A Look Into Community Pain Medicine

SS 133: A Look Into Community Pain Medicine

Session 133

Dr. Alex Dressler is a community anesthesiologist and pain medicine specialist. He’s been out of training now for a year and so he joins me today to dispel myths, talk lifestyle and more.

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[01:23] Interest in Pain Management

Having done research at Connecticut Children’s Center during his undergrad, he was sure he was going to do surgery or pediatric surgery. He was also convinced to do neurosurgery between first year and second year of medical school.

When he got to his surgical rotation, he had the chance to do an anesthesia elective knowing very little about it. Learning that there are small intricate niches that you can be a part of, he was drawn to the field.

For the pain side, part of him also enjoys some of the operating room procedures with patients. He realized this during his PGY-2 year in anesthesia.

[03:05] What a Pain Management Physician Does

'Very rarely are opioid medications the first thing that we jump to.'Click To Tweet

Alex explains that there are so many other adjuments and other medications for pain management. A lot of typical pain they see is back pain that goes to the arms, including nerve irritation across the spinal cord or further out.

The pain physician is taking time for physical exams through various tests to find the source of pain.

Steroid injections are very useful as well to calm down the nerve irritation and inflammation. He has patients who do fantastic three to five days after injection.

At the end of the day, it’s all about balancing those procedures with some of the other extra medications to improve people’s functional status. Opioids are useful after surgeries and in cancer pain.

[05:05] Other Specialties He Considered

Alex was initially interested in pediatric anesthesia and thought about doing a second fellowship actually.

'Having to deal with the kids and their parents during difficult times is a special skill set to have every single day.'Click To Tweet

[06:20] Typical Day

On pain days, Alex sees patients between 7:30 am and 3:30 pm to 4 pm, which is a mix of office and procedure visits. He would have patients returning for procedures.

Then they may have to delay their procedure for a number of reasons like insurance reasons, getting things approved, or if they’re on some of the different blood thinners.

He sees anywhere between 20 and 25 patients a day. Some days are mostly procedures and in such cases, he would have to see fewer patients.

[07:30] Biggest Misconceptions Around Pain Medicine

One of the biggest misconceptions is that pain medicine doctors are going to take over every prescription. They have a lot of people show up and just expect that.

'Some of the community doctors have decided they may not want the opioids as part of their practice for various reasons.' Click To Tweet

Some community doctors come to them because they’re concerned about legal precautions of some of their prescriptions. So sometimes there’s the misconception that they can automatically take over somebody’s prescriptions.

A lot of times, the first visit with somebody’s patients is readdressing goals and establishing what may be the new norm.

There’s also the misconception especially within medicine often from other doctors that the pain medicine doctors will just inject anything and everyone for financial reasons. 

[08:50] Doing Procedures

About 60%-75% of his practice involves doing procedures. That may actually be skewed towards the higher side. A piece of that is a number of patients he sees had been seen by their team of nurse practitioners prior to seeing him.

Sometimes he’ll be seeing patients for procedures but they have already had full workup and some medications trialed with their team of nurse practitioners who do an amazing job.

[09:30] The Training Path

Pain Medicine is a multidisciplinary team. For the pain fellowships traditionally, there are some coming from anesthesiology as well as from physical medicine and rehabilitation.

Neurology can be another pathway into Pain as they offer a huge resource for those with neck pain and headache pain. Other paths to the pain pathway include psychiatry and radiology.

Alex describes Pain as one of the more competitive fellowships for a number of reasons. There’s the perceived lifestyle. They spend a lot of time in the hospital and having a typical schedule draws more people into it. The neuromodulation technology side of pain also often draws in a lot of people.

'There's the potential for a lot of research within pain.' Click To Tweet

[11:40] Taking Calls and Work-Life Balance

Alex is part of a private group that covers a number of surgical centers as well as outpatient centers. He takes in-house trauma call for anesthesia typically on Saturday nights a few times a month.

'It's a mix of urgent or emergency cases that have to go during the night as well as some anesthesia coverage.'Click To Tweet

Alex thinks he has a life outside of the hospital. One of the reasons he chose pain is to have family balance. His wife is also a physician and they have two little daughters. That being said, he’s still able to prioritize family.

[13:00] Subspecialty Opportunities

Not in traditional training, but there are pediatric pain fellowships throughout the country. Within the different communities and different practices, people will gravitate towards different things.

There’s a fair amount of what people consider bread and butter pain. But there are people who subspecialize and seek further training in headache medicine and issues like pelvic pain, female pain, and oncology-related pain.

That being said, they see most of everything without really focusing too much on just one aspect.

[14:30] Bias Towards DOs

Alex thinks there are probably some programs throughout the country that still have a bias towards MD only versus the DO pathway. In his day-to-day training, it wasn’t a big split for him. Everyone was on the same level playing field. 

If you’re doing away rotations and you’re interested in pain, look at the program leadership. Look at the program attendings within the programs and just find DOs who have become leaders within the program.

'If you look at four years of anesthesia residency and there's not a single DO student, that program may not be the place.'Click To Tweet

Do your research and find places that are open to finding the best candidate and not necessarily looking for certain designations. 

[16:15] Message to Primary Care Physicians

'If you look at four years of anesthesia residency and there's not a single DO student, that program may not be the place.'Click To Tweet

They may not understand all of the interventional options they have. There’s the perception that they jump to injections but some of these injections really work. They’re able to target pain.

Things like spinal cord stimulation and peripheral nerve stimulation can now be done with just ultrasound and through needle-sized holes. These are great options for people who have dealt with pain for years and haven’t been able to get a hold of it. 

Just really understand some of the different interventional options that have even progressed over the last three to five years that may not have been around when they did initial training.

[17:15] Working with Other Specialties

They work a lot with orthopedic surgeons and ortho spine doctors as well as the general orthopedic surgeons for some of the joint pain.

Other specialties they work with a lot include neurosurgery, neurology, rheumatology, primary care, and general surgery, breast surgery, and plastic surgery, and oncology.

They also work with palliative medicine specialists. Alex emphasizes another misconception that palliative medicine can only be helpful in the last days of a patient. 

[19:45] Message to Residents

Look at the big picture. Don’t stress out about each and every test. Anesthesia is one of the specialties where there’s a lot of tests you’re going to be taking every year.

Sometimes you get wrapped up in preparing for the next test and then the next. But take a step back and ensure you’re getting the most out of each and every encounter.

'Learn from each of the patients you deal with.'Click To Tweet

Sometimes you get too wrapped up in the tests and you lose sight of why you actually want to do medicine.

[21:04] The Most and Least Liked Things

Alex enjoys the gratification he gets from treating someone and seeing results. On the flip side, what he likes the least is seeing his patients who don’t necessarily agree with what you’re recommending.

'Sometimes you have the occasional patient that you may not be the best physician to take care of them.'Click To Tweet

A big piece of this would be what the insurance would and would not approve. That said, this scenario may be changing over time.

[26:27] Final Words of Wisdom

Keep in mind what you see as your long-term goal. You will get there. There may be certain tests or classes that can get in the way but just persevere through it.

Ultimately, you will figure out the “how” to get to the endpoint. It may not be the traditional path or the path anyone else is taking but just keep on that path and you’ll get to the end result you want.

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