Dr. Matthew Kohler is an interventional pain & regenerative medicine specialist. Today he shares his experiences on the frontier of a rapidly advancing field.
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[01:00] Update on the USMLE Step 1 Going Pass/Fail
Just to give you an update, USMLE Step 1 went pass/fail. You can go back to previous episodes where I asked program directors about how this would affect their scoring. Some of them said they didn’t know yet. And some said it really wouldn’t because they look at every application anyway.
A lot of these programs don’t get that many applications. There are obviously going to be some of the programs getting a ton of applications. But for a lot of programs, they’re looking at around 500 to 1,500 applications. It’s pretty easy to go through that many applications relatively quickly if you’re looking for very specific things outside of the objective USMLE Step 1 score.
Step 2 is still scored, which I don’t agree with personally. If they changed Step 1 to pass/fail then they need to change them all to pass/fail.'It's still way too early to have this discussion on how Step 1 going pass/fail is going to affect your ability to match into a competitive specialty.'Click To Tweet
There are still so many variables in your residency application. So please don’t that you only have to go to the best MD schools and that you shouldn’t go to a DO school. Or you shouldn’t go to your state school. There are still so many options out there for you. There is still lots of data we need to collect on how this is going to affect students in the future.
[03:55] Check Out Bad Batch
The podcast network Wondery did a podcast called Bad Batch. It’s about the regenerative medicine field, particularly about the topic around stem cells, and about one company that had some shenanigans that hurt a bunch of people.
It’s the same company that did Dr. Death Podcast about Dr. Christopher Duntsch, a neurosurgeon who was convicted for medical malpractice and now behind bars.
[04:450] Interest in Pain Medicine and Regenerative Medicine
Matthew got interested in pain medicine during fourth-year medical school while doing rotations with anesthesia and a week or two in the pain facility.
He initially loved anesthesiology and as he went through residency, he got more and more exposure to pain medicine. He fell in love with long-term patient interaction. He liked doing cutting edge therapy and interventions. He also loved the lifestyle of the field being able to spend time with family and friends. And be able to pursue different passions.
Regenerative medicine is finding ways to supercharge your body’s own processes. They try to help people recover from injuries or degeneration by using PRP (platelet-rich plasma) or stem cell injections.'It's a way to get people feeling better without the use of things that can potentially be harmful.'Click To Tweet
With this type of therapy, you do away with things that can potentially be harmful. These include anti-inflammatory medications being used long-term as well as opioids and corticoid injections.
There are studies coming out suggesting that intra-articular injections, in particular, can cause accelerated degeneration of cartilage and the joints. In the long term, you may actually be doing more harm than good with these.
It’s trying to find more sustainable, long-term ways to get people better is what ultimately drew Matthew to the regenerative medicine area.
[08:05] Biggest Myths and Misconceptions Around Regenerative Medicine
Matthew reveals that Google has actually prohibited doing AdWords for regenerative medicine. They won’t allow you to do paid ads. The reason for this is because there are a lot of claims about the benefits of certain types of regenerative medicine.'In the U.S., it's a very closely regulated thing. PRP and stem cells have to be really extracted and injected in the same patient visit.'Click To Tweet
It’s not like places in the Caribbean or Panama where they can actually process these stem cells in a lab and grow lineages. They can have a proven lineage from embryonic stem cells. The U.S. doesn’t allow this at this point.
But there are companies marketing these stem cells from Wharton’s jelly. But the problem is that they’ve been found to be basically non-viable. So they’re not really doing anything when you inject these.
And so these companies go around to doctors and chiropractors doing injections and feed them this information. Because it’s a new field, people buy into it and they pass it along to patients sometimes.
There have been some cases of pretty serious complications from this. Some were doing intraocular injections with stem cells at one point that caused blindness.'There's this risk and a lot of misinformation and misunderstanding in the community about how they use these and what's effective and what's safe.'Click To Tweet
All this being said, there’s a lot of very good research about how to process these PRP and stem cell modalities. They try to optimize how they administer these to patients and how to do it in a safe and effective manner.
One of the companies they’re currently aligning themselves with is Regenexx. They’re doing a lot of the research right now that is moving the field forward. They’ve got lots of good data and anecdotal evidence that it’s helpful for patients.
