Father's Day & Pain Doctor Million-Dollar Baller Club

[Ferrismonk]

I practice in Georgia. Your avg pain doctor makes nothing close to 750k. I value my time more than anything; I have a family. I make plenty of money, but I simply cannot imagine a situation where I made that much, nor do I see it as even possible without 2 min pt visits (I refuse) and fraudulent documentation at a minimum.

GDub said they do 70 fluoro shots per week, and that is possible how? You're going to convince me you can sit down with a pt and take a history, do a PE, review imaging, look at PDMP, etc... and still schedule volume like that?

That is looking at an MRI report and searching out words like "moderate" and "severe," walking into the room, 1-2 min conversation with no PE, leave room and move on...Someone else dictates your note. That pt gets stuck 3x and you're done with them bc you can't see them again bc they don't offer injections anymore. Move on to NPV only...

With enough NP/PAs, anything is possible.

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[drusso]

I practice in Georgia. Your avg pain doctor makes nothing close to 750k. I value my time more than anything; I have a family. I make plenty of money, but I simply cannot imagine a situation where I made that much, nor do I see it as even possible without 2 min pt visits (I refuse) and fraudulent documentation at a minimum.

GDub said they do 70 fluoro shots per week, and that is possible how? You're going to convince me you can sit down with a pt and take a history, do a PE, review imaging, look at PDMP, etc... and still schedule volume like that?

That is looking at an MRI report and searching out words like "moderate" and "severe," walking into the room, 1-2 min conversation with no PE, leave room and move on...Someone else dictates your note. That pt gets stuck 3x and you're done with them bc you can't see them again bc they don't offer injections anymore. Move on to NPV only...

But, what if the OUTCOMES aren't that different? What if the Million-Dollar-Baller's with their 2 min conversations, scribes, no PE, and steady of churn of NPV have non-inferior outcomes compared to the rest of the half-hearted shmoes humping it for $300K?

At the end of day, does the process matter if the result is the same?

 

[lobelsteve]

So PO benzo. What about the abx? You doing PO or the IM abx?

Anyone putting IVs in for these trials?

Draping then c-arm or just the patient and sterile gown for yourself?

I would this the overhead would add up.

Us plebs want to know


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Occasional PO ativan 1mg #2. Take 1 at home and bring the other if you need it.
IM abx if nurses not around to drop in 2g Ancef.
No c-arm drape in office. Not sure it does anything in OR for our cases. I trained in a high volume practice and we did not use it and had one infection in 3 years I had contact with program. Started gowning when latest guidelines came out. About a year ago.

 

[lobelsteve]

But, what if the OUTCOMES aren't that different? What if the Million-Dollar-Baller's with their 2 min conversations, scribes, no PE, and steady of churn of NPV have non-inferior outcomes compared to the rest of the half-hearted shmoes humping it for $300K?

At the end of day, does the process matter if the result is the same?

Outcomes shouldn’t be much different. Some people got into this to care for people. Others are here to rape the system. There should be a ban of any investment or profit opportunity in doctors. If you paid every doc in the country 750k-1million and we had tort reform and no profiteering in the system. Oh wait, I just created government run healthcare and saved a trillion.

 

[bedrock]

This thread should really be in the private forum

 

[Ferrismonk]

But, what if the OUTCOMES aren't that different? What if the Million-Dollar-Baller's with their 2 min conversations, scribes, no PE, and steady of churn of NPV have non-inferior outcomes compared to the rest of the half-hearted shmoes humping it for $300K?

At the end of day, does the process matter if the result is the same?

And you wonder why this exists
.

 

[SommeRiver]

But, what if the OUTCOMES aren't that different? What if the Million-Dollar-Baller's with their 2 min conversations, scribes, no PE, and steady of churn of NPV have non-inferior outcomes compared to the rest of the half-hearted shmoes humping it for $300K?

At the end of day, does the process matter if the result is the same?

If outcomes are no different I submit to you the field you work in is a sham, and your professional life is a joke.

 

[drusso]

This thread should really be in the private forum

Million Dollar Baller is the next "Opioid Epidemic in a Nutshell..."

 

[oldiebutgoodie1211]

Outcomes arent different between spending 2 minutes with a patient versus spending time actually understanding their issue? People will tell themselves whatever they have to to sleep at night..

 

[drusso]

Outcomes arent different between spending 2 minutes with a patient versus spending time actually understanding their issue? People will tell themselves whatever they have to to sleep at night..

I'm looking for proof to back up that statement.

 

[SommeRiver]

I'm looking for proof to back up that statement.

