Pain Fellowship Reviews

[anesthesiology]

hi Lizard 1,
Thanks for your nice summary of the emory program. So u mean no intrathecal pumps, discograms, vertebroplasty and other big interventional stuffs? Just curious becasue I was thinking of applying to emory for next year? Thanks again for your response.

---

Members don't see this ad.

 

[anesthesiology]

Anybody with any information about the University of Iowa Pain fellowship program?
Any information will be greatly appreciated.
thanks.

 

[Tenesma]

paindevil - do you realize how idiotic your statement is about doing procedures without fluoro? I don't care if you are anesthesia trained or not, it shows a disregard for the current literature as well as increases your medical liability...

 

[trezur]

Anyone have any insights to the Pain programs at Virginia Mason or Mass Gen/Harvard? Thanks

 

[md2k]

I am wondering if there are fellowship programs which additionally offer advanced teaching in peripheral nerve blocks. I've heard that VM offers a 1 month elective during te fellowship, do we know if there are others that might offer more than one month?
Thanks.

Duke, ask the paindevil. They will even show you how to do spinal procedures without fluoro

 

[Lizard1]

So u mean no intrathecal pumps, discograms, vertebroplasty and other big interventional stuffs?

They do happen - an attending will call nearly all the fellows to come and watch while one will scrub in just because they don't happen that often. I think last yr each fellow prob did 5 or so - I'm not real sure. We'll see how this yr goes.

If I were you, I'd definitely apply to Emory and come take a look first hand. You will want to keep alll your options open as Pain is becoming more & more competitive and you can get decent training here.

 

[PainDevil]

paindevil - do you realize how idiotic your statement is about doing procedures without fluoro? I don't care if you are anesthesia trained or not, it shows a disregard for the current literature as well as increases your medical liability...

I see your point, but I respectfully disagree.

I believe that residency/fellowship training is an invaluable time to get exposed to a variety of techniques. Being able to perform certain procedures such as stellates, LESIs, and even LSBs via the anatomical approach (I guess "blind" is not the correct term) can only help you become more adept at these, even when you use fluoro. I think it is somewhat analogous to placing central lines via the anatomical approach, vs using US. Similarly, US guided regional blockade is gaining momentum, but it seems to me most training programs also allow residents to become facile in performing those procedures without US. Of course, there are important differences here (fluoro is standard for pain procedures), but I hope you see my point.

Secondly, I have an interest in international pain medicine and knowing how to perform such procedures without fluoro may be of help in places where fluoroscopy is not readily available.

Thirdly, in my review of the fellowship, it should be apparent that the vast majority of procedures are fluoro-guided. Perhaps my wording may have suggested otherwise... I'll take care of it.

Once again, I do see your side of the argument, esp with regards to medical liability... in PP obviously I'll be doing my procedures under fluoro, but I think I'll be grateful that I had the experience of doing them a different way.

 

[PainDevil]

I am wondering if there are fellowship programs which additionally offer advanced teaching in peripheral nerve blocks. I've heard that VM offers a 1 month elective during te fellowship, do we know if there are others that might offer more than one month?
Thanks.

The pain fellowship at Duke does offer electives in PNBs. Basically, you go to the holding area of the OR where regional blockade is performed. The attendings there are very aggressive about placing regionals, and there is a core group that specializes in it. There is a catch, though... residents and regional fellows get first preference (understandably), so it might be hard for a pain fellow to get to do them.

And MD2K is correct, they will show you how to perform PNBs without fluoro.... they use U/S instead

 

[lobelsteve]

Lets make sure we get the EMory fellowships sorted out. The WIndsor run fellowship is now being partially taught by a dufus (Dr. Steve Lobel). He took 3 hours on each of two cases today. The first involved 6 quads with 3 extension leads and a single octrode hooked up to 2 EON's. The second involved a single octrode, dual quads and an extension hooked up to a single EON. Granted, he let the fellows do most of the work (not the ones who started 3 days ago). No excuses, 90 minutes per case will have to be the standard. ANd if ever talks in the third person again, well....I'll have another beer.

The EMory fellowship from Geogia Pain Physicians is outpatient implant rich. The volume is daunting. The lectures are all going to be done at the finest restaurants in ATL. This years restaurants picked by PAZ also known for holding the record for most wires out in one patient (10).

