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Episode 29 New Challenges And Exciting Opportunities For Today’s Pain Physician w. Dr. Timothy Deer

Oct 25, 2019

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

This Episode

Interview w/ Dr. Timothy Deer

You Will Learn

 You will learn:
 – How the science of pain implants have evolved in the last 20 years
 – What are the most exciting opportunities and research being done in pain treatments today
 – The role of industry collaboration in advancing the science of pain treatment
 – Key differences between pain research in academics vs. pain research in the private practice setting
 – The importance of a talented research coordinator to create a productive research organization
 – How studies are funded by companies in order to get FDA approval
 – How to build a career working with cutting edge technologies
 – How to build a team of talented professionals to run a complex organization like the Spine & Nerve Centers of the Virginias.
 – How ASPN came to be and why pain doctors should consider getting involved.
 

Resources & Links

This week I talk to Dr. Timothy Deer about his perspectives as one of the foremost leaders in the interventional pain community.  We discuss the evolution of the field over the last 25 years, unique challenges for today’s pain practitioners, and his vision for the new organization he co-founded, the American Society of Pain & Neuroscience.

[This transcript was auto-generated]

Dr. Deer: [00:02] Again, a team of like minded people with different skill sets around you. If you can’t do that, then you probably should join a larger group. You join a larger group, you have two options. Stay there forever. Become part of the community partner or learn from the older person in the group who’s the managing person and over time go out and row. Hey, this is Justin Harvey, your host of the anesthesia success podcast. My wife is an anesthesia resident and I’m a financial planner and I work with anesthesia and pain doctors as my clients. This podcast is designed to help the anesthesia community be informed about their careers, their finances, and more by taking important questions straight to the experts. Thanks for tuning in this week. I had the pleasure of sitting down with dr Timothy. Dear dr deer and I talk about all kinds of things ranging from his career and endurance athletics to some of the most exciting things he sees right now in pain research. Two things that he recommends that young clinicians get exposure to in order to succeed in the business. End of pain is all that. Some of the exciting new work that he’s doing with the American society of pain and neuroscience. So you don’t want to miss this episode. Thanks for tuning in.

Justin: [01:12] Welcome to episode 29 of the anesthesia success podcast this week. I’m very excited to interview dr Timothy deer. Tim is the president and CEO of the spine and nerve centers of the Virginias. He’s the past president of the international neuromodulation society as well as the co founder and chairman of the American society of pain and neuroscience. He’s a prolific researcher and thought leader in pain medicine and he’s also a 13 time iron man and I understand maybe soon to be 14 and 15 time Ironman and I couldn’t be more pleased to have him here today. Welcome dr deer.

Dr. Deer: [01:44] Well, Justin, thank you for having me. It’s a pleasure to be here. I look forward to our conversation

Justin: [01:48] And to start us off, I understand that you are a proud Mountaineer from West Virginia. And,as I mentioned, I’m from, ‘m from Western Pennsylvania, so I have some of my earliest memories growing up or watching the backyard brawl in Pittsburgh where university of Pittsburgh and the mountaineers.

Dr. Deer: [02:02] Yeah, that’s a, that’s true as well for me. We’ve been through a lot of backyard brawls and it’s certainly a good rivalry. People from West Virginia don’t tend to like people from Pittsburgh very much, but you seem to, you seem to be a nice guy, Justin. So I think we’ll get along just fine.

Justin: [02:17] So in addition, I recently listened to your interview on the purple patch podcast, which is dedicated as I understand it, to endurance athletics. And one of the, you know, perhaps little known fact about you,is that you recently completed the Badwater ultra endurance race. So can you maybe just starting us off, staying away from medicine for a minute, just tell us a little bit about this race and what that entails. Because I am learning about this. I just found it to be absolutely incredible.

Dr. Deer: [02:42] Well, so, you know, I, I was I’ve been a longterm marathoner and,I’m here to do my 15th Boston this year. And so then I went to iron man. And actually I be really just to correct a little bit what you said in the beginning. I’m going to do my 20th and 21st iron man coming up to date. Yeah. Coming up here on the, on next week in Chattanooga and then 13 days later and Kona. So, so I wanted a new challenge. I started doing a hundred mile runs. I did the Leadville 103 times and then did the, he keys 50 miler and was lucky enough to win that race overall. Wow. And then I did the keys 100, ad then use those races to apply for the Badwater one 35 which many people feel is the hardest, yo know, event and running in the world. And it’s, it’ been kind of called that by many people, including people like David Goggins and some of the world’s greatest endurance people. So I was able to complete that this July and in death Valley.

Justin: [03:42] Wow. So, and just for our listeners, it’s, can you just describe the race in brief? Like the, the course, it’s 135 miles, but it’s not just any hundred and 35 miles. There’s massive elevation changes as all as extreme temperatures.

Dr. Deer: [03:53] Yeah. The Badwater one 35 as a, as a foot race from Badwater basin, the lowest point in continental America to Whitney portal, which is on the highest mountain in continental U S Mount Whitney. And during that time you run a across death Valley during the July, mid July, which is the hottest time of the year, ithout stopping. Basically, you know, you have 48 hours to complete that race, ad to be a finisher. And the a hundred people are chosen each year, about 2,500 people have applications that meet the requirements, which is a certain number of $100. And then of those 2,500, they choose a hundred. And so, to ge in the race as the hard part, once you’re in the race, finishng the races a somewhat even harder. And then once you finish your race, you’re retty happy. So it was a great experience for me. And, Chris Coman and his team there at the, Badwater oe 35 did an amazing job.

