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Is this part of my new grad job a red flag or is it normal? Ortho/spine

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So Im a new grad and left a ridiculous urgent care job because of crazy high patient load and not really learning anything...

listened to all your advice and went on a few interviews.. I was enticed at this orthopedic + spine interview that entailed 2 days OR+ 3 days office/wk ~20 pts a day/8hr shift (an hour lunch break factored in) and thought it over for a week and decided to take it;. I liked the offer 125k 40hr/wk 20 day pto, full benefits and occurance/tail end malpractice coverage, 10 min drive from home. I also verbalized my concerns of not wanting to work in a high liability arena as a new grad and he said he understood. 

During the interview, . The surgeon (employer) told me that only 20% of the patients are on opioids and that they have been cutting down on this number over the years, they dont take new pain management cases, and they actively try to ween them off meds. He also assured me that this would be a more "sophisticated" experience that would give me a backbone into a specialty

Today on my first day of work, Ive noticed that maybe 50-60% of the patients were on some sort of opioid, granted it seemed like a low dose PRN, and its been the same drug for years,  and the patients so far have seemed like educated middle class backgrounds but obviously I know this profiling can only go so far. The PMR doc who works in the practice is super laid back and honest told me that this practice used to have a HUGE problem with opioids 5-6 years ago but since he was added to the practice, and with the help of the last PA, they now have it under control confidently. he also says that 50%  of pts on opioids is a more realistic # than 20%. He also chuckled that the doctor sort of just threw me into see a few patients to see how I swam today and hasn't really taught me the first thing of opioids yet. The PMR doc said that I would not be at a liability risk and he wouldn't have stayed himself for 6 years if he felt there was one. the previous PA was also there for 4 years which I know for a fact (my friend knows this pa currently)

At the end of my shift I told the surgeon again that I would need to be trained on opioids as I know nothing and he said it would happen

The surgeon today was incredibly busy going from one patient to another then dictating charts. we saw one-two interesting pre op cases, a few postop checks, but the rest were basically all refills. he seemed to be more focused on getting me introduced to the groove of the patient schedule rather than the medical care portion of the job. 

 

I Know its only the first day.. but I dont want to end up working in a PMR practice as a new grad when I had these ideas in my head that it would be a purely orthopedic surgery practice.... unless this is just how the game works

 

Any thoughts would be appreciated...

I like the idea of specializing in ortho. I dont want people to read this and think im just job chasing for salary.. although it a nice benefit 

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I would relax as it was only your first day.  You should be getting the feel for how the practice/schedule flows as the surgeon told you.  

Being that you are a certified PA, hold a license to practice, and presumably having a DEA, you should already be trained on opioids.  With such high stakes involved with prescribing opioids, only you can make sure you prescribe them oppropriately.  You can discuss safe prescribing with the surgeon and PMR, but it all falls back on you if your name is on the RX.  Make sure you are aware of all state requirements when prescribing if there are any restrictions.  

On a side note.....I think an ortho surgeon seeing a lot of patients for opioid refills and not pre/post-op visits is...well not the norm.  In my experience the ortho practice I've been at does ZERO chronic pain managment.  Nobody comes in for a refill of an opioid unless they just had surgery.  They are referred to pain management if we can't fix them with surgery or injections.  It could be nothing, but also could be something.  

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^Agreed.

Like you said, it was just the first day. However, ortho is a high liability field so your notion of not working in a high liability field is out the window. And it's ortho-spine which includes back pain. It could turn out that you saw a unique day, but heavily consider what current providers are saying. Why did the previous PA leave? Is your surgeon purely spine? Does he take ortho call? Why is he managing chronic pain as a surgeon? Is it just lack of due diligence because he's too busy to bother and instead just refills anything or does he like the influx of paid visits? 

If we have people with chronic pain in our ortho trauma practice, we refer out after a period of time. We are not chronic pain specialists 

If you look around on this forum, there are quite a few stories of getting into a job and then seeing that it isn't what they thought... However, I don't think one day is quite enough time to completely gauge a practice.

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You are a PA, with a masters degree.

You don't need someone to teach you about opioids.

If you don't already know (and you SHOULD!),  then do some self-learning kid!

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People acting like you can know everything right out of school or at any point. Sure, you can self educate, but there is nothing wrong with asking for assistance in areas of known deficits. Good job on you for recognizing. Catch yourself up as much as possible and take the extra training and do not harm. 

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I don't think the question is about opioids, but the role of chronic pain management in an ortho practice, especially when it was sold as "cutting down".  

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If it isn't provided through the group, it might be beneficial to invest some of your CME money into a subscription for Dynamed or Up-to-Date. 

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You need to relax. You’re all over the place. Don’t expect someone to hold your hands. You will learn as you go. Stop listening to others. Figure it out yourself. You’re now a medical professional. Pain mgmt is a huge component of spine surgery. So prepare to deal with it. You sign up for the job. CME! CME!! This is coming from a formal neurospine PA. Just my 0.2cents.

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Give yourself some time to figure it out. There is still a lot of opioid use in ortho and there is a lot of residual from the days of pain being the 5th vital sign and any amount of pain meds was OK. Just because medicine flipped the switch on opiods doesn't mean those patients who were on high dose opioids for years (which we willingly gave them) still have to be managed and the slow and easy plan of weaning, not taking new pain patients seems pretty reasonable to me. IMO all long term opioid patients who are not having interventions performed by ortho should be in pain management.

Take a breath. Give it a while. Nothing about this sound wonky to me.

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Ortho Spine is not distinctly like Ortho, Ortho Trauma or Sports Ortho. I have worked in all of these.

Ortho Spine involves a lot of PM&R, EMGs, ESIs, psychology of pain, rehabilitation and much less surgery.  Only 3% of all back pain needs surgery. That means that the 97% other percent need rehab and more rehab. 

Disclaimer -- I am old and came out of spine before cages and disc replacements - things have indeed changed.

If you want get up and go surgery with multiple skills and casting and reducing fractures and trauma - wrong office.

There is a PMR guy in the office - so - I hear EMGs, injections, maybe trigger points, etc. That is good in my book.

I hear opioids and that is a little less great. In my area - NO ORTHO - PERIOD - does chronic pain. Perhaps this doc got caught up and is now trying to render aid to reduce large doses - kudos. 

You can check a prescribing record on a provider in most state PMPs. You can check the doc's state license to see if he/she has received dings or instruction on anything and malpractice. If you find hokey things - then, there you are. 

From reading your discussion - I hear that things don't "move" in this office and you are going to get bored. Back pain is - well - back pain - and neck pain and dysfunction. LOTS of psychology. Lots of rehab. Lots of time. 

Look at the daily patient log and amount and types of surgery and think about it. 

And, I agree - you should know something about opioids without someone teaching you now. Read up on state regs and current data, trends, etc.

My gig at the VA - I have to stay below 50 MEDD and no mixing with benzos - I don't have to worry about it - it's just not legal. I have an entire pharmacy staff behind me looking at all the rx's and even a pain specialist PharmD to help with tapers. Not bad at this stage in my career - in my opinion.

Just my old 2 cents

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