First, I would like to state that this is only a problem for Physiatrists. All anesthesia pain fellowships are accredited and "spine" fellowships were in general created for Physiatrists.
The problem lies in the training philosophy of PM&R residency. Many Physiatrists, as you are all well aware, are entering the specialty with the intention of practicing "musculoskeletal" or "interventional" Physiatry. This is one of our talents. Anatomy, Kinesiology, biomechanics, muscle and nerve (yup, just like the AANEM's journal), rehabilitation. In not so many words, the non-surgical complement to a Neurosurgeon or Orthopaedic sports/spine surgeon. Look at the majority of Physiatrists who grandfathered into subspecialty certification. Most of them do not practice comprehensive pain, and I think it a bit unfair to accuse these practicioners of "cherry picking" certain patients for their practices. Most of these practicioners don't even call themselves "pain" docs. So you see, there is a difference between a "needle jockey/block jock" and a musculoskeletal physiatrist who performs a narrow scope of basic interventional pain proceedures. Most musculoskeletal Physiatrists perform peripher joint steroid injections. So, why should these physicians with documented training perform diligent workups of spine patients only to refer the injection to a "pain" doc?
Unfortunately, until interventional training and musculoskeletal medicine is fully embraced as part of the Physiatric training curriculum (meaning standardized), as we have done with electrodiagnostics, many Physiatrists will feel pressured to enter pain fellowships to gain procedural training and board eligibility. After fellowship many will seek employment in "spine" centers or musculoskeletal type practices. What if an EMG fellowship with substantial training in neuromuscular disease was required to perform basic carpal tunnel studies or radic screens? The thought is ridiculous if you ask me. So why can't we do the same with our interventional/MSK training?
Don't get me wrong, I believe Physiatrists make excellent pain docs (functional restoration, rehab, psychosocial approach, etc..), but until we do the right thing and provide residency training in basic needle skills, you will see a glut of Physiatrists (some interested in pain, some in MSK/spine) entering pain fellowships and then masquerading as "pain" docs in private practice. Provide solid training in basic needle skills for all during residency and then let those truly interested in pain and higher end procedures enter ACGME pain fellowships.
So, I do support a multidisciplinary pain residency, but I also see the difference between a pain doc and an interventional/musculoskeletal Physiatrist. I consider myself to have acquired pretty good musculoskeletal/structural evaluation skills through my residency training. However, there are several PM&R sports/spine/MSK fellowships available (RIC, Mike Geraci, Heidi Prather, etc..) that offer training far beyond my abilities at this point in time, in addition to basic needle skills, reinforcement of EMG skills and radiologic image interpretation. This is what PM&R fellowships offer that cannot be gained through a pain fellowship.
In summary, I believe you can be a highly skilled, safe and responsible interventionalist without doing a "pain" fellowship. Take for example, someone like a Curtis Slipman (well published, highly respected). I believe he was former editor of "Pain Physician" and maybe editing the new ISIS journal (correct me if I'm wrong). I don't think anyone who has interviewed at his program would say he runs anything but a spine fellowship.
As an aside, maybe the leaders of the ABPMR are finally listening. There were actually questions covering interventional pain management (fluoroscopic images included) on this year's PM&R resident self assessment exam (SAE).
