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Episode 61: Building The Future Of Pain Management With Real-Time Patient Feedback w. Dr. Michael Fishman

Aug 24, 2020

This Episode

Dr. Michael Fishman

You Will Learn

– Dr. Fishman explains neuromodulation, as well as why he has chosen to focus on it
– Dr. Fishman’s experience at dinner with Dr. Ricardo Vallejo
– How Dr. Fishman went about building his team
– Dr. Fishman’s tips for new physicians
 

Resources & Links

This week I’m joined by Dr. Michael Fishman. Dr. Fishman has worked hard to become a key opinion leader in the interventional pain and neuromodulation space. He is also an entrepreneur building a platform in conjunction with some colleagues who were also running into the same problem of real-time feedback from patients.

Justin (00:24):
This week. I’m very pleased to be joined by Dr. Michael Fishman. I enjoyed hearing from Mike about his career and how it has been aided by both preparation and hard work, as well as serendipity. I think you’re going to enjoy that story. He’s developed into a key opinion leader in the interventional pain and neuromodulation space, and he’s also an entrepreneur and we talk a lot about an exciting platform that he’s building in conjunction with some other physicians who were all running into the same problem, which is we were having difficulty getting feedback in real time from patients about the efficacy of various treatments that they had undergone. We also talk about some of Mike’s personal reflections and general advice for physician entrepreneurs with many competing priorities as always, thanks for joining this week. Hello and welcome to this episode of the anesthesia success podcast. I’m joined today by Dr. Michael Fishman, Mike practices, outside of Philly here where I’m located with my wife. And he’s also a personal friend. He’s here to share a bit about himself and his career. Some of the innovations he’s working on in interventional pain that have application not only for his specialty, but medicine in general. Mike, thanks for being here.
Dr. Michael Fishman (01:27):
Hey Justin, thanks for having me
Justin (01:28):
So quick story for our listeners. One, I would say like impactful experience that I’ve had, where we were at ACEP last year. And Dr. Fishman was on a panel with Dr. David Provenzano, talked to Ricardo Vallejo and a couple others talking about the future of neuromodulation. It’s a cutting edge area of study and science and patient care. And talking about the future of a segment of pain that is sort of the future in itself. I just remember my mind being kind of bent and perhaps blown in different ways. Hearing you describe some of the things that you think might be out there in the future.
Dr. Michael Fishman (02:03):
Yeah, that’s a, that was a talk that was really fun to give, you know, oftentimes, and a lot of the research we’ve been doing and presenting on have been related to clinical trials and, you know, of course we’re presenting the scientific typic rationale behind the study and where, how we came to those results and ultimately the results of the study. But that’s not a particularly artistic way to get a lecture and being invited to give a futuristic talk on the future of neuromodulation, probably spawned by an article that I coauthored with some really, really smart guys and future thinking, neuromodulators it last year, got me really thinking about, you know, what is neuromodulation? Is it just a, a therapy, but how can it also be tools to help us understand Bain and painful pathways and validate, you know, many ways you know, it’s hard for us to be sure of what we’re doing with both neuromodulation and pharmacotherapy and chronic pain, but, you know, neuromodulation and neuromodulation techniques have really important implications in starting to understand that to the future.
Dr. Michael Fishman (03:06):
So Justin, just to give like some insight into, so I’m not talking about just like what you called before star Wars stuff. One thing are these little things called neural dust particles and these little neural dust particles can be injected or implanted percutaneously, you know, in your anesthesia residents can inject them to much as they would with ultrasound and like a block. The difference is these little dust particles. They actually, they actually can sense and make recordings from the brain and neural tissues. And those recordings can be read or detected using ultrasound or high frequency ultrasound. Neural dust has been used to monitor epileptiform patterns in rat models. Think about the implications for starting to monitor the neuropathways and sort of interact with them once this becomes by phasic and bi-modal, that’s pretty cool. Another is optogenetics. So how we can use light and light activated molecular switches that can be inserted into specific cell types using five vectors to start to understand how photo neuromodulation and using this to understand how turning off specific signals can give us almost reversible knockout models, if you will to start understanding pain pathways and the selectivities of different pharmacologic agents and things like that.
Dr. Michael Fishman (04:32):
What’s really cool about that. The star Wars stuff is that there a little mice running around with, with led light chips in their brains. And those are pretty cool and interesting experiments to watch, but in general, what it really starts to highlight. And I think the overall concept of the future of neuromodulation and I’ll extend this to the future of pain care is starting to understand why we’re doing what we’re doing and aligning the metrics that by which we judge success and patient success as appropriate to the disease state where a linear pain scale from a zero to 10 may be appropriate in the post operative phase or in the PACU. That’s probably not appropriate for the chronic pain patients coming into my office every day. Where in general, the pain scale is looked at as you know, I think the same way many of us would look at a, you know, sign that says no standing more than 20 minutes.
