Pain Medicine is an Official Subspecialty of Emergency Medicine

[BoardingDoc]

Starting compensation for my major metro area pain job is about on par with EM salaries in the area. Difference is, assuming things go decently, that is my floor whereas EM pay is rather stagnant. The ceiling is much higher than local EM pay. Finding the job was pretty tough, much harder than getting an EM job, however.

Ballpark numbers for comparison? Happy to share as a point of reference.

I'm in a high COL large metro area.

Local EM gigs around here pay around 300k - 350k / yr for typical workload. I'm in a unique gig that puts things more in the 425k-500k total comp range. Pain docs around me are getting base salary offers of around 280k with productivity putting them at around 400k (from my small sample size where I know specific numbers). I know that elsewhere that number can be much higher.

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[GatorCHOMPions]

Ballpark numbers for comparison? Happy to share as a point of reference.

I'm in a high COL large metro area.

Local EM gigs around here pay around 300k - 350k / yr for typical workload. I'm in a unique gig that puts things more in the 425k-500k total comp range. Pain docs around me are getting base salary offers of around 280k with productivity putting them at around 400k (from my small sample size where I know specific numbers). I know that elsewhere that number can be much higher.

EM pay around me is like $200/hour employed and $215/hour IC. Pain starting salary is like 300-350k. In hospital based work you can expect $60-65/RVU. From what I’m told it’s fairly easy to hit like 8k RVU after a couple years in practice, and 10k if you work in a busy/efficient system, excluding benefits. In private practice there is a lot of variability with in-network vs OON billing, % collections you’re given, and ancillary revenue streams among other things. An average job looks something like base salary x2 and 35% collections after that (ex. 300k salary and 35% collections above 600k). In the worst case scenario you should clear 350k after 1-2 years of practice. Anecdotes from non-partners of jobs I’ve interviewed with and some personal contacts say you can reach 400-450k without much of a problem, and a lot more depending on exact setup.

 

[HemorrhagicShock]

@GatorCHOMPions Aside from the lifestyle improvements (8-5, no weekends, no holidays, etc) how have you enjoyed pain medicine thus far? Are you liking the day-to-day better than EM? Do you ever find yourself meaningfully missing the ED? Or is it more of a nostalgia that you move on from quickly because the pain medicine situation is so good?

Just wondering if this is a reasonable move for me!

 

[GatorCHOMPions]

@GatorCHOMPions Aside from the lifestyle improvements (8-5, no weekends, no holidays, etc) how have you enjoyed pain medicine thus far? Are you liking the day-to-day better than EM? Do you ever find yourself meaningfully missing the ED? Or is it more of a nostalgia that you move on from quickly because the pain medicine situation is so good?

Just wondering if this is a reasonable move for me!

I don’t think I have quite enough Pain experience to make a final judgment, but so far so good. The average day is better. I’m not about to say it’s all roses and unicorns, though. I do miss EM sometimes. I’m doing per diem to quench the occasional thirst and maintain skills.

 

[Birdstrike]

Yet, another:

“After reading virtually everything you have posted about transitioning from EM to pain, I started shadowing some pain docs and realized this was what I wanted to do. Everyone I spoke to said it was impossible…This morning I matched at my number one program.”

 

[namethatsmell]

While pain is not all sunshine and rainbows, it can be pretty satisfying.

You can't hit the rare EM homerun of bringing a coding patient back w/a neuro-intact discharge, but you can hit far more doubles and triples. A small proportion of the patients are miserable, but most range from benign to pretty pleasant. And you can actually help many of these patients. I get roughly 3425% more "thank you doctor" during a pain clinic day than a month in the ED and sometimes a patient will leave a small gift at the office. There are times I miss the variety of pathology and wackiness of EM, but that's tempered by trying to keep up with the evergreen pipeline of new pain treatment options or methods for doing things. Keeps things interesting enough.

Biggest key to pain is finding the right job/practice setup, which can be tough depending on geography. Some places operate too loosely with meds, push procedures inappropriately, or pay you peanuts--or all 3. If you can find a job where none of these 3 apply, it can be incredible.

 

[TrailRun]

Could you share some of the typical patient complaints you can actually help? I’m imagining a lot of fibromyalgia, or pain 2/2 obesity that there’s not much that can be done

 

[Groove]

It's nice to see several of you guys moving over to pain. I wish I could get interested in the idea but I just can't bear the thought of dealing with that pt population day in day out no matter what the schedule. I find it really odd that so many people seem to show interest in the field and can't help but think it's just a symptom of burn out in EM. 90% of my angst with the specialty is schedule and circadian rhythm disorder related. Unfortunately, I'm in a group where 37% of my shifts are overnights. Although I can deal with it since they are all blocked together, I won't lie that it sucks. However, if I were desperate enough for something different, I feel it would be much easier to shop around for a gig with a full set of nocturnists where I only had to do 1-2 overnight shifts a month. That would be cake and so much easier to buy into than ejecting myself from an entire specialty and careers worth of experience/mastery to do something else entirely that I was never interested to do in the first place...merely so I could have a 9-5, regular schedule type of job. It just seems desperate to me. We deal with the chronic pain pt's all day long during a regular ER shift. I know they can't be somehow magically different in a pain office compared to the ER. They are an absolutely miserable bunch to deal with in the best of circumstances. Half of them have legitimate pain disorders and half of them didn't get enough hugs growing up and a sizable component of their pain disorder is supratentorial and psychiatric. I know a bunch of you like to say you are in practices where you don't write for narcotics or minimal narcotics but c'mon now.... You and I both know that's not reflective of the majority of pain clinics, nor is it a recipe for job security as a new pain doc, nor is it how you get into the top 5% percentile of pain compensation or how you grow your practice the fastest.

