PM&R Pain Medicine & Subspecialty Fellowship FAQ's [Archive]

drusso

06-05-2003, 01:29 PM

From time to time, students inquire about the path to becoming a pain medicine specialist. Basically, pain medicine is sub-specialty accessible through fellowship-level training in either anesthesiology, PM&R, neurology, or psychiatry.

The ACGME is largest accrediting organization for residency programs and fellowships. There are a multitude of quality fellowship programs in the country in a variety of settings, but those approved by the ACGME are viewed by hospitals and third-party payors as having attained a specified level of quality education and training.

ACGME rules specify that an institution cannot have the same kind of fellowship offered in more than one academic or clinical department. Thus, when the field of pain medicine started out most fellowships were housed within anesthesiology departments and the field of anesthesiology came to dominate pain medicine. However, physiatrists and other specialty trained physicians are eligible to apply to any pain medicine fellowship regardless of its academic affiliation within an institution. Below is an updated list of ACGME-approved pain fellowships housed specifically within PM&R departments. I've also included a couple non-ACGME approved "interventional physiatry" fellowships that offer similar training. Please let me know if there are others that I've over-looked.

LIST OF ACGME APPROVED PM&R RUN PAIN FELLOWSHIPS (http://www.painrounds.com/index.php?option=com_content&task=view&id=10&Itemid=28):

[3410531003] VA Greater Los Angeles Healthcare System Program
Greater Los Angeles Veteran Affairs Health Care System
11301 Wilshire Boulevard (w117)
Los Angeles, CA 90073
Pain Management (PM) Quynh Pham, MD (310)268-4935
PMRPainFellowship@mednet.ucla

[3410713011] University of Colorado Program
University of Colorado
1635 North Ursula Street
Anschutz Outpatient Pavilion, 4th Floor
Aurora, CO 80045
Pain Management (PM) Venu Akuthota, MD
(720)848-1980
venu.akuthota@uchsc.edu

[3411222008] Emory University Program/Georgia Pain Physicians
2550 Windy Hill Road, Suite 215
Marietta, GA 30067
Pain Management (PM) Robert E. Windsor, MD (770)850-8464
(770)850-9727

[3412312007] Sinai Hospital of Baltimore Program
York Center for Pain Management and Rehabilitation
2901 Pleasant Valley Road
York, PA 17402
Pain Management (PM) Michael B. Furman, MD, MS (717)848-4800
(717)755-9618
mbfurman@hotmail.com

[3412412004] Harvard Medical School/Spaulding Rehabilitation Hospital Program
Harvard Medical School/Spaulding Rehabilitation
125 Nashua Street
Boston, MA 02114
Pain Management (PM) Alec Meleger, MD (617)573-2178
(617)573-2769
ameleger@partners.org

[3412521006] University of Michigan Program
University of Michigan
1500 E. University Drive
Ann Arbor, MI 48109
Pain Management (PM) J. Steven Schultz, MD (734)937-7210
(734)936-7048
jssch@umich.edu

[3412812012] University of Missouri-Columbia Program
University of Missouri-Columbia
52 Medical Park East Drive, Suite 115
Birmingham, AL 35235
Pain Management (PM) Bradly S. Goodman, MD
(205)838-3900

[3414112010] Temple University Hospital Program
Temple University
139 East Chestnut Hill Road
Newark, DE 19713
Pain Management (PM) Frank J. Falco, MD
(302)369-1700

[3414813005] Baylor University Medical Center (Oklahoma City) Program
St. Anthony North Ambulatory Surgery Center
6205 North Santa Fe Avenue, Suite 200
Oklahoma City, OK 73118
Pain Management (PM) Michael J. Carl, MD (405)427-6776
(405)419-5646

[3415121001] Virginia Commonwealth University Health System Program
Medical College of Virginia/VA Commonwealth Univ. Program
P.O. Box 980661-0677
Richmond, VA 23298
Pain Management (PM) David X. Cifu, MD (804)828-0861
(804)828-5074
dfdrake42@hotmail.com

UC Davis Pain Program (sponsored by the Anesthesia Dept)
University of California, Davis Medical Center
Scott Fishman, MD and Gagan Mahajan, MD
916-734-6824

LIST OF INTERVENTIONAL PHYSIATRY FELLOWSHIPS (http://www.painrounds.com/index.php?option=com_content&task=view&id=22&Itemid=33)

Curtis Slipman, M.D.
Director, The Penn Spine Center
Chief, Division of Musculoskeletal Rehabilitation
Associate Professor, Department of Rehabilitation Medicine
Ground Floor White Building
Hospital of the University of Pennsylvania
3400 Spruce Street
Philadelphia, Pennsylvania 19104
(215) 349-8062
Slipman@mail.med.upenn.edu

Univ of Penn Interventional Physiatry Fellowship (http://www.uphs.upenn.edu/rehabmed/educ/penn%20spine%20center.htm)

Gregory E. Lutz, MD, Chief of Physiatry for Hospital for Special Surgery
Hospital for Special Surgery
535 East 70th Street
New York, NY 10021
lutzg@hss.edu

Raj Mitra, MD (http://isc.stanford.edu/about.html), Director of the Interventional Spine Center
Stanford University Medical Center
900 Blake Wilbur Drive
W1001
Stanford, CA 94305

Stanford Interventional Spine Center (http://isc.stanford.edu/index.html)

Andrew Haig, MD
University of Michigan Spine Program
The Spine Program
325 E. Eisenhower Parkway
Ann Arbor, MI 48108
734-998-6644

University of Michigan Spine Program (http://www.med.umich.edu/pmr/spine/index.htm)

Gerard Malanga, M.D., Program Director
Sports and Musculoskeletal Medicine
Department of Physical Medicine and Rehabilitation
University of Medicine and Dentistry New Jersey

University of Medicine and Dentistry New Jersey (http://njms.umdnj.edu/physmed_and_rehab/fellowship/fellowship_opps.htm)

briandavis

07-12-2003, 11:48 AM

One program that I believe is ACGME-accredited is the combined Anesthesiolgy-PM&R pain program at UC Davis in Sacramento, CA. The Pain Program is run by a board-certified Psychiatrist/ Internist with Anesthesiology training and the fellowship director is a PM&R doc. It is a great combination. I believe they take 2 PM&R and 2 Anesthesiology residents each year.

Scott Fishman, MD and Gagan Mahajan, MD
University of California, Davis Medical Center
916-734-6824

Moderator's Note (6/3/04): The ACGME-approved fellowship at UC Davis is not formally dually sponsored by the PM&R and Anesthsiology departments. (Gagan Mahajan--personal communication). However, they do interview and accept applicants from all sponsoring specialties on a competitive basis.

--DR

axm397

11-19-2003, 06:42 PM

What is the difference between fellowships in pain management, interventional spine, and musculoskeletal?

drusso

11-20-2003, 05:06 AM

Originally posted by axm397
What is the difference between fellowships in pain management, interventional spine, and musculoskeletal?

Pain management offers comprehensive training for the the diagnosis of a variety of pain syndromes (malignant, nonmalignant, RSD, trigeminal neuralgia, etc) and usually geared toward an interventional approach. These programs are usually in anesthesiology departments.

Interventional spine focuses on diagnosis and treatment of spine conditions. There is usually an interventional component, but the interventions are limited to the axial spine. No bier blocks, sympathetic ganglion blocks, etc.

Musculoskeletal fellowships are broadly-based training experiences in musculoskeletal medicine emphasizing diagnosis and nonoperative management of a variety of common musculoskeletal problems. There is usually some training in sports medicine, occ medicine, spine, EMG, and pain management. There is also usually an emphasis on musculoskeletal radiology too.

rehabdoc

11-20-2003, 10:04 PM

I would like to start this thread since many of PM&R resident are interested in pain management and or spine care. Obviously there is a huge market for this branch if physiatry these days. Almost 50 percent of the jobs offered in the red or blue journal are combination of interventional pain/spine-EMG and musculoskeletal medicine.

So should I choose a pain fellowship or a spine fellowship? The answer is quite easy it depends on the area of interest, these two sub-specialties have some common procedures but besides that they are quite different.

As pain specialist you not only will manage spine related painful syndromes but also will deal with other pathological issues with pain and their symptoms. You have to have the knowledge of medical and interventional pain control. You have to combine your rehab skills and integrate the interventional and non-interventional skills to manage pain. Your referral sources are spine specialists, which have completed diagnostics and therapeutic interventions without significant help and are looking into more sophisticated pain management like spinal cord stimulator or implantble Intrathecal pumps or pure medical pain control. PCP’s , other rehab docs and orthopedic groups are your other major referral source. Your work would be hospital or clinic based and interventions are done in clinic or in the surgical-center or OR. All implantble devices are done in the OR. You could generally train in a pain fellowship which is ACGME accredited which makes you eligible to sit for pain boards. There are many pain fellowship around the country both ACGME and non-ACGME. Some are rehab based which seems to be more interdisciplinary and provide broad base pain training. Physiatrist, psychiatrist and Anesthesiologist compete for the pain fellowships in the country and the competition for the good fellowships are quite tough. Financially you will do quite well and the amount is based on your skills, aggressiveness in interventional aspect, practice style and set up, location, insurances and private vs. academics. Range of income is from 130K academic in metropolitan with incentives to 500k in private practice and up.

A spine specialist to most part will only concentrate on pathological spine issues in more depth. Their knowledge of spine is vast and they are skillful in diagnosing different spine diseases. They complement this part of their practice with performing EMG. Their referral sources are other PMR or Ortho docs to most part. They do market themselves as interventionalist and to most part refer chronic pain situations to pain specialists. There is generally a good working relationship between spine and pain specialist since more sophisticated spine procedures are often done by spine docs like Vertebroplasty and Nucleoplasty. Many pain specialists now perform similar procedures as well to expand the clinical skills. The spine specialists generally work in spine centers and or in private groups with neurosurgeons or orthopedic practices. Interventions are done at spine center or OR. Some procedures like Vertebroplasty is generally done in OR setting. There is no ACGME for spine fellowships yet. Some are PASSOR certified which are the better programs. There are many good and some excellent spine fellowships around the country almost all rehab-based programs. Competition for the best programs are generally tight but since you are only competing within the PM&R specialty, there is a chance that if you are a good resident, you will be able to secure a position. Financially you will also do excellent. Range is similar to pain. If you choose to perform EMG then your income obviously will increase in both specialties.

As an interventional pain fellow interested in many aspects of pain, I love what I do but you should know it is not that easy. Population of patient with chronic / acute pain is a very though population. There are many layers to their problems many of which are psychosocial and difficult to manage. Certainly the burnout rate in pain management is high for this reason and many pain clinicians tend to do it part time. You should be comfortable taking care of difficult patients, have a solid knowledge of anatomy, have a good training in pain and spine procedures and be efficient to become an overall well rounded and successful pain doc. You can’t claim to be a pain specialist and only do injections and not manage patients medically. So many physiatrists tend to choose spine fellowships to avoid the chronic pain population, which in theory is good idea but there are may limitations to how far you could be helpful with the injections and eventually many of the patients will end up moths later in pain centers.

There are many good programs around the country and recommending one over the other is sometimes tough. My only advise is to look into the structure and look at how broad base is the program. Programs, which only do injection type interventions, are missing a big chunk of other pain management techniques and the strictly medical management programs are obviously missing procedures skills. Cancer pain exposure, Inpatient pain exposure, Acute pain exposure, chronic pain exposure, headache management, musculoskeletal medicine and interventional pain management including pumps and stims all should be incorporated in a well balanced curriculum which is compatible with ACGME requirement.

Same is valid for a good spine program. Look at all the aspects of the program including EMG skills, interventions, medical management, Disc and Bone interventions and so forth. Look for PASSOR approval as well.

Personally I advise you to do an elective in a pain clinic as well as a spine center to get a feeling what it is all about. They are both excellent career choices. Both are major help to patients and are on cutting edge of medical science with more sophisticated procedures they can offer.

