PASSOR workshops vs ISIS workshops

PASSOR is a 3 level approach, whereas ISIS is more like 6 or 7. Both are excellent, filled with many instructors that are experts in their fields...

algosdoc said:

PASSOR is a 3 level approach, whereas ISIS is more like 6 or 7. Both are excellent, filled with many instructors that are experts in their fields...

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I wonder if anyone else besides me has a problem with these courses teaching cervical transforaminals and discography to weekend warriors? Yes, I know they are not accredited to do the procedures at the end of the course, but do you really believe docs lay out thousands of dollars and give up a weekend, and then DON'T start doing these procedures the following Monday morning?

Once again, it's all about the money, and these otherwise reasonable organizations make a whole lot of it by offering these courses.

If one has years of experience in pain medicine and then takes a weekend course to upgrade their skills, then it would be difficult to fault them for doing so. If a person has no prior pain medicine skills and tries these procedures, it would be potentially disastrous. This is made clear to the participants and that is exactly why the weekend courses are graded.
Spending a year in fellowship in interventional pain does not insulate one against the hazards of performing these procedures, nor does a fellowship confer ubiquitous fungibility in the skill sets or experience necessary to perform these procedures.
If there are those with clearly inferior skills at the courses, they are told they need more experience before attempting the procedures. PASSOR and ISIS Courses do not offer any certification of capabilities or knowledge of the participants. But given the proper format and testing, it would be possible to create a procedure by procedure certification process.

That is the most elegantly written summary of interventional training I have come across. I completely agree with Algos. We all know that there are people out there with no training who are willing to forge ahead into new procedures with little consideration for the consequences. I also know that there is tremendous variability in the depth/volume of the training among fellowship programs. Either road can result in disaster when a person reaches beyond his or her skill level. I think that at some point a system needs to be developed in which the interventionalist's skills are assessed by a governing body. Post-graduate training/fellowships would provide the eligibility to participate in the testing of learned procedures. It would be no different than sitting for boards after residency. Some people may be credentialed to do SCS, while others only SI joint injections.

We all know that residencies differ in their strengths - and therefore not everyone gets board certified.

I have attended a PASSOR course taught by some of the experts who post on this site in order to get a different perspective from my training - I thought the course was exceptional.

algosdoc said:

Spending a year in fellowship in interventional pain does not insulate one against the hazards of performing these procedures, nor does a fellowship confer ubiquitous fungibility in the skill sets or experience necessary to perform these procedures ... PASSOR and ISIS Courses do not offer any certification of capabilities or knowledge of the participants.

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I realize it is politically correct to agree with Algos on all matters, but the above is clearly nonsense, albeit "elegantly written" nonsense.

Of course fellowship training doesn't confer ability. It does, however, give the trainee a huge amount of experience beyond that of the weekend warrior.

In contradistinction, weekend courses provide a certificate of attendance. For instructors and governing bodies to dismiss what these certificates imply, and simply collect the several thousand dollars from attendees is at best willful ignorance, and at worst tacit complicity in unleashing undertrained, and potentially dangerous injectionists onto an ignorant public.

Course attendance and increased experience gained at such courses IMPLY competance, even if it is not stated OVERTLY. When you went to nulceoplasty, or stimulator, or IDET courses, they never certified you as competant to perform the procedures. But everyone understood that you were going to those courses to learn how to do the procedures in order to come back to the office and start DOING them, not just to hang the certificate on the wall behind your desk.

Do some attendees come back for refresher courses? Absolutely. But to pretend that is even a reasonably large segment of your participants is laughable. And the notion that saying at some point during the course "now don't try this at home, kids" gets you off the hook may fly with the lawyers, but it certainly remains ethically and morally troubling, even if your legal counsel has found you a technical loophole to wiggle through.

Shame on you, Algos, for trying to justify such practices.

