Midlevel Creep

[PainDoc2025]

What is the level of midlevel creep in the field of Interventional Pain medicine? Are most NP/PAs typically hired to follow up with clinic patients? Do you see any practices where NP/PAs are doing any of the interventional procedures? Do you believe the field is more protected than other fields from scope creep? What do you foresee the future role of midlevels in the field?

Discuss

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[Dr. Ice]

What is the level of midlevel creep in the field of Interventional Pain medicine? Are most NP/PAs typically hired to follow up with clinic patients? Do you see any practices where NP/PAs are doing any of the interventional procedures? Do you believe the field is more protected than other fields from scope creep? What do you foresee the future role of midlevels in the field?

Discuss

Do a search..discussed at nauseam

 

[Ducttape]

advanced practice providers have been creeping in to interventional pain management continuously.

certain states allow these APPs to perform procedures, and there are doctors that are teaching them via courses, and "certifying" them. these "turncoats" are probably making a killing...

the field is not really protected as the major organizations are so focused entirely on maintaining reimbursement.

 

[painfree23]

Dang. I thought this post would be a bout a mid level who’s a creep

 

[DrSpine]

I actually don't think midlevel creep is much of an issue. Only thing I see most Pain Practices do is hire NPs for follow ups or to Rx Opioids. I cannot envision an NP even doing a Facet Block, Epidural, RFA, or anything of the sort. If so, most patients tend to stop short of allowing an NP to do anything invasive with them.

 

[SSdoc33]

the really sketchy practices are where the NP sees the patient, and decided which shot to schedule. the "doc" then just does the shots and the f/u is with the NP.

 

[RoloTomassi]

I actually don't think midlevel creep is much of an issue. Only thing I see most Pain Practices do is hire NPs for follow ups or to Rx Opioids. I cannot envision an NP even doing a Facet Block, Epidural, RFA, or anything of the sort. If so, most patients tend to stop short of allowing an NP to do anything invasive with them.

I've only seen a couple cases of interventional creep in my region (neurosurgeon having PA do injections, pain doc training rural PAs to do injections) but others on this forum have seen more of it.

If it becomes more common, patients aren't going to know it's inappropriate--like they don't question it when ortho has PA do joint injections.

 

[DOctorJay]

I actually don't think midlevel creep is much of an issue. Only thing I see most Pain Practices do is hire NPs for follow ups or to Rx Opioids. I cannot envision an NP even doing a Facet Block, Epidural, RFA, or anything of the sort. If so, most patients tend to stop short of allowing an NP to do anything invasive with them.

Pain Management | USF Health

 

[RoloTomassi]

Pain Management | USF Health

That's crazy. This is the interventional portion:

NGR 6473C Interventional Procedures/Simulations in Pain Management Credit Hours: 3 (Partially online)
Students must come to campus for a weekend simulation activity at the Center for Advanced Medical Learning and Simulation - CAMLS.

 

[Leukocyte]

No medical (and eventually surgical) specialty is fully immune from the creeps, as long as there are doctors willing to teach the creeps what they know for more money/profits. Unfortunately, the creeps are everywhere, and the business people in medicine (who care more about money) love them.

 

[MitchLevi]

Your avg PP pain physician can't survive without 2-3 midlevels who refill opiates, check PDMP, get urine, schedule shots and do TPI, joint CSI and bursa shots.

That is the set up; it is usually 2:1 or 3:1 midlevel to physician.

We all know great midlevels, but none should be needling the spine.

An ortho PA is more than capable of safely injecting a knee, shoulder, hip...More than capable, and that's completely within their scope of practice.

 

[Joosbocks]

advanced practice providers have been creeping in to interventional pain management continuously.

certain states allow these APPs to perform procedures, and there are doctors that are teaching them via courses, and "certifying" them. these "turncoats" are probably making a killing...

the field is not really protected as the major organizations are so focused entirely on maintaining reimbursement.

Advanced practice nurse, or midlevel provider

"Advanced practice provider" has "advanced" as a modifier to the wrong noun.

 

[Darkside_]

the really sketchy practices are where the NP sees the patient, and decided which shot to schedule. the "doc" then just does the shots and the f/u is with the NP.

Aren't there academic practices run like this? There seems to be a huge emphasis on APP education lately in certain society meetings.

 

[ateria radicularis magna]

Aren't there academic practices run like this? There seems to be a huge emphasis on APP education lately in certain society meetings.

Indeed. There have been posters at asra on algorithms for apns. Won’t be long until one of these apns moves to Washington, hires 3 apns to feed her shots and becomes a fully fledged KOL for minutemonkey.

 

[drusso]

Aren't there academic practices run like this? There seems to be a huge emphasis on APP education lately in certain society meetings.

Collaborative interdisciplinary care of patients is the future.

 

[MitchLevi]

As someone who is a patient (lots of health problems), has had a prior career working closely with PLPs, and now in my career as a physician the elusive “great” mid level has yet to cross my path..

Cool story.

I work with several.

 

[Darkside_]

Collaborative interdisciplinary care of patients is the future.

