Only trained physicians should provide interventional pain services

Only trained physicians should provide interventional pain services

A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.

As an anesthesiologist and pain physician, I understand the complexity of pain management procedures required for chronic pain disease. Chronic pain is a disease like others such as hypertension and cardiac disease. Several interventional pain procedures can be dangerous, even in the hands of the most specially trained interventional physicians, as they are performed near or around the spinal cord and surrounding nerves.

Potential complications from pain procedures include allergic reactions, infections, bleeding, nerve damage, spinal cord injuries (e.g., paralysis) and brain stem tissue damage. In addition, pain services include complex prescription medication regimens involving opioids. With the escalating use of prescription drug abuse in the U.S., it is critical for chronic pain physicians to determine the appropriate multimodal pharmacological therapies, taking into consideration the complex co-morbities that these patients have.

I recently treated a young woman for pain who had Tetralogy of Fallout at birth, a congenital heart defect, and had multiple cardiac surgeries and sternotomy incisions. With my medical background and training, I was able to recognize the patient needed CT scans of the chest to determine the cause of pain. Prior to seeing me, the patient was  about to withdraw from graduate nursing school. However, following all the needed tests and using very precise needle placement in the nerves and joints around the sternotomy incisions, the pain was diminished and the patient was able to return to school and her normal activities.

Only physicians have the education, training and skill set to perform pain procedures, as well as prescribe pain medication. Currently, a variety of physicians have specialty training in chronic pain management, including anesthesiologists, physiatrists, radiologists, orthopedic surgeons and other medical specialists. These physicians deliver pain procedures across the country.

Unfortunately, last month the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule establishing a national policy for nurse anesthetist pain management. The rule would allow nurses more freedom to practice pain medicine across the U.S. The proposed rule is unnecessary and unwise. It also will not improve access to care, as physicians deliver more than 99.8 percent of pain services, even in underserved areas.

Chronic pain management is the practice of medicine and only properly trained physicians should provide interventional pain services. All patients have the right to receive the safest and highest quality of care, particularly pain patients who receive complex and dangerous treatments.

If you are a patient who is concerned about who will deliver your pain management services, contact CMS. For more information on pain management and pain medicine, visit Lifeline to Modern Medicine.

Asokumar Buvanendran is a member of the American Society of Anesthesiologists’ Committee on Pain Medicine. 

email

Comments are moderated before they are published. Please read the comment policy.

  • ProudOkie

    Disruptive innovation is what it is called. The free market should and will be allowed to reign. As long as there is full disclosure concerning the credentials of the provider caring for the customer, then there is no issue. I don’t understand the anecdotal examples the medical community always uses concerning care – “I had this one case where……..”. I have lots of anecdotal examples where my customers move from the local family practice physician to my clinic and I catch critical issues they missed. They aren’t bad physicians, just humans. We all make mistakes. Do you think CRNAs aren’t aware of the physiology surrounding the central nervous system and all of those complications you mention? You make them sound like a 4th grader with a butterknife. CMS already knows what they are doing. If they made this ruling in spite of your powerful lobbies, then it is probably the right one. As the battle rages on, CRNAs and APRNs continue to open and maintain successful practices. Many have been open for several years. The data is slowly being collected and eventually even physicians will no longer be able maintain the untrue argument that we are unsafe. Slowly but surely we go……and for those of you who talk about the “dumbing down of medicine – again, full disclosure. Customers have a choice and anesthesiologists aren’t the only one anymore.

    • Pinester

      I don’t agree with the above response. Nurses shouldn’t be in charge of patient care and procedures; they should only be allowed to operate under the prefecture of an attending physician. In this instance the winning lobbiests are those of big pharma who now have more man-power to dole out their medications. Physicians keep giving up their rights and are suffering while nurses pull in salaries that dwarf many physicians. It’s gone too far, it’s time for physicians to take back the reigns before its too late.

  • Jack Cain

    @ProudOkie:disqus
    While you may have points in principle, in my experience
    most patients do not evaluate health care services the same way they should. Most feel that they are unqualified to make judgments
    about health care. I wish more people
    would make these types of determinations as health care would probably improve.

