I'm curious if you wouldn't mind mentioning how large your practice is? Don't most of your partners refer to you the patients that fit under your subspecialty training?
There are 9 of us, plus a couple of PAs. Two of the MDs (one is the chief and one has been here forever, so they get to do pretty much whatever they want) seem to do almost 100% subspecialty work. The other MDs all do about 50% subspecialty work and 50% general neuro. Unfortunately, we don't have anyone with specific pain/headache interest/training, or anyone doing 100% catch-all "general neuro" in our group, so those patient populations (which are large) have to get split up between everyone.
While the practice tries to funnel new patients toward the appropriate subspecialist, this isn't always easy given that, #1, we often get limited information from the patient or refering physician regarding the actual nature of the problem, and #2, any given patient can have multiple problems (i.e., headaches
and seizures, myopathy
and sleep apnea, etc). Also, some of the subspecialties are booked months and months in advance while others are not, and patients would rather see anyone sooner rather than wait for a specific doc or subspecialist. We will sometimes refer to others within our group, but this is not really as frequent or as easy as you might think, primarily due to schedule issues.
As for inpatient, everyone takes turn in rotating on the inpatient service.
aubreytex said:
Thanks for the insight Neurologist! What makes dealing with chronic pain patients so bad?
Well, it's really a matter of preference. Honestly, some people love it, God bless them.
The main issues as I see it are these:
First, there is a huge disconnect between what most patients expect from pain treatment (i.e., "make all my pain go away, now, with no side effects.") and what we can actually deliver (i.e, "we can reduce your pain by X percent but never completely eliminate it, so you need to learn to live with it to some degree"). This sets up a lot expectational dissonance between provider and patient. They are frustrated that we can't "fix" them. We are frustrated that not only can't we fix them, but that they can't or won't understand that, or in some case do much in terms of lifestyle change to help themselves (i.e., losing that extra 50 lbs can do wonders for back pain . . .). After a while, this wears you down. Occasionally you hit a home run and the patient gets better with a nerve block or a little bit of gabapentin, but these are few and far between.
Second, many chronic pain patients have associated Axis 1 or 2 behavioral issues, often times under- or even untreated. This makes them even more difficult to deal with on an ongoing basis.
Third, a chunk of them are very needy/clingy/dependent, need a lot of handholding, and take up a lot of time, which, frankly, many of us don't have or don't honestly have the personality for. You really have to be willing to invest a lot of time in many of these patients. If you don't have that outlook, you will not be happy with this field or patient population.
Fourth, there is a lot of potential for medication abuse/misuse, which can become a vast quagmire that many clinicians would prefer to avoid at all costs. Pretty much nobody in my current practice prescribes opioids, ever, for anything.
I'm sure others could add to the list. There was someone floating around here a couple months ago named Snowdog or Snowhound or something like that who I think might have some interesting perspectives on this as well. Or, you can go visit the Pain Forum.
), and, perhaps somewhat discongruently from the other specialties, pathology.
