SS 17 : What is Pain Medicine? A Community Doc Shares His Story

Session 17

Dr. Fred Weiss is a Radiologist by training who did a Fellowship in Pain Medicine. However, he's going to share with us today what he likes least about the specialty, part of the reason he's not currently practicing Pain Medicine.

Let's jump right in and learn about Pain Medicine!

[01:38] Residency and Fellowship

Fred is currently an emergency radiologist at Geisinger Health System in Danville although he previously practiced as a Pain Medicine physician in Florida. Finishing his last fellowship in 2014, he's been practicing as an attending for about two years now. He actually did two fellowships, one was a half and half fellowship in Neuroradiology and Musculoskeletal Radiology, and the second was in Pain Medicine in University of Pennsylvania.

Prior to medical school, Fred was a physical therapist and he really enjoyed the musculoskeletal system and the nervous system, finding those were the easiest for him to understand, digest, and put into practice. During rotations, Fred enjoyed all the subspecialties affiliated with pain but didn't actually see himself as a surgeon although he liked interventional radiology-type procedures. So it was a matter of choosing a base specialty for going into Pain, doing neuro and musculoskeletal procedures the most.

[03:45] Traits of a Good Pain Doctor

Fred underscores patience as a major key to becoming a good Pain Medicine physician, along with compassion since you mostly see patients with chronic pain as a Pain doctor. Although right now, Fred admits that the best trait to have is patience with a political system and medical system we're currently in with all the complications going on with opioids where a lot of physicians feel like they have targets on their back. More so, pain physicians feel that the most because they're prescribing opioids considering the country is going through a national opioid epidemic right now.

[05:05] The National Opioid Epidemic

During interviews for attending jobs, Fred sees a lot of diversity in the way people practice pain medicine. There are those that practice only interventional procedures such as injections, epidurals, facet injections, Neuro Blocks, spinal cord assimilators, etc. On the opposite end of the spectrum, there are those that only prescribe pain medications and when you only do this type, there are only a few classes of medications being prescribed including opioids. And there are those people doing things in moderate amounts of injections and pain medications.

There's a lot of heterogeneity in the way people practice and there are people who abuse these medications and seek them while there are those who really need it and those who don't. Fred finds how difficult it is not just on a day-to-day basis, but also, on a patient-to-patient basis to figure out who's a good candidate for certain medications and for certain procedures, and who would respond to what.

[06:46] Ways to Get into Pain Medicine

In the physical therapy world, Fred's specialty was manual therapy as he enjoyed putting his hands on someone to make them feel better either for mobilization or for therapy purposes, similar to osteopathic medicine. It drew him toward that especially that he found success in those sort of techniques so he wanted to carry it over to the Pain Medicine field. To some extent, he was fairly successful in getting patients off pain medications by simply using manual therapy techniques and other modalities. Fred is not an osteopathic physician. He actually applied to nine osteopathic medical schools and got rejected from all of them. Instead, he got accepted to an allopathic school.

When he was in medical school, there were a limited number of specialties eligible for Pain Medicine Fellowship such as Anesthesiology, Physical Medicine, Neurology, and Psychiatry where he has done rotations in all of those. When he did his rotation in Radiology and met an interventional radiologist who did a bit of pain management procedures, he decided to go into Radiology, then do Interventional Radiology, and do the pain part of it. But when he went into Radiology while doing interventional rotations, he found that the only part of it that he enjoyed were the pain procedures. So he wanted to do a Fellowship in Pain Medicine.

Along the way, he met his mentor who is a neuroradiologist and a neuro interventional radiologist at UC San Diego, who was actually the first radiologist to become board-certified in Pain Medicine. What he actually did was apply for fellowship in UC San Diego where he was already part of the faculty, completed the fellowship, and was able to be boarded under the American Board of Psychiatry and Neurology. The institution then sponsored him for the exam to get certified. A few years later, another physician did the same thing but he was sponsored by the American Board of Physical Medicine and Rehab.

However, there was a lot of political change happening in the field of pain management around the time he applied. The Anesthesiology board was simultaneously closing and opening options and required physicians to have their primary boards sponsoring the examination. Consequently, Fred appealed to the American Board of Radiology (ABR) and had multiple organizations rally around this and lobby for pain medicine to become an official subspecialty of Radiology since many of the procedures were even invented by radiologists. So he wrote an 80-page application for the ABR and then to be submitted to the American Board of Medical Specialties (ABMS) and were successful in getting Pain Medicine to become an official subspecialty for Radiology. Other boards that applied included the American Board of Emergency Medicine and the American Board of Family Medicine. As a result, pain medicine is now an official subspecialty of those skills as well.

