March 31, 2025 • 25 mins
Summary
The video covers a conversation between Dr. David Rosenblum and Dr. Hamed Sadeghipour, discussing board preparation experiences and the current state of pain management practice. Dr. Rosenblum begins by announcing upcoming events, including a May 17th ultrasound course in New York City and his lectures at various conferences. He also mentions shadowing opportunities at his office. Dr. Sadeghipour shares his board preparation experience, discussing three main resources he used: Huntoon book (800 questions), Board Vitals (700 questions), and Pain Exam. He achieved notably high scores using these resources. Regarding his current practice, Dr. Sadeghipour describes working both in academic anesthesia (40-50% time) and private pain practice, managing four offices with four nurse practitioners The discussion then shifts to the changing landscape of pain management, with both doctors noting concerning trends: increasing focus on surgery center procedures over office-based ones due to reimbursement differences, the challenge of maintaining competency in advanced procedures, and competition from non-specialists entering the field. They also discuss the future of the specialty, suggesting it's moving toward becoming a hybrid of neurosurgery and orthopedic surgery with traditional pain management procedures.
For pain medicine Board Prep go to NRAPpain.org
For ultraound training go to NRAP Academy
Highlights
Introduction and Upcoming Events
Dr. Rosenblum introduces the podcast and announces several upcoming events, including an ultrasound course in New York City on May 17th, appearances at ASPN and Pain Week conferences, and opportunities for shadowing at his practice.
Board Preparation Experience Discussion
Dr. Sadeghipour details his board preparation strategy using three main resources: Huntoon book (800 questions), Board Vitals (700 questions), and Pain Exam(700 questions videos, lectures, ultrasound training, regenerative medicine training and more). He explains the strengths and limitations of each resource and mentions achieving exceptionally high scores.
Current Practice Structure
Dr. Sadeghipour describes his dual practice model:
Evolution of Pain Management Practice
Both doctors discuss the shifting landscape of pain management, noting increased focus on surgery center procedures, reimbursement challenges, and competition from non-specialists. They address concerns about fellowship training adequacy and the financial pressures affecting new practitioners.
Future of Pain Management Specialty
The discussion concludes with perspectives on the specialty's future, suggesting it's evolving toward a combination of minimally invasive spine surgery and traditional pain management, with concerns about maintaining specialty integrity and the need for stronger regulatory oversight.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Welcome back.
(00:00):
This is a unique podcast in which one of my former pain
exam alumni who took the boards took the pain exam review
And a few other reviews reached out to me to discuss board
prep maybe Collaborating on academic endeavors,
and so I invited him on the podcast.
I hope you guys find this interesting before we get into it
We have a May 17th ultra ultrasound course in New York City
(00:26):
I'm going to most likely be at ASPN as well as pain week at
pain week I'm lecturing on regenerative medicine and
ultrasound guided interventions in your pain practice and
regional anesthesia We also have Latin American pain
society coming up a lot of good things But I also wanted to
(00:48):
tell you about the opportunity to shadow me or my partners
at my office Where we do ultrasound and fluoroscopic guided
procedures.
If you have any interest, please reach out to me.
Look forward to meeting you
It's the Pain Exam Podcast with your host, David Rosenblum,
MD.
(01:26):
Our high yield premium episodes are now available on the
pain exam app with a premium subscription or access for
free with a CME subscription at painexam.com.
And now, without further ado, here's your host,
Dr. Rosenblum.
Welcome back to the pain exam podcast.
(01:47):
And thank you for joining us today.
I'm joined by interventional pain physician
Hamid Sadeghipour . Welcome.
Thank you so much.
Thank you for having me.
And Hamid and I, we connected via the board prep platform,
the pain exam.
And Hamid gave me some honest and real feedback about some
of my questions.
(02:07):
And I actually happened to agree with him.
I think what one of the contention points we discussed
about the board prep was some of the pelvic pain and
headache questions and chest pain questions or HIV
questions, which did not really appear on the boards,
but they did show up on my review and some of those
questions I happened to get from the books,
(02:29):
but that the pain management books at the time I was
writing it and I figured even though I'm updating this
thing every year,
I just leave those questions in because I figured it
couldn't hurt might stress you out a bit when you're
practicing.
But anyway, Hamid,
why don't you just tell us a little bit about the board
prep experience and feel free to share what you'd like to
(02:49):
say about it and your prep journey.
Yeah, so basically, I shop around like,
for a good amount of time, you know, as we all know,
that when you get to a job,
the difference between the pain exam compared to the other
one that we have, or maybe oral board as well is,
at this point, we have a job, you're not, you know,
(03:09):
resident anymore.
So the time is very
Sorry to interrupt.
You're an anesthesiologist, correct?
Yes, yes, I'm in a syllogia.
at the oral anesthesia boards,
which is a whole other animal.
Right.
Or another animal.
And I did crazy about Care Fellowship too,
but that's another animal too.
Right.
And top off to the other one.
Yeah.
So I shop around to make sure that, you know,
(03:30):
with the time that I have,
I can do the best to utilize my time.
And basically I come with three good resources that
actually it worked great at the end.
Those three was Hantun book is the book with,
and I'm going to get a little bit, you know,
description in each of them briefly.
(03:52):
And if needed, we can go deeply as well.
So Hantun book is somehow 800 question covers most of the
topics.