Dr. Michael Fishman (05:39):
Most people are gonna say, well, you know, I gotta stay there for 25 minutes. I’m pretty much okay. And most people, if you ask them the difference between a seven and eight, they really can’t tell you the difference at the end of the day, pain scales are almost insulting to both physicians and to patients. And so, you know, with respect to understanding molecularly the mechanisms behind why we’re doing what we’re doing, which is actually a lot of the work that Ricardo a who has done. And I know you want to talk about later we still have to understand what treatment success means to our patients. And, and here we’re going to understand what anesthesia success means to to Justin Harvey and his, his podcast listeners.
Justin (06:19):
Yeah, it’s funny. I was. So I had, I told you Mike separately, but I had that problem with my neck last year. I had the spinus process of the C7 fractured and I was w I remember waking up, my wife was on call. I was in a 10 out of 10 on the VAs, and I remember going to the emergency room and I remember them asking me like, you know, on a scale of zero to 10, like, where are you? And I, you know, you’re friends with too many pain management docs when they were asking me this question, I was like, Oh, this is that thing that they were talking about. You know, the, the, the problem with this like subjective question, there’s no objective criteria. And, you know, so I, as I’m in blinding pain done at Presby in the ed, I was thinking about this. But I know that you had a kind of funny story about meeting Dr. Vallejo.
Dr. Michael Fishman (07:01):
Oh yeah. That’s, that’s an interest. That’s, you know, that’s an interesting story. I was at a dinner a couple of years ago at Nan’s my first year out of fellowship with my partner. And so I got invited to this dinner. I had no business being invited to, frankly, and I sat down at a fellowship for about six months. And I’m at this table with very, very experienced well-known neuromodulators people who, you know, are writing all the articles and doing all the studies and the top of the game people and my partners on the other end of the table. And I’m sitting next to these guys. And I started talking to this guy across the table with a funny accent about Pollstar RF, and we’re talking, cause I’m really interested in pollster F. And when I was a fellow, I got interested in it because we at Stanford, we did things because they made sense for patients.
Dr. Michael Fishman (07:46):
We didn’t always do things just because, you know, they were available commercially. And, but we were doing a lot of Pulser at the time. And one of my faculty there told me, you know, it’s okay to get obsessed with things. If you want to learn more about them, go read everything you can. And we had this project that we were supposed to do to present to the group. So I put picked Pollstar and I got obsessed. I read every paper, every written, and there was this one paper that actually described the mechanism by which pollster F modulating gene expression by via are. So here I am talking about bolster up with this guy across the table. And I finally figured out the fact that, cause you don’t know his name, I don’t know anybody’s name, but I just know that these are all important guys.
Dr. Michael Fishman (08:28):
You know, it’s six months out of fellowship and I find out this is [inaudible] and then all of a sudden it’s like, Oh my gosh. So how’d you come to that conclusion? Like, tell me more about this. And we’re going back and forth and people start paying attention to what we’re talking about. And at the end of that dinner, he said, you know, this has been a real pleasure. I’d love to work with you sometime. And ever since then, I’ve had, have had this great mentor and this opportunity to, to get an engaged in clinical research and really spur clinical research in our practice, such that we’ve, you know, over 20 studies in the last five years both initiated by us and working with industry partners and working with startup companies. It’s been one of the most exciting parts of my career. And most of it was really the, the hearing Ricardo story, which is he did research real clinical research, you know, high fidelity clinical research rapidly in private practice and was innovative and effective in doing that. And it was a huge inspiration to my partner, Phil Kim and I, to, to start doing this really aggressively. And since then, we’ve had such an enriching practice because of it and had the opportunity to work with new therapies and offer them to our patients that has been extremely rewarding.
Justin (09:35):
It’s it just goes to show you the, the role that you know, serendipity can play in creating our vocational destinies.
Dr. Michael Fishman (09:42):
It’s absolutely true.
