Fellowship decisions - HELP!

[AviatorDoc]

So after going to several interviews, I am getting the impression that it is more and more imperative to do an ACGME Pain fellowship if you want to do ANY axial injections in practice. Basically, from a medicolegal as well as a marketing/referral standpoint, you need to be all-or-none.

Any thoughts?

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[PMR 4 MSK]

So after going to several interviews, I am getting the impression that it is more and more imperative to do an ACGME Pain fellowship if you want to do ANY axial injections in practice. Basically, from a medicolegal as well as a marketing/referral standpoint, you need to be all-or-none.

Any thoughts?

ACGME fellowships cannot possibly train enough docs to do all the prcoedures that need to be done, or serve all the patients who need to be seen. While some hospitals and insurance plans may move this way, it will only result in underserved populations.

 

[dc2md]

See, I'm getting just the opposite impression as I go along. I'm feeling that it really doesn't matter much and that a good training despite ACGME accedidation, is what matters most. What insurance companies will do in the future is all theoritical. Hell, they may decide to not cover procedures at all. Who knows. Think of all the non-ACGME trained interventional pain docs out there. I know Dr. Charles Aprill wasn't fellowship trained at all. But who's gonna say he's not qualified. I'm guessing people will get grandfathered in if a "rule" ever pops up.

And as far as referrals are concerned, you'll still be able to advertise yourself as "fellowship trained pain physician" or "fellowship-trained interventional pain physician".

 

[normalforce]

Take the essenitals course and sit for the AAPM or APS board. Then you are still board certified.

I am going into practice without a fellowship. I trained at a great institution. I have over 500 TFESI/SIJ/Facets. My employer did not want me to do a fellowship. They will train me in any other procedures I want to use (RF, SCS, etc..) I will be credentialed and will start practicing in June.

It all depends on where you are going, what the laws and credentialing issues are, what the politics are.

 

[SSdoc33]

So after going to several interviews, I am getting the impression that it is more and more imperative to do an ACGME Pain fellowship if you want to do ANY axial injections in practice. Basically, from a medicolegal as well as a marketing/referral standpoint, you need to be all-or-none.

Any thoughts?

this topic has been debated on this forum at length in the past. look to older posts within the last year or 2 for some insights. i disagree with your main thesis, though.

 

[AviatorDoc]

"this topic has been debated on this forum at length in the past. look to older posts within the last year or 2 for some insights. i disagree with your main thesis, though."

I know this is something that is an ongoing discussion, but my impression comes from a few people (current fellows and soon-to-be fellows, as well as PASSOR-trained attendings) who have told me the following:

1. There is currently a push to change Medicare reimbursement for axial procedures to be different if you are ACGME trained or not.

2. If you want to develop the hands for doing interventional procedures, you need to go to a program that does lots and lots and lots.

Here's what I want out of life -- a well-balanced MSK practice, incl EMG, U/S, manipulation (if time allows), peripheral injections, axial injections, med management as long as they behave. If they want an implant, then they get sent to a Pain physician.

Is this too much to ask?

 

[dc2md]

normalforce is right. i've already gotten 281 ESI, SI, facet, RFA (and some TPs, knees, subacromial) halfway thru my PGY2. I'm going to feel very confident doing those procedures coming straight out without fellowship training...but not cervicals and thoracics or any others (SCS, intrathecal, vertebro/kyphoplasties, stellate ganglion). well maybe stellate ganglion blocks, since I've done a couple and they seemed relatively easy(ish). but of course fellowship training sounds best and will prepare me a ton more.

If by AAPM you mean american academy of pain management, that's a pretty lame credentialling group that will basically let anyone join after they pass a very easy test. But it'll fool the public and other physicians for sure.

 

[SSdoc33]

"this topic has been debated on this forum at length in the past. look to older posts within the last year or 2 for some insights. i disagree with your main thesis, though."

