InterviewsMedicalPhysician Q&A

20 Questions: David Russo, DO, Pain Medicine and Physiatry

John T. Sinnott
Russo

Recently The Student Doctor Network interviewed David Russo, DO, who specializes in interventional pain medicine and physiatry in private practice at Columbia Pain Management in Hood River, Oregon. Thanks for the interview, David!

Describe a typical day at work.
The scope of practice and breadth of issues that patients bring through the door makes for a very heterogeneous practice.

Usually my day involves a blend of office-based practice, office-based procedures, and occasionally hospital work as well. We’re in a smaller community, so the practice takes more of a generalist orientation within the specialty.

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We have our own fluoroscopy suite and do essentially all of our neuraxial procedures in the office. Intrathecal catheters and spinal cord stimulator implants are done in the OR.

My base specialty training is in physiatry, so our group is also involved in directing a small inpatient rehabilitation unit in the community. The majority of our referrals are from primary care physicians seeking recommendations for optimizing pharmacologic management and referrals for interventional pain procedures. We also do workman’s compensation evaluations and independent medical examinations. There is a lot of chronic pain management, and that population can be very challenging, but these are the patients who really need sub-specialty recommendations and management the most.

If you had it to do all over again, would you still become a doctor? (Why or why not? What would you have done instead?)
I wanted to be a doctor for as long as I can remember. I think that I dressed up as a doctor for Halloween once. That doesn’t mean that I didn’t seriously consider other professions. I’ve always felt that my alternate career might have been in something like management consulting or organizational psychology. I’m fascinated by how groups of people work or don’t work well together.

Why did you choose your specialty?
Physical Medicine & Rehabilitation (physiatry) appealed to my sense of order and organization. It involves coordinating care and bringing a team of professionals together for a common good—maximizing a patient’s function. I found the broad orientation of the field and its focus on functional restoration instead of strict disease management intriguing. My interests bounced around between family medicine, neurology, and anesthesiology before deciding on PM&R. I felt that the addition of a pain medicine fellowship and training was key because it really broadens your repertoire—adds more arrows in your quiver, so to speak! Interventional pain medicine allows you to be a “thinker” and a “doer” in medicine.

Did you plan to enter your current specialty prior to med school?
No, I didn’t know what kind of doctor I wanted to be. I had exposure to neurology, psychiatry, infectious diseases, and public health before starting medical school. It was serendipity that one month before starting medical school I met a physiatrist in the neurology department where I worked as a research assistant. After I was accepted to medical school, the admission office assigned me a faculty mentor who was a physiatrist. Finally, during medical school, my mother was diagnosed with a terminal illness, and I saw how important pain management is for quality of life. Things just started falling into place.

Now that you’re in your specialty, do you find that it met your expectations?
Yes, but medicine as a whole has been more disillusioning than I expected. It’s like not ER, House, Grey’s Anatomy, Marcus Welby, or any of the other popular depictions. The doctor-patient relationship has become increasingly more complicated. There are a lot of interests and issues at stake in healthcare these days, and in some fashion those issues converge on the doctor-patient relationship.

Moreover, both pain medicine and physiatry involve what I like to call “Humpty-Dumpty Medicine.” You’re called after all the other specialists have told a patient that “there’s nothing left to do” or “you’re just going to have to live with it.” Often, there are still many things to try or modalities to optimize, but you’re always left feeling a little frustrated that you weren’t involved earlier in things. In a system with more coordinated and integrated health care, interventional pain medicine and physiatry would ideally be involved earlier in the continuum of care.

Still, there is no greater satisfaction that relieving someone’s pain and suffering. When a patient tells me that they’re able to do more because their pain is managed, that they can participate in their family or careers more fully because of an intervention I made, that’s the pay off.

Are you satisfied with your income?
For the time being, I feel like the reimbursement is commensurate with the level of complexity, skill requirement, and risk in the field. There is a continuous and exhausting downward pressure on reimbursement by third-party payers and managed care organizations. Physicians need to be involved and at the table justifying what they do.

What do you like most and least about your specialty?
The complexity I’ve alluded to is both a blessing and a curse. I didn’t realize that chronic pain was such a socially stigmatizing condition until I got into this field, but it is and patients bring that baggage with them into the examination room. Patients living with chronic pain have usually been seen by many other physicians before they get to my door. They are not exactly every doctor’s favorite kind of problem. Along the way, patients with chronic pain have absorbed a lot of accurate and inaccurate information about their condition. You have to be willing to sit down and get to know them and try to change some of the attitudes that they may have absorbed from other providers. Sometimes there are medico-legal compensation issues, vocational and occupational issues, and psychosocial issues that give patients an incentive to “stay sick.” That’s tough. The technical/procedural and technical part of the field is great, but you also have to be willing to do the other piece just as well if you really want to help people. Not every solution is at the tip of a needle.