Your statement presumes that chronic pain is neither physiologic nor appropriate for physician level evaluation and management.

 

[chudat]

Further decrease in pain reimbursement coming in 1, 2, 3.....

 

[oldiebutgoodie1211]

Further decrease in pain reimbursement coming in 1, 2, 3.....

I don’t think that’s how that works lol

 

[ateria radicularis magna]

It’s hard to establish credibility in an online forum due to the mostly anonymous nature of the interaction with others we have so it’s possible I’m wasting time typing this but here it goes anyway.

I fall in this million dollar category as does my partner, two other hospital employed doctors here that I know very well personally, as well as our main solo practice competitor right across the street. Those are just the guys in my close proximity. I know plenty of others and would say at least half of the graduates from my training program make this much (there’s only been 12 graduates, it’s a young program).

There is no secret to doing this. Work hard and efficient. Like if we were mowing lawns...I just mow more lawns in a more efficient time than the guy making half as much as me. I pay some cheap laborer to run the weed eater while I ride the biggest and fastest mower money can buy. The lawn mower making half as much insists on running the weed eater himself due to “lack of quality” if the other guy does it and refuses to use a riding mower because “push mowing is the proper, safe, and traditional way to mow”.

Every person I know making over a million a year sees more than 30 patients a day, runs an interventional type practice doing injections on roughly 50% of their patients, uses scribes and MAs to do a lot of the busy work, etc. If as a pain doctor you’re seeing patients for routine refills of gabapentin and tizanadine that’s a dead giveaway you’re not getting it. Gotta get them back to the PCP and go find some patients with burning pain down their leg who need an ESI!

If you are a national average pain doc only doing 6400 RVU a year I promise in an afternoon we could sit down and come up with an easy plan to improve efficiency and get you in the 9000+ range.

Maybe I’ll start a consulting business. Anyone?

If I have 9000 rvu I will make about 450.
One mil?? I will never make anywhere close to this, and I am fine it.

 

[ateria radicularis magna]

I do 75% of my injxns in the clinic, and I'm 5% of the ASC with a bunch of ortho guys. I only sedate for stellate and stim. I haven't done a clinic trial, but I've been debating it. You think PO Valium 10-15mg and lido 2% would get it done?

Why don’t you just give IV sedation in the clinic ?

 

[SommeRiver]

Why don’t you just give IV sedation in the clinic ?

If I'm doing a procedure that is appropriate for a clinic setting why do I need IV sedation?

 

[ateria radicularis magna]

If I'm doing a procedure that is appropriate for a clinic setting why do I need IV sedation?

IV sedation is very frequently used in clinics. If you are an anesthesiologist giving 2 mg versed is like taking a piss. Furthermore, many fellowships use IV sedation in clinic for all RF, trials.

 

[SommeRiver]

IV sedation is very frequently used in clinics. If you are an anesthesiologist giving 2 mg versed is like taking a piss. Furthermore, many fellowships use IV sedation in clinic for all RF, trials.

I too attended fellowship.

 

[ateria radicularis magna]

I too attended fellowship.

And?

 

[gdub25]

Sheesh, why did I ever get into this discussion.

Doing 70 procedures a week is possible seeing 30-35 patients a day 5 days a week. Of those around half end up being injections. Seeing 30 patients in a day isn’t hard with a scribe. I don’t have a midlevel and see every patient every time. Yes, when Gerald, or Mary, or any other legacy patient comes in for a follow up with their ole “sciatica” hurting down their leg it’s a 2-3 minute office visit. We say our pleasantries, I make sure this is the same old pain it’s always been that always gets better for 6 months with an ESI and I give them a shot.

 

[lobelsteve]

IV sedation is very frequently used in clinics. If you are an anesthesiologist giving 2 mg versed is like taking a piss. Furthermore, many fellowships use IV sedation in clinic for all RF, trials.

Used frequently and completely inappropriately. Goes against guidelines and is expensive unnecessary care that increases risk. Bad for everyone.

 

[SommeRiver]

And?

You're telling me what ppl do in fellowships and I'm sure 100% of fellowship grads know that.

Yes, we could set it up where I give IV sedation but I don't want to...If I'm in the clinic setting I'm using Valium alone. I'm not an anesthesiologist (therefore I do not believe ppl need Versed to take a dump).

 

[SSdoc33]

You're telling me what ppl do in fellowships and I'm sure 100% of fellowship grads know that.