Please feel free to expand the discussion.:clap:

drusso

11-28-2003, 02:33 PM

PASSOR Web Page (http://www.aapmr.org/passor/about.htm)

PASSOR is an official council of the American Academy of Physical Medicine and Rehabilitation, founded to address the specific needs of musculoskeletal physiatrists. It sponsors procedural workshops and as well as educational events as well as maintains a database on PM&R-based fellowships (largely non-ACGME approved) in musculoskeletal medicine, sports medicine, and interventional spine.

Residents or medical students interested in musculoskeletal medicine and/or pain medicine should consider joining.

Idiopathic

03-01-2004, 02:13 PM

We had a speaker on Thursday last who was trained in surgical anesthesia, but now manages a chronic pain clinic. He was truly a fascinating individual who seems to have a challenging practice, and when I spoke with him of my interest in this and related fields, he told me that anesthesiology was the way to go, because: "you spend five years learning how to stick needles in people's backs," a practice he emplys a great deal in managing his severe pain patients. My question is this: do the current PM&R residents/docs do much pain management in this sense? Or do you devote more time to pure rehab medicine, delaing with a more acute level of patient.

Also, is there any training in intrathecal techniques? Enough to where you would feel comfortable if called upon to administer? Or do physiatrists generally not deal with chronic pain patients without 'rehabilitable' injuries?

Just curious, any words would be helpful.

drusso

03-01-2004, 02:21 PM

In most practices it is the PM&R guys who do more of the chronic pain management and the anesthesia guys do the acute pain, cancer pain, sympathetically-mediated pain stuff. There's a lot of overlap. A PM&R physician who does a pain fellowship will have more than plenty of skill when it comes to "putting needles in people's backs"---or as it is termed in pain circles "being a needle jockey." Knowing how to put a needle somewhere is a fundamental skill, but what it equally important is knowing "why to put a needle somewhere" or "WHY NOT to put a needle somewhere". Through conversations with several pain physicians, most have commented that anesthesia-trained pain docs are woefully under-educated in musculoskeletal medicine---the majority of pain complaints. Moreover, they lack EMG training and interpretation, musculoskeletal radiology, and other skills that are bread and butter PM&R skills.

I'm not knocking anesthesia guys, they have been pioneers in the field. But, increasingly, PM&R trained pain physicians are being recognized has having more of the "total package." That said, pain is a very complex and very broad field and multiple specialties---PM&R, anesthesia, psych, neuro---all bring something important to the table.

Idiopathic

03-01-2004, 03:22 PM

Thanks, Dr. Russo. Maybe I can come rotate with you in a year or two;)

Finally M3

03-01-2004, 04:07 PM

As an aside, I was flipping through the latest journal AAPMR puts out and who's name did I spy? :laugh:

PainDr

03-03-2004, 05:12 PM

I would have to agree that different specialities bring different skills to the field. Personally, I chose neurology. We get great training in EMG/NC, musculoskeletal medicine and various central and peripheral pain syndromes. I'd say at least half the pts presenting to a general neurology clinic do so because of pain (back pain, head ache, painful neuropathies, RSD, etc.). Actually, I'm surprised more neurologists don't go into the field. Also, I would agree that "putting needles in peoples backs" is not a difficult skill to master. Of course, as a neuro resident, I could do lumbar punctures in my sleep, so learning epidurals was a snap! Now having said that, I'll also admit that neurology training doesn't teach you squat about regional anesthesia or malignant pain. But that's what fellowship is for. By the end of training, everyone has a pretty equal knowledge and skill base.:D

Tenesma

03-03-2004, 05:28 PM

i agree that pain is a very multi-faceted field - and I think PM&R, neurology, psychiatry, palliative medicine, all bring great points of view to the table...

but i would stay away from the broad generalizations that PM&R does the chronic pain with anesthesia doing acute, cancer, etc...
because that isn't true...

nor is the statement: "anesthesia-trained pain docs are woefully under-educated in musculoskeletal medicine---the majority of pain complaints".

pain is one of the few truly multi-disciplinary fields, and if PM&R provides such a great pain education, then why even do a fellowship???

the point: pain fellowship (at most good programs) will teach you everything you need to know to manage a complicated pain patient.... PM&R can bring their rehab, EMG skills to the table... Neurology can bring their in-depth understanding of the nervous system, EMG skills to the table... Psych can bring their understanding of mental health (which definitely plays a role) to the table... Anesthesia can bring their understanding of pain and procedures to the table.

bottom line: stigmatized patients finally get specialized help.

so no more anesthesia bashing...

DigableCat

03-03-2004, 07:46 PM

As a person seeing firsthand both an ANES trained fellow and a PM&R trained fellow both starting out in the same program last July...I can truly say that it was obvious that the PM&R fellow was by far the better prepared of the two. That is not to say that the ANES fellow was not able to improve his physical exam skills over the year...but wouldn't it be so much easier if you had that background to begin with?

It's not all about the injection...it's why you're doing the injection and whether you are doing it for the right diagnosis. An epidural steroid injection won't cure anything if you haven't figured out that the pain is really from his SI joint.

Tenesma

03-04-2004, 01:17 AM

whoopdeedoo... PM&R can do a better physicial exam ... I bet a neurologist can do a better neuro exam, and an orthopod can do a better joint/skeletal exam... gimme a break.

by they way, where do you think most PM&R pain specialists got their training??? at anesthesia programs... even the directors of the current ACGME-approved pain programs were all trained by anesthesiologists.... I can only pray for them that their PM&R training during residency made up for the inadequacy of their attendings during their pain fellowship :)

and regarding the regurgitated line of: anesthesia can do the procedure but they don't understand the why nor do they know how to make the correct diagnosis... that is a bunch of hogwash... do you realize that most if not all techniques (based on diagnosis) were developed by anesthesiologists and neurosurgeons???
the only group of physicians this statement applies to are the interventional radiologists doing pain procedures based on referrals from spine-surgeons and orthopods.....

by the way, i am just curious: what do you do when you place your patient on the table for a diagnostic SI joint placement, and just as you insert the needle into the skin the heart rate falls to 20 and the patient becomes unresponsive... what do you do when you do a BIER block and there is a large leak of local anesthetic into the systemic circulation and the patient starts having short runs of v-tach....

so from my point of view: i have seen PM&R fellows, Neurology fellows and Anesthesia folk doing their pain fellowship... they all have their strengths and their weaknesses.

DigableCat

03-04-2004, 07:08 AM

Get aggressive much?

Dude, I'm only speaking from experience. And when I'm doing my pain rotation with an anesthesiology resident and I have to explain to him how to check for posterior facet dysfunction or the Spurling test for cervical radiculopathy...it just reinforces my point.

drusso

03-04-2004, 09:05 AM

Originally posted by Tenesma

by the way, i am just curious: what do you do when you place your patient on the table for a diagnostic SI joint placement, and just as you insert the needle into the skin the heart rate falls to 20 and the patient becomes unresponsive... what do you do when you do a BIER block and there is a large leak of local anesthetic into the systemic circulation and the patient starts having short runs of v-tach....

Woh, slow down cowboy! I'm not saying that advanced airway management and ACLS shouldn't be a part of pain fellowships! I'm not saying that anesthesiologists are not competent pain practitioners...I was seriously considering anesthsia residencies because I really liked the regional techniques. Can't we all get along?

Stinky Tofu

03-04-2004, 10:23 AM

Originally posted on Physician's Online (https://home.po.com/cgi-bin/pol_www/signon/signon.cgi):

1fb0fe9: Although I was originally trained as an Anesthesiologist, I have practicied "Pain" exclusively for the past 8 years and I agree completely with the last post. I had to learn a lot of musculoskeletal medicine under the gun of practice and it is better to do so under the protection of a residency. Also, quite frankly, I have been terribly disappointed in the quality of medicine I see my collegues in "Pain" practicing who started out in Anesthesia. My observation is that the PM&R docs practicing "Pain" are simply more knowledgable and have better judgement. I don't see them doing crazy things like laser percutaneous discectomy when they can't even do a competent physical exam and correctly manage a herniated disc.

12c3393: If you plan on practicing pain medicine, I reccomend a physiatry residency, and an interventional pain managment fellowship. It doesn't take long to learn where and how to stick needles in someone, but it does take a while to learn musculoskeletal medicine, which is what the majority of pain managment deals with. In anesthesia residency, you don't learn squat about musculoskeletal medicine. You learn how to intubate people and place lines. The only thing that I use from my anesthesia residency is my comfort with deep sedation for the rare instance that I need it. Otherwise it was a waste of 4 years. Also, I definetly did not learn all there is to learn about pain medicine and musculoskeletal medicine in my one year of pain fellowship. The fundamentals take time to learn. Learning how to stick needles in people doesn't take long.

529537: I may be unpopular here, but Pain Management (i.e. interventional) is the perview and should remain the perview of the Anesthesiologist. We are the ones that started this business and we are the best at it.

But, what anon 12c and 1fb said is correct. If you want to be a full fledged Pain Medicine Specialist, you can do it from anywhere. What this specialty really needs is more Psychiatrists specializing in Pain Medicine. Most of what you do with your patients is talk to them, reinforce that their is someone out their who actually believes them. That is worth more to them than anything.

No matter what you choose, you'll have to learn a lot on your own. If you choose Anesthesia, you'll have to learn good people and physical exam skills. If you choose PM&R, you'll have to learn procedural skills. What good is all the diagnostic skills if you can't put the needle where it belongs. My choice, if you are considering a procedurally based pain office, is to do Anesthesia. You are abviously motivated sincy you're asking as a student. I'll bet you have the people skills and can learn the physical exam skills along the way much easier than the procedural skills. Thats my 2 cents.

982cff: I have already completed 3 years anesthesiology and year of Pain fellowship (by the way my co-fellow was PMR doc) Now I am in practise 50% pain and 50% Anesthesia since last 2 yrs. I do full gamet of Interventional pain procedures. I am wondering by doing Neuro or PMR I can also get training in EDX and spine imaging.

c1c63b: If you want to be a block-doc - anesthesia
If you want to practice full spectrum pain management and be mediocre at sticking needles in people - PM&R. Having seen "interventional physiatrists" and "interventional anesthesiologists" practice, anesthesiologists are better at sticking needles in people and physiatrists are better at musculoskeletal medicine

18ed41b: If you are interested in pain - no pun intended - then go the anesthesia route. However, if you are interested in spine and musculoskeletal then you have no choice but to go the physical medicine route.

People who know the fields, know the difference.

I found this discussion on POL (https://home.po.com/cgi-bin/pol_www/signon/signon.cgi) relevant to the questions raised in this thread. I've worked at the Spine Center at MGH and NEBH and plan to do rotations at BWH and MGH in the Pain Center. I think Tenesma is right in that all the different specialties bring something to the table. I do feel that the fact that we can do a much better neuromusculoskeletal exam is important, but its degree of importance lies in what type of practice you want. Our training in performing EDX studies and interpreting imaging studies is also extremely important to the management of a certain subset of pain patients out there. This is the reason that MGH has both a Spine Center and a Pain Center because certain patients are better managed at one or the other even if the procedures done at each do overlap. MGH's Pain Center website also has a link to SRH's Pain Program and the Anesthesia-run fellowship has taken several of our graduates into their fellowship. This demonstrates to me that we each bring something unique to the broad field of Pain Management and hence I've often seen referrals between the three centers.

During residency, the best rotation we have to learn Interventional Pain procedures is with an Anesthesiologist because of the sheer volume and variety of procedures he does. In terms of technical skills, some of the best that I've worked with are the Neuroradiologists that trained at or work at MGH. Physiatrists are better at diagnosing the source of a patient's MSK complaints and providing a broader spectrum of conservative care. I think each group has a certain type of pain practice that they want and probably wouldn't want to do what another group does. I feel fortunate that my residency will provide me with exposure to the different types of practices out there and this will help me to develop my own approach, send appropriate referrals, and help me decide which type of fellowship I want to pursue.