Justin: [04:51] Yeah. And one of the stories that made me laugh from that that interview was you running 10 miles a day in Florida in the heat, in a parka and a hat. So I’m sure that was, that was turning some heads down there in Florida.

Dr. Deer: [05:02] Yeah. You know, I have a place in Northwest Florida where a vacation often and where I’ve ventured probably were retired to some day. And, and so my coach Matt Dixon and I talked about acclimation and we decided to do a two week acclimation and eight days of that, I was on vacation in Florida. So every afternoon about three o’clock, it’d be in the 90s, and I was wearing a fleece, a sweater, a parka, and a wool hat with sweatpants. And,I’d do about 10 miles of that. And now, yeah, there it looks. I got Justin, we’re pretty, eople thought I was a little psychotic, but, hving said that, I, I didn’t cramp any, I never got nauseated and I had a really good race in the and bad waters. So that acclimation worked pretty well.

Justin: [05:42] Well that is excellent. So I’d love to get to know you just a little bit as a person. So, you know, obviously right now you’re a very accomplished physician and endurance athlete. W where do you come from, from like a family geography education standpoint? Yeah, I’m from Chesapeake, West Virginia

Dr. Deer: [05:58] Where I grew up which is a coal mining town about 15 miles,due East of Charleston, West Virginia where I currently live. My dad was a coal miner, my mother, a licensed practical nurse. And they, thy, raied me to through in that little town and, and , I was really into sports like a football from the time I was a little kid and, and ran track. And, certanly sports and academics were the two things I really enjoyed as a kid and grew up there until I went off to college and played a few years of college football and, and then a small college in West Virginia and then, medica school at West Virginia.

Justin: [06:38] Okay. And when did you decide that a medical school was going to be in your future?

Dr. Deer: [06:42] Well, that was about five or six years old. My dad would come home from the mines and both my grandpas and they would be a pretty beaten up at the end of the day, you know, and they are hardworking people, but it looked like a pretty rough life. And so I decided at that point,one of my uncles, im Cottrell was a, a physician and a, I would visit him in New York city. And I thought, well, you know, this type of lifestyle might be a little better life for me. And then I started really looking into the helping people in medicine and what we could do for people. And the combination of wanting to do something different than coal mining and a wanting to help people brought me the medicine.

Justin: [07:18] Yeah. Okay. And what about pain specifically? Was that something that you knew from the beginning?

Dr. Deer: [07:22] No, actually when I finished up, I was a, I was a fairly intense medical student and so I was torn between cardiology and neurosurgery. I couldn’t make my mind up. In fact, I interviewed for both for residency and I chose cardiology over neurosurgery because I really thought individual cardiology, they were doing this new thing called angioplasty. And I thought this is going to be the future. But after about six months of internal medicine, which, no offense to him, any internist friends. But that drove me crazy because it was so non-interventional I decided I either needed to go do neurosurgery or do critical care. Well, at that time, critical care was an anesthesia based specialty. Now it’s more pulmonary. So I switched in the anesthesiology to really focus on critical care initially.

Justin: [08:07] Hmm. And then and then you made your way to paint. Did you come decide that critical care wasn’t a good fit?

Dr. Deer: [08:14] No, I, I like critical care, like transplant anesthesia. I like neuro and the SEASHA I’d never heard of pain before. I didn’t know it was a specialty. There was a guy at university of Virginia named John Rawlinson who was a, a really renowned rejoin, the CC ologists and he was running the pain program. So they made me rotate through pain because it was a requirement and a, I didn’t want to do that,to be honest with you. And then as we, we did a couple of procedures on people suffering from cancer pain who were miserable and they got amazing relief and was able to, they were end of life patients, but they died quite comfortably, ith their family, ater these procedures. And I realized what we could do. And then, I earned about neuromodulation a while while it was a training and decided to do a pain fellowship and I really thought neuromodulation was going to be the future of our field.

Justin: [09:04] Hmm. And what was the neuromodulation landscape like at that time? You know, during your training? Obviously it was, it was probably in its nascency. I would imagine

Dr. Deer: [09:12] It was pretty poor. There was a few people around the country doing it and,they had a, a course, n Washington D C, aout a month into my fellowship. And they only had two spots for fellows. And, so thee was about 40 people ahead of me on the waiting list. And somehow or another I talked my way into that course. And so I met, I met people like, Ellitt Krames, Sam huse and Bush, John Carlo bare lot, Rick Nrth. And those people were, were the early pioneers in this area for me. And, and, I reall enjoyed that. Went back to university of Virginia and I said, let’s do an implant. And a, that didn’t, that didn’t happen. So my, my attendings weren’t doing many implants, so I’ll say, can I go spend some time with some other folks? So I got to spend a little time with, someone nmed Dean Willis, a doctor down in Alabama, little Tom with know their Krames a little time up at Johns Hopkins with my friend Peter stats. So, I was ableto see other things going on and I decided when I got to West Virginia after my fellowship that this was going to be a a way I was going to try to avoid chronic opioids. Even back then I wasn’t a big fan of, of longterm chronic opioids. I thought we could do a better job with this type of advanced medicine. So that’s the landscape was, was mostly paddle leads under a surgeons and there wasn’t many of us around at that time.