The elitism of academia with respect to qualifications to perform interventional pain procedures is noted and not unexpected, but largely irrelevant due to the vast quality and experiential differences within the fellowship programs. Because of the variations in philosophies of pain medicine, practical approaches, financial considerations, risk management considerations, and experiential variations, the pain fellowship programs were given new standards to meet as of 2007 and those not meeting them will be decertified. Therefore at this time, it is implausible to argue the only pathway to interventional pain should be restricted to fellowship trained physicians given their lack of standardized quality or approach until now (not fully implemented at this time).
Neither can it be rationally argued ABMS certification with additional qualifications in pain medicine be the litmus test since the ABMS sequentially opened up large holes in the certification by permitting "grandfathering" for virtually anyone that had an interest in pain medicine. Initially, anesthesiologists with no specific training in pain medicine were grandfathered in by taking a test (that was readily passable after a board review), followed by grandfathering of physiatrists, neurologists, psychologists, and through the latter pathways, family physicians that had an interest in pain medicine. Therefore the training, skills, background education, and demonstration of decision-making capabilities vary all over the map due to the enormous array of those permitted to hang "ABMS pain certified" on their wall. Many of these physicians never had to demonstrate to anyone they knew anything about physically placing a needle nor understood contrast patterns before being "certified" in pain medicine by the ABMS. Therefore the ABMS has created a huge credibility problem since their certification criteria over time have varied wildly.
While weekend courses are not ideal, they provide updated and scientifically derived approaches to the technical and patient selection issues. They are not meant to serve as a substitute for fellowship training, but in many cases result in a better understanding of the pros and cons and various approaches to patient care due to fellowship variability. Organizations such as ISIS and PASSOR are non-profit educational programs. The instructors receive $500 for spending part of the day traveling on friday canceling cases in order to do so, and work for 8 hours teaching on saturday, then another 5 hours on sunday, only to arrive late at night or early the next morning at home to start their own clinical duties once again. The instructors certainly do not come to these courses for money, nor for vacation since there is far too little money and far too little time to enjoy the weekend. The preparation for these courses sometimes requires many hours and weeks of putting together powerpoint presentations, contacting industry reps and engineers, and constructing presentations that conform to the standards of the respective society. The organizations do not build skyscrapers with the funds they acquire for the courses: they pay for cadavers (cost up to $27,000 each), shipping, and sometimes for fluoroscopes to be brought in to the meetings. Of course meeting room costs are quite high. Meetings in hotels can be less expensive for the sponsoring organization than having the meetings in some of the well known anatomical labs, but requires enormous organizational oversight due to details that may not be self evident. Finally, the organizations pour the money they gain from these courses directly back into research and education. ISIS and PASSOR have no political action committees nor do they attempt to exert influence on senators or representatives. They are purely scientific organizations. ISIS and PASSOR offer a perspective in their courses that may not be gained by training in a fellowship program. In many fellowship programs, the attending physicians may have little or no experience in private practice pain medicine where things are done quite differently than academia. Most instructors from ISIS and PASSOR are in private practice and effectively donate their time and years of experience for the cause of education.
Of course there is a better way than either the current rag-tag fellowship programs trying to teach an entire medical specialty in one year or a certification that has credibility problems......that is the development of a full fledged 4 year residency program in pain medicine beginning after the 4th year of medical school. But be forewarned: those graduating from a full pain residency program will be making the same arguments deriding those of you with fellowship training and castigating the fellowship programs as being money grubbing offshoots of a base residency program.
In time, ISIS and PASSOR will probably change their missions more towards research rather than education if there is eventually developed a viable residency model. But until then, cut the organizations and instructors a little slack....the instructors volunteer their time and efforts to promote quality in practice and advancement of the science. Many of the students in these programs have fellowship training but are seeking to enhance their understanding of a particular focused set of skills from a different perspective.
I think we can all live together quite happily for now.
Eventually, antiquated and somewhat arcane physicians like me will be relegated to performing basic injections as the winds of change blow past us. And I will smile at those that come after me, knowing in their lifetimes they will face the same arguments that they are not qualified to do some procedure due to the lack of certain letters behind their name, regardless of their skills or experience. But all the tools we use now to treat chronic pain will be completely replaced over the next 30 years due to rapid advances in pathophysiology of pain and novel treatments of the same pathology. So don't get too hung up on the tools we use to treat pain...they are just tools. Count yourself fortunate, as do I, that we have had the great privilege of assuaging some of the suffering of mankind.

Louisville04 said:

Well I assume anesthesiologists get a lot more hands on experience putting things next to a spinal cord than other residencies. I have heard some pm&r docs say they do around 200 epidurals in residency. Shouldn't that be enough to do interlaminar, transforaminal, facet, and other bread and butter procedures without requiring a fellowship?

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That's just it. It doesn't matter when you get the training, as long as you get the training.

Contrast these two hypothetical situations.

Pain doc #1 completes a residency with poor pain medicine exposure, then goes on to a fellowship where he/she spends 1/4 or more of the fellowship in Psyche/Neuro rotations, etc. to satisfy ACGME requirements.

Pain doc #2 (who decides ahead of time they don't really want to do permanent implants, willing to do trials though) goes to a residency where he/she spends 4-6 months in the pain clinic or spine center, plus 4 months elective and ends up performing x number of procedures under supervision.

How much difference is there really?