It's written like many years ago, to be honest.
And I actually met Dr.
Hantun when I was looking for a job.
And then I asked him like,
why you're not basically advising this book.
It seems that he's busy that he didn't have enough time to
(04:12):
revise his book, but it's still, I think is a good source.
It has a good explanations.
It just a hard copy is not anything online.
So for it just need a little bit patients to go over those
question when you reading it.
So I know that many of our folks is not friendly with hard
books, but this is the only version that exists.
(04:36):
The second one is board vitals.
It has around 700 multiple question with answers.
The answers is not like what like you world or, you know,
other prep that we had for anesthesia.
Their answers are very short and concise.
So it's easy to go over them and covers questions,
(04:59):
but it has some lack of some subjects that doesn't touch at
all.
Then we come to basically pain exam and other resource that
covers the area that mainly some of the like board vital
doesn't cover, but then give you to some, you know,
areas that I didn't see any question coming from those.
(05:22):
So maybe is like a little bit over prep you for those areas
that doesn't exist in anesthesia.
But I, I know that you already, you know, this,
the aim of this one is for probably other pain boards as
well.
I'm talking about ABA anesthesia board exam,
which on tune and board vitals are mainly for those
(05:44):
anesthesia ABA exam, but pain exam is for, you know,
covers the other ones as well.
So those are three that I went through all of them.
And I actually,
I don't want to bring like exact percentile,
but among whatever I did so far in my exams,
that was very highest percent times that I surprised me
actually.
(06:05):
So I did well on it.
Good, congratulations, that's great.
So tell us about your practice.
So my practice, that's a funny,
other funny story that like, when you come to the job,
it's, you know,
you just open the door that is not familiar to us and no
one during your, you know,
(06:25):
residency or fellowship speaks about details of these jobs.
So I was in LA,
I did my residency and critical fellowship at Cedars-Sinai.
And then I did my pain fellowship at USC.
Then I got the job offer in St.
Louis, that is supposed to be a brand new surgery center.
And that's how they attract me to come to Midwest.
(06:47):
And, but when I come here, unfortunately,
that didn't exist.
It was full of grass.
It was they made it so green.
So because it was during COVID.
And that plan, you know, unfortunately changed.
So I was, I have a very strong background in research.
So I wanted to be an academic and, as you know,
better than me, academic pain,
(07:10):
the turnover is not that much.
So whoever goes there stays,
so it's very job is very limited in pain academic.
So this was, you know,
attracted me because it was academic, it was, you know,
surgery center pain, but but didn't exist.
So I ended up but I have, at that time,
two child now I have three.
So it was family moved from LA to here.
(07:33):
But I was lucky that there was a bunch of, you know,
a private practice around me as well.
So what I ended up doing, I kept my basically,
if the as fool at the beginning, then I decrease it to 60%.
And I'm now doing 40%, which practically is that I'm 50%.
So I'm doing 50%.
And it's easy and regional in a big academic center,
(07:54):
which I work with the residents, I do, you know,
lots of research with them.
I'm so happy with that part.
And my private is nurse practitioner,
for nurse practitioner, we have four offices.
And I have four nurse practitioners for MA and my own team
has like five, six other people.
And they have an algorithm that they go over it,
and I help them to see the patient and the follow up.
(08:17):
So that brings a room for my time to magnitude procedures.
So when I'm basically there, I do mainly like, you know,
around 30 procedure per day, on average,
so it's very heavily procedure based.
I can later on talk about how, in my view,
in the last three, four years,
the pain practice has been changed nationwide.
(08:38):
And what what I'm thinking, the way that this goes,
because I'm thinking,
the fellows that from our program went to the pain
fellowship and the resident that I'm talking to and trying
to convince them to go to pain,
there are some barriers that I can talk to them as well.
But before you go there, a question for you.
So you're working for an academic anesthesia practice part
(09:01):
time,
and they're okay with you doing your own private pain practice
on the side, not related?
They are because, basically, I went down for my FTE.
So as far as your FTE goes down, that's fine.
I mean,
they don't care about the time that you are not there,
the time that you are there.
And I'm not doing pain in both sides,
(09:22):
so it's not competitive to their practice.
It actually crushed the river, which is in the noise side.
And do you think you'll transition to full-time pain
eventually?
I like it.
I haven't found the right position to cover a little bit of
academic and research and the pain at the side.
(09:43):
I have to, like everyone else,
the financial aspect of it is very important when you're
young and you have family,
so I have to be careful about what contract I sign and I
don't want to end up being in a place that do two years and
then don't become partnership and at the end I lose money
as well.
(10:04):
Yeah, I'm sorry.
So your pain practice is with others like it's a group
practice or it's on your own or it's a partnership track or
It's a group practice,
but I'm the main pain physician there,
so I'm basically director of the pain platform,
so I'm managing all of the procedures and algorithm and the
protocols and guidelines and everything,
(10:25):
but obviously that's not permanent,
like many other jobs that exist there, but as of now,
I'm happy that I'm doing both.
I'm not sure if that's going to continue anytime,
but I leave at the moment, and at the moment I'm happy.
That's good.
I mean,
it sounds like you figure out a nice little niche in both
worlds, you know, you dabbling between both worlds,
(10:47):
sort of like what I'm doing in a way,
but really just for one practice, but, um, to,
to get the best of anesthesia and the best of pain,
hopefully not the worst of each one.
hydrate.
