This week my guest is Dr. Gary Schwartz. Gary is an interventional pain physician and Director of Acute Pain Management at Maimonides Medical Center in Brooklyn, NY. He is board certified in both Pain Management and Anesthesiology. We discuss the importance of practice management for pain management and how the Practice Management Committee helps to educate ASRA.
I’m very pleased to be joined today by my friend, Dr. Gary Schwartz. Gary is an interventional pain physician. He’s the director of acute pain management at AABP which also has an affiliate relationship with my monities in New York. Gary, thanks for joining us today, Justin. Thanks for having me. It’s always good to see you again. I want to [inaudible]
Dive right in. I know we had first connected at Azure a couple of years ago and you’re, you’re one of these physicians who has a special place in my heart because when it was my very first meeting, I remember we were sitting down getting dinner and they were very welcoming. I think this speaks a lot to like the asthma community. It’s always been my experience that whenever I’m at the Azure conference, there’s a lot of good people who all want to help each other and help pull everybody in the right direction.
Dr. Gary Schwartz (01:10)
It’s just a wonderful organization of an inclusivity of friendliness. I think everyone wants to help each other just further the educational component of a regional anesthesia and interventional pain. Just bring everyone together from all groups of life just to help patients really. Yeah. To provide education. It’s really a welcoming organization. That’s why I’m a part of it.
Yeah. And so you were just mentioning to me that you are, were recently added to the practice management committee of the Azure meeting. And so tell us, I know you and I had, we connected back in November in new Orleans at that, that practice management committee meeting. And we were just talking about how, how critical this kind of Intel is. So talk a little bit about what is the practice management committee do and what’s the content of that? That track like at these meetings with the practice management
Dr. Gary Schwartz (01:52)
Committee helps educate the organization as HRA about the practice management side of pain management and regional anesthesia including coding, billing, how anesthesiologists and pain management doctors get paid a regulations through CMS. That’s the center for Medicare, Medicaid, which dictates payments to hospitals and physicians. And it’s important that set up, cause unfortunately we can’t help patients unless we get paid and our hospitals get paid to provide access. So as HRA, every meeting has, as part of their meeting, they have a certain educational component that allows lectures for this topic. So at the fall meeting that you’re discussing, because they started with new 2020 regulations for payment models through CMS, it was standing room only for that section just to discuss the different coding changes, the different reimbursement changes, which obviously we’re all in this to assist patients and make sure everyone decreases pain gets through anesthesia safely and surgical safely surgery. But our organizations or our own private practices still have to be paid to pay our staff to put the lights on and to provide these services.
Absolutely. So I’m curious, in your experience as you look across the landscape of not only, you know, attending physicians and both private practice and academic medicine, but maybe also the residents and fellows, the next generation of pain practitioners how do you evaluate the current levels of financial literacy, both on the business side and the personal side?
Dr. Gary Schwartz (03:30)
Yeah, I do have a private practice, but I get to take call with the residents. So when I’m on call we sit down and we just discuss their future, what they want to do, if they want to do fellowship and kind of where they see themselves in a year, five years, in 10 years. Because obviously your roles do change. Five years ago you probably didn’t think you had a son. Now your life’s a little bit different. So congratulations on that. Thank you. So the first thing I asked my residents is what they plan on doing with their life, where they would like to live and what are their goals and then we further the conversation from there
That that makes a lot of sense. That’s actually the perfect place to begin and my financial planning practice, that’s always a good place to start is like what do you want? What do you want the end to look like? And then we reverse engineer what kinds of answers do we hear from people?
Dr. Gary Schwartz (04:16)
So some people say, I just want money. Very rarely now. Most people want like a work life balance or they just want to be happy and fulfilled at work. It’s, it’s changed a little bit if you just want to make the most money as possible. Probably a big city is probably not your best bet. Go off to Alaska. The Midwest, they have these large different Pat practices and anesthesia for a lot of vacation, a lot of money, but you have to decide where you’d like to live. The biggest thing I see now is that they want to just be happy in their practice and just have some free time to either start a family or be with their family, which is important to me.
