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pain fellowships

Discussion in 'Pain Medicine' started by amyl, Feb 12, 2007.

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  1. amyl

    amyl ASA Member

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    So I have heard that it is easier to get a pain fellowship from an anes residency than a pmr residency. any thoughts? how common is it for a pmr trained doc to get into an anes based pain fellowship? is there any difference in training between the anes-based pain and pmr-based pain fellowships? thanks in advance - amy
  2. drusso

    drusso Moderator Emeritus Lifetime Donor

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    Anesthesiology departments exist to train anesthesiologists. They have the *OPTION* to train others, but no obligation to do so. Physiatry departments exist to train physiatrists. They have the *OPTION* to train others, but no obligation to do so. Some see value in cross-training different specialists, some do not. Some see value in being cross-trained, others do not. There is no single correct answer.

    All ACGME-accredited pain fellowships have to abide by the same program requirements regardless of their departmental affiliation. A patient with CRPS, spinal stenosis, or radiculopathy looks the same in every pain clinic regardless of where that pain clinic is physically located. There are only so many ways to do any given interventional pain procedure and its going to be done essentially the same way where ever you roam.

    PM&R has a variety of MSK/Spine/Sports type fellowships in addition to pain fellowships. Anesthesiology has regional fellowships among others. Choose the base specialty you like the best...the fellowship stuff will work itself out later.
  3. algosdoc

    algosdoc algosdoc

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    According to the new ABMS rules that went into effect in Jan 2007, now family docs, pediatricians, geneticists, and anyone else with an ABMS base residency is eligible for pain fellowships. The requirements for having some skills vaguely related to pain medicine in order to be eligible for a pain fellowship have been thrown out the window. You competition for a pain fellowship slot may turn out to be an allergist.
  4. mille125

    mille125

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    incredible
  5. amyl

    amyl ASA Member

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    a couple of the programs that I looked into wanted candidates to have completed a residency in anes, neuro, or psychiatry (?) -- didn't expect that at all.
    anyone have any thoughts on neuro before pain?
  6. PainDr

    PainDr

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    I'm a neurologist. What would you like to know?
  7. amyl

    amyl ASA Member

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    just curious -- what do you think of a neuro residency before a pain management fellowship?
  8. PainDr

    PainDr

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    I was interested in pain first, then decided on my residency. I always assumed I'd go into anesth but didn't enjoy the work. I also considered PM&R but didn't feel it was a good fit. Then I did my neuro rotation and absolutely loved it. Pain is a neurological function and to me it seemed a natural pathway to the subspecialty. This isn't really a novel idea. Neurologists have always been involved in pain...ever heard of Russell Portenoy? I think many would be suprised by the variety of pain syndromes seen by most neurologists...neuropathies, radiculopathies, CRPS, headache, myopathies, central pain syndromes, etc. Everyone supported me although I did have to seek out my own interventional exposure. I started doing pain rotations as an MS III and was always welcomed by my anesth colleagues. If you have any specific questions, feel free to ask.
  9. DO_2007

    DO_2007 New Member

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    I'm also Interested in pain. I trried PM&R and did not like, Treid Anaes, did not like the OR, then I found myself ion love with Neuro, I applied and now I have matched and will start in July, but my eyes on Pain. Any advise for me? BTW I'm a DO, does it make any difference?

    Thank you
  10. PainDr

    PainDr

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    Please search and review my past posts...there are many.
  11. Doctodd

    Doctodd

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    i did PMR and then anesthes pain fellowship. It wasnt the best program in the country, but you get what you put into it. I was next in line at a very good pain fellowship in florida and would have been the first PMR to get in. But alas...it all worked out. They loved that i had skills with touching and talking to patients who were awake....lol.