It seems to me that it would be far easier to shop around for an EM job with a full complement of nocturnists vs shopping around for a healthy pain practice that does minimal narc writing. Am I wrong?

Regardless, with EM applications down and some of you running off to do pain, I suppose it bodes well for the rest of us staying in the trenches. Hopefully it stabilize salaries or even brings them up a bit. Maybe I'm just jealous of the idea that I would be so much happier practicing pain compared to EM but damn.....I really doubt it. I guess I'll never know.

I am genuinely happy for all you that made it though. Just...incredulous, I suppose.

 

[GatorCHOMPions]

Could you share some of the typical patient complaints you can actually help? I’m imagining a lot of fibromyalgia, or pain 2/2 obesity that there’s not much that can be done

Axial low back pain, SI joint pain, radiculitis, failed back surgery syndrome, osteoarthritis (particularly like the successes in knees with radiofrequency ablation or RFA), myofascial pain, occipital neuralgia, CRPS, spinal stenosis, and the list goes on. Now most of the time you aren’t hitting home runs, adding years of pain free existence, like the previous poster noted. However it’s very common to get patients performing more ADLs, stating they haven’t felt this good in years, etc. for several months. Some patients get injections a couple times a year for several years because they are happy with the results of therapies.

It's nice to see several of you guys moving over to pain. I wish I could get interested in the idea but I just can't bear the thought of dealing with that pt population day in day out no matter what the schedule. I find it really odd that so many people seem to show interest in the field and can't help but think it's just a symptom of burn out in EM. 90% of my angst with the specialty is schedule and circadian rhythm disorder related. Unfortunately, I'm in a group where 37% of my shifts are overnights. Although I can deal with it since they are all blocked together, I won't lie that it sucks. However, if I were desperate enough for something different, I feel it would be much easier to shop around for a gig with a full set of nocturnists where I only had to do 1-2 overnight shifts a month. That would be cake and so much easier to buy into than ejecting myself from an entire specialty and careers worth of experience/mastery to do something else entirely that I was never interested to do in the first place...merely so I could have a 9-5, regular schedule type of job. It just seems desperate to me. We deal with the chronic pain pt's all day long during a regular ER shift. I know they can't be somehow magically different in a pain office compared to the ER. They are an absolutely miserable bunch to deal with in the best of circumstances. Half of them have legitimate pain disorders and half of them didn't get enough hugs growing up and a sizable component of their pain disorder is supratentorial and psychiatric. I know a bunch of you like to say you are in practices where you don't write for narcotics or minimal narcotics but c'mon now.... You and I both know that's not reflective of the majority of pain clinics, nor is it a recipe for job security as a new pain doc, nor is it how you get into the top 5% percentile of pain compensation or how you grow your practice the fastest.

It seems to me that it would be far easier to shop around for an EM job with a full complement of nocturnists vs shopping around for a healthy pain practice that does minimal narc writing. Am I wrong?

Regardless, with EM applications down and some of you running off to do pain, I suppose it bodes well for the rest of us staying in the trenches. Hopefully it stabilize salaries or even brings them up a bit. Maybe I'm just jealous of the idea that I would be so much happier practicing pain compared to EM but damn.....I really doubt it. I guess I'll never know.

I am genuinely happy for all you that made it though. Just...incredulous, I suppose.

The night free gig doesn’t exist where I live, or want to live. I also genuinely missed long term continuity of care and patient appreciation. You’re largely wrong about the pain patients in a pain clinic vs the ER. It’s not entirely night and day but pretty close. Some of the most pleasant patients I’ve seen are those on chronic opioids. You may not realize how effective a clinic screening process is, the fact that we aren’t bound by EMTALA, visits being confined to 30 mins for new patients and 15 mins for follow ups, and the general chaos and dysfunction that an ER exudes that just festers bad behavior in patients. As a pertinent example, all patients in pain clinics should have opioid contract agreements signed if they’re on opioids. Violation = d/c from practice, or at least a firm warning that next time is d/c. Lot less nonsense and concerns about dispo and liability in a pain clinic.

 

[bravotwozero]

Yeah that’s the key as a counter argument to @Groove ‘s point. Pain docs aren’t bound by EMTALA and can screen out and/or fire problematic patients.

 

[Birdstrike]

It's nice to see several of you guys moving over to pain. I wish I could get interested in the idea but I just can't bear the thought of dealing with that pt population day in day out ...

Full stop. We don't. You already do. This is the part some just can't see. When you finally see it reality will never look the same to you. Literally.

 

[Birdstrike]

Another one, today:

"Bird,

I matched at my #1 pain program.

Thank you for blazing the trail. Thank you for your guidance. Can’t wait to get started!

Lots of EM pain fellows this cycle. Upwards of 20!"

