Nyc Pain

[jhoppenfeld]

I wanted to know if anyone had an opinion on any of these NYC pain fellowships:
1: Memorial Sloan-Kettering
2. Albert Einstein
3. Mount Sinai
4. Columbia
5. Cornell (proper)
6. Cornell at sloan
7. NYU
8. St. Lukes
9. St. Vincents

I am in a neurology residency so do all these programs take neurologist as well as Anaesthesiologist?

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[C Fiber]

I heard from a recent graduate/fellow, SK does not do ANY disc procedures at all!!!

 

[C Fiber]

I heard from a recent graduate/fellow, SK does not do ANY disc procedures at all!!!

 

[TheAssMan]

Cornell(@sloan) has merged with Cornell(proper) and is one program of 8 fellows. Sloan is a cancer hospital, not much call for disc procedures.

 

[lobelsteve]

The dreaded disc cancer!!!!

It's a shame that the ACGME has allowed the changes to the PIF so hastily without inviting comment from the majority of programs. THe new PIF destroys the likelihood that fellows can come out of a 12 month training program competent in discography, SCS implants, and other less common procedures. The new training may not adequately prepare docs for 100% outpatient ASC type of practice positions.

Still unsure if we will attempt to make the changes for next year to keep our accreditation. Georgia Pain Physicians, Emory UNiversity-PMR-Pain Medicine.

 

[drusso]

The dreaded disc cancer!!!!

It's a shame that the ACGME has allowed the changes to the PIF so hastily without inviting comment from the majority of programs. THe new PIF destroys the likelihood that fellows can come out of a 12 month training program competent in discography, SCS implants, and other less common procedures. The new training may not adequately prepare docs for 100% outpatient ASC type of practice positions.

Still unsure if we will attempt to make the changes for next year to keep our accreditation. Georgia Pain Physicians, Emory UNiversity-PMR-Pain Medicine.

However, for physiatry to lose an accredited PM&R-based pain fellowship would be disheartening and fuel the arguments among some anesthesiologists I know who believe physiatrists are not seriously comitted to the sub-specialty.

 

[PainDr]

THe new PIF destroys the likelihood that fellows can come out of a 12 month training program competent in discography, SCS implants, and other less common procedures. The new training may not adequately prepare docs for 100% outpatient ASC type of practice positions.

Absolutely not true. I came from a program that was very multidisciplinary, very comprehensive and will easily be able to comply with the new rules. I had a broad based fellowship experience with plenty of exposure to advanced techniques and I'm very adequately prepared for private practice.

 

[lobelsteve]

Absolutely not true. I came from a program that was very multidisciplinary, very comprehensive and will easily be able to comply with the new rules. I had a broad based fellowship experience with plenty of exposure to advanced techniques and I'm very adequately prepared for private practice.

That's great. The new PIF does set the bar exceedingly low for interventions, and exceedingly high for acute pain / hospital based pain / anesthesia services. That is: 15 bag mask, 15 intubations, 50 inpatients, 20 cancers, 15 palliatives. Only 3 IT pumps- however, these are cost prohibitive from an outpatient standpoint, so logistically done in hospital or workers comp. No number of SCS implants listed. So how do we judge competency- by me saying so for our current group of fellows. THat introduces bias. I know folks who will be competent in 5 procedures, and others who I wouldn't recommend do it even after 20. From a PMR standpoint it is biased against my training and my career goals. Now I did get inpatient experience in private practice (hated it) and found it wasting my time and disrupting my outpatient clinic schedule. Just my 2 c.

 

[drusso]

That's great. The new PIF does set the bar exceedingly low for interventions, and exceedingly high for acute pain / hospital based pain / anesthesia services. That is: 15 bag mask, 15 intubations, 50 inpatients, 20 cancers, 15 palliatives. Only 3 IT pumps- however, these are cost prohibitive from an outpatient standpoint, so logistically done in hospital or workers comp. No number of SCS implants listed. So how do we judge competency- by me saying so for our current group of fellows. THat introduces bias. I know folks who will be competent in 5 procedures, and others who I wouldn't recommend do it even after 20. From a PMR standpoint it is biased against my training and my career goals. Now I did get inpatient experience in private practice (hated it) and found it wasting my time and disrupting my outpatient clinic schedule. Just my 2 c.

