehensive pain physician." *WE* know what "churning" and "fiscal abuse" is when we see it. These are necessarily vague and non-specific terms because they are solely dependent upon professional judgment. The lay person, no matter how intelligent and insightful, cannot make these judgments because they don't know what we know.

If we don't clean our house others will. So, an ethical pain physician should be a zealous advocate for responsible practice patterns. This does not mean that you don't do things that aren't supported by 5 RCT's, 2 meta-analyses, and 3 professional group practices guidelines. The very nature of pain medicine, at this time, does not have this level of rigor for anything it does.

Waiting for the feds to identify and remediate the bad apples is a bad idea. The pressure should come from within the field. Perhaps someone should study and elucidate the risk factors for the feral practice of pain medicine...

From Professor Bogduk:

I have on occasions used "feral" as a metaphor in Pain Medicine. There are practitioners that strike me as feral. They are ones who were once domestic (they went to medical school and were trained in the correct answers and correct behaviors) but once released into the wild (Pain Medicine) they become feral.

For reference, the features of feral practitioners are any of the following, alone or in combination.

§ They perform procedures without proper indications.
§ They perform procedures contrary to indications or contrary to best practice guidelines.
§ Incorrectly they call what they do by the same name as the legitimate procedure.
§ They charge the same CPT code even when they do the procedure wrongly or suboptimally.
§ They abuse the procedure by not assessing their results, i.e.
they perform diagnostic blocks but do not formulate a reliable or valid diagnosis; they perform therapeutic procedures but their outcomes are substandard or nil;
§ neither of which concerns them.
§ They misuse the literature, usually by quoting the legitimate literature to support what they do, even though what they do bears little resemblance to that literature.
§ They announce that what they do is better than what is reported in the literature, but never subject their techniques to scrutiny and evaluation.

Ours is a fractious field, rife with both nay-sayers and ner-do-wells. There are thieves in ANY field. Ours seems to relish the chance to air our dirty laundry in public.

When insurers or referral sources see us publicly eating our young, they tar all of us with the same brush we intended only for the outliers.

You want to figure out standards and guidelines, sounds good to me. But I want to do it behind closed doors, with reasonable people, not in the middle of the town square for all to see.

As for Professor Bogduk, please note he LOVES to speak in hyperbole. His feral injectionist ought to be contrasted to the egotistical, arrogant Australian who was probably beaten up as a young child as a result of his brilliance, and now takes great pleasure in beating up everyone else in the room verbally as a result of his childhood trauma. Intimidation and intellectual bullying are his stock in trade. In fact, if you note his voluminous literature, Professor Bogduk's patients seem to respond astoundingly well to his techniques (VAS often reduced to ZERO!) Now either Dr. Bogduk simply does this kind of work BETTER than anyone else, Australian patients are capable of more complete recovery than their American counterparts, or ... (things that make you go hmmm). I would challenge any of you to accomplish that in your own patient population. Which might lead one to wonder if Professor Bogduk's DATA might have an element of hyperbole too!

 

[lobelsteve]

Ours is a fractious field, rife with both nay-sayers and ner-do-wells. There are thieves in ANY field. Ours seems to relish the chance to air our dirty laundry in public.

When insurers or referral sources see us publicly eating our young, they tar all of us with the same brush we intended only for the outliers.

You want to figure out standards and guidelines, sounds good to me. But I want to do it behind closed doors, with reasonable people, not in the middle of the town square for all to see.

As for Professor Bogduk, please note he LOVES to speak in hyperbole. His feral injectionist ought to be contrasted to the egotistical, arrogant Australian who was probably beaten up as a young child as a result of his brilliance, and now takes great pleasure in beating up everyone else in the room verbally as a result of his childhood trauma. Intimidation and intellectual bullying are his stock in trade. In fact, if you note his voluminous literature, Professor Bogduk's patients seem to respond astoundingly well to his techniques (VAS often reduced to ZERO!) Now either Dr. Bogduk simply does this kind of work BETTER than anyone else, Australian patients are capable of more complete recovery than their American counterparts, or ... (things that make you go hmmm). I would challenge any of you to accomplish that in your own patient population. Which might lead one to wonder if Professor Bogduk's DATA might have an element of hyperbole too!

Please, nothing disparaging against Bogduk......unless of course it is about tobacco.

 

[Disciple]

No, the BIG problem with pain medicine is that we have no ability to see that there is more than one way to skin a cat.

George Carlin, in describing his fellow drivers, "Everyone going slower than me is an idiot, everyone going faster is a maniac."

In fact, just cause you do more or fewer injections than the next guy does NOT mean that you are the only one who does things the right way. "Block jock" is a phrase that ought to be banned from this board, or acknowledged that all of us, to one degree or another, are block jocks.

I dare you to define the term and not use a fuzzy word like "excessive" or "indiscriminate" that could describe any of our algorithms when viewed by a fellow practitioner.

So lighten up on your judgmental terminology.

Are there folks who do way too many blocks in our field? Absolutely. But look to orthopaedics, where there are certainly an equal number of surgeons who operate on patients with less than clear cut indications. If they address the issue at all, they keep it in house. Ours is a field that is already too disparate, and clearly too fractious. “Why can’t we all just get along?”

Rather than casting aspersions, let me recommend that what we really need to do is present a united face to the outside world, and perhaps address the outliers in our profession from within.

The issue of CRNAs doing procedures is one ISIS, ASIPP, AAPM, et al can all agree upon, and it would be nice to see them all working together for a change.

There are lots of guys who do three bilateral transforaminals when one caudal will do. Clearly they do it for the money. That being said, I don't feel the need to call them block jocks. I just roll my eyes, and suggest that they are outliers. Maybe I am fooling myself, but I believe that eventually referral sources or the OIG will recognize they are practicing outside of the usual and customary practice parameters, address the issue, and that practicing legitimate interventional pain medicine will ultimately carry the day.

The difference is that Orthopaedic surgeons have the ABOS made up of surgeons all trained under the same guidelines to provide regulation. Surgical specialties are generally at least five years in length and require that cases are logged the first year out of residency before board certification is awarded.

What does pain medicine have? "Subspecialty" certification through four member boards, now open to any and all ABMS base specialties with training through one year fellowships comprised of several "mini" rotations.

With practicioners from so many different backgrounds, unity is unlikely. We can’t get along because there are too many differing agendas and points of view, which is why we try to make each other look bad and air our “dirty laundry” in public.

So if over or improper utilization of procedures is the real concern, why not make that the central issue of discussion, and not what is the right or wrong regarding practice philosophies. Why shouldn’t an Orthopaedic spine surgeon be able to perform their own procedures if they have the experience and the skill to do so. Does he of she really need training in Pediatric pain or Cancer related pain to responsibly and skillfully perform spinal injections? The same goes for family practicioners who may see a lot of patients in the acute and sub-acute stages of pain.

So in lieu of a pain residency (which would be the ideal method to standardize skills/philosophy but is unlikely to happen anytime soon due to politics), I would be in full support of a certification for the performance of interventional pain procedures, perhaps including an oral and/or practical component to the exam. The AANEM has such an exam for electrodiagnostics (not requiring comprehensive knowledge of Neuromuscular Disorders) and it is difficult. No, it is not ABMS recognized, but remains the only respectable electrodiagnostics certification of its kind.