PRO

James P. Rathmell, M.D., Chair
Committee on Pain Medicine

hat is pain medicine? Is it a full-time endeavor or a field that is easily practiced as a small aside within an operating room (O.R.) anesthesiologist’s daily routine? I aim to outline the conflicts that arise between anesthesiology groups and their pain medicine subspecialists. With an understanding of these friction points, anesthesiology groups can successfully integrate pain medicine practitioners.

Imagine you are a practice manager who is grappling with keeping an existing pain group in check, or perhaps you are contemplating expanding an existing pain practice to offer the “full scope” of pain medicine to your patients. What are the problems you will face? In an insightful editorial, former ASA NEWSLETTER Editor Mark J. Lema, M.D., Ph.D., wrote knowingly of the tensions that arise between pain medicine practitioners and their anesthesiology colleagues practicing exclusively in the O.R. setting.¹ Understanding both perspectives is essential to integrate pain medicine practitioners within an anesthesiology group.

This Is a Democratic Group, Right? (“Let’s Vote on It.”) It is not likely that the size of pain groups will rival that of anesthesiology groups. Pain practitioners, for the foreseeable future, will be a minority unless they are independent of anesthesiology groups. If every decision affecting the pain group is put to a vote of the entire anesthesiology group, the pain folks will always lose, thus setting the stage for a disgruntled minority.

Is the Work Equivalent? (“You’re Goofing Off in the Pain Clinic, While I’m Working Hard.”) There is a universal tendency to assume that when you cannot directly observe what your colleagues are doing, they must be goofing off. This is a powerful and destructive force that operates against the pain practitioner. Pain work is real work. If your pain colleague shows up an hour late to assume O.R. call duties because he or she was completing a consult, that should be recognized as real work. On the other hand, the potential for abuse is very real. Dictations and consults can be done at various times throughout the day, and the pain practitioner may choose to leave duties for days-end to avoid O.R. call responsibilities.

Are We Equally Productive? (“I Should Be Paid More Than You.”) Productivity in the O.R. is largely beyond the anesthesiologist’s control. In the pain clinic, though, productivity is directly controlled by each practitioner. Leaving productivity unrewarded in the pain clinic inevitably leads to either poor productivity or unhappy pain practitioners.

Can Clinicians Effectively Master Both Pain and O.R. Practice? When I return to the O.R., I find it to be a refreshing break. As I spend less and less time in the O.R., though, my skills become rusty, and my level of comfort declines. There is more than enough to master in the pain clinic: the minor surgical skills needed to place implanted devices, interventional techniques and the knowledge and skills needed for comprehensive care of chronic pain patients. These skills are just not a part of the O.R. anesthesiologist’s armamentarium.

Can We Be Expected to Share Call? At some point, the specialized skills required of the pain practitioner and those required of the O.R. anesthesiologist will diverge to such an extent that cross-covering on-call duties will no longer be reasonable. Unless your pain specialists spend significant time in the O.R., it is unreasonable to expect them to safely and comfortably cross-cover in the O.R. Likewise, the non-pain practitioner cannot be expected to know how to manage most of the patients seen in an interventional pain practice. A famous quote from one of my own cross-covering colleagues: “Ma’am, I don’t know what to tell you, I’ve never even heard of IDET.”

Let us look at practice styles that some have used successfully, at least for a time, to integrate anesthesiology and pain medicine.

We’ll All Do Pain. Some groups have chosen to share and share alike. All practitioners do some pain work, which minimizes cross-coverage and productivity quarrels. Indeed some practitioners enjoy pain practice — as long as they do not have to do too much pain. I have yet to see a chronic, full-service pain clinic, however, where there is not at least one practitioner who spends the majority of his or her time in the pain clinic. Offering comprehensive services, managing office staff, assuring availability and continuity of care and progressing into more difficult areas of interventional pain require a tremendous effort that needs leadership. The all-partners-do-pain groups will inevitably limit themselves to the simpler techniques that minimize the need for close follow-up and numerous telephone calls between infrequent times in the clinic.

A Few, Mostly Pain Practitioners, Who Do Enough O.R. to Share Call. This works quite well for the anesthesia group — having your cake and eating it, too. It puts the onus of responsibility on the pain practitioner to whip the pain clinic into a full-time, well-run operation but stay up-to-snuff enough to relieve the anesthesiologist in the O.R. This is where I believe many groups have stalled in development.

Hire Folks Who Specialize, But Keep Them in the Fold. I believe this is where the majority of young fellowship-trained practitioners are going today. They are close enough to residency to have some allegiance to the O.R. anesthesiologist; they are young and hungry and risk-averse as they are usually saddled with significant debt from their years of education. Anesthesiology groups have deep enough pockets and significant business skills to offer turn-key operations to these practitioners. Beware, though: the nonproductive will quickly appear as a drain on the anesthesiology group while the very productive will soon be asking for additional, productivity-based salary increases. Both lead to dissatisfaction and the demise of the congenial relationship.