Until they have this big multidisciplinary studies that show level 1 evidence, it’s going to be tough to get this covered by insurance.
[12:50] Types of Patients
They’re seeing patients with mild to moderate osteoarthritis, which is the most well-studied. Other cases that respond very well are tendon tears like on the Achilles for example, as well as for intradiscal issues.
For these cases, imaging is a very important aspect of determining whether someone is a good candidate or not. But in most cases, most patients see them for joint degeneration and joint injuries.
A lot of patients come to them as sort of their first stop. They typically have this back or pain issue. But a lot of their patients are also coming from referrals from internal medicine specialists, orthopedists, and neurologists or neurosurgeons. Those who come across these issues but don’t necessarily want to jump to treating them with surgery, they come to them first for evaluation. They want to see other options to help avoid surgery.
[15:44] Ratio of Procedures to Evaluation
Matthew takes a pretty conservative approach to management for patients, typically recommending conservative treatment whenever possible for every patient.
If someone has an acute herniated disc and can’t walk, he could make a quick treatment like a steroid injection to get them feeling better.
A lot of people would also come in with pain and they’re still able to walk and do their job but at some point, it’s distracting them. They feel uncomfortable and unhappy throughout the day. For these patients, Matthew essentially lays out all the possible options, throwing all the risks and benefits of everything.
[17:40] Typical Day
Matthew is seeing around 25-30 patients in a day, 5 of which are new patient interactions while the rest are followup visits. They have a procedure room in their office where they can provide injections for patients. And if they’re able to get same-day authorizations, they can get the patient in and do the procedures in the office.'Most of the pain medicine procedures are pretty quick.'Click To Tweet
An epidural procedure can take about 5 minutes. Radiofrequency is a little longer for about 10-15 minutes. They can do these procedures throughout the day without disrupting their workload too much when they’re consulting.
In terms of patient relationships, they get both long-term and short-term patient care. Some do a one-time visit where they come in to feel better and decide not to follow up.
Sometimes, they can also have a long-term relationship. As long as you’re available to them and taking their insurances, a lot of them can go to you for long-term care.
One thing you have to know about these injections is that they don’t last long term. And if you have a patient with a severe, degenerative spine condition, it’s unfortunately not a reversible thing that’s going to get better. So it generally requires some follow up treatments every several months to keep them functioning.
[21:15] Taking Calls and Life Outside of the Hospital
They don’t take that many calls. They’re not necessarily required to go into the ER. As they usually handle cases that can wait until the next day unless it’s a serious emergency. So it’s really not bad. Their hours are generally Mondays through Fridays, sometimes Saturdays.'It's rare that we get any calls after hours.' Click To Tweet
That being said, they have a great lifestyle. Matthew thinks the field is very conducive to a life outside of the hospital. You can basically set it up however you want to.
With pain medicine, there’s acute inpatient pain medicine which a lot of doctors do. They go do rounds in the hospital and manage nerve block epidurals and medications and drips. This requires more in-hospital call versus just doing purely outpatient which Matthew does.
He does mostly interventional outpatient regenerative medicine. Because of this, he has a very good schedule where he doesn’t have to go to the hospital as much.
[23:50] The Training Path
There are multiple pathways to regenerative medicine. A lot of different specialties are incorporating PRP and stem cells into their practice including the orthopedics and the O.R.
Most fields get some exposure to regenerative medicine. But the fields that have the most exposure are the interventional fields – orthopedics, physical medicine & rehabilitation, anesthesia-based pain medicine. Matthew thinks these are the best pathways for incorporating this into your practices.
They do the PRP and the stem cell injections as intervention-based sports medicine and chronic pain implementations. So these are the specialties that get the best exposure to it.
[25:40] A Message for Students Interested in Regenerative Medicine
Matthew would not recommend going all-in with regenerative medicine. It’s not because he doesn’t think it’s a very strong field and there’s not much evidence. It’s there, but it just takes some time for this to develop.'At this time, the trajectory is less clear as to how long it's going to take to get there.'Click To Tweet
Insurance-wise, this is an issue too. The procedures can be relatively expensive and it’s unavailable to everybody. This is frustrating for Matthew because he sees patients from all economic backgrounds and demographics. Unfortunately, it’s not available for everybody at this time.