At least its fun.

 

[paz5559]

The Emory fellowship from Geogia Pain Physicians is outpatient implant rich. The volume is daunting. The lectures are all going to be done at the finest restaurants in ATL. This years restaurants picked by PAZ also known for holding the record for most wires out in one patient (10).

At least its fun.

I have to defend myself here! The patient with 10 wires actually only had an SCS tripole, two thoracic quad PNSs, and two PSIS PNSs (ie 6 active leads). Admittedly, this also required three extensions, which is how my partner in crime Dr. Lobel gets close to 10 (and is also why it took three hours to do the REVISION , as the single octrode was already in place) but the patient now has no mid, low, or radicular pain at the end of the day, and so to me, that was time well spent.

Emory's PM&R program is an extrordinary opportunity to try things with the supervision of several of the best minds and technicians in the country keeping a watchful eye. The procedures you can do are limited only by your imagination (eg the array detailed above) and the reimbursement issues we all face. I did my second retrograde approach for sacral leads in the clinical setting of IC late last week as well, and I am 6 months into my fellowship, if that is any indication of how quickly you can advance. On the ride home from work yesterday, Dr. Lobel and I discussed doing the GRC blocks we had rambled on about on this very board a few monhs ago. In short, as Steve says, it is a great place to learn.

 

[mehul_25]

Nice program with tremendous facility. U oF I hospital is beautiful and getting bigger all the time. Hardwood floors everywhere. They have a nice multi-disciplinary team and at least one neurologist on their staff. They do a lot of acute pain procedures are are very strong for regional. On the flip side they do very few interventional procedures, most days the fellows do one or less.

The chair is really nice and nationally known, currently the President of ASRA.

 

[chinochulo]

The patient with 10 wires actually only had an SCS tripole, two thoracic quad PNSs, and two PSIS PNSs (ie 6 active leads). Admittedly, this also required three extensions, which is how my partner in crime Dr. Lobel gets close to 10 (and is also why it took three hours to do the REVISION , as the single octrode was already in place) but the patient now has no mid, low, or radicular pain at the end of the day.

Man, with that much fluoro time you guys must be glowing in the dark at the end of your fellowship....hope you donated to the sperm bank already!!

 

[lobelsteve]

Man, with that much fluoro time you guys must be glowing in the dark at the end of your fellowship....hope you donated to the sperm bank already!!

Excellent point. And one I am driving home to the fellows daily. I did not allow PAZ to use fluoro today on a dual octrode PNS as the leads would be palpable in their final position and essentially limited placement by point of maximal tenderness.

Our radiation safety lecture is tomorrow night at Food 101 in Sandy Springs.
Funny that PAZ will be at the ISIS meeting in Utah when he reads this and will be absent from that very important lecture.

As for me, 2 kids and done. Not a fan of thyroid CA or any CA for that matter. I will train the current fellows in the approprate use of fluoro as a guide not a gift that replaces 3D spatial understanding of the anatomy.

Most single level procedures should take 10 seconds in skilled hands.

Back on topic: Lectures are weekly and given by staff. They are held at the finest restaurants in ATL sposored by our Pharma and vendor reps. Lectures given by people who only claim to know what they are talking about (me) and we are not really sure yet.

 

[paindefender]

I have to defend myself here! The patient with 10 wires actually only had an SCS tripole, two thoracic quad PNSs, and two PSIS PNSs (ie 6 active leads). Admittedly, this also required three extensions, which is how my partner in crime Dr. Lobel gets close to 10 (and is also why it took three hours to do the REVISION , as the single octrode was already in place) but the patient now has no mid, low, or radicular pain at the end of the day, and so to me, that was time well spent.




What is the diagnosis of this patient? Taking any narcotics?

 

[PainDr]

Steve,

Just curious, how is your program (Georgia Pain Physicians) going to implement the new fellowship requirements that go into effect next year? I interviewed with Windsor two years ago and thought he was amazing, but it's going to be pretty hard/next to impossible for you guys to continue after the new guidlines go into effect.