I know this is something that is an ongoing discussion, but my impression comes from a few people (current fellows and soon-to-be fellows, as well as PASSOR-trained attendings) who have told me the following:

1. There is currently a push to change Medicare reimbursement for axial procedures to be different if you are ACGME trained or not.

2. If you want to develop the hands for doing interventional procedures, you need to go to a program that does lots and lots and lots.

Here's what I want out of life -- a well-balanced MSK practice, incl EMG, U/S, manipulation (if time allows), peripheral injections, axial injections, med management as long as they behave. If they want an implant, then they get sent to a Pain physician.

Is this too much to ask?

no, its not. do a good passor fellowship. you are not describing the job of a pain doc, you are describing the job of a versatile outpatient physiatrist. you will get zero EMG, U/S, manipulation, and improvement in your physcial exam skills in a typical ACGME pain fellowship. stick with your family and stay in PM&R. some of the passor fellowships have way more volume that some of the Pain fellowships. it is definitely program-dependent. you are not an anethesiologist. if you want to be one, go the pain route. nobody truly knows what will happen with reimbursements and injections. i think itll be tough to tell the slipman grads out there that you need to be ACGME certified to perform the injections.

 

[dc2md]

Here's what I want out of life -- a well-balanced MSK practice, incl EMG, U/S, manipulation (if time allows), peripheral injections, axial injections, med management as long as they behave. If they want an implant, then they get sent to a Pain physician.

That sounds GREAT!!! Although I haven't been too impressed with MSK U/S so far.

 

[PMR 4 MSK]

I know this is something that is an ongoing discussion, but my impression comes from a few people (current fellows and soon-to-be fellows, as well as PASSOR-trained attendings) who have told me the following:

1. There is currently a push to change Medicare reimbursement for axial procedures to be different if you are ACGME trained or not.

Medicare does not pay different RVU's for different training. CPT code + locale = set rate for the procedure no matter who does it. You can look up any payment schedule online for medicare.

Medicare has no idea who had an ACGME-approved fellowship and who didn't, and to bring that into play would result in too many legal challenges to be worth it. You're talking about a goverment agency that's constantly looking for ways to pay everyone less. Not to mention the amount of paperwork it would generate, new departments to review the paperwork, standards to be created. It's all wishful thinking by those wishing to scare you.

 

[Disciple]

What insurance companies will do in the future is all theoritical. Hell, they may decide to not cover procedures at all. Who knows.

Agree. This is what I've been seeing. Blue Cross will no longer pay for SI joint injections in my state, and a few other states that I am aware of.

 

[Disciple]

See, I'm getting just the opposite impression as I go along. I'm feeling that it really doesn't matter much and that a good training despite ACGME accedidation, is what matters most. What insurance companies will do in the future is all theoritical. Hell, they may decide to not cover procedures at all. Who knows. Think of all the non-ACGME trained interventional pain docs out there. I know Dr. Charles Aprill wasn't fellowship trained at all. But who's gonna say he's not qualified. I'm guessing people will get grandfathered in if a "rule" ever pops up.

And as far as referrals are concerned, you'll still be able to advertise yourself as "fellowship trained pain physician" or "fellowship-trained interventional pain physician".

It's funny how Physiatrists have such a complex about all of this. Of all the specialists in my geographic area, Physiatrists are the only ones who put "ACGME" or "ABMS" in their sig lines

PCPs and surgeons could care less about this. What they are most concerned about is that patients stop calling their offices for pain meds. If you can help them with this in as short a time as possible per patient, the more they're going to refer to you.

 

[Disciple]

"this topic has been debated on this forum at length in the past. look to older posts within the last year or 2 for some insights. i disagree with your main thesis, though."

I know this is something that is an ongoing discussion, but my impression comes from a few people (current fellows and soon-to-be fellows, as well as PASSOR-trained attendings) who have told me the following:

1. There is currently a push to change Medicare reimbursement for axial procedures to be different if you are ACGME trained or not.

2. If you want to develop the hands for doing interventional procedures, you need to go to a program that does lots and lots and lots.