BubbleBobble

03-05-2004, 10:40 AM

I'm starting medical school at UWash next year, and since my undergraduate major is in neurobiology, I have some idea of what neurologists do. However, I recently discovered PM&R and think that this might be a better fit for me. From what I've researched, it seems like there is a lot of overlap between PM&R and neurology.

What are main differences/similarities between the two, in practice?

Stinky Tofu

03-05-2004, 04:38 PM

I think Physiatry and Neurology are similar in that we can both see the same type of patients (Stroke, Parkinson's, Alzheimer's, Cerebral Palsy, Polio, Muscular Dystrophy, etc.). In fact, on the inpatient Stroke service, most of our referrals are from the Neurology service. We see these patients at different stages of their recovery. Neurology tends to deal more with the acute management and diagnosis of CNS disorders. Physiatrists tend to focus on their functional recovery (possibly involving botox/phenol/joint injections, gait analysis, orthotic prescriptions, etc.) as well as the medical management and prevention of complications that often ensue. At Harvard, we spend two months on the Neurology service as a PM&R resident. It's not uncommon to admit a CVA at the end of your Neurology rotation and discharge them after three days and then see them on the Physiatry service for six weeks. Another similarity is that we both get trained to do EDX studies. Both specialties also get a lot of training in ordering appropriate imaging studies and interpreting them. The difference is that Neurologists are better at looking at the brain while Physiatrists are better at looking at the MSK system.

Other differences in our training can also lead to very different types of patients. We get much more exposure to musculoskeletal medicine and interventional procedures. I'm not saying that these things aren't available to Neurology residents, but it certainly isn't a standard part of the Neurology curriculum. One of the attendings that we rotate with as a PGY-2 is a former Neurologist (who also completed a Cerebral Vascular Disease Fellowship after his Neuro residency) at HMS. After practicing several years as a Neurologist, he went back and did a PM&R residency at Harvard. He now does Occupational & Musculoskeletal medicine.

PM&R is very broad field so you can really see the same types of patients if you do inpatient rehabilitation or you can see really different types of patients if you decide to do Spine/MSK/Pain/Sports. I've included a link to a Physiatrist at UWash (http://www.spine-health.com/doctor/AndrewCole/) to give you an idea of what he does in practice.

BubbleBobble

03-06-2004, 02:47 PM

This is terrific information! Thanks! :thumbup:

drusso

03-07-2004, 08:44 AM

More from Physicians Online (POL: www.pol.net) about this very topic. Apparently, we've generated some discussion among our attending/staff colleagues:

Anon_746515 on 03/05/04 11:13 AM

I am physiatrist, doing 100% non-surgical spine practice. I did a two-year fellowship in musculoskeletal, spine and sports medicine and is pain boarded through ABA. I work with a renowned conservative spine surgeon. We read X-rays, MRIs ourselves and often discuss with the radiologists about their readings.

I have seen many anesthesiologists doing pain management who are big on needles but have no clues to their diagnoses. Most of their impressions after a very poor hitory and physical examination is 'multifactorial low back pain'. These are the pain specialists that end up doing one dozen facet joint injections on one patient at one sitting and then go ahead with RF abaltion of bilateral MBBs for all those levels.

Or, they do series of epidurals irrespective of outcome. To me they may be excellent in maneuvering their needles, but by putting needles where it was not needed, make themselves and others, including the patients, more confused. It is like having weapon in your hand and you know how to kill, but do not know who is your friend or foe.

I do not want to generalize. There are good docs and not so good docs in every specialty and as Dr. Soriano mentioned, every specialty, by virtue of their training have their strength and weakness at certain faculties. We should not look down upon other specialties based on their weakness, rather look into ourselves and see what we are lacking in managing our patients and try to gather skills from other specialties for a more gratifying practice.

If you are a good doc, know what you are doing and your patients like you, you do not need to fear other docs taking your practice.

--------------

Anon_18ed41b on 03/06/04 07:12 AM

Anon 746515:

I have a similar background as a PM&R residency followed by an orthopedic fellowship performed in an Orthopedic Dept with Spine Surgeons - and practice as you. My clinical interests are pretty much limited to spine and EDX and I'll be sitting for the EDX boards next month. I am a member of NASS, ISIS, and the AAEM.

I do not consider myself a pain physician, but an interventional physiatrist. I do not want to bear the pain moniker as, more often than not, my observation has been that chronic pain is a much more psychosocial than biological phenomenon and I am still not convinced even after having worked in an internationally recognized multidisciplinary chronic pain clinic- that specialty physicians have a meaningful role in its management let alone treatment. Moreover, as I eluded earlier, interested observers - insurance companies, health epidemiologists, occupational health clinics, etc. - are coming to equate the "interventional pain management designation" with a practice pattern - expensive and anecdotal - that I do not want to be associated with.

However, as a concession to the 'turf' war I plan to sit for the ABPM&R sponsored pain boards. This is not due to the salience of the material to my practice or my interest in "pain" but merely out of recognition of the turf wars between a small specialty - PM&R - and a much larger specialty - Anesthesia. I do not buy the Spine = Pain argument put forward by the pain tribe; why not chest pain? Pain for me is a symptom, not a disease, and as a physician my focus will always be on the treatment of the underlying disease.

For the studentdoctor.net residents: in the end, evidence, outcomes, and continued education should be your guiding principles. Those practioners who are trying to take an evidence-based, nosological approach, to spine and musculoskeletal problems will be more familiar with the etiology and natural history of the diseases they treat and this will lead to measurably better outcomes.(1, 2) With that in mind, you need to think about your fellowship training carefully.

1. Klein, Ben J. PhD. Radecki, Richard T. MD. Foris, Michael P. MBA. Feil, Edward I. MD. Hickey, Martin E. MD. Bridging the Gap Between Science and Practice in Managing Low Back Pain: A Comprehensive Spine Care System in a Health Maintenance Organization Setting. Spine. 25(6):738-740, March 15, 2000.

2. Saal, Jeffrey A. MD, FACP. 1996 North American Spine Society Presidential Address. Spine. 22(14):1545-1552, July 15, 1997.

------------

Rinoo Shah on 03/06/04 04:39 PM

anon 18e..or shall we call you p.c, ....which BTW stands for politically correct [medicine] and does not represent the initials of an individual on the p.o.l. discussion boards with a portuguese namesake

your arrogance in these matters is stifling and what is particularly appalling is the stark dichotomy between some of your posts on the ISIS web site and on p.o.l.

in one recent ISIS post you describe a transdural L5-S1 discogram for a patient with a posterolateral fusion to help the referring physician decide if the patient is a candidate for an anterior interbody fusion or is 'nuts'..i.e., a candidate for psychological counseling.

I truly wonder how you can ethically convince a patient that this discogram is in the patient's best interest as well as an ALIF if positive...and tell the patient (based on your posts on p.o.l.) that SCS, lysis, intrathecal opioid, oral opioids, neurontin and other AEDs do not have sufficient evidence and are not in the patient's best interest..

there is no such thing as a spinal diagnostician nor interventional physiatrist...

diagnose what? if a patient doesn't have an analgesic or provocative response to your repertoire of 'spinal interventions'..which based on your posts are limited to your interpretation of evidence to discos, transforaminals and may be SIJs, or medial branch blocks...so if a patients pain cannot be reproduced or blocked with these interventions...then they would only benefit from psych...or if their pain is reproduced or blocked...and they don't reach a therapeutic endpoint..then they go to your REFERRING spine surgeon?

additionally, according to your ISIS posts percentage-wise you see a larger number of run-of-the-mill disc herniations...how did you develop such a cozy practice...do you turn a blind eye (selection bias) to patients you cannot help and dissuade them from seeing pain physicians in your community

this latter practice generates the scorn and ire of cadde5 against physiatrists...you see the easy to treat patients and dump the waste baskets on the pain physicians and then crib about there approach to treating them

you call interventional pain physicians 'goats'.....but as a 'spinal diagnostician' you appear to be a greater goat...fueling the spinal surgery business

In Merrill's article in Reg Anesth in 12/03...the estimated cost to medicare from interventional pain in 2001(excluding implants: SCS and IT pumps)...was about 370 million...he estimated that since medicare' share of physician fees was 21% then the costs to the USA overall, could be as high as 1.8 billion

...but take a look at his TABLE 3...out of this 370 million to Medicare...translaminar ESIs accounted for 130 million, transforaminals for 36 million, medial branch blocks 60 million, medial branch RFTC 13 million, and sympathetic 3 million,, there were extra dollars and cents for fluoroscopic guidance, epiduraography....but all in all the vast majority of costs were by spine interventions...very familiar to p.c.

now look at the spinal surgery business that p.c. is helping promote...according to Mirza and Deyo...implants alone for spine surgery generate 2 billion in revenue...the implants alone! cost health care more than most interventional pain procedures

now look at Figure 1...250,000 spinal fusion surgeries were performed in 2001 and that rising trend may outstrip total knees and hips...according to DEyo the average inpatient hospitalization (EXCLUDING THE SPINE SURGEON's FEES) is 34,000

250, 000 x 34,000 = 8.5 billion dollars...and with physician fees it may top 10-12 billion

I feel your relentless criticism of interventional pain is in the hopes of keeping your spinal diagnostic business alive...the last thing you would want is an interventional pain physician to spoil your cozy party with your spinal surgery colleagues...here is your motto

'lets keep the spinal diagnostic and spinal surgery business alive...shall we?'

your acceptance of chronic pain as less of a biological problem and your lack of respect of interventional pain physicians and the premier clinic founded by JJ Bonica and subsequently headed by J. Loeser further underscores your ulterior motives not to mention your ignorance in recognizing the vast achievements in our understanding of chronic pain over the past 50 years...you have no interest in the psychological aspects of pain apart from trying to protect your turf

p.c....doesn't stand for politically correct medicine but paul...it stands for...

pork chop for me (spinal diagnostician and spine surgeon) and nay for you (pain physician and pain patients)

Ligament

03-07-2004, 03:11 PM

david, what forum within POL did you find these posts? thanks!

Finally M3

03-08-2004, 10:51 AM

Hey Ligament, dunno if David forwarded the info to you but here it is;

http://discuss.po.com/cgi-bin/discussion/disclist.cgi/local/80/html/disc_data2/1/39/795/0/?LEVEL=3&PATH=/local/80/html/disc_data2/1/39/795

It's the Medial Branch Rhizotomy thread, near the bottom of the thread.

It's a funny read :laugh:

daphilster

03-19-2004, 11:52 PM

Ok the next logical question is this:

Who gets the best spots in pain fellowship since they are available to psych residents, pmr, anesthesiogists? and what criteria do PD's use to judge applicants? reputation of their program, LORs, research, etc? You don't exactly have "grades" anymore in residency right?

My guess would be the anesthesiologist would have the edge since most pain programs are run by anesthesiology dept. Do programs typically reserve x amount of spots for psych residents, pmr residents, etc??

Stinky Tofu

03-20-2004, 09:22 AM

The PM&R Pain fellowships are open to PM&R residents only. There are several Pain fellowships that are jointly run and they save a certain number of spots for PM&R and for Anesthesia. Many Pain fellowships are run by Anesthesia and these fellowships would be easier to obtain as an Anesthesia resident. That being said, many of the top Anesthesia fellowships (MGH, BIDMC, BWH, Children's, Mayo, etc.) like to take both PM&R and Anesthesia residents because they can learn a lot from each other as well. Whether you choose PM&R or Anesthesia as your route to Pain Management, I don't think you'll have much of a problem getting a Pain fellowship. I think the important thing to figure out is which type of residency will prepare you better for the type of Pain practice you want. If you want to do a lot of Interventional Pain/Spine procedures, I think PM&R or Anesthesia would be a better route. Check out the thread below for different perspectives on the route to Pain Management:

http://forums.studentdoctor.net/showthread.php?threadid=107433

All of the things you mentioned are important to obtaining a fellowship (research, LOR, and reputation of your residency program). Connections also play a large part in the selection of fellows as does impressing them on an elective rotation.

freelancewriter

04-07-2004, 09:16 PM

I'm surprised that no one has mentioned palliative medicine and pain management. Your dealing with dying people, so there is definitely a different dynamic. There is a spiritual aspect to it, to be sure. I would think some folks interested in pain management would be interested in a palliative medicine fellowship, but maybe haven't been exposed.