 

[md2k]

Nice program with tremendous facility. U oF I hospital is beautiful and getting bigger all the time. Hardwood floors everywhere. They have a nice multi-disciplinary team and at least one neurologist on their staff. They do a lot of acute pain procedures are are very strong for regional. On the flip side they do very few interventional procedures, most days the fellows do one or less.

The chair is really nice and nationally known, currently the President of ASRA.

I am currently with a fellow at my program who graduated from U of I. He personally said the program was weak. Yes, they only do 1 or maybe 2 procedures a day.

 

[anesthesiology]

Thanks for the info. You said 1-2 procedures/day. I was wondering u meant the regular pain procedures like epidurals/facets or the more interventional like intrathecal pumps?
thanks

 

[anesthesiology]

I am currently with a fellow at my program who graduated from U of I. He personally said the program was weak. Yes, they only do 1 or maybe 2 procedures a day.

Thanks for the info. You said 1-2 procedures/day. I was wondering u meant the regular pain procedures like epidurals/facets or the more interventional like intrathecal pumps?
thanks

 

[mehul_25]

I dont think they do very many highly interventional procedures (i.e. pumps, scs or intradiscal) at all, mostly facets and TFESI/ILESI

 

[md2k]

Thanks for the info. You said 1-2 procedures/day. I was wondering u meant the regular pain procedures like epidurals/facets or the more interventional like intrathecal pumps?
thanks

epidurals/facets and SI Joints

 

[md2k]

The pain fellowship at Duke does offer electives in PNBs. Basically, you go to the holding area of the OR where regional blockade is performed. The attendings there are very aggressive about placing regionals, and there is a core group that specializes in it. There is a catch, though... residents and regional fellows get first preference (understandably), so it might be hard for a pain fellow to get to do them.

And MD2K is correct, they will show you how to perform PNBs without fluoro.... they use U/S instead

I think Ultrasound is excellent for PNB's. Did you use them at the VA for your spinal procedures when you didn't have flouro.

 

[jhoppenfeld]

Does any one know about the NY programs?

 

[rockum]

I'm new to the forum and have found it extremely helpful reading the previous messages as I'm applying for a Pain fellowship currently. The info about U of I confirms what I heard and has helped rule them out as I do want to learn some regional but desire more interventional training of the two. I'm looking for a program that is well rounded but has a heavier emphasis on Interventional mgmt of Pain.
Does any one have any info about the programs at U of Michigan and the Medical College of Wisconsin in terms of the quality of training and how much emphasis is placed on Interventional techniques??

 

[lobelsteve]

Brief update:

Emory Georgia Pain Physicians congratulates Dr. Varghese on performing his first octrode and EON implantation. Start date 7/5/06. Implant date 7/28/06. He was assisted by a highly qualified PA-C, Howie Friedman.

 

[paz5559]

Brief update:

Emory Georgia Pain Physicians congratulates Dr. Varghese on performing his first octrode and EON implantation. Start date 7/5/06. Implant date 7/28/06. He was assisted by a highly qualified PA-C, Howie Friedman.

Please excuse my colleague's over-enthusiasm - afterall, he has only been asst program director for a little more than three weeks.

I promise to reel him back in and convince him it is unnecessary to so blantantly advertise our program's opportunities for SCS skill development in future

 

[lobelsteve]

Emory GPP newsflash. PAZ extended 6 months for additional/remedial training.

 

[fluropanda]

Hi, I find this forum very informative.
I'm about to go on my first interview at St. Luke Roosevelt. Was wondering if there's any specific word of advice for this program (besides what's been posted prior). Is the interview only 1 hour?
Also, do they stagger their fellows' start date, or does everyone start on July 1st?
Thanks.

 

[joshmir]

Please excuse my colleague's over-enthusiasm - afterall, he has only been asst program director for a little more than three weeks.

I promise to reel him back in and convince him it is unnecessary to so blantantly advertise our program's opportunities for SCS skill development in future

a few things the binary world may not know about the intensCity of PD Stee-Lo:

-walked on to a Division 1 football team in universidad, and though he looks at squashed discs every day, still has and uses the squat rack *at his house*

-keeps it real by pushing a gnarly Wrangler over rocky terrain

-when faced with flaws in the system that others overlook, seriously has No Fear- they actually made a T-shirt about him, they're in some dusty boxes in a factory storeroom in Hmong (copyright issues)

-has the most important trophy a man needs to complete his trophy collection

-made a difference at the VA

 

[mdseekingtohelp]

Is anyone aware of a pain fellowship / training position still open starting sometime this late summer or fall? I'd like not to wait until next summer if possible. Thanks.