The intubations and bag masks can be knocked out in a couple AM's per week in month. The cancers and palliative care requirement is also pretty easy to meet if your practice sees any cancer pain. The inpatient consults would probably require some time away from an outpatient setting at a dedicated pain service for approximately 2 weeks.

Your sense about the requirement is correct though not strictly intended to bias against PM&R, they are certainly trying to promote a more academically-oriented tertiary-care training experience. I know an individual who was involved in drafting the new requirements and he summed up the frustration among some of the academically-oriented practitioners in the field as such: "You don't see interventional cardiologists doing fellowships in private practice cardiology offices do you?"

So, I think that the larger issue is, "Where were the pain physiatrists when the requirements were being drafted?" Who was at the table? Which program directors? Did the Academy or the AAP send anyone? Are any individuals in these groups even able to knowledgably advocate for the field and its practioners? As much people may say that they "hate all the political stuff," if you're not engaged in the process, at the end of the day the *ss you're handed might be own...

 

[lobelsteve]

The intubations and bag masks can be knocked out in a couple AM's per week in month. The cancers and palliative care requirement is also pretty easy to meet if your practice sees any cancer pain. The inpatient consults would probably require some time away from an outpatient setting at a dedicated pain service for approximately 2 weeks.

Your sense about the requirement is correct though not strictly intended to bias against PM&R, they are certainly trying to promote a more academically-oriented tertiary-care training experience. I know an individual who was involved in drafting the new requirements and he summed up the frustration among some of the academically-oriented practitioners in the field as such: "You don't see interventional cardiologists doing fellowships in private practice cardiology offices do you?"

So, I think that the larger issue is, "Where were the pain physiatrists when the requirements were being drafted?" Who was at the table? Which program directors? Did the Academy or the AAP send anyone? Are any individuals in these groups even able to knowledgably advocate for the field and its practioners? As much people may say that they "hate all the political stuff," if you're not engaged in the process, at the end of the day the *ss you're handed might be own...

The politics are overwhelming. I believe Rathmell chaired the meeting. Unsure if anyone from a PMR program was invited or attended.
I agree the requirements could be met in a one month rotation at the sponsoring institutions "big house". And now for more politics- getting to integrate- how do you get your fellows in the big house without offending the Anes folks. We do more procedures, have no in house call, no weekends, no consult service for chronic pain (polysubstance abuser admitted by ER at 3AM, Pain doc called at 5AM to help manage withdrawal- happenes in private practice all the time). If we offer what we do that is better than what they do- they will get offended.

 

[paz5559]

Absolutely not true. I came from a program that was very multidisciplinary, very comprehensive and will easily be able to comply with the new rules. I had a broad based fellowship experience with plenty of exposure to advanced techniques and I'm very adequately prepared for private practice.

Just curious how much cancer and peds your program had you dedicated months to? How much neurology and psychiatry?

The new rules do not allow you to get "exposure" during clinic, and so I am curious if you are merely puffing, or if you actually would have met ALL of the new rigid requirements.

 

[paz5559]

The politics are overwhelming. I believe Rathmell chaired the meeting. Unsure if anyone from a PMR program was invited or attended.
I agree the requirements could be met in a one month rotation at the sponsoring institutions "big house". And now for more politics- getting to integrate- how do you get your fellows in the big house without offending the Anes folks. We do more procedures, have no in house call, no weekends, no consult service for chronic pain (polysubstance abuser admitted by ER at 3AM, Pain doc called at 5AM to help manage withdrawal- happenes in private practice all the time). If we offer what we do that is better than what they do- they will get offended.

Barry Smith was our representative at the table when the new rules were drafted (PM&R RRC rep, PD @ Baylor Dallas at the time, has since retired)

 

[PainDr]

Just curious how much cancer and peds your program had you dedicated months to? How much neurology and psychiatry?

The new rules do not allow you to get "exposure" during clinic, and so I am curious if you are merely puffing, or if you acutally weould ahve met ALL of the new rigid requirements.

