Are advanced procedures critical during fellowship year

[22yis]

I know this question has been asked and it seems split that ~75% would argue "focus BB, learning flouroscopy and the rest will come", and ~25% would argue something along the lines of "advanced are the future and exposure is critical during fellowship and you'll get the BB anywhere".

My question is more specifically if I was to go to a primarily BB focused fellowship with low volume advanced, assuming I would go to training courses for the advanced procedures I want to incorporate, would I be disadvantaged in the following ways:

1. Difficulty identifying patients who are candidates for the advanced procedures due to exposure being limited to a training course?
2. Difficulty dealing with complications of these advanced procedures because of limited exposure?
3. Lack of comfort of doing these procedures due to having to do it on your own license, and not having as much guidance as you would get from an attending in the OR with you when learning the procedures in fellowship?

I know that the learning truly begins when you become an attending, but nonetheless I want to be best prepared for independent practice coming out of fellowship. Thanks for the advice in advance!

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[Baron Samedi]

No. The "advanced procedures" change every couple years. The ones that exist now will be gone in the next cycle. When's the last time you saw a biacuplasty?

 

[Ferrismonk]

I went to a high-volume B&B fellowship. I learned how to manage medications, diagnose properly, and how to steer a needle well. As far as "advanced" procedures, I did a handful SCS trials and 1 implant. I managed but did not do any pumps. I did a lot of lysis of adhesions in fellowship which isn't really done anymore.

I do SCS trials all the time now. I do DRG SCS trials/implants. I do kyphoplasty. Recently I trained on Vertiflex.

Only thing I felt not trained well enough on was post-op SCS complications, how to handle SCS infections, etc. How to admit/discharge someone from the hospital under my name without residents. This is all learnable. Make friends with surgeons and other pain docs and ask a lot of questions.

Seriously, don't worry about the advanced stuff nearly as much as the basic stuff. You can get trained on anything if you know the basics.

 

[Ducttape]

if you cannot identify a pedicle or dont know where Kambin's triangle is or cant drive a needle, then the advanced stuff wont ever come to you.

learn the basics in fellowship. you will always be able to add the advanced stuff later. the only advanced procedure that i learned in fellowship that i still use is SCS.

 

[epidural man]

I think the dangers of not doing any advanced procedures is probably a mental issue.

If you never felt the anxiety of a more difficult potentially more dangerous proc or got comfortable with the procedures that cause your heart rate to increase a little bit, than you may not ever find yourself willing to do that on your own.

It isn't a technical thing, or skill thing.

Actually, if you can get comfortable doing cervical epidurals - everything else is kinda easy.

 

[Orin]

I know this question has been asked and it seems split that ~75% would argue "focus BB, learning flouroscopy and the rest will come", and ~25% would argue something along the lines of "advanced are the future and exposure is critical during fellowship and you'll get the BB anywhere".

My question is more specifically if I was to go to a primarily BB focused fellowship with low volume advanced, assuming I would go to training courses for the advanced procedures I want to incorporate, would I be disadvantaged in the following ways:

1. Difficulty identifying patients who are candidates for the advanced procedures due to exposure being limited to a training course?
2. Difficulty dealing with complications of these advanced procedures because of limited exposure?
3. Lack of comfort of doing these procedures due to having to do it on your own license, and not having as much guidance as you would get from an attending in the OR with you when learning the procedures in fellowship?

I know that the learning truly begins when you become an attending, but nonetheless I want to be best prepared for independent practice coming out of fellowship. Thanks for the advice in advance!

This is a question more about you than anything else.

How do you learn? Are you comfortable extrapolating? Are you an early adopter? Are you comfortable asking for help? Are you comfortable not knowing everything?

If you can do this all independently and don't mind being uncomfortable, just go somewhere to get the basics. You'll go to training courses. You'll read guideline papers. You'll talk to people that do these things and ask about the things that worry you. You'll rely on the company reps.

If you're not that type of person, then go somewhere that does the more advanced stuff so you can have someone else to show you all the things, with the understanding that you will not necessarily be an early adopter for new procedures in the future.