 

[mid|ine]

I think it would be helpful to have a list of pain procedures that a fellow should have exposure to / comfort with. There are alot of different procedures in the pain world that many residents don't really know about.

Can anyone put together a decent list?

Thank you.

 

[Spine Specialist]

I think it would be helpful to have a list of pain procedures that a fellow should have exposure to / comfort with. There are alot of different procedures in the pain world that many residents don't really know about.

Can anyone put together a decent list?

Thank you.

Hmmm..lemme think of decent incomplete list of injections

1. Occipital Nerve Block
2. Trigeminal Nerve Block
3. Glenohumeral joint Injection.
4. Acromioclavicular Joint Injection
5. Suprascapular Nerve Block
6. Cervical, Thoracic , Lumbar and Caudal epidural Injections
7. Sacroiliac Joint Injection
8. Coccygeal Injection
9. Z-joint Blocks
10. Knee joint Injection
11. Intercostal Nerve Block
12. Stellate Ganglion Block
13. Lumbar Sympathetic Block
14. Hypogastric Block
15. Ganglion Impar Block
16. Provocative discogram
17. Celiac plexus block
18. Hip Joint injection
19. Bursa injections
20. Carpal tunnel injection
21. Illio-inguinal nerve block
22. Trigger point injection

Just open the Waldman Illustrated Atlas of pain procedures.....

 

[mehul_25]

I think this potential list would be more useful if it was divided into categories (i.e. exposure to, expertise with). Minimum "requirements" for fellowships would be an interesting thing to debate given the variety and variability of programs across the country, not to mention the differences between pain, interventional spine and musculoskeletal programs.

This is how I would divide things up:

Expertise with:

Interlaminar (cervical, lumbar)
Transforaminal (cervical, thoracic, lumbar)
Intra-articular (facet [cervical, lumbar], sacroiliac, joints [hip, knee, elbow, shoulder])
Median Branch Blocks (cervical, lumbar)
Epidural Blood Patch
Sympathetic Blocks (cervical, lumbar)
Caudals
Trigger Points
Greater/Lesserr Occipital Nerve Blocks
Bursa Injections

Moderate expertise with:

SCS trials (cervical, lumbar)
Discography (lumbar)
Celiac Plexus Block

Experience with/Exposure to:

SCS implantation (lumbar)
Discography (cervical)
Intrathecal Pump (trials, implantation)
Vertebroplasty/Kyphoplasty
Regional Procedures (femoral nerve, hypogastric , suprascapular, ilio-inguinal nerve blocks)

 

[lobelsteve]

Or you could go to the ACGME website and download the updated PIF for Pain Management.

After you do this and recover from astonishment at how incomplete and fruitless the requirements are, we can quickly come up with a consensus on regional, spinal, surgical, and peripheral procedures used in PM.

My favorite board questions discuss brachial plexus blocks for the OR and intrapleural catheters for pain mgmt.

 

[PainDr]

To obtain privileges for advanced procedures (SCS, pumps, vertebroplasty, discograms, discectomy) many hospitals require documentation of at least 10 cases. Personally, I didn't feel comfortable until I had done a few more than that.

 

[wannabepainmd]

Does anyone know how difficult it is to get into a pain fellowship in the California programs or other top programs like cleveland clinic, harvard?

Also is Rush in Chicago and MD anderson good programs?

 

[bbbmd]

Does anyone know how difficult it is to get into a pain fellowship in the California programs or other top programs like cleveland clinic, harvard?

Also is Rush in Chicago and MD anderson good programs?