Justin (09:44):
You know, to go back to what you’re talking about before the, the, the VAs scale and understanding how to, how do we quantify pain, which is an experienced phenomenon and diff it’s not like, you know, measuring a blood pressure or a heartbeat. It’s, it’s a lot more squishy than that. And I think this has been based on what you’ve told me, one of the classic problems of being able to treat pain is saying like, how do we have some sort of objective markers to be able to say, are we giving a patient the right treatment? Is it being affect? Is it affecting the change that we want? And do we need to make any changes based on that feedback
Dr. Michael Fishman (10:16):
Matters? Is it probably more importantly? And I think that’s individually defined, you know, just like I would never presume to tell you what your financial goals are. Presumably as a financial advisor, you don’t tell people what their financial goals are. Either you ask them. And I would say that that similarly with pain management, you know, that has to be the driver of this conversation. Now there’s ways that you can help people understand what their goals are. And what I mean by that is you can identify in a nonthreatening and carer caring way that there are factors related to their bio-psychosocial condition that are not an advantage to them. And that could be in severe anxiety, severe depression, anger sleep disturbance, you know, obvious lifestyle choices. You know, you just need to be able to put a plan in place that takes into account. Realistically, what’s achievable for this patient.
Dr. Michael Fishman (11:21):
And also what’s going to be the greatest impact because, you know, if you look just in that, what matters to people and you attempt to value health outcomes, using something called quality adjusted life years. One thing you do is you ask people for a set of trade offs and what are the trade offs? Usually when we talk about quality adjusted life years, that the trade off is as follows. I would give up X years of my life, shortened my life in order to avoid Y years of this condition. And when you ask people and hundreds of people, if they would rather give up years of their life to avoid living one year with even rare depression, more than 50% of people are willing to give up a year of their life. And when you start to look at being often depressed, I mean, you’re talking about close to 75% of people are willing to give up a year of their life, goes to 50% are willing up to give, to give up four to five years of their life to avoid living with severe depression, less than 50% of people are willing to give up any years of their life to avoid living with mild or moderate pain.
Dr. Michael Fishman (12:31):
We didn’t ask about severe pain in that study. I didn’t ask about it. So when you think about that, and you think about how under recognized comorbid depression, anxiety, mood disorders are in the chronic pain population, and they probably exist in 40 to 50% of those patients. Those ranges, you know, in the literature go anywhere from 30% to 60%, you know that if you don’t start your visit with some objective information surrounding a holistic view of that patient, how is their sleep? How is their mood, how has their physical function as there are their activities of daily living, how’s their pain on average, then what you end up with is a trap of politeness, where you ask people how they’re doing, and they say, they’re doing great. And they don’t tell you that they’re severely depressed. They don’t tell you that they feel hopeless and worthless. And so, you know, there’s a challenge and a societal perceived shame related to that that makes objected information East semi objective patient reported outcomes, very important as an initial tool.
Justin (13:35):
Yeah. That makes a lot of sense, especially with, you know, the more I’ll call them stigmatized questions about mental health specially and where there is that shame associated. It’s. I mean, it makes sense looking at the full orb of the human experience. And so you are, you’ve probably perceived these things over years as a clinician. And, and then at some point you got to a place where you thought, you know what, the way we’re treating pain, I think that perhaps can be, we can improve it. We can maybe even revolutionize it by asking the right questions and getting better access to data. So tell, tell me about that process.
Dr. Michael Fishman (14:12):
Yeah. So Justin, what you’re describing is nothing new and I’m not you know, when I, I will tell you is I I’ve always been somebody who scratches their own itch, who does things that in a way have always helped me automate busywork and helped me go to every, literally wake up every day and move through it with doing the tasks that I’ve really selected for myself that give me both, you know, productivity and also are enjoyable. So to me, the concept of using outcomes in my practice to really help me patients better was not new operationalizing it to work in private practice for me was the itch that had to scratch in my fellowship. We collected a prospective patient reported outcomes using the promise measurement system using the choir system and choir was something that worked in, in the academic setting.
Dr. Michael Fishman (15:14):
And you know, was a really important part of the way we took to every encounter. The concept of using multidimensional metrics in chronic pain care has been espoused in every major consensus document in the last 10 years. And that goes from the Institute of medicine report to the NIH task force for low back pain to the federal and national pain strategies. And even the interagency task force 2018. I mean, all of these things talk about multi-dimensional metrics. Everybody knows that pain is a Microsoft five psychosocial construct. Nobody doubts that the biology, the psychology and the social impacts of pain are important. One of my Australian colleagues, Dan Bates calls pain, a social disease. And I think that’s actually very accurate because the impact of pain on social function and marginalization and access to care does create multiple tiers within the chronic bank community.