    T
  12. Lizard1

    Lizard1 Member

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    so should you also just be able to step into a neuro surgery fellowship? i mean, the brain/spine is part of your studying in neurology???

    what about psych? those residents deal with depression and we all know depression is intricately involved with chronic pain......so they should be able to do pain fellowships?

    get my point? you can justify anything - we're all in medicine
  13. PainDr

    PainDr

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    Chronic pain mgmt is a very unique subspecialty that requires a special skill set, with contributions from PM&R, neuro, anesth and yes, even psych...but then, you should already know all this. Aren't you getting ready to start a pain fellowship? I was fortunate to train at a top anesth program with a progressive group of attendings who valued multidisciplinary training and good patient care over antiquated and illogical turf battles. I hope you are as fortunate.
  14. sga430

    sga430 Removed

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    i am going into psychiatry yet have an interest in pain. how does a pain psych practice differ from other pain practices? also what is the compensation for a pain psychiatrist? is getting a fellowship for psych tough? are the psych-based pain fellowships required to teach procedures?
  15. jhoppenfeld

    jhoppenfeld New Member

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  16. jhoppenfeld

    jhoppenfeld New Member

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    I could not disagree anymore! If you want to do an interventional pain fellowship, you have to do an anesthesiology residency. Even more so you have to do an anesthesiology residency that has its own pain fellowship.

    Basically, all the procedural interventional fellowships are run by the department of anesthesiology. Most fellowship programs have three spots. So let's say University X has 18 residents in there class and three of them want to stay and do the pain fellowship - you're not getting in unless you are part of that residency class. This year, in New York City, every program basically filled from within. Even Cornell which has something like 10 spots filled I believe 4 or 5 of those spots from within.

    Lets say they take two of their own and they have one extra spot. There are solid anesthesiology departments like Yale that don't have a pain fellowship. So for that extra spot you are now competing with the Chief resident of anesthesiolgy at Yale. Most major chairmen within the same specialty are familiar with each other and they make phone calls to each other for their residents.

    I am a neurologist and was very lucky to get an interventional position. I was a qualified candidate who applied to every program I could and worked as hard as I could over a couple months to find a position. I am going to Dr. Portenoy's program and could not be happier. He is a neurologist and I am the only neurologist in the class
  17. Disciple

    Disciple Senior Member

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    You just contradicted yourself.
  18. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    Is Jhoppenfeld and Spinal the same person?

    2 guys who jump on the forum and aggressively start giving advice, though both are clearly a little green to be such experts.

    Gentlemen: there are many ways to become a Pain Physician. There is not a best way, but there are better ways than others. Fellowship training can be either ACGME accredited or not, and this does not affect the caliber of physician being trained. 3 of the Mayo's best PM&R residents are doing a recently withdrawn ACGME fellowship due to politics. Is their training going to be less than the 4 graduates finishing June 30?

    We have discussed the topic here a few dozen times and it always reverts back to the need for a Pain Medicine residency program separate from Anesthesiology, PM&R, Neurology, and Psychiatry. We have even drafted the 3 year rotation schedule after either 1 year internship in Surgery or IM. My preference would be 6 months of each then the 3 year deal.

    When the political climate changes over the next few years, Algosdoc, myself, and several others will sit down and talk about how and when we can make this happen. :hardy:
  19. savealife

    savealife Chief Resident

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    So where does that leave people like myself, lobelsteve, who are going to go into PM&R and then pursue a Pain fellowship? Will the pain management fellowship no longer exist?

    I'm an MSIII and I know that what I want out of my life is to practice Pain Medicine. If I go through a PM&R residency and then CANNOT have a fellowship in Pain because a new residency exists, that would really ruin my career aspirations (and I'm certainly not alone). Has anything like this happened in the past? How did it get sorted out?

    Thanks, savealife
  20. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    I'll train you. Send me a CV when you are a PGY3. YOu will sit the ABPM boards and be considered board certified. I do not think we can have a residency program in place that soon.
  21. Disciple

    Disciple Senior Member

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    Well, for one, no one is going to stop you from prescribing opiates, fellowship or no fellowship.

    If it's the procedures you're worried about, you can breathe a little easier.

    I admit I've been overly critical of the PM&R leadership.