Ive been a fellow at MD Anderson for 6 weeks and have been very happy with the training so far. The other 3 fellows will likely agree with me. We do EVERYTHING here. Here's an abbreviated list of the advanced procedures that I have done in the first month:

Pump implants- (2 pediatric cases)
Stim implants- 2
Stim trials- 2
Vertebroplasties (each case multi-level)- 4
Kyphoplasties- 5
Disc Dekompression/discograms- none so far, but these are done at MDACC and our private rotations

We do get all the bread and butter cases at MDACC main hospital, but we learn speed and proficiency when we do our private rotations (2 months). A few attendings here are very aggressive in terms of interventional management on sick patients so you will definitely learn procedures and the complications that could arise from them. I think this is key in a training program because it will prepare you for anything. We have good neurosurgical back-up for complications, but since I have been here the pain attendings are the ones that surgically repairs complications (mostly from pumps)--> and, of course, the fellow scrubs in!

We work hard here, the hours are long, but we all think that the experience we are getting is worth it. You will not find many other places that perform the procedures that we do. Dr. Burton (our section chief), Dr. Phan (director of interventional pain) and Dr. Brown (our chairman) have transformed MDACC to a once heavy "medical management" program to a HIGHLY interventional fellowship.

Once my fellowship is done, Ill be ready for anything. Will I do complicated cases in private practice??? I dont know yet, but at least I know that Ill be well prepared if I decide to go down that road!

 

[PainDr]

Does anyone know how difficult it is to get into a pain fellowship in the California programs or other top programs like cleveland clinic, harvard?

...very difficult. There are several other posts that give specific numbers of applicants vs positions. Please review this thread for more info.

Also is Rush in Chicago and MD anderson good programs?

I don't know anything about Rush. MD Anderson is outstanding...top tier.

 

[mehul_25]

To obtain privileges for advanced procedures (SCS, pumps, vertebroplasty, discograms, discectomy) many hospitals require documentation of at least 10 cases. Personally, I didn't feel comfortable until I had done a few more than that.

I have heard 10 as a magical number and I agree that I would not truly feel comfortable until I had done a few more particularly of cervical discos, vertebroplasty, and permanent implants.

 

[PainDr]

cervical discos

Yikes! Personally, I'd recommend sending those folks to a surgeon!

 

[lobelsteve]

Yikes! Personally, I'd recommend sending those folks to a surgeon!

Typically, this is why the surgeon sends them to us.

 

[Disciple]

I have heard 10 as a magical number and I agree that I would not truly feel comfortable until I had done a few more particularly of cervical discos, vertebroplasty, and permanent implants.

For discos, intradiscal, Vertebroplasty, etc.

Would that be 10 discs/levels or 10 patients?

 

[PainDr]

Typically, this is why the surgeon sends them to us.

I'm very comfortable with disc work, but am not interested in doing cervicals...very few people are. However, if you're brave enough to do them, be my guest.

Would that be 10 discs/levels or 10 patients?

Probably depends on your institution, but I'd guess patients.

 

[FLK 1]

Is anyone familiar with the fellowship program at Wash U.?

 

[Jizzy]

St Vincent's Hospital - Manhattan pain fellowship with Dr. Amr Hosny. Anybody have any information at all regarding this program? Thank you.

 

[gecko]

St Vincent's Hospital - Manhattan pain fellowship with Dr. Amr Hosny. Anybody have any information at all regarding this program? Thank you.

I did a 1 month rotation there, and could fill you in on the details. Dr. Hosny is very personable, and easy to work with. He was trained at BIDMC, so, the fellows will be learning how to do interventional procedures as they were taught at BIDMC. The number of fellows there is in flux...when i rotated, there was only one, but I believe there are three spots/yr. The fellow unfortunately had to do all the work for the other two. But still didn't seem overworked.

The typical day starts at 7am, when you round on inpatients and write notes...then meet up with Dr. Hosny at 8am to go over any complicated or interesting cases. 9am, you walk a couple blocks over to the University Pain Center where it's very much like a private practice setting....office-based practice. Tues and Thurs, you do more procedures (about 10/day), but also do quite a few during other days of the week. Also, on Weds, you may have more invasive procedures lined up, which will be done at the ASC in St. Vincent's. However, the fellow at the time did complain that he didn't have enough exposure to SCS/pumps/vertebroplastys...I think he only assisted on 2 SCS the entire yr.

I also believe the fellows had to round on the weekends (alternating) on inpatients...however, I don't remember clearly.

The main perk of the program is Dr. Hosny, and his training background. It should prepare you well for bread and butter private practice pain management. Dr. Hosny has done a lot during the 3(?) years that he has been Director of the program. In his first year, he managed to increase his patient pool by 50%, and he added an EMR system to increase efficiency.

