What is a Physiatrist? | An Interview with Dr. Anand Gandhi

The selective nerve root block is a diagnostic tool. So a very small volume of anesthetic based medication to identify if the nerve is the primary pain generator. The epidural steroid injection is a larger volume. It includes steroids. It has more of a therapeutic component to it.

Hey, what's going on everybody? Dr. Jeff Langmaid with the evidence based chiropractor here. And we are lucky to have a guest, a friend of mine, Dr. Gandhi, an interventional pain and spine focused physician. We're going to talk about the differences between pain management, interventional spine, talk a little bit about MD DC relationships and also some of the benefits of outpatient procedures and surgeries. Thanks for taking some time.

Thanks for having me. Really appreciate being here.

You got it. So you and I practiced together at an outpatient spine surgery group and it was pretty unique, not only in terms of how the chiropractors practiced there, but also in terms of how you practiced. And I guess we take it from the top. What would be the difference for the docs out there who don't know what's the difference between practicing in interventional spine and or pain management and how does that break down?

I think it's a good question. I think a lot of it is people use those terms interchangeably and some of the nuances are in the differences. And so I think in the interventional spine world, the focus is on more of a spine and musculoskeletal related disorders. In the pain management world you're going to see all types. You'll see everything from fibromyalgia to chronic pain to failed back syndrome. And there may be a long term relationship in both avenues, but one seems to focus more on the neurologic musculoskeletal. One focuses on all components of pain and people kind of choose their avenue in between.

And with your role, which I think was pretty unique, it really was in kind of that the surgical realm. So describe a little bit of kind of your day to day or how you went about either seeing, treating or diagnostically evaluating a patient.

My primary focus, and I think we worked in conjunction with each other for many years, was to evaluate a patient and more importantly, identify a pain generator. And I think that's the primary focus. I think very difficult to offer any type of treatment option without having a clear cut pain generator established.

What are some of the best ways. I'm gonna skip ahead to a question that I was gonna get to down the road, but a lot of times we use the, you know, the nomenclature to say ESI or snurb, which is epidural steroid injection or a selective nerve root block. And the selective nerve root block was something I know we leaned on very heavily in terms of diagnostically evaluating what's going on, identifying the pain generator. What are the differences between an ESI and a SNURB and how are each kind of utilized?

Right. Again, same thing. That term can be used interchangeably in the community. Theoretically. If you look at the SIS guidelines, which is a society that I'm part of, the spine intervention Society, I think what they'll tell you is the selective nerve root block is a diagnostic tool. So a very small volume of anesthetic based medication to identify if the nerve is the primary pain generator. The epidural steroid injection is a larger volume, it includes steroids. It has more of a therapeutic component to it. So spread will go everywhere with an epidural. In a selective nerve root block, you try to have localized spread. Excuse me, to kind of identify a target.

Why do you think it is that the selective nerve root blocks are not utilized as often? Because to me it seems very logical that you'd want to put a little, you know, anesthetic on an area, determine ultimately, you know, is this the area of complaint? Obviously, if you put a little bit of medication there, the pain is relieved. Do you have a higher likelihood that that's the actual spot of issue, especially with multi level pathology, which, you know, by the time you get over 40, who doesn't have multiple challenges on their MRIs, why do you think it's not adopted in every practice, really?

Well, twofold. I think one of it is what type of practice is. If you are a multidisciplinary practice, which is the environment that we came from, it made sense. You saw them initially, I did the injection, worked them up, and then we transferred them to a surgeon. If that was indicated. If you're, if it's your individual practice or you're not multidisciplinary, if you're the treating physician or the treating practitioner, for that, you're going to do everything in your power. So very difficult to bring the patient in, do an injection for 30 minutes worth of relief and then see them back in a couple weeks in clinic. And so I think the setup is the biggest difference. Also the patient expectation. If the patient is expecting that you are treating their pain, that's different than diagnosing their pain.

Good point, good point. If we peel it back a couple decades, perhaps what got you interested in becoming a physician or a doctor, how'd that all begin?

For you, it's funny story, I always say my mom grew up in a family. My mom's not a physician, but grew up in a family physician. So I don't actually ever remember having a choice. She always just told me, you will be a doctor. So I said, okay. So both my brother and myself became doctors.

Gotcha. What mama says goes.

Yes, pretty much.

That's. Yes, that's easy.

Yes.