But, um, so,
so how do you see the landscape of pain management changing
in your practice over the last few years?
Right.
So the thing is, the main thing is,
(11:08):
the way that Medicare and all of these, you know,
private companies, insurance companies are going,
it seems that they're paying more attention to surgery
center,
and they're paying less attention to office-based procedures.
So by...
That in terms of restrictions or in terms of like.
(11:29):
In terms of reimbursement, in terms of reimbursement,
so like just example,
so if you want to get X amount of money,
you have to do let's say 30 procedure per day,
which is a full day procedure to get that amount of money,
but you can do one SI fusion, you can do one CAIFO,
or you can do, you know,
one or two implants in a surgery center,
(11:50):
and you can get maybe three times more than that,
which takes like two hours of your time.
If you own the center, if you own the center.
Exactly.
If you own your center.
So that's why for most of the people that I know of,
they're trying to basically shut down their offices,
or they being in a partnership with their ASC,
(12:12):
and moving towards that path.
And because the bigger reimbursement exists in those big
procedures, your practice needs to go towards that path.
That's why nowadays, many people are doing SI fusion mild,
you know, I don't want to name all of these, you know,
specific brands, but there was a brand to, you know,
(12:33):
do them, jacking this, you know, transverse process,
there was a bunch of brand there now,
they moving shifting to other things.
So, and that's, so that's bring two things.
One is, you have to be, you know,
capable of acting as a surgeon now,
because now you're a microinvasive spine surgeon,
(12:56):
microinvasive ortho surgeon.
And unfortunately, in our fellowship, one year fellowship,
not many people get enough confident to doing those
procedures.
That's one thing.
The other thing is, basically,
the partnership of that ASC becomes more and more tricky
when you're dealing with, you know, ortho group,
and you're doing with spine group that, you know,
(13:18):
have more power.
So that's why, and at the same time, I have to be honest,
at the same time, anesthesia market is so hot.
So post COVID, anesthesia market change tremendously, like,
I was offered like, locum job by like X amount per hour,
now is two weeks, easily, I can get any job, locum,
(13:39):
even the 20 or, you know,
30 minutes drive with two X amount of hour.
And that counts, like,
just imagine how much that will add up in a month or a
year.
So when I'm when I'm trying to convince my residents to go
to pain, the first question is like, okay, financially,
if I go to pain,
I'm gonna end up with this amount of money.
(14:00):
But if I can go to anesthesia is this.
Second, if I go to the pain,
I'm not going to get confident at the end, because,
you know, in one year fellowship,
they have to train you to hold how to hold the needle out
to epidural, this transform and all this and that.
And there is no time to train you well,
with all of those big surgeries that you needed when you
(14:21):
sign up with a big practice and that owns a surgery center,
they want you, they want you to do SI fusion.
How many of anesthesiologists are comfortable to do SI
fusion?
I don't know.
Probably, you know, better than me, that answer.
Right, right.
So that's that the shift that unfortunately is going
through.
(14:41):
And I hope that ABA, you know, soon address the issue,
because it's just changing him changing everything.
Like, because there's I see less and less interest,
unfortunately, in pain fellowship these days,
which in my year, like even four years ago,
it was one of the top fellowship in the country, like,
(15:02):
even compared to like fellowship in the surgery fellowship
in other, you know, fields,
and it's easier fellowship pain was top, I mean,
it was very hard, very competent to get it.
But, but these days are not, it's getting down.
So I'm seeing it going down, to be honest.
It's also very saturated,
it's so much working against us because you have people who
(15:22):
have no business doing epidurals,
trying to learn epidurals.
I teach these courses and sometimes you see people,
like an internist will come into the course and say, oh,
I'm here to do epidurals, I'm like,
you're not doing an epidural here.
I'm like, if you want to learn about it,
I'll talk to you about it,
but you can't just go to a weekend course and learn
epidurals.
You want to learn a knee injection, sure,
anyone can do that,
(15:43):
but the big spine procedures or some of the high-level
stuff, I taught a course,
an ultrasound course a few weeks ago and not to get on
anybody's case,
but an internist came and she wanted to do cellulite
ganglions.
I'm like, well, okay, why?
She's like PTSD and I understand they want to help
(16:05):
patients, make some money, I get that, but I'm like,
first of all, have you ever held an ultrasound?
No.
You don't even know,
the problem is they don't know what they don't know.
They don't know how dangerous it is and how high,
it's one of the highest level ultrasound procedures we do,
so I completely discouraged her and I told her to focus on
(16:29):
the knee injection and I think she understood and she took
that away.
It's scary because they're also in different states, CRNAs,
PAs, nurses, everybody is allowed to,
they allow them to do almost anything in certain states,
(16:51):
and then you have the insurance companies trying to pay us
less,
so you have so many different things working against us.
Absolutely.
I totally agree with you.
Um, yeah, that's, I mean, I just ketamine like, um,
ketamine killing, like they all think that they can,
you know, infuse ketamine without any issues.
(17:12):
So a nurse practitioner are doing it, some, um,
internal medicine doc doing it, um,
psychiatric is doing it.
So it just,
and they give her said like 4 milligram versus and ketamine
infusion, barely a patient can breathe.
