Resident interested in pain med.

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TeslaCoil

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Just wondering if its a good time to go into pain medicine. Love the field, but constantly hearing dooming and glooming. Thanks!


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Thats quite a trick... simultaneously typing and sitting on your hands.


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I'm not confident is a great time to go into medicine, but since that ship has sailed, I can't think of a better area of the field, personally.
 
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Mainly reimbursement cuts is what people say... but I have a hard time believing its as bad as people make it out to be...


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I've had an eye towards the pessimistic doom and gloom since I was in your shoes wondering if I should do pain and even went to an isis conference to talk to more people. Maybe it's because I've always looked for the doom and gloom that I always see it. Ive recently quit PP to join the VA and do medicolegal work on the side because of the doom and gloom. Doom and gloom only refers to admin/paperwork/lawsuits/fights for reimbursement/denials/sequestered payments/regulatory oversight/etc. this doesn't include seeing the chronic pain patients too!

I can't think of a better gig though. I never learned to be a salesman, otherwise I would do that.
 
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Just wondering if its a good time to go into pain medicine. Love the field, but constantly hearing dooming and glooming. Thanks!

So my calculus as a resident planning to apply to pain is pretty complex, as I think these decisions often are, but I can hit some of the highlights. I came into residency as a heart/lung guy, convinced I'd be doing hearts and ICU. Intern year cured me of my desire to ever do a critical care fellowship, and while I liked my cardiac rotation well enough, I wasn't appreciably happier than I was on ortho/neuro/general etc etc. This realization that I could be happy (or at least 95% of the way there) as a generalist was coupled with a growing resentment for how I'm treated as an anesthesiologist but nearly everyone, all the time. And I'm a resident- eating s*** is part of my job description now, but my personality is such that it's going to eat at me more and more. Bottom line: providing anesthesia isn't a bad gig- in fact it can be a lot of fun- but I find being an anesthesiologist near-intolerable too many days to lock myself into an OR-only career.

So when I did a pain rotation and liked it, it was kind of a no-brainer. Becoming a general anesthesiologist is still an option, but here's this whole other skill set I can use to break free of the BS of the OR, be my own boss (or at least get treated like a physician), and do some cool stuff.

A question for you is, if you like it what's the hesitation? What else are you considering? If declining reimbursements (let's make up numbers and say your potential salary is now 300k instead of 500k) is enough to scare you away, you're going to have a hard time feeling secure no matter what field you choose to pursue.
 
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Lots of factors. 300k where? 300k in NJ/ny/pa/cali is very different from 300k elsewhere. Are you married? If so does your spouse work? Do you have kids? If you live in the northeast or cali are you a homeowner? If not what kind of house would you be in the market for? Do you have loans? If so when would you like to be able to pay them off?

These are obviously rhetorical questions but you get what I'm saying..lots of factors..
 
For those in PP how do you guys keep up with all the denials/medical necessity crap? Currently in fellowship so me and the other fellows do all the grunt work but when I finish I'd love to work and just be a doctor and not deal with this nonsense. Hire a midlevel to see patients and do that crap? Have an RN write up the note and you just sign it?
 
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I really think a lot of this seems to be what part of the country you work in. My friends who work in the mid west and southeast don't deal with it nearly as much as I do
 
For those in PP how do you guys keep up with all the denials/medical necessity crap? Currently in fellowship so me and the other fellows do all the grunt work but when I finish I'd love to work and just be a doctor and not deal with this nonsense. Hire a midlevel to see patients and do that crap? Have an RN write up the note and you just sign it?

There's no way around it. It costs a lot of money to pay extra staff just to deal with that stuff, considering that it does not generate revenue.

If you really want to avoid it, work in a closed/integrated hospital system, e.g. Kaiser. Trade-off is that you will have to follow protocols/system formularies.
 
Mainly reimbursement cuts is what people say... but I have a hard time believing its as bad as people make it out to be...
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Not just reimbursement cuts. The opioid epidemic is a big part of it as well.
 
So if I were interested in applying, what are some things to know? What sort of scores do I need to land a good spot? Do I need to do research? Do I need to contact programs ahead of time? Thanks!


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id start by doing a search of these very forums and look at the information already posted...

How to make myself competitive for a pain fellowship?

How to make myself competitive for a pain fellowship?

