Is it feasible to do both critical care and interventional pain fellowships?

[DiscoReinhardt]

I absolutely love the thrill of critical care but also feel that down the line I would want something that is more relaxed and outpatient (where I could have some patient contact). So I’m thinking of doing both fellowships. Is there perhaps an overlap between the two (i.e. a practice model where I can do both), or is this an utterly terrible idea?

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[Guillemot]

Terrible Idea.

 

[pocafx]

R u a med student ?

 

[DiscoReinhardt]

R u a med student ?

Yes

 

[DiscoReinhardt]

Terrible Idea.

What would you suggest?

 

[vector2]

What would you suggest?

One or the other

 

[IMGASMD]

What would you suggest?

Do a rotation with both…. And see which one you cannot live without.

They’re so far apart, you will lose skills while you’re doing one or the other.

You “can” do a fellowship later in your career, but at that point you may not want to.

Good luck.

 

[Agast]

Is there perhaps an overlap between the two (i.e. a practice model where I can do both),

I know of a few instances where a pain patient was rushed to ICU after their procedure. Generally not considered a good thing.

 

[POW16]

Decide during residency after rotating in each and talking to experienced attendings in both fields.

 

[Beeftenderloin]

There are several threads discussing this topic in detail: Both the upside and downside of each, as well as why they’re for the most part incompatible. I would look back at those.

I thought crit care was super high energy and exciting as an intern/CA1 and was all but certain that’s what I wanted to do. Then I did cardiac anesthesia and realized how comparatively slow and boring the ICU was most of the time. Go into residency with an open mind and have your primary focus be learning to be a great anesthesiologist.

 

[The Duck Knows]

Why give those stress dose steroids IV when you could give them transforaminally to the epidural space?

In all seriousness, I’ve never heard of it but that’s probably due to very few people enjoying both fields. If you found a critical care job where you covered a week on and a week off, then I guess you could be a workaholic and spend the off weeks in clinic. Sounds miserable to me though

 

[IMGASMD]

Why give those stress dose steroids IV when you could give them transforaminally to the epidural space?

In all seriousness, I’ve never heard of it but that’s probably due to very few people enjoying both fields. If you found a critical care job where you covered a week on and a week off, then I guess you could be a workaholic and spend the off weeks in clinic. Sounds miserable to me though

Chronic pain patients followed up a week of ICU?! As I was typing that…. I am very happy to be a general guy.

 

[kidthor]

OP - sure you could do both fellowships but there's no point in doing so. You'd be hard pressed to find a job that allows you to do both. It's hard enough to find a job that facilitates doing both anesthesia and critical care! Plus there's no meaningful overlap to make a viable academic niche really. Just pick one or the other (or pick neither and be a generalist, making the same money as the rest of us).

 

[UscGhost]

As a generalist you will do a little bit of everything. Spinals, epidurals, nerve blocks, critical care (just in the OR) without the headache of clinic and dealing with insurance

 

[midazzoler]

Not sure about feasibility but one of my attendings had done both fellowships. She was the director of the pain program and part of the team that covered our ICUs. Doable but didn’t seem practical.

 

[hiyaman]

It's really not feasible. It's not like crit care and cardiac where there is some overlap. I have not met anyone who was pain and crit care trained but I have met pain and cardiac. It was cos they left pain to do cardiac

 

[psychbender]

I knew one older guy, who was Anes-CCM, loved acute and chronic pain, and somehow set himself up in a situation in which he flipped between pain clinic, ICU, and general OR. I think he's retired now, and just teaches, but those grandfathered, niche practices really don't exist for folks nowadays.

 

[nimbus]

I have a couple of partners who do cardiac and very basic pain. They do a full anesthesia schedule and do an occasional afternoon of epidural injections on patients referred by spine surgeons who are their friends. One of them will also occasionally work a week here and there at our peds hospital where he is assigned non-intense cases. No monster liver resections. It gets harder and harder to maintain “full scope” anesthesia practice in this era of subspecialization.

 

[epidural man]

I absolutely love the thrill of critical care but also feel that down the line I would want something that is more relaxed and outpatient (where I could have some patient contact). So I’m thinking of doing both fellowships. Is there perhaps an overlap between the two (i.e. a practice model where I can do both), or is this an utterly terrible idea?