Yes, we could set it up where I give IV sedation but I don't want to...If I'm in the clinic setting I'm using Valium alone. I'm not an anesthesiologist (therefore I do not believe ppl need Versed to take a dump).

i think versed is constipating, actually

 

[ateria radicularis magna]

Used frequently and completely inappropriately. Goes against guidelines and is expensive unnecessary care that increases risk. Bad for everyone.

I would honestly like to see how you do these procedures. I get it that you have done more than me, and you have no issues doing them with only local. But...specifically when you are positioning the 18g RF needle, you can’t inject local once you are heading into the interface or your sensory/motor test won’t be valid. So you aren’t using any local at this point. Doesn’t this hurt a lot? What am I missing?

 

[ateria radicularis magna]

You're telling me what ppl do in fellowships and I'm sure 100% of fellowship grads know that.

Yes, we could set it up where I give IV sedation but I don't want to...If I'm in the clinic setting I'm using Valium alone. I'm not an anesthesiologist (therefore I do not believe ppl need Versed to take a dump).

Makes sense. You’re right, I do think a big dump would be more comfortable with versed.

 

[SommeRiver]

Sheesh, why did I ever get into this discussion.

Doing 70 procedures a week is possible seeing 30-35 patients a day 5 days a week. Of those around half end up being injections. Seeing 30 patients in a day isn’t hard with a scribe. I don’t have a midlevel and see every patient every time. Yes, when Gerald, or Mary, or any other legacy patient comes in for a follow up with their ole “sciatica” hurting down their leg it’s a 2-3 minute office visit. We say our pleasantries, I make sure this is the same old pain it’s always been that always gets better for 6 months with an ESI and I give them a shot.

So you're in clinic seeing pts 5 days a week. You mix it up clinic and procedures simultaneously?

 

[ateria radicularis magna]

Used frequently and completely inappropriately. Goes against guidelines and is expensive unnecessary care that increases risk. Bad for everyone.

I feel like this statement should be reserved for pain docs or ortho spine guys who use general anesthesia for injections. That’s nuts.
What’s the danger in 2 of versed?

 

[SommeRiver]

I would honestly like to see how you do these procedures. I get it that you have done more than me, and you have no issues doing them with only local. But...specifically when you are positioning the 18g RF needle, you can’t inject local once you are heading into the interface or your sensory/motor test won’t be valid. So you aren’t using any local at this point. Doesn’t this hurt a lot? What am I missing?

Using IV sedation for an RFA is ludicrous. I haven't been around as long as Lobell, but I've done several thousand of these without sedation. It is not hard.

 

[lobelsteve]

I feel like this statement should be reserved for pain docs or ortho spine guys who use general anesthesia for injections. That’s nuts.
What’s the danger in 2 of versed?

Against guidelines. Increased risk of nerve injury, cord sticks. Often done for profit and not care.
Did you do a fellowship?

sensory/motor tests? Go take a course. Or read SIS manual. Sensory always useless. Motor block would take how many cc 1% lido to block twitch response at 2v?

 

[DOctorJay]

No reason to do trials in an ASC for sterility. As others have indicated, office is sterile. I’ve done hundreds of offices trials. No infections.

When you guys says no sedation for the office trials, do you mean no IV sedation? I still give trials P.O. Xanax, which many patients still appreciate for a office trial.

I’ve never had a patient request oral sedation for a stim trial but I’d give it if they asked.


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[DOctorJay]

So PO benzo. What about the abx? You doing PO or the IM abx?

Anyone putting IVs in for these trials?

Draping then c-arm or just the patient and sterile gown for yourself?

I would this the overhead would add up.

Us plebs want to know


Sent from my iPhone using SDN

IV ABX prior to trial
Cap, lead & glasses, mask, scrub, gown & gloves for me
Shower cap thing on c-arm
Prep and drape patient
Mark, Anesthetize, 11 blade skin puncture
Access epidural space in CLO with coude needle
“Tip of the needle, bottom of the screen!”
Thread to target
Test
Pull needle(s)
Secure lead(s) with mastisol, steris and stay fix dressing, cover with 2-3 Tega derm
PO ABX for duration of trial
Post op X-ray across hall in radiology office so we know where lead(s) settled out


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[Yo GabbaPentin]

How is that?

In general, surgeons think they are more important than us and subsequently think they deserve more money. In many cases, I’ve seen arrangements where surgeons are the pain physicians partner. In those cases there is a lot of extra overhead thrown on pain doc or collections skimmed off top. Keep in mind that I’m mostly being a smart ass and don’t know your individual situation.