Yeah, and one of the trends that we’ve been tracking that we talk a lot about on the show is how the autonomy, the flexibility, the power of self determination of physicians, especially in anesthesiology and I think to a lesser extent in pain management is a, is being continually challenged and continually pushed against by all the forces of healthcare. Especially like, I’m sorry, go ahead. Oh, sorry. Finish what you’re saying. Just say especially like in the context of insurance reimbursement contracts, like how the big insurance companies sort of have the ultimate leverage to be able to either have a contract or not with a physician group and it, it can create a lot of stress and tension and it, it creates an environment with a lack of autonomy. A lack of self determination for physicians.
Dr. Gary Schwartz (05:36)
I think that’s people looking for is just autonomy in their work. Obviously to be mentally and physically challenged at work. The cases you like, make sure patients are safe and obviously comfortable, but also to have some flexibility in your schedule to enjoy time with your family. If you’re working all the time, you can’t spend time with your children. So I tell my residents is to look at what you want in their job and talk to people who are working there. Do they have young children? Do they not have children? How much time off do they have? Do they get to attend their kids’ sports events? To me that’s very important. So I make my schedule around that.
So if if someone is interviewing on a prospective practice, you would encourage them, either ask the interviewer or maybe some of the other physicians in the practice. Like do you go to your kid’s tee ball game?
Dr. Gary Schwartz (06:21)
Yeah. So I tell people when I interviewed for my practice and I give advice for my residents interviewing. So when I tell people, number one, when people come into view with me, I try to be as upfront as possible. I ask them what they’re looking for, I show them my daily schedule. I will pull up about how my schedule looks in the pain practice. I show them my typical Oh our day and then I normally give them my personal cell phone and I say, look, go home, talk to your significant other or your mom, your dad, grandma, whoever that that close knit person your relationship is. And think about it for a couple of days. You can call me off the cuff. I’m not going to repeat this conversation just to any questions you specifically have with a job. When my residents go on interviews, I tell them to have a plan of what they looking for, whether it be financial time or autonomy in their practice. And then once you finished the interview, like it asked to speak to some of the younger practitioners and the older practitioners who have been there and get their thoughts on the practice, you know, you never know what’s going to happen until you actually start working there. But you try to get as much information as possible similar to investing or for financial literacy. Yeah. You never know how the future’s going to hold you. Try to prepare yourself as best as possible.
Absolutely. So talk a little bit about your practice at ABP and how it’s structured and type [inaudible] yeah, go ahead.
Dr. Gary Schwartz (07:37)
I guess we’re medium anesthesia group with a pain practice. So we have about 55 anesthesiologists, six pain practitioners. So as you said, we’re a private group, but we’re affiliated with my modernity’s medical center where we have an anesthesia residency, no fellowships, but 10 residents a year. Okay. Me personally, I’m in my interventional pain office four to five days a week. So what that is for some of your listeners is a, I’m seeing patients anywhere from 20 to 40 a day and a lot of different interventional procedures, nerve blocks under ultrasound, epidural, spinal cord stimulators, peripheral nerve stimulators PRP, STEM cells, everything of the sort. And then I’m in the operating room about four times a month and I take about one to two calls a month. I round on the pain patients in the hospital. I teach the residents nerve blocks, pain management. I do the whole lecture series for pain management and I just teach them about life on call.
Wow. It sounds like a really well rounded, a really well rounded life for you.
Dr. Gary Schwartz (08:38)
I like it. It keeps me pretty happy. I enjoy teaching the residents. I find it fun. It also gives the lay of the land of what people are thinking about in terms of anesthesia, pain management, fellowship.
Yeah. What are some of the biggest challenges you’re facing right now in your practice?