    Dr. Buvanendran is right about chronic pain diagnosis and
    treatment. If done right, it is very
    complex and balances a huge variety of factors.
    On the other hand, different patients require different levels of
    care. For the fairly simple or common
    situations as well as repeat visits, a trained nurse would be as helpful as a
    doctor. As always, the problem is that a
    person does not know what they do not know.
    A nurse may miss a symptom that a doctor would see right away because of
    their more extensive training.

    It comes down to this:
    appropriate training for the appropriate job. Nurses are a vital link in the health care
    chain, but only doctors have the training necessary to evaluate a chronic pain
    patient.

    • ProudOkie

      Thank you Jack – I too, would like to see consumer knowledge increase. People could make their own choices and the cost of healthcare would probably come down as well.

  • stinkpickle3L

    Keep dreaming Okie. The CRNA vs anesthesiologist battle sure is hot right now but when the dust settles, the AANA is going to be in world of pain with all the bridges you are burning. “the hand that feeds”

    Also, if you’re all about full disclosure and free choice by customers, make sure to fully disclose to the patient that you are a “nurse” and not a “doctor” and give me an honest breakdown of the responses you get.

    • ProudOkie

      Thanks for all of the responses – can’t pass this one up. All of my new customers must sign that they understand there are no physicians in my clinic (MD/DO). They are notified it is an NP owned practice and there is no physician involvement in their care unless they are referred to a specialist. They sign the form every day and tear the doors of our clinic off the hinges. Again, full disclosure means full disclosure. No self serving comments here. There is your answer Mack. I never treat anyone without them knowing I am a NURSE Practitioner. We all wear name tags in our clinic. All of my degrees are hanging on the wall and they all say “School of Nursing”. Sorry – we do everything above and beyond “by the book” for naysayers like you. Your statements show how out of touch you are with what is really happening on the front lines (no offense intended).
      And as far as “the hand that feeds”, NPs in 16 States have no “hand that feeds them”. Where are all of the news reports in these States that NPs in private practice are dangerous and are killing people? Where? Apparently they all know their limits and are able to practice appropriately without much issue. I only approached my initial post with the tone I did because of the OPs statement that “only physicians have the skill set and training to provide pain medications.” Incredible – I do it every single day and refer those who need more extensive care to a physician specialist. The system works as it should.
      So – let’s let the free market work. Require everyone to clearly identify who they are and what they do. Free market should apply to healthcare as well. Free market for one is free market for all. Don’t believe in small business and then try to control my business or the business of a CRNA in a remote hospital trying to provide care and make a living.

  • http://www.facebook.com/NURSE.ANESTHESIA.ORG Nurse Anesthesia

    Wow.
    Another absolutely evidence free proclamation by the ASA. Shocker.

    Here is what they conveniently forget to mention.

    - MDs require exactly ZERO extra training to do pain management. None. Nadda, Zip. How would you like your family MD who has never placed a block during ANY of his training doing so after a weekend course?
    - CRNAs have been doing pain for over 40 years. There is no evidence to show they have higher complication rates or lower rate of success. In addition CRNAs are TRAINED to do blocks, place epidurals etc all part of pain management.
    - Florida is one of 2 states in the entire country which does not allow Nurse Practitioners to prescribe scheduled substances. They state that no NP is qualified to do so. Interestingly enough Florida, the state where only PHYSICIANS can prescribe narcotics, is also prescribing 10X more oxycodone than providers in every other state in the country combined. So clearly the problem with prescriptions is not nurse practitioners.
    - The ASA talks a lot about “training” but they seem to have no interest in stopping physicians in places like florida who just put up a shingle and call themselves pain management MDs. You know, the ones writing 10X more oxy scripts than EVERY OTHER STATE in the country combined.

    Don’t let the ASA and other physician organizations fool you. They have no interest in patient safety or they would be getting their own house in order before attacking anyone else. This isnt about anything less than protecting their own wallets and the FTC has said so now on multiple occasions. This is Sherman Act level anti-competitive rhetoric at its best. Instead of simply competing in the market place they just want to corner the market by force.

    Unreal but typical.