[12:12] Types of Patients

Pain Medicine physicians treat patients across the board from the developmental spectrum treating patients, children and adults alike. When he was in Florida, Fred was treating mostly 80-year-old females with back pain and neck pain as the most common issues.

The youngest patient he has treated was a eight-year-old for a chronic pain, biomechanical issue due to pes planus (flat feet) where he gave her a few exercises (incorporated with martial arts exercises being a black belt himself) and prescribed no medications. She was pain free after a month.

[14:40] A Typical Day: Clinics and Procedures

Fred's typical day depends on whether it's a clinic day or procedure day. If mixed, he would see about 15-20 patients between 8am -12pm. Then do a 10-minute follow-up on someone he did facet injections previously. Other patient are those with chronic regional pain syndrome where he would do regional blocks or ultrasound-guided like stellate ganglion block. He also treats chronic ankle pain where he injects joins with ultrasound guidance. Fred describes his typical day as similar to sports medicine clinic day.

On his procedure, he would usually have epidurals, facet injections, nerve blocks that are image-guided under fluoroscopy. His nurses would then bring patients in from the waiting room to have them prepped and ready to go and doing procedure after procedure. Fred also adds how patients would cry and give you a hug after they've treated you and they're pain-free which is very rewarding for him.

Fred performs procedures on 60%-70% of his patients since a lot of patients will respond to physical therapy. Being a physical therapist, he has a general idea of who responds well to it or who may need a little push like an injection to give them temporary relief in order to be able to tolerate more physical therapy. While there are also patients who flat-out refuse to go through physical therapy which he finds pretty challenging. He further explains that injections are only temporary for the vast majority of patients and what helps long-term is physical therapy and rehabilitation. This is reflected in the newest guidelines where physical therapy and exercise modalities are the first line of defense rather than prescribing opioids or doing injections.

Fred remembers one of his deans who taught in primary care class that there is no evidence for physical therapy prescribed for back pains and now it's come to a complete 180 degrees which he thinks as much more appropriate.

[19:05] The Role of Injections

With a lot of theories on how injections work, Fred points out that reducing inflammation is one of them. He also adds being a radiologist poses an advantage who are able to figure out what types of patients can respond really well to steroids coming from a perspective of decreasing inflammation. However, most of the time, physicians don't see much inflammation going on but there is remodeling or irritation of bone-on-bone arthritis and those patients respond to a combination of local anesthetics and steroid since the steroid will allow the local anesthetic to last longer, where the duration of which varies from patient to patient.

One of the challenges they have in pain medicine is really figuring out who is going to respond the best and the most to the procedures that we do for the best bang for their buck. Fred can actually figure things out based on what he can see on the MRI.

[21:23] Taking Calls and Work-Life Balance

For outpatient pain, you don't take any calls. In the practice he was in, he would take calls Mon-Fri/8-5 and no call on weekends. If patients had issues, they were instructed to call the emergency room or the primary care doctor and follow up during daytime hours with their office if the issue is really urgent.

As pain doctor, your work-life balance basically depends on your practice setting. If you're just opening a private practice, you will be developing your practice so you have to put your heart, soul, gut, and time so you probably won't have any vacation. But on a typical steady state, you get to have your 3-4 weeks of vacation per year, work Mon-Fri, 8-5, and no call on weekends.

[23:10] Different Pain Fellowships and Matching

Fred explains that the process for fellowships is unifying more and more every year where it's the same umbrella and category of fellowships, largely housed in Anesthesiology academic programs throughout the country, with only six or seven are currently in Physical Medicine and only one or two in the Neurology department. Everyone is applying for those fellowships and depending on the department, there is some bias as to whether it's calculated or not in terms of taking a certain number of anesthesiology or PM&R residents for their program. For instance, for anesthesiology, you can apply to any program and that's fine but if you're in PM&R, only a certain of spots are allotted for some fellowships.

Moreover, Fred describes matching as very competitive in that back in 2015, 65% of those who applied ended up matching which means 35% did not match, quite a large percentage of people.

[25:18] How to be a Competitive Applicant

If you're in Anesthesiology, Pain Medicine is already built into your program where you will be doing a couple months of it irregardless. In order to be a competitive applicant, you have to go in rotations, work hard, show some interest, and a get as much hands-on as you can. Ask for it. Sometimes you even have to beg for the fellows to give up their procedures or work directly with the attending to do some procedures. Other ways to be competitive is to get involved in research and doing a presentation for society meetings to show some initiative and to show the attending physicians that you're willing to put a little extra work in it as there is really not that much work to put in.

If you're a PM&R resident, seek out pain doctors who are fellowship-trained for this process. Get to know them and get their tips. Get their connections. A lot of times, it's not necessarily what you know but who you know. So really network as much as you can. Fred gives the same advice to the Anesthesiology resident to put an extra effort to do a little bit of research and get to know the people in your department and work with them.