When done appropriately, these are very way lower risky than doing steriods and a lot of medications being utilized in pain medicine.
And people are already starting to come around to this and realize that it’s a better way to get people back on their feet without causing any long-term harm.
The future is great but for now, there are still a lot of questions as to how long this will take to get to a place where they can offer this to everybody.
Hence, students looking into this field have to consider diversifying their practice and make sure they’re doing other things too until they can offer this to everybody.
[28:00] Message to Primary Care Physicians
It’s a matter of dicussion around the treatment modalities available for diferent types of pain problem. They have a lot more of options becoming more available to them to help these patients.
There are advances coming along where they can now offer safer medications and safer injections that won’t affect a patient with diabetes or hypertension, for instance, where steroids can worsen their symptoms.'We're doing procedures that can help without affecting those other co-morbidities.'Click To Tweet
Neuromodulation is another exiciting area in pain medicine. These are the spinal cord stimulators and peripheral nerve stimulators that inhibit pain signals in patients.
These are great for patients with chronic pain issues like failed back surgery syndrome or CRPS or peripheral diabetic neuropathy.
[30:25] Working with Other Specialties
Specialties they work most closely with include spine surgeons, orthopedics, neurology, rheumatology, and internal medicine.'Not talked about enough in pain medicine is the psychosocial component.'Click To Tweet
Matthew actually refers a lot of patients to pain specialty therapists who can do behavioral therapy and other kinds of modalities that can help with the psychosocial aspect of a patient’s pain syndrome.
[31:55] What He Wished He Knew that He Knows Now
Matthew explains that the patients in pain medicine aren’t really that bad. As he was going through medical school and residency, he heard they were going to have a difficult patient population.
But once he got out into practice, he realized it’s such a small percentage of dealing with difficult patients. He found he has so many awesome patients and found every interaction to be gratifying.
It’s something he wished he had known earlier on that he could have very rewarding relationships.'The patient population is challenging but it's not bad by any means.'Click To Tweet
[32:55] The Most and Least Liked Things
Matthes loves having the ability to be on ther verge of something up and coming. He’s excited about the possibility of the field becoming more refined in the future and be able to offer something that’s very specialized for patients.'There's a lot of promise for getting people better without really doing harm to them.' Click To Tweet
They’re learning about how people can use their own bodies’ healing factors and get them feel better and recover from injuries. They’re seeing how this can help reverse signs of aging and joints, tendon, and ligament injuries. It’s a very exicting place to be right now.
On the flip side, what he likes the least about the field is the fact that not many insurance insurance is covering it at this point at all. Worker’s comensation will sometimes cover it.
Commerical insurance companies obviously don’t cover it. And having to have that conversation with patients can be tough sometimes.
There’a lot of interest in it from patients but when you have to go over pricing, it takes this away from Matthew’s desire to help everybody.
[36:10] Major Changes in the Future
Having a precision-based approach to injecting these therapies is very important. When they’re doing the injections, they’re looking at MRIs and looking at exactly where the injury is. They use ultrasounds and xrays to help guide the injections to the specific site of injury.
So when they take a person’s stem cells, they process it in a centrigure. They find the optimal concentration. The same thing with PRP. Then they do these precision-based injections to maximize the effect of the treatment.
The next step is just trying to optimize how these cells are processed. This is to maximize the release the cytokines and communication factors that help signal to heal the area to be injected.
They want to be able to create an environment where you inject those cells and they’re differentiating into the type of tissue you want them to. And there’s a lot of research being done on this right now.
[38:05] Final Words of Wisdom
If he had to do it all over again, Matthew would still have chosen the same field. He loves his job. Again, he finds the long-term relationships to be very gratifying. The modalities right now are helping them reduce the amount of opioids being described.'People getting better by healthier means is a very exciting place to be right now.'Click To Tweet
Finally, for those students who are looking to get into this field, feel free to reach out to Matthew. Visit Regenexx to know more about more studies being published.
Just try to get exposure as early as possible. Find some doctors in your area that are providing this for patients.
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