So it just, uh, it's very hard.
So, um, when, uh,
when I think we need more relations on all of these.
(17:34):
Absolutely, and you know, it's at the end of the day.
I blame the government because I really think it's there
Are there societies or the state governing bodies?
They're the ones who are supposed to protect the specialty
I mean people are learning to take procedures on YouTube So
it is only so much regulation we could do of ourselves you
know if they're gonna read an article about ketamine and
(17:56):
just do it without any qualifications,
so I Think I need you know the scope of practice needs to
be more clearly defined But so, okay,
so are you doing regenerative medicine?
Pardon me.
Are you doing regenerative medicine in your procedure?
Yes, I do
Yes, I do hyaluronic acids.
(18:17):
For me,
we have actually our office has a patent C for like 25
years on that.
So we have a very defined nice because all of our four
offices have PT inside on site PT.
So that's why they come, they get the injections,
they go to the PT, they come back.
So that's one thing.
And then recently, I'm moving more aggressive about PRP.
(18:39):
Actually, I tore my ACL two, two months ago, soccer play,
don't ask my date of birth, but that I play soccer,
and then I just tore my ACL and I did two injections so far
for myself.
And then my PT was,
was couldn't believe that the progress that I'm making.
So it's I think it's really helpful still that like,
(19:02):
you know, it depends on who reads which article.
But, but for something that doesn't have any harm,
and there's lots of, you know, background research on it.
I, I really excited about it.
At the same time, I'm,
I started collaborating with one of the famous lab at the
(19:23):
SLU,
that they're trying actually to make an artificial PRP.
So it's a, it's a very big collaboration that I made.
So I'm trying to help.
PRP, what do you mean?
They're getting so basically the goal
Right.
The goal is to make it as a powder.
So it doesn't need to be autologous.
(19:45):
So but it can be like as a powder and then you can
basically mix it before injection.
And by the molecular level and the conjunction that can
make and the solubility that can make is something superior
to any hyaluronic acid.
No, it's not.
autologous you're saying it's like from somebody
It's exactly from something that you can buy it.
(20:08):
Well, at that point,
it kind of sounds like it could be endosomes, exosomes,
because exosomes are like really how this stuff works,
right?
It's when the platelets secrete, so or stem cells secrete.
So interesting stuff.
I mean, where do you see the specialty in 10 years?
I think we're going to be a small neurosurgeon,
(20:33):
a small ortho surgeon,
and a little bit of epidural at the side.
But the problem is, their society are strong too.
And I'm sure they go to DC and they lobby as well.
So it depends at the end who meets the battle.
Right, right.
(20:54):
I, you know, in New York,
some of us are doing these fusions,
but not as many as outside New York.
I think outside the state, New York State,
you have a higher percentage of doctors doing the more
minimally invasive surgical thing.
Part of it is reimbursement,
part of it is pushback from the ASCs or from various
practices.
That's my opinion, I don't really have stats on that,
(21:15):
but I do think you're right.
I think we are moving towards neurosurgery and more
regenerative procedures, and I think at the end of the day,
it's really kind of the way their regulations go that are
really gonna shape the way healthcare's going.
Dropping reimbursements,
I think more and more people are gonna be paying more cash
for their care, unfortunately.
Right.
(21:36):
Absolutely.
Because it's just a battle.
It's just, you know,
hard to deal with all of these insurances.
Like for simple like injection,
you have to each of those like insurances have in a like
different algorithm, different pattern, they required MRI,
one required PT, one required this,
one required two injection.
Before doing this, one required five injection.
(21:58):
Before you jump into this,
it's very hard to keep track of all of these different,
you know, insurances and at some point you just gave up.
Right.
That's their hope.
They just want to confuse you so you can't figure out.
Anyway, I'm going to wrap it up sooner.
Is there anything else that you want to say to any young
(22:18):
pain physicians out there listening or maybe even the older
guys and girls?
So I think the new generation are the one who are going to
build this practice and we just need more motivated people
that can work with their hands, you know, as well,
good as well.
And don't be disappointed.
(22:40):
I mean, the good example for it is radiology.
So when I was at Brigham around 2016,
I was actually in the surgery program at Brigham,
at that point, diagnostic radiology went so down,
there was unfilled like,
I can like even 100 maybe spots that was unfilled.
(23:00):
And when I talked to all of these folks there,
they were concerned.
But what they did basically, they review everything,
they publish a couple of data, they said, okay,
in five years, if you continue this,
their diagnostic radiology will die.
And that's how basically they come with the idea of
intervention to be started at the beginning,
not waiting for six years and then having the subspecialty.
(23:24):
And they worked so hard, their society worked so hard,
and now is back to the track and they earn, you know,
as much as they were earning before.
Otherwise, this was so bad,
no one had motivation to go and they were saying, oh,
you can send the radiology report to oversee, you know,
some, you know, Middle East, India,
there are some people there,
they can read it faster than here.
(23:45):
But they took very seriously, and they hold it so hard,
and they didn't lose a job and didn't lose, you know,
that practice.
So I think what we need is the same thing,
we should be keeping hope and we should work hard,
our society, ABA and other paying societies should be,
you know, united to each other and be strong.
(24:07):
Yep.
Sounds good.
Well, I thank you for coming on the show.
I think I 100% agree with you.