One caveat is that you may need to get advanced case volume logged for credentialing depending on your base specialty or where you end up.

More importantly, you're developing a foundation for how to do things, how to evaluate patients, and a network of people you can ask for help when things go wrong.

I also tell people that programs change, so even if they do advanced procedures now, it may be totally different when you get there, or vice versa, so this shouldn't be the sole reason you select or don't select a program. You need to like all the other stuff too.

 

[lobelsteve]

I think the dangers of not doing any advanced procedures is probably a mental issue.

If you never felt the anxiety of a more difficult potentially more dangerous proc or got comfortable with the procedures that cause your heart rate to increase a little bit, than you may not ever find yourself willing to do that on your own.

It isn't a technical thing, or skill thing.

Actually, if you can get comfortable doing cervical epidurals - everything else is kinda easy.

I recommend not getting comfortable with cervical epidurals. But do them when indicated.

 

[drusso]

I know this question has been asked and it seems split that ~75% would argue "focus BB, learning flouroscopy and the rest will come", and ~25% would argue something along the lines of "advanced are the future and exposure is critical during fellowship and you'll get the BB anywhere".

My question is more specifically if I was to go to a primarily BB focused fellowship with low volume advanced, assuming I would go to training courses for the advanced procedures I want to incorporate, would I be disadvantaged in the following ways:

1. Difficulty identifying patients who are candidates for the advanced procedures due to exposure being limited to a training course?
2. Difficulty dealing with complications of these advanced procedures because of limited exposure?
3. Lack of comfort of doing these procedures due to having to do it on your own license, and not having as much guidance as you would get from an attending in the OR with you when learning the procedures in fellowship?

I know that the learning truly begins when you become an attending, but nonetheless I want to be best prepared for independent practice coming out of fellowship. Thanks for the advice in advance!

It's critical that you learn to do advanced procedures in fellowship. That is what medical training is for--a time to for mastery and confidence building. You will never stop learning, but if you don't offer your patients something more than the guy down the street, you're fungible.

Don't settle for being a replaceable cog. Be selfish and gain as much experience now as you can. It will be dividends in the future for you, your patients, and your family.

 

[22yis]

It's critical that you learn to do advanced procedures in fellowship. That is what medical training is for--a time to for mastery and confidence building. You will never stop learning, but if you don't offer your patients something more than the guy down the street, you're fungible.

Don't settle for being a replaceable cog. Be selfish and gain as much experience now as you can. It will be dividends in the future for you, your patients, and your family.

Is this being facetious/sarcastic? I know Steve is pretty anti a lot of the advanced procedures from his prior posts and he liked your message.

Appreciate everyone's advice!

 

[drusso]

Is this being facetious/sarcastic? I know Steve is pretty anti a lot of the advanced procedures from his prior posts and he liked your message.

Appreciate everyone's advice!

 

[Ducttape]

drusso wants to be a KOL.

to become one and get admitted to "The Club", one has to master basic techniques such as epidurals while in high school, so that one can master techniques the likes that you and i considered advanced by internship year, and then develop and market and become the sole proprietor for a groundbreaking procedure by fellowship.

if you havent reached these milestones already, then you'll be forever stuck at being a run of the mill regular pain doc.

sorry.



(welcome to the real pain doctor club tho)

 

[lobelsteve]

Is this being facetious/sarcastic? I know Steve is pretty anti a lot of the advanced procedures from his prior posts and he liked your message.

Appreciate everyone's advice!

I am against newer procedures where the only evidence is being created by the company selling the widget.
We have over 20 years of failed experiment with posterior fusion devices. 30 years of failure with SIJ fusions without Fx.
Intradiscal treatments have never panned out (looking at you as well vertebrogenic pain).

Literature supports MBB/RF, supports ESI for radiculopathy and claudication pain from spinal stenosis (2-3mo relief).
SCS: FBSS, CRPS, PDN.
Pumps for end of life care.
PRP: tennis elbow and OA knee.
TPI: Meh, just a distraction.
Kypho for TL spine Fx with STIR edema.