 

[sloh]

It's nice to see several of you guys moving over to pain. I wish I could get interested in the idea but I just can't bear the thought of dealing with that pt population day in day out no matter what the schedule. I find it really odd that so many people seem to show interest in the field and can't help but think it's just a symptom of burn out in EM. 90% of my angst with the specialty is schedule and circadian rhythm disorder related. Unfortunately, I'm in a group where 37% of my shifts are overnights. Although I can deal with it since they are all blocked together, I won't lie that it sucks. However, if I were desperate enough for something different, I feel it would be much easier to shop around for a gig with a full set of nocturnists where I only had to do 1-2 overnight shifts a month. That would be cake and so much easier to buy into than ejecting myself from an entire specialty and careers worth of experience/mastery to do something else entirely that I was never interested to do in the first place...merely so I could have a 9-5, regular schedule type of job. It just seems desperate to me. We deal with the chronic pain pt's all day long during a regular ER shift. I know they can't be somehow magically different in a pain office compared to the ER. They are an absolutely miserable bunch to deal with in the best of circumstances. Half of them have legitimate pain disorders and half of them didn't get enough hugs growing up and a sizable component of their pain disorder is supratentorial and psychiatric. I know a bunch of you like to say you are in practices where you don't write for narcotics or minimal narcotics but c'mon now.... You and I both know that's not reflective of the majority of pain clinics, nor is it a recipe for job security as a new pain doc, nor is it how you get into the top 5% percentile of pain compensation or how you grow your practice the fastest.

It seems to me that it would be far easier to shop around for an EM job with a full complement of nocturnists vs shopping around for a healthy pain practice that does minimal narc writing. Am I wrong?

Regardless, with EM applications down and some of you running off to do pain, I suppose it bodes well for the rest of us staying in the trenches. Hopefully it stabilize salaries or even brings them up a bit. Maybe I'm just jealous of the idea that I would be so much happier practicing pain compared to EM but damn.....I really doubt it. I guess I'll never know.

I am genuinely happy for all you that made it though. Just...incredulous, I suppose.

Perception of pain is way too rosy in this thread haha. Read this.

“Most Fellows I had met are envisioning doing shots all say and going home at banker hours with little concern for the above issues. Rude awakening when they actually graduate and see what's out there.

Welcome to check out the pain forum and the annual applicants thread where they wish to go to heavily interventional programs without strong consideration of the above matters.

@Planktonmd made a post years ago joking that pain management is patients showing up for procedures in the hopes of you refilling their opioid of choice.

Before my fellowship, I thought the comment was silly, crass and parody of true pain management. It turns out he was describing the pills for shots model so prevalent in PP pain management.

Check out the pain forum for going salaries. There are fully interventional clinics closing because of insufficient revenue.

Another important topic is the co-optation of pain procedures and management in recent years. @Aether2000 had a post regarding this. Essentially, ortho and neurosurgery want to send patients for procedures without interference to their foreseeable and planned surgery. Rather than have your management change or delay these surgeries, it's easier for them to send to a proceduralist with no followup eg IR or in house "block jock".

On the other hand they are more than happy to refer patients who had failed surgery for "optimization of their pain management ".

Caveat Emptor

I don't write this to discourage people from pain but to have an open and honest understanding of what we can offer to chronic pain patients. Just know what you are getting into.

The academics for the most part are legit and have difficult conversations with patients and their referral base and are not reluctant to put their foot down or say no. Doing the same in PP can get you canned (depending on who you work for) or results in your referral base drying up.

BTW I worked in both academic and PP pain settings.”

Entrepreneurial Opportunities in Anesthesiology

Entrepreneurial Opportunities in Anesthesiology

Absolutely. MILD pts come back clickin their heels. RFA’s can achieve excellent results. I dont understand why anesthesiologists think pain doctors are all crackpots. I'm saying this without an intent to offend. This is how the conversation played out as I read it: @OptionOffense : is pain...

forums.studentdoctor.net

 

[Birdstrike]

Yesterday, a regular patient of mine brought in fresh eggs that were laid by her chickens. Another patient regularly brings in a box of Dunkin Donuts munchkins and two coffees, for me and my nurse. Getting messages like this, on the EMR, is not rare (trigger point injections don't last 5 years, but that's besides the point):

 

[Birdstrike]

Full disclosure: Much of what is in @sloh 's post is true. Some of it needs added context. Here's my take on it.

“Most Fellows I had met are envisioning doing shots all say and going home at banker hours with little concern for the above issues. Rude awakening when they actually graduate and see what's out there.

Some think they'll just do a pain job where the do only procedures. I was guilty of thinking I could pull this off. This is analogous to the unicorn job in EM. You'll hear about it, but probably won't ever see it. But you can do nothing but procedure, just not every day. You can, two days per week. Maybe three. Some days you’re in the fluoro suit all day (Tues and Wed for me). Some days you’re in clinical all day. Most surgeons and proceduralists need some clinic time to find patients to work on, and time to follow up and assess the results. This shouldn’t surprise anyone.

The procedure-only jobs do exist, though. But they're rare. You probably will have to write for low-moderate dose opiates for some patients that need the medicine and don't abuse it. If you can't do that and still sleep at night, Pain Medicine isn't for you. If so, Emergency Medicine isn’t for you, either.

@Planktonmd made a post years ago joking that pain management is patients showing up for procedures in the hopes of you refilling their opioid of choice.

Before my fellowship, I thought the comment was silly, crass and parody of true pain management. It turns out he was describing the pills for shots model so prevalent in PP pain management.

There are practices like this around and I despise them. It's true. They are many of my competitors. They're unethical and they will always make more money that me. I can't stand them. One of these near me just shut down and one of their docs pled guilty to federal charges.

If you can't stay ethical in an environment with unethical competitors around you, then Pain Medicine isn't for you.

Check out the pain forum for going salaries. There are fully interventional clinics closing because of insufficient revenue.

It's true, there have been reimbursement cuts this year for Pain procedures. 2014 was another very bad year of cuts. Every year they target a different specialty. Some years, it's every specialty. Neither I nor anyone else can guarantee what salaries will do in Pain, in EM or in any specialty. I'm still able to pay all my bills, save for retirement and have some money to spend. If you require a guarantee Medicare won't cut payments for you in the future, or you must live above your means, Pain Medicine isn't for you. When you find the specialty with that guarantee, let me know. Because I'll apply to it with you.

