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13 Articles in Volume 18, Issue #7
A Commentary on Medical Cannabis
Are Abuse-Deterrent Opioids Appropriate for Your Pain Patient?
Behind the AHRQ Report
Challenges Facing Abuse-Deterrent Formulations
Demystifying Opioid Abuse-Deterrent Technologies
Editorial: Our Clinical Pain Neighborhood
Independent Pain Practice: A Case Example
Inside Performing Arts Medicine
Letters to the Editor: ACT Therapy; Compounded Topicals
Nerve Growth Factor and Targeting Chronic Pain
Pain Control for Athletes: What Works?
Quality Training: One Center’s Experience with Pain Assessment
The Importance of Developing Professional Relationships in Pain Practice

The Importance of Developing Professional Relationships in Pain Practice

Specialized clinicians treating patients with a variety of pain-related conditions may improve overall outcomes by fostering relationships with other healthcare professionals.

The Perspective of a Functional Neurosurgeon

As a neurosurgeon or spine surgeon, it is important not only to be able to treat patients throughout their disease process but also to offer therapies when their pain persists following a surgery. A radiographic and technically successful surgery does not always translate into a positive outcome for the patient, and it is well known that 30 to 40% of spine surgery patients will develop failed back surgery syndrome (FBSS).

By providing collaborative care opportunities from the start, a physician can reinforce the provider-patient relationship as well as the practice’s standing in the medical community. For a surgeon in particular, this effort may be in realizing that surgery is not always the only option. For a pain physician, this effort may involve working closely with the patient’s primary care physician and surgeon to ensure that different therapies are made available at different points in the care spectrum. The overall key to a successful patient outcome is being able to reach beyond one’s own toolbox and guide the patient through a treatment algorithm that involves multiple practitioners.

While the following recommendations are geared toward spine surgeons, based on the author’s experience, these strategies have application to any provider practicing in today’s healthcare environment.

Shaking hands.Specialized clinicians treating patients may improve overall outcomes by fostering relationships with other practices. (Source: 123RF)

Connect, Refer, Share

Most physicians prefer to utilize a screening trial prior to permanent implantation of a therapeutic device or system, such as a spinal cord stimulator (SCS). However, few modalities allow for an adequate trial to predict the efficacy of the system. Within the spine surgeon community, a screening trial with 50% pain relief, in most cases, warrants permanent implantation. Once this approach is settled on, there are several relationships to forge and maintain throughout the patient’s care.

Build a Referral Network

It is crucial to establish a proper referral network, including an upfront determination of who will perform the potential therapies including the trial and permanent implant. Some providers develop a “niche” and serve as the go-to physician in the community that offers such therapies. Others work with an interventional pain physician/surgeon with expertise in these therapies. Either way, building a network with these providers enables the “sharing” of patients and the provision of multidisciplinary therapies to patients living with chronic pain. Once referral relationships are established, it is important to maintain the relationships for optimal practice growth and reputation building.

Appreciate Each Other’s Skills

The pain practitioner typically offers first-line treatment for patients with chronic pain before—and after—referral to surgery. He or she initially identifies a patient for a surgical procedure, performs a trial of the therapy, and, based on the outcome, either moves forward with a referral to a surgeon for permanent implantation or tries a different therapy. The surgeon confirms (or denies) the patient’s candidacy for the procedure, determines the specific surgical procedure to be utilized, and creates the post-operative care plan. The surgeon also helps to determine next steps in the patient’s treatment plan after surgery.

By discussing key questions together, the pain physician and surgeon can work toward the best outcome for the patient. For instance, is it time to proceed with surgery? Is it time for a repeat surgery/intervention? Is an initial surgery warranted over an intervention? Is a different kind of therapy trial warranted?

This relationship should not remain static, but rather, be moldable and dynamic based on individual patients. For instance, in some cases, the pain physician may conduct a permanent implantation. In other cases, it may be determined that an interventional SCS does not necessarily preclude spinal surgery later, or that a patient does not have to exhaust all spinal interventions to be considered a candidate for SCS.

A strong relationship between the pain physician and the surgeon may help to ensure that these roles are effective and mutually beneficial for each other and for the patient. Strong relationships may also span those patients who have undergone successful spinal surgery, and yet, continue to have ongoing pain. Remember that relationships among healthcare providers are not simply “favors.” A pain physician should treat a patient upon referral from a surgeon, and vice versa, regardless of the choices made or the outcomes determined. Followup and continual care represent an extension of that relationship.

Reap the Business Benefits

In a successful pain physician-surgeon relationship, an implanting surgeon may be able to increase his or her case volume and reimbursement, thereby building a niche in the community with a steady referral base. Common referrals might include evaluation for surgery versus a SCS, which impacts both providers as they share responsibility for the patient.

Financial incentives for in-office and Ambulatory Surgical Center (ASC) SCS trials may be favorable for pain physicians. This is especially true when the length of the procedure is kept reasonable and the practitioner is able to continue with normal office procedures, such as the performance of injections. This is not the case for surgeons, however, who may lose a substantial amount of operating room (OR) time to account for room turnover to perform a trial. For them, a permanent implant may be more favorable as they are able to use dedicated OR time and maintain efficiency in the procedure.

Model Your Practice with the Times

Healthcare providers are living in an era where specialty care has become crucial in medicine. Patients living with chronic pain conditions are housed in multiple areas of disciplinary care. A patient with peripheral neuropathy, for example, may be working with a primary care physician, a neurology group, a podiatrist, and a pain physician. It is imperative, therefore, to think outside the box and look for these patients in multiple locations.

Experienced physicians can work to educate other providers on the variety of care that is available. In chronic back pain alone, interventional treatment options may include dorsal root ganglion (DRG) stimulation, neuromodulation, and SCS. The premise of understanding these specialties and their necessary relationships will bring physicians together for the best possible patient outcomes.

Last updated on: October 3, 2018
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Independent Pain Practice: A Case Example
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