I can assure you that I'm not "puffing". We didn't have dedicated cancer or peds months as we saw these patients throughout the year. We didn't have dedicated neurology or psych months, but again, saw this type of pathology throughout the year. You are correct in that it's difficult to obtain this type of exposure with a strictly outpt population, which is why I chose a program with alot of inpt exposure. Although I knew I would be pursuing outpt private practice, I wanted a very broadbased fellowship experience, which is exactly what I received.

 

[jsaul]

yeah,

where did you do your fellowship

 

[PainDr]

If you really want to know, just pm me. However, I would guess that most of the large academic programs would be able to provide a similar type of experience. The programs that will have problems are those that are primarily outpt based. I did interview at a couple of these types of programs but found them sorely lacking. At one in particular, they didn't even have hospital priviledges! When I asked what would happen if a patient suffered a complication, the response was..."I guess we call 911"?!?!?! I don't know how others feel, but I'm not sure these types of programs should have accreditation.

 

[lobelsteve]

If you really want to know, just pm me. However, I would guess that most of the large academic programs would be able to provide a similar type of experience. The programs that will have problems are those that are primarily outpt based. I did interview at a couple of these types of programs but found them sorely lacking. At one in particular, they didn't even have hospital priviledges! When I asked what would happen if a patient suffered a complication, the response was..."I guess we call 911"?!?!?! I don't know how others feel, but I'm not sure these types of programs should have accreditation.

I have a polar opposite view to yours.
My fellowship prepared me for private practice, outpatient interventional pain. I do not want to do acute pain, be called for consults, or take time away from my clinic to have to see hospital patients. My first year in private practice was burdened with hospital responsibility. I even had to disco, SCS, and IT work there for a paltry pro-fee. Not worth my time.

 

[paz5559]

... The programs that will have problems are those that are primarily outpt based. I did interview at a couple of these types of programs but found them sorely lacking. At one in particular, they didn't even have hospital priviledges! When I asked what would happen if a patient suffered a complication, the response was..."I guess we call 911"?!?!?! I don't know how others feel, but I'm not sure these types of programs should have accreditation.

Most private practitioners do as little inpatient pain as they can possibly manage. As for whether you are sure outpatient-based programs should have accreditation, remind me again why it is I should be concerned what your opinion is?

I supose it is a good thing fellows don't have a seat on the ACGME.

 

[Kwijibo]

What did you guys do during your residency?
The point of training is to be well versed or at least have an understanding of the spectrum of a specialty. You don't need to perform all of what you experience, just at least be able to if you need to. Outpatient blocks are only one aspect of pain medicine, albeit the most fun and most profit generating. So I somewhat understand that they want us to be exposed to inpatient pain, cancer pain, peds pain, and whatever else the requirements are.
It sounds like you have a great fellowship- tons of procedures and less of the tedious crap that you aren't going to be doing anyways.

 

[PainDr]

Most private practitioners do as little inpatient pain as they can possibly manage. As for whether you are sure outpatient-based programs should have accreditation, remind me again why it is I should be concerned what your opinion is?

I too am most interested in outpt pain mgmt, however, I wanted to be able to consider myself a well rounded subspecialist. Isn't that what being a subspecialist is all about? Obviously, I'm not the only one who feels this way...hence the new guidelines.

Also, you don't need to be concerned about what my opinion is, but I'm certainly entitled to have one.

My fellowship prepared me for private practice, outpatient interventional pain. I do not want to do acute pain, be called for consults, or take time away from my clinic to have to see hospital patients. My first year in private practice was burdened with hospital responsibility. I even had to disco, SCS, and IT work there for a paltry pro-fee. Not worth my time.

If a referring physician occasionally needs my help with a difficult inpt, I'm not going to turn my back on them. I don't consider it a "burden" but rather, a valuable service that I'm able to offer my community. However, if others are not interested in that type of training/practice that is their choice.

The point of training is to be well versed or at least have an understanding of the spectrum of a specialty. You don't need to perform all of what you experience, just at least be able to if you need to.

I couldn't agree more.

 

[jhoppenfeld]

So back to my original question?

 

[TheAssMan]

What Are You looking for?