And I hope to see you at the upcoming conferences,
either ACIP, Aspen, Pain Week, NYSIP, Latin American Pain,
so whatever.
They keep going.
There's so many conferences.
But anyway,
it was really a pleasure to have you on the show.
(24:29):
Hamid is also volunteer to write some questions for pain
exam.
So I want to thank you for that.
And anyone else out there who's looking to please let me
know.
Thank you, Hamid.
Have a great evening.
Thank you so much for having me.
Same to you.
My pleasure, and we'll be in contact.
Absolutely.
All right.
Take care.
Take care.
Bye.
(24:49):
Dr. Rosenblum is here solely to educate and you are solely
responsible for all your decisions and actions in response
to any information contained herein.
These podcasts are not intended as a substitute for the
medical advice of a physician to a particular patient or
specific ailment.
You should regularly consult a physician and matters
relating to yours or another's health.
You understand that this podcast is not intended as a
(25:11):
substitute for consultation with a licensed medical
professional.
Copyright 2017 David Rosenblum.
All rights reserved.
No part of this publication may be reproduced stored in a
retrieval system or transmitted in any form or by any means
electronic mechanical recording or otherwise without the
prior written permission of See y'all.
Welcome back.
(00:00):
This is a unique podcast in which one of my former pain
exam alumni who took the boards took the pain exam review
And a few other reviews reached out to me to discuss board
prep maybe Collaborating on academic endeavors,
and so I invited him on the podcast.
I hope you guys find this interesting before we get into it
We have a May 17th ultra ultrasound course in New York City
(00:26):
I'm going to most likely be at ASPN as well as pain week at
pain week I'm lecturing on regenerative medicine and
ultrasound guided interventions in your pain practice and
regional anesthesia We also have Latin American pain
society coming up a lot of good things But I also wanted to
(00:48):
tell you about the opportunity to shadow me or my partners
at my office Where we do ultrasound and fluoroscopic guided
procedures.
If you have any interest, please reach out to me.
Look forward to meeting you
It's the Pain Exam Podcast with your host, David Rosenblum,
MD.
(01:26):
Our high yield premium episodes are now available on the
pain exam app with a premium subscription or access for
free with a CME subscription at painexam.com.
And now, without further ado, here's your host,
Dr. Rosenblum.
Welcome back to the pain exam podcast.
(01:47):
And thank you for joining us today.
I'm joined by interventional pain physician
Hamid Sadeghipour . Welcome.
Thank you so much.
Thank you for having me.
And Hamid and I, we connected via the board prep platform,
the pain exam.
And Hamid gave me some honest and real feedback about some
of my questions.
(02:07):
And I actually happened to agree with him.
I think what one of the contention points we discussed
about the board prep was some of the pelvic pain and
headache questions and chest pain questions or HIV
questions, which did not really appear on the boards,
but they did show up on my review and some of those
questions I happened to get from the books,
(02:29):
but that the pain management books at the time I was
writing it and I figured even though I'm updating this
thing every year,
I just leave those questions in because I figured it
couldn't hurt might stress you out a bit when you're
practicing.
But anyway, Hamid,
why don't you just tell us a little bit about the board
prep experience and feel free to share what you'd like to
(02:49):
say about it and your prep journey.
Yeah, so basically, I shop around like,
for a good amount of time, you know, as we all know,
that when you get to a job,
the difference between the pain exam compared to the other
one that we have, or maybe oral board as well is,
at this point, we have a job, you're not, you know,
(03:09):
resident anymore.
So the time is very
Sorry to interrupt.
You're an anesthesiologist, correct?
Yes, yes, I'm in a syllogia.
at the oral anesthesia boards,
which is a whole other animal.
Right.
Or another animal.
And I did crazy about Care Fellowship too,
but that's another animal too.
Right.
And top off to the other one.
Yeah.
So I shop around to make sure that, you know,
(03:30):
with the time that I have,
I can do the best to utilize my time.
And basically I come with three good resources that
actually it worked great at the end.
Those three was Hantun book is the book with,
and I'm going to get a little bit, you know,
description in each of them briefly.
(03:52):
And if needed, we can go deeply as well.
So Hantun book is somehow 800 question covers most of the
topics.
It's written like many years ago, to be honest.
And I actually met Dr.
Hantun when I was looking for a job.
And then I asked him like,
why you're not basically advising this book.
It seems that he's busy that he didn't have enough time to
(04:12):
revise his book, but it's still, I think is a good source.
It has a good explanations.
It just a hard copy is not anything online.
So for it just need a little bit patients to go over those
question when you reading it.
So I know that many of our folks is not friendly with hard
books, but this is the only version that exists.
(04:36):
The second one is board vitals.
It has around 700 multiple question with answers.
The answers is not like what like you world or, you know,
other prep that we had for anesthesia.
Their answers are very short and concise.
So it's easy to go over them and covers questions,
(04:59):
but it has some lack of some subjects that doesn't touch at
all.
Then we come to basically pain exam and other resource that
covers the area that mainly some of the like board vital
doesn't cover, but then give you to some, you know,
areas that I didn't see any question coming from those.
(05:22):
So maybe is like a little bit over prep you for those areas
that doesn't exist in anesthesia.
But I, I know that you already, you know, this,
the aim of this one is for probably other pain boards as
well.