If you took out educational loans, is paying them back a financial strain?
I call my monthly student loan payment the “summer home I’ll never own.” It’s not a strain yet, but it’s impressive how all that compounded interest catches up with you!

On average: How many hours a week do you work? How many hours do you sleep each night? How many weeks of vacation do you take?
Hard to say: we only see patients in the office four days per week but work 10 to 12 hour days. When you add the hospital work, it approaches 50 to 60 hours per week. I need my sleep, so I make that a priority. I like to travel, so I take not less than three weeks of vacation per year.

Do you have a family and do you have enough time to spend with them?
So far, it has not negatively impacted time with my family. But, you have to make time away from work a priority no matter what you do.

In your position now, knowing what you do – what would you say to yourself 10 years ago?
RUN LIKE THE WIND! No, seriously, I would have said, “Try to enjoy the process.” Everyone focuses on the “outcome,” getting into medical school, getting a good residency, getting the best job, etc. Things would have been easier if I had been a little more Zen and lived in the “present tense” as a medical student and pre-med. It is so hard to do when the process conditions you to think and behave in just the opposite way.

What information/advice do you wish you had known when you were a premed? (What mistakes or experiences have you encountered that you wished you had known about ahead of time so you could have avoided them?)
Instead of shadowing doctors who have already completed their training, try to spend time with medical students and residents who are in the thick of it. Try to get a feel for what the next eight to 10 years of your life are going to be like before jumping in both feet first. If you’re not prepared, I have come to believe that medical education sort of emotionally stunts people. You become completely absorbed by the process while you’re studying and working 12 to 14 hours per day, taking long calls in the hospital, and enduring the many rituals, rites, and hazing of medical education while your friends from college are having “real lives.”

The reality is that your life is just as real, but you’d better be prepared to be the low man on the totem pole for a long time. When you’re a student or resident, everyone has something “over” you: the nursing staff, your attendings and senior residents, the medical school, etc. Everywhere you turn, someone is grading you, evaluating you, measuring you, ranking you, etc. Meanwhile, your non-physician friends are moving up in their jobs, becoming more senior in stature and acquiring authority in their companies, buying first homes, enjoying salary raises, and spending time with family and friends. Ultimately, medical education is a sacrifice paid for the privilege to be a physician.

Read House of God. It’s getting a little dated, but it gets the big picture right. Then read Catch-22. It’s also dated, but it provides a beautiful example of the kind of “cognitive flexibility” required at times to survive in an absurd environment.

From your perspective, what is the biggest problem in healthcare today?
Healthcare costs and financing. Fundamentally, our society will have to decide if healthcare is an entitlement or a commodity. The outcome of that decision will change everything.

From your perspective, what is the biggest problem within your own specialty?
There is a lack of evidence-based medicine in both pain medicine and physiatry. Both fields still suffer from the influence of various “cults of personality.” The fields need to evolve past this stage and begin tackling basic questions about the nature of nociception, tissue healing, and neurologic recovery of function.

What impact do mid-level providers have on your day-to-day practice?
We use physician extenders in our practice to assist with follow-ups, medical management, and new consults. They are an asset.

Where do you see your specialty in 10 years?
I think the indications for neuromodulation and spinal cord stimulation are going to increase. I think that surgical approaches to pain management are going to become more refined, especially with respect to peripheral nerve disorders. New neuropathic drugs and analgesics are on the horizon. There is an emerging appreciation of the psychoneuroendocrinology of pain and its treatment. I hope that the field has the fortitude to stay true to its roots and remain broad and comprehensive and not attempt to over-simplify things. When it comes to pain, I like the expression, “For every complex problem, there is a solution that is simple, neat, and completely wrong.” Some speculate that pain medicine could become its own specialty, but I think that field is fed and nourished by its multidisciplinary make-up.

What types of outreach/volunteer work do you do, if any? Any international work?
I’m actively involved in health policy and advocacy. Physicians need to catch up with other groups and get their voices heard in the political arena. We have a lot of credibility, and I believe that being politically active on behalf of our patients is a moral duty.

Favorite TV Show?
The Office.

Leno or Letterman?
Letterman.