Dr. Gary Schwartz (08:54)
So me, some of the bigger PR problems that I have in the issue is just the pre-authorizations and coverage for some of these pain treatments. Yeah. For my pain patients not all. Obviously there’s the opiate crisis. I’ve heard you cover that in numerous times in different episodes and as people put on CNN, MSNBC, Fox, whatever you want, it’s all over the news obviously before the Corona virus. But just every procedure I do or different type of pain management intervention, most insurances now recover prior authorization, which sometimes delays care to patients who need it. Let’s say for neuromodulation, spinal cord stimulation assists a lot of our chronic pain patients who have suffered for a while and insurance makes you jump through hoops sometimes for that treatment.
Yeah. We recently did an episode episode 36 with dr Josh Sudirman and he was talking about some of the work he has been doing to try to alter the legislation to make prior auths less onerous for pain physicians. Especially because it’s such a, unfortunately it’s such a normal part of the practice. Having to take the gloves off and go toe to toe with somebody in an office somewhere about how to treat your patient.
Dr. Gary Schwartz (10:02)
We’ve hired two extra staff people just to get authorization for different imaging modalities and our procedures. And then we have peer-to-peer, yesterday I waited about 40 minutes to get into peer-to-peer, which was a two. It’s a peer to peer just for the users is a physician talking to a physician or a nurse or a PA to get authorization for a procedure and sometimes you have to wait, go back and forth. And literally I was on the phone with this person for two minutes and they authorize the procedure, but it just takes time out of my day where I’m not seeing patients. Yeah. The other challenge for myself is the educational component. I like going to the Azur meetings and be involved. The ASA, those are my two large meetings and just to find time with a work life balance in a nonacademic center to be involved. I think it’s important because I learn and I’ve just made some great connections personally and professionally through these organizations.
Yeah, that’s one of the interesting things that I’ve seen about the pain world is the bridging the gap between academics and private practice in the, you know, some of the organizations like Asmara that it does. I think it has like a more, a more, a just a broader perspective, a more diverse perspective because of private practice in leadership and you know what you just described, dr Provenzano, yourself and some others doing the practice management committee. That’s so immensely valuable.
Dr. Gary Schwartz (11:19)
I think you need the private practice research, especially in the pain management world. There’s only a, I think 80 some odd fellowships in the country, so there’s only a certain amount of pain practitioners in academic medicine, so they can only see a certain amount of patients and only do so much research. The pain fellowship after anesthesia or PMNR neurology is only one year, so there’s only so much you can get done in the real life. Most people will go to a private practice. Pain management. I think it’s important that myself, other the pain practitioners get involved in research because it translate it translate to real world problems which will further give new technologies, new treatments to patients who suffer. People are living longer, we expect more out of life. We don’t want to be in pain. Right.
I think another statistic we’ve covered on the show is that something like 30% of new medical research is funded by the government and all the rest is coming from industry and industry collaborations. So I think pain is a space where that’s really, really important.
Dr. Gary Schwartz (12:14)
Yes, and the government has a large role in research, but obviously they don’t have unlimited coffers. And you know, there’s a whole back and forth debate about how much industry should punch sponsor research. But they do, they’re offering the research. I think as physicians scientists, we have to play a role in this because if we don’t, someone else will shape the research. Yeah. And it’s important. We’re looking always looking at new treatments for our patients or different ways of using different technologies to help our patients, which I think is immensely important. Yeah.
I was speaking to a group of fellows recently talking about contracts and the business of pain medicine, and somebody asked me this question that I had no idea what the answer to was, so I’m just going to throw it out to you right now. You mentioned PRP and STEM cells as part of this stuff that you’re doing in your practice. As somebody who’s vetting a potential practice, especially a practice that might have a a considerable focus on regenerative medicine, how should they, how should they think about that? What are some of the important specific questions to ask? Obviously cause it’s an area of a little bit more, it’s, it’s just, it’s a younger subspecialty it feels like so
Dr. Gary Schwartz (13:16)
One they have to be comfortable performing these procedures in as they train their fellowship. If they’re not. One of the questions I would ask if these practitioners in the prospective job market is willing to teach them some of these technologies too. It’s important to find out if you will be doing them because you don’t want to be doing just the consults for them and sending them the procedures to someone else. That’s important for their contract too. They want to find out the reimbursement. Unfortunately, currently these modalities are not covered by insurance, so it’s normally cash out of pocket for patients, but the kits or the devices to do the PRP or STEM cells do cost money. So you, the fellows should want to find out about their reimbursement model. Are they getting reimbursed by just the cost the patient’s paying? Are they getting paid by just the profit margin, meaning the cost of the procedure, minus the products and the time or the practice translation.