 

[octrode]

I actually becaume quite competent in inpatient pain management and opiate and acute pain management durring my PMR residency-- listening to my pals who went to anesthesia pain programs- they found themselfves much better prepared for the inpatient, cancer, acute, peds and psych issues-- that the anesthesiologists don't get in their residency training. Additionally, they found themselves much better diagnosticians than the anesthesia attendings-- who were routinely surprised by their accumen in dealing with the total pain picture. I did an ACGME ASC based outpatient PMR pain fellowship, and now have in-patient pain duties in practice-- and handle them quite adroitly.
Perhaps it is the anesthesiologists who need extra training?

 

[Disciple]

This whole thing is starting to sound like another royal Physiatry debacle (same as sports medicine-another thread I think)

If memory serves me correctly, information from the ACGME pain revision meetings was presented by Barry Smith at a discussion during the AAPMR annual meeting, Oct 2004. Slipman, Furman and others also spoke or were moderators of the panel discussion. At that meeting we were still advocating getting our programs newly accredited. What was the purpose of that if the meetings with Anesthesia, Neurology and Psyche had already taken place? Why didn't we make our voices heard? On top of that, why did we then agree to confer subspecialty certification to those in unrelated specialties? My excuse is that I was a resident and didn't really have a clue as to what was going on. Physiatry may have to concede this as another loss.

What we should have done, and can still do now is to push for the legitimacy of Physiatrists as experts in non-operative spine care, musculoskeletal disorders and sports medicine. Ortho accredits its own fellowships, some of which are not university based.
Looking at the big picture, where do our PMR leaders reside? Joel Press/Heidi Prather and others (NASS-spine), Paul Dreyfuss/Pauza (ISIS-spine), Slipman-spine, all the rest and some of the former (PASSOR-sports/spine/MSK). There are a few others (ASIPP), but one notable Physiatrist holding an ASIPP position with whom I had spoken with stated that he no longer considers himself a Physiatrist, only a pain management specialist. Martin Grabois is the only other I can think of having held an office in a "pain" organization (AAPM). PM&R representation in organizations such as ASRA and APS in virtually non-existent.

Maybe Dr Robert Windsor is the only one who has been able to cross all lines (Dr. Lobel feel free to comment here).

As much as it has been argued that the new ACGME revisions are not about "power" and are meant to uplift the standards of pain medicine, I remain highly skeptical. During a fellowship interview last year I was told by the president of ASRA that he was against a pain residency and that "too many" Physiatrists were becoming interventionalists. He also related to me that many others shared his views. So, we get the next best thing which is an attempt to compress all pain training into little mini-rotations totaling 12 months. The point to all this is that Interventional Physiatry has flourished in the past 10 years (under the grandfather clause of ABMS pain board certification). The powers that be have effectively put a cap on that, so maybe it's time concede our losses and separate. Will the new ACGME guidelines lower the number of Physiatrists performing injections? How can it when the demand is high? As noted in other threads CRNAs and PCPs are now performing injections, and access is still limited.

With the new guidelines ready to take effect and the interest in/demand for interventional Physiatry continually growing, the responsible thing for the ABPMR to do (in the best interest of the membership and for the safety of the general public) is to create a defined body of knowledge for musculoskeletal medicine and to train residents in basic injection skills, thereby creating a pathway or track to the acquisition of advanced skills while creating some semblance of quality control for the increasing numbers of Interventional Physiatrists of the next decade, many of whom will not be fellowship trained. Hopefully this will help put to rest the arguments of what I do being better than what another pain practitioner does and vice-versa, because "what I do" would be recognized as a different specialty altogether. Of course, pain fellowships would continue to be multi-disciplinary and those desiring to be trained in this manner would be encouraged to go that route.

 

[lobelsteve]

It may be time to do just that.

As PMR trained 09'ers, it will be important to allow continued years of residents the opportunity to become ABMS board certified.

Q1: ACGME or non-ACGME - we need to have a meeting of current fellows, recent grads, and current faculty to discuss the best means to OUR goal.