Dr. Michael Fishman (16:12):
Those who are socially isolated are probably significantly worse off taking that a step further to operationalize using multidimensional metrics metrics in my practice. I also needed to operationalize using that to do prospective clinical research on the procedures and interventions that I was performing. And so the real world outcomes platform and Clary health came from Jason Pope. And I getting stuck in an airport together and looking at the spreadsheets, we were keeping to try and keep track of the devices and the outcomes associated with those and looking at it as this incredibly love driven hate rewarded, torture chamber of that had this precipitous, you know, kind of fall where one piece of bad data kind of led to you questioning well, is the whole thing questionable, like, is this even valid? And, you know, that’s like watching a house of cards fall down and I was really discouraged by that.
Dr. Michael Fishman (17:18):
So I wanted to create a situation where I could automate the busy work of capturing all my interventional proceeds, like all my procedures, what I was doing, how many implants I was doing, what my trial to input conversions rates were, what the programming was for my spinal cord stimulators and pumps what the different medications that patients were on. And it turned into this, this project that ultimately serve several functions and that’s to do clinical research, actually, because for anybody who was doing a lot of clinical research in their practice, start to learn that the data capture systems we use are clunky at best. They’re not built for docs to use in real world practices. And so what we paired was what we thought to be a slick, easy to use patient reported outcomes, collection data capture system, with a part 11 compliant clinical data capture system for research that revolves around patient reported outcomes assessed either in your clinic or by text message or SMS or email.
Dr. Michael Fishman (18:19):
And that correlates that with a built in procedure registry that tracks the patient journey from the moment they walk into your practice and to start to understand how patients are doing and the real impact of these procedures on things that matter. So that’s pain impact, which is really defined as pain scores, partly but mostly to find pain, interference and physical function, and that pain impact score that was validated in 2014 by the NIH research task force for low back pain. And what we’ve done is we’ve really looked through the literature, what makes sense as a one off measurement for chronic pain. And we think the, that the promise 29, which is a set of 29 questions that gives you mood that is anxiety, depression, social isolation, sleep, disturbance, fatigue, physical function, pain interference, and chronic pain. It gives you those metrics, but also allows you to calculate this pain impact score. That’s kind of the, you know, the, the first you know, metric that we want to collect universally relevant to most patients. And we’ve used that successfully to start defining what spinal cord stimulator success means by correlating it to percent pain relief. And we look forward to engaging other docs to use this tool, to start redefining the measurement of what matters in pain care.
Justin (19:50):
So let me just make sure that I understand, especially from a, from a physician experience, what you just described. So you said, you know, there’s say 10 different types of maybe spinal cord implants that I might be using. So I, as a physician, I might have a little dashboard that has 10 different line items on it, say here’s all the, this thing and all about that thing that I’ve implanted over the last six months. And then based on feedback that you’re getting in real time from patients, every, maybe you text them every week or every couple of weeks, there’s data points that are getting automatically aggregated into this system. So that a physician who is doing these procedures can not without having to have somebody call and say, Hey, mrs. Smith, how, how are you from one to 10, they’re punching something in, on their phone, or they’re replying to an email and giving this data. And, and that’s something that physicians can just monitor in real time. Is that, is that accurate?
Dr. Michael Fishman (20:42):
Yeah, so, so exactly right. So the way we see it and, you know, you, that pain is a squishy vital sign and pain as the fifth vital sign was a miserable failure by Jayco to you know, try and identify and create awareness surrounding the undertreatment of chronic pain. Now we can go historically into that, but suffice it to say that that’s really based on two studies by a guy named Warfield and another guy named Applebaum which were basically postoperative phone call studies of like 200 patients where they asked the people to experience what, you know, what type of pain they experience postoperatively. And it turned out that a lot of people had experienced an episode of moderate to severe pain, like 60 something percent upon discharge. And that particular narrative, I believe in my understanding of history really was what took off this chronic pain or pain as the fifth vital sign endeavor.
Dr. Michael Fishman (21:41):
Now what that did though and there’s a complexity and a historical and political significance to that and opioids that I don’t want to go ahead and get into, but what that did was made pain numbers and the lowering of them really important for hospitals and administrators. Now what we know and what we’ve described earlier in that, that probably works for acute pain. Like you break your arm, or you have a surgery that probably works doesn’t work for chronic pain and the impact of these chronic pain devices and implants. And this extends to just any procedure. So it could be spinal cord stimulators. It could be a minimally invasive stenosis treatments. It could be SSI, joint, fusion devices. It could be spine surgery. It could be radiofrequency procedures, epidurals, et cetera, is to me, what’s the functional improvement that this patient’s gaining from this. And so when we look at a spinal cord stimulator or an implant, or a Verta flex inner spine, a spacer implant, what we see as this longitudinally after that implant date, the patient will get a text message or an SMS or an email, and they’ll fill out from their doctor a brief promise 29.
