Importance of Advanced Procedures in Fellowship?

[TheNolano]

Hello Pain Docs,

Recently matched pain fellow here. While I am excited for my next year of training, I am a bit bummed about my match to be honest. It's a solid, big-name program with mainly B&B, SCS trials and permanents, and some PNS, but not a ton more. No Kypho (IR does them), pumps (neurosurg does these, though very few), vertiflex, or intracept. During my interview the program argued that many of those advanced procedures are still less proven, and most pain docs in the community don't do them. The chair also pointed out that their focus was on understanding anatomy and pathophysiology, and that with those any strong pain doc could learn whatever new procedures come into vogue. However, the programs I ranked more highly all viewed these types of procedures as cutting-edge and an important part of pain training.

To be honest, I was very excited about being exposed to all these advanced procedures, and worry that doing none of them in fellowship will mean I won't feel comfortable doing them as an attending. I would prefer to at least do a couple of each while in a training environment and decide if I want them to be part of my practice.

So wondering what the community's thoughts are. Am I making too big of a deal of these less-common procedures? Is it something I could pick up during my first job or through industry courses? I suppose I am committed to my fellowship at this point, since backing out which virtually ensure I wouldn't match again. I just want to make sure I set myself up to have any type of practice down the road, and want to avoid closing any doors.

Thanks in advance. I am sure part of this is just the disappointment of falling on my rank list. Part of life I suppose.

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[Agast]

None of the KOLs selling the newer procedures were trained how to do them in fellowship. You basically attend a weekend cadaver course and then have at it. That’s how we all learn this kind of stuff that came out like 2-3 years ago.

Are ACGME fellowship programs incorporating these things now? I’d imagine the neurosurgery/spine department would put up a fight.

 

[RoloTomassi]

Be glad you don't do pumps. The rest you listed are weekend course type procedures. New stuff is going to keep coming out, so you'll just have to get used to that type of learning, which you'll get more comfortable with as your confidence in your skills grows.

 

[deleted131481]

To give my n=1 at a fellowship program. We do kypho, pumps, MILD, Vertiflex, and Intracept is pending. All in relatively low numbers.

I agree with the above - these can be learned at weekend courses if you have a strong understanding of anatomy and fluoro. Pumps are the worst just forget about them, leave them to reluctant academics. SCS implants have a bigger learning curve so experience here is a plus.

Advanced procedures is always the number one concern for incoming fellows. Not a big deal if you have strong bread and butter base.

Are ACGME fellowship programs incorporating these things now? I’d imagine the neurosurgery/spine department would put up a fight.

MILD and Vertiflex we discussed with our neurosurgery colleagues and they are on board but prefer it for poor operative candidates. I rarely do these and if they are a poor operative candidate I'm usually not that excited about doing either of these in them.

 

[deleted185747]

You forgot spinal simplicity which I think will replace Vertiflex. Also reactiv8 and painteq. Too bad you aren’t at my program you would get to learn all of these

 

[Espn123]

The chair said it best. Don’t worry about it, get strong on the fundamentals. The learning curve is 3-5 years. Fellowship is year 1

 

[unchockey21]

I’m sure there were people worried about not getting enough IDET, biacuplasty, chymopapain, etc experience. Think they care now? Whenever one of these new procedures come out, >99.9% of pain docs will have never done one in fellowship. Like others have said, getting a good fluoro skill base is the most important thing. Go to as many cadaver courses as you can during fellowship and learn from a variety of people. You’ll figure out what works best for you but also pick up different tricks and techniques that you can use if your primary approach isn’t working for a particular patient.

 

[Analgesia108]

Master fluoroanatomy & patient communication - the rest will follow

 

[DOctorJay]

don't be disappointed. learn the basics well and learn how to be safe in the cervical spine. get a good foundation. go spend some time with IR if you really think you want to do kypho out in practice. and go to as many courses as you can during the year as mentioned above.

 

[RoloTomassi]

I would add, focus on being a good diagnostician. Placing a needle is important but if you are doing the wrong procedure it's a moot point. Crazy how many times patients will present with history of multiple ESIs, SI injections from fellowship trained docs for pain consistent with facets, for example. This includes becoming an expert at reading MRIs and correlating. Procedures-wise, get your reps in with perms. Needle skills don't exactly translate well to suturing, and it's the thing most pain docs are slowest at.

 

[Agast]

To give my n=1 at a fellowship program. We do kypho, pumps, MILD, Vertiflex, and Intracept is pending. All in relatively low numbers.

Are you on admissions? Have you been crushing hopes and dreams lol

 

[deleted131481]

Are you on admissions? Have you been crushing hopes and dreams lol

Yes, isn't that the point of academics?

 

[Ligament]

I’m sure there were people worried about not getting enough IDET, biacuplasty, chymopapain, etc experience. Think they care now? Whenever one of these new procedures come out, >99.9% of pain docs will have never done one in fellowship. Like others have said, getting a good fluoro skill base is the most important thing. Go to as many cadaver courses as you can during fellowship and learn from a variety of people. You’ll figure out what works best for you but also pick up different tricks and techniques that you can use if your primary approach isn’t working for a particular patient.