    • Resident77

      @facebook-100001472501612:disqus

      Just wanted to address some of the points you make above:

      -A Board certified Pain Medicine physician typically does a 3 year residency in anesthesiology where they perform a large number of blocks. The minimum to pass residency currently is 40 peripheral nerve blocks, 20 epidurals, and 20 spinals, however, the average resident does much more of each. Then you must complete a year of fellowship in Pain Medicine where you do even more blocks and procedures. [Of note: a small number of physicians do a Neurology or PM&R residency before Pain fellowship}

      -I have not seen any reliable study that shows that CRNAs do NOT have lower complication rates or rates of success. Maybe you can help initiate a large population prospective study examining outcomes between CRNA-only and physician-only practices? Also, I was not aware that SRNA education includes training in implanting spinal cord stimulators or placing intrathecal pumps along with managing the possible post-operative complications.

      -I would like to see data from Florida as it regards to Board certified Pain Medicine physicians versus all providers. It’s my suspicion that the numbers are skewed by the non fellowship trained physicians.

    • eric sanders

      Really? How many blocks, epidurals, and spinals do CRNAs have to perform before they can graduate. Remember I said perform not manage. The answer I believe is “zero” correct me if I am wrong by showing me a source. I just recently talked to a graduating CRNA and they had done 6 epidurals, 10 spinals, and one femoral block prior to graduation. I have done 160 epidurals, 60+ spinals, 100+ blocks including femoral, sciatic, interscalene, supraclav, infraclav, pop, saphenous, etc..who do you want working on you after graduation. The fact is that 95% of graduating CRNA are really incapable of practicing independently when they graduate while 95% of anesthesiologist who are graduating are ready to be independent practitioners. So why would the govt pay CRNAs the exact same as a physician when they are not even trained to perform the procedures. You always claim show me the data….how do you make a proper study that blinds patients from their providers to compare outcomes….what IRB will take a group of CRNAs and a group of anesthesiologist and randomly assign them to cases of all complexities and look at outcomes….no one will ever pass such a study because pts will clearly have increased mortality with new CRNAs attempting to do complex cases of any kind…that is why I can’t show you the data

    • http://www.facebook.com/jattaman Jason Attaman

      “CRNAs have been doing pain for over 40 years”

      This shows how ignorant you are about medicine. CRNAs have been doing peri and intra operative ANESTHESIA for over 40 years. You have NOT been “doing” outpatient chronic pain management nor are you trained in it.

      “In addition CRNAs are TRAINED to do blocks, place epidurals etc all part of pain management.”

      You are trained to do blind anesthetic blocks at best. These have no relevance nor carry over to performing steroid injections within a mm of precision, such as a cervical transforaminal epidural steroid injection under fluoroscopy. Again, demonstrating your ignorance. I have taught many Anesthesiology 3rd and 4th year residents in a University pain clinic, and thought they think they know how to do pain management blocks for the same reasons you stated, they soon realize there is no carryover skill. Thats why they do a 1-2 year FELLOWSHIP, which CRNAs cannot do, will not do, and are not qualified to do. Rather, CRNAs take weekend workshops on how to do “pain management.” Total joke and very dangerous.

      “MDs require exactly ZERO extra training to do pain management” Again, you show your ignorance. To be a real pain management physician, one must complete 4 years of college (which many CRNAs do not do), 4 years of medical school, 1 year of internship, at least 3 years of residency specialty training, and then 1-2 years of a Pain Medicine fellowship. Sure there are feral and unqualified MDs posing as pain management specialist, but they are a joke, just as CRNAs are who claim to do this. The difference is, these MDs STILL have far more training than any CRNA, because ANESTHESIOLOGY DOES NOT EQUATE TO CHRONIC PAIN MANAGEMENT.

      This is not about free market competition. It is about patient safety and proper treatment, which CRNAs cannot deliver in this context. Might as well let your medical assistant or Starbucks barrista be a “pain management” “provider,” because they are just as qualified as you are to be pain management specialists. Why? Because your anesthesia skills are not relevant to the practice of outpatient chronic pain.

      The fact that you think doing “blocks” is what pain management is about is sad.