I’m not going to get too deep into this general discussion. However I can say that I’ve been at the absolute bottom (225k base with no bonus), middle (350k base with 50k bonus) and upper end. I have worked equally as hard at each tier. The only differences have been in how many people have been screwing me and how hard they are thrusting. I can say with certainty that the docs bringing home what they actually earn are rarely calculating RVUs. Nothing against employed gigs, but you have to accept that you are making someone else money in those situations.

 

[Ronin1]

There is a world of difference between minimal IV sedation( i.e. 100 if fentanyl or 2 versed) and conscious sedation/MAC for RFA or stim. As long as patient is awake and verbally responsive it’s perfectly reasonable in anxious patients.

 

[SommeRiver]

...why does it have to be IV sedation? You just have to place an IV when you could instead do PO Valium or Ativan or Xanax...or anything at all for that matter?

 

[bedrock]

...why does it have to be IV sedation? You just have to place an IV when you could instead do PO Valium or Ativan or Xanax...or anything at all for that matter?

There is a world of difference between minimal IV sedation( i.e. 100 if fentanyl or 2 versed) and conscious sedation/MAC for RFA or stim. As long as patient is awake and verbally responsive it’s perfectly reasonable in anxious patients.

Agree that minimal IV sedation as you described is safe and perfectly reasonable for some patients who really need it. However most don’t and it definitely slows you down.


Re Somme comment, I wouldn’t bother with an IV just for versed.
You can just give PO Xanax. Would only do an IV if I was thinking both IV fentanyl and versed.

 

[callmeanesthesia]

I’ve never had a patient request oral sedation for a stim trial but I’d give it if they asked.


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We must have a very different demographic. I get “you’re going to put me out, right?” all the time (My answer is no but it doesn’t stop them from asking)

 

[SommeRiver]

"I numb it up real good."

 

[gdub25]

So you're in clinic seeing pts 5 days a week. You mix it up clinic and procedures simultaneously?

Yes, I see clinic patients and do injections all at the same time. It requires that I hire one extra staff member to work the procedure room and they call the patient in, draw up the meds, put them on the table, get a scout image, and ring the bell when they’re ready for me. Like pavlovs dog, when the bell rings I take off to the procedure room and do a time out, say a quick hello to the patient and make friendly small talk while putting on my lead, gloves, and draping. Then I go see clinic patients until I get another bell.

 

[ateria radicularis magna]

Against guidelines. Increased risk of nerve injury, cord sticks. Often done for profit and not care.
Did you do a fellowship?

sensory/motor tests? Go take a course. Or read SIS manual. Sensory always useless. Motor block would take how many cc 1% lido to block twitch response at 2v?

Using sedation the way I use it increases risk by 0%. I am willing to take that risk.

 

[lobelsteve]

Using sedation the way I use it increases risk by 0%. I am willing to take that risk.

Arrogance level: 100

For the frequently performed spinal procedures mentioned, default use of conscious sedation does not add a clear health/outcome benefit. The use of sedation may increase the risk of rare but catastrophic neurologic complications. Use of moderate sedation also adds to health care costs. While it seems that when given the option, patients with anxiety are more likely to elect the use of sedation, only a very small percentage of patients report dissatisfaction if sedation is simply not offered. When sedation is used, it does not predict patient satisfaction. If “significant anxiety” or vasovagal reaction is a concern for a particular patient, conscious sedation can be considered. Physicians should be judicious in the safe use of sedation. Patients should be advised during informed consent that sedation is not necessary, but elective. The physician and patient need to weigh the risks and benefits of procedural harm with any potential advantage attributed to intravenous sedation. Providing patient educational material regarding sedation can assist patients in making informed decisions. If the physician performing the procedure decides to administer and supervise the sedation, they should be trained and qualified to do so. In these situations, a separate healthcare provider is required to assist with the administration of the medications and monitoring of the patient.

 

[Ferrismonk]

Using sedation the way I use it increases risk by 0%. I am willing to take that risk.

https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/factfinder/FactFinder_2018_02_Conscious.pdf

 

[Ronin1]

Know your definitions

Arrogance level: 100

For the frequently performed spinal procedures mentioned, default use of conscious sedation does not add a clear health/outcome benefit. The use of sedation may increase the risk of rare but catastrophic neurologic complications. Use of moderate sedation also adds to health care costs. While it seems that when given the option, patients with anxiety are more likely to elect the use of sedation, only a very small percentage of patients report dissatisfaction if sedation is simply not offered. When sedation is used, it does not predict patient satisfaction. If “significant anxiety” or vasovagal reaction is a concern for a particular patient, conscious sedation can be considered. Physicians should be judicious in the safe use of sedation. Patients should be advised during informed consent that sedation is not necessary, but elective. The physician and patient need to weigh the risks and benefits of procedural harm with any potential advantage attributed to intravenous sedation. Providing patient educational material regarding sedation can assist patients in making informed decisions. If the physician performing the procedure decides to administer and supervise the sedation, they should be trained and qualified to do so. In these situations, a separate healthcare provider is required to assist with the administration of the medications and monitoring of the patient.