My way of rationalizing this threat (reimbursement cuts) is this: "Medicare cuts could happen to me in any specialty. But if my salary as a pain physician takes deep cuts, I may not make a lot of money, but at least I get to have a normal life. At least I get to sleep at night and be awake during that day and be there for all the important days in my family life. I don't have to live under a cloud of chronic, circadian rhythm dysphoria or borderline-PTSD. In most other specialties, I can't be assured that." This rationalization, might not work for everybody. But so far, it's worked for me.

Another important topic is the co-optation of pain procedures and management in recent years. @Aether2000 had a post regarding this. Essentially, ortho and neurosurgery want to send patients for procedures without interference to their foreseeable and planned surgery. Rather than have your management change or delay these surgeries, it's easier for them to send to a proceduralist with no followup eg IR or in house "block jock".

On the other hand they are more than happy to refer patients who had failed surgery for "optimization of their pain management ".

I can sum this us in two words: "Bad referrals." Every specialty gets them. They are the EM patients where primary care could have handled it but since it's 4:59 pm on Friday they say, "Go to the ER." It's the referral to cardiology that smokes, gains weight, refuses to take any meds, whose arteries are too severe to stent another time. The DNR, nursing home admit to the hospitalist where there is zero he can do for them, but he still has to do the work admit them, for what reason, nobody knows. The derm referral that clearly needs surgery to cut out their massive cancer; or the punch biopsy a family medicine intern could have done. Everybody gets them.

Yes, you get them in Pain, too. Pain and ortho/neurosurg send a lot of patients back and forth. They send me some patients I can clearly help, some they clearly were trying to get rid of. But they get it from us, too. Sometimes I send them a patient that clearly needs a surgery that they will want to do. Sometimes I send them someone who is complicated, that I know they're not going to enjoy seeing, but still needs (or wants) to see them. This happens in every specialty. You take the good with the bad. It's annoying, but that's why they call it work. Again, at least I get to deal with it when I'm rested and fresh. Not in a deep dark basement of circadian-rhythm dysthymia. If you need a guarantee that every patient will be fun, Pain Medicine isn't for you.

 

[Birdstrike]

Worth noting: Doing a Pain fellowship isn't an irreversible decision that takes Emergency Medicine away from your forever and puts you on an irreversible path to a specialty you are uncertain about. It isn't the subtraction of one specialty, replacing it with another.

Instead, you go in with one specialty and come out with two. You don't exchange your skill set. You expand it. Adding skills to your skill stack opens opportunities that become very unique to someone with that unique skill-stack.

But it's not for everyone. Not everyone can make it work. Not everyone wants to make it work. That’s okay.

 

[Frazier]

Another important topic is the co-optation of pain procedures and management in recent years. @Aether2000 had a post regarding this. Essentially, ortho and neurosurgery want to send patients for procedures without interference to their foreseeable and planned surgery. Rather than have your management change or delay these surgeries, it's easier for them to send to a proceduralist with no followup eg IR or in house "block jock".

This can be true. At my current hospital all the blocks are done by IR. At my fellowship institution, there was a robust pain fellowship and in-house presence.

While our IR guys are good, the efficacy (or "success rate", if we want to call it that) of blocks was much higher when done by the pain docs.

I maybe have had 10% success rate with celiac block referrals over the past year. Fellowship they tended to ride more about 60% when done by the pain dept. Similar story for other blocks.

 

[GatorCHOMPions]

Perception of pain is way too rosy in this thread haha. Read this.

“Most Fellows I had met are envisioning doing shots all say and going home at banker hours with little concern for the above issues. Rude awakening when they actually graduate and see what's out there.

Welcome to check out the pain forum and the annual applicants thread where they wish to go to heavily interventional programs without strong consideration of the above matters.

@Planktonmd made a post years ago joking that pain management is patients showing up for procedures in the hopes of you refilling their opioid of choice.

Before my fellowship, I thought the comment was silly, crass and parody of true pain management. It turns out he was describing the pills for shots model so prevalent in PP pain management.

Check out the pain forum for going salaries. There are fully interventional clinics closing because of insufficient revenue.

Another important topic is the co-optation of pain procedures and management in recent years. @Aether2000 had a post regarding this. Essentially, ortho and neurosurgery want to send patients for procedures without interference to their foreseeable and planned surgery. Rather than have your management change or delay these surgeries, it's easier for them to send to a proceduralist with no followup eg IR or in house "block jock".

On the other hand they are more than happy to refer patients who had failed surgery for "optimization of their pain management ".

Caveat Emptor

I don't write this to discourage people from pain but to have an open and honest understanding of what we can offer to chronic pain patients. Just know what you are getting into.

The academics for the most part are legit and have difficult conversations with patients and their referral base and are not reluctant to put their foot down or say no. Doing the same in PP can get you canned (depending on who you work for) or results in your referral base drying up.

BTW I worked in both academic and PP pain settings.”

Entrepreneurial Opportunities in Anesthesiology

Entrepreneurial Opportunities in Anesthesiology

Absolutely. MILD pts come back clickin their heels. RFA’s can achieve excellent results. I dont understand why anesthesiologists think pain doctors are all crackpots. I'm saying this without an intent to offend. This is how the conversation played out as I read it: @OptionOffense : is pain...

forums.studentdoctor.net

Appreciate your perspective, but it’s a different beast comparing Pain to EM vs Pain to Anesthesiology/PMR/Neuro/Psych. No one said pain is perfect. EM consistently leads the burnout rankings and those other fields don’t.