Here's what I want out of life -- a well-balanced MSK practice, incl EMG, U/S, manipulation (if time allows), peripheral injections, axial injections, med management as long as they behave. If they want an implant, then they get sent to a Pain physician.

Is this too much to ask?

I think you should do a little deeper research into what certain people are telling you. Push to change Medicare by whom?

AAPM&R?--obviously not
AMA-no
AAPMed-no (actually quite the opposite)
ISIS-no
ASIPP-no
NASS and the surgeons--obviously not
ASA/ASRA--maybe

That's 1/7. Basically, the only ones who may spend the time and resources toward such a goal would be "Pain" academicians, and really no one else.

Remember, the government wants to increase access and cut reimbursement for all, not decrease access and increase payments to a few doctors.

I would also disagree that it takes, lots, lots and lots of procedures to "develop the hands for doing them". Maybe if someone is really clumsy. It takes a high volume to do them super fast, not to do them safely. Remember, these are injections, not surgery. If you're any good at video games, I have no doubt you could do these procedures proficiently without much difficulty.

Fellows and Residents are always going to be worried about these types of things, because that's what fellows/residents do. I'm sure you'd hear similar fears from surgical residents/fellows when talking about integrated plastics vs. plastics fellowship, plastics vs. general ENT, etc.

From what you've described about your desired practice, your concerns are pretty common and expected. PM&R residents, who want to practice Physiatry but feel compelled to chase the ACGME "pain" thing out of fear.

If you're really worried about it, you should go to the AAPM&R meeting in San Diego and voice your concerns at the new council/SIG meetings--maybe get some reassurance.

 

[normalforce]

I have spoken to many people about this insurance issue. I have spoken to people on PMR, anesthesia, surgery..... People with good reputations, people who have been practicing 20 yrs, 10 yrs, 5 yrs.....

They all tell me the same thing. There is absolutely no way in hell that the government or an insurance agency will stop reimbursing based upon ACGME approval. If you are CREDENTIALED in YOUR STATE to perform a procedure, then you will get treated the same as everyone else.

I WILL POST THIS IN BOLD AND CAPS... THE ONLY THING YOU HAVE TO WORRY ABOUT AS A RESIDENT IS GETTING HIRED AND CREDENTIALED BY A GROUP/HOSPITAL. WITH THAT SAID, THERE MAY BE SOME LOCAL POLITICS IF YOU ATTEMPT TO WORK IN AN AREA WITH LOW PMR SATURATION, MEAN GAS PASSERS WHO SIT ON THE CREDENTIALING BOARD OF THE HOSPITAL, THAT WILL NOT ALLOW YOU TO PERFORM PROCEDURES THERE. IT WOULD BE RARE, BUT IS THE ONLY REASON TO DO AN ACGME PAIN FELLOWSHIP (IF YOU ARE SCARED ABOUT THAT). IF YOU ARE SCARED, DO YOUR RESEARCH EARLY ABOUT WHERE YOU WANT TO GO AND WHERE YOU WANT TO PRACTICE.

NF

 

[drusso]

What our field (interventional pain management) really needs to do is to rise above "guild" status and become a bonafide sub-specialty. Standardized training would be the first step in that direction. I used to be hopeful that ACGME-accredited programs would be the most useful way to perpetuate that training especially if they incorporated a multispecialty orientation and attracted and trained practitioners from a variety of "specialties of origin." I still think that the pain animal is too big for just one specialty to get its entire hands around it.

However, I'm becoming frustrated with the way things are developing and fear that even with the new multi-disc. training requirements the whole process is devolving into political interests. I find it interesting that no one seems to care if hospice or addiction medicine specialists come from a variety of training backgrounds...but when it comes to Pain Medicine...Woh! Like most things in life, it's all about the $$$.

 

[dc2md]

DRusso,
4-year pain residency would help with that right? People would be coming out as "pain docs" (basically; i'm not a fan of the algos name derivative they're proposing). So they won't be a physiatrist or anesthesiologist or psychiatrist with pain fellowship training. They'll simply be pain physicians who received training in all facets of pain (biopsychosocial).