Pain and Pain Only. Many former anesthesiology group members have gone this route. Once they realize that they can control their own lot in life without answering to an unsympathetic group, they are gone. Indeed anesthesiology groups who have opted out of the pain business are becoming all too common. A few years with a working pain clinic is enough for the hospital and the physician community to mourn the loss. More and more hospitals are entering the business of establishing pain practices, and they are not at all shy about turning to the increasing wealth of physiatrists who have pain medicine training.

With an understanding and sensitivity toward the most frequent strains, pain medicine practitioners and other anesthesiologists can remain as happy and productive partners, but the reasons to stay together are dwindling.


Reference:

1. Algology — the next medical specialty? ASA Newsl. 2001; 65(6):1,33.

CON

Timothy R. Deer, M.D.
Committee on Pain Medicine

ith the development of syringes and open-bore needles in the 1850s, physicians began to treat pain with increased interest and abilities. In modern medical care, acute pain is often treated by anesthesiologists using regional techniques and intravenous infusions to alleviate discomfort. Anesthesiologists have been the logical choice to treat these patients because of our knowledge of pharmacology and physiology and our ability to perform regional anesthesia. In the area of postsurgical pain and acute post-traumatic pain, anesthesiology should be the specialty to address the patient’s needs.

With the exception of this arena, anesthesiology has very few similarities to the practice of pain medicine. The practice of pain medicine, involving those with chronic pain of cancer and noncancer origin, more closely resembles that of our surgical colleagues. The practice resembles surgical-based practices because it is based on office evaluation and procedure-based treatment.

The differences in practice dynamics and characteristics make combining anesthesiology and pain medicine a losing formula for all involved. Because of the differing priorities and endpoints, the two specialties cannot be mixed in a manner that is optimal for either practice.

Different as Night and Day. The dynamics of a successful pain medicine practice differ from anesthesiology in every aspect. The daily challenges of a successful pain medicine practice involve controlling an office overhead that can approach 50 percent of collections, maintaining and managing a staff with complex and different roles, meeting the vigorous demands of documentation for evaluation and management codes and documenting medical necessity for procedures that may be poorly understood by insurers. Pain reimbursement is based on a complex documentation system that requires a thorough knowledge of medical necessity, diagnosis-based appropriateness and insurance-approved procedure codes. The ability to achieve these goals requires a full commitment to success in the pain arena.

The Paper Chase. A successful pain practitioner also must concentrate on balancing a financially viable practice with quality care and patient access. This requires controlling payer mix, insurance participation, procedure selection and additional continuing education. In an anesthesiology-based practice, the surgeon often determines what payers are accepted into the practice, what rates are negotiated and what hours the practice will be open. In groups where pain and anesthesiology are joined, the requirements of the operating room (O.R.) practice to take all comers brought forth by surgical colleagues becomes an obstruction to the goals of the pain medicine practice.

The practice of pain medicine requires extensive documentation with the average physician spending 10 hours a week in the process of updating records by dictating notes, writing letters and creating letters of medical necessity. These services are required to be reimbursed but do not have any direct financial billing for the time spent; this represents another major hurdle in the pain/anesthesiology relationship. Many groups find conflict when trying to decide on reimbursement for the pain doctor who may work longer hours, but with no receipts to show for up to a third of the time. There is no reimbursement based on time units for pain; therefore, an equitable salary model cannot exist in a practice that houses both types of practitioners.

Communication Breakdown. In our experience of consulting with many anesthesiology groups, another large hurdle is the ability to understand the diverse roles each physician plays. The demands on the pain physician are not often understood by the anesthesiology practitioner, and the demands of the O.R. practice are not often understood by pain clinicians. These problems with communication often lead to conflict. In many scenarios, anesthesiologists want call relief in the operating theater when the pain physician is still seeing patients in the clinic. This can lead to resentment by both parties and an attitude of “I am working harder than them” exhibited by each group. Perhaps the most difficult role of all is the physician who attempts to do both types of practice. In many situations, the requirements to meet the needs of pain patients conflict with the need to take anesthesia call and care for patients. In such settings, this leads to less-than-optimal care for pain patients and difficulty in providing adequate O.R. coverage.

In summary the practice of pain medicine is not the practice of anesthesiology. To try to persuade ourselves otherwise is dishonest. Groups persisting in trying to mix the two often lead to failure in their pain practices financially and, most tragically, failure to provide the best care possible for those who suffer. We should strive to practice pain medicine as a commitment that has a primary goal of long-term success with good patient outcomes and financial viability. The practice of O.R. anesthesiology does not allow for this commitment to be pursued with the necessary vigor for a pain practice to develop in a quality fashion that our patients deserve.

Pain medicine and anesthesiology truly are oil and water. You can shake them up and make them appear to be a solution, but in the end, they will always separate.

James P. Rathmell, M.D., is Director, Pain Center, Fletcher Allen Health Care, and Professor of Anesthesiology, University of Vermont, Burlington, Vermont.

Timothy R. Deer, M.D., is Director and CEO, Center for Pain Relief, Charleston, West Virginia, and a clinical faculty member at West Virginia University School of Medicine, Charleston, West Virginia.