Full completion of 36 months of Anesthesia, PM&R or Neuro base training is not necessary to begin training in Pain Medicine.

Disciple said:

That's just it. It doesn't matter when you get the training, as long as you get the training.

Contrast these two hypothetical situations.

Pain doc #1 completes a residency with poor pain medicine exposure, then goes on to a fellowship where he/she spends time in Psyche/Neuro rotations, etc. to satisfy ACGME Guidelines.

Pain doc #2 (who decides ahead of time they don't really want to do permanent implants) goes to a residency where he/she spends 4-6 months in the pain clinic or spine center, plus 4 months elective and ends up performing x number of procedures under supervision.

How much difference is there really?

Full completion of 36 months of Anesthesia, PM&R or Neuro base training is not necessary to begin training in Pain Medicine.

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You are absolutely right - I wouldn't let EITHER of them do a cervical procedure on anyone i cared about.

What about lumbar?

Disciple said:

What about lumbar?

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The problem remains one of how much experience did they get. OK, let's pretend a resident really did 200 procedures INDEPENDENTLY during their residency. Let's further assume they didn't do any implantables. Assuming an even distribution of interlaminars, transforaminals, MBBs/facets, RFs. So now we are down to 50 of each procedure.

The vast majority of these procedures are accomplished at either L4/5 or L5/S1, and also that these two levels have different considerations that need to be taken into account. Again assuming an even distribution, we are down to 25 or each procedure at each level.

About 50% of the time, the case goes smoothly, and there are no particular wrinkles. I find these to be the least interesting, and least worthwhile cases from a teaching standpoint. Again, that means that of the 200 injections, you have 12 useful ones for each procedure at each level.

Personally, that does not seem adequate to me, but then again, I also wouldn't feel comfortable putting in stimulators after a weekend course, and lots of people do.

A somewhat related example: During residency, I did a good portion of my EMG training in the Neuro department alongside the Neuro EMG fellows. We attended the same didactics, were proctored by the same attendings, and performed EMGs on the same patients. I did well over my requisite 200 studies. Is there any real difference in our training because I was a resident and they were fellows?

I think it was Ligament who had posted that he had done over 300 TFESIs in residency. I've witnessed lesser repetitions (but still greater than 150) at other programs. Shouldn't that be enough? On the other hand, as a resident, I had visited some pain fellowships that did not do transforaminals or cervical ESIs, no implants, limited RF, no discography, etc. How much more watered down will it be with the revised ACGME requirements? That's what I was trying to get at in the above post. If anything, base judgements on procedural logs or experience.

And, I don't think we can assume an even distribution. How many practicioners do RF as frequently as lumbar TFESIs? Residents doing lumbar MBBs are likely to do 3-6 per patient, thus case volume is often sufficient with a smaller number of patients. To me, personally, lumbar TFESIs on obese patients with severely degenerated, post-op or osteoporotic spines have been far more difficult than MBBs, FJIs, RF, Sympathetic blocks, etc. which likely require far fewer repetitions to master.

Algos summed it up nicely in his post. Quality of Interventional training is just too inconsistent to make assumptions about anybody. Alot of practioners perform spinal injections (Interventional radiologists, surgeons, Physiatrists, etc.) other than those coming from pain fellowships. Not every practioner requires competency in the entire scope of interventional procedures to suit their purposes. We're years away from a pain residency, and until then, it's best to assess each practicioner's qualifications on a case by case basis.

Disciple said:

Algos summed it up nicely in his post. Quality of Interventional training is just too inconsistent to make assumptions about anybody. Alot of practioners perform spinal injections (Interventional radiologists, surgeons, Physiatrists, etc.) other than those coming from pain fellowships. Not every practioner requires competency in the entire scope of interventional procedures to suit their purposes. We're years away from a pain residency, and until then, it's best to assess each practicioner's qualifications on a case by case basis.

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Absolutely - but I think we CAN assume that, since there is no such assessment at present other than FIPP (a competency test administered by WIP, an offshoot of ASIPP, and thus in my mind the wrong organization for the job), we have to rely on minimum training until such time as a reliable organization does establish such a standard.

Relying on the individual practitioner to make such a judgment on his/her own is is the fox guarding the hen house, and not a solution. To paraphrase Winston Churchill, the current fellowship system is the worst method of determining competency, except for all the others.

Disciple said:

And, I don't think we can assume an even distribution. How many practicioners do RF as frequently as lumbar TFESIs? Residents doing lumbar MBBs are likely to do 3-6 per patient, thus case volume is often sufficient with a smaller number of patients. To me, personally, lumbar TFESIs on obese patients with severely degenerated, post-op or osteoporotic spines have been far more difficult than MBBs, FJIs, RF, Sympathetic blocks, etc. which likely require far fewer repetitions to master.