From what I've read, palliative medicine fellowships are open to PM&R and Neuro residents. I think they might be open to an even broader range than that.

I did a Google search and stumbled across a fellowship directory on the American Academy of Hospice and Palliative Medicine (AAHPM) site. Lots of fellowship programs. The only program I saw on the list with a link was Marshfield Clinic www.marshfieldclinic.org/palliativefellowship. To quote their site, "The Fellowship is open to applicants BC/BE in Internal Medicine, Family Practice, Neurology, or Physical Medicine & Rehabilitation."

Not sure if any palliative medicine programs are (yet) ACGME-accredited. Many of these programs started with grant funding in the last year or two, so I suspect it's a relatively new fellowship offering.

I'm not a med student/resident/physician - that may already be obvious - but am very interested in the med school-residency-fellowship process. I lurk on these boards a lot, and post occasionally. (We all need a hobby.)

Please give me some insight on the differences with "traditional" pain management and palliative medicine. Two things seem obvious:
1. Dying people
2. Large spiritual component

What else?

islander

04-14-2004, 12:23 PM

Hey all - I'm a (soon-to-be) neuro resident who may be interested in pain. It seems as if anesthesiology or PM&R are the 2 best ways to get a pain fellowship, but I wasn't specifically interested in pain while selecting a residency. If I still want to do a pain mgmt fellowship 3 years from now, is it reasonable to think that an anesthesiology-run fellowship SOMEWHERE would be attainable? I'll be coming from a strong neuro program, & already have a bunch of research credits on various neuro/psych topics (papers, chapters, abstracts, etc.); I assume clinically I'll do well in residency and get good LORs, and will do pain electives during residency... As I said, I'm not shooting for the stars; just curious if entry to the field through some pain fellowship somewhere is feasible. Thanks for any opinions.

rehabdoc

05-03-2004, 08:03 AM

neurologists actually do well when it comes to pain fellowships and many of well respected rehab based or anesthesia based programs do take neurology residents as their fellows. good luck.
rehabdoc

paz5559

05-19-2004, 10:15 AM

I am curious what your thoughts are for a pecking order of anesthesia based interventional pain management fellowships

I know I tend to think of Slipman, Furman, HSS, Falco, Windsor, Stanford, CINN, and maybe Utah and Colorado as the top that are PM&R run.

drvlad2004

05-19-2004, 11:13 AM

Is there any type of sub-specialty certification specifically for interventional spine once you are done with fellowship?

paz5559

05-19-2004, 03:37 PM

You can sit for the ABA (Anesthesia) Pain Boards, so long as they keep grandfathering in non-ACGME acredited programs. However, that tests an array of skills beyond what is generally taught in an Interventional Spine Fellowship.

PASSOR has talked about creating a sub-specialty boards, but that is still in the early planning stages.

AAPM also offers pain boards, but to date, these are not ABMS acredited, so it is unclear what the point of taking them is.

Bottom line is, since you will likely do these in a surgi center, you will not need to get hospital privaledges to perform these procedures.. Even if you do, I know of no one who has needed pain boards to be on an insurance pannel or to get privaledges yet. That may be coming in the future, but not at this point.

Hope that helps

rehabdoc

05-19-2004, 03:55 PM

Well, I am not quite sure about the order of fellowships you mentioned.
some of those are pain and some are spine fellowships. It depends on your interest.

Slipman is a good high volume spine program but it not as nearly comprehensive as pain specialty can offer you. so if spine is all you want to do, it is very good choice.

Windsor, furman and Falco I believe provide a broader based exposure to procedures offered especially at Atlanta. you cant go wrong with them. Last I know, Falco was not ACGME.

The one program that people don't know much about and is quite comprehensive and has tremendous interventional exposure including implantable pain devices is at Spaulding. Its ACGME, It is a hybrid of spine and pain management , faculty are both Anesthesia interventionalist, PM&R interventionalist (couple of Slipman trained are there too), has headache training by experts and common lectures with MGH pain fellows. I think in the rehab based program, the curriculum is the most comprehensive one and you get a Harvard degree out of it as a bonus.

FYI, the pain management board is common board between PM&R, Anesthesia and neurology. so if you are from ACGME program and sit for it, your boards is accepted regardless which program you are from. Spine fellowship people can sit for the boards till 2005 and after that, they cant become board certify in pain unless they do a fellowship. Hopefully a spine subspecialty will be created for them.

One other small info for stinky, PM&R pain fellowships (ACGME) are not forced to take PM&R fellows only. they are allowed take many of the specialities including internal med, peds, Psych,anesthesia, neurology, and PM&R. obveiosly they prefer to have a bright rehab fellow but if better candidate come, they are legaly free to choose.

good luck to the future specialists.

paz5559

05-20-2004, 01:33 PM

pain - spine - sports is semantic continuum (yes, I know it is more extensive training, but when spine fellowships call themselves interventional pain management, and when all three can also be lumped into musculoskelletal, the distinction gets pretty fuzzy, at least to me).

Currently there are 7 ACGME acredited PM&R pain programs (http://www.abpmr.org/certification/pm_fellowships.html). However acreditation is only required to take the pain boards after 2006, and that deadline has been extended several times in the past, so it may well be extended further again in future.

paz5559

05-23-2004, 01:45 PM

I wondered if someone could give me advice as to the reputations, stengths, and weaknesses regarding the Anesthesia and Anesthesia/PM&R jointly run Pain programs?

paz5559

05-24-2004, 10:21 AM

A few additional items since I last posted:

I spoke to a recent graduate of the UC Davis residency. She advised that the program typically takes two PM&R and two Anesthesia residents yearly. Despite it's "joint" nature, it seems the vast majority of the training offerd is through the Anesthesia department, and the fellowship director is an anesthesiologist. You take ER call, which the fellows were not happy about, and cover an in patient service, which I suspect is probably typical for most pain fellowships. However, there was a high dropout rate, so that the fellows felt overworked during the time this recent graduate was there. One particular fellow became pregnant during the fellowship, and no accomodation was made regarding her radiation exposure, and she therefore went through her 8th month being exposed. I know Dr. Davis has a role in the program, and he is clearly a huge plus, but from what I was told, there were certainly issues that anyone considering the program should look into before committing a year.

New Topic - I spoke to the ABPM&R today about the temporary criteria that currently enable fellows at unacredited fellowships to sit for Pain Baords. The American Board of Anesthesia has advised the ABPM&R that no further extensions will be granted for unacredited programs. Also, the deadline to ahve completed your residency to sit for the pain boards will not be extended. So the bottom line is, if you finish your residency after August 31, 2004, or if you complete 12 months of your fellowship after August 31, 2006, you can only sit for the ABA pain boards if you have completed an ACGME acredited fellowship.

Hope that is helpful, and please don't hesitate to PM me if you have any questions

paz5559

05-27-2004, 11:01 AM

Clearly I am now talking to myself, but I got two interesting emails today I thought I would share. I particularly mention these two programs becuase when I spoke to the head of our Neurology pain center at LSU, he mentioned these as two of the very top pain fellowships in anesthesia:

1) UCSF: I should tell you that typically we don't consider non-anesthesia residents for candidacy for our program. The reason for this is that because of the high volume of invasive procedures we do in our clinic, we prefer anesthesia residents, who have been trained in nerve block techniques as well as airway management. however, if the pool of anesthesia resident applicants is sparse, and/or if your credentials are exceptional, you may be considered for an interview.

I know this sounds discouraging; apparently there are other pain fellowships throughout the country with a similar policy. I would urge you to apply regardless if you are interested in our program.

2) University of Washington (annonymous report from current PM&R resident:
"The anesthesia program here is not very strong.

The only anesthesiologist doing interventional work is a private practice
guy from the eastside one day a week. There are ?3 fellows, all
scavaging for whatever they can do, and spending a lot of time sitting
around. I also think they take anesthesia call, which would not be a
pretty site for a rehab doc.

Overall, doesn't sound like a good deal."

Food for thought.

Spine Specialist

05-31-2004, 07:26 PM

Hi Dr.Mahajan-

Thanks for your input in this PMR forum. I am a PMR resident joining Pain Medicine Fellowship starting July,2004.
What is your take on physiatrists joining Pain medicine fellowship?
Can u recommed some books and give me some advice to become a good pain specialist? As you said one year fellowship will roll very quickly. How can i make use of that one year to maximun learning?
Thanks :)

paz5559

05-31-2004, 07:31 PM

I certainly may have been mis-informed, although the source of my information was a PM&R resident at UC Davis during the relevant period. Clearly, I will defer to Dr. Mahajan's presentation of the facts.

I would wonder how a "Combined PM&R/Anesthesia Pain Program", one of only seven ACGME accredited "PM&R" Pain Fellowships in the nation, could count itself in the realm of PM&R, present itself as a "joint" program, market itself to PM&R residents, and then accept only one out of a total of ten fellows who are PM&R trained during the past two calendar years. I guess in a fiercely competative fellowship, PM&R residents are just not as well-qualified as the 70% Anethesiologists or 20% Neurologists who did fill those positions.

drusso

06-01-2004, 04:20 AM

Dr. Mahajan,

Thanks for your contribution to this discussion. I really appreciate it when you, Brian Davis, and others in PM&R/Pain/Spine/Musculoskeletal Medicine post your observations and suggestions. As has been reiterated on this forum very often, perhaps more by young physiatrists than by young anesthesiologists, pain medicine is indeed a multi-disciplinary endeavor requiring a broad set of skills and knowledge. Patients benefit from different perspectives.

Keep posting as you feel appropriate. I've been working hard towards making this forum one of the leading informational resources for residents and medical students interested in PM&R and its subspecialties.

--David

Spine Specialist

06-01-2004, 07:07 PM

I appreciate your reply Dr.Mahajan. Thanks a million! :)

charcot

06-05-2004, 01:32 AM

Stinky Tofu

06-08-2004, 01:55 PM

As a resident in PM&R, I am realizing more and more that there are few spots in anesthesiology-based programs that take PM&R grads. I am a solid resident from a solid PM&R rogram. I see that there is definately a bias towards anesthesia and neuro grads, particularly in interventional geared programs. This doesn't make much sense given that we do more EMG's than many neurology residents. I dont want to do meds management which is where we seem to be shunted and I am thinking about doing EMG's instead of pain.

Based on your post in the Neurology forum, I thought you were an aspiring Neurologist.

I disagree regarding the bias towards Neurology, but I do agree that in general, Anesthesiologists have an advantage in securing Anesthesia-based Pain fellowships. In 2004, there were roughly 1300 spots offered in Anesthesia and 350 in PM&R. The fact that you see more Anesthesiologists in these programs is not surprising. I can only speak about my experience in the Harvard system and my impression is that we are welcomed at all the different fellowship programs. In fact, I've been told that they want PM&R residents in their fellowship programs. Every Spaulding resident that I know of that has wanted to do a Pain fellowship has gotten one. The Tufts and BU residents also seem to be getting Pain fellowships as well. Children's Hospital, BWH, MGH, and BIDMC all take PM&R residents and their fellowships are considered competitive.

I agree that we do more EDX studies than Neurologists. At Partners, the average Neurology resident spends less than one month in the Neurophysiology lab. We spend 4-6 months at either MGH or BWH doing EDX studies. I'm not sure what this has to do with securing a Pain fellowship though. If you are interested in doing both EDX studies and Interventional Spine procedures, a Spine fellowship might be a better route.

In summary, I think that Pain fellowships are still wide open to Physiatrists and if you want to do Interventional Spine, there are other routes you can take as well.

paz5559

06-08-2004, 05:13 PM

You make it sound as though there is a significant difference between Pain, Spine, and Interventional Pain Management.