I loved critical care. My favorite rotation was Cardiac, but PEDS was close behind. Peds was really great.

I ended up doing pain.

If you really want to do both - you can, and you can pave an untraveled path. Remember the words from the song from the timeless classic "Pete's Dragon" - there's room for everyone in this world.

However, as others have said, it doesn't seem likely, or practical - but neither does making an electric car company out of scratch and becoming the leader in the field, but it WAS doable despite many people saying otherwise. Point is, if you really want to do it - go for it.

I will say this about pain....and I've said it many times before (and usually get a lot of crap for it). Pain is a dying field. Chronic pain is not a problem with nociception and a nociceptive anatomical problem. It is a complex issue that mostly involves cognition and emotion - and insurance companies will not pay for the correct treatment (intensive outpatient pain programs), and pain physicians seem to think that if they can just block the right thing, patients will be okay, and patients don't want to recognize that to get better, truly better, THEY have to do the work. They all want passive treatments, and physicians want to give it to them because it pays them gobs of money to do so.

 

[TheLoneWolf]

I loved critical care. My favorite rotation was Cardiac, but PEDS was close behind. Peds was really great.

I ended up doing pain.

If you really want to do both - you can, and you can pave an untraveled path. Remember the words from the song from the timeless classic "Pete's Dragon" - there's room for everyone in this world.

However, as others have said, it doesn't seem likely, or practical - but neither does making an electric car company out of scratch and becoming the leader in the field, but it WAS doable despite many people saying otherwise. Point is, if you really want to do it - go for it.

I will say this about pain....and I've said it many times before (and usually get a lot of crap for it). Pain is a dying field. Chronic pain is not a problem with nociception and a nociceptive anatomical problem. It is a complex issue that mostly involves cognition and emotion - and insurance companies will not pay for the correct treatment (intensive outpatient pain programs), and pain physicians seem to think that if they can just block the right thing, patients will be okay, and patients don't want to recognize that to get better, truly better, THEY have to do the work. They all want passive treatments, and physicians want to give it to them because it pays them gobs of money to do so.

Practice both anesthesia and pain. This is 100% true. An anesthesia background does not prepare one well for multidisciplinary pain. It is a good start for those who think they will be multimillionaire needle hockey's with no med management. This practice may have existed but again is dying, lack of data and insurance to support.

Multidisciplinary pain is a money loser and rarely exists outside of academia. Academic pain is legit but is very different than private practice.

As epiduralman noted, patient's in large part want passive treatments as a "cure" for their chronic long term pain. They also tend to have little insight into the ongoing issues driving their pain and tend to chemically cope. I spend a lot of time on patient education, pushing PT, psychotherapy, and nonopioid med management, tapers etc. I am heavily interventional and can tell you it is not the pancea it is advertised as for the long term management of chronic pain.

Private practice pain is largely a wasteland of trading opioid for shots or as a blockjock in the factory line algorithm of an ortho/spine surgery practice to tee up for planned surgery and dealing with their postop failed surgical patients. Also, "producing" against a high overhead.

If you think that you will be a hot shot 100% interventional pain doc, you are in for a rude surprise when your referring physicians expect that you take over the management of the opioid, muscle relaxant, benzo combo or the referral base dries up.

I experienced it, I'm ok with it , but your partners won't as they think you are "leaving money on the table " or letting good money walk out the door for not pushing up your billings through unnecessarily high volume or poorly studied but highly reimbursed procedures .

Expectation vs reality.

 

[Status Sciaticus]

Practice both anesthesia and pain. This is 100% true. An anesthesia background does not prepare one well for multidisciplinary pain. It is a good start for those who think they will be multimillionaire needle hockey's with no med management. This practice may have existed but again is dying, lack of data and insurance to support.

Multidisciplinary pain is a money loser and rarely exists outside of academia. Academic pain is legit but is very different than private practice.

As epiduralman noted, patient's in large part want passive treatments as a "cure" for their chronic long term pain. They also tend to have little insight into the ongoing issues driving their pain and tend to chemically cope. I spend a lot of time on patient education, pushing PT, psychotherapy, and nonopioid med management, tapers etc. I am heavily interventional and can tell you it is not the pancrea it is advertised as for the long term management of chronic pain.