Justin: [10:34] Did you have any formative experiences or patient interactions with like a specific instance where you can remember where you, it was sort of a, you know, an inflection point for you where it made you kind of believe in the future of neuromodulation?

Dr. Deer: [10:47] Yeah, absolutely. So my, I like the concept of it. I thought it made a lot of sense. I read all the articles I could, I could get, and then when I left my fellowship, I had met four patients at Virginia who needed what I thought this therapy would be and they lived in between Virginia and West Virginia my first week. In practice. I actually had all those folks come see me as new patients and we did four trials and one of those patients had had rectal carcinoma and he had radiation and he was miserable. And I placed an implant in him, a trial than a permanent. And they came back to see me for his two week visit and he came in, he had been in a wheelchair. He came back in walking and smiling and it was amazing. And the second gentleman had a back fusion and he’d been on high dose morphine and he came back to see me after he’d seen my PA about two months later he was off his morphine and then the other two patients did well. So my first four patients were all very well selected neuropathic pain patients who did phenomenally well. So I knew that if we could pick the patients correctly, we would have good outcomes in most of them. So that, that was really when it was those early experiences with, with these patients who I saw life changing events that I knew that we have, we could make this therapy better and better. And pick the patients correctly. It can be impactful.

Justin: [12:09] Yeah. And then as far as being, you know, such a significant contributor with regards to research, how did that sort of get turned on for you and what made you want to you know, really put pen to paper and move the ball down the field with, with doing these trials and helping to advance the field with research?

Dr. Deer: [12:26] Yeah, so I’ll talk a little bit about a few different things and I’ll start with one and then we can go into other things. So I’ve worked in a lot of areas in pain and so one area was intrathecal drug delivery. So I got my start there and research with a guy named Dick Penn, who was a neurosurgeon in Chicago, in New York. And Dick had done a lot of research and the winter study Octreotide, which is a type of growth hormone, but he didn’t really have the ability to do it in his center. So Dick Penn approached me. He was working with Medtronic, a company that makes pumps and they asked me if I would do the study, the initial pallet work for the feasibility study for the FDA. So that was my first real FDA interaction with dr Penn and that w that went very well, didn’t get FDA approval, but it certainly worked very well.

Dr. Deer: [13:11] And then shortly thereafter I was introduced to a drug called [inaudible] X one 11, which became known as icon untied later. And I got involved in that study. That study didn’t work very well either,because a, there was a lot of side effects because we had too high of a dose, but eventually we got the dose right. And, and that led to FDA approval and they got involved in a cancer study with, om Smith and Peter staffs. The three of us led it looking at pumps versus medical management. And that led to, FD, appoval of, of intrathecal drugs for therapy and CMS payment for that therapy and became kind of a landmark article published in the journal called clinical oncology. So those were my first real steps into researching the interest equal drug delivery field.

Justin: [13:57] Okay. And during this time, what is your, what’s your clinical practice look like?

Dr. Deer: [14:01] Well, at that time I was pretty much working though about 48 works a year in practice and a very high volume of, of patients, mostly spine, although at a significant amount of cancer patients. And certainly it was, we were a small group of physicians at that point here in West Virginia. We became a tertiary care center for the most part because we could do things other than epidural steroids and, and medications. We could do newer, more advanced things at that time.

Justin: [14:28] Okay. And so was that practice just an earlier version of the one which you currently practice?

Dr. Deer: [14:33] Yeah, I’ve been, I’ve only had one. So Justin, I’ve had one job my whole life. I came out of fellowship, I took the job I’m in and I’ve been in this job ever since. So yeah, we’ve, we’ve we’ve changed with the times. We’ve modified things, we’ve done more and more research. We’ve done more and more pivotal IDE studies. But,the end, the day, it’s the same job I’ve had, the only job I’ve ever had.

Justin: [14:54] Can you talk a little bit about research in the private practice world versus doing it in an academic setting and how that differs?

Dr. Deer: [15:03] Yeah. It’s funny you asked me that. I had a young man call me tonight on my way home from work and he, he chosen an academic practice and he asked me, you know, what did I think the differences were? So this, this question is timely for a lot of people. You know, certainly if you’re an academic setting, you have a lot of support. You have colleagues around you who can give you a lot of insight and, and research and experience. You have, inancial resources for, you know, departments of research. So that part’s easier. The part that’s more difficult for the academician, which we have in private practice, we can decide what study we want to do pretty easily. They’re going through the IRB locally or for national IRB, ad we can use each other as, as advice. So we have a network of people around the country we’ve established.

Dr. Deer: [15:50] So I think in private practice it’s, it can be quite easy to do research, but you have to spend the resources. For example, we have a great research coordinator, Amy Young in our practice and, and she’s phenomenal. So without, without, if you have a private practice without some expertise like that, then you aren’t going to do well. And then your other team members or nurse practitioners or PAs or other physicians have to be on board with the philosophy that we’re going to try to solve problems and answer questions. So in doing that, I was able to help develop, you know, things like spinal modulation early stages of never, never,those are all things I was able to get involved with, which I don’t, I’m not sure the academic model I would have been, it would have been as easy to be involved in those, those projects.