Artwork by Brandon Luk

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I'm very interested in discussing possible collaboration between SDN and your organization. I'll call you this afternoon.
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SDN Administrator
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    Keith Fairbanks
  • June 21, 2007
Surprised there was not question about incorporation of OMT into his PM&R practice.
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    HolisticMed
  • June 21, 2007
Disappointed about the fact that there was no mention of OMT in this interview - certainly, suprised - unfortunately not.
A few weeks ago SDN interviewed an osteopathic opthalmologist and of course there were no questions/answers in which the word OMT was ever used. But with an opthalmologist... I perhaps can understand.
But an osteopath physiatrist... cmon, the problem here isnt SDN, its the doc. A national forum composed of virtually all health care providers(SDN), a public environment in which very few know about osteopathic medicine... and you dont even make mention to the core of what your degree stands for... He deals with neuromusculoskeletal complaints every single day... its very very upsetting.
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    David Russo
  • June 21, 2007
Holistic and Keith,
I'm a strong advocate for OMT and manual medicine. In fact, I have a research background in manual medicine and MSK pain. I moderate the OMT Online Journal Club on SDN. I often prescribe, and occasionally personally perform, manual medicine treatment for my patients.
Still, all manual modalities are essentially passive in nature. While it is often indicated for some acute MSK problems, it is generally not very effective for chronic pain problems. In this setting, it is not an optimal therapy for patients.
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    David Russo
  • June 22, 2007
Kevin,
Without knowing the details of your father's condition I can't make specific recommendations and no information in my interview or response to your question should be construed medical advice or an acknowledgment or endorsement of a physician-patient relationship between you, me, or your father.
Having said that, in general, most of the data seem to indicate the surgical intervention for chronic pain in the abscence of progressive neurological deficit is of uncertain benefit.
I would suggest that your father be evaluated by multi-disciplinary, functionally-based, pain rehabilitation program. These program are usually outpatient-based 3-6 week programs. They may or may not be covered by insurance. Some of these programs have published their outcomes in peer reviewed journals using validated and accepted outcome instruments. I would ask a reference librarian to assist you in a Medline search using the terms "pain rehabilitation" and "outcomes."
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    Alison
  • June 22, 2007
Dr. Russo,
Thank you for your very in depth responses! I, like you, have sort of stumbled upon PM&R as a potential field weeks before entry to medical school (only time will tell). Your interview has made this mysterious and elusive field personal and feasible. Once again, thanks for spending time sharing on SDN!
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    v.ajoy kumar ghosh
  • June 30, 2007
india 1.7.2007
i am aschool student waiting for my admission into a proffesional college.i am very much interested to get into medical course.in that way i was in needfull of informations regarding medicine courses.this website is very useful for me to make myself clear about the circumstances in studying medicine.thank you.
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    Sarah Khan
  • July 1, 2007
Thank you so much for the honest and in-depth responses. I am quite interested in interventional pain medicine, and have come to see how complex and challenging this specialty must be. I was wondering, as a student entering a DO program, how do you view your experience with your program? Did you feel well-prepared for your residency and did you see any advantages/disadvantages in osteopathic schools as compared to allopathic schools? Thanks.
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    David Russo
  • July 3, 2007
Hi Sarah,
I was very pleased and felt very well prepared by my training. I never had any negative feedback. In fact, the added exposure to musculoskeletal medicine is an added benefit as a significant proportion of pain complaints a pain doctor sees are musculoskeletal in origin.
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    David Russo
  • July 7, 2007
Hi Alison,
I somehow overlooked your comment a couple of weeks ago. I encourage you to do an elective in PM&R. Try to find one that gives you both inpatient and outpatient experiences in the field. I think that you'll find it to be a rewarding and stimulating experience.
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    Joey
  • September 24, 2007
finding a good doctor in the telemedicine wourld is hard try http://www.myeclinic.com
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    Peter Inkpen
  • October 8, 2007
Dr.Russo,
Interesting article. As a Canadian Physiatry resident I see most of the Spinal cord Stimulators implanted by NeuroSx. Are many Physiatrists into the above mentioned procedure in the US?
Cheers,
Peter
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    David Russo
  • October 14, 2007
Hi Peter,
Physiatrists who are trained in interventional spine and pain medicine do implants with the percutaneous leads. The neurosurgeons do implants with the laminotomy leads.
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    David Hill
  • November 22, 2007
Dr. Russo,
I was somewhat surprised by your comment, "I feel like the reimbursement is commensurate with the level of complexity, skill requirement, and risk in the field."
I work closely with the pain management group in my hospital - their clinic being in the professional building attached to the hospital - and the level of complexity and skill required is that of a midlevel provider. They take a cookbook approach to pain management, and the "procedures" such as facet and SI injections can be learnt quite quickly. The same is true of stim trials.