Building a robust fellowship app PGY-1

2017-18 Pain Fellowship Interview Thread

Pain fellowship rotation?

ad infinitum... almost...
(there are 396 potential threads to review. if you review 1 thread a day, it will take over a year to look at them. a lot of info already posted. )


Totally agree with this post and the contents within. I'm a PM&R resident and was on the trail this year. I can definitely say this was an incredibly long journey. But it was also an incredibly fun experience to meet people with similar interest, see various programs and learn about the training options we have out there. I did the many of the same things above (built my CV especially in PGY-2, did pain rotations, made contacts, sought experiences, even rotated away for a month at a very well known/sought after program) and wish I found these posts earlier. In the end, I had the "unfortunate" problem of having too many interview offers, many from top/well-known/desirable programs.

Point is getting exposure will help you determine if Pain is the right career for you. Exposure comes from all angles: shadowing, research, conferences, chit-chat with pain attendings and even with alumni of your residency in Pain.

I plan on writing a full breakdown of my application and experiences as a PM&R applicant after match day to hopefully give knowledge to other pain hopefuls (I don't know which forum I'll post on). I already gave an in-service to my own co-residents who will be applying this year, but to anyone reading this and consider pain, feel free to message me.
 
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Personally, this biggest "doom and gloom" in medicine, all specialties included, is having to work nights, weekends, holiday's and being on call. The fact that Pain allows you to avoid all that completely if you choose, just like Derm (although the patients are not as difficult in Derm) makes worth considering. All the other doom and gloom, although worth keeping in mind, is minor compared to the fact that Pain allows one to have an entirely normal life. That's very rare in Medicine.
 
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Only a few months out of fellowship into a PP job, so take this with a grain of salt, but I think pain is an awesome job. Like emd said, the lifestyle is comparable to derm, known as the ultimate "lifestyle specialty." I work no nights or weekends. And coming out of anesthesia residency, the 3 major benefits of pain over anesthesia practice are:
1) autonomy
2) autonomy
3) autonomy
 
What is the realistic income potential for someone not running a pill mill or an unethical block shop? Is the pressure to prescribe absurd amounts of opioids in order to keep patients coming back and maintain a referral base a serious problem? Is there a concern going forward about declining reimbursement and insurance denials for standard interventional procedures due to "lack of evidence" of benefit? Is it possible to limit the amount of clinic you have to do weekly with the help of PAs or PMR/Anesthesiology physicians who only want to to pharmacological management? Is there going to be more incursion by Pain into the fields of Ortho Spine and Neurosurg for procedures like discectomies, etc? I would like to pursue Pain Medicine, but these are some of my concerns going forward and I would appreciate some insight from some seasoned attendings. Thanks.
 
You are being a bit contradictory. You don’t want a pill mill or a block shop but you seem interested in having a crew of helpers to rx so you can be doing procedures all day.
 
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You are being a bit contradictory. You don’t want a pill mill or a block shop but you seem interested in having a crew of helpers to rx so you can be doing procedures all day.

I would like to do only what I think people need, but I don't particularly like a ton of clinic. I like the procedures much more, but I wouldn't want to be unethical about it.
 
I'm actually worried about the extent to which I'll have to use midlevels to stay in the black. I've found I enjoy clinic, especially when balanced against some procedure time. Can't imagine picking this subspecialty if I didn't like it- why not just stay in the OR?
 
I know a lot of anesthesiologists chose the field because they don't necessarily like all the talking or clinic or paper work involved w medicine. It seems like a lot of problems involved in medicine are also present in pain? The ton of paperwork, the patient calls after procedures with questions and stuff, difficult patients etc, calling patients after procedure days to see how they are doing , billing etc etc. I'm surprised I see a lot of anesthesiologists happy in pain despite not liking the medicine life style. I guess Anes must've been really bad

You see people comparing pain lifestyle to derm. Is that really the case? How is it different than if you opened a medicine clinic as a internist lifestyle wise?
 
difference between int medicine and pain is night and day.

1. the variety - injection day vs clinic day for example.
2. the time you get to spend with the patient is much greater.
3. the fact that, as a specialist, you can say "these medications aren't good for you" and be extremely confident that you are correct.
4. some patients get better from their chronic pain. not many, but some. rarely does anyone ever get better from a chronic IM condition, be it cardiac, pulmonary, diabetic, HTN, etc.
5. its much easier as a pain doc to "discharge" a patient from a practice. just say "I have nothing more to offer, go to Ducttape's clinic." at least that's what happens around me...
 
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