mupmr

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Does anyone know what are the ACGME requirements for a pain fellowship seeking ACGME accreditation? I looked on the ACGME site but was unsuccessful. Also, does anybody have any idea if Goodman's program in Alabama will be accredited?
 

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paz5559

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mupmr said:
Does anyone know what are the ACGME requirements for a pain fellowship seeking ACGME accreditation? I looked on the ACGME site but was unsuccessful. Also, does anybody have any idea if Goodman's program in Alabama will be accredited?
I spoke with Dr. Goodman at length about this very topic. first, let me say his fellowship is terrific, and one that generally slips below the radar, but is clearly worth a look. (only downside is that you do have some minimal inpatient responsibilities).

He is attempting to become ACGME accredited, although he is not at present. Now for the odd part - in order to become ACGME accredited, you need to affiliated with an accademic instututon. Rather than UAB, Dr. Goodman is attempting to become affiliated with the University of Missouri's PM&R program (where a number of his fellows have come from in the recent past). He tends to give preference to residents from that program at the moment, and will tell you he does this in order to become ACGME accredited.
 

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DigableCat said:
Ultimately, the programs themselves know what they need to do and it involves ALOT of paperwork. And many are just not interested, but they may be soon when they see their applicant quality and numbers fall off as more residents will only consider ACGME accredited programs.
Any resident who does not consider Slipman, Aprill, Prather, CINN, HSS, RIC, BI, Falco, FSI, Cole, Pauza, Stanford, Michigan's Spine fellowship, etc, solely because they are not ACGME accredited, is missing out on some of the best training in the country, IMHO.

Your focus should be on getting the best training first, second, and third. The sky is falling pronouncements made by those on the ABPM&R are just not borne out by the facts at present. Will you need Pain boards? Who knows? Will you get better training in Oklahoma City (an ACGME accredited PM&R progam) than any of the aforementioned places? What do YOU think?
 

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paz5559 said:
Any resident who does not consider Slipman, Aprill, Prather, CINN, HSS, RIC, BI, Falco, FSI, Cole, Pauza, Stanford, Michigan's Spine fellowship, etc, solely because they are not ACGME accredited, is missing out on some of the best training in the country, IMHO.
No, I agree wholeheartedly. Just because someone put out the time/effort to fill out the paperwork needed to be ACGME accredited, does not make them any better than the others. BUT with being ACGME accredited, in my opinion, there has to be certain quality of standards that has to be met. Otherwise they lose their accreditation. There is a higher power to answer to than themselves. And ultimately, I think this is theoretically in place for the benefit of the fellow and the protection of our patient population at large. Regardless of whether Slipman, Pauza, or Gotlin would like to acknowledge it, as more pain physicians are being churned out...in order to remain competitive(and especially against ANES pain physicians) we should try to ensure a certain standard of care and pursue ACGME accreditation. What are the drawbacks to having it? Why don't they want it?