I'm talking about ABA anesthesia board exam,
which on tune and board vitals are mainly for those
(05:44):
anesthesia ABA exam, but pain exam is for, you know,
covers the other ones as well.
So those are three that I went through all of them.
And I actually,
I don't want to bring like exact percentile,
but among whatever I did so far in my exams,
that was very highest percent times that I surprised me
actually.
(06:05):
So I did well on it.
Good, congratulations, that's great.
So tell us about your practice.
So my practice, that's a funny,
other funny story that like, when you come to the job,
it's, you know,
you just open the door that is not familiar to us and no
one during your, you know,
(06:25):
residency or fellowship speaks about details of these jobs.
So I was in LA,
I did my residency and critical fellowship at Cedars-Sinai.
And then I did my pain fellowship at USC.
Then I got the job offer in St.
Louis, that is supposed to be a brand new surgery center.
And that's how they attract me to come to Midwest.
(06:47):
And, but when I come here, unfortunately,
that didn't exist.
It was full of grass.
It was they made it so green.
So because it was during COVID.
And that plan, you know, unfortunately changed.
So I was, I have a very strong background in research.
So I wanted to be an academic and, as you know,
better than me, academic pain,
(07:10):
the turnover is not that much.
So whoever goes there stays,
so it's very job is very limited in pain academic.
So this was, you know,
attracted me because it was academic, it was, you know,
surgery center pain, but but didn't exist.
So I ended up but I have, at that time,
two child now I have three.
So it was family moved from LA to here.
(07:33):
But I was lucky that there was a bunch of, you know,
a private practice around me as well.
So what I ended up doing, I kept my basically,
if the as fool at the beginning, then I decrease it to 60%.
And I'm now doing 40%, which practically is that I'm 50%.
So I'm doing 50%.
And it's easy and regional in a big academic center,
(07:54):
which I work with the residents, I do, you know,
lots of research with them.
I'm so happy with that part.
And my private is nurse practitioner,
for nurse practitioner, we have four offices.
And I have four nurse practitioners for MA and my own team
has like five, six other people.
And they have an algorithm that they go over it,
and I help them to see the patient and the follow up.
(08:17):
So that brings a room for my time to magnitude procedures.
So when I'm basically there, I do mainly like, you know,
around 30 procedure per day, on average,
so it's very heavily procedure based.
I can later on talk about how, in my view,
in the last three, four years,
the pain practice has been changed nationwide.
(08:38):
And what what I'm thinking, the way that this goes,
because I'm thinking,
the fellows that from our program went to the pain
fellowship and the resident that I'm talking to and trying
to convince them to go to pain,
there are some barriers that I can talk to them as well.
But before you go there, a question for you.
So you're working for an academic anesthesia practice part
(09:01):
time,
and they're okay with you doing your own private pain practice
on the side, not related?
They are because, basically, I went down for my FTE.
So as far as your FTE goes down, that's fine.
I mean,
they don't care about the time that you are not there,
the time that you are there.
And I'm not doing pain in both sides,
(09:22):
so it's not competitive to their practice.
It actually crushed the river, which is in the noise side.
And do you think you'll transition to full-time pain
eventually?
I like it.
I haven't found the right position to cover a little bit of
academic and research and the pain at the side.
(09:43):
I have to, like everyone else,
the financial aspect of it is very important when you're
young and you have family,
so I have to be careful about what contract I sign and I
don't want to end up being in a place that do two years and
then don't become partnership and at the end I lose money
as well.
(10:04):
Yeah, I'm sorry.
So your pain practice is with others like it's a group
practice or it's on your own or it's a partnership track or
It's a group practice,
but I'm the main pain physician there,
so I'm basically director of the pain platform,
so I'm managing all of the procedures and algorithm and the
protocols and guidelines and everything,
(10:25):
but obviously that's not permanent,
like many other jobs that exist there, but as of now,
I'm happy that I'm doing both.
I'm not sure if that's going to continue anytime,
but I leave at the moment, and at the moment I'm happy.
That's good.
I mean,
it sounds like you figure out a nice little niche in both
worlds, you know, you dabbling between both worlds,
(10:47):
sort of like what I'm doing in a way,
but really just for one practice, but, um, to,
to get the best of anesthesia and the best of pain,
hopefully not the worst of each one.
hydrate.
But, um, so,
so how do you see the landscape of pain management changing
in your practice over the last few years?
Right.
So the thing is, the main thing is,
(11:08):
the way that Medicare and all of these, you know,
private companies, insurance companies are going,
it seems that they're paying more attention to surgery
center,
and they're paying less attention to office-based procedures.
So by...
That in terms of restrictions or in terms of like.
(11:29):
In terms of reimbursement, in terms of reimbursement,
so like just example,
so if you want to get X amount of money,
you have to do let's say 30 procedure per day,
which is a full day procedure to get that amount of money,
but you can do one SI fusion, you can do one CAIFO,
or you can do, you know,
one or two implants in a surgery center,
(11:50):
and you can get maybe three times more than that,
which takes like two hours of your time.
If you own the center, if you own the center.
Exactly.
If you own your center.
So that's why for most of the people that I know of,
they're trying to basically shut down their offices,
or they being in a partnership with their ASC,
(12:12):
and moving towards that path.
And because the bigger reimbursement exists in those big
procedures, your practice needs to go towards that path.