 

[AviatorDoc]

I'd love to go to San Diego, but I've spent all my vacation time on interviewing and moonlighting.

 

[Disciple]

However, I'm becoming frustrated with the way things are developing and fear that even with the new multi-disc. training requirements the whole process is devolving into political interests. I find it interesting that no one seems to care if hospice or addiction medicine specialists come from a variety of training backgrounds...but when it comes to Pain Medicine...Woh! Like most things in life, it's all about the $$$.

This is why I feel like we've given a pretty good effort (in good faith) toward diplomacy/negotiation and that it's time to move on.

AAPMed can straighten things out in Pain Medicine.

Physiatry should take care of its own house.

As for it being all about the $$$, interestingly enough, the problems I've had with being blocked from joining some insurance plans have come from other Physiatrists, not Anesthesiologists.

 

[Ligament]

If your only doing basic lumbar and SI procedures you are a physiatrist specializing in the lumbosacral spine, but not a pain physician. There's nothing wrong with that.

 

[Disciple]

True, but I think the concern of the OP, also summarized in drusso's post is that there are those whose aim is to use the vehicle of "Pain Medicine/Management" like The Matrix, as a system of control over musculoskeletal/Interventional Physiatrists.

Radiologists are pretty much immune to this because they have their own accredited IR fellowships and can basically teach whatever they want. Surgeons are immune because of the considerable political power they wield. Physiatrists are protected by surgeons, to a certain extent, only as much as we work for them. So, Physiatry is the little guy here, and stands the most to lose.

For residents like the OP, it's a less than ideal choice. "I want to learn more about Physiatry and become really good at it because I enjoy musculoskeletal medicine and want to have a musculoskeletal practice. Should I do the PM&R fellowship or spend a year to obtain an insurance policy with the pain fellowship? Doing 2 fellowships is out of the question".

It's the responsibility of the PM&R leadership to make sure future residents are not put in this difficult position.

 

[chauffeur]

There is absolutely no way in hell that the government or an insurance agency will stop reimbursing based upon ACGME approval. If you are CREDENTIALED in YOUR STATE to perform a procedure, then you will get treated the same as everyone else.

THE ONLY THING YOU HAVE TO WORRY ABOUT AS A RESIDENT IS GETTING HIRED AND CREDENTIALED BY A GROUP/HOSPITAL. WITH THAT SAID, THERE MAY BE SOME LOCAL POLITICS IF YOU ATTEMPT TO WORK IN AN AREA WITH LOW PMR SATURATION, MEAN GAS PASSERS WHO SIT ON THE CREDENTIALING BOARD OF THE HOSPITAL, THAT WILL NOT ALLOW YOU TO PERFORM PROCEDURES THERE. IT WOULD BE RARE, BUT IS THE ONLY REASON TO DO AN ACGME PAIN FELLOWSHIP (IF YOU ARE SCARED ABOUT THAT). IF YOU ARE SCARED, DO YOUR RESEARCH EARLY ABOUT WHERE YOU WANT TO GO AND WHERE YOU WANT TO PRACTICE.

NF

After speaking to many attendings, I totally agree with this. On the other hand, who knows what medicine will be like 30 years from now given the current state of affairs. If you find a PMR ACGME accredited fellowship, this might suit you best.

 

[drusso]

Practically speaking, all politics is local as Normal and others point out. You can do what you can get credentialed to do. But, then what's the point of ACGME-accreditation at all? Why should any training standards matter?

There is a quality movement in medicine that the Pain Medicine specialty is late to join. But, in the coming years, pain physicians will need to do the hard work of actually delfining what constitutes *quality* interventional pain medicine---3 blind epidurals done by a non-fellowship trained anesthesiologist in the PACU between cases, 3 blind epidurals dones by a fellowship-trained anesthesiologist, a caudal in the office by a non-fellowship trained physiatrist, an image-guided transforaminal injection by a non-fellowship trained physiatrist, etc...Personally, I don't think that "specialty of origin" matters as much as the quality of the training you receive. You can be well-proctored and trained in procedures without a fellowship and many, many anesthesiologists, physiatrists, and pain physicians are.