Dr. Michael Fishman (22:58):
If they have a inner spinal spacer for stenosis, they’ll get a CCQ ERs or claudication questionnaire. And those longitudinal results will be tracked and presented back graphically to the physician. And they can use that to understand the impact of these therapies on their, on their patients. And what I look for is their pain. The first thing I look for pain, interference, pain interference, ask them really simple questions. Does the pain interfere you from doing a normal activities like preparing a meal? This is a pretty simple question, pain interference to me, if you’re in the severe range, and that’s the promise 29 is pure the inner pain and pain interference patients in the country. If you’re there yet, we have a problem if we do an intervention or some treatment, and that reduces your pain interference, even if your pain score doesn’t change, the, the meaningful difference for, for pain interference is about a score of three. And when you think about that, that means about a third of a standard deviation. That’s not that hard to achieve actually for most patients, if they’re responding to a therapy and I don’t care if their pain score goes from a seven to a six or from a nine to a two, if their pain interference dramatically improves, that’s really meaningful to that patient
Justin (24:22):
Makes sense. So I’m curious, you know, take me from that moment at the airport, with Dr. Pope to all of a sudden, we’ve got this whole platform interface that’s really slick and capturing all this data in real time. Obviously there’s a couple of steps in between. So tell me about the Genesis of the company you’re putting together a team, you know, delegating all that stuff.
Dr. Michael Fishman (24:40):
Yeah. So fortunately this is a real team sport and from day one Jason and I sat down and we had we talked to my brother, who’s a serial computer programmer, chief architect, CTO, entrepreneur. And we were able to very quickly identify that we needed a data scientist and another pain doctor, Michael Haynes and Jacksonville was able to introduce us to his brother. Who’s a data scientist with background in industrial failure analysis and radiology and actually worked for for a health system previously. And so we put together this team along with our head of design who’s again, within this network of people and really ultimately built a minimum viable product which worked and has continued to work with iterations upon iterations, leveraging the, the, the honestly thousands of hours of time and the technical expertise without the technical team that we’ve had the vision that Jason Pope and I had would never have kind of come to any sort of fruition.
Dr. Michael Fishman (25:54):
And this goes to show you that in general ideas are really only a small part of the puzzle. There’s so many layers of feasibility, especially with software. There’s many things that the answer is yes, but, and that, but could be extreme costs time or hurdles that, you know, in many ways, fortunately, we live in a world where work arounds are oftentimes easier to start thinking about them, this primary pie in the sky solution. Now I’m a pie in the sky thinker. And so I would tell you without any of these kind of people to channel that into a, a level of productivity that is feasible in the real world and not in Mike land, that would be like that that’s the key is surround yourself by people and understand your own shortcomings. And for me, that’s totally focused on, I don’t really take no as an answer, and I think everything’s feasible. So it’s been fortunate to be balanced.
Justin (26:53):
Yeah. Tell me about one of those times maybe that you ran into when you, the answer was. Yes, but it’s like, Oh, there’s a big hurdle. There’s a big operational challenge. There’s something that seems like an impassable chasm. How’d you guys work that out?
Dr. Michael Fishman (27:04):
Honestly, at the end of the day, I, I think it’s always been about a willingness to think about alternatives. And so I would tell you that on several occasions, the exercise of seeking alternatives led us to get back to the chasm and for the other side to cross to my side or vice versa. And you know, we learned this actually in a parenting class, my wife and I one of, you know, we’ve never, w I think we’ve successfully done this, maybe a handful of times of their kids, but maybe once I’m not sure, okay. Either way, one exercise is to, you know, when you have an impassable chasm between your two kids to sit them down and say, okay, let’s get our crowns out. And let’s write down what the alternative solutions are. And the parenting expert T said, it could be, if he, if he says, you know, I’m gonna, I want to kill my brother.
Dr. Michael Fishman (28:03):
You write it down, write down all the options, and then, you know, seriously go through them and say, okay, let’s look at this option. We wrote this down. Is this something we really could do? She says, most of the time they’re going to look at it. They’re going to be rational. And they’re gonna be like, okay, I guess, I guess, I guess that’s not an option. So I think it’s about the willingness to sit down and expand, even if you’re, you ultimately get back to where you were. And I think myopia is something that most people are both guilty of and fall victims to myself included. And that’s one of my biggest personal growth. And being able to be to work in a team has to be, has, has been to kind of expand beyond the individual contributor and start to not being so myopic.