Justin: [16:36] Yeah, it makes sense is, so I’m curious just from an economics standpoint, who pays for obviously like using expensive technologies and doing experimental treatments in different contexts. Is is not something that you can just do without significant financial resources. So in an academic setting, I would imagine that, you know, I think about university of Pennsylvania here in my backyard, they’ve got a lot of money I guess cause they’ve got the Penn endowment and all that. But in a private practice setting, how does that work? Who pays for stuff?

Dr. Deer: [17:05] Yeah, so the way it works, and again this is all on the government websites, clinical gov.com and things of that nature. If you were in a practice,which is like university of California, San Diego, I have a good friend there who does a lot of research than some of your funding will come through NIH grants and things of that nature. That that also occurs sometimes in private practice. But if someone wants to get an FDA approval for a device or drug, it’s, you know, the company themselves have to sponsor this study. That’s not anything you can change that. You have to have a company sponsored FDA, what’s called an IDE study, which is investigational device exemption. And that has to be funded by the company. And supervised by the company with the FDA overlooking the study. So that’s how you get approval for any device you want to develop in the United States.

Dr. Deer: [17:53] If, if you have a device that’s anything essentially new. For example, if you’re wanting to create a devices just like my device and I have a new device, you might get approval through another pathway where you don’t have to do this study, but if it’s a significant improvement in the care, the FDA would like you to do a study. So most of those are funded by the as multicenter studies,by the sponsor, which usually is a company, the company has gone with the FDA to get approval for their study. The studies designed by physicians and, and whoever the company may be. And then that study design is approved by the FDA. And then what happens is during the study, and I’ve gone through this now multiple occasions, the FDA will come to your clinic and audit your charts to assure you’re following those protocols.

Dr. Deer: [18:36] So in a lot of ways, most of the studies that are done in the United States are phenomenal because the FDA oversight is quite good. They do a great job of oversight of the study. Now one last thing about that. Some of these studies we have to do overseas initially because the FDA may not approve it right away. So for example, our spinal modulation study that I’ve helped design and help design the product actually through for DRG, we did those studies early in Australia and Europe because it was easier a regulatory wise to get those studies up and running. And that led to the initial work, whereas the never study, which I was involved in on the scientific board that was done in the United States. So it kind of depends on the regulatory pathway, what type of device it is, things of that nature.

Justin: [19:22] It makes sense. So you mentioned early on you had dr Penn approached you while you, while he was at never, I guess he was the neurosurgeon at Medtronic and he sort of,

Dr. Deer: [19:32] He wasn’t a Medtronic, he was working with them in collaboration. He actually was a prophesy. He was a private practitioner, but he actually was an academics as well up at university of Chicago. And so he had a fund. He had been funded to do a study, which he couldn’t complete because he was slowing his career at that time.

Justin: [19:49] Got it. Okay. So the question I was gonna ask is for someone who thinks, wow, this sounds interesting, I liked the idea of working with experimental technologies that are cutting edge, that are doing things that we haven’t done before and I want to get involved. And it sort of necessitates these unique partnerships and collaborations between the FDA and device manufacturers. How do you sort of break into that, break into that career track or doing some of that work?

Dr. Deer: [20:14] Well, I think some of it comes down to the ideas you have. For example, I’ve had some ideas that have led to development of products. For example,there’s a company called Axonics, which, ay colon runs as a CEO who’s a phenomenal, bsinessman and CEO. And now that that product came about, wewere collaborating. There was a guy named Al Mann who was a, extaordinary person who helped develop several companies, advanced Bionics, bio ess, several companies and, but Alice foundation was working with myself and a of engineers do. We were trying to develop a different product. We weren’t trying to develop a sacral nurse in later. But as we went through the process of, of looking at different designs engineering-wise, and we went through different designs on the cadaver, the cadaver labs, we came up with what we fulfilled was really a extraordinary improvement on previous devices for incontinence.

Dr. Deer: [21:07] So that led to the development, that device and I hope found that company. So sometimes you have ideas that you collaborate with other people and you get together and you come up with those ideas and develop those ideas and half the time that idea will fail and the device won’t be made or it won’t be successful. But sometimes the device is successful in, for example, a Exxon X just got FDA approval in the United States for incontinence of both fecal and urinary disorders. So I think that goes to really show you where you can go from over five years. We go from an idea to a device has been studied in level one studies in both Europe and America and now FDA approved for use in human populations. And really it’s significant upgrade from previous devices. So that’s one way you can do it. The other way you can do it is you don’t have the idea, but you have a great research facility you’ve created by being committed to compliance with the protocols, committed to ethics and committed to having a team around you, which costs money and you have to use some of your own finances to do so.

Dr. Deer: [22:12] And then you then you make the, the folks aware that you’re willing enabled to participate in studies, but it has to be something you believe is potentially better for your patients than what you currently do.

Justin: [22:22] Right. Well, the way you described that five-year collaboration to, to get something across the finish line with FDA approval and level one studies that I kind of makes the Badwater sound a little bit easy, I think.

Dr. Deer: [22:34] I think once a mental anguish in one’s physical English, but a, I’m not sure. I’m not sure what you switched because they both have a little bit of little bit of both.

Justin: [22:42] Yeah. Were there any studies that stick out in your mind as something where you tried and tried and maybe it was like a, just a disaster or you came really close and it was like a bitter defeat that left a Mark on you.

