| Deciding on a Practice Model |
Independent comprehensive pain center- These clinics often include a physician, nurse practitioner, physical therapist, psychologist, have their own fluoroscopy and procedure rooms with sedation capabilities, and may have CT or MRI capabilities and rehabilitation services. Referrals are often from multiple sources including family physicians, orthopedists, neurosurgeons, other patients, workmans comp, chiropractors, etc. This type of practice model is designed for diagnostics and therapeutics with an emphasis on long term care of patients. Medications, injections, functional restoration, and psychology are integrated into a single one-stop shopping unit that is convenient for patients, reduces the management demands on referring physicians, and is cost effective to the health care system through avoidance of hospital or ASC facility fees. The potentials for integration of new therapies are enhanced in this model because of its independence. Because of the number of personnel, large space requirements, cost, and difficulty acquiring a like-minded team, it is suggested a new pain physician integrate with an already existing comprehensive unit rather than creating this model from scratch. Years of experience are needed to define the direction of such a large unit, therefore if this model is selected, it would be wise to learn from others who have already set up such a program. Hospital based multidisciplinary pain units- A true multidisciplinary (interventional pain, spinal diagnostics, neurosurgery, neurology, occupational therapy, PT, pool therapy, support groups, hypnosis, EMG diagnostics, on-site radiographic diagnostics, psychology/psychiatry, addiction medicine) approach is becoming increasingly rare as a single unit. More common are the interdisciplinary units in which the patient is referred to various departments or physicians within the hospital. While these approaches offer the most comprehensive assessments and outcomes, their enormous cost precludes setting up true multidisciplinary pain units. Interdisciplinary is a more commonly seen therapy. Advantages of these types of clinics are patient convenience, physician interaction with different specialties in patient discussion sessions, and access to the most advanced skills of each specialist without the need guess at capabilities of external physicians/providers. Disadvantages are the cumbersome and sometimes plodding nature of diagnostics/therapeutics and cost. Employee or de facto employee of a neurosurgical or orthopedic spine group- An increasing trend of these groups is to bring lucrative pain management procedures "in-house" and employ physiatrists or anesthesiologists to perform blocks. The employers take a percentage of the revenue generated (up to 50% in some situations) in return for the referrals. The vast majority of referrals come from the employer who expects rapid patient turnover and may have specific demands on what is required in the performance of procedures. This situation limits the introduction of new technologies, especially those that would in any way compete with the open surgical techniques of the employers. Typically patients referred to neurosurgical or orthopedic spine practices are seen by the pain diagnostic unit for diagnostic injections (sometimes before seeing the surgeon) or the lucrative obligatory three epidural injections prior to surgery. The pain doc then handles the patients pain medications in the post surgical period, then discharges the patient back to the family physician. Rarely there are long term pain clinics associated with these groups, but since long term management is less lucrative, such services are not usually seen. The de facto equivalent is that of a pain physician who uses the office of a neurosurgeon for consults and pays a percentage of injection block revenue back to the neurosurgeon in lieu of standard office rental fees. In both the employee and the de facto situation, the neurosurgeon/OSS has discovered a way to effectively receive kickbacks from the pain physician for referring patients for injections. While the loss of independence, independent decision making, advances in technology, and loss of income may make this practice model seem less desirable, it is one that may fit quite well into the lifestyle of a pain physician who effectively wants only to do injections, receives a steady predictable income, and does not want the hassle of running a business. Such a model is an excellent way to treat acute and subacute pain, but not chronic pain. Part time pain physician- This is the model most used to transition between anesthesiology and full time pain practice. In the best circumstances, the physician has a time slot carved out of the schedule in which he sees pain patients and performs injections, limiting their practice to basic to moderate procedures. Often this is done in a hospital setting. While the hospitals legally are supposed to charge rental to the physicians for space and personnel, some do not. Usually injections performed are blind non-fluoroscopically guided injections in this model since it is only a small step from obstetrical epidural analgesia to epidural steroid injections. In the worst circumstances, physicians will try to run a pain clinic between OR cases or chronically overschedule OR time while giving poor service to pain patients who may be forced to wait for hours to see the physician. Some practices unfortunately see part time pain physicians implanting devices with no arranged coverage should they be involved in a long OR case as an anesthesiologist. Part time arrangements have the advantage of a controllable