Primary Care and Pain

Here is an article that basically summarizes a recent lecture done in Palm Springs, California about chronic pain.   Usually I blow by these things when I get the journal in the mail but a few things struck me about the piece.   I always find it laughable when pain specialists complain about their referrals.   The pain doctors in my small community are some of the richest people around.  One guy makes almost a million dollars a year.  How?  Well, he puts a needle in almost everyone he sees.  Reading that “the best people to take care of most pain problems are primary care doctors” feels like someone is putting a needle in my eye.   Let’s be honest.  The pain specialists want only the most perfect specimens coming their way so that they can really hone in on doing more procedures and making more money.  That’s calling a spade a spade.   Now I will be honest with you.  If they don’t take the bad (managing the chronic pain people who just get meds) then they don’t get the good (a new summer house and boat).  That is why this article is a waste of my time.   But the saddest part was the dude doing the lecture.  Dr. McCarberg, who is a family doc and pain specialist ,is an absolute sellout not only on the pain issue but also on how he states he treats his patients. Just look at this quote from the article:

In his pain practice, Dr. McCarberg can see a patient for 45 minutes to deal with a single problem – but in his primary care practice, a patient typically arrives with a list of problems for a 15-minute visit.  “I get paid according to the hemoglobin A1c – whether or not we’re controlling diabetes. That’s part of where my salary comes from,” he said. “If I have blood pressure control,” other financial incentives kick in. There are no similar metrics for pain management, he added.

Dr. McCarberg is an example of what is wrong in primary care as well.  Do you see how he has bought in the quality metrics philosophy?   He treats it like it is standard of care or dogma.  He cares about getting PAID according to blood pressure and blood sugar measurements.  Are you kidding me?  How sad is that.  Hey, doc, what about the patient?
Lastly, Dr. McCarberg reported that he is an advisor for Endo Pharmaceuticals, Forest Laboratories, PriCara, a division of Ortho-McNeil-Janssen Pharmaceuticals, and NeurogesX.
So, let’s summarize.  Dr. McCarberg is the founder of the Chronic Pain Management Program at Kaiser Permanente and wants family docs to do the pain control while he can do the procedures.   He treats patients as numbers and not people.   And he is getting paid by Big Pharma.   I shed a tear for our profession.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  9 comments for “Primary Care and Pain

  1. Dave F
    April 25, 2012 at 8:50 am

    Let’s not forget that the technician (often loosely called ‘Doctor’) who is making a clean Mil a year is seeing patients with some form of health coverage…
    Good luck getting him to see the unwashed, uninsured masses who flock to my ED with pain complaints…I refer them to the pain management guy and they get laughed off the phone by the office staff who demand an unmanageable up-front payment just to schedule an appointment…
    Only when EMTALA covers the entire house of medicine (or gets repealed) will things be equitable…Or perhaps I should be allowed to write off my unreimbursed care as a tax deduction…I wouldn’t pay a red cent in taxes if that EMTALA rule could be passed!

  2. April 23, 2012 at 7:57 pm

    But isnt Technician McCarberg responding as society, through it’s legislature, judicial system, mixed-market economics, and toady medical societies have demanded? If McCarberg is espousing the quality medics as dogma, then hasn’t become the exact logical outcome of a society grown explicitly anti-physician, in the traditional sense? When a patient comes into the ER with even moderate risk factors and minor symptoms, we are very likely to admit them, not because we are convinced that their is a substantial cardiac risk, but because the external forces upon which we base our livelihoods compell us to that path of less resistance.

    I don’t defend what McCarberg has become, but admit that we should have expected him and increasingly many others, to be exactly that. Sad, but logical.