Dr. Deer: [22:56] Oh, so, so let me, let me, if I could just, I’m a positive guy. Let me talk about, I’ll talk very briefly about two or three really positive studies that were great and then I’ll talk about a couple of things I wish would have turned out a little bit different. So I’m an optimist. I’m definitely good with that. Yeah. So the accurate study, we got FDA approval for DRG and that was to me one of the best studies we’ve ever done. And we compared DRG to conventional medical management or our, pardon me for, to mental stimulation spinal cord stimulation for complex regional pain syndrome and causalgia the limbs. And so to me that was our, one of our best studies. I just completed a study called the bold study, which was a small study. But you know, it’s a study looking at low electricity levels to treat patients with this bold study, which we hope to publish, ver the next three months is a multicenter study at can we use almost no electricity, 1.8 hours a day of electricity to, to help someone versus 24 hours a day of stimulation.

Dr. Deer: [23:53] And to me, that’s going to be a phenomenal study. It may change the field even though it’s a small study. And then lastly, I’ll mention the Saluda study, which we just completed enrollment and now in points that looks at the feedback loop for stimulation,where we actually measure what the court is doing and then the computer changes with the person several thousand times, you know, a minute. So those are some studies that stand out as really positive studies. I’ve been very proud of. There’s probably 15 more negatively. So, so to answer your question, I wasn’t involved in the Gabapentin study and I really wanted it to be. So Gabapentin is a drug early that works quite well for pain. And so one of the, I think that can kill me, that made Gabapentin and Medtronic combined to make a study for intrathecal Gabapentin. And I tried to get into that study, but I wasn’t invited in that study.

Dr. Deer: [24:42] It was ran by some good friends of mine, and unfortunately that study failed. And I think that was really somewhat sad because we need a non-opiate intrathecal drug besides icon the tide. And so I was so disappointed. I was sure that drug was going to work. And when the study came out that it failed, I was extremely disappointed because I thought we were going to have another option for patients. So I think that, I think not getting into that study, but it was probably my biggest disappointment and, and research thus far in my career.

Justin: [25:10] And you mentioned the bold study. That sounds really interesting. So I’m again, not a clinician obviously, but I know that one of the issues with the implantables is the charging. And so I would imagine that if it’s much, you’re just using a lot less electricity that opens up new opportunities for longevity of devices and things like that.

Dr. Deer: [25:28] Absolutely. So I think there’s two sides to this, this discussion. So for example, I mentioned a moment ago, the urinating in Congress than later, which you charged would be once a month and it’s five cc’s. That’s one I was mentioning to you. We had developed. And so if someone charges their battery once a month and these, and it’s a small battery like sacral nerve stimulation, it’s not been shown to be an issue. In fact, to me being an advantage. But if you’re using stimulation for pain, generally you recharge a lot more often. Now people have tried things like Bluetooth connections and things like that. Most of those don’t work very well for energy, in fact becomes very cumbersome unless there’s a disc or something over the, the actually receiver, which works better. But in situations where you have to recharge your battery every day, studies have shown that patients get those devices X plan and more than others.

Dr. Deer: [26:16] So if they have a device they never have to recharge and chronic pain, they tend to keep the device in and get it replaced when it does. So the problem with that’s been when you do high energy wave forms or high energy frequencies, that device doesn’t last very long. So that’s why people have to recharge it every day or every three days or every seven days. And patients get tired of that because there’s a, you know, that’s reminder every time they recharge it that they’re in pain is reminder that they have to change their life. And so what happens is if we can get that where they recharge less or not at all, many people do better in pain therapy. So this study looks at using electricity either six hours a day or 1.8 hours a day. And we think there might be patients who could even use it less than that.

Dr. Deer: [27:00] And they have just, they have just optimal pain relief in six months to someone using a 24 hours a day. And what that does, it can increase the longevity of a non rechargeable battery from three to five years, maybe up to 10 years. Wow. That’s what the F that’s what the FDA labeling may say. A, the FDA hasn’t labeled that device yet, and I think we’ll hear about that in the next a few weeks. But I think when we see that labeling of it, it says, you know, seven to 10 years, that would be pretty impressive for patients that they wouldn’t. Yeah. So I think that’s what it may happen. That’s why I say, even though it’s a small study, I think it could potentially change the way we do things going forward.

Justin: [27:35] That must be incredibly exciting to be a part of stuff like that. That’s, that’s awesome.

Dr. Deer: [27:39] Yeah, I think it’s a, hopefully will change some lives with that, you know, in a very positive fashion.

Justin: [27:44] Cool. So we mentioned before we a four, he hit record here about how how much of the pain world, especially for for younger clinicians, there’s, there’s a business element in the private practice pain setting that is a little bit unique and often, you know, what I’ve seen, and I’m sure you’ve seen the same, is that, you know, residency and med school very are very limited in the exposure that young clinicians get to sort of the, the business side and the operations and the management side of what it means to run a pain clinic. So you mentioned you’ve only had one job. Can you talk about the evolution of the spine and nerve centers,over the years and how you have matured as a, as a businessman, as part of that sort of that process?

Dr. Deer: [28:26] Yeah, let me talk, I’ll answer your question, Justin, but I’ll do it in a way that’s more global than that. That’s what’s important for presidents of fellows. So when I started out, you know, we were part of an end, the seizure group, right? So pain was a small segment of that. And a lot of those groups didn’t get along because the anesthesiologists were working in the or and they wanted the pain person to come take call and vice versa. And it was really adversarial most. And we left that model within five years. So we were one of the early groups as separate. And then what happened over time, the pain groups did very well, particularly if they were more interventional and they did things for the right reasons and they didn’t use over-treatment a, they did very well. And so that was the next evolution.