I may be wrong, but I would hazard a guess that most PM&R residents would prefer to be involved in a purely interventional fellowship. The problem is that there is no subspecialty certification for that area at present. The quandry we are faced with, as a result, is do I pursue the best respected, best most accademically rigourous fellowship with those who are leaders in our field (ie. Slipman, CINN, Falco, Aprill, Stanford, Florida Spine Institute, Hospital for Special Surgery, just to name a few) which are NOT ACGME accredited, and thus do not enable me to sit for the pain boards, or do I spend a year in a fellowship which may well be excellent, but is either too new to have a track record (MCV/VCU, Spaulding, Michigan), or whose focus is not primarily interventional (UC Davis, other Anesthesia fellowships).

Furman and and Windsor are the only ACGME accredited, primarily interventional fellowships, but that is a grand total of 8 fellowship spots - by reputation, Windsor's is lagely practical, not a huge amount of research. Furman's is a more optimal mix of hands on and research - the only criticism is that it means you have to spend a year in York, PA.

I would therefore argue that there needs to be either a PASSOR, ISIS, or NASS certification in interventional pain management. I, for one, don't want to do hospice. I don't want to do acute inpatient pain. I don't want to do headaches. I want to do procedures. At present, there is no ABMS certification, and there needs to be. ABA, and ABPMR Pain certification is all we have at present (neither AAPM nor ABPM are ABMS member organizations), and it does not meet the needs of a large segment of the new graduates in our field.

paz5559

06-09-2004, 08:01 PM

I am sorry, but when Dr. Mahajan spins things to his fellowship's advantage, it makes me see red. Phrases like "If all you want to do ..." and "If you want to be well rounded and knowledgeable ..." belie a non-objective bias which may help to recruit more residents to the his fellowship, but is disingenuous, and does a disservice to those who are not sure who to believe, especially on forums like this. I do not begrudge him the ability to shill for his program, but please label it up front as an infomercial, rather than a legitimate opinion from a responsible, reliable source.

Opiod refill referrals - boy, isn't that the group of patients you want to build your practice around? Dr. Mahajan, they are all yours. By the way, you can have the fibromyalgics too, while you are at it. I would prefer to limit my practice to those I legitimately believe I have a good chance of actually providing pain relief to, rather than feeding their addiction or their supra-tentorial disease.

The business model is clearly not just join a group of manage your own meds - a third option is to go into practice with a psychiatrist/neurologist/physiatrist with an interest in pain who can manage the meds while you build your interventional practice. Will you have to build your practice by doing good work for and marketing yourself to primary care physicians, neurosurgeons, and orthopedists? You bet. Does that make you any different from any other physician who strikes out on his own rather than joining a multi-specialty group? Not in the slightest.

By the way, we won't be "getting away with" anything when we pursue spine practice over pain practice - we will be making a well-reasoned, legitimate choice. Dr Mahajan, I respect your position, and all the work you have done to rise to your lofty position, but suggesting to impressionable students and residents that your field is better than my field, that your choice is better than my choice, that your expertise serves your patients better than my expertise, smacks of elementary school recess playground immaturity, rather than rational discussion.

Anesthesia fellowships, even the most interventionally-based amongst them (and here I can not speak for UC Davis specifically) suggest a series of three intralaminar injections for radicular low back pain. There is no basis for the series of three, and the literature clearly shows that transforaminal selective nerve root injections provide a great specificity in terms of diagnosis and treatment. Anesthesiology programs teach the intralaminar approach primarily. A greater sin yet is that they teach the loss of resistance technique, and often advocate doing blind epidural steroid injections. The literature shows this approach can lead to spinal, rather than epidural injections, and not being in the epidural space ~25-30% of the time. So of your 25 to 30 procedures a day (split amongst your 5 residents that comes to 5/day/resident, by the way) how many are done with fluoroscopic guidance. How many are caudal injections (the simplest procedure, one you can be trained for in about a week at the most)?

Dr. Mahajan is right - learning to do a procedure IS easy. Learning how to do it WELL, safely, and for the appropriate indications is the hard part. Learning when NOT to do it is even harder.

Reputations are built on years of quality practice, quality research, and presentations at national meetings. I am not quite sure why those are bad criteria to use when choosing a fellowship, so perhaps Dr. Mahajan can enlighten me on that score.

Again, the basis of the post Dr. Mahajan used as an excuse to once more advertise the virtues of his program was not to suggest that non-ACGME accredited fellowships would allow one to sit for the pain boards after this year, but rather to point out the glaring need for an interdisciplinary organization, without an agenda of the type so blatantly epitomized by Dr. Mahajan, to serve as arbiter of who gets to pursue interventional pain management. Dr, Mahajan suggests, and the ACGME requires, that one needs to be trained in the management of inpatient pain, hospice pain, cancer pain, and non-interventional headache management, hypnosis, acupuncture, and relaxation techniques, in order to be a good interventional pain management specialist. I beg to differ. To pack that all into a year of training, AND pretend that you will be as adept at IDET, percutaneous discectomy, discography, kyphoplasty, and vertebroplasty, as well as neurological ablative technologies like RF, cervical and lumbar zygaphohyseal joint and transforaminal injections will not make you well-rounded, it will make you a jack-of-all-trades, master of none.

Gee, I guess I have a bias after all. The difference is, I don't couch my bias to pretend that I am giving good advice. You agree with me? Great! You want to do a pain fellowship instead? Good for you! I do not pretend to know what is best for you, dear reader. My point is, neither does Dr. Mahajan.

Tenesma

06-09-2004, 09:50 PM

it kind of freaks me out to see a program director go to such pains to advertise his program.... If the fellows or residents from UC Davis were on this board (and thus still fit under "student" doctor/doctor-in-training) then their comments i think would be far more welcome....

If Dr. Mahajan would like to contribute I would suggest more along the lines of what a program director is looking for in applicants and so on... not infomercial mode...

In the meanwhile, after reading this thread, all I can really assume is that there must be some serious insecurities at a program to have the director in every posting (5 total - and counting) push UC Davis.

kingyogurt

06-10-2004, 02:50 AM

I think Dr. Mahajan is doing a great job sharing his knowledge with us. Life is a long journey of collecting information, and we should always welcome others to share their stories. Of course I am just a medical student right now so I am sure I will get ignored :D (j/k)
Side Note: Dr. Mahajan I will be doing a 4th year rotation at UC Davis in Pain Medicine soon and I was wondering if you could recommend a review book for a medical student?

paz5559

06-10-2004, 05:06 AM

I was and am amazed and appreciative that a PD like Dr. Mahajan would take the time to address the concerns of PM&R resdients and potential residents, particularly since only 1 PM&R resident has successfuly obtained a fellowhip positon at UC Davis in the past two years (ie. 1/10, or 10% of the successful candidates).

Dr. Mahajan will , of course, give us the standard answer "more qualified applicants than we have positions available." I dont know about you, but to me, that rings about as hollow as the "We are sorry to inform you ..." letter most of us got from some college or med school we didnt get into. They AREN'T sorry, and Dr. Mahajan, you and I both know that they were not deemed as well qualified, in some manner, real or imagined, legitimate or not, or they would have been your fellows over the past two years.

I would be more appreciative if he were to post objectivley, however, given his stature, rather than skewing his perspective to the point where it looses any hint of legitimacy.

Actions speak louder than words - if you think highly enough of potential and current PM&R residents to take the time to post here on SDN, then perhaps we are also worth taking at more than a 10% clip into your fellowship.

charcot

06-10-2004, 06:55 PM

What are the top programs that focus on interventional pain managment?
I also have less interest in med refills, acute inpatient care, or palliative care.
I think I am becoming more and more interested in developing a surgi-center that provides comprehensive outpatient interventional pain management.

daelroy

06-14-2004, 02:24 PM

Couple of questions.

1. How many years is the pain fellowship after completing a PM&R residency?

2. Is this "interventional pain fellowship" associated with anesthesiology or PM&R? If is associated with anesthesiology, then I take it is more difficult for physiatrist to match into this fellowship?

charcot

06-14-2004, 04:07 PM

My understanding is that Pain management is a 1 year fellowship. It is offered either by anesthesiology depts (90%) or PM&R depts (10%).
The anesthesiology based programs seem to be open to all resident types, anesthesia, neuro, PM&R. PM&R-based programs seem to be only for PM&R residents.

It also seems to me that the anesthesiology-based programs are more procedure oriented, blocks, epidurals, neurolysis, cord stimulators, etc where as PM&R is mostly blocks but in the context of a musculoskeletal examination and understanding of pain.

Finally, the top programs texas tech, BI deaconess, UCLA and others are all anesthesiology not PM&R and most fellows did anesthesia.
I only point this out because I heard that the best private practice jobs go to people trained at top programs (makes sense), assuming they leave academia.

paz5559

06-14-2004, 07:02 PM

Let's see, how many ways can someone be wrong in a three paragraph post? So far, I give honors to Charcot:

Anesthesiology programs generally offer Pain Management fellowships, which include management of acute pain (ie. ER coverage, inpatient consults), hospice, cancer pain, psychopharmacology, and a whole host of non-interventional foci.

Interventional procedures, despite what anyone says, are not easy to do WELL. They are fraught with potential complications, as evidenced by the recent rash of deaths and complications from cervical transforaminal injections. That being said, the hardest part of interventional pain management is determining, in advance of the injection, who is the candidate most likely to receive benefit from the procedure. My personal perception is that the majority of anesthesiology fellowships train technicians, whereas the majority of PM&R fellowships focus at least as much on the rationale for the injection as the technical aspects. In short, it is the process that is the hardest part - who to inject, where to inject them, and most important of all, who NOT to inject, either becuase their pathology requires surgical intervention, psychological intervention, or the intefvention of the legal profession (i.e. patients whose priority are their secondary gain isssues).

Lastly, a little history: no institution can have more than one pain fellowship, interventional or otherwise. PM&R was late to the game, and so most of the programs in the "name" institutions were started by Anesthesia (it should also be noted that not every top institution even HAD a PM&R program, so it would be doubly hard to start a fellowship in that setting.) None the less, the membership of the Interventional Spinal Injection Society is about 35% PM&R, and 65% Anesthesia. The membership of the Board of Governors is 50-50, and NEITHER Nikolai Bogduk NOR Charles Aprill are either specialty (Bogduk is an anatomist, Aprill is a radiologist). The Saal brothers have been prominent members (ok, HATED prominent members, but prominent none the less) of NASS for years. Kevin Pauza won NASS's Outstanding Paper Award thgis past year for his paper on IDET. Joel Press is the incoming President of NASS. ALL of the aforementioned are prominent PM&R docs, NOT anesthesiologists.

The bottom line is, get the best training. I personally think I am more apt to get that with Curtis Slipman, Michael Furman, Rob Windsor, FSI, CINN, CSSOR, HSS, Frank Falco, MCV, the University of Michigan, Spaulding, Stanford, etc, etc, etc. On the other hand, lots of important interventional pain mangement specialists (Way Yin, Ray Baker, Rick Derby) are well-trained anesthesiologists, and clearly extrodinarily talented interventionists. Way and Ray do their research with Paul Dreyfuss, and Rick just brought Yung Chen into his practice. Want to know what those two men have in common? PM&R training.

The one number you did say, although I would love to know your source, that sounds about right, is the 90-10 split - there are lots more anesthesia positions than there are PM&R positions. As a PM&R resident, however, I would argue that just makes ours more sought after, competative, and less easily obtained.

hotwheel

06-15-2004, 10:25 PM

Tenesma

06-16-2004, 01:45 AM

pazzz... come on... using the old line of anesthesia folk being technicians, and PM&R are the only people to understand the WHY behind a procedure, is getting very, very old.

