neurosurgeons doing pain medicine injections

[MitchLevi]

We've all shot ugly epidurals.

I shot an ugly bilateral L3-4 TF this AM. Huge facets with advanced stenosis.

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[Ducttape]

We've all shot ugly epidurals.

I shot an ugly bilateral L3-4 TF this AM. Huge facets with advanced stenosis.

yes, but you know when youve done one.

a lot of them dont know or dont care.

 

[drpainfree]

ortho/neuro spine doing injection in their own ASC, paid handsomely on facility fee, then proceed to discectomy/fusion/what have you, because their injection didn't work.

now you figure why US healthcare costs not skyrocketing

 

[DrMDAware]

What always gets me is how do these patients and community not figure it out?

I like to think injecting in the correct space leads to less pain and more referrals since patients are telling their friends and referring physicians see better results.

I could be wrong.

 

[hyperalgesia]

What always gets me is how do these patients and community not figure it out?

I like to think injecting in the correct space leads to less pain and more referrals since patients are telling their friends and referring physicians see better results.

I could be wrong.

There are just too many confounding variables. I think the nuance of placebo effect is underappreciated, as is how much relief people get from the systemic absorption of misplaced steroid injections.

We could probably make a "1 inch minimally invasive, laser guided incision" in the back and compete favorably with the neurosurgeons.

 

[hyperalgesia]

ortho/neuro spine doing injection in their own ASC, paid handsomely on facility fee, then proceed to discectomy/fusion/what have you, because their injection didn't work.

now you figure why US healthcare costs not skyrocketing

Yep, it's like a zoo. Too big to manage.

 

[painfree23]

There are just too many confounding variables. I think the nuance of placebo effect is underappreciated, as is how much relief people get from the systemic absorption of misplaced steroid injections.

We could probably make a "1 inch minimally invasive, laser guided incision" in the back and compete favorably with the neurosurgeons.

Had a patient today say she didn’t want an RFA bc I wasn’t using a “laser” to heat the nerve up

 

[geauxg8rs]

Had a patient today say she didn’t want an RFA bc I wasn’t using a “laser” to heat the nerve up

I can’t believe you use radio signals. So 1930s. I use the soon to be announced net gain of energy laser fusion.

 

[Agast]

Had a patient today say she didn’t want an RFA bc I wasn’t using a “laser” to heat the nerve up

Back when Laser Spine Institute was still a thing, they were advertising RFA as well. I was curious how they spun this as laser surgery; they claimed the procedure was “laser-guided.”

I think they were referring to the little red beam the C-arm shines to show you where the middle of the field is…

 

[forchinet121]

This should be reported 100 percent

 

[RoloTomassi]

If he is reprimanded and starts using lateral and going deeper, I bet he's just going to stick it in the foramen and spear the nerve if he always does under anesthesia.

 

[cowboydoc]

Recently retired guy in my area dictated his ESIs were “laser guided” referring to the pointer on the c-arm.

 

[hyperalgesia]

Back when Laser Spine Institute was still a thing, they were advertising RFA as well. I was curious how they spun this as laser surgery; they claimed the procedure was “laser-guided.”

I think they were referring to the little red beam the C-arm shines to show you where the middle of the field is…

I asked a pt to show me his op report from them. Not a single mention of laser anywhere...

 

[Ronin1]

Damn. I love that “laser guided “. May have to offer that service

 

[Ducttape]

yes just tape a pointer to the side of your c arm. easy peasy.

and if you want, tape 2 at 90 degrees apart. then you can tell the patient that this is a dual laser guided injection.

but dont do 3. thats just ridiculous.

 

[Agast]

I asked a pt to show me his op report from them. Not a single mention of laser anywhere...

Oh it gets better. I read a report where after they went in with their laser doohickey and “treated the disc” they shot a bunch of steroid in after for post-op inflammation. Everyone gets an epidural steroid injection with their laser spine surgery…..