That's why nowadays, many people are doing SI fusion mild,
you know, I don't want to name all of these, you know,
specific brands, but there was a brand to, you know,
(12:33):
do them, jacking this, you know, transverse process,
there was a bunch of brand there now,
they moving shifting to other things.
So, and that's, so that's bring two things.
One is, you have to be, you know,
capable of acting as a surgeon now,
because now you're a microinvasive spine surgeon,
(12:56):
microinvasive ortho surgeon.
And unfortunately, in our fellowship, one year fellowship,
not many people get enough confident to doing those
procedures.
That's one thing.
The other thing is, basically,
the partnership of that ASC becomes more and more tricky
when you're dealing with, you know, ortho group,
and you're doing with spine group that, you know,
(13:18):
have more power.
So that's why, and at the same time, I have to be honest,
at the same time, anesthesia market is so hot.
So post COVID, anesthesia market change tremendously, like,
I was offered like, locum job by like X amount per hour,
now is two weeks, easily, I can get any job, locum,
(13:39):
even the 20 or, you know,
30 minutes drive with two X amount of hour.
And that counts, like,
just imagine how much that will add up in a month or a
year.
So when I'm when I'm trying to convince my residents to go
to pain, the first question is like, okay, financially,
if I go to pain,
I'm gonna end up with this amount of money.
(14:00):
But if I can go to anesthesia is this.
Second, if I go to the pain,
I'm not going to get confident at the end, because,
you know, in one year fellowship,
they have to train you to hold how to hold the needle out
to epidural, this transform and all this and that.
And there is no time to train you well,
with all of those big surgeries that you needed when you
(14:21):
sign up with a big practice and that owns a surgery center,
they want you, they want you to do SI fusion.
How many of anesthesiologists are comfortable to do SI
fusion?
I don't know.
Probably, you know, better than me, that answer.
Right, right.
So that's that the shift that unfortunately is going
through.
(14:41):
And I hope that ABA, you know, soon address the issue,
because it's just changing him changing everything.
Like, because there's I see less and less interest,
unfortunately, in pain fellowship these days,
which in my year, like even four years ago,
it was one of the top fellowship in the country, like,
(15:02):
even compared to like fellowship in the surgery fellowship
in other, you know, fields,
and it's easier fellowship pain was top, I mean,
it was very hard, very competent to get it.
But, but these days are not, it's getting down.
So I'm seeing it going down, to be honest.
It's also very saturated,
it's so much working against us because you have people who
(15:22):
have no business doing epidurals,
trying to learn epidurals.
I teach these courses and sometimes you see people,
like an internist will come into the course and say, oh,
I'm here to do epidurals, I'm like,
you're not doing an epidural here.
I'm like, if you want to learn about it,
I'll talk to you about it,
but you can't just go to a weekend course and learn
epidurals.
You want to learn a knee injection, sure,
anyone can do that,
(15:43):
but the big spine procedures or some of the high-level
stuff, I taught a course,
an ultrasound course a few weeks ago and not to get on
anybody's case,
but an internist came and she wanted to do cellulite
ganglions.
I'm like, well, okay, why?
She's like PTSD and I understand they want to help
(16:05):
patients, make some money, I get that, but I'm like,
first of all, have you ever held an ultrasound?
No.
You don't even know,
the problem is they don't know what they don't know.
They don't know how dangerous it is and how high,
it's one of the highest level ultrasound procedures we do,
so I completely discouraged her and I told her to focus on
(16:29):
the knee injection and I think she understood and she took
that away.
It's scary because they're also in different states, CRNAs,
PAs, nurses, everybody is allowed to,
they allow them to do almost anything in certain states,
(16:51):
and then you have the insurance companies trying to pay us
less,
so you have so many different things working against us.
Absolutely.
I totally agree with you.
Um, yeah, that's, I mean, I just ketamine like, um,
ketamine killing, like they all think that they can,
you know, infuse ketamine without any issues.
(17:12):
So a nurse practitioner are doing it, some, um,
internal medicine doc doing it, um,
psychiatric is doing it.
So it just,
and they give her said like 4 milligram versus and ketamine
infusion, barely a patient can breathe.
So it just, uh, it's very hard.
So, um, when, uh,
when I think we need more relations on all of these.
(17:34):
Absolutely, and you know, it's at the end of the day.
I blame the government because I really think it's there
Are there societies or the state governing bodies?
They're the ones who are supposed to protect the specialty
I mean people are learning to take procedures on YouTube So
it is only so much regulation we could do of ourselves you
know if they're gonna read an article about ketamine and
(17:56):
just do it without any qualifications,
so I Think I need you know the scope of practice needs to
be more clearly defined But so, okay,
so are you doing regenerative medicine?
Pardon me.
Are you doing regenerative medicine in your procedure?
Yes, I do
Yes, I do hyaluronic acids.
(18:17):
For me,
we have actually our office has a patent C for like 25
years on that.
So we have a very defined nice because all of our four
offices have PT inside on site PT.
So that's why they come, they get the injections,
they go to the PT, they come back.
So that's one thing.
And then recently, I'm moving more aggressive about PRP.
(18:39):
Actually, I tore my ACL two, two months ago, soccer play,
don't ask my date of birth, but that I play soccer,
and then I just tore my ACL and I did two injections so far
for myself.