Dr. Deer: [29:09] And then pain became opioid focused in a lot of places. And there were these pill mills and terrible people making tons of money for the wrong reasons. So that, you know, I think that was the, the, you know, there’s good business and then there’s bad care. You can only have good business if you give good care. And so I always tell young people, do a great job of your patient. You will do fine financially. But that, that’s now gotten harder. So, I’m not sure that’s as true as it was five years ago at what the evolution is now. There’s very few freestanding groups left. Most groups have either been bought by larger groups and became a consorti if you will. Or they’ve, people have gone to work as an employee of the hospital. So we’re kind of a almost, you know, we’re one of that small segment of people right now who we’ve not sold our practice.

Dr. Deer: [29:55] We’ve been offered many options to sell our practice and we’ve not been employed by the hospital as of yet. So we’re still a free standing. To do that, you have to surround yourself with very good people. So I’ll just spend two minutes on you who those people are and you need a CFO, you need a CFO, Jeff Peterson, our CFO’s amazingly good. You need another, you need at least one partner who knows the business world well, who knows how to look at accounts receivable, accounts payable, you know, expenses, healthcare insurance for the employees. And so certainly I’ve played that role. You need another partner or two who is a sounding board that you can talk with who has a good understanding. So in our practice, that’s Chris, Kim, Nick Brimmer, warm gray. So I use those gentlemen to give me advice. We’re interviewing a few new folks to join us over the next six months.

Dr. Deer: [30:42] So we’re going to add to that and then we need to think a lot about compliance. So I have compliance attorneys who looks at our healthcare compliance to make sure those are good. And so that’s very important. And then you need to have a proper billing company that bills properly and that’s part of your compliance and you have to do audits. So it takes a lot of folks to make that practice successful and it has to continue to be reevaluated every six months. We look at our practice very carefully. So I guess what my message is, it’s evolved tremendously in 25 years, but now I think it’s as hard as it’s ever been, if you’re going to be independent, but still very doable if you have the right team of people.

Justin: [31:22] Yeah, makes sense. So, you know, you mentioned the importance of, well, I mean, there’s a lot of different roles there and they’re all frankly indispensable. And probably when you try to wear too many hats, you cease to be able to do anything. Well, just like in anything else in life. I’m curious for somebody, if there’s a young,pain physician out there who says, I want to, I want to be that guy who understands the business, who, who can be the sort of a managing partner. If you have like a law firm equivalent, somebody who is going to be a clinical participant, but also keep an eye on the business side of things, what kind of resources would you recommend or where would you point them to really, evelop that expertise?

Dr. Deer: [31:59] So that’s a such a great question. And in fellowship, you don’t get that very much and you’re, then you’re thrown into the world. Some people do go out on their own. And I think you have to get some mentors. For example, you know, American Saudi pain, neuroscience, we created that society really so we can have information exchange and mentor young people. And use or older physicians to really help each other but also help young doctor. And so a lot of times you have to go out to folks who’ve been successful, spend some time with them, you know, spend three or four days in their practice and then you have to pay for help. So that’s, you may have to take a loan out, but you have to get a business person. Like for example, a lot of people make their office managers, someone who has no at all on business, that won’t work very well.

Dr. Deer: [32:41] Or you make your spouse, your office manager, and that’s their, unless they’re a business person, that’s a terrible idea. You have to go out and get real expertise and you have to pay for that. So I think all of those things are critical. So mentors really paying for people to help you. And if you can’t afford someone full time, you can go in and talk to some of your mentors and say, who can help me with establishing my staff? Who can help me with establishing, you know, my compliance plan, who you know, so that sort of thing. But I think you have to get, again, a team of, of likeminded people with different skill sets around you. If you can’t do that and you probably should join a larger group, you join a larger group, you have two options, stay there forever and become part of the community partner or learn from the older person in the group who’s a managing person and over time go out on your own. And a lot of people do that. Very few people have one job. Most people have three jobs in their first five years of practice. So one way is to learn by watching someone else you respect and you may not get along with and you may not want to stay there forever, but you may be able to learn everything you need to know during that.

Justin: [33:45] Yeah, that makes a lot of sense. And I’m glad you mentioned the the ESPN American society of pain and neuroscience. Can you talk a little bit about that? I know this is a newer organization that you co founded. Why, why does a ESPN exist and what, what’s your vision for this group, especially in the context of mentorship and sort of bringing up the next generation of pain practitioners?

Dr. Deer: [34:04] Yeah, we had a, no, we had 520 people at our first annual meeting down in Miami, so we were pretty happy with that. I, I, I thought it was going to be a small, small, simple,society, you know, but it, it’s getting big prickly. I, yeah, I’ve been involved with almost every society and I’m, I’m pro, you know, ins and pronouns. I’m pro Azur and pro ACEP profitably PN. I’m not anti any society that exists currently, but I thought a real void, fr young people. So a lot of people, I’d meet a train fellows and fellows courses and they would try to get on committees and they couldn’t get on one and they would try to get, you know, a time to be on a panel or time to, you know, get involved in some activity or activism or whatever it may be.