And you kind of touched on, you know, when, when we worked together, you know, at the outpatient surgery center, we. It was kind of a unique situation in terms of not only what I did, but I think in terms of what you did and kind of how that process went. And I know that's been a majority of your experience and really your focus as a professional, but I guess kind of tailoring into that, what's been your experience working with chiropractors throughout time?

Well, like I said, I was there for many years and I've worked with chiropractors like you and your colleagues in a very multidisciplinary, patient focused approach. And so I think that's been very positive, been very beneficial. I did not have a lot of experience in the community prior to starting our job together working with chiropractors in the community. So that I couldn't answer. But I can tell you, like, in terms of what we did, I thought it's been very beneficial.

And one thing that I'm always curious about from the other side of the coin is as you go through your schooling and education and training, are you taught up essentially, or educated on what goes on within a chiropractic facility or within a chiropractor's office, and what may or may not be an appropriate referral, or is that something that's really not touched upon in current medical education?

At least when I was in training, that wasn't really pushed to the forefront. I mean, we worked very closely. I mean, my training is in physical medicine and rehabilitation or physiatry. My fellowship is then in interventional pain medication, pain management per se. But we worked a lot more closely with physical therapists, especially in residency training, and did not have a lot of exposure to chiropractors, at least in the academic hospital system.

Gotcha. One of the big things that at least I advocate for within the evidence based chiropractor is really, you know, the docs, the chiropractors practicing their community to take the time and reach out to, whether it's the pain management physicians, whether it's the physiatrists, whether it's the surgeons and primary care physicians in their community, because I think that that is so important to educate as far as, hey, here's. And we were talking a little bit before we came on saying, gosh, like just letting you know, here's how we evaluate a patient and here's some of the clinical direction we may go with that I think can be a big thing. Nobody likes the unknown. You know, a physician or a patient for that matter, and you want to know if and when you're sending somebody. You kind of want to have the gist of what's going to happen over there and not go in blind. That friction is going to kill any referral base. But that's something that I've advocated for and I think you reinforced by saying, you know, it's not something that's second nature from a practicing physician perspective as far as what goes on in the chirophysis. So with the team approach to care that we were both involved in, what did you see as some of the big benefits of having chiropractic physiatry, surgeon, all of the team under the same roof and working together, what did you find to be some of the biggest benefits to that model of care?

Well, I think this was patient focused and patient centered care. You had every different discipline and specialty using what was in their wheelhouse to help identify, diagnose and treat patients to the best of their care. And I think that is sometimes lost in the medical system that we're part of now.

That's a perfect transition into my next question. And when we look at the challenges that have arise with musculoskeletal care and spine care as the biggest subset of that, probably a lot of the opioid epidemic, I mean, if we just get it out there, it's a big issue. And I believe that a lot of that has stemmed from chronic musculoskeletal complaints and people kind of go off the rails. And where do you think, where did those cracks begin to surface? I mean, where do you think the medical system started to go astray regarding that?

Well, if you can look at, you know, there's some current legal stuff going on with Purdue Pharmaceuticals, but more importantly, I look at it and say there was a big push 20 years ago or so to make pain the fifth vital sign and that pain needed to be treated and that now if you look at all the other vital signs, these were objective measures. Heart rate, blood pressure, pulse. Pain is a subjective measure. And we see that on a regular basis. And I think that became A challenge. And how do you treat something subjectively? And so that's kind of where it started. And then it's, unfortunately, it spiraled out of control.

Do you think the best way to look at that is maybe through the lens of function rather than pain? I know, and I'm going to tie it to imaging a little bit. I know both of us, we reviewed a lot of imaging and you know, we'd see, you know, it just doesn't tell the story all the time. Right. You see people with crazy pathology and they're like, I feel pretty good. And then you see somebody has mild pathology and they can't get out of the chair. And that ties to pain. Right. What's their subjective assessment of what are they experiencing and going through? Do you think that maybe the focus should be more on functional abilities rather than pain? I mean, what do you think? How can we begin to change?

I think that's a, that's a great starting spot. It's, you know, what is trying to set realistic expectations to. What are we trying to get back to? You know, we commonly would see the 65 year old patient with chronic degenerative back pain who's limited in what they can do. Well, they're not going back to running a marathon. But if we can get them functionally better through therapy, through chiropractic, through injections, and possibly surgery if needed, let's set functional goals as to what we're trying to accomplish with this patient and treat those and use those as benchmarks. Instead of relying on the numeric pain scale and saying, well, your pain's an eight, let's try to bring it down to a three because that's a very, it's a variable, subjective matter that's difficult to really delineate.