  • http://www.facebook.com/carol.levy.336 Carol Levy

    Let me speak as one person with chronic intractable pain. My pain is facial but I also have severe back pain. I would never let a nurse do a procedure on me such as back injections nor would I ever go anywhere where medical care is not supervised, at the least, by a physician.
    Carol Levy
    author A PAINED LIFE, a chronic pain journey

    • ProudOkie

      Hi Carol,
      That is called the free market. Everyone respects your choice. But others, many many others, feel differently. You are just one of many and have made your choice. Be glad you live in a country with a free market system (for the most part) where you can feel so strongly about the issue! Happy choosing Carol!

      • stinkpickle3L

        The truth hurts, doesn’t it, Mr. Okie? No, many many others don’t feel differently and you know it.

        • http://www.facebook.com/NURSE.ANESTHESIA.ORG Nurse Anesthesia

          actually yes, many do. The thousands of patients per year who have pain procedures by CRNAs.

          • kjindal

            how many of those patients even KNOW (or have a choice in the matter) they they’re being treated by a non-doctor?
            I think with all the push for “separate but equal” by mid-level providers, they should absolutely be granted indepedent status, with their own malpractice and no supervising MDs, and should take (and pass) the same boards passed by MDs in the same specialty.
            I would bet that less than 2% of CRNAs would pass the Anesthesiology boards.

          • http://www.facebook.com/NURSE.ANESTHESIA.ORG Nurse Anesthesia

            Kj

            They ALL know who they are being treated by. Where is the evidence that there is ANY deception? There isnt any because it does not happen bud. Welcome to reality.

            CRNAs are not “mid level” anything. We do the exact same job as our physician counterparts. I do it without any MDAs on a daily basis. As with every practicing CRNA in the country I too have my own malpractice. We all do and in fact case law has shown DEFINITIVELY that even in a practice where CRNAs and MDAs work together MDAs are not found liable (nor are surgeons and even the ASA acknowledges this) for the actions of a CRNA.

            As for passing MDA boards? Id be willing to take them tomorrow. However, what does that even prove? Nothing. Its a test like any other and there is no benefit to anyone in us taking it. Here is why…

            The proof, as they say, is in the pudding. For over 130 years CRNAs have been practicing without MDAs. This is nothing new. Over that time the argument from detractors has been safety and training differences. However, also over that entire time EVERY SINGLE STUDY DONE has shown that the safety is the SAME and the difference in training obviously isnt relevant as it makes no difference.

            You can keep ‘pushing the goal posts’ all you like but the facts have no changed in over 130 years.

          • http://www.facebook.com/people/Ailan-Medici/1409476759 Ailan Medici

            Nurse Anesthesia, what happens if a patient refuses your care and wants an MD to administer their anesthesia?

          • http://www.facebook.com/NURSE.ANESTHESIA.ORG Nurse Anesthesia

            If they come to my facility where there are no MDAs then they have to go somewhere else.

  • Douglas G.

    What a professionally self serving useless epistle. The truth is, it is about the money. MD/DO’s want to keep it. Mid-levels want more of the pie.
    Old story.

  • Douglas G.

    Well said.

  • LPS

    As a board certified anesthesiologist and board certified pain physician I find the comments below inaccurate, biased and insulting, as they grossly misrepresent the time and effort anesthesiologists and pain practitioners have spent in acquiring their knowledge and skills. Anesthesia and pain management ARE the practice of medicine, both fields requiring extensive postgraduate medical training.
    Namely, to become a board eligible anesthesiologist you must have graduated from an accredited Medical School and successfully completed a year of internship and 3 years of anesthesia residency. Anesthesia residency prepares physicians with advanced skills in airway management, intraoperative life support AND pain management. Regional anesthesia, including neuroaxial and peripheral nerve block techniques, are therefore are an integral part of any anesthesiology residency curriculum. Anesthesiologists who have successfully completed the required 4 years of postgraduate medical training may pursue additional sub specialty training in Pain Medicine–usually a 1 year fellowship– where anesthesiologists may continue to refine their cognitive and technical skills in the management of both acute and chronic pain.
    Board Certification in Anesthesia and Pain Management requires the successful completion of the aforementioned training plus having passed rigorous Board Certification requirements in both these fields… These are the facts, not the wild and unsubstantiated rhetoric of some CRNA factions!