  3. Dr. Bonz
    April 23, 2012 at 7:24 am

    Wait a second Doug. As a ten year PJ veteran I am almost always on your side on these issues but to be really honest with you, aren’t you the pot calling the kettle black here? For the past few years you have continually decried the fact that specialists make a lot more MONEY than YOU as a family practice doc. In fact, as a specialist it is getting sort of old. Have you ever gone back and read how many articles (The PJ, the PG, and on FB)you have written complaining that you don’t make the $ that the orthopod, the neurosurgeon, the cardiologist, or now in this case, the pain management guy? Hey, you CHOSE your postion. If you wanted more money you could have done the longer residency, gone WAY more sleepless nights away from your family and worked longer hours, more holidays and more weekends and made that kind of money. You didn’t. You chose FP, a very noble position. I have always respected my FP referral men and women. But moreso because they DON’T complain about not making specialist money and because the DO care about their patients. And finally, just because we specialist make more $, doesn’t automatically mean we don’t care for/about our patients. Come on Doug. You’re better than that.

    • Doug Farrago
      April 23, 2012 at 8:43 am

      Yes, I chose family medicine. I am okay with that (most of the time). I agree that most specialists should get paid more. For example, a neurosurgeon doing 7 years every other day on call and losing his life to his or her job should get paid more. That being said, the disparities between primary care and most specialties is ridiculous. Derm, anesthesia, radiology, etc do not have excruciating residencies and the money some make are obscene. One buddy of mine in anesthesia just turned down a 500K/yr job. A neighbor, radiologist, makes 500K with 16 weeks off. The pain dude I mentioned in the blog makes almost $1 million. Unbelievable. Back to your response. Choosing FP should not be vow of poverty and that mindset is what is driving students not to going into primary care. But that wasn’t my point. This pain doc is a sell out and he wants us to be his bitch while he does the injections. And we should be pushing back. Capisce?

      • Dr Bonz
        April 23, 2012 at 10:32 am

        “Derm, anesthesia, radiology, etc do not have excruciating residencies and the money some make are obscene.”


        “Choosing FP should not be vow of poverty and that mindset is what is driving students not to going into primary care.”


        I just hate to see this deteriorate into a bitch session about doctor’s salaries since almost all docs make a fairly comfortable living. We don’t get any sympathy as it is and complaining about what we make in light of the economy and unemployment isn’t going to get us any points with our beloved public.

        • Doug Farrago
          April 23, 2012 at 11:06 am

          I agree with you 100%. Here is the thing. The dude does a lecture scolding family docs that they need to take care of all the chronic pain stuff. Why? Because he wants to skim the big money off the top. This really wasn’t about all specialists. It was about the pain guys who most, if not all, somehow learn to inject everything. And their money is obscene and makes the good guys (YOU) look bad and get defensive. The other issue or point I was making was how this doc talks about family medicine. And that gets me ranting about the whole BS quality iniative going on.

          No hard feelings, ok?

          • Dr. Bonz
            April 23, 2012 at 8:41 pm

            None at all. Keep on rockin Doug!

  4. Brad Albien
    April 23, 2012 at 6:59 am

    Smells like bona fide fraud, committed under a bona fide set of government guidelines, recommendations, and laws. When is the American majority going to wake up to the simple fact that any forays into the private sector are always filled with BS, corruption and financial loss. Eg; Medicare losing $, social security losing $$$, US Postal service facing bankruptcy, etc., etc. Let’s not even get into the debacle that our gov’t run mortgage giants are in!

    As it looks to me the gov’t is now going to make damned sure that one of the most technically advanced medical systems in the world is going to become another collasal catastrophe. Thusly driving out the “truly” caring and committed care givers we now have, and leaving us to rely upon yet “another fine mess you’ve gotten us into–Uncle Sam”.

    • big picture doc
      April 26, 2012 at 7:33 pm

      Oh, but it’s not just Uncle Sam my friend, it really is mostly our private insurance companies screwing us [come on sheep, how many times do I have to tell you this?]. Doug, you have hit upon some great topics with this issue. In Summary, greedy doctors and their societies have helped get politicians into office and on to the supreme court, who have take away all the checks and balances from greedy corporations and now they run the show and the sheep follow. Then the sheep complain, complain, and complain some more, but they keep sitting in their big fat chairs, on their big fat butts, writing their big fat prescriptions. Go figure.

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