The demise of interventional pain-The rise of minimally invasive spine surgery

The history of medicine is without question characterized by the constant of change, and none more so evidently than in the field of spine over the last two decades. Approximately twenty-five years ago physicians trained in the field of regional anesthesia started to branch out into the interventional-based management of chronic pain syndromes, moving away from the traditional anesthesiologists. This innovative group of physicians saw an opportunity to expand their scope of practice and build a business outside of the hospital, which would allow them to escape the cruel politics of the corporate hospitals.

Interventional Pain as a coherent group began in the mid 1990s, with primarily anesthesiologists performing the procedures consequent to their advanced spinal regional skills. However it did not take long before other specialties, such as internal medicine and family practice jumped on the bandwagon, assuming the moniker of pain management physicians. It was not difficult for me to see the beginning of the end for interventional pain, which as far as I remember commenced about 2000. Realising that the writing was on the wall I did not need to get any closer to the wall, to know what I had to do to protect my professional and business interests.

At about the same time the emerging field of minimally invasive spine surgery was beginning to make its mark around the world, and I consciously sought out surgeons who I considered pioneers and I would ensure I spent time with these individuals acquiring their knowledge and skills. I quickly realized that if I was going to stand a chance of survival in the competitive medical market I would have to differentiate myself from every other pain management physician, which would involve becoming very proficient in minimally invasive spine surgery.

From 2002 to 2012 I travelled the world extensively teaching and training surgeons in the field of MISS, making the attainment of clinical excellence my main goal. As I developed the skills, and established the practice back in the US, I was also able to observe the constant attacks by the insurance companies on the interventional pain doctors with a relentless campaign to lower their fees and demoralize their professional standing. I attempted on several occasions to persuade these doctor that if they did not advance their practice into MISS they would eventually fall prey to the insurance onslaught against pain management. What surprised me about most of these doctors was their ‘head in the sand syndrome’, and despite my persuasive arguments about the importance of expanding their scope of practice in a unified manner, their professional egos most likely prevented then from agreeing with my reasoned arguments. I knew the day would come when their ability to run a financially viable business would end and that day is sadly almost upon them.

Minimally Invasive Spine Surgery is now the ‘golden boy’ of spine care and will predictably set the standard for spine surgery of the next decade. I commenced my career in this specialty in 2002 and was able to develop a large practice, good reputation and build my own Medicare certified surgical center. This model should have provided an example to other interventional pain doctors but sadly the majority of them were either too afraid of the professional attacks they thought the neurosurgeons would launch, and meekly chose to continue on their bread and butter track. This strategy has failed miserably and it can be almost guaranteed that within the next five years the majority of interventional pain procedures will be performed by nurse practitioners, who the insurance companies will pay a fraction of the fee they paid the doctor.

The physicians have only themselves to blame for this pathetic situation and despite the warning and multiple suggestions that they expand their practice to include MISS they did not, most likely out of fear. The great irony is that the situation they are now facing is of greater concern and one, which potentially could end their careers entirely. It is my opinion that these doctors should have had the courage to take the MISS bull by the horns and make it theirs. It is no secret that I have been involved in one of the largest and most high profile professional battles known widely as The Spine Turf Wars, in which I fiercely fought the New Jersey medical board as they attempted to curtail the scope of practice. The expectation of the main protagonists was that I would dutifully pack my bags and leave the country, which, obviously I did not. I remained in the US to fight a very important battle that had consequences for a large part of the spine community.

The fight is not yet over and there are now many countries around the world in need of minimally invasive spine surgical services that would gladly welcome physicians from the interventional pain and radiology communities. This changing demographic with the ever increasing trend of medical tourism will inevitably result in a reduction of volume of patients treated in countries that fail to allow physicians to practice in sync with advancing technology. Medicine is moving into an entirely new era where digital based tools and communication strategies are becoming the standard. This ‘new world’ takes the parochial power away from local medical licensing boards and puts it straight into the hands of the consumer who will choose his of her surgeon based on their skills, outcomes, expertise and not whether they possess privileges at some politically charged rinky dink hospital in New Jersey.