Letter to the Graduating Pain Fellow: Why I Do My Own ImplantsBy Vipul Mangal, MD Jun 7, 2017
Section Editor: Magdalena Anitescu, MD
Vipul Mangal, MD
It 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.
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.
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 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 refer placement of the permanent implant out to an orthopedic- 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.
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, spinal cord stimulator trial in the clinic followed by surgical implant by neurosurgeon. I decided to do my own implants because: one, it was what I actually enjoyed, and two, 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 break room 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.
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 ok to see patients postoperatively, it’s ok to be on-call for your surgical patients, it’s ok 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 become just “injectionists,” as a former attending of mine would say. The insurance landscape is changing; no longer can we just inject patients without showing adequate improvement. You need to have another tool in your tool belt. Most of us receive implant training during residency and fellowship. For further knowledge and practice, most device manufacturers provide training outside of fellowship. They offer cadaver courses and on-site visits where you can observe a practicing pain physician placing a permanent implant. Our society meetings provide training courses. You just have to get the motivation, ask for help if needed, and often take a leap of faith to do it. Doing your own implants may provide you with the personal satisfaction that you are able to provide the best care possible for your patients and probably keep you wanting to practice medicine.
So, my dear pain fellows, when the time comes to apply all of the excellent training and knowledge you acquire during your esteemed pain fellowships across the country, I can only say: JUST DO IT!
Vipul Mangal, MD, is an attending physician at Advanced Spine and Pain, Sentara Hospital, in Stafford, VA.
Note: This article originally appeared in the ASRA News, Volume 17, Issue 2, pp. 35-36 (May 2017).