Possibilities: 1. separate ABPMR fellowship track with ACGME approval
2. ASIPP/ABIPP support for ABMS application
3. AAPM/ABPM support for ABMS application
4. ISIS support for ABMS application
5. other

I'd work with Windsor to convince him to lead us forward. We would need Falco, Furman, Slipman, Press, et al to step up to the plate and work with the pain socieities and the ABPMR to make things happen.

I'd donate as much time as I could to help this along as I am annoyed at Rathmell and the gas boys for trying to pinch us off.

I know of gas PD's and staff that still perform blind stellates, CESI, and others, and some are still against using contrast agents in their injections.

Maybe ISIS and AAPM or APS can get some funding and start a separate PM residency. We keep getting back to the same point- current training is not fully appropriate, and it is made much worse by excluding PMR from the field.

 

[Disciple]

I'm annoyed at Rathmell for all the crappy blurred pictures in his book

1. ABPMR fellowship track or revised residency requirements?
-Revising residency requirements may not be as difficult as it sounds. We already have PASSOR technical guidelines for basic injections (contributed by Pauza I believe) and suggested bibliographies for supplemental reading.
-What ever we call it, a subspecialty certification can't be called "spine" anything due to opposition from Neurosurg/Ortho who themselves can't agree on ACGME guidelines for the spine. In any case, requirements would have to be drawn up, as the current "PASSOR Approved" designation doesn't mean a whole lot.

2. I would be reluctant to support ASIPP and the ABIPP exam unless they revise their eligibility requirements. One must be ABMS pain boarded or have practiced pain medicine for something like 5 years as a prerequisit to taking the ABIPP exam. So, it sounds like its real purpose is to promote exclusivity and to give further control to ASIPP.

3. I would fully support the AAPMs ongoing attempts to establish a pain residency, though I have no idea how they're going to garner support from the Anesthesia pain departments. From what I hear, their exam is much more comprehensive and difficult than the ABMS exam anyway.

4. ISIS doesn't seem at all interested in setting up a certification, though in all honesty, they may just be the most appropriate organization to back one. Such a certification could follow the mold of the AANEM certification, which, while not ABMS backed, is recognized as an academic certification conferring competency in performance and interpretation of electro-diagnostic testing and not the totality of Neuromuscular Medicine.

There are some positive signs:

1. Last month I was e-mailed a survey by the AAPMR on what type of practice I planned on having, addressed to '06 and '07 graduating residents. I have an idea what the data will show, so hopefully the academy is planning to do something useful with this information.

2. There have been a flurry of job listings in the Archives of PM&R the last few months for academic MSK/interventional pain positions.

3. The AAPMRs newsletter "The Physiatrist" has been running articles on subspecialization to generate discussion amongst the membership.

4. Joel press, coming off a term as president of NASS, will be sworn in as AAPMR president in November, coupled with the disbanding/re-integration of PASSOR to "better serve the needs of the academy" as they are saying. Maybe a coup d'etat?

 

[lobelsteve]

PAZ has a firm grasp on who's who in the field. Waiting for him to chime in, but since he is on the interview trail we may take this thread private.
Email me if you want in.

 

[drusso]

Step back and look at the Big Picture...How did we get here???

Here are the 11 ACGME-accredited PM&R-based fellowships:

http://www.abpmr.org/certification/pm_fellowships.html

Here are the 95 ACGME-accredited Anesthesia-based fellowships:

http://www.painrounds.com/index.php?option=com_content&task=view&id=11&Itemid=28

There are less than a handful of neurology training programs that essentially number "too few to count."

So, it's sort of clear who is the Big Gorilla on the block. There are clearly not enough pain fellowship spots for PM&R grads who desire to train in the sub-specialty. The Academy has provided resources for Departments of PM&R interested in establishing either ACGME-accredited or NON-accredited fellowship:

http://www.aapmr.org/passor/resources/painmed.htm

http://www.aapmr.org/passor/resources/fellowshiptraining.htm

Now, the interested reader might stop here and ask right away, "Why is the field's PROFESSIONAL society providing ACADEMIC resources and programatic planning in post-residency fellowship development? Ought not the AAP (the field's academc group) be doing this?? Are not our ACADEMIC leaders charged with pushing the field to the frontier?" Your answer might generate a variety of uncomfortable feelings...