    The AAPMR/ABPMR by their actions, and to the dismay of some, have made it clear that they aren't going to put their full support/resources behind the specialty (currently sub-specialty) of pain medicine. Instead, they've chosen to develop the MSK/Interventional Spine component of PM&R.

    This is evident in the renaming of the AAPMR's journal (now Musculoskeletal and Rehabilitation Medicine), the Integration of PASSOR into the whole of the AAPMR (PASSOR remains smaller and weaker as a segregated group within a small organization) and the concerted effort by more if not most PM&R residencies to hire the appropriate faculty and arrange the proper training experiences for residents. The last national PM&R inservice exam I took in early 2006 included identification of anatomic landmarks on fluoroscopic images of the lumbar spine. Evaluation of PASSOR fellowships is being conducted to determine the amount of polarization towards "injection heavy" vs "PT heavy" fellowships. Expect a more balanced, uniform and consistent approach in the coming years.

    I recently got a copy of the program for the AAPMR annual meeting in September. There is now a "Spine" lecture tract separate from the MSK and Pain rehabilitation tracts which includes the most interventional procedural content I've yet seen (including lectures on the current evidence base, complications and procedural algorithms) for an AAPMR annual meeting. Some interventional training will likely be a part of your core training in PM&R. Should you become a Physiatrist but not a pain medicine specialist, you may find that the skills you possess will be more than adequate to suit your purposes.
  22. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    It would be like becoming a general surgeon but limited to lap appe's and lap choles's.
  23. Disciple

    Disciple Senior Member

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    I suppose.

    However, many Physiatrists, including a good number graduating from Anesthesia fellowships, go on to work for surgical or musculoskeletal groups/practices.

    So maybe it's what the masses want.
  24. GassiusClay

    GassiusClay PGY-2

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    I didn't get my chance to check out UCLA for a potential residency, but I would like to take a shot at the pain fellowship in the future. So, I was wondering how many spots (3 or 4) and how many outsiders? Please PM if you have any suggestions to build up the CV or maybe what is important for applicants there.

    Thanks.
  25. defphiche

    defphiche Pain Medicine Forum Moderator

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    The UCLA WLA VA program for Pain Medicine has 4 positions, all ACGME approved. The program is interested in training PM&R physicians to be well suited in the field of pain medicine. Our goal is not to take internal candidates only, but to broaden the experience for both the residents and the staff with new ideas and personalities. Last year we had 4 outside fellows which I think makes the program better for all involved.

    I agree with the AAPMR/PASSOR focus away from pain and more to the spine/MSK, but have felt that this is short sighted. The UCLA WLA VA program is trying to be competitive with Anesthesia based programs with all aspects of pain medicine training. There is a strong emphasis on intrathecal pump implantation and management with dorsal column stimulation trials and implantation, but obviously, there is a flair of PM&R with the training (EMG, MSK, and Rehabilitation). I think this is what makes the UCLA WLA VA program unique.

    I had hoped more PM&R programs would become accredited, but with the change of focus on a 'single' program at an institution, the PM&R training has combined with most of the Anesthesia programs. For example, the EMG aspect is lost, which for a PM&R physician, is an important tool to use for patient evaluation. The UCLA WLA VA program is unique because it is based out of the VA which is why it is a program separate from the UCLA Anesthesia Pain program. The fellow will rotate at UCLA for 6 months out of the year and 6 months at the VA.

    The UCLA WLA VA PM&R program looks for applicants that have a firm background in MSK, EMG, and rehabilitation from a strong residency training program. Research publications in pain, national presentations, letter of recommendations, high scores on all SAEs, extracurricular activities, as well as a good personality and communication skills, will set the applicant apart from all others.

    The UCLA WLA VA PMR program is not a 'spine intervention' or 'MSK' program but has strong features of both embedded in the training. If your focus is on spine only, this is not your program. If your interest is in all aspects of pain training, which will of course include the spine, then the UCLA WLA VA PMR Pain Medicine Fellowship will hopefully fulfill all of your goals.
  26. ampaphb

    ampaphb

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    Does that mean the UCLA PM&R residents didn't apply? Or weren't selected?
  27. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    Dr. Fish = defphiche = PD at UCLA?