 

[namethatsmell]

Could you share some of the typical patient complaints you can actually help? I’m imagining a lot of fibromyalgia, or pain 2/2 obesity that there’s not much that can be done

The guy/girl above described many of the common pain conditions we can often change the trajectory of. Ie I put in a stimulator for a patient last week and they came in reporting 0/10 pain at their followup yesterday--certainly not the average response but was nice to hear. Smattering of some random/less "sexy" ones I've had recently that I found rewarding:

Working with a patient for months to taper off high-dose opioids from a surgeon following failed back surgery while trying to keep said patient functional enough to do PT and their ADLs. Got a message from the patient this morning that they've fully titrated off and are doing great.

Injection for coccydynia, allowing patient to sit down with their family for dinner for first time in months.

Using qutenza on a patient with post-herpetic neuralgia who has tried and failed every medication under the sun-- non-opioids and opioids. Pain was reduced to the point where they could finally take a shower without crying.

Ilioinguinal nerve ablation for a patient with nerve entrapment after hernia surgery -- cutting their pain in half and allowing them to exercise again.

Meeting opioid-naive patient who was asking for opioids, taking the time to explain why I didn't think it would help... and then have them actually listen and go along with a non-opioid treatment plan (which also doesn't involve a procedure) and do well. Having another patient agree to taper off methadone (prescribed by somebody else for >decade) and onto belbuca (orders of magnitude safer) while allowing them to stay functional...outcomes for both of these patients were pretty swell.

It's nice to see several of you guys moving over to pain. I wish I could get interested in the idea but I just can't bear the thought of dealing with that pt population day in day out no matter what the schedule. I find it really odd that so many people seem to show interest in the field and can't help but think it's just a symptom of burn out in EM. 90% of my angst with the specialty is schedule and circadian rhythm disorder related. Unfortunately, I'm in a group where 37% of my shifts are overnights. Although I can deal with it since they are all blocked together, I won't lie that it sucks. However, if I were desperate enough for something different, I feel it would be much easier to shop around for a gig with a full set of nocturnists where I only had to do 1-2 overnight shifts a month. That would be cake and so much easier to buy into than ejecting myself from an entire specialty and careers worth of experience/mastery to do something else entirely that I was never interested to do in the first place...merely so I could have a 9-5, regular schedule type of job. It just seems desperate to me. We deal with the chronic pain pt's all day long during a regular ER shift. I know they can't be somehow magically different in a pain office compared to the ER. They are an absolutely miserable bunch to deal with in the best of circumstances. Half of them have legitimate pain disorders and half of them didn't get enough hugs growing up and a sizable component of their pain disorder is supratentorial and psychiatric. I know a bunch of you like to say you are in practices where you don't write for narcotics or minimal narcotics but c'mon now.... You and I both know that's not reflective of the majority of pain clinics, nor is it a recipe for job security as a new pain doc, nor is it how you get into the top 5% percentile of pain compensation or how you grow your practice the fastest.

It seems to me that it would be far easier to shop around for an EM job with a full complement of nocturnists vs shopping around for a healthy pain practice that does minimal narc writing. Am I wrong?

Regardless, with EM applications down and some of you running off to do pain, I suppose it bodes well for the rest of us staying in the trenches. Hopefully it stabilize salaries or even brings them up a bit. Maybe I'm just jealous of the idea that I would be so much happier practicing pain compared to EM but damn.....I really doubt it. I guess I'll never know.

I am genuinely happy for all you that made it though. Just...incredulous, I suppose.

I think there's a lot of truth here...no matter what kind of pain practice you're in...a muggle can always slip through (or a ton of them, depending on how your clinic is structured). That's true for every field of medicine of course, and that certainly includes pain. Your thought process on going after a pain fellowship makes sense to me -- trying to break into pain with the main goal of avoiding EM night-shifts is a plan destined for misery. While it's true there aren't nights in pain...pain is hardly the only way to practice as an EM-trained doc and not work nights...and depending on your personality and type of practice you're in you can easily burn out in Pain. There need to be specific things about practicing pain that hold interest other than just the hour (and wielding a needle).

FWIW, most of the patients you describe we don't see in the pain clinic since they've either been screened out, terminated, or are too dysfunctional to show up to appointments -- much like Bird has said.

I complete agree with you that a shift of EM docs out of the ED will improve the market for those who stay in--I really hope it meaningfully helps as we need excellent EM docs (who are well-compensated and treated decently) in the ED now more than ever.

I know a bunch of you like to say you are in practices where you don't write for narcotics or minimal narcotics but c'mon now.... You and I both know that's not reflective of the majority of pain clinics, nor is it a recipe for job security as a new pain doc, nor is it how you get into the top 5% percentile of pain compensation or how you grow your practice the fastest.

IMHO, 3 big factors that determine the decency of a pain gig: opioid prescribing patterns, use of procedures, and if compensation is fair relative to med prescribing+procedures+workload. While pain jobs with minimal to no opioid prescribing are uncommon...there are many more of them around than unicorn SDG gigs. I pounded the pain pavement hard in some very competitive markets and was offered 3 gigs like this. I took one of them. It's a pretty secure gig. Pay is fair, but nowhere near top 5% of pain compensation and I can contently say I'll never be there. Many other perks to a pain job other than just take-home pay. That said, I know guys in less "desirable" areas with minimal competition who do minimal/no opioids, work hard, and do extremely well...and that is pretty rare.