 

[Ferrismonk]

I am against newer procedures where the only evidence is being created by the company selling the widget.
We have over 20 years of failed experiment with posterior fusion devices. 30 years of failure with SIJ fusions without Fx.
Intradiscal treatments have never panned out (looking at you as well vertebrogenic pain).

Literature supports MBB/RF, supports ESI for radiculopathy and claudication pain from spinal stenosis (2-3mo relief).
SCS: FBSS, CRPS, PDN.
Pumps for end of life care.
PRP: tennis elbow and OA knee.
TPI: Meh, just a distraction.
Kypho for TL spine Fx with STIR edema.

Agree, although I would argue that Vertiflex seems to have stood test of time if patient selection is appropriate. Reversible. Opens up the space a smidge for moderate stenosis patients with claudication not resolved with more conservative measures and not appropriate for surgery.

 

[lobelsteve]

Agree, although I would argue that Vertiflex seems to have stood test of time if patient selection is appropriate. Reversible. Opens up the space a smidge for moderate stenosis patients with claudication not resolved with more conservative measures and not appropriate for surgery.

Coflex, X-stop, Inspan, Axle, Aspen, Rocker, etc.....
But Vertiflex works.

 

[cowboydoc]

drusso wants to be a KOL.

to become one and get admitted to "The Club", one has to master basic techniques such as epidurals while in high school, so that one can master techniques the likes that you and i considered advanced by internship year, and then develop and market and become the sole proprietor for a groundbreaking procedure by fellowship.

if you havent reached these milestones already, then you'll be forever stuck at being a run of the mill regular pain doc.

sorry.



(welcome to the real pain doctor club tho)

Coflex, X-stop, Inspan, Axle, Aspen, Rocker, etc.....
But Vertiflex works.

That's why it's called superion!

 

[BobBarker]

Vertfiflex works great.

 

[IYKYK]

I recently graduated from a high volume fellowship. Everyone is correct in saying that it is possible to learn these advanced procedures after fellowship. However, as echoed by drusso, the best time to become comfortable is during fellowship. Seeing what can go wrong during fellowship helps you handle it better in the real world. Learning how to interpret the literature surrounding these procedures is critical too, so you can choose what is best for your patients.

I don't think enough people talk about this, but doing more advanced procedures in fellowship makes you far more marketable when you are looking for jobs, especially private practice. PP wants physicians that can do more of the advanced procedures because thats where the field is going as a whole. It was much easier for me and my co-fellows to find jobs than fellows in less interventional fellowships. Of course its not impossible, just easier.

 

[callmeanesthesia]

I recently graduated from a high volume fellowship. Everyone is correct in saying that it is possible to learn these advanced procedures after fellowship. However, as echoed by drusso, the best time to become comfortable is during fellowship. Seeing what can go wrong during fellowship helps you handle it better in the real world. Learning how to interpret the literature surrounding these procedures is critical too, so you can choose what is best for your patients.

I don't think enough people talk about this, but doing more advanced procedures in fellowship makes you far more marketable when you are looking for jobs, especially private practice. PP wants physicians that can do more of the advanced procedures because thats where the field is going as a whole. It was much easier for me and my co-fellows to find jobs than fellows in less interventional fellowships. Of course its not impossible, just easier.

Private practice wants the advanced procedures to make more money for their ASCs. I’m in private practice and looking for a partner. Don’t really give a damn about someone being able to do all the latest widgets, but it would be nice to get someone comfortable with stim and kypho so I don’t have to do all that by myself.

 

[Espn123]

In my opinion there are two types of advanced procedures, those that make an incision and those that are percutaneous for the most part. SCS implant experience during fellowship I think is the determining factor on whether you will feel comfortable managing surgical incisions before/during/after the procedure. If you don’t get that during fellowship then the chances of doing any advanced procedures in the future that involves an incision like an implant is low. From an SI joint injection to MILD to a kyphoplasty, the basic principles are the same and can be learned.