Most PM&R pain people (who were fellowship trained) learned they WHY from Anesthesiologists during fellowship - so tone the rhetoric down. Plus Charcot is a young member of SDN and deserves a chance without you sounding so condescending.

paz5559

06-16-2004, 05:33 AM

I guess the best way to respond to Hotwheel would be to suggest that, when you disparage my field, you disparage me, and all of the other PM&R docs I work with. Implied condescention in statements like the top programs texas tech, BI deaconess, UCLA and others are all anesthesiology not PM&R or It also seems to me that the anesthesiology-based programs are more procedure oriented deserve correction, and I feel I did nothing other than that in the entirety of my post. Quoting one sarcastic comment out of the cotext of the whole, and then taking the "I'm gonna tell mommy" tattletale approach by invoking the help of the forum moderator in no way deminishes the veracity of what I said - Charcot was wrong, and I spent 5 paragraphs explaining WHY he or she was wrong - I did not merely flame him/her.

As for Tenesma, I have read your comment Most PM&R pain people (who were fellowship trained) learned they WHY from Anesthesiologists during fellowship in prior posts. Forgive me, but you just plain wrong about that. Most of the PM&R patriarchs DEVELPOED the field, and are thus not fellowship trained in the first place (Slipman, Windsor, Dreyfuss, Bogdok, Aprill), or trained with the aforementioned (Furman, Falco, Plastaras, members of the Spaulding & MCV staff).

As for my response getting old, let me suggest that it may be old, but is is also true to suggest that anesthesiologists do not, on the whole, tailor their approach to the patients symptomatology. You have chronic back pain? You get three epidural intralaminar injections, period. MAybe floroscopically guided, maybe not. Always intralaminar, NEVER transforaminal (which is the more effective technique (Clin Rheumatol. 2003 Oct;22(4-5):299-304; Pain Digest 1999; 9:277-285) IS there any evidenced reason why top stick with the less effective technique? Nope. In fact, the literature shows that the loss of resistance technique employed by most anesthesiologists, when done blindly can lead to spinal, rather than epidural injections, and not being in the epidural space at all ~25-30% of the time. Evidence based medicine, Tenesma. I have the literature on my side on this one. Unless you have contrary references you would care to share?

Tenesma

06-16-2004, 08:35 AM

pazz - nobody is arguing the literature with you - in fact at MGH all ESIs are done fluoroscopically (even though they don't all get reimbursed with the fluoro coding).

You are citing the literature incorrectly - the randomised controlled study your refer to, compared fluoro-guided transforaminal vs. blind intra-spinous.... that is a poor way of looking at it. It should have been a comparison between fluoro-guided transforaminal vs fluoro-guided intra-spinous (no good literature as far as that is concerned - yet...)

and i don't understand how there is any condescention implied by stating that the top interventional programs are primarily anesthesia based. That is a fact based on historical development of the field, it doesn't imply that PM&R is unable to have a top interventional program. In fact there are some very good interventional PM&R pain programs (they just don't have the national reputation yet).

If you look at most interventional PM&R pain programs - their directors (unless they were grandfathered-in) trained at anesth. programs (ie: Raj Mitra at Stanford).

it sounds like, to me, that you should spend some time in a good pain clinic and observe what anesth. pain docs actually do, instead of making large generalizations

Ligament

06-16-2004, 02:19 PM

"Lastly, a little history: no institution can have more than one pain fellowship, interventional or otherwise."

I dont know where that info comes from. I can tell you for a fact that the University of Michigan has TWO separate pain fellowships. One is run by PM&R, and takes two fellows per year. The other is run by anesthesiology and takes two per year.

Maybe some regulations have changed? Best, Ligament

Tenesma

06-16-2004, 02:44 PM

stanford has a pm&R and an anesth. pain program... two separate programs

hotwheel

06-16-2004, 05:56 PM

I guess the best way to respond to Hotwheel would be to suggest that, when you disparage my field, you disparage me, and all of the other PM&R docs I work with. Implied condescention in statements like or deserve correction, and I feel I did nothing other than that in the entirety of my post. Quoting one sarcastic comment out of the cotext of the whole, and then taking the "I'm gonna tell mommy" tattletale approach by invoking the help of the forum moderator in no way deminishes the veracity of what I said - Charcot was wrong, and I spent 5 paragraphs explaining WHY he or she was wrong - I did not merely flame him/her.

As for Tenesma, I have read your comment in prior posts. Forgive me, but you just plain wrong about that. Most of the PM&R patriarchs DEVELPOED the field, and are thus not fellowship trained in the first place (Slipman, Windsor, Dreyfuss, Bogdok, Aprill), or trained with the aforementioned (Furman, Falco, Plastaras, members of the Spaulding & MCV staff).

As for my response getting old, let me suggest that it may be old, but is is also true to suggest that anesthesiologists do not, on the whole, tailor their approach to the patients symptomatology. You have chronic back pain? You get three epidural intralaminar injections, period. MAybe floroscopically guided, maybe not. Always intralaminar, NEVER transforaminal (which is the more effective technique (Clin Rheumatol. 2003 Oct;22(4-5):299-304; Pain Digest 1999; 9:277-285) IS there any evidenced reason why top stick with the less effective technique? Nope. In fact, the literature shows that the loss of resistance technique employed by most anesthesiologists, when done blindly can lead to spinal, rather than epidural injections, and not being in the epidural space at all ~25-30% of the time. Evidence based medicine, Tenesma. I have the literature on my side on this one. Unless you have contrary references you would care to share?

There you go again, paz5559...disrespecting others! If you actually take the time to READ my initial quote, no where in there did I disparage Physiatrists.

Here's what I said, and I'll say it again:

"So paz5559, I would like you to share with the rest of the residents and medical students of this forum why you feel it necessary to devalue someone else's opinion with giving out "honors...about ...how many ways can someone be wrong in a three paragraph post?"

I would also like the moderator of this forum, Dr. Russo, to speak up about how inflammatory statements like paz5999's contribute to the overall "positive" purpose of this forum."

By the way, I am a Physiatrist...and proud of it. So your comment that "when you disparage my field, you disparage me, and all of the other PM&R docs I work with" makes even less sense when placed in that context. As far as getting the moderator involved?why not? Your response further supports my initial comment. I am in agreement with one of the other participants that your statements are just plain condescending.

And Pain Digest? Truthfully, I?ve not met any pain practitioner (academic or private) who quotes articles from this journal. Personally, I?m used to reading Pain, Pain Medicine, The Clinical Journal of Pain, Journal of Pain and Symptom Management, Spine, JAMA, NEJM, Anesthesia and Analgesia, Regional Anesthesia and Pain Medicine, etc.

Anyway, I took the liberty of pulling the abstract from the other article you cited in Current Rheum, 2003, as that probably carries more weight in academic circles. I?ve copied the abstract verbatim for everyone to read:

ABSTRACT: A prospective, randomised, double-blind study was carried out to compare the respective efficacies of transforaminal and interspinous epidural corticosteroid injections in discal radiculalgia. Thirty-one patients (18 females, 13 males) with discal radicular pain of less than 3 months duration were consecutively randomised to receive either radio-guided transforaminal or blindly performed interspinous epidural corticosteroid injections. Post-treatment outcome was evaluated clinically at 6 and 30 days, and then at 6 months, but only by mailed questionnaire. At day 6, the between-group difference was significantly in favour of the transforaminal group with respect to Schober s index, finger-to-floor distance, daily activities, and work and leisure activities on the Dallas pain scale. At day 30, pain relief was significantly better in the transforaminal group. At month 6, answers to the mailed questionnaire still showed significantly better results for transforaminal injection concerning pain, daily activities, work and leisure activities and anxiety and depression, with a decline in the Roland?Morris score. In recent discal radiculalgia, the efficacy of radio-guided transforaminal epidural corticosteroid injections was higher than that obtained with blindly-performed interspinous injections.

Seriously, is this what you consider substantive research that withstands the the rigorous criteria of evidence-based medicine? I certainly don?t, and I would be embarassed to quote this to my colleagues as an article that proves the ? evidence is on my side.? This article has numerous flaws, the least of which are the following:
1. It is NOT a double-blinded, prospective, randomized placebo-controlled study. It is only a prospective, randomized placebo-controlled study.
2. Only 31 patients were enrolled
3. Less than stringent inclusion/exclusion criteria were used
4. Comparison of a fluoro-guided technique with a non-fluoro guided-technique

I respectfully suggest you do some further reading and come back to this forum with something more substantial? perhaps, give us the abstract as well. There is stuff out there, but my guess is you will find that most (but not all) of the procedures done in by pain practitioners (Physiatrists or Anesthesiologists) are not supported by strong research, ie randomized, double-blinded, placebo-controlled studies with large populations. Even look in the Cochrane data base. None-the-less, this does not negate the fact that many patients obtain pain relief with associated functional improvement from these various procedures.

Finally, I agree with Tenesma. You need to spend time in a good pain clinic, but specifically an Anesthesia-based pain clinic, before you start casting broad generalizations about them. I will agree with you, however, that some of the PM&R based pain clinics have a well-established reputation of excellence...others do not (but maybe with time they will).

charcot

06-16-2004, 08:03 PM

It is so wonderful to see such enthusiastic postings, and I appreciate all of them. No offense is taken by the postings. I am new to the forum and I am trying to learn about this specialty. As I read the postings I learn more about the field, and some of the personalities who make up the specialty. I would still like to hear more discussion on the top programs, particularly west coast and east coast. (I hope I don't offend any midwesterners). I can appreciate the importance of comprehensive pain management training, including the pathophysiology of pain and the logical selective use of interventions. I am trying to find out which programs will teach the above mentioned and provide didactics on the conceptual basis for pain medicine, as well as hands on training in the interventions, a good mix of outpatient, inpatient, and hospice.

paz5559

06-16-2004, 08:07 PM

charcot

06-16-2004, 08:40 PM

[QUOTE=paz5559]...what I was quoting, it was from charcot's original post, not your response. It was he/she who I felt was disparaging the field, and like it or not, I am entittled to take humbrage, just as you, and all contributors to the field are entittled to pile on when you dislike me, my lopinon, or my perspective.

.... I responded to charcot's post the first time, and my comment "when you disparage my field, you disparage me, and all of the other PM&R docs I work with," I referred to his disparaging comments. Your response referred to my characterization of him/her, and I EXPLAINED why I had responded as I did. I hope that is helpful, and clarifies what I thought would have been obvious to the keen reader.

QUOTE]
PAZ-
Hey man, I was not putting out any disparaging comments. You are mistaken about my intention. I was, as others have pointed out, stating the current state of pain fellowships as being mostly anesthesia-based, and that most of the better programs seem anesthesia-based, and most of the fellows seem to be anesthesia-trained. This is all in the context of trying to find out where a non-anesthesia based person can fit in as a trainee in this exciting, inspiring and potentially lucrative field. I have heard that a PM&R person can go far, but should go into an anesthesia program. I'm simply trying to learn about the best ones.

hotwheel

06-16-2004, 11:51 PM

hotwheel

06-16-2004, 11:59 PM

I will do this in stages, ?cause I am getting it from all sides

To answer the most egregious error first, hotwheel, had you taken the time to note what I was quoting, it was from charcot's original post, not your response. It was he/she who I felt was disparaging the field, and like it or not, I am entittled to take humbrage, just as you, and all contributors to the field are entittled to pile on when you dislike me, my lopinon, or my perspective.

Once again, just so you are clear, I did not respond to you, hotwheel, except in the sense that I responded BECAUSE of your post. Had you taken the time to read what I wrote, perhaps you would have noticed that. I responded to charcot's post the first time, and my comment "when you disparage my field, you disparage me, and all of the other PM&R docs I work with," I referred to his disparaging comments. Your response referred to my characterization of him/her, and I EXPLAINED why I had responded as I did. I hope that is helpful, and clarifies what I thought would have been obvious to the keen reader.

Also what I would have assumed was obvious was the distinction between condescension and sarcasm. My intent was for the latter. That you read it as the former may speak to your lack of insight, or my lack of subtlety. Your call. In any case, not cause to call for banning me, which is clearly an over reaction, whether you recognize it or not.