Private practice pain is largely a wasteland of trading opioid for shots or as a blockjock in the factory line algorithm of an ortho/spine surgery practice to tee up for planned surgery and dealing postop with their failed surgical patients. Also, "producing" against a high overhead.

If you think that you will be a hot shot 100% interventional pain doc, you are in for a rude surprise when your referring physicians expect that you take over the management of the opioid, muscle relaxant, benzo combo or the referral base dries up.

I experienced it, I'm ok with it , but your partners won't as they think you are "leaving money on the table " or letting good money walk out the door for not pushing up your billings through unnecessarily frequent, high volume, or poorly studied but highly reimbursed procedures .

Expectation vs reality.

What if I just want to put spinal cord stims in everybody? /s

 

[deleted875186]

Pain is exactly as described above …. Financial incentive to see high volume or prescribe meds in a patient population that will not get better. You do help people, acute radics, RFA lumbar or cervical facets, maybe low dose opioids for 80yo people with no joints left in their body, but you also get dumps from PCPs more often than not.

I will say, I don’t do critical care, but it kind of seems worse to me than the pain clinic.

 

[TheLoneWolf]

What if I just want to put spinal cord stims in everybody? /s

Implanted spinal neuromodulation interventions for chronic pain in adults - PubMed

We found very low-certainty evidence that SCS may not provide clinically important benefits on pain intensity compared to placebo stimulation. We found low- to very low-certainty evidence that SNMD interventions may provide clinically important benefits for pain intensity when added to...

pubmed.ncbi.nlm.nih.gov

Cochrane review of Spinal Cord Stimulation

Authors' conclusions: We found very low-certainty evidence that SCS may not provide clinically important benefits on pain intensity compared to placebo stimulation. We found low- to very low-certainty evidence that SNMD interventions may provide clinically important benefits for pain intensity when added to conventional medical management or physical therapy. SCS is associated with complications including infection, electrode lead failure/migration and a need for reoperation/re-implantation. The level of certainty regarding the size of those risks is very low. SNMD may lead to serious adverse events, including death. We found no evidence to support or refute the use of DRGS for chronic pain.

Pretty sad for industry funded studies once pooled to produce a small to modest benefit at best.

It's a useful tool but very overulilized.

Manchikanti et al Spinal Cord Stimulation Trends of Utilization and Expenditures in Fee-For-Service (FFS) Medicare Population from 2009 to 2018

Spinal Cord Stimulation Trends of Utilization and Expenditures in Fee-For-Service (FFS) Medicare Population from 2009 to 2018 - PubMed

The analysis of spinal cord stimulators in the FFS Medicare population from 2009 to 2018 showed explosive increases of trials, implants and overall costs.

pubmed.ncbi.nlm.nih.gov

The industry sponsored docs who make their rounds on the conference circuits keep pushing that the idea is sound but that the technology is evolving and each 1-2 years the stimulator producers release a new or novel feature. Eg open vs closed loop stims.

And yes, I have heard of a former doc who graduated from my fellowship who will do 8-10 stimulator trials on a Friday to finish their week.

 

[nimbus]

Are many pain docs recommending weed these days? Not a pain doctor. Just curious.

 

[deleted875186]

Are many pain docs recommending weed these days? Not a pain doctor. Just curious.

Never. Can try CBD for neuropathy. No marijuana while on opioids.

 

[Agast]

Are many pain docs recommending weed these days? Not a pain doctor. Just curious.

I think it depends on the state. I’m a square, so never. But there are pain docs selling CBD oil out of their clinics so it’s not a stretch to think that there are pain docs selling branded buds.

 

[epidural man]

Are many pain docs recommending weed these days? Not a pain doctor. Just curious.

I start patients on Marinol. I've been pleasantly surprised.

 

[pocafx]

We have a pain fellowship here and ~40% new consults are marijuana cards.

 

[2Fast2Des]

Met a guy during residency doing chronic pain fellowship after doing a CCM fellowship the year prior. He was a weirdo and kept talking about how great he was at anaesthesia and all, don't know what he does now but he graduated with 2 fellowships... He intended to practice both but not sure how, and sustainably

 

[nimbus]

I start patients on Marinol. I've been pleasantly surprised.