And their positive reviews are all written within the first week of the procedure. I wonder why everyone “felt better already” hmmmm

 

[SSdoc33]

Oh it gets better. I read a report where after they went in with their laser doohickey and “treated the disc” they shot a bunch of steroid in after for post-op inflammation. Everyone gets an epidural steroid injection with their laser spine surgery…..

And their positive reviews are all written within the first week of the procedure. I wonder why everyone “felt better already” hmmmm

yeah, that was their shtick.

i boatload of local and steroids after their sham procedure. by the time the patients are in pain again, they have left florida. SMH. florida......

 

[blockstar]

my current boss is pain trained anesthesia. "sees" 90 patients a day. "injects" about 50. 20 asc surgical cases a week. I imagine this is similar to these hack neurosx. its my first job that I will be putting in notice for shortly most likely. I "only" see double booked 15 min slots and do about 15 procedures a day. not sure if this is the standard for PP pain but Im very grossed out.

 

[Doctodd]

my current boss is pain trained anesthesia. "sees" 90 patients a day. "injects" about 50. 20 asc surgical cases a week. I imagine this is similar to these hack neurosx. its my first job that I will be putting in notice for shortly most likely. I "only" see double booked 15 min slots and do about 15 procedures a day. not sure if this is the standard for PP pain but Im very grossed out.

wow and i thought i was crazy busy when i did 30/day at my block shop after graduation.

 

[RoloTomassi]

my current boss is pain trained anesthesia. "sees" 90 patients a day. "injects" about 50. 20 asc surgical cases a week. I imagine this is similar to these hack neurosx. its my first job that I will be putting in notice for shortly most likely. I "only" see double booked 15 min slots and do about 15 procedures a day. not sure if this is the standard for PP pain but Im very grossed out.

That's nuts

 

[geauxg8rs]

my current boss is pain trained anesthesia. "sees" 90 patients a day. "injects" about 50. 20 asc surgical cases a week. I imagine this is similar to these hack neurosx. its my first job that I will be putting in notice for shortly most likely. I "only" see double booked 15 min slots and do about 15 procedures a day. not sure if this is the standard for PP pain but Im very grossed out.

What keeps him from 100?

 

[MitchLevi]

my current boss is pain trained anesthesia. "sees" 90 patients a day. "injects" about 50. 20 asc surgical cases a week. I imagine this is similar to these hack neurosx. its my first job that I will be putting in notice for shortly most likely. I "only" see double booked 15 min slots and do about 15 procedures a day. not sure if this is the standard for PP pain but Im very grossed out.

What are these 20 surgical cases per week?

 

[Ferrismonk]

There are just too many confounding variables. I think the nuance of placebo effect is underappreciated, as is how much relief people get from the systemic absorption of misplaced steroid injections.

This is also a problem I see all the time from other shady pain docs.

"But his branch block lasted weeks and yours only lasted that day!" - Because he added steroids and uses 2mL of local each branch.

"His epidural worked so much better than yours!" - Because he used tons of fentanyl for sedation, tons of local and Depo in his 3-level blobogram transforaminal plus he did an under-the-table facet block and TPI.

Frustrating.

 

[blockstar]

What keeps him from 100?

sometimes he breaks 100 and gets to 120 depends on who shows up.

worst part? modeled exactly after timmy deers shop

FML

Going back to Anesthesia seeming like a warm hug from an old friend

 

[blockstar]

What are these 20 surgical cases per week?

the standard

si fusions scs drg mild pns discs kyphos

one positive i can say is very good surgeon

 

[MitchLevi]

sometimes he breaks 100 and gets to 120 depends on who shows up.

worst part? modeled exactly after timmy deers shop

FML

Going back to Anesthesia seeming like a warm hug from an old friend

I met someone who spent a year with TD and his practice is exactly what you're describing.