I feel like kind of going one step farther from the patient's perspective as they go through that care. What are your big, what's the big benefits to from outpatient care versus inpatient care? Outpatient surgery center care versus inpatient hospital care. What are some of the benefits and. Or differences between the two that you've seen?

Sure. I mean, I think the outpatient model, usually it's a little bit more efficient than the inpatient hospital model. I think people are trying to push toward outpatient. I think patients like that, I think even just as healthcare providers. But if you had a family member or even yourself, if you had an option, you wouldn't want to be in the hospital having this procedure, staying in the hospital for a couple days, you'd want to go for that outpatient model, surgery center, clinical setting, and then get back, you know, feel like you can get back to doing what you want to do sooner rather than later.

What's the biggest challenge in the outpatient model?

I think the biggest challenge, at least that we saw, was making sure that patients are healthy enough to actually be able to tolerate the outpatient model. Just because a injection or a chiropractic treatment or a surgery can be done in an outpatient setting doesn't mean that the patient, both mentally, physically, emotionally, or even with family support can manage that. And I think that's kind of balancing that. You have to find what's the best for the patient.

Yep. And what gets you excited about the future, like, what's interesting in your world, in your realm, that's kind of cutting edge. You're interested to see how it unfolds or just seems intriguing from a medical technology standpoint.

I think regenerative medicine, to me, is very intriguing. I think it will be the future. I don't think anyone's found the secret sauce yet as to, you know, what's the exact dose of stem cells, prp, potentially hgh. That can be used as treatment options. But I think there appears to be, at least in the literature, some benefits that we can provide patients. Relatively straightforward procedures, minimal scar tissue, minimal side effects, minimum downtime. I think that's what patients want going forward. I think that's something that we can provide.

Yep. Yeah. Right now, it's definitely wild west territory.

It is.

But I think a lot of that'll shake out as time goes on.

Correct.

And kind of tying back to one of the early questions as we get towards the close is you brought up the term. And really where your classification is in the world of physiatry. So for anybody that's not familiar with that, kind of break that down.

What.

What does that mean? If that's a new term for any of the docs out there, what is it?

Well, really, it's a. In terms of the medical field, it's actually a newer field of medicine. It's only been around since the world wars. And these initially started as this was how to regain function. These were soldiers that were coming back from the war that were injured. They had brain injuries, they had amputations, spinal cord injuries, and then strike. You know, not as much stroke, but we do see a lot of stroke population. So these were. That was the big four. Like, how do you. These patients have had a significant insult or injury to their life. How do we help them maximize function through Therapy through medications, through bracing and orthotics, through injections. And then from there it kind of spun on to musculoskeletal care. And so I've always thought, you know, just like there's cardiology to cardiac surgery, we could have been orthopedic medicine to orthopedic surgery, you know, non surgical orthopedic musculoskeletal care. That could have been another name. It's kind of a long name. It also works, you know, how do you maximize function in these patients to get them back to wherever level they want to get to?

Yep. And I guess, last question, tying right into that, what is your favorite exam treatment?

What?

You know, day to day, what is the thing that you love doing the most?

I mean to me, when you do an injection on a patient that's had chronic pain and you see their response to that injection and they, you know, the smiles, the ability to get up and walk, the dancing that they do in the recovery room of like, wow, I can't believe my pain that I've had for so many years has been delineated, you know, has been knocked down and been reduced significantly. I think that alone helping somebody identify a pain generator who's seen multiple providers, who's gone through multiple treatment options, I think that alone is probably my kind of golden spoon right there of happiness.

I love it. And that's the key thing. I think the big take home messages for today is as we talked about team approaches to care, the word came from you many times. Patient centric approach and really tailoring your day to day the best you can as a practicing doc, no matter what kind you are, if you're taking a team approach to care, if you're looking at it through a patient centric model, you're probably gonna be on the right track overall.

Correct.

And I think that's a key take home. So if you have any questions, follow up questions, leave them down below, I'll be sure to get to them. And I wanna thank Dr. Gandhi for taking some time and coming over.

Thank you. Hey, thanks buddy. Appreciate it.

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