    The reason PM&R programs gotstiffed was a politcal coup by Rathmell. Our representation at the RRC meeting was silent and many of the PD's did not know about the changes until after they were being made.

    My opinion of the anesthesia training programs is low,as is my opinion of the PM&R programs. None address the need of the US population which is to have a multidisciplinary pain center provide for all aspects of their care.

    Not a pill mill, not a needle jockey who sends them back to their PCP with recommendations, not a psychobabble three times a week. It should all get done in one place, under one tax id, and not to make money at the expense of patient care. This is currently not the case in almost all of the "Pain Clinics" in the US.

    The Pain paradigm is broken and no one wants to fix it, they all just want a bigger slice of the $$$.

    We can propose a pain residency, but who will stop the money grubbers from doing 40 epidurals on Friday when the OR is slow, the stim weenies who think PN of DM warrants a 4 octrode trial, and the docs who rapidly titrate opioids in an effort to get them reasdy for IT meds.

    Ben Crue should be required reading for Pain Fellowship.

    I'm ranting....and disenfranchised.
  28. DigableCat

    DigableCat Senior Member Lifetime Donor

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    David Fish is the Associate Director of the Pain Fellowship. Quynh Pham is the Program Director.

    UCLA / WLA VA multicampus fellowship in Pain Medicine.

    Makes you wonder what exactly were many of these PD's doing when the changes were being suggested...I figure, too busy making money to give a crap at the time.

    The thing I suspect these now non-accredited fellowships lost the most out on was the free slave labor they were acquiring. Many PM&R applicants have wised up, and unless residents know they can get their accreditation, they aren't even bothering to apply to these programs. Especially when hospital privileges can be limited by your ACGME Board Certification.

    The writing was on the wall well before now...most just refused to see it.
  29. ampaphb

    ampaphb

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    By the time Dr. Smith presented the details that had been agreed to by the four RRC representatives at the Annual Assembly, it was a done deal. The fellowship directors in attendance seemed dumbfounded, as though they had not been kept in the loop.

    Struck me as yet another example of the old guard not respecting pain/spine as a legitimate are of focus for physiatrists, and this was their way of limiting PM&R's participation in the field as much as possible. We didn't get blindsided, our leadership was aware of the ramifications, and intended the results to happen. While the current PASSOR leadership may be getting re-incorporated into the Academy's power structure, the founders of the organization have, on the whole, always been viewed and treated as outsiders.
  30. defphiche

    defphiche Pain Medicine Forum Moderator

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    the residents did apply and were not selected.
  31. Disciple

    Disciple Senior Member

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    The AAPM&R conducted several surveys first amongst member Physiatrists and then residents looking at career choice/practice focus. The decision was made to focus toward Spine/MSK versus "pain". In my opinion the AAPM&R (pushed by PASSOR), is trying to best and accurately represent the wants and needs of its membership.

    The vast majority of Interventional Physiatrists practice in MSK practices, surgical groups or Spine centers. The reason I think a lot of Physiatrists train in Anesthesiology based pain fellowships is because the ABPMR will not provide them with what they need via an "Interventional Spine" model, i.e. standardized procedural training to supplement the non-operative management of orthopedic conditions of the spine. Many Physiatrists training in Anesthesiology based pain fellowships go on to practice in surgical groups or musculoskeletal PM&R groups (take several of the inquiries on this forum as an example). Assuming said Physiatrist had good MSK/Spine training in residency, then he/she likely uses a small fraction of the skills learned during a 12 month multi-disciplinary fellowship in their spine based private practice, which would be the interventional skills minus intra-thecal implants. The region in which I practice (metropolitan area in a saturated state) is densely populated with Interventional Physiatrists. I cannot think of a single one off the top of my head who implants and manages intra-thecal pumps, manages headaches (non-cervicogenic), pelvic pain, non-spinal cancer pain, etc. whether they possess the proper training or not. Those with the largest practices certainly do not. The situation is similar in 2 other cities (2 of the top 4 US cities by population) in which I have lived.