Justin (28:49):
It’s true what they say, everything you need in life, you learned in kindergarten that applies all the way, all the way down the line. Tell me what, you know, as the pie in the sky guy that you are, what does an ideal future for clarity look like? And as this gets continued to be, you continue to refine and to roll out this platform with other practices and things. What does the future look like for this
Dr. Michael Fishman (29:10):
Endeavor and the world we’re living in? I think the biggest challenge that we have is creating a virtuous loop, and I think Clarion health has the potential to create that virtuous loop. And I w what I would say is that’s born out of my own frustrations and my understanding of the frustrations of my colleagues and patients. And so what I’ll say is this, we believe that reframing the, by which we judge the success of treatments is a critical first step to then identifying which treatments are successful and impactful, and then understanding the medical necessity of those treatments. And to do that in a patient centric way, and in a way that continuously updates the dataset and understanding and algorithms bringing in the latest information from disparate sources, integrating multiple data channels in a environment that embodies extreme interoperability and the liquification of health, health care data on locking outcomes and the understanding of where our patients have been and where they’re going from the EHR will afford us the opportunity to get patients the right treatment at the right time to improve the societal impact of chronic pain, to hopefully answer important questions regarding which medications have real world evidence surrounding them, and which have literature surrounding them with, you know, inherent biases, unfortunately, that literature has, and that study’s designed for things like FDA approval have and to occupy the space.
Dr. Michael Fishman (31:10):
And this is most important. I think something that Jason Pope really says very nicely to occupy the space between clinical practice and level one evidence. We need this collaboration and enormous collaborative experience to drive forward the selection of therapies, the implementation of therapies, the medical necessity, and access to therapies, so that a patient who’s probabilistically going to respond to therapy X, Y, and Z, does not have to try therapies, a, B, C, D, E, et cetera, including fentanyl, morphine, methadone. I mean, I’ve gotten these letters before patient can have this drug or this medicine. They need to try these five opioids that is like ludicrous speed, right? So, so we need to get to that stage where we align everybody’s interest, and it will save everybody money, save everybody time, get everybody back to work and feeling better. And in more productive way than the current state of affairs we have, that was a longer answer than you wanted. So what’s the future. The future is right patient right treatment, right time in a virtuous loop created by collaborating between physicians and patient reported outcomes to measure what matters to define the future of pain care.
Justin (32:31):
It makes a lot of sense that I’m, I’m thinking even like in terms of application for insurance and reimbursement for procedures, and being able to set to, to have this, you know, much more robust data set for certain implants or certain devices or procedures, like getting, getting things paid for, or being able to much more quickly determined which devices are working and which aren’t. And because obviously in pain management, there’s a lot of industry collaboration that can create these conflicts of interest. It, the water can be muddy when we have more objective data that’s more readily accessible. You just shorten the runway on all of that and say, we can get much more quickly from beginning to end on a lifecycle of a product, if something sucks and we can see it, and everyone can see it all at the same time, they’re not going to have people, their salespeople are going to stop knocking on your door much more quickly, presumably, and that’s good for everyone.
Dr. Michael Fishman (33:22):
I think that’s a, I think there’s competition that was in, it created in this space by the entry of neveroh and the sons of data that revolutionized the way we think about level one evidence for low back pain and spinal cord stimulation. And the competition that has been spurred on by their entry into this market has been incredibly impactful for patients and for physicians. And also for those device companies. I totally agree that that the next data revolution though, is big data. It’s this extreme interoperability, it’s it’s liquid education. It is this giant leap forward, and it’s an innovation and acceleration because like you just said, without a compass, we were in trouble. And I can just as easily show you many oppor opportunities for those who say these therapies don’t work and should not be medically necessary and covered and paid for to enter and say, you know, well, there’s a lot of evidence here that has bias.
Dr. Michael Fishman (34:25):
There’s a lot of evidence here that doesn’t actually compare apples to apples. And I think as physicians, you know, you need to understand your own practice dynamics, how things work in your hands, because there’s no way to me, for me to believe anything. I see published in a clinical trial, or certainly in some marketing material, unless it’s replicated in my practice. And that in, in evitable, in pain care has to involve seeing people who get better. And that doesn’t mean pain scores. That really means, you know, holistically is this patient better? What does treatment success mean to them? How can we align our treatment strategy with their interests? And that might be as simple as saying, you know, to my nurse practitioner, for example, look, if people are severely depressed and they’re on, on medications for pain, if they’re not on an antidepressant, we’ll do we’ll use for pain, we should put them on it unless there’s a contraindication, you know, taking this objective or semi objective patient reported outcome as the starting point for a conversation.