Dr. Gary Schwartz (14:09)
Translating that into a work RVU and paying them like that. So that’s important for them to ask all of those questions. Yeah. All of those aside for your fellows, the most important thing, if they haven’t done it during fellowship, is to ask if there’ll be trained, you should never do something that you don’t feel comfortable doing because it’s not, I used an example, it’s the practice of medicine. We’re working on real life people who could be in our communities, our friends, just fellow human beings. It’s not like you’re going to a restaurant. If you cook a steak wrong, you get a new one. It’s an actual life person, so you have to feel comfortable doing what you’re doing. Right. It’s not just about billing or finances, it’s looking out for the best thing of the patient, which is referring to a colleague who has more experience than yourself in certain procedures.
Absolutely. talk a little bit about the role of mentorship for you along the way. It sounds like you really go out of your way. You know, random person who just interviewed. Here’s my personal cell phone number. Call me anytime and ask me any question that says a lot about the kind of person that you are.
Dr. Gary Schwartz (15:11)
There’s two things to get to this point in life. People have helped me get to where I’ve been, whether it be in medical school, in residency, cause before I was at my monities I was at st Vincent’s hospital in Manhattan, which unfortunately closed. I know you’re in the Philadelphia area. Hanaman had a similar situation which was very distressing, so I’ve had a lot of people from that old job who helped me out always. I still speak to them. I saw one in the supermarket the other day and we caught up who has given great mentorship to me in a professional situation. I had people in my job have taken me under their wings who allowed me to have leadership positions and in a professional society role. Like if you said David Provenzano and the veal and Mariano Raj group, the Eric Schwenk, they’ve all taken me under their wing and have become friends, so I think it’s only right to give back. No one climbs this mountain by themselves. It’s the old saying, it takes a village with the job thing. It’s not only me being nice, I don’t want to make like I’m the nicest person ever. It’s, it’s a two way street, so I want the person to fit in and I want them to feel like they fit in to make sure you’re happy. The worst thing you could have is someone who’s unhappy at work,
Right? Especially if you’ve gone through all the trouble of hiring them, onboarding them, getting them up to speed and you’re four months in and then it’s not a fit. That’s,
Dr. Gary Schwartz (16:21)
It’s a lot of times it’s a lot of time and money to hire someone in an anesthesia practice, you have to get malpractice, you have to cover their four Oh one K and in anesthesia you have to get people on all the insurances. It’s hard to find someone. We have a one big hiring session in general in the anesthesia world and in medicine at July. August. Yeah. So you have someone that doesn’t work out in December, January. It’s a limited pool of applicants to hire someone else. Right. We want both sides to be happy.
Right. Makes sense. Can you talk about a specific story when that mentorship, either that you received or maybe that you, granted a, was gay, gave some impactful insight?
Dr. Gary Schwartz (16:59)
So, perfect. So through Asmara I met someone Emmett power from the UK. He lectures at the regional spring meeting. I think he’s the head of the regional anesthesia in the U K wonderful gentleman. I had a difficult case that I was consulted from one of my surgeon, my surgical oncologist for breast cancer and he published a lot of these non general anesthesia nerve block mastectomy cases. So this lady unfortunately had some comorbidities where she could not undergo general anesthesia. So myself, the surgeon and Emmett discussed a peri-op and postoperative pain management plan. So we could use this technique. I’ll be at modified to get the patient through safely. We’re presenting the case at the, the Azur spring meeting and hopefully eventually we’ll publish it. So their mentorship has had a huge role. Also at Mariano who you mentioned before, I believe he was a previous guest on the [inaudible] success has been a great mentor for how to get involved in societies, both the ASA and as WRA, which has been invaluable to myself.