    Interventional Radiologists do not practice pain medicine, but do undergo standardized procedural training and obtain certification through their own fellowships. There are some who have a fondness for Vertebro/Kyphoplasty and spinal injections. By the reasoning supported by the 4 core pain RRCs, shouldn't they be doing a pain fellowship? What about surgeons? Let's say a neurosurgeon does alot of spine work, implants some pumps and stims and now wants to add a few injections to his repertoire. Should he/she have to do a pain fellowship or would it be acceptable to learn from an experienced colleague? (The Smith & Nephew course I attended on IDET a couple of years ago was taught by the chairman of the Ortho dept at a large surgical hospital). Wouldn't a pain fellowship for a surgeon in this situation be a complete waste of time?

    Would we even be having these issues if the ABPMR put its stamp on musculoskeletal Physiatry?

    As a parallel example, I consider myself a competent electromyographer. Even though most of my studies are done to screen for radics and peripheral nerve entrapments, with some review I feel confident I could do a proper electrodiagnostic study to confirm Neuromuscular Disease (ALS, Myotonic Dystrophy, etc.) Does that mean I should be capable of managing that condition long-term? Should I even be expected to manage the rehabilitative aspect or should that be referred to a Physiatrist with extensive longitudinal experience with these types of patients.

    If you look at all the Pain Medicine/Spine/Interventional Pain Management organizations we subscribe to, we have:

    ISIS-Guys who like to do procedures
    ASIPP-Guys who like procedures and money
    AAPM-Guys interested in pain who favor a more balanced approach
    NASS-Surgeons, and then Interventional Spine guys who work for/with surgeons or have a large referral base from surgeons
    APS-Guys who like neurobiology and the psychosocial aspects of pain
    ASRA-Anesthesiologists who like the OR/pain clinic hybrid model
    PASSOR-Physiatrists who are into non-surgical orthopaedics and who may supplement with some spinal procedures

    Think of all the practicioners in these organizations (Gas, Physiatry, Neuro, Primary care, Psyche, Spine surg, Rads), all the patients they treat, and how many of them actually practice comprehensive pain medicine. Is everyone of them a pain doc? If so does that mean that each practitioner who does not practice comprehensively is providing substandard care? Is it realistic to think that we can take all the relevant knowledge from Anesthesiology, Physiatry, Neurology and Psychiatry, condense it into 12 months of training and spit out pain docs with the same skill set, level of competency and uniform knowledge base? With the relative shortage of pain docs in this country and hypothetically taking some of the above specialties out of the picture, who is going to treat all their patients?

    Is it realistic to think that you can take a physician, train him/her for 12 months and equip that physician with the tools to evaluate, diagnose and effectively treat all types of pain with all types of interventions, medications and modalities from the moment a patient's pain starts up until and on a continuing basis after it becomes chronic?

    The value of multi-disciplinary pain management is well documented, but is it realistic that this be the standard for every community pain practice in every state? Perhaps, the expensive full scale multi-disciplinary pain clinics should be left to the tertiary and quaternary referral centers. As stated above, the number of pain docs in this country does not meet the current need. So should E&M be OK for PCPs, but expensive procedures be referred out? For Physiatrists, in part, the ABPMR is to blame for not standardizing or performing some sort of quality assurance to the interventional training of Physiatrists.

    So let's be honest about the real motive behind proposing a multi-disciplinary 12 month fellowship as a viable substitute for a pain-residency. Over-utilization of procedures.

    The most simple solution is to let nature take its course and to let the reimbursements fall.
    When the reimbursement for pumps fell, many with large pump practices stopped providing this service. Now, those who continue to implant a high volume of pumps generally are dedicated to it and do it well.
    Let the reimbursements fall, most of the unethical behavior will stop and those abusing the system will leave. Auto-regulation. Of course, this path is not favorable to those who stand to lose from it, and thus, we have the current solution which is a poor patchwork attempt at improving the current situation.

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