 

[lobelsteve]

Lab Owner Convicted in $463 Million Genetic Testing Scheme to Defraud Medicare

A federal jury in the Southern District of Florida convicted a Georgia man today for his role in a scheme to defraud Medicare by submitting over $463 million in genetic and other laboratory tests that patients did not need and that were procured through the payment of kickbacks.

www.justice.gov

Still not in this guy’s league.

 

[DrMDAware]

my current boss is pain trained anesthesia. "sees" 90 patients a day. "injects" about 50. 20 asc surgical cases a week. I imagine this is similar to these hack neurosx. its my first job that I will be putting in notice for shortly most likely. I "only" see double booked 15 min slots and do about 15 procedures a day. not sure if this is the standard for PP pain but Im very grossed out.

I believe you.

1. How does this logistically work? Don’t the patients get creeped out seeing a million people in the waiting room?

Unless there are a ton of rooms and physicians/midlevelers working.

2. They’re ok being seen for 2 mins?

I have seen the nurse (not NP) go in after the physician leaves and explain the risks vs benefits to a fairly affluent crowd. Couldn’t believe it.

 

[Asclepius186]

my current boss is pain trained anesthesia. "sees" 90 patients a day. "injects" about 50. 20 asc surgical cases a week. I imagine this is similar to these hack neurosx. its my first job that I will be putting in notice for shortly most likely. I "only" see double booked 15 min slots and do about 15 procedures a day. not sure if this is the standard for PP pain but Im very grossed out.

I’ve always wondered how these sorts of physicians obtain the mass amounts of referrals needed to even support this volume? Are they really just that great at sales and marketing?

 

[deleted875186]

sometimes he breaks 100 and gets to 120 depends on who shows up.

worst part? modeled exactly after timmy deers shop

FML

Going back to Anesthesia seeming like a warm hug from an old friend

Never a better time to switch back to anesthesia. More vacation time, equal or better pay, and life is much easier.

 

[blockstar]

I hesitate to go into the details. However its definitely very doable and not super hard if your only goal in practicing medicine is money.

But I do know for a fact TD is the master of it.

He has a four story factory with diff levels for different cogs of his machine.

Lets just say the industry has a large hand in whats going on. And it provides cover for many levels of BS.

In my lowly newbie humble position no one should aspire to this and it makes me want to throw up on our specialty.

 

[blockstar]

Never a better time to switch back to anesthesia. More vacation time, equal or better pay, and life is much easier.

I hear that! The jobs available look amazing. Just hate to give up on how much Ive put in to making it to being a pain specialist. Trying to clean up the mess and give these people
some dignity but damn its like a tsunami.

 

[deleted875186]

I hear that! The jobs available look amazing. Just hate to give up on how much Ive put in to making it to being a pain specialist. Trying to clean up the mess and give these people
some dignity but damn its like a tsunami.

How much have you put in. One year of fellowship. If the job sucks, why waste another whole year. Life is too short.

 

[RoloTomassi]

I’ve always wondered how these sorts of physicians obtain the mass amounts of referrals needed to even support this volume? Are they really just that great at sales and marketing?

Wondering the same. I imagine rural location, not a lot of competition, pills for shots ordered by mid-levels.

 

[callmeanesthesia]

Wondering the same. I imagine rural location, not a lot of competition, pills for shots ordered by mid-levels.

Referral base wise I could probably pull it off but I spend too damn long with patients (30 minute new, 15 f/u, 1-2 double-books per half day). Rural location with minimal competition, with mid levels, but no pills.

 

[drrosenrosen]

I hear that! The jobs available look amazing. Just hate to give up on how much Ive put in to making it to being a pain specialist. Trying to clean up the mess and give these people
some dignity but damn its like a tsunami.