Fully agree with this. I bet you've never even heard of some of these procedures OP. They are now defunct.

Lots (if not most) of the "Advanced" procedures you are talking about exist only because a device manufacturer made it so. They rarely stick around for long. They exist only for early adopters to make a lot of money on them via billing loopholes or shady practices. By the time level headed doctors adopt them, they are no longer reimbursed and are on the way out. Meanwhile, the early adopters aka KOLs are at it again with the next new medical device that has billing loopholes and pays well for a few months. Rinse and repeat.

This is the game; introduce a device. Exploit reimbursemet angles. Payors catch on. They stop paying. Procedure dies. Rinse and repeat.

 

[p1at0]

Fully agree with this. I bet you've never even heard of some of these procedures OP. They are now defunct.

Lots (if not most) of the "Advanced" procedures you are talking about exist only because a device manufacturer made it so. They rarely stick around for long. They exist only for early adopters to make a lot of money on them via billing loopholes or shady practices. By the time level headed doctors adopt them, they are no longer reimbursed and are on the way out. Meanwhile, the early adopters aka KOLs are at it again with the next new medical device that has billing loopholes and pays well for a few months. Rinse and repeat.

This is the game; introduce a device. Exploit reimbursemet angles. Payors catch on. They stop paying. Procedure dies. Rinse and repeat.

“Scott’s parabola”

 

[Status Sciaticus]

You forgot spinal simplicity which I think will replace Vertiflex. Also reactiv8 and painteq. Too bad you aren’t at my program you would get to learn all of these

what program? PM me if you wish to keep it private.

 

[rexed]

Master fluoroanatomy & patient communication - the rest will follow

I would add get ultrasound experience as well if possible. Coming from Anesthesia pain back in mid 2000's there was no US in pain fellowships, had to learn US on my own. Still learning even now!

 

[Ducttape]

You forgot spinal simplicity which I think will replace Vertiflex. Also reactiv8 and painteq. Too bad you aren’t at my program you would get to learn all of these

its good to learn them now.

this gives you a larger pool of useless information for the future.

focus on anatomy.
focus on patient communication. find the doc who does this best, and learn techniques of how to approach and work with difficult patients. or at least, how to get them out of the office without making a scene.


after you get a firm grip on the basics, pay close attention on what attendings do when confronted with a difficult procedure. it may be obvious (getting CLOs beforehand, or angling c-arm, or spinning needle to change trajectory, etc.)

 

[drrosenrosen]

its good to learn them now.

this gives you a larger pool of useless information for the future.

focus on anatomy.
focus on patient communication. find the doc who does this best, and learn techniques of how to approach and work with difficult patients. or at least, how to get them out of the office without making a scene.


after you get a firm grip on the basics, pay close attention on what attendings do when confronted with a difficult procedure. it may be obvious (getting CLOs beforehand, or angling c-arm, or spinning needle to change trajectory, etc.)

This. No one likes to hear it going into fellowship, but clinic is the majority of your job. It is super important to learn how to communicate and educate effectively, in different ways for different people, with an efficient use of time. Learning really good physical exam skills - which you will be behind on if you're coming from anesthesiology - and learning how to diagnose conditions is way more important than learning Intracept.

Fellowship really is the "wax on wax off" of pain medicine. You will be learning essential fundamentals that may not seem exciting or interesting but which you will use every day for the next 35-40 years. Once you know how to figure out what's wrong with the patient, explain to them what's wrong and how you're going to help them, interpret their fluoro- or sono-anatomy, and get the needle where you need it to be, you can learn any new procedure that comes along easily.

One other tidbit I'll give - learn as much "boring" stuff as you can from anyone who will teach you. Billing/coding is essential and puzzlingly barely covered in many fellowships. Staff management. Difficult patient management. Insurance/PA stuff. Logistics of things like UDS, referrals to PT or surgery, dealing with pharmacies. All of this stuff is part of the job that you'll need to know about, especially if you plan on true private practice (i.e., not a hospital employee). Even as an employee though, knowing about this stuff can help you communicate to the administrators or staff who may be doing some of these other things, so you can know what's going on with your practice.

 

[Orin]

Academic pain docs need these arguments about low volumes and being slow adopters to preserve their fragile egos, but that doesn't mean they're wrong.

Procedurally, get the basics down. The advanced stuff builds on all that.
Spend the rest of the time figuring out the pragmatic and soft skills stuff of managing people, clinic and OR flow, and knowing how to ask for help. You want to know when you need to know more, whether about anatomy, complications, or techniques.

You're not done training coming out of fellowship. If you're committed to always growing, you're never done.

 

[soccrwz]

I would add get ultrasound experience as well if possible. Coming from Anesthesia pain back in mid 2000's there was no US in pain fellowships, had to learn US on my own. Still learning even now!

Ultrasound is a very good skill to learn. Joint injections, peripheral nerves, stellates, etc

 

[deleted185747]

what program? PM me if you wish to keep it private.

Loma Linda, CA