[27:05] Pain Medicine Subspecialities and Boards

As part of the training, you basically do some hospice palliative care training so you can work in that type of setting. So you can also do a subspecialty in Cancer Pain, which is a lot of opioid management but nothing to worry about patients getting chronically addicted because they really won't live that long so it's really just for palliative care. The procedures tend to be more complicated with cancer pain patients. Additionally, opioids don't have a complete effect for relieving their pain so they have to get intrathecal opioid pain pumps, another type of procedure which is very effective in cancer pain.

Just like any board exam prep, you're going to have to study and work hard. But because only a few people talk about pain medicine boards in general, there's this fear about them. For those in pain fellowships right now, Fred suggests that it's almost identical to the process of taking the in-training exam. So if you did well on the in-training exam, you're going to do well on the boards. There are books available online (some for free) that you can download and do those questions. There are also question banks online that you can practice on but they are fairly expensive and Fred thinks they're only marginally useful. Overall, you can do this easily with just a free book.

[30:08] Primary Care and Other Specialties

What Fred wants to communicate to, not just primary care physicians, but also to all fields referring to pain medicine, that pain medicine does not equal opioids. Pain medicine equals a comprehensive management for pain that's both behavioral, procedural, medical, and rehab. Fred often encountered patients who'd say they've been referred to him by their primary care doctor because it's illegal for them to prescribe it. The truth is that it's never illegal for a primary care doctor to prescribe opioids but the bottom line is that opioid care is not good pain care. It requires procedures and rehab and other types of medications that are much better for pain.

Therefore, if you're going to refer to Pain Medicine, Fred believes that patients need to have a clear expectation of what to think and what they're going to receive on the first day and it's certainly not going to be a controlled substance.

Other specialties Pain Medicine works the closest with include Neurology, Neurosurgery (for nerve blocks), Orthopedics (for chronic knee pain), and Primary Care referrals.

[32:30] Special Opportunities Outside of Clinical Medicine

As in any field, you can do medico legal consulting as well as present for various pharmaceutical companies but there could be a lot of ethical issues involved so you want to make sure you're not only pushing the drug but that it also works for your patients. Several pain doctors also open their own surgical centers.

[33:33] The Emotional Aspect of Pain Medicine

Going in from radiology which is really cognitively challenging throughout the day, Fred finds pain medicine as less cognitively challenging because you have already practiced patterns for step-by-step management so the cognitive aspect is not there as much as the emotional aspect. It is very emotionally challenging throughout the day. 20% of Fred's patients do really well, while some do neutral, a chunk of them just don't get better. What Fred wished he would have known before entering this field is how emotionally taxing the practice can be throughout the day as you will be seeing a lot of patients crying and feeling hopeless. And on top of the chronic pain, patients also have financial issues and even on top of that is the absence of physical therapy practices that took Medicaid. In fact, a lot of the procedures he offered that he thought would be best for patients were not covered since the organization he worked for did not believe in free care so he was not allowed to provide those procedures.

In the end, his patients were stuck taking medications they didn't want to take because that was the only option they had, some stuck with opioid medications because that was the only class of medications that their insurance company or Medicaid would cover.

Sadly, a fairly large part of our country has been addicted to prescription opioid medications. This is one of the reasons Fred went back to the practice of Radiology because he didn't believe in this process that is self-feeding and defeating at the same time, making the problem worse than better.

On the other hand, what Fred likes the most about Pain Medicine is seeing his patients get better especially when he's able to bring the two skill sets of Radiology and Pain Medicine together. Patient get better with the right diagnosis and the right directed targeted treatment.

If he had to do it over again, Fred would still have chosen Pain Medicine despite all the political issues being that it's a fantastic and rewarding field because it challenges you on every level.

[38:44] The Future of Pain Medicine

What Fred sees on the horizon is more technology dedicated to things like spinal cord stimulation, a device implanted subcutaneously that create electronic bursts to block pain signals. These types of technologies would come forward in the algorithm of treating patients earlier with higher end procedural intervention rather than doing medications, steroids, and local anesthetics on a frequent basis.

Stem cell therapy is another thing that he sees having a lot of potential. As more research comes out, there's going to be niche indications for certain types of stem cells to be injected into various nerves, joints, and tendons that will stimulate healing.

[40:25] Final Words of Wisdom

If you really want to do this despite the political climate, go for it. At the end of the day, you're going to be extremely well-rewarded for the work that you do. The patients are going to love you and get tons of Christmas cards and hugs. It's a very rewarding field but it takes a lot from you cognitively, emotionally, and physically but at the end of the day, it's well worth it.

Links:

ryan@medicalschoolhq.net

Geisinger Health System

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