But, looking forward I think that since the ACGME has gone through the trouble to define what constitutes a quality training program, then perhaps our field should get on board.

http://www.acgme.org/acWebsite/newsRoom/newsRm_acGlance.asp

 

[ampaphb]

While conceptually I agree with drusso, at the present time, I need to take issue with his assumption that an ACGME-accredited fellowship is in any sense of the word better than one that is not accredited.

Those who trained/are training with Curtis Slipman, Joel Press, Stan Herring, or the UMichigan spine program, Heidi Prather, Mike Geraci, Gerry Malanga, Greg Lutz, Stu Kahn/Rob Gotlin, Rob Windsor, Brad Goodman, Benoit Benny (Baylor), CINN, Florida Spine Institute, etc were all exceedingly well trained, yet NONE of them are ACGME-accredited. BFD.

 

[Disciple]

The ABPMR is a sponsoring board of the pain sub-specialty certification, so we should probably continue to support it to some degree.

Due to circumstance, we just can't do it in a manner as originally planned. Maybe in the future it should be made more appealing for Physiatrists who want to have RIC type comprehensive pain programs.

Let AAPMed fix Pain Medicine.

Physiatrists should look inward, get this whole "council" mess straightened out and then start setting down some real training standards for any Physiatrist of any practice type who wields a needle. That would end this argument about accredited/non-accredited, what is "Pain", what is "Spine", what is "MSK".

 

[drusso]

Physiatrists should look inward, get this whole "council" mess straightened out and then start setting down some real training standards for any Physiatrist of any practice type who wields a needle. That would end this argument about accredited/non-accredited, what is "Pain", what is "Spine", what is "MSK".

It just occurred to me that physiatry appears to be a specialty that prefers to defines its scope of practice by what it *DOESN'T DO* than by what it actually does.

Don't do anything interventional ---> General PM&R/Neuromuscular Med/EMG

Do EVERYTHING interventional ---> Pain

Don't do (or very limited) axial spine procedures ---> MSK

Don't do cancer, don't do headache, don't do meds, don't do fibro ---> Spine

Don't do chronic pain, don't do fibro ---> Sports

Don't do spinal cord injury ---> Acquired Brain Disorders

Don't do brain injury ---> Spinal Cord Injury Medicine

Don't do adults ---> Pediatrics

Don't do living people ---> Hospice/Palliative Care

Don't do inpatient ---> return to top

 

[Finally M3]

While conceptually I agree with drusso, at the present time, I need to take issue with his assumption that an ACGME-accredited fellowship is in any sense of the word better than one that is not accredited.

Those who trained/are training with Curtis Slipman, Joel Press, Stan Herring, or the UMichigan spine program, Heidi Prather, Mike Geraci, Gerry Malanga, Greg Lutz, Stu Kahn/Rob Gotlin, Rob Windsor, Brad Goodman, Benoit Benny (Baylor), CINN, etc were all exceedeinly well trained, yet NONE of them are ACGME-accredited. BFD.

ampaphb; do you know if Benoit has managed to get ACGME cert for his fellowship? As of last year, I know he was yapping about it.

Not to toot the alma mater...but Dr. Benny is a UMich grad (fellowship, Spine)

 

[ampaphb]

Not to toot the alma mater...but Dr. Benny is a UMich grad (fellowship, Spine)

Wait, you mean Dr. Benny was trained at a non-ACGME accredited fellowship? The horror! Does not seem to have limited his ability to head up his own Baylor-based fellowship program one iota!

 

[nvrsumr]

Wait, you mean Dr. Benny was trained at a non-ACGME accredited fellowship? The horror! Does not seem to have limited his ability to head up his own Baylor-based fellowship program one iota!