The facility I am at is one of the top medical institutions in the country and has 1 or 2 fellows a year in their pain program. Patients are referred here from other pain groups.
You may practice a broader approach to pain management as you appear to have a more diversified practice and have a PM&R background, but from what I have seen the ability of anesthesia docs is limited to strict pain management. You may not want to work in an "injection mill", but that's exactly what the majority of pain management clinics are. And, it's all about the money. Do you think that anesthesia would be taking it up if it payed less or even the same?
It is interesting that there are no studies that demonstrate the efficacy of many of the techniques currently in use, and I would be interested in hearing a justification for the reimbursement levels for 64470, 64475, 27096, etc.
Sincerely,
David Hill
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    David Russo
  • December 8, 2007
David,
I can't comment on others' practice patterns. Certainly, it's easy enough to do anything poorly. Personally, I find the complexity of comprehensive pain management to be incredibly challenging and based upon referrals I recieve from "mid-level" providers I would say that the typical mid-level's understanding of pain mangement and pain physiology is poor to say the least.
I maintain that neuraxial procedures for the treatment of pain (being essentially elective procedures) are moderately risky, require skill, and should be done by those who do a dedicated practice to pain management (an obstetric epidural or a peri-operative epidural is very different than a therapeutic injection done for the treatment of a painful condition.) Any procedure will certainly be ineffective if patients are inappropriately selected.
Pain medicine, as a specialty, has its roots in anesthesiology and anesthesiologists continue to make important contributions to the field and make significant advances. Most academic pain clinics are in anesthesia departments because those departments typically have more basic science resources and grant dollars than neurology or physiatry departments.
There is a shortage of adequately trained pain physicians in the USA and tremendous burden of under-treated pain. There are proposals to create and advance a dedicated 4 year residency program in Pain Medicine for physicians. Maybe that will address your concerns.
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    Nate
  • December 9, 2007
Dr. Russo,
I am an pain physician who is preparing for a partnership in a busy interventional pain group. Can you give me some insight as to what I should be looking for in the upcoming contract?
I assume "partner" means equal partner. Is that being naive on my part?
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    David Russo
  • December 10, 2007
Congratulations.
First, assume nothing.
Second, find out EXACTLY what kind of corporate structure your practice has and how it is set-up.
Third, consult extensively and frequently with an attorney who is skilled and knowledgable in corporate law and has negotiated other physician partnerships and "buy-ins."
Medical practice structures typically include sole proprietorships, general partnerships, limited liability companies (LLCs), limited liability partnerships (LLPs) and professional corporations (PCs), which can be either C corporations or S corporations. In most states, physician groups are set up as PC's. The primary distinctions between all these structures involve are liability protection and taxes. Depending upon your state, PC's may be subject to special regulations and/or protections.
When it comes time to "buy-in" into the practice as a new owner, you will become a shareholder in the PC. You will have vote in the management decisions of the practice. The price of the buy-in is determined by the value of the practices "hard" and "soft" assets. If you should leave the practice, the remaining owners will be obligated to "buy-out" your shares based upon a new evaluation of the practice's assets at the time of transaction. It is important to have a written buy-sell agreement covering the value of the stock.
In addition, it is important to have a written deferred compensation agreement to cover the value of a physician's share of the accounts receivable. There are many ways to set up buy-ins and buy-outs using these basic principles. Consult your tax/corporate attorney for more details.
Good luck.
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    Jorge
  • August 10, 2008
Dr. Russo,
Is it harder to get a pain fellowship from a physiatry or anesthesiology background?
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    Nic
  • October 10, 2008
Thank you very much Dr. Russo. I appreciate your in depth comments. Your descriptive answers made me understand your perspectives on a realistic level. I wish you all the best Sir.
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    NM
  • December 18, 2008
Dr. Russo, I really enjoyed your style of writing, logical reasoning, adept insight, and foresight. Regarding your interest in business management, have you not considered medical business management? I'm sure you have. I only say that to encourage you to pursue it further. Best of luck to you in all your endeavors. I hope you are able to fulfill all (or at least most) of your dreams and interests.
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    Toonie
  • January 24, 2009
Thank you Dr. Russo. I've been reading your comments and blogs since I was pre-med. You've been very helpful in providing me advice and recommendations. Good luck with your career and keep being a role model for medical students.
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    Rain
  • December 13, 2009
Thanks for the excellent review. I've debated about going PM&R versus anesthesia and am now leaning more towards PM&R. Thanks for the interview.
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    togaboga
  • October 2, 2010
Dr. Russo,
I am interested in applying to PM&R programs but would like to find one with more of an emphasis on pain management and sports medicine. Any suggestions? Where do you think that pain management is heading? Will insurance continue to pay for pain management?

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