I blab on about this to make the point that opioid prescribing patterns at pain clinics vary widely and can get pretty nuanced--ie I passed on a job where it was expected that you didn't prescribe opioids...or really medications at all. The job I took allows me to prescribe as selectively as I like, which gives me the flexibility to help taper the semi-rare patient on opioids who is truly interested/motivated to titrate down (something I find very fulfilling). I get pitched jobs from recruiters regularly with pretty low-dose prescribing...all the way up to fancy and reputable appearing group who commonly prescribe whopping doses of opioids. Or I could open up my own practice and do as I please and risk the practice booming or busting. Working in pain has a more chose-your-own-adventure feel to it than EM where job factors tend to be more binary.

Full stop. We don't. You already do. This is the part some just can't see. When you finally see it reality will never look the same to you. Literally.

I remember you telling me this many years ago...and me not quite believing it at the time. You were right.

 

[GonnaBeADoc2222]

I think the major problem with EM to really any fellowship is that the push factors override the pull.

Aka "EM sucks so I'll literally do anything but this, even though I'm not really in love with anything else."

It's an unfortunate thing. We were lied to by our mentors

 

[TrailRun]

It seems like to me, at least, Pain and Palliative make the most sense among available fellowships; each gives you a different schedule and practice environment, and they are only a year. I've gotten the advice to apply to every pain program in the country due to its competitiveness; at this point I really can't justify uprooting my family for a year to Oklahoma (no offense) or wherever I could find a spot. Palliative I have a good sense of, pain I'm still not clear on exactly what a day in the life is like, and unfortunately haven't heard back from the dozen or so Pain docs I've asked to talk with/shadow. Considering dual applying to Pain and Palliative since either would be a major logistical improvement over EM, and both focus on relieving suffering in one way or another (likely mine and my patients

 

[Frazier]

It seems like to me, at least, Pain and Palliative make the most sense among available fellowships; each gives you a different schedule and practice environment, and they are only a year. I've gotten the advice to apply to every pain program in the country due to its competitiveness; at this point I really can't justify uprooting my family for a year to Oklahoma (no offense) or wherever I could find a spot. Palliative I have a good sense of, pain I'm still not clear on exactly what a day in the life is like, and unfortunately haven't heard back from the dozen or so Pain docs I've asked to talk with/shadow. Considering dual applying to Pain and Palliative since either would be a major logistical improvement over EM, and both focus on relieving suffering in one way or another (likely mine and my patients

Palliative is not competitive fellowship in general. You will match unless you have something egregious in your app. Matching at a desired region should be quite doable; however matching at a specific city or institution will be uncertain.

It is a great field. I don't dread going to work every day -- and can do this until I'm 80 if really wanted to for some reason.

The practice of medicine and satisfaction of being a physician are entirely different once becoming a subspecialist.

 

[swamprat]

I want to add my 2 cents. I am 5 years pain attending BC in EM as well. I am a minimally invasive spine specialist - I do injections as well as minimally invasive spine surgery(MIS). See image below -

This was an endoscopic discectomy done in the OR a few weeks ago - the disc was located in the axilla which is between the thecal sac and where the traversing S1 nerve root passes. I went interlaminar at L5/S1. Mind you not all pain MDs do this but it is becoming more and more popular as a minimally invasive approach to discectomy. I manage opioids and all that too but it is part of the territory and I consider myself an expert on opioid management for both non malignant and malignant pain. Oh and I get paid way more than an EM physician and its 9-4 for me M-F.

 

[Groove]

I want to add my 2 cents. I am 5 years pain attending BC in EM as well. I am a minimally invasive spine specialist - I do injections as well as minimally invasive spine surgery(MIS). See image below -

This was an endoscopic discectomy done in the OR a few weeks ago - the disc was located in the axilla which is between the thecal sac and where the traversing S1 nerve root passes. I went interlaminar at L5/S1. Mind you not all pain MDs do this but it is becoming more and more popular as a minimally invasive approach to discectomy. I manage opioids and all that too but it is part of the territory and I consider myself an expert on opioid management for both non malignant and malignant pain. Oh and I get paid way more than an EM physician and its 9-4 for me M-F.

I rest my case, lol...

 

[GonnaBeADoc2222]

I wish I had the flexibility to do a pain medicine fellowship. However, as a result of my ex-wife's shenanigans, I am geographically constricted and would only be able to apply to one program.

Is it feasible to apply to pain as an EM attending with no research and no pain rotations, or will my application just be tossed?

Still lucky in the sense that I don't work nights at my gig. I also enjoy the time off EM affords me to be with my kid, work out, travel, etc. But man, the work sucks. It's hard when you feel like your work doesn't make a difference.

 

[Groove]

I wish I had the flexibility to do a pain medicine fellowship. However, as a result of my ex-wife's shenanigans, I am geographically constricted and would only be able to apply to one program.

Is it feasible to apply to pain as an EM attending with no research and no pain rotations, or will my application just be tossed?

Still lucky in the sense that I don't work nights at my gig. I also enjoy the time off EM affords me to be with my kid, work out, travel, etc. But man, the work sucks. It's hard when you feel like your work doesn't make a difference.

My ex wife had this super nice grandfather. The gentlest of souls and he had such a positive attitude about everything. He worked graveyard shifts for Coors for his entire life. I remember asking him about it one time and he very nonchalantly told me that he absolutely detested every working hour at that company but it afforded him a nice retirement, put food on the table and a roof over their heads. He's dead now and was one of the few people that I genuinely cared for in that family but I still think of him to this day whenever I have a really bad shift.