Like him or hate him, Laxmaiah Manchikanti is a prominent member of the field of interventional pain management. (For those not aware, Dr. Manchikanti is the President and Executive Director of the American Society of Interventional Pain Physicians). I do find it interesting that you fail to list The Spine Journal, the official publication of the North American Spine Society, and JBJS, but instead list medical resources like NEJM and JAMA. Perhaps if you ahd taken the time to read what I have posted, you might see I was making reference to INTERVENTIONAL Pain Management, rather than the totality of the field of Pain Medicine.

Having attended last years meetings of NASS, ISIS, AAPM, and AAPM&R, I find it comical that your ONLY standard is the gold one of double-blinded, prospective, randomized placebo-controlled. Exactly ONE paper was presented meeting that criteria last year relating to interventional pain management, and Kevin Pauza's paper regarding IDET was the winner of NASS's Outstanding Paper Award, in part BECAUSE of the difficulty involved in such a study. In it, he screened in excess of 4000 potential participants to end up with an N of 64. Thus to be critical of an N of 31 demonstrates your lack of familiarity when it comes to the trials and tribulations of research related to placebo, or sham procedures.

But let?s go further. Assume for sake of argument, you were able to recruit sufficient participants. How do you propose that you would blind the investigator? After all, he is the one who would be performing the procedure, and would thus HAVE to know which procedure he was to perform on each patient. And lastly, just to nit pick, when comparing two efficacious procedures, you compare them against each other, not against a placebo. The ethics of sham procedures are dubious at best, and no IRB would allow you to perform them when the point of the study was to determine which of two procedures that have demonstrated efficacy provide better relief.

COMMENTS CONTINUED

As for the gold standard of research being a randomized, double-blinded, prospective, placebo-controlled study? that is a fact. The lack of such a standard is why the results of many pain studies are fraught with errors in interpretation and conclusions drawn. And not being able to blind the researcher makes this even more difficult.

And to say I have a ?lack of familiarity with the trials and tribulations of research and placebos and sham and not getting IRB approval?, let?s get serious here. Did YOU actually read Pauza?s NASS paper of the year? And by the way, it was NOTa double-blinded randomized placebo-controlled prospective trial as you alluded to in your quote. It was a randomized, placebo-controlled, prospective trial (see abstract below, under "study design/setting")

Here is the abstract from Pauza?s paper (which is listed on PubMed) for everyone to read:

BACKGROUND: Intradiscal electrothermal therapy (IDET) is a treatment for discogenic low back pain the efficacy of which has not been rigorously tested. PURPOSE: To compare the efficacy of IDET with that of a placebo treatment. STUDY DESIGN/SETTING: Randomized, placebo-controlled, prospective trial. PATIENT SAMPLE: Patients were recruited by referral and the media. No inducements were provided to any patient in order to have them participate. Of 1,360 individuals who were prepared to submit to randomization, 260 were found potentially eligible after clinical examination and 64 became eligible after discography. All had discogenic low back pain lasting longer than 6 months, with no comorbidity. Thirty-seven were allocated to IDET and 27 to sham treatment. Both groups were satisfactorily matched for demographic and clinical features. METHODS: IDET was performed using a standard protocol, in which the posterior annulus of the painful disc was heated to 90 C. Sham therapy consisted of introducing a needle onto the disc and exposing the patient to the same visual and auditory environment as for a real procedure. Thirty-two (85%) of the patients randomized to the IDET group and 24 (89%) of those assigned to the sham group complied fully with the protocol of the study, and complete follow-up data are available for all of these patients. OUTCOME MEASURES: The principal outcome measures were pain and disability, assessed using a visual analog scale for pain, the Short Form (SF)-36, and the Oswestry disability scale. RESULTS: Patients in both groups exhibited improvements, but mean improvements in pain, disability and depression were significantly greater in the group treated with IDET. More patients deteriorated when subjected to sham treatment, whereas a greater proportion showed improvements in pain when treated with IDET. The number needed to treat, to achieve 75% relief of pain, was five. Whereas approximately 40% of the patients achieved greater than 50% relief of their pain, approximately 50% of the patients experienced no appreciable benefit. CONCLUSIONS: Nonspecific factors associated with the procedure account for a proportion of the apparent efficacy of IDET, but its efficacy cannot be attributed wholly to a placebo effect. The results of this trial cannot be generalized to patients who do not fit the strict inclusion criteria of this study, but IDET appears to provide worthwhile relief in a small proportion of strictly defined patients undergoing this treatment for intractable low back pain

So did the authors screen 4000 patients? Yes (4253 patients to be exact), but it was a combo of referrals and a media blitz that brought the patients in. So let?s agree that 4253 people were ?screened? and whitled down to 1360 as it indicates in the abstract. So what? Some of these were patients whose only complaint was low back pain and did not even have an exam until they agreed to randomization. And then only 260 were eligible based on a clinical exam, and of these only 64 were enrolled in the study. Still a small number as far as I?m concerned. However, I commend the authors for doing this study and the laudable task of putting it together.

Furthermore, I?m impressed with the placebo control: ?Sham therapy consisted of introducing a needle onto the disc and exposing the patient to the same visual and auditory environment as for a real procedure.? And by the way, that is how you do a sham treatment with the approval of the IRB! So, would you agree or disagree with your previous statement that ?the ethics of sham procedures are dubious at best, and no IRB would allow you to perform them when the point of the study was to determine which of two procedures that have demonstrated efficacy provide better relief.? Here you could try to get me on a technicality that the study did not compare two procedures, and that's fine with me. But one could plausibly say it was 2 procedures: that of IDET vs. merely sticking a needle into the patient and placing it onto the disc. But then answer this question: should the authors have even used a sham treatment in patients with a positive discogram, when the "alternative therapy" could be surgery? Oh and it looks like the conclusion of the study was not that forceful either, with 50% of patients obtaining no appreciable benefit. It probably reinforces why many (but not all, ie work comp especially) insurance companies continue to deny authorization for the treatment. Certainly, this is the type of study that should have been done before every interventionalist (physiatrists and anesthesiologists) jumped on the wagon of doing IDETs on everyone with a positive discogram. If you go back and read the earlier studies of some of the ?PATRIARCHS??2 of whom developed the procedure?and you will see that Pauza?s study probably supports much of the skepticism about the procedure when it first came out and the Saal brothers started publishing their data. But don?t mistake this for me believing IDET is invaluable?it is in the right patient. Certainly, surgical outcomes and outcomes research for LBP are not great either, but insurance companies have no problem paying for that.

paz5559

06-17-2004, 05:22 AM

drusso

06-17-2004, 12:52 PM

I would also like the moderator of this forum, Dr. Russo, to speak up about how inflammatory statements like paz5999's contribute to the overall "positive" purpose of this forum."

There is nothing wrong with spirited debate: It's interesting and introduces juniors/novices to this important topic. Let everyone just remember that this is a professional forum.

hotwheel

06-17-2004, 03:40 PM

Quite a diatribe, hotwheel. Yet at the end of the day, you have still not suggested how it would be technically possible to accomplish what you have suggested is the only acceptable form of evaluating transforaminal vs. intralaminar epidural injections. I wait with bated breath for your proposed double-blinded, prospective, randomized placebo-controlled protocol. I for one believe you have set the bar impossibly high to then be able to throw darts with impunity, but perhaps you will prove me wrong.

By the way, while an interesting discussion, I wonder if it hasn't been hijacked from its original mission of addressing "PM&R and Pain Fellowships"

Why don't you PM me, of if you feel your harangue must continue in public (misguided though it is), why not start a "beat up on PAZ", "PAZ is a moron", or "Anesthesia is better than PM&R" thread? (That was sarcasm, by the way, just so nothing is "left open to the interpretation of the reader" in this instance.)

paz, surely you jest about my not having answered your question about the "proposed double-blinded, prospective, randomized placebo-controlled protocol" for transforaminal vs. translaminar epidural injections. Look, you have not even answered any of my questions, especially the ones about the literature YOU posted in your comments. When you answer my questions, then I?m happy to answer yours. Until then?keep waiting with bated breath. Besides, my diatribe today is too long anyway!

As for my setting the bar too high, don?t blame me on this one. The bar is set by the scientific/research establishment to keep unsafe procedures and drugs from coming to the mass market. So forgive me if I view the literature with a high level of scrutiny. Make no mistake, though, there are merits to many of the interventional procedures that are performed even though they don?t meet the ?gold standard?. To be clear, I?m not throwing darts with impunity. On the other hand, I'm not going to justify doing some of those procedures with the authoritative mandate of "evidence-based medicine" being on my side, when it is clearly not. (And as an aside, what do you think about research that is published by authors who are speakers for the products/devices they are testing? Should those studies be weighted equally with those studies where the authors have absolutely no bias?)

As for hijacking the discussion and haranguing you in public...c?mon! Let?s just stick to the facts. You're the one that's quoting the literature being on your side. I merely pulled the Rheumatology study that I?m assuming you've read but never-the-less the results of which you clearly defend. I then read the article and posted the abstract for everyone else to view so they, too, can reach their own conclusions about the study?s veracity. (Note: I tried to get to Pain Digest, but unfortunately our library doesn't have access to that, it doesn?t exist in Pub Med/NLM, and I don?t have a subscription. So you?ve got me on that one, but once again I haven?t heard of Pain academicians quoting it ? and this includes AAPM&R, AAPM, ISIS, IASP, ASRA, or APS. (Missed the NASS conference, so I?ll have to defer to you on that one.) And as for Pauza's paper, I'd already read that one when it came out (And I forgot to mention in yesterday?s original post?while 64 patients were ultimately analyzed, the final data was only based on 56 patients). So, once again all I did was post the abstract..

So really, the bottom line is this: misquoting and misrepresenting scientific articles as being something more than what they are, is in my opinion, an egregious error. Most of the research in the field of pain management, especially interventional pain management, should be reviewed with a keen eye. The scientific literature is littered with many studies, and it's up to the reader to recognize each studies limitations, as it ultimately is extrapolated to affect one's clinical practice.

With respect to determining which are the best types of Fellowships, you list quite a few. But you also state that your ??personal perception is that the majority of anesthesiology fellowships train technicians, whereas the majority of PM&R fellowships focus at least as much on the rationale for the injection as the technical aspects.? Now, I respect your opinion and your right to put it out there in this forum like everyone else. I am not being sarcastic when I ask that I genuinely would like to know what forms your perception, as it is obvious that you have a clear bias is towards PM&R Pain Fellowships. (As for my bias, I have none as I?m equally receptive to both)

PainDr

06-19-2004, 02:29 PM

Originally Posted by paz5559

"As for my response getting old, let me suggest that it may be old, but is also true to suggest that anesthesiologists do not, on the whole, tailor their approach to the patients symptomatology. You have chronic back pain? You get three epidural intralaminar injections, period. MAybe floroscopically guided, maybe not."

As a neurology resident going into interventional pain, I consider myself somewhat impartial. I have to disagree with the statement that anesthesiologists are not as well trained as physiatrists. I've worked with several very well trained anesthesiologists. Believe me...they know what they're doing. Also, I'm in the process of applying for fellowship and have carefully scrutinized quite a few programs. I must say I haven't been too impressed with MOST of the PM&R programs. Personally, I've been encouraged not to apply to them as most are not as well developed or nationally known as the Anesthesiology programs.

Also, someone mentioned that rehab residents are much better at EMG than neuro residents because we sometimes do less than one month of EMG. Just for the record, that's incorrect. AAN guidlines require a minimum of 2 months of EMG, but I don't know ANYONE who only does 2 months. Most people do at least 3-4 months. Additionally, the quality of training makes a great deal of difference. Are you learning from clinicians who are just fellowship trained or are you training with nationally known neuromuscular specialists? In the best situation you get both quality and quantity, but I doubt most physiatrists OR neurologists are fortunate enough to have that type of resident experience. My experience has been GREAT and it sounds like yours has too, but lets not delude ourselves into thinking that everyone is so lucky! I mean, if that were the case, there wouldn't be a need for neuromuscular fellowships! :rolleyes:

Finally M3

06-19-2004, 08:51 PM

Originally Posted by paz5559

"As a neurology resident going into interventional pain, I consider myself somewhat impartial.