Yeah. Awesome. Talk a little bit about you know, we talked on the phone the other day about sort of the value of outsourcing things in your life as a physician. I was, I was talking to you and I could hear your kids like screaming in the background and it was clear that you had a very lively household [inaudible] happening. And, and, and you and I were talking about, you know, how important is it to be able to take things that you just don’t have time to prioritize and have someone else in your life handle that? Oh,
Dr. Gary Schwartz (18:31)
We’re lucky as physicians that we have a, a decent financial level that we could outsource stuff in. There’s only a certain amount of time for the day, like to speak to you now. I got here an hour before office as I’m reviewing MRIs to get this podcast. So one of the things that my wife and I have decided is we decided, one that’s not totally outsourcing. We live in our means so that she could stay home and raise our kids. That’s important to myself and her. Yeah. To we hire a helper slash a babysitter two nights a week, so one we can get some stuff done like laundry, et cetera and like grocery shopping. And we’ve also hired a cleaning person that comes a couple of times a week to assist with laundry, helps keep the house nice and tidy so it gives us more free time to take the kids to events. Those are the two biggest things. The babysitter slash housekeeper that comes over a few times. It’s been invaluable to us. Sometimes I also outsource driving to work. I will, if I have a big meeting or a big presentation, I’ll use the Uber to review it or do some paperwork there beforehand, which is definitely worth my time.
Yeah, that’s great. I we’re facing this very question ourselves right now with Sarah on maternity leave right now as the posting of this podcast. We’ll probably be back at work and so we’re interviewing nannies and trying to figure out what child care is gonna on.
Dr. Gary Schwartz (19:50)
It’s tough to find somebody to trust. The other thing I do is I have a financial advisor. Unfortunately, before you started to doing this anesthesia financial business, I outsource a lot of my investing just because where I am in my career in terms of society’s professional work, building my practice and getting to my kids’ activities, I outsource my investing for now. Eventually I’d like to play a bigger role. I’m looking at your website, looking at the white coat investor, physicians on fire. I’ve been going to transition eventually, but my kids are just too young and too many activities right now and I still need a few hours of sleep.
Yup, absolutely. And that’s one of those things. I think even for financial, I always recommend not only should visit, I’m obviously super biased in this, not only should physicians hire fee only financial planners who don’t have internal conflicts and compensation, but also I think financial advisors should hire them too because they’re busy. I have the same situation that you have, you know, we’ve got like lively household here and I don’t even have time to spend on my own finances sometimes. And having the accountability and somebody else that’s being paid to make sure that it happens can be immensely valuable. So Sarah and I have said, you know, as soon as we’re done with residency, this is a high priority for us just cause I do think it adds a ton of value. There’s only a certain amount of time in a day. You can’t do
Dr. Gary Schwartz (21:09)
Everything we’d like to, but it’s nearly impossible. So you have to outsource certain stuff occasionally. Obviously we use Amazon, sometimes order our groceries from like the stop and shop brand. We recently bought an exercise bike at home just because it saves me instead of going to the gym, I just exercise in the house. Yep. So right then and there now I’m able to exercise 30 minutes a day but I don’t have to travel back and forth or just exercise, shower done.
Yeah. I’m curious, this is a question that I’ve thought about asking on this podcast, but I haven’t before. What is an opinion that you have that perhaps if you were in a crowded cocktail party of many of your peers, you would be one of the only people with that opinion, but that it’s something that you think and hold strongly. It could be medically related or otherwise.
Dr. Gary Schwartz (21:52)
Well just I’ve seen some people, I’ve gone out of my way to help some of the younger practitioners in my group and people always ask it cause it’s not as such almost opinion what’s like, they think some of the younger people think what’s in it for me in general. Like, Oh why are you being so nice or why you’re trying to help me? And it’s really just, I truly believe in paying it forward. People have helped me along the way a lot. Like I think people are always hesitant sometimes. Like we have a new pain practitioner and I’m bringing him across the practice. I’ve keep on arguing him to have more time in the office. I’m even transitioning some of my patients to him and he’s like, why are you doing this? It’s, these are not like drug seeking patients. They’re nice. I’m like, I’d, I’d feel more professional success if you get busy.