Dr. Deer: [34:45] And they had to spend years trying to get involved. And I thought that was really unfortunate because the way we’re going to change the field and stick our brightest showing people and, and to help them develop the skill sets they need to push forward. And we need as many of those people as we can get. So one night, one night I was sitting with that would say, and my friend from Kansas and all would I, we’re talking and he trains fellows, although he’s a Kansas fan, which I have trouble with BP in the big 12 people from West Virginia, although we did beat Kansas last weekend and football. But, but that would, I said, you know, why don’t we create something where we can help these younger folks learn these skills, not just implanting devices, but you know, speaking and mentoring and teaching and you know, all those things they want to do and get a social media presence.

Dr. Deer: [35:33] And so we actually went out and short talking to some of the younger fellows and people out of training three or four years. And the excitement level I felt was huge. But we also have doctors who are 55 years old who, you know, wants to learn new procedures and things. They didn’t, it wasn’t around when they did their fellowship. We thought there was a big need there as well too. A mentor, older physicians to learn new tools if they had the skill set. So there’s so many needs. So we created this society to be really a group of people encouraging each other. And one of the things I really felt the need for in our field, you know, there’s a lot of encouragement, but there’s a lot of professional jealousy among doctors and amongst societies and it’s really detrimental. So our, one of our goals was to not let anyone join our society who was negative.

Dr. Deer: [36:19] We want only positive people who, for example, Justin, if you’re successful, I should be happy for your success and I should try to make your success even better because that doesn’t hurt me. That makes me look good because I’m your friend or I’m your calling. And I think that’s the attitude we’re looking for with ASMR for the Aspen, ESPN, because we really feel like we need to be building success through each other and through that collaboration. And I think it’s important that, that be diverse. So one of our other major goals is to encourage women in the field on, I have three daughters and a wife, so I’m very pro woman. We need to help encourage our women colleagues, not just encouragement, but sponsorship and development and all other races, genders all those things. So we’ve, we’ve also been a society,and our initial founding of diversity and inclusion. So we have so many goals that are so exciting and we’re going to continue to build on those, I believe, over the next few years.

Justin: [37:11] Yeah, that is incredibly exciting. So if I am a fellow or a young attending, and, and I think this sounds interesting to me and I’m kind of curious what mechanisms specifically in Aspen are going to be, you know, how am I going to benefit? Like, what are the, what’s the boots on the ground impact in my life if I join Aspen?

Dr. Deer: [37:28] Well, I think first of all, so a couple of things. First of all, if you’re a fellow, it’s free to join Aspen cause we don’t charge fellows every, not a fellow but charge $100. Most societies I belong to are $1,000 are pretty expensive. So we made it kind of a inexpensive way to, to, to collaborate. But the main advantages, the network you will find there of likeminded people. So you know, our average age in our societies under 35 if you add average over our membership ages together. So we’ve got a very good group of young people. And so I think one is, you have a network of people immediately you can talk with email. You see at conferences too is our annual meeting that we have is only panels. We don’t have any, there’s nobody. There’s no 10 dear lecturing to you for two hours telling you what’s right and wrong.

Dr. Deer: [38:11] I might be on the panel with 12 people. So when, you know, so we actually made it so that no one’s more right than anyone else, you know, so we have four people up on stage and we disagree than the audience can decide who’s right. And so there’s no one that’s right necessarily. That’s a lot of fun, but it’s also good. Yeah, it’s been really, really positive and I’ve done similar things in the past, but that’s our, our main goal there. And then we have a think tank. Think tank is not a CME accredited. So it can be of course. So people that like for example, let’s say you have a startup company, let’s say Justin has a certain company today, you can come to the think tank, you can get on the podium because there’s not CME accredited. Of course, we’re not giving any credit to be there.

Dr. Deer: [38:51] And you can talk about your project. Well, somebody in the audience may say Johnson, that’s a horrible idea. You know, here’s what we think you should do. And so that think tank is a really unique setting. We had 90 people in Aspen, Colorado last March. We’re having our second one down in The Bahamas here in next March. And so that’s a unique thing. And then we have a workshop out in December out in Phoenix and we have, you know, relieve Vant a, which is a, you know, a new technique we have, you know,things like corner lock, which the new sr fusion technique, we have things, you know, we have virtuals, we have Virta flex, we have all these new skillsets that we have a lot of positions coming to learn that they may not get in fellowship because in fellowship, I mean the, these newer techniques aren’t taught or sure ganglion stimulation and salt, some fellowships out, but not all.

Dr. Deer: [39:37] So there’s all these things out there that, you know, we can offer. So, and most of our instructors have that at that course are people that are very young. They’ve been out of fellowship five years or less and now they’re instructing other people just out of fellowship. So it’s kind of exciting that younger people are teaching younger people. Having said that, we’ve got some older physicians like myself. Micah scary,other people who is going to come there and also teach. And so they’ll hopefully they’ll get some experience, hat, you know, learn about what we’ve done. So, I mean, there’s so many things I could go on and on just it, but that’s the, you can see we’re trying to make this pretty unique.

Justin: [40:10] Yeah, absolutely. And as you’re describing it, I’m thinking about what I’ve heard about the, the Nan’s residents and fellows section a and sort of the, the push there to do many of the same things it sounds like. How would you sort of differentiate or distinguish between those if I’m, you know, sort of sitting on the sidelines saying, Oh, it kinda sounds like there’s a lot of overlap there.