Heh, isn't this statment re; a neurologist speaking about PM&R an oxymoron?

:laugh:

Sorry, I couldn't resist. You've been very professional in your postings, PainDr, and brought a lot to this discussion and our discussion board! :D

Stinky Tofu

06-19-2004, 11:09 PM

Also, someone mentioned that rehab residents are much better at EMG than neuro residents because we sometimes do less than one month of EMG. Just for the record, that's incorrect. AAN guidlines require a minimum of 2 months of EMG, but I don't know ANYONE who only does 2 months. Most people do at least 3-4 months. Additionally, the quality of training makes a great deal of difference. Are you learning from clinicians who are just fellowship trained or are you training with nationally known neuromuscular specialists? In the best situation you get both quality and quantity, but I doubt most physiatrists OR neurologists are fortunate enough to have that type of resident experience. My experience has been GREAT and it sounds like yours has too, but lets not delude ourselves into thinking that everyone is so lucky! I mean, if that were the case, there wouldn't be a need for neuromuscular fellowships! :rolleyes:

I can't speak for every program, but at least at Harvard and the institutions that the MGH/BWH fellows came from, it is not the norm to to 3-4 months. In fact, the Partners Neurology residents hardly ever spend time in the Neurophysiology lab (definitely less than two months on average) unless they are interested in doing a fellowship. The ones that do rotate through split their time between EEGs and EDX studies. On the other hand, we spend 4-6 months learning from the same neuromusclar specialists as the Partners Neurology residents do. This is in addition to the EDX studies we do on other rotations, our weekly EMG conferences, and the lectures we get.

Neurologists are certainly capable of becoming good Neurophysiologists, but from what I've heard from the residents and fellows, it would be difficult without a fellowship. On the other hand, Physiatrists don't necessarily have to do a fellowship. All PM&R residencies require you to do 200 studies prior to graduation and this is so that you will be eligible to sit for the AAEM's (American Association of Electrodiagnostic Medicine) exam.

For the average Neurology resident interested in doing both EDX studies and Interventional Pain, I think it would be difficult to do both without a fellowship in each.

PainDr

06-20-2004, 09:14 AM

drusso

06-20-2004, 11:07 AM

The minimum requirement is 2 months of dedicated EMG and 2 months of dedicated EEG (4 months total). Unless I'm mistaken, it is an ACGME/AAN requirement. We also do/interpret EDX studies on other rotations and have regular EMG lectures and conferences. However, both my chairman and program director are fairly well known neuromuscular specialists therefore, I'll concede that my program is probably somewhat unique in the amount and quality of EMG exposure.

I didn't realize that All PM&R residencies require you to do 200 studies prior to graduation. That's impressive. However, I was recently told by one of our fellows that the ABEM is changing it's eligibility criteria (I'm sure you meant the ABEM, as the AAEM doesn't have anything to do with confering board certification). The previous requirement of 200 completed studies is being revoked and in the future, only those with fellowship training will be allowed to sit for the boards. This is to go into effect in the next year or two. If this is incorrect, please let me know.

At Mayo we do a total of 6 months of EMG/EDX with our neurology colleagues. The neuro residents have an option of doing only four months and we have to do six months. Many of the neuro residents at Mayo are more interested in other fellowship opportunities--MS, stroke, movement disorders, etc. and tailor their experiences that way

The neurophysiology lab is a joint venture by Neuro and PM&R. I'll have to check with my program chairman about the 200 EMG requirement going away. She sits on the board of the AAEM. I do know that there is a push to further subspecialize EMG/EDX training as in some states physical therapists can do needle examinations as well as in the military. Scary. If even the best electrodiagnostician can miss ALS versus a polyradic or other "zebra EDX" finding how on earth will a PT make the call? It's not all carpal tunnel and L5 radics out there...

Stinky Tofu

06-20-2004, 11:41 AM

As far as I know, that policy isn't going to change for the AAEM/ABEM. I would think that if the policy was going to change, they would probably mention it. I'm sure DigableCat would've heard about it as well since Dumitru and Walsh are at his program. I think that what you are referring to is the ABPN's (American Board of Psychiatry and Neurology) subspecialty certification in Clinical Neurophysiology. I remember one of the fellows mentioning this, but since I'm not a Neurology resident, I didn't really pay attention.

The resident should be exposed to patients with neuromuscular disorders at all levels of their training. While some aspects of this can be accomplished during their rotations on the in-patient service and resident clinics, it is recognized that many neuromuscular patients are seen only in sub-specialty clinics. The residency should provide rotations for all residents in neuromuscular clinics preferably the equivalent of 2-3 months during their residency. The adult neurology residents should be exposed to pediatric neuromuscular patients in a similar manner. It could be included as part of the 3 month pediatric neurology rotation.
A rotation in the EMG laboratory is an excellent way for residents to see a variety of neuromuscular patients, understand the physiologic aspects of these disorders, and learn when to order studies and how to interpret EMG results. It should be understood that the practice of electromyography requires extensive training and post-training experience. This is usually not possible to obtain during a short rotation during residency. Residents interested in performing EMG examinations in their future practice are encouraged to pursue further training in a fellowship.

From what I gathered from a quick look at the AAN's website, it appears to be a suggestion rather than a requirement. The average Partners Neurology resident does not spend 2-3 months in the EMG laboratory; they'd rather spend their elective time pursuing other areas of interest and probably wouldn't want to be forced to spend that much time in the EMG lab.

PainDr

06-24-2004, 10:05 AM

"From what I gathered from a quick look at the AAN's website, it appears to be a suggestion rather than a requirement. The average Partners Neurology resident does not spend 2-3 months in the EMG laboratory; they'd rather spend their elective time pursuing other areas of interest and probably wouldn't want to be forced to spend that much time in the EMG lab."

I suppose both my Chairman and Program Director could be wrong...I'll check into it. :rolleyes:

paz5559

06-27-2004, 07:03 AM

Stinky Tofu

06-27-2004, 02:52 PM

Reference was made earlier that PM&R REQUIRES that residents perform 200 EMG's during their residency. While individual programs may, the AAEM is the body that uses that benchmark in order for you to sit for their board certification exam.

I could be wrong, but I tried to read through the ACGME RRC requirements prior to posting this disagreement with the prior post, and I can't find any such requirement listed.

http://www.acgme.org/downloads/RRC_progReq/340pr703.pdf

Anyone who can find rules and regs I haven't stumbled across, please let me know.

I got this from the link you provided above:

7. The clinical curriculum must be written and implemented for the
comprehensive development of measurable competencies for each resident in
the following areas:

a. history and physical examination pertinent to physical medicine and
rehabilitation,
b. assessment of neurological, musculoskeletal and
cardiovascular-pulmonary systems,
c. determining disability evaluations and impairment ratings,
d. data gathering and interpreting of psychosocial and vocational
factors,
e. performance of electromyography, nerve conduction and
somatosensory evoked potential studies, and other electrodiagnostic
studies. In general, involvement in approximately 200
electrodiagnostic consultations per resident, under appropriate
supervision, represents an adequate number.
f. therapeutic and diagnostic injection techniques,
g. prescriptions for orthotics, prosthetics, wheelchairs and ambulatory
devices, special beds and other assistive devices,
h. Written prescriptions with specific details appropriate to the patient
for therapeutic modalities, therapeutic exercises and testing
performed by physical therapists, occupational therapists,
speech/language pathologists. It is necessary to provide for an
understanding and coordination of psychologic and vocational
interventions and tests.
i. familiarity with the safety, maintenance, as well as the actual use, of
medical equipment common to the various therapy areas and
laboratories,
j. a formal experience in evaluation and application of cardiac and
pulmonary rehabilitation as related to physiatric responsibilities,
k. the rehabilitation of children,
l. collaboration with other medical professionals and members of the
allied health team, including management techniques consistent with
the resident's team leadership role, and the treatment program
management role of the physiatrist,
m. geriatric rehabilitation,
n. prevention of injury, illness and disability
o. counseling of patients and family members, including end of life
care,
p. the importance of personal, social and cultural factors in the disease
process and clinical management,
q. the principles of pharmacology as they relate to the indications for
and complications of drugs utilized in PM&R, and
r. experience in the continuing care of patients with long-term
disabilities through appropriate follow-up care.

I'm not sure if this is a firm PM&R requirement, but at every program I interviewed, there would be some sort of mention about their residents having no problem meeting the 200 cases required. In retrospect, they may have meant the AAEM/ABEM requirement.

DigableCat

06-28-2004, 03:25 PM

Unless I interpreted him wrong, this is what he says...

1. There is no intentions on making EMG fellowships required for PM&R residents to become ABEM certified. The fact that we have to do >200 during our residency makes up competent enough to sit for the exam.
2. Neurologists have to do a EMG fellowship to be able to sit for the boards. I'm not sure if they have to be ABEM certified to do EMGs(and it's highly unlikely). Although I hesitate to think how they could be done and interpreted with confidence. Half of the time, when I get an EMG consult from the Neurology service and I call the resident...they don't know exactly why they are ordering it or what they are looking for. It's more of a shot gun approach. Hoping something comes up positive.

PainDr

06-28-2004, 05:25 PM

Stinky is right. Neuro residents must do a fellowship to get ABPN subspecialty certification. However, DigableCat is wrong. We are not required to do a fellowship to sit for the boards. We have the same 200 study requirement as you...something many programs could easily accommodate during elective time.

Surely I don't need to tell you that programs vary greatly in their strengths and weakness. For example, I find it laughable that a neurologist would consult pm&r for an EMG, but if you tell me that's what's happening at your program, I suppose I'll take your word for it. I mean, after all, the pm&r residents at my program are the most worthless group I've ever seen and I wouldn't refer my worst enemy to them. So...I've seen first hand how an institution can have both strong and weak programs under the same roof.

charcot

06-28-2004, 06:21 PM

Any word on top west coast pain programs? particularly in terms of breadth of training in interventions as well as didactics and collegiality amongs fellows and faculty.

By the way, Bonica's book is one of the most amazing textbooks I've come across in a very long time.

DigableCat

06-28-2004, 08:40 PM

But...I stand corrected. As is sometimes the case.

American Board of Electrodiagnostic Medicine Eligibility Requirements (http://www.abemexam.net/certexam/EligibilityRequirements.cfm)

Training in Electrodiagnostic Medicine
A period of preceptorship in electrodiagnostic medicine that is coordinated with presentation of didactic material must be satisfactorily completed under direct supervision of an experienced electrodiagnostic medicine consultant, preferably an ABEM Board Diplomate. This preceptorship may be taken during and/or after an approved residency training program. The period of preceptorship must be at least 6 months fulltime,1 or equivalent thereto, with the first 3 months rigidly structured with regard to supervision. Any postresidency course of study in electrodiagnostic medicine must be conducted where there is an ACGME, AOA, or RCPSC recognized neurology or physiatry residency training program, or at a participating institution to a sponsoring institution that has been approved by the ACGME in order to qualify as a portion of the 6-month preceptorship. During these 6 months, at least 200 complete electrodiagnostic evaluations must be performed on separate occasions; these studies must be documented and interpreted.

Full-time equivalent: One month of full-time equivalent is defined as 160 hours

Independent Experience
Competency in electrodiagnostic medicine can only be achieved by performing and interpreting additional electrodiagnostic examinations. Candidates, therefore, must also document at least 1 year of experience following training during which they must perform 200 additional complete electrodiagnostic evaluations on separate occasions.

I get my 6 months and >200 EMGs easily. Don't know how easy it is for Neurology programs to do the same. Maybe what I was meant to understand is that Neurology programs typically do not receive the 6 months necessary, thereby making the EMG fellowship more of an option than say someone who is a PM&R resident.

Ready to be wrong...