PASSOR has attempted to wrestle with The Gorilla, but in all fairness, Pain Medicine is not "their schtick." It may be PART of their schtick, many PASSOR members and practitioners may in fact be excellent pain physicians, but PASSOR doesn't stand for Pain And Sports Spine Occupational Rehabilitation.

My point is that the subspecialty is an INTELLECTUAL orphan within the vast majority of our residency training programs. Imagine as a resident if you sat in your Department Chair's office and said, "I want to be a Pain Physiatrist, how can you help me?" In our academic training programs, there generally exists one of three dominant opinions toward Pain Medicine: 1) Physiatrists are already ipso facto Pain Doctors so we don't need it. 2) Physiatrists should not be doing interventional procedures because it poisons the well of tradition and culture upon which our fine field was built. 3) Get out my office you Greedy *&^%$#@ and go figure it out for yourself; I don't have time for you.

Complicating the issue is that PM&R does invest and support the notion of "Interventional Spine" which is sort of like pain medicine, but not exactly. More academic PM&R Departments are invested and involved in Spine Centers than Pain Clinics. I have nothing against the IS folks and value their contributions tremendously, but I don't think that they even consider themselves "Pain Doctors" per se.

So, I think the first step is for the entire field to say that it's either "on the pain bus" or "off the pain bus." The field is deeply divided and confused about its relationship to subspecialties in general and Pain Medicine in particular. If our specialty board co-sponsors a sub-specialty (for which it cannot even adequately support) then I think that the residency training requirements need to change substantially in order to redress that. How many PM&R residency programs require PM&R residents to rotate on acute pain services, perform a certain number of axial spine injections, and gain basic competency in procedural skills related to the field?? It's like trying to have an Internal Medicine residency without a required nephrology rotation.

There's The Problem. Here's The Solution:

1) Our academic leaders need to get a little "Religion" on the issue. They need to become zealous advocates for Pain Physiatrists in their training programs. They need to have long, uncomfortable, and heated discussions with Chairs of Anesthesia Departments and Deans and say, "This is how it has to be," in order to secure training experiences for their PM&R residents.

2) The AAP needs to recognize the Handwriting on the Wall. The Cheese moved a long time ago...Get on the bus or risk ending up left at the depot, or worse, underneath it.

3) The PM&R residency program accreditation requirements need to be re-written to incorporate basiccompetency requirements in procedural pain medicine.

4) PM&R Department Chairs need to hire academic Pain Physiatrists and pay them at least what they would be paid in Anesthesia Departments. Yes, it will hurt...a lot...

5) PM&R needs to stop poking The Gorilla with a stick. Failure to prepare is preparing to fail...there are a lot of anesthesia-based fellowships having problems with the new accreditation requirements too. Reach out and make new friends...

 

[Disciple]

You make many good points and I am in agreement with your overall strategy, though it is the implementation that I am unsure about.

One of my spine mentors (administratively active in NASS/PASSOR) came up in the early to mid-90s, with the rest of our interventional front-runners. This is hardly elder statesman status. You and I are at the PGY-5 level. Somehow I don't see either of us convincing Joel Delisa, Elliot Roth et al about anything, regardless how much time and money I'm willing to invest in advocacy efforts. The AAP meeting in Daytona this spring was hands down one of the worse conferences I've ever been to, and I would be reluctant to put my faith in that organization to advocate on my behalf.

What I'm saying is, that if this situation seems beyond repair or if it looks like it's just "not gonna happen", then maybe it's time to cut our losses, and go to Plan B.

Separation.

and support of our own specialty/subspecialty, in an attempt to fix the mistakes of the past, including what happened with sports medicine.

I would argue that it would have to be done under the banner of MSK/Spine because in general, that's where our interventionalists are. If we had more academic interventional "pain" guys, then we would have more options. Look at any of the standard "pain" texts, few chapters written by Physiatrists and those that were, were likely written by Spine/MSK guys. And let's face it, the majority of Interventional Physiatrists, even the ones in Anesthesia fellowships, are going to choose Spine/MSK jobs when they start practice.

There are several ways to approach the problem. The question is, which is the most feasible?

But,

I'm a patient individual. And as I've listed above, there are some signs of improvement.