Dr. Gary Schwartz (22:41)
I’m already busy in my practice. I think people always is. People always are afraid that they’re just looking out for themselves. Like people are afraid to help other people either afraid that it’s going to hurt their reputation or their own practice or there’s something going on like you’re trying to screw them per se. I’ve had that a lot with some of our newer colleagues in the practice and it’s not like there was no ulterior motive. I think people are always afraid now. I think in medicine and just in life that there’s an ulterior motive of someone trying to either get something from a person or borrow a favor down the road. People are afraid to just do the right thing. Almost like the golden rule.
Yeah, I think people have forgotten about it. Yeah. Isn’t that a great thing to be able to restore some semblance of humanity to your profession to say, I just want to do something to help you professionally and help you develop and help you thrive and there’s no strings attached like a lot of people, people
Dr. Gary Schwartz (23:38)
Have helped me to get along this way there, but intentionally or unintentionally, like I found the law. I found that the last day of my fellowship, now, this is like nine ago that one of my former mentors at st Vincent’s went up to the fellowship director at that time and said, you know, you guys didn’t take him for residency. You made a mistake. I’ve never done this before. You really should not make the same mistake twice. You should take them for the fellowship. And I found that out as our graduation dinner. And fellow. I had no idea after the whole year. So he didn’t have to do that. That was just going out of his way to do the right thing for someone.
I got one question left. I want to close on this note and I’ll let you get back to your day. So as it relates to, you know, your current scope of responsibilities, you get a lot of things going on. You’ve really given yourself to a lot of different pursuits, family, medical practice organizational leadership, mentorship. As you look across the things that you’re currently working on as a physician or have worked on, what are, what’s one thing, tell me a story, an anecdote about a time when you were involved in something that you felt like in this moment, I feel like the work that I’ve put in is, has paid off. There’s a moment of validation, a moment of I’m making progress, we’re moving the profession in the right direction. A person has been helped, things are, things are going the right way.
Dr. Gary Schwartz (24:54)
So does that. I just have to off the top of my head, cause one was just recently I had a young girl with CRPS, chronic regional pain syndrome, which is just a nasty, painful neuropathic disease of her. I think it was a right leg after a knee surgery. It was all swollen red. She was 19 years old coming to the office, walking in crutches like almost in tears. She can’t touch her foot. We did a spinal cord stimulator trial and then we put a permanent implant. She came back a few weeks later off the crutches, 90% relief, went back to work, going to go back to college. That’s a wonderful feeling. To which just happens a lot is now that I’ve been working for my group for eight years, I have rounds of residents who have graduated. So when they call back and either say thank you or one just texted me the other day, he ended up doing a pain fellowship after I helped mentor him and he’s like, look, I just had this difficult case.
Dr. Gary Schwartz (25:54)
Could I send you the images? I have the patient’s permission to send me the HIPAA, could review it, let me know that I’m doing the right thing. Does this make sense? And that was just so rewarding that my former resident decided to take the same career path as myself and then feels comfortable enough to just call back after say thank you and say, Hey, can you just go over this with me, make sure this is correct. That was one of the most rewarding things because now he’s a full out colleague but still respects my opinion enough to ask for his difficult cases and that’s just, that’s what it’s all about and all of them, the benefit of benefiting patients safely. It was just a wonderful feeling. Yeah.
Awesome. Well, Dr. Gary Schwartz, thanks all for joining us today on the anesthesia success podcast. It’s been a pleasure speaking with you,
Dr. Gary Schwartz (26:40)
Justin. Pleasure. Again, congrats on the new baby and I hope to you soon at some of the next
Meetings. Thanks. Sounds good. Have a good one. 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.