IV Sedation - Risks & Side Effects | Made for This Moment

What is IV sedation? Learn more about this pain control technique, including its side effects.

www.asahq.org

I can say that as a board certified anesthesiologist with a separate RN monitoring the patient minimal sedation is safe when indicated

 

[ateria radicularis magna]

Arrogance level: 100

For the frequently performed spinal procedures mentioned, default use of conscious sedation does not add a clear health/outcome benefit. The use of sedation may increase the risk of rare but catastrophic neurologic complications. Use of moderate sedation also adds to health care costs. While it seems that when given the option, patients with anxiety are more likely to elect the use of sedation, only a very small percentage of patients report dissatisfaction if sedation is simply not offered. When sedation is used, it does not predict patient satisfaction. If “significant anxiety” or vasovagal reaction is a concern for a particular patient, conscious sedation can be considered. Physicians should be judicious in the safe use of sedation. Patients should be advised during informed consent that sedation is not necessary, but elective. The physician and patient need to weigh the risks and benefits of procedural harm with any potential advantage attributed to intravenous sedation. Providing patient educational material regarding sedation can assist patients in making informed decisions. If the physician performing the procedure decides to administer and supervise the sedation, they should be trained and qualified to do so. In these situations, a separate healthcare provider is required to assist with the administration of the medications and monitoring of the patient.

Thank you. Your criticism, though misplaced, is appreciated. I don’t think I am arrogant in this particular matter, as every person I personally know who does interventional pain, including all the academic staff at my fellowship, use IV sedation for most rf procedures. That said, because I respect your ideas, I am going to try rf without any sedation and see how it goes. Why not?

 

[ateria radicularis magna]

https://cdn.ymaws.com/www.spineintervention.org/resource/resmgr/factfinder/FactFinder_2018_02_Conscious.pdf

Thanks, I am going to give it a try!

 

[Ferrismonk]

Thanks, I am going to give it a try!

Anecdotally, my non-sedation RFs (and every other procedure) are a million times easier.

I do offer sedation in my clinic, but I make it clear the risks and my preference is always no sedation. For what it's worth, this is my template:

Monitored Anesthesia Care/Moderate (Conscious) Sedation. Patient was advised of the risks of associated with sedation during pain procedures. Patient is aware that there is an increased risk of spinal cord injury and neurologic injury. There are also independent risks from sedation itself including possible apnea, hypoxemia, hypercarbia, and death. Patient is also aware that sedation is purely voluntary and my preference is the patient have no IV sedation. Patient also understands that sedation provided is not "asleep". The patient will remain conversant and able to respond purposefully to verbal commands during the procedure. There may, however, be amnesia during/after the procedure. After weighing the risks associated with sedation, the patient has requested sedation be given due to significant anxiety and/or expected pain from the procedure.

 

[lobelsteve]

SO guidelines don't matter, as long in your hands and if everyone you know does it......

THis is whats wrong with our field.

 

[drusso]

SO guidelines don't matter, as long in your hands and if everyone you know does it......

THis is whats wrong with our field.

Here are the things that people are saying make a difference between being a million-dollar-baller and a regular doctor: Using IV sedation for cases, selective use of guidelines, limited physical examination of patients, using mid-levels, seeing more new patients, churning for surgeons, not doing sensory stim on RFA, "numbing it real good," limiting your practice to only interventional work, seeing at least 30 patients per day five days per week, being a majority owner in ASC or doing most things that pay well in the office, speaking for device companies, doing beaucoup kypho & stim, having ancillaries in your practice, being of OON, doing everything in the HOPD and getting $O$ transfers to base salary or wRVU comp, using scribes and MA's to do your scut work, practice in low cost of living geographic location, and having a good payer mix.

Anything else?

 

[lonelobo]

Medicare Fraud

 

[lobelsteve]

I heard of a group just get their 855s on for DME for bracing. THey created a 3rd party company to buy and resell from vendor to their practice.

 

[Ronin1]

SO guidelines don't matter, as long in your hands and if everyone you know does it......

THis is whats wrong with our field.

The guidelines are just that. But they are mainly discussing conscious sedation which is NOT minimal IV sedation. As previously stated