I agree that the shifts can be brutal sometimes but damn...if you're not working nights, I'd trade your gig for mine in a heartbeat. That's 90% of my angst. The circadian insanity is literally my biggest beef with the specialty.

 

[Birdstrike]

… working nights,…That's 90% of my angst. The circadian insanity is literally my biggest beef with the specialty.

Same

 

[kirbydoc]

I think the most difficult part for me is getting letters from a home PD especially if they don't really like you because you are EM and also the personal statement: like aside from our patient population being similar (lot of pain in different stages), etc, how have people been expressing their candidacy for pain medicine in their personal statement as EM docs? It's tough.

 

[TrailRun]

I think the most difficult part for me is getting letters from a home PD especially if they don't really like you because you are EM and also the personal statement: like aside from our patient population being similar (lot of pain in different stages), etc, how have people been expressing their candidacy for pain medicine in their personal statement as EM docs? It's tough.

I have the same question... like, you can't lead with you're interested due to good pay, lack of nights and weekends.. Similarly, I wonder what people say when asked why they want to go into Derm... "I love skin, it's the window to the soul."

@Birdstrike how does one know if this is the right field for them?

 

[Birdstrike]

@Birdstrike how does one know if this is the right field for them?

Shadow someone who does Pain. Afterwards, make a list with two columns, 1) Advantages, and 2) Disadvantages, of Pain versus EM.
In your personal statement and interviews, share the portions of that that are honest and appropriate to share.

It's no different than when we all applied to EM. Except we're a little wiser now.

 

[kirbydoc]

Anybody know when a good time to ask for a letter of recommendation is? Only asking bc i just asked a few attendings I’ve worked with on a two week rotation a couple weeks ago and they haven’t responded so now I’m debating whether 1) I’m just too early and they are busy vs 2) asking pain attending to evaluate me from a two week stint is too unreasonable of an ask.
Sweating juuuust a little, haha

 

[AlvinKamara]

Anybody know when a good time to ask for a letter of recommendation is? Only asking bc i just asked a few attendings I’ve worked with on a two week rotation a couple weeks ago and they haven’t responded so now I’m debating whether 1) I’m just too early and they are busy vs 2) asking pain attending to evaluate me from a two week stint is too unreasonable of an ask.
Sweating juuuust a little, haha

Ask now. You’ll need to submit apps by mid January. Latest, early February. So get your letters in by the end of 2022.

 

[kirbydoc]

Ask now. You’ll need to submit apps by mid January. Latest, early February. So get your letters in by the end of 2022.

Thanks. Have you or anyone else had trouble getting attendings you did an away rotation with to respond to you after emailing them for a letter after a few weeks? Seems like a polite sign that they’d rather not but if that’s the case I’m kinda screwed lol

 

[Birdstrike]

Thanks. Have you or anyone else had trouble getting attendings you did an away rotation with to respond to you after emailing them for a letter after a few weeks? Seems like a polite sign that they’d rather not but if that’s the case I’m kinda screwed lol

I have. Writing a letter of recommendation letter is the type of thing most people are going to procrastinate on until the very last minute. Be polite but persistent and let them know what your deadline date is. Make it a little earlier than your actual target date so you have a buffer, if they're late.

 

[NYEMMED]

I have. Writing a letter of recommendation letter is the type of thing most people are going to procrastinate on until the very last minute. Be polite but persistent and let them know what your deadline date is. Make it a little earlier than your actual target date so you have a buffer, if they're late.

Any idea if any programs will take an experienced ED doc out about 7 years? Im burnt, I need out.

 

[TrailRun]

I’m hoping this is a good time to be applying, since anesthesia job market is so good right now, seems a fair amount of graduating fellows from last couple years just ended up doing anesthesia or only half pain… so maybe their more open to EM people? Guess we’ll see…

 

[Birdstrike]

Any idea if any programs will take an experienced ED doc out about 7 years? Im burnt, I need out.

Of course they would. Why wouldn't they?

 

[GatorCHOMPions]

Any idea if any programs will take an experienced ED doc out about 7 years? Im burnt, I need out.

I was out 4 years before fellowship last year. You need to do volunteering/shadowing to get a Pain LOR, though.

 

[sandiego1]

I was out 4 years before fellowship last year. You need to do volunteering/shadowing to get a Pain LOR, though.

I'm 3 years out of residency and am interested in doing some shadowing but have been told I won't be able to rotate with an ACGME program because I am no longer a resident (and don't carry ACGME insurance). I want to shadow someone but my concern is finding a pain doc who is practicing good quality medicine vs. someone prescribing lots of narcotics - I don't know how common the latter is these days but I want to get an accurate view of the field. Is that a valid concern or at this point should I just be cold calling anyone I can find to get a foot in the door?

Thank you

 

[GatorCHOMPions]

I'm 3 years out of residency and am interested in doing some shadowing but have been told I won't be able to rotate with an ACGME program because I am no longer a resident (and don't carry ACGME insurance). I want to shadow someone but my concern is finding a pain doc who is practicing good quality medicine vs. someone prescribing lots of narcotics - I don't know how common the latter is these days but I want to get an accurate view of the field. Is that a valid concern or at this point should I just be cold calling anyone I can find to get a foot in the door?