I always thought of "interdisciplinary" as collaboration between specialties to provide a well-rounded approach to patient care. I think in today's world it is a term used in a system-wide race to the bottom in order to maximize profits while devaluing physician training and expertise.

I agree that there are great NPs, PAs, CRNAs, but I will always respect the experience and clinical intuition that comes with the rigors of current medical training for physicians.

 

[drusso]

I always thought of "interdisciplinary" as collaboration between specialties to provide a well-rounded approach to patient care. I think in today's world it is a term used in a system-wide race to the bottom in order to maximize profits while devaluing physician training and expertise.

I agree that there are great NPs, PAs, CRNAs, but I will always respect the experience and clinical intuition that comes with the rigors of current medical training for physicians.

“Four legs good, two legs better! All Animals Are Equal. But Some Animals Are More Equal Than Others.”
― George Orwell, Animal Farm

 

[NJPAIN]

I always thought of "interdisciplinary" as collaboration between specialties to provide a well-rounded approach to patient care. I think in today's world it is a term used in a system-wide race to the bottom in order to maximize profits while devaluing physician training and expertise.

I agree that there are great NPs, PAs, CRNAs, but I will always respect the experience and clinical intuition that comes with the rigors of current medical training for physicians.

Well said.

 

[lobelsteve]

Re: NASS position on APN scope of practice - interventional pain/spine procedures​

Inbox

Zack McCormick​	9:13 AM (34 minutes ago)
to MD, bcc: me

All, a brief follow-up:

The NASS CME committee has officially approved the addition of the following requirements to all injections courses:

"Due to the risks associated with these procedures, NASS Interventional/Injection courses are intended only for Board Certified or Board Eligible physicians either in a fellowship training program, or in practice."

Big thanks to Allen Chen and Scott Kriener for their work on this with the NASS CME committee.

Zack

 

[bedrock]

SIS (and NASS) needs to stop allowing surgeons to do their courses as we all know well surgeons do these procedures.

 

[MitchLevi]

SIS (and NASS) needs to stop allowing surgeons to do their courses as we all know well surgeons do these procedures.

Not sure I agree TBH.

In some areas, there are no pain doctors.

My own practice has so much volume our spine surgeons combine to do around 150 TFESI per month.

 

[Ronin1]

Not sure I agree TBH.

In some areas, there are no pain doctors.

My own practice has so much volume our spine surgeons combine to do around 150 TFESI per month.

Sounds like you need a partner or two

 

[bedrock]

Sounds like you need a partner or two

Exactly. That Is a much better plan.

I have repeated countless epidurals after local surgeons did them and I have never seen a patient not do better after my epidural than after the epidural with crap technique by a surgeon.

 

[geauxg8rs]

Exactly. That Is a much better plan.

I have repeated countless epidurals after a local surgeon did them and I have never seen a patient not do better after my epidural than after the epidural with crap technique by a surgeon.

Cms has all of these garbage rules about mbb and how they are to be done prior To RFA but they have no problem with ortho Surg doing their own esi and them “failing” prior to a multi level fusion

 

[rexed]

Exactly. That Is a much better plan.

I have repeated countless epidurals after local surgeons did them and I have never seen a patient not do better after my epidural than after the epidural with crap technique by a surgeon.

I just reviewed patient records for a new consult who underwent 3 epidural injections (separate visits) by a local spine surgeon. The notes said he did a TFL at T12-L1 x 2 and a TFL at L5-S1. OP notes said he used an 18G spinal needle and injected Kenalog. All done at his surgery center of course. Patient got zero relief and was recommended for fusion at T12 and L5. BTW, her pain was upper mid back, not lower back and she had no radicular leg pain.

 

[painfree23]

I just reviewed patient records for a new consult who underwent 3 epidural injections (separate visits) by a local spine surgeon. The notes said he did a TFL at T12-L1 x 2 and a TFL at L5-S1. OP notes said he used an 18G spinal needle and injected Kenalog. All done at his surgery center of course. Patient got zero relief and was recommended for fusion at T12 and L5. BTW, her pain was upper mid back, not lower back and she had no radicular leg pain.

Wow.

 

[Ferrismonk]

I just reviewed patient records for a new consult who underwent 3 epidural injections (separate visits) by a local spine surgeon. The notes said he did a TFL at T12-L1 x 2 and a TFL at L5-S1. OP notes said he used an 18G spinal needle and injected Kenalog. All done at his surgery center of course. Patient got zero relief and was recommended for fusion at T12 and L5. BTW, her pain was upper mid back, not lower back and she had no radicular leg pain.

I wish there was some recourse we could do for this nonsense.

 

[chibadriver]

I just reviewed patient records for a new consult who underwent 3 epidural injections (separate visits) by a local spine surgeon. The notes said he did a TFL at T12-L1 x 2 and a TFL at L5-S1. OP notes said he used an 18G spinal needle and injected Kenalog. All done at his surgery center of course. Patient got zero relief and was recommended for fusion at T12 and L5. BTW, her pain was upper mid back, not lower back and she had no radicular leg pain.

So are we gonna see these images or what?