 

[jimbomd]

can anyone comment on the boston programs? either current fellows or grads would be great...

thanks.

 

[Jizzy]

Thanks Gecko!! It's nice to have this forum and helpful people like yourself putting in their two cents otherwise it would be very very difficult to determine which programs are actually worthwhile. I've heard of programs where the fellows quit after 6 months because they're just being scutted and not learning what they need to learn to succeed in the real world once they're out. Anyway, I appreciate the information!

 

[gecko]

No prob Jizzy!

Note that there are a few reviews of some Boston pain programs (amongst others) if you go to scutwork.com. Some old reviews, but still good info as most were written by previous fellows.

 

[doctim]

appreciate all the input. everyone talks about the big name fellowships available. any advice on the smaller, less well-knowns, ie. utah, WA, etc?

 

[TheAssMan]

Columbia has two programs, the main campus (Presbyterian) one does not do much interventional procedures. They have a new attending trained at Hopkins who might make the program a little more interventional. But currently, he is stuck in the OR most of the time and doing minimum pain. There are two fellows in the program, alternating doing in-pt pain and clinics. So basically, you are spending half of your time (6 months) doing in-pts. However, at Columbia, you don’t do much scud work. You go to work at 8am, and don’t need to put in thoracic epidurals early in the morning. You have residents doing the initial work for consults most of the time. For out pt clinics, it is very medically oriented. Agree with md2K, it is a weak interventional program.
The other Columbia program is St Luke’s Roosevelt. It is well known for its regional program. However, they have a well established pain center. Multiple people have told me this is the best interventional pain fellowship in NYC. They have four fellows, rotating every week. Basically, each month, you do two weeks of fluoro rooms, one week follow up clinics, and one week chronic pain consultation. PCAs are taken care of by a nurse. Minimum scud. No thoracic epidurals in the am either. The day starts at 8am with daily lectures. Dr. Hertz is regarded as the best teacher by fellows there. They all seem very happy. I know people have chosen St Luke’s over BID and many fellows there claimed that it was their first choice when they applied. Actually, the set up at St Luke’s is very similar to the BI. If you like the BI, look into St Luke’s also. Both are among the best providing training in bread and butter fluoro procedures.
Cornell has a great name in terms of the medical center. The fact that fellows rotate through HSS and MSK seems very attractive. However, there are a lot of undesirable things in the set up. Fellows there spend 3-4 months at the NY hospital, during which you are essentially on call everyday, taking care of all PCA and epidural pts (30-40pts). You go in at 6:30am to place them and would be on beeper call all day and all weekend. Fellows work until 8pm most of the time. I think they still do fluoro procedures in the OR (I could be wrong on this though). HSS is where you get most of your fluoro procedures. You spent 3 months there. There are a lot of volume there. However, those are all private patients. The message some attendings send out is that: “these are my pts, and I can handle them myself. I don’t need you to be here. If you are here, you’d better not mess up with them.” Some fellows complained that they had to watch procedures sometimes at HSS. MSK is mainly medical management for cancer pain, which is great. However, you may not want to spend 3-4 months out of your 1 year long fellowship just to do that. You also need to do epidurals in the morning and be on call a lot. Overall, Cornell has a great name, but it is not a very strong interventional program with significant amount of intern level scud work. I know people have quite mid way there due to lack of hands on procedures.

No need to believe me as I am one of the people at Cornell. Much has changed since the last post in this program-more organization, less scut. Prgram combined with MSK and now is one program with 8 fellows. HSS is most inteventional, but after 2 weeks the private patient mentality wanes as the Attendings trust fellows more. NYH-Cornell-lots of variety of procedure. And yes there is scut, but now there are 3 fellows there and so much less/fellow when there used to be one. MSK, least procedures, but least scut as well-however good didactic and highest drug doses you will ever see which makes epidural trialing and IT pump management complicated-but you get savvy at it. AM Epidurals at NYH and MSK are now done by residents. Acute Pain at NYH is by PA, at MSK by NP & Attending. NPs at MSK do most of the call. Call at HSS, NYH relatively benign in that NYH also has residents who are first call. Program also offers 2 months of elective time.