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MBBs are the exception, 'cause generally, they are hard to do patients harm with. But how many residents would you trust with your 350lb, osteoportotic, FBSS patient with a fusion mass obstructing the usual pathway to a transforaminal. Sure facets are easy to get into in a 20 year old, but how about the severely narrowed, arthrotic joints you have struggled to get into. And there is no resident I would let do an RF unless i checked the needle position in three views first

As for TESIs, how many residents are even aware of the risk of low lying Arteries of Adamkiewicz described by Houten & Errico's case report of three patients developing paraplegia after lower lumbar or lumbosacral injections? How many understand the whys and wherefores of a test dose? Its not just the cookbook of how to do procedures fellows are taught. Understanding the risks, finding out the difficulties, and as well as how to avoid, or even deal with possible complications when they inevitably do occur, in a controlled, supervised setting - that is where the benefit of repetition and constant oversight benefits you most.

To judge technical competency in this field is difficult and I agree with most of the above. Who, for instance, would be qualified to *judge* whether a pain interventionalist is qualified to perform OA blocks, gasserian RF, Cervical nucleoplasty, lysis of the pituitary? How many people even do these? In such procedures, there are many approaches and to my knowledge no gold standard approach. Hell, there is not even a gold standard approach to the TFESI. Is subpedicular, retroneural, preganglionic, or lateral recess the best approach?

If we really try to evaluate technical competency to the nth level who would be qualified to judge?

Ligament said:

To judge technical competency in this field is difficult and I agree with most of the above. Who, for instance, would be qualified to *judge* whether a pain interventionalist is qualified to perform OA blocks, gasserian RF, Cervical nucleoplasty, lysis of the pituitary? How many people even do these? In such procedures, there are many approaches and to my knowledge no gold standard approach. Hell, there is not even a gold standard approach to the TFESI. Is subpedicular, retroneural, preganglionic, or lateral recess the best approach?

If we really try to evaluate technical competency to the nth level who would be qualified to judge?

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I think we need to distinguish optimal technique, which I agree, is a moving target, from minimal level of technical competence. There is, for example, a death reported in the pathology literature, from a vertebral artery perforation during a C7 transforaminal ESI (Rozin L, Rozin R, Koehler SA, et al. Am J Forensic Med Pathol 2003;24:351–5). I think we can agree that the practitioner who is that far off target is not technically competent, nor sufficiently aware of the complications and anatomy, to be doing sophisticated interventional procedures.

lobelsteve said:

Maybe he was not off target, maybe the vertebral was just in the wrong place. The vertebral artery location around C7 is highly variable, but the original designer did not take into account that people would have needles coming into the body in this region.

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It may be variable, but still there is no way it is in the foramen

I am fellowship trained from a program where I did >1000 fluorscopically guided procedures and several dozen implants in a year. I used to look down on ISIS and PASSOR but I agree with algos about their unique role in the education of us all. After attending my first ISIS course recently I was impressed.

What the previous posts have missed, however, is that up to this point there has been no standard methadology in the research for interventional techniques. i.e. somebody needs to show that actually putting the medicine inside the facet joint with good arthrograms is better then putting it very,very, near the facet. What is needed is to show three arms in the studies, placebo, poor technique, and standard technique with improved pain and functional outcomes in the last group greater than the other two. Otherwise we are arguing over if we are qualified technicians but not if we actually help people more then placebo when using bad technique. What is the point arguing about technique if we can't show the efficacy first?


What if ISIS and PASSOR combined forces and tripled the cost of the weekend programs and used the funds to do high quality research?

ampaphb said:

Absolutely - but I think we CAN assume that, since there is no such assessment at present other than FIPP (a competency test administered by WIP, an offshoot of ASIPP, and thus in my mind the wrong organization for the job), we have to rely on minimum training until such time as a reliable organization does establish such a standard.

Relying on the individual practitioner to make such a judgment on his/her own is is the fox guarding the hen house, and not a solution. To paraphrase Winston Churchill, the current fellowship system is the worst method of determining competency, except for all the others.

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The problem is that interventional spinal procedures are spread over many different specialties, so you can't really only use pain fellowships as the benchmark.

This is analogous, or will be more so in the future to the example I cited above with Neurology EMG fellowships and PM&R residency, except with inteventional spinal procedures, add in surgeons and radiologists as well. To further complicate matters, each specialty has its own organization(s) to support its cause i.e. ASRA, NASS, PASSOR, etc. in addition to the pain doc societies AAPM, ASIPP.