Dr. Michael Fishman (35:43):
And the objective kind of defining document for each visit is important in the chronic pain population. Of course, the person who comes in with a herniated disc with back and leg pain, you know, maybe, you know, if, even if they’re severely depressed, if they have an acute ridiculopathy, I’m probably treating the acute radiculopathy. I bet you, the next time I assess their biocycle status, social status, it will probably be better. So, you know, you have to contextualize this, but we should be looking for this in our patients. And everything you, you know, you need to know in life, you did learn in kindergarten. I agree with that. And that includes sometimes being polite and not talking about, you know, real things that are going on in your life that may impact, or maybe a covariate of success or failure in your treatment. And ultimately in my treatment, right?
Dr. Michael Fishman (36:31):
If you come in and here’s a, another base case, Justin, how many times is a device or an implant judge based on a pain score for a different body area. It wasn’t designed to treat the patient comes in with a pain score of nine overall, but it’s all in their neck and their back and legs are great. After the spinal cord stimulator. If I did a chart review on that patient, if those scores weren’t separated out, we would never know that at calleri, what we’ve done is we actually assigned pain areas and body maps to devices. So we can really make sure we’re tracking the right metric for the right implant over time. And again, while pain scores are unfortunately still important and still something we track the focus is more on functional metrics because that’s really what matters to patients. What matters to me.
Justin (37:22):
Yeah. That makes sense. I I wanna pivot briefly and then we’ll wrap things up and I appreciate your time today. You are a guy who has a lot of things going on. You have your clinical practice and a lot of the research you’re doing and then Clary. And then I know you’re a, you’re a family man and lots of other things. And you talked about a little bit about, you just mentioned in passing, like the way that you stay organized and like set your tasks for the day and you get out of bed and you love what you do and you love every day. And I’m curious, you know, as somebody who personally in the last 12 months, I’d say I’ve spent a lot of time thinking intentionally about how do I build a life that is most productive and optimal for the goals that I have professionally and as a human, as a spouse, as a dad, what are some of the resources that you’ve used or some of the methods, like, how do you, how do you build your life for optimal productivity right now?
Dr. Michael Fishman (38:11):
Well, that’s a great question. And the first, the first step was by utterly, almost failing in doing it and spending too many nights consecutive nights up until two and three o’clock in the morning, working on side projects and papers and other endeavors. And so the first, and I did that for about a year and really was at the point where I really it was, I was having impacts. So what I learned was I need to set aside time and stick to it and say no to things, and then fill up the time that I do have with things that I enjoy doing, I’m really interested in doing. And what that means is either automating busywork, or I know it’s horrible for hardship, for me to even say does delegating it out to people, but at the end of the day, what I’ve realized is that the few unpleasant things that I have to do as part of my professional life are things that no one else can do.
Dr. Michael Fishman (39:10):
I have to do them. They just got to get done and almost everything else that I don’t necessarily have to do. I have figured out a way to take those, give them to other people who I trust and take the things that I am interested in that are productive for me. Of course, if they weren’t productive, I wouldn’t be able to delegate the other things, but that are productive for me. And that drive me to continue to think and innovate and create and be interested in what I’m doing. And when I walk into my clinic, Justin, I it’s humming with clinical care. I’m seeing patients, my nurse practitioner, seeing patients, we have medical assistants and procedures that are occurring. My research coordinators are doing some in-office studies. We’re seeing subjects that are following up from research. Our clinic is humming with this activity.
Dr. Michael Fishman (39:59):
When I walk in there, it is, it’s like a beautiful orchestra and I get to walk into the music that’s occurring every day. So to me, professionally, when I take that daily experience and I marry it with the opportunities that I have to do, engage with smart likeminded people physician colleagues across the country at night on webinars and calls. And to do that in a way that also gives me time with my family and mostly late nights with my, you know, my neuromodulation brother, brothers and sisters that’s, that’s the beauty of it. It’s the whole thing feeds into one other piece of it. The clinical part feeds into the research. The research feeds into the idea generation and collaboration, the idea generation collaboration fuels better patient care, better patient outcomes, more innovation and acceleration of the space we’re in. And ultimately these are intellectually satisfying. They provide a common ground for me to, to collaborate with my who, you know, friends and colleagues in the space and ultimately to really impact the world we’re living in for the better. So I’m just grateful for every day of this. Like I said, this beautiful orchestra.