That is a blast from the past. We prescribed a lot of Marinol during my internship to stimulate appetite in HIV wasting syndrome. Most of the patients were too far gone for it to turn things around. I think back on how terrible the timing was for them. If they got the disease a few years later, many would still be alive but most of the early AIDS patients died.

 

[DiscoReinhardt]

Thank you for your replies! I guess I’ll have to choose only one.

In this case, I was wondering which has better compensation (and how much is the difference if any)? I plan to work in academia in a midwestern city for a few years, then switch to private.

 

[kidthor]

Thank you for your replies! I guess I’ll have to choose only one.

In this case, I was wondering which has better compensation (and how much is the difference if any)? I plan to work in academia in a midwestern city for a few years, then switch to private.

It’s a wash.

Just do what you enjoy most.

 

[deleted875186]

If looking for compensation, than just do general anesthesiooogy as it’s paying more at the moment.

 

[DiscoReinhardt]

If looking for compensation, than just do general anesthesiooogy as it’s paying more at the moment.

Could you give me a rough estimate of the relative compensation in each (assuming similar location, practice type, work hours)? I was under the impression that pain paid more than critical care and general.

 

[CCM-MD]

National MGMA 2020 means-
Anesthesiology 470k
Critical Care: Intensivist 450k
Anesthesiology: Pain Management 500k

Compensation will vary based on location. IMO these numbers are not very far apart from each other and shouldn’t impact your decision making too significantly. Figure out what you like to do and choose that.

 

[Status Sciaticus]

National MGMA 2020 means-
Anesthesiology 470k
Critical Care: Intensivist 450k
Anesthesiology: Pain Management 500k

Compensation will vary based on location. IMO these numbers are not very far apart from each other and shouldn’t impact your decision making too significantly. Figure out what you like to do and choose that.

There are some nuances though that one can overlook. For example, the average hours worked for anesthesiologists may be 55 hours per week compared to Pain which borders 40 hours per week. So a $$$/hour is a more apt comparison and pain comes out ahead. The compensation reports only look at professional income, but I doubt they mentioned income generated from ASC ownership.

 

[CCM-MD]

There are some nuances though that one can overlook. For example, the average hours worked for anesthesiologists may be 55 hours per week compared to Pain which borders 40 hours per week. So a $$$/hour is a more apt comparison and pain comes out ahead. The compensation reports only look at professional income, but I doubt they mentioned income generated from ASC ownership.

Theres various nuances in CCM and I’m sure anesthesia as well. But that’s as close to an apples to apples comparison as it gets. The trajectory of compensation growth is also important to consider - I’m not a pain doc, but from what I hear things haven’t been all rosy in that part of town recently.

 

[deleted875186]

I’m in northeast. Pain is saturated, and now pays less than general anesthesia. While anesthesia is more “hours”, pain full time is quite busy, especially if your seeing 25 patients or more a day as is typical in a full time pain practice. Pain is significantly less vacation. Add in the discomfort of dealing with opioids, add in note writing and administrative stuff ….

 

[deleted875186]

From my understanding of critical care, most places seem to be on for a week at a time which can be quite busy, and your in call that whole week

 

[DiscoReinhardt]

What does the future look like for CCM in terms of growth in compensation, and job availability (especially in Midwest cities)?

Theres various nuances in CCM and I’m sure anesthesia as well. But that’s as close to an apples to apples comparison as it gets. The trajectory of compensation growth is also important to consider - I’m not a pain doc, but from what I hear things haven’t been all rosy in that part of town recently.

 

[Zekchar]

What does the future look like for CCM in terms of growth in compensation, and job availability (especially in Midwest cities)?

What's that term they use during rotations?

Why don't you look that up and present it tomorrow.

Go to www.gaswork.com, click some filters, and give us a report. Don't rely on internet randos to do your own research.

 

[IMGASMD]

What's that term they use during rotations?

Why don't you look that up and present it tomorrow.

Go to www.gaswork.com, click some filters, and give us a report. Don't rely on internet randos to do your own research.