Therefore, you can't really use a pain organization's practical exam as the standard (though one doesn't exist). With the different specialties involved, you would need an organization/exam that is mainly focused on the procedures. I would say that ISIS is the closest thing we have for the time being.
As a possible model, the EMG world has the AANEM and the ABEM which is concerned with electrodiagnostics and not the totality of expertise in Neuromuscular disease.

I do agree with your point about no experience other than weekend courses. I believe PASSOR attempts to address this issue in their "white papers" which state something along the lines of: in lieu of formal fellowship training, a Physiatrist applying for priviledges should 1. have performed x number of procedures under the supervision of a physician credentialed to perform these procedures at a JCAHO accredited facility, and 2. have x number of CME hours specific to the procedures priviledges are being requested for.

ampaphb said:

MBBs are the exception, 'cause generally, they are hard to do patients harm with. But how many residents would you trust with your 350lb, osteoportotic, FBSS patient with a fusion mass obstructing the usual pathway to a transforaminal. Sure facets are easy to get into in a 20 year old, but how about the severely narrowed, arthrotic joints you have struggled to get into. And there is no resident I would let do an RF unless i checked the needle position in three views first.

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If a resident was dedicated as in the example I had described above (4-6 months plus 2-4 months elective) and had performed a good number of easy TFESIs under my supervision, then why not let them try the difficult ones? I would be standing right behind them to help out if they couldn't complete the procedure.

You're right, not many residents would likely have this type of experience (6-10 months), but things are in flux, and I think you may see this more of this type of training in the near future. Going back to example above, if fellowships on the average begin to provide less interventional training due to ACGME requirements, the gap between experience during fellowship and that acquired during residency may continue to shrink and become less significant.

alocketz said:

I used to look down on ISIS

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Any particular reason why?

Disciple said:

Any particular reason why?

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Before I had attended a course I felt they took the low road in promoting compentency. Although they state that no one should attend a course and then start doing the procedures, as has already been stated, the reality is clearly the opposite. People are doing this all over the place. As I see now the problem is not with ISIS. They are trying to promote the field the best they can given the reality of the marketplace and postgraduate training. They can not be held acountable for the situation. I do still feel though could have higher standards and tighten the belt on who gets to go for the training. They might not be as financially sucessful if that were the case but it would advance the field over time.

Wow, I thought this was a great discussion. I was trained by a fellowship trained anesthesiologist from a well respected program. We graduated at the same time from residency. Due to family reasons and the dearth of fellowships at that time, I did not do a pain fellowship, though that (strangely enough) was where my heart was. He only learned bread and butter spine techniques and subsequently has learned implants , discograms, RF's and nucleoplasty the same way that I did-on the job. But I am looked down upon.

I really love Algos's comment regarding the wide variety of quality and dearth of studies. People who really care about this field will address how do we make sure get quality procedures and which procedures really work for which indication. That is what I want to know....

Louisville04 said:

If you could only go to one workshop, which one would you recommend?

1) PASSOR Introductory Workshop 9/25 and 9/26 Boston Hilton Hotel near
Logan Airport (prior to AAPMR conference) $1650 for residents/fellows.
Lumbar interlaminar, Sacroiliac, and Caudal injections.

2) ISIS Phase 1 Workshop 9/8 and 9/9 Memphis at Medical Education &
Research Institute (MERI) $1050 for residents/fellows.
S1 TF, L4-L5 TF, Interlaminar, Zygapophysial, MBB, Caudal

The ISIS workshop seems better since there are a lot more procedures and it is much cheaper.

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and which course did you end up doing?
Impressions?

Louisville04 said:

I procrastinated for a long time and finally decided on the ISIS since it was cheaper and seemed to offer more procedures. Unfortunately, the ISIS course got filled

I have already signed up for the ISIS course for January 19 and 20 in San Francisco.

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You should also consider coming down to New Orleans and taking the Clinical Anatomy and Imaging of the Spine course this weekend

http://www.spinalinjection.com/pdf/events/Anatomy-Imaging07.pdf

A quick comment on prior posts... As a physiatry resident, I only followed the one interventionalist and mimicked his technique. My own technique developed from watching many attendings through fellowship and picking up subtle nuances that made sense to me. So, weekend course work can provide that exposure and should not be underestimated.

However, I have been disappointed in watching my colleague's technique during the practical flouro sessions of these courses. Taking a long time for tunnel vision view or basics about general needle movement through tissue is often overlooked. I want to thank the MANY attendings who were responsible for my training.