Dr. Deer: [40:31] Oh, we have a lot of good friends, so we have a lot of members in both. So, you know, first of all, I’m an, I’m an ANZ member. I’ve been on the board of Nan’s in the past, president of the ins, ins as the,over, you know, the overall international Saudi that all chapters are within that, hat kind of umbrella. And Nancy’s one of the chapters of ins. So I’m very pro Nan’s. You can be in both and you can do both. There’s parts of the Nan’s Rosie village programs that some of the leadership there are also leaderships in our societies. So I don’t think there’s any, any difference. The, the main difference I think is, is just a different identity as far as, you know, what you’re actually doing. You’re not, you’re, you’re breaking away from the Rose and some fellows and becoming your own person.

Dr. Deer: [41:12] So as you evolve, you know, I don’t think you’re going to be the resident fellow sections forever. Hopefully you’re going to evolve and, and as you evolve, you know, I think it’s a really logical place to at make that part of evolution. And I would encourage you to stay in Nancy as well and, and work there as was a very good society that, you know, I’ve done a lot of work with over the years. So there’s other societies you can involve in too. But I think the, you know, our goal is to make the politics of, of how to do that very easy for you. If you’re well trained, energetic person who’s nice to people. If you’re not, if you’re not, if you’re not a little trained, you’re not nice, you’re not collaborative, we’d rather you not come here.

Justin: [41:48] Yeah. Well I love the positivity. I can tell, you know, I’m sort of picturing you in this like endurance, athletics sort of situation and unless you’re like an indomitable optimist, there’s no other way you can, you know, run those marathons, especially at the end of 112 mile bike and all that. So, you know, this is all coming together in my mind as you’re describing your vision for Aspen. I want to just close with one more question and I really thank you for your time this evening, Tim. So you, you know, you’re a very accomplished physician, you’re an accomplished athlete. A lot of the things that you’ve done require a lot of sacrifice. So I’d love to hear just a brief story or anecdote about one of your proudest moments as either a doctor or an athlete or a father or husband that made you glad for the sacrifice. Glad for the effort, glad for all the time that you’ve put in.

Dr. Deer: [42:34] Well, you know, I always tell people in particular young people, a couple of roles I have, you know, in one role is for men particularly who have had trouble with their fathers. And my dad left when I was a young pretty young child and I forgave him later and we became very close. So for young men always say, you know, and I’m sure that they thing plans for young women, I just can’t speak to that. But I always say forgive your father if there’s something goes wrong. So I think that’s one thing that I’ve kind of always giving people advice for. The other advice I give people though that I think is really important is when you die, the only people who’s going to remember you is your family and your friends. You know, you might be as well known in whatever field you’re in as anybody’s ever been.

Dr. Deer: [43:13] But when I, when I go out and ask fellows, you know, do you remember such and such, you know, Sam Hassan Bush, one of my mentors, John Oakley and one of my mentors, both of who passed away over the past decade and most fellows are never heard of either one of those doctors and they impacted me dramatically. So I think one thing we have to always remember is that the thing you should be most proud of should always be what you do with your family. So I think the thing I’m most proud of, Justin, to be quite honest with you, I have four children and they’re all doing phenomenally well. You know, they’re all really proceeding in their educations or they’re going to be very impactful to society, you know, so,one of my daughters is really doing well in nursing. One in law school, my son’s going up probably into some of the industry you’re in and to the world of business and devices and such.

Dr. Deer: [44:01] And then my youngest child is pre law. So I think seeing them all do well and see them, you know, become not just smart people, but good people doing the right things for the right reasons and having good ethics. So to me, that makes me proud every day. And when they call me for advice, you know, Justin, the best thing in the world is when you’re a 25 year old calls and says, I need some advice dad or your 20 year old in college, you know. So I think the fact they call me for advice a lot of times it makes me extremely happy because that tells me that we did something right. And then the last thing I’ll tell you is I’ll have my 30th anniversary in January. And certainly I’m very proud of that because, you know, 30 years of with one person I think is a, is a, is a great thing to accomplish and it takes two people to give a lot and to take a lot from each other. And I think being able to do that has been a, I think one of my greatest accomplishments in my white strips accomplishments. And hopefully we’ll continue that for 30 more years if she can keep putting up with me.

Justin: [44:54] Mm, well that is, that’s excellent. And I’ll tell you as somebody who was expecting his first child in December and who just passed the one year Mark of marriage I take that to heart and that’s,that’s really great to hear. Thank you very much for sharing that. My pleasure. So doctor Timothy, dear, it’s been a pleasure speaking with you this evening. Thank you for your time and thank you for joining us on the anesthesia success podcast.

Dr. Deer: [45:15] Well, Justin, thank you for having me and I think a, I wish you nothing but the best.

Dr. Deer: [45:22] Hey Justin here, this may shock you to learn, but I am actually not a full time podcaster. I also run a financial planning company called quantify planning, where I work closely with anesthesia and pain docs to build and implement customized financial plans. If you’re interested in working with a financial planner who knows many of the ins and outs of your profession, shoot me an email or head on over to quantify planning.com for more information. If you’re a resident or fellow, I can also offer you a free student loan analysis if you’re interested, but there might be a waiting list. So check out the link over there to see if you’re interested in learning more about the topics we discussed today. Head over to anesthesia, success.com to join our community, residents and attendings and others to ask a question or get more free resources. If and only if you liked this episode, please leave us a review and subscribe. Thank you very much for listening to the anesthesia success podcast.

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