Thank you

Yea, you won't be able to do a formal rotation per se, but you should be able to find someone to volunteer with. I would first reach out to nearby academic centers to see if they would accommodate because they have a lot more time in their schedules to mentor and teach. If that fails move onto the private practices and in that scenario you could market yourself as being willing to scribe for them a day a week or something. Just thinking out loud here, I have no idea if that would be kosher. Opioids are part of most pain practices for better or worse so I would not avoid those practices. However, you want to make sure they are also doing interventional procedures so you can get that exposure as well. I would also make sure they did an ACGME fellowship.

 

[Birdstrike]

Yea, you won't be able to do a formal rotation per se, but you should be able to find someone to volunteer with. I would first reach out to nearby academic centers to see if they would accommodate because they have a lot more time in their schedules to mentor and teach. If that fails move onto the private practices and in that scenario you could market yourself as being willing to scribe for them a day a week or something. Just thinking out loud here, I have no idea if that would be kosher. Opioids are part of most pain practices for better or worse so I would not avoid those practices. However, you want to make sure they are also doing interventional procedures so you can get that exposure as well. I would also make sure they did an ACGME fellowship.

Agree. Find someone fellowship trained and who focuses on Interventional Pain. Don't waste your time with someone who only does meds.

 

[HemorrhagicShock]

Is med-only pain not a viable career within the subspecialty? Are there people who do it successfully?

I understand that its the procedures that bring in the big $$$, but just wondering about med-only

 

[GatorCHOMPions]

Is med-only pain not a viable career within the subspecialty? Are there people who do it successfully?

I understand that its the procedures that bring in the big $$$, but just wondering about med-only

Think about our primary care colleagues. An office visit is an office visit for reimbursement purposes, and opioids automatically get you moderate complexity. You can make decent money if you have the volume, but is that juice worth the squeeze? Not only will you be a target for the shadiest of shady patients, but the DEA will probably be watching you very closely. I’m still fairly new in my pain practice, but already my 10-20% opioid patients represent 80-90% of my headaches.

 

[GassYous]

Is med-only pain not a viable career within the subspecialty? Are there people who do it successfully?

I understand that its the procedures that bring in the big $$$, but just wondering about med-only

It's like being a psychiatrist but for the most annoying patients who just want pills, not help.

 

[Birdstrike]

Is med-only pain not a viable career within the subspecialty? Are there people who do it successfully?

I understand that its the procedures that bring in the big $$$, but just wondering about med-only

I agree with @GatorCHOMPions and @GassYous . The procedures give you a necessary break from the daily grind of clinic. I have a very conservative practice as far as prescribing (1/5th the amount as colleagues in my specialty, in my state, per drug control reports). Increasing that would make my job much less enjoyable and wouldn’t benefit patients.

 

[doctoroxygen]

Is med-only pain not a viable career within the subspecialty? Are there people who do it successfully?

I understand that its the procedures that bring in the big $$$, but just wondering about med-only

I’m a current pain fellow who interviewed for a job like the one you’re describing and opted against it. It’s definitely an option (the VA has a couple of open jobs like this around the country right now) and the salary they quoted me was surprisingly high but agree with the other opinions. In the right system it could be rewarding medicine but I don’t think it represents the best of the specialty.

 

[namethatsmell]

Is med-only pain not a viable career within the subspecialty? Are there people who do it successfully?

I understand that its the procedures that bring in the big $$$, but just wondering about med-only

Very uncommon, but I know of a few docs who do this without things devolving into a pill mill.
They aren’t really med-only per se— they just don’t do procedures. They dive deep into the nitty gritty of off-label meds, multimodal pain care, and the biopsychosocial stuff with patients. All are within multi-doc practices. They seem reasonably happy.
My group would actually gladly hire somebody who wanted to do this.

That said, one guy nearby has a solo med-only pp where he embraces patients with fibro and chronic abdominal/pelvic pain without clear causes. I think he grandfathered into pain via PM&R. I hear he no longer does much opioids, but who knows. Sounds terrible.

 

[RustedFox]

Very uncommon, but I know of a few docs who do this without things devolving into a pill mill.
They aren’t really med-only per se— they just don’t do procedures. They dive deep into the nitty gritty of off-label meds, multimodal pain care, and the biopsychosocial stuff with patients. All are within multi-doc practices. They seem reasonably happy.
My group would actually gladly hire somebody who wanted to do this.

That said, one guy nearby has a solo med-only pp where he embraces patients with fibro and chronic abdominal/pelvic pain without clear causes. I think he grandfathered into pain via PM&R. I hear he no longer does much opioids, but who knows. Sounds terrible.

I had one of these fibromyalgeurs file a police report against me for assault about a month back, claiming that I punched her arm, drove my knuckles into her neck, and put her in an armlock with her elbow extended and her wrist behind her.

All in a hallway bed. With security steps away. And in view of the camera.

Needless to say, crazypants is crazy and nothing like that ever happened.

These people are dangerous.

 

[Birdstrike]

I had one of these fibromyalgeurs file a police report against me for assault about a month back, claiming that I punched her arm, drove my knuckles into her neck, and put her in an armlock with her elbow extended and her wrist behind her.

All in a hallway bed. With security steps away. And in view of the camera.

Needless to say, crazypants is crazy and nothing like that ever happened.

These people are dangerous.

What triggered her? Lemme guess... No vitamin D-lala

 

[RustedFox]

What triggered her? Lemme guess... No vitamin D-lala

Yep. She reported 10/10 fibromyalgia related pain during the most gentle of touches, sent away 3 nurses because they "were too rough getting an IV", but had no difficulty pounding her fists on the bedrails and adjacent wall during her womantantrum. I put a stop to that nonsense by saying flat-out: "Your abusive behavior will not be tolerated."

Woman belongs in a freaking asylum.