American Society of Regional Anesthesia and Pain Medicine May 2017 - 35

Letter to the Graduating Pain Fellow: Why I Do My Own Implants

I

t was not long ago that I was
starting my fellowship. Pain
medicine fellowship is competitive,
and I wanted to make sure I was
accepted into a comprehensive
program that performed surgical
implants. Personally, as a resident,
I was specifically interested in a
fellowship that fostered a curriculum
where I would learn how to treat
pain from start to finish-one
spanning appropriate use of
medications, injections, trials (spinal
cord stimulators and intrathecal drug
delivery systems), and implants.
During my fellowship, I loved being
in the operating room, and the truth
of the matter is, so did each of my
co-fellows. It felt good to scrub in,
operate, and enjoy the comradery of
the operating room.

refer placement of the permanent implant out to an orthopedic
surgeon or neurosurgeon. Many private practice doctors told me
they didn't want to deal with the "headache" or "responsibility"
of implantation. After fellowship, some physicians feel intimidated
by the operating room or nervous about doing their own implants
independently.

Vipul Mangal, MD
Attending Physician
Advanced Spine and Pain,
Sentara Hospital
Stafford, Virginia
Section Editor:
Magdalena Anitescu, MD

When I finished my fellowship, I was fully committed to apply the
knowledge gained, but I was quickly discouraged. Many of my
former colleagues and experienced practicing pain physicians
elected not to implant their own stimulators and pumps. So, I
wonder, why is it that many pain
practitioners, some of them my
very esteemed and surgically
talented fellowship colleagues,
don't do their own implants after
fellowship? I didn't understand
the answer myself until I started
in private practice. But I realized
quickly that outside of the academic world, the reason why many
private practice pain doctors don't do their own implants is often
financial.

So, is it bad that I decided to stick out and do my own implants?
Why did I decide to do that? This was an easy decision for me, and
I am presenting it hoping that it will help you decide how would you
want to manage your practice upon graduation. For me, I entered
a saturated pain market, which is typical of most geographic
regions. Most physicians practiced with the model above, a spinal
cord stimulator trial in the clinic followed by surgical implant by
neurosurgeon. I decided to do my own implants because (1) it was
what I actually enjoyed, and (2) I came out of my fellowship with
this notion that I would like to treat pain conditions from start to
finish. Doing so, I also end up differentiating myself from other
pain practitioners in the area. I feel that when a patient walks into
my clinic, I can look him or her in the eye and say that if a spinal
cord stimulator or intrathecal pump is indicated, I can do the
entire process myself. The patient doesn't need to be referred out
to a surgeon halfway through treatment. My operating room day
provides a different environment and perspective than being in
clinic or in the procedure room doing injections. I was able to grow
my practice and became busier in a saturated pain market. I did
what made me happy, using
and expanding all the skills I
achieved in fellowship. I got to
know several of my surgical
colleagues personally just
by being around them in the
breakroom between cases.
They became my friends and
my professional collaborators in the hospital and became more
apt to refer patients to me. So, even though I may lose revenue by
missing a clinic day to do my own implants directly in the operating
room, my revenue increased indirectly because my clinic schedule
got busier.

"The best you can do is remember
your training, take your time, and do
the best you can."

As pain practitioners, reimbursements per amount of time spent
are often higher when we see and do injections on patients in clinic
versus taking patients into the operating room for surgical implants.
The private practice market is flooded with this model. When
graduating fellows join these groups, a dominant culture exists with
the understanding that the physician sees patients and performs
injections in clinic.
Peer and institutional pressure rise, and then what would you, my
dear fellow, freshly out of an esteemed academic center, versed in
surgical procedures, do? Align with all, stick up as a sore thumb
among your group colleagues, or compromise? And many do
just that . . . compromise. When indicated, pain physicians will
typically do a spinal cord stimulator trial in their office and then

My dear graduating fellow, let me tell you a secret from my
personal experience: Every surgeon is nervous during their first
surgery, and you will be too. The best you can do is remember
your training, take your time, and do the best you can. It's okay
to see patients postoperatively, it's okay to be on call for your
surgical patients, it's okay to do what you were trained to do.
After all the years in training-medical school, residency, and
fellowship-you will provide the best patient care. There are
plenty of resources at your disposal, including advice from other
physicians, former attendings, medical literature, and the device
industry. We as doctors cannot be afraid of treating our patients
from start to finish. Pain physicians should be careful not to

American Society of Regional Anesthesia and Pain Medicine
2017

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