Actually it was complicated. At the time UM PMR department offered 1 spine and 2 ACGME pain medicine fellowships. Dr. Benny accepted the spine position and then through alot of extra effort and time(I believe he even stayed on for an extra month) he was able to obtain ACGME accreditation(UM was able to change the spine postion to a ACGME position at the end of his fellowship year).

You will never be sorry for obtaining ACGME certification.

 

[Disciple]

It just occurred to me that physiatry appears to be a specialty that prefers to defines its scope of practice by what it *DOESN'T DO* than by what it actually does.

Don't do anything interventional ---> General PM&R/Neuromuscular Med/EMG

Do EVERYTHING interventional ---> Pain

Don't do (or very limited) axial spine procedures ---> MSK

Don't do cancer, don't do headache, don't do meds, don't do fibro ---> Spine

Don't do chronic pain, don't do fibro ---> Sports

Don't do spinal cord injury ---> Acquired Brain Disorders

Don't do brain injury ---> Spinal Cord Injury Medicine

Don't do adults ---> Pediatrics

Don't do living people ---> Hospice/Palliative Care

Don't do inpatient ---> return to top

What if you combine pain/spine/sports/EMG.

Does that justify don't do headache, don't do narcs, don't do fibro?

 

[olafa]

Hillarious... i think your right. These tidy little boxes have summed up practice preferences quite nicely. I think its AAPMR way to get people to agree by putting the like minded together....

It just occurred to me that physiatry appears to be a specialty that prefers to defines its scope of practice by what it *DOESN'T DO* than by what it actually does.

Don't do anything interventional ---> General PM&R/Neuromuscular Med/EMG

Do EVERYTHING interventional ---> Pain

Don't do (or very limited) axial spine procedures ---> MSK

Don't do cancer, don't do headache, don't do meds, don't do fibro ---> Spine

Don't do chronic pain, don't do fibro ---> Sports

Don't do spinal cord injury ---> Acquired Brain Disorders

Don't do brain injury ---> Spinal Cord Injury Medicine

Don't do adults ---> Pediatrics

Don't do living people ---> Hospice/Palliative Care

Don't do inpatient ---> return to top

 

[TRAMD]

normalforce is right. i've already gotten 281 ESI, SI, facet, RFA (and some TPs, knees, subacromial) halfway thru my PGY2. I'm going to feel very confident doing those procedures coming straight out without fellowship training...but not cervicals and thoracics or any others (SCS, intrathecal, vertebro/kyphoplasties, stellate ganglion). well maybe stellate ganglion blocks, since I've done a couple and they seemed relatively easy(ish). but of course fellowship training sounds best and will prepare me a ton more.

If by AAPM you mean american academy of pain management, that's a pretty lame credentialling group that will basically let anyone join after they pass a very easy test. But it'll fool the public and other physicians for sure.

Are you saying that you PERFORMED these or watched most of them? That is 2.66 per day EVERY weekday since you started. Don't you have to do any inpatient? I guess I just frontloaded my inpatient rotations to my first year and have zero axial injections so far in my PGY-2. Now if you observed most of those I have around 400 observed axial injections (TFESI, ILESI, CESI, SIJ, facets, discograms, CT myelograms, RFA, stellate ganglion) between a month in 4th year MS and a month and a half during my internship but only 3 performed - all caudal epidurals.

 

[dc2md]

TRAMD,
Don't forget at LSU we actually start doing PM&R rotations our PGY1. But to be more specific, of 281 procedures so far. I've only done 110 all by myself (start to finish), assisted with 50 (only did a portion of the procedure), and the rest were observed. Now of course the TFESI, facets, RFAs were mostly all multi-leveled...so that's a lot more practice of finding the hole, sticking the needle, and shooting the juice than 110. The real difference at LSU as far as getting our numbers/experience has been the VA. The rotation at another hospital is more observational the first month you work with the guy. And the last one was once the highest yielding rotation with the dude letting the resident do everything completely for about 40 a week (so i'm told). Now it's run by a recent fellow grad that isn't as comfortable with residents doing the procedures. :-(

 

[ampaphb]

The issue with any program is does the teacher know what he or she is doing, and almost more important, if something goes awry, is he/she both able to recognize the problem, and work around it?