And then my PT was,
was couldn't believe that the progress that I'm making.
So it's I think it's really helpful still that like,
(19:02):
you know, it depends on who reads which article.
But, but for something that doesn't have any harm,
and there's lots of, you know, background research on it.
I, I really excited about it.
At the same time, I'm,
I started collaborating with one of the famous lab at the
(19:23):
SLU,
that they're trying actually to make an artificial PRP.
So it's a, it's a very big collaboration that I made.
So I'm trying to help.
PRP, what do you mean?
They're getting so basically the goal
Right.
The goal is to make it as a powder.
So it doesn't need to be autologous.
(19:45):
So but it can be like as a powder and then you can
basically mix it before injection.
And by the molecular level and the conjunction that can
make and the solubility that can make is something superior
to any hyaluronic acid.
No, it's not.
autologous you're saying it's like from somebody
It's exactly from something that you can buy it.
(20:08):
Well, at that point,
it kind of sounds like it could be endosomes, exosomes,
because exosomes are like really how this stuff works,
right?
It's when the platelets secrete, so or stem cells secrete.
So interesting stuff.
I mean, where do you see the specialty in 10 years?
I think we're going to be a small neurosurgeon,
(20:33):
a small ortho surgeon,
and a little bit of epidural at the side.
But the problem is, their society are strong too.
And I'm sure they go to DC and they lobby as well.
So it depends at the end who meets the battle.
Right, right.
(20:54):
I, you know, in New York,
some of us are doing these fusions,
but not as many as outside New York.
I think outside the state, New York State,
you have a higher percentage of doctors doing the more
minimally invasive surgical thing.
Part of it is reimbursement,
part of it is pushback from the ASCs or from various
practices.
That's my opinion, I don't really have stats on that,
(21:15):
but I do think you're right.
I think we are moving towards neurosurgery and more
regenerative procedures, and I think at the end of the day,
it's really kind of the way their regulations go that are
really gonna shape the way healthcare's going.
Dropping reimbursements,
I think more and more people are gonna be paying more cash
for their care, unfortunately.
Right.
(21:36):
Absolutely.
Because it's just a battle.
It's just, you know,
hard to deal with all of these insurances.
Like for simple like injection,
you have to each of those like insurances have in a like
different algorithm, different pattern, they required MRI,
one required PT, one required this,
one required two injection.
Before doing this, one required five injection.
(21:58):
Before you jump into this,
it's very hard to keep track of all of these different,
you know, insurances and at some point you just gave up.
Right.
That's their hope.
They just want to confuse you so you can't figure out.
Anyway, I'm going to wrap it up sooner.
Is there anything else that you want to say to any young
(22:18):
pain physicians out there listening or maybe even the older
guys and girls?
So I think the new generation are the one who are going to
build this practice and we just need more motivated people
that can work with their hands, you know, as well,
good as well.
And don't be disappointed.
(22:40):
I mean, the good example for it is radiology.
So when I was at Brigham around 2016,
I was actually in the surgery program at Brigham,
at that point, diagnostic radiology went so down,
there was unfilled like,
I can like even 100 maybe spots that was unfilled.
(23:00):
And when I talked to all of these folks there,
they were concerned.
But what they did basically, they review everything,
they publish a couple of data, they said, okay,
in five years, if you continue this,
their diagnostic radiology will die.
And that's how basically they come with the idea of
intervention to be started at the beginning,
not waiting for six years and then having the subspecialty.
(23:24):
And they worked so hard, their society worked so hard,
and now is back to the track and they earn, you know,
as much as they were earning before.
Otherwise, this was so bad,
no one had motivation to go and they were saying, oh,
you can send the radiology report to oversee, you know,
some, you know, Middle East, India,
there are some people there,
they can read it faster than here.
(23:45):
But they took very seriously, and they hold it so hard,
and they didn't lose a job and didn't lose, you know,
that practice.
So I think what we need is the same thing,
we should be keeping hope and we should work hard,
our society, ABA and other paying societies should be,
you know, united to each other and be strong.
(24:07):
Yep.
Sounds good.
Well, I thank you for coming on the show.
I think I 100% agree with you.
And I hope to see you at the upcoming conferences,
either ACIP, Aspen, Pain Week, NYSIP, Latin American Pain,
so whatever.
They keep going.
There's so many conferences.
But anyway,
it was really a pleasure to have you on the show.
(24:29):
Hamid is also volunteer to write some questions for pain
exam.
So I want to thank you for that.
And anyone else out there who's looking to please let me
know.
Thank you, Hamid.
Have a great evening.
Thank you so much for having me.
Same to you.
My pleasure, and we'll be in contact.
Absolutely.
All right.
Take care.
Take care.
Bye.
(24:49):
Dr. Rosenblum is here solely to educate and you are solely
responsible for all your decisions and actions in response
to any information contained herein.
These podcasts are not intended as a substitute for the
medical advice of a physician to a particular patient or
specific ailment.
You should regularly consult a physician and matters
relating to yours or another's health.
You understand that this podcast is not intended as a
(25:11):
substitute for consultation with a licensed medical
professional.
Copyright 2017 David Rosenblum.
All rights reserved.
No part of this publication may be reproduced stored in a
retrieval system or transmitted in any form or by any means
electronic mechanical recording or otherwise without the
prior written permission of See y'all.
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