What do you like though? If you really like and/or miss the OR, and would be happy doing that, including all the tradeoffs - call, irregular schedule, occasional life and death medicine, surgeons - then go back to anesthesia. You can always leverage your pain fellowship if you want to - get into acute postop pain, set up a pain service in your hospital, make yourself known as the guy who can do an in-hospital kypho on your day off. If, however, you really like pain, and prefer it to the OR, in spite of its tradeoffs - dealing with insurance, declining reimbursements, dealing with pain patients day in day out, less vacation - then find yourself a private practice or employed job that you feel comfortable with, and get on with making that your career. I've done both over the years, but overall I've been happy with my decision to stick with pain.

 

[blockstar]

What do you like though? If you really like and/or miss the OR, and would be happy doing that, including all the tradeoffs - call, irregular schedule, occasional life and death medicine, surgeons - then go back to anesthesia. You can always leverage your pain fellowship if you want to - get into acute postop pain, set up a pain service in your hospital, make yourself known as the guy who can do an in-hospital kypho on your day off. If, however, you really like pain, and prefer it to the OR, in spite of its tradeoffs - dealing with insurance, declining reimbursements, dealing with pain patients day in day out, less vacation - then find yourself a private practice or employed job that you feel comfortable with, and get on with making that your career. I've done both over the years, but overall I've been happy with my decision to stick with pain.

This is for sure something to think about and what Ive been thinking about.

Just kind of makes me sad seeing how some of the system works.

 

[GoBeers]

This is for sure something to think about and what Ive been thinking about.

Just kind of makes me sad seeing how some of the system works.

beauty of pain management is every practice is different... just gotta find it or start it.

 

[deleted875186]

What do you like though? If you really like and/or miss the OR, and would be happy doing that, including all the tradeoffs - call, irregular schedule, occasional life and death medicine, surgeons - then go back to anesthesia. You can always leverage your pain fellowship if you want to - get into acute postop pain, set up a pain service in your hospital, make yourself known as the guy who can do an in-hospital kypho on your day off. If, however, you really like pain, and prefer it to the OR, in spite of its tradeoffs - dealing with insurance, declining reimbursements, dealing with pain patients day in day out, less vacation - then find yourself a private practice or employed job that you feel comfortable with, and get on with making that your career. I've done both over the years, but overall I've been happy with my decision to stick with pain.

Let me just say, anesthesia is much easier than pain. Work in a hosptial with surgeons that are nice to work with, no trauma, and you have a nice work day with reasonable and predictable hours, and potentially many more days off or getting out early than you would have otherwise if your doing pain every day.

 

[Agast]

Let me just say, anesthesia is much easier than pain. Work in a hosptial with surgeons that are nice to work with, no trauma, and you have a nice work day with reasonable and predictable hours, and potentially many more days off or getting out early than you would have otherwise if your doing pain every day.

Until you’re “supervising” a CRNA who forgets to turn the d@mn gas on, or tubes the goose, or whatever screw up and suddenly your patient is brain dead and you’re on trial

 

[deleted875186]

Until you’re “supervising” a CRNA who forgets to turn the d@mn gas on, or tubes the goose, or whatever screw up and suddenly your patient is brain dead and you’re on trial

Sure, complications happen in every field. Could say the same about getting some lawsuit over opioids, maybe a complication from an injection, etc.

 

[geauxg8rs]

My fear from anesthesia, and why I did pain full time, was from PE buying out groups. Losing contract and being forced to move or work under lesser conditions than you thought?

Pain has its issues with stable employment too, with crazy bosses, declining reimbursement causing docs to want to pick hopd etc

 

[Agast]

Sure, complications happen in every field. Could say the same about getting some lawsuit over opioids, maybe a complication from an injection, etc.

The difference is, at least I’m the one who actually did the injection. I don’t mind being responsible for my own handiwork.

 

[blockstar]

The difference is, at least I’m the one who actually did the injection. I don’t mind being responsible for my own handiwork.

But are you responsible for your partners behavior?

 

[deleted875186]

But are you responsible for your partners behavior?

If you see their patients, absolutely.

If your seeing a patient that normally sees one of the other physicians you work with and Yoj refill their opioid, and they later have an issue with the opioid script, your liable.