Justin (41:14):
Yeah. What would you say to somebody who’s listening and thinking, Oh my gosh, I walk into my practice and it does not sound like an orchestra, and I’m just trying to get at least in tune. What, what was the first step for you to be able to make progress in that direction when you were redlining?
Dr. Michael Fishman (41:28):
I think it’s about scratching your own itch. You know, if you’re plagued by notes, get ascribed I can tell you that I had the experience of having an amazing scribe, that super well trained and describes who that, you know, honestly, it was my fault. I didn’t spend, I didn’t really spend enough time, whatever week it was that they started. I was a fatigue kind of person. I didn’t spend the time, training them, get a scribe and train them. If you train a scribe and you write up your own, you know, little tidbits and statements that surrounding common talk tracks that you have, you’re going to find that your scribes sounds like you because they’re using your words. And as that becomes refined, it will liberate you from the documentation and let you get back to interacting with the patient. And actually that alone makes the patient and interaction extraordinarily more in, you know, interactive and fulfilling.
Dr. Michael Fishman (42:26):
And at the end, if you’re described as really good, if you’ve taken the time to teach them what the physical exam is and means and what your thought process is. And ultimately, really what that means is you’re just giving your patient a pretty, you know gentle synopsis of what you did and your scribe captures it. You’re going to your documentation will be fine if they didn’t use the exact right word, get over it. Who cares if you feel better about putting a disclaimer at the bottom, that it was dictated, but not read. So be it, but don’t care about it. A little mistake. You’re there. As long as they channel your direct energy, that is enlightening, it frees you up. That’s the best. One of the best things that I can say. The other thing is for me, it’s about the limitations in chronic pain care.
Dr. Michael Fishman (43:14):
Okay? Most people think you have to try a million things, including all these outside of the box treatments. And you can, and I’ve been down that road. But at the end of the day, if you look at the evidence based treatments and the French chapter of the international association for the study of pain, just published this, this article the French recommendations, they are the French experience. It’s fantastic. There’s literally three lines of therapy for chronic neuropathic pain and it’s lidocaine and tens. And then SNRI eyes and Gabapentin. Then there’s a second line therapy and it’s capsaicin and Botox and pregabalin and tricyclic, antidepressants, maybe Tylenol and Tramadol. Then there’s third line therapies. And that’s basically spinal cord stimulation. And then opioids, neuromodulation, PNS, et cetera. If people actually practice this way, this formulaically in their practice. And we put evidence-based therapies with level one evidence much earlier on in the care continuum, you’d be less frustrated.
Dr. Michael Fishman (44:21):
Your patients would probably be on less opioids if we went a whole level earlier. And we said before, anybody goes onto a strong opioid, they should be on or attempt to buprenorphine formulation in a micro doses on label for pain. We would be in a better place. And if you formulaically practice like that. So for me, I don’t prescribe opioids to everybody who walks in the door. I prescribe opioids when they’re appropriate. And almost everybody who comes in has been on opioids, the same opioids for years and years, and years and years undergo some rotation. And usually that rotation is to an atypical agent. So I don’t have unpleasant opioid conversations. I tell people that upfront, if you want to be on my patient, that’s it take her to leave it. And most people, frankly, even if they’re resistant upfront, they’ll do it.
Dr. Michael Fishman (45:05):
And most people do better. The ones who don’t actually believe that most of the time. And I’m okay with them going back to where they were, because they demonstrated to me their willingness to try and to engage with the kind of therapy that we are open minded to in our practice. So if you create your practice, that becomes open-minded patient centric, you talk to patients about what matters to them and you don’t just, you know, mindlessly practice medicine it’s fulfilling. It really is. And you layer on research, you layer on. I mean, there are other people who are more interested in medical legal work. They’re more people are interested in advanced therapies and doing lots of advanced procedures. There’s lots of people who are not, you know, you have to do what works for you. And if there’s something that you dread acts it, cause it, chances are good. It doesn’t have to be you doing it or just don’t do it change.
Justin (45:58):
I think we’ll end on that note, Dr. Michael Fishman, it’s been a pleasure speaking with you today. Thanks for joining us on the anesthesia success podcast.
Dr. Michael Fishman (46:05):
Thanks Justin. Hey, that was a real pleasure.
Justin (46:07):
If you liked what you heard this week, head on over to anesthesia success.com, where you can find more content and free resources to help you build a successful career in anesthesiology and pain management. If you want to leave a review in iTunes, I would also really appreciate it. Thanks for using some of your valuable time to join me today on the anesthesia success podcast.

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