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October 2002
Volume 66 |
Number 10
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CON: Exclusive Contracts Should
Not Include Pain Medicine
Lawrence S.
Gorfine, M.D.
Committee on Pain Medicine
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Exclusive hospital contracts should not include pain medicine/management
as the sole domain of hospital-based anesthesiologists.
It is illogical and presumptuous that anesthesiologists
are the only practitioners of this branch of medicine and
entitled to an exclusive contract. Pain management is a
complex multispecialty and multidimensional study and practice
of medicine. It encompasses the anatomic, physiologic and
psychological study of pain. The treatment of this complex
mix of multisystem components often requires more than one
medical and psychological specialty. Frequently, physical
rehabilitation of some type also is needed. Many of these
areas of treatment are not usually part of the expertise
of the pain medicine anesthesiologist. To exclude other
anesthesiologist and nonanesthesiologist pain practitioners
from the hospital denies patients of that community access
to a potential mix of physicians with different experiences
and treatment skills.
Anesthesiologists have had a leadership role in the development
of pain medicine as a subspecialty. We should continue in
that leadership role by trying to offer options and choices
to our hospitals and communities. Closing a hospital or
medical staff to pain physicians other than those in the
contracted anesthesiology group limits choice and options.
It does not promote the growth of new ideas in pain medicine,
and it does not promote the growth of new treatment modalities
or the general promulgation of pain medicine as a specialty.
We need to encourage the growth of different perspectives
and facilitate the availability of physicians with different
treatment skills and experiences. Our reputation as leaders
in this field will be lost if we continue to request exclusivity.
We will, instead, be viewed as protectionists who are not
interested in the growth of knowledge and the advancement
of patient care.
The practice of anesthesiology is very different than the
practice of pain medicine/management. Though many hospitals
and their operating rooms function more efficiently with
a single anesthesia group, no such increased efficiency
occurs as a result of having an exclusive contract in pain
medicine. Pain medicine better resembles a surgical subspecialty
than it resembles the practice of anesthesiology. Pain medicine
procedures are often scheduled in an operating room or special
procedure suite similar to the scheduling process utilized
by surgery and endoscopy. In fact, pain medicine physicians
often perform surgical procedures such as pump and stimulator
implants requiring anesthesia. After these procedures, patients
are followed up with in an office or outpatient clinic.
Some of these patients need long-term care and medication
treatment. These types of procedures are not hospital-based
and work better in an office or clinic setting. There is,
then, no increased efficiency or other benefit if the pain
physician is a member of a hospital-based anesthesia group.
Where the practice of pain medicine is more like a surgical
subspecialty practice, an exclusive contract serves to merely
block competition. This inevitably leads to less availability
of treatment options and services. Typically, each physician
group or single practicing physician has an area of major
interest. Some pain physicians prefer treating cancer pain;
others treat back pain or acute postoperative pain. Physicians
develop more expertise and skill in their specific areas
of interest. These skills are noted and appreciated by other
physicians in the community, and patients requiring these
skills are naturally directed to these specialist doctors.
Other areas of pain medicine are, then, underserved if other
physicians or groups are not present. Patients requiring
medication for neuropathic pain, weaning and narcotic detoxification,
for example, may not have a physician with interest and
expertise available to help.
Although competition is eliminated by an exclusive contract,
it does not necessarily benefit the hospital-based anesthesia
group. If more physicians are available, more services are
offered. The availability of more pain medicine-trained
physicians leads to a greater awareness of the benefits
pain medicine has to offer and, as a result, increases the
utilization of these services. Instead of decreasing the
amount of work performed by the pain medicine physician
in the anesthesiology group, there is often a greater request
for pain medicine services in general by the physicians
and members of the community. The hospitals and often the
anesthesia groups in the hospitals increase the volume of
work relating to pain medicine. The hospital-based anesthesia
group with an exclusive contract in anesthesiology has nothing
to fear by opening the staff to trained pain physicians.
The increase in services offered, increase in awareness
of the community and increased options for the patients
ultimately benefit even the hospital-based anesthesia group.
Physicians who are fellowship-trained in pain medicine
and who have no desire to join an anesthesia group to provide
anesthesia services should be allowed to work. Many of the
fellowship-trained anesthesiology pain physicians want only
to practice pain medicine. Unfortunately, if they are not
on the medical staff of a hospital, they are not able to
work in most areas. In some states, the law requires that
a physician have hospital or surgical center privileges
for the procedures performed in an office. Some states require
emergency transfer agreements to hospitals if procedures
are performed in an office setting. Peer review and quality
assurance can only be performed effectively if the physician
is on a hospital or surgical center staff. Most medical
insurance companies require a physician to have hospital
privileges before a contract is written to care for the
patients covered under the plan. Therefore, hospital medical
staff privileges are needed to practice medicine today.
Exclusive contracts do not allow trained pain physicians
to obtain these necessary hospital privileges. In many cases,
pain physicians are forced to join an anesthesia group and
work only part-time in pain or not work at all. This creates
an unjust environment for pain medicine physicians, which
does not exist in other medical specialties. This unfair
treatment of our fellowship-trained pain medicine anesthesiologists
must be changed. Our pain medicine physicians must be allowed
the opportunity to open a medical practice in the area of
their choice without being unfairly blocked by established
anesthesiologists.
Restricting pain medicine physicians from a community serves
no benefit to that community, the hospital or the anesthesia
group. Exclusive contracts for pain medicine serve to restrict
pain medicine physicians from practicing in their chosen
field of medicine. It further creates division and hostility
between pain anesthesiologists and hospital-based anesthesiologists.
This hostility often extends to encompass all anesthesiologists,
who are then perceived by pain medicine physicians as unfriendly
and protectionists. This division in our specialty and this
unjust environment have pushed pain medicine anesthesiologists
to join organizations other than ASA for support and representation.
Exclusive contracts for pain medicine are wrong, unjust
and divisive. It must be changed on moral and ethical grounds.
It must be changed to allow diversity in treatment options
and for improved quality of care. Reasonable anesthesiologists
must speak out against this unjust treatment of a segment
of our specialty. We can expect pain medicine anesthesiologists
to return to ASA only if we demonstrate a real commitment
to rectify these injustices and show a true appreciation
of the difficulties exclusive contracts have caused.
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Lawrence
S. Gorfine, M.D., is Medical Director, Southern Pain
Institute, Lake Worth, Florida. |
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