Volume is important, but not MORE important than technical ability and agility.

I can't tell you the number of cases I have reviewed where the images purported to have the needle tip in the epidural space when, in fact, it was a trigger point injection or intrathecal. One local interventionists, who taught the residents and fellows, was supposedly letting them do CTFEs! I spoke to the PD, expressing my grave concern. But I stopped worrying when I saw an image, and understood that what the residents believed were transforaminal injections were at least 2cm peripheral to the foramen. The busiest guy in town has injected the cervical cord THREE times in the past 5 years, each with catastrophic results. Another busy pain doc left a patient quadriplegic within the past year after a misadventure with a CTFE. The most generous guy on staff when I was a resident (ie. let us do the lion's share of his procedures) only does lumbar transforaminals in the AP plane, and NEVER gets laterals.

So pay attention to what your staff does, but don't automatically assume that because they are staff, they have a clue what THEY are doing. Afterall, most PDs and Department Chairs couldn't do any of the procedures we do, no less tell who is competent to do them, or teach them.

Sometimes, the lesson you need to take away from watching a procedure is what not to do.

 

[AviatorDoc]

I was PM'ed about an update to my query a few years back, so I thought I'd give the run-down.

I chose to do a PASSOR fellowship. I do not regret my decision in the least. I had a tremendous fellowship experience, geared to the type of practice I want to do. I have no fear regarding hospital credentialing, and if some bonehead administrator decides to get persnickity, I will simply take my fluoro into the office. If you count individual levels, I performed over 1,500 fluoro-guided injections, and had lots of hands-on ultrasound-guided injections as well as continuing my EMG experience (which is always good). I would contend I am as safe as any other just-finishing fellow in the country. This isn't to say something bad might happen (knock-on-wood), but that I learned how to perform injections safely, not to set any land-speed records.

At this point, I am far more concerned about Medicare's slashing across the board than about my specialty in particular. Quite frankly, I'm more concerned about the state of the economy in general than cuts to my reimbursements.

Nevertheless, I have hedged my bets, and will be doing a little inpatient along with my MSK practice. This is the "safety net" that will protect if injection reimbursements go down the tubes. (Yes, I know inpatient is being threatened as well, but there is at least more job security.)

 

[nleeds24]

It just occurred to me that physiatry appears to be a specialty that prefers to defines its scope of practice by what it *DOESN'T DO* than by what it actually does.

Don't do anything interventional ---> General PM&R/Neuromuscular Med/EMG

Do EVERYTHING interventional ---> Pain

Don't do (or very limited) axial spine procedures ---> MSK

Don't do cancer, don't do headache, don't do meds, don't do fibro ---> Spine

Don't do chronic pain, don't do fibro ---> Sports

Don't do spinal cord injury ---> Acquired Brain Disorders

Don't do brain injury ---> Spinal Cord Injury Medicine

Don't do adults ---> Pediatrics

Don't do living people ---> Hospice/Palliative Care

Don't do inpatient ---> return to top

I am a physiatrist and this cracked me up. Thanks for the laugh.

 

[RUOkie]

Nevertheless, I have hedged my bets, and will be doing a little inpatient along with my MSK practice. This is the "safety net" that will protect if injection reimbursements go down the tubes. (Yes, I know inpatient is being threatened as well, but there is at least more job security.)

There is one other thing that the little bit of inpatient will give you.
Exposure.

By sitting in the Dr's lounge, going to Med staff meetings, calling other docs, the surgeons, orthopods, and PCP's will get to know you. Then casually talk to them about what you want to see in the office (as well as what you are willing to see), and volunteer to see the tough people. They will love you, and try to send the good (in addition to the typical bad )