patient base without getting burning out from seeing solely chronic pain patients. It is a nice diversion from anesthesiology, and may require some of the skills of a pain physician. Certainly it is a good place to start if one is contemplating the transition to full time pain practice. One disadvantage is that the physician may have their schedule controlled by competing forces, of which the operating room will usually win out over pain patient coverage. Another disadvantage is that there should be limitations on what a part time pain physician will be willing to do. Another is that malpractice rates are higher for pain management than for anesthesiology in many malpractice insurers rating systems. Subspecialization Model- There exist headache clinics, RSD clinics, neurovisceral clinics, holistic clinics, spine clinics, etc. which are all designed to focus on the skills of one or more select individuals with specialized training and understanding of unusually complex and often intractable pain conditions for which there are no easy answers. These clinics may be extremely expensive to the patient and may not be covered by insurance plans. Usually patients entering these programs have already been to several physicians and have attempted treatments at other pain centers. Unless you as a physician have extraordinary skills in a particular area with years of underlying experience, it would be wise to avoid employment with these entities. Independent Block Jock Model- In this model, the physician is a full time block jock, does no medication management, and uses only injections as therapy. When the injections fail, the physician refers the patient back to the referring doc or to the patient's family practitioner. Often the doctors practicing this kind of pain management market heavily to workmans comp, family practice, etc. and may make well over $1,000,000 a year. Unfortunately, this type of practice jettisons patients who need long term care or if the blocks do not work. On occasion, as many as 50 spinal/axial procedures are performed in one year on a single patient. Referrals are not based on results but are usually obtained by schmoozing the referring doctors. This is the model called the "mindless block jock" in which only superficial diagnostics/therapeutics are available to patients. Often the block jock treats chronic pain patients in addition to acute patients (disc herniations) with the same therapies, failing to distinguish between the two very different types of pain. The drive towards extraordinary financial gain may supplant medical ethics and good medical practices. Certainly chronic pain patients should avoid these block shops. Chronic pain patients sent to these physicians for pain control feel betrayed after they are unceremoniously dumped after a series of steroid injections and referring family physicians are realizing there is little to be gained long term when the patient sent for pain management is dumped back into their lap. It is this type of practice that is drawing the ire of insurers and is giving pain management a decidedly bad image in the eyes of patients and referring physicians alike. Independent physician solo comprehensive practice- If there are enough referrals possible, this is an excellent way to start a practice. It is possible to mold the practice according to your skills, and add such skills as are needed gradually. Expansion is forever looming over well received pain physicians. The downside to this type of practice is the lack of acquisition of business skills necessary to make it work. However, it is the purpose of this manual to lead the physician through the maze of paperwork in order to develop their own practice. University Model- typically pain fellowships are subsets of the anesthesiology department (with the notable and laudable exception of Mayo Clinic Jacksonville), and their fellows may have to take OR call. While there are a handful of PM&R pain fellowship programs and a neurology pain fellowship program which have a slightly different focus, most programs are based on the anesthesiology model of pain. Often those who are the medical directors of pain fellowship programs have little experience outside academics. The subsequent vacuum of knowledge due to inadequate experience and training subsequently affects the training of pain fellows to such a degree that graduating fellows must seek additional pain conference education outside academia to be basally functional as pain physicians. However academic pain programs must deal with pressures from several other departments constricting their expansion into advanced techniques and financial pressures due to the ubiquitous Medicaid population base of university programs. That being said, the University model is an excellent motif for research, which is sorely needed in pain management. Private practitioners in pain management only rarely engage in research so it is left to the ivy covered halls of our teaching institutions to do what we in private practice fail to do. If a physician is seriously considering an academic post in pain management/medicine, it would behoove them to spend at least 3-5 years in private practice first in order to avoid appearing insular. Hybrid Models-Many physicians find themselves in models that are not so incisively defined, with some elements of each of the above. Some hybrid models are university adjunct professor/private practice, part time block jock for a neurosurgical practice with independent satellite offices elsewhere, etc. Such hybrids can be tailored to the needs of the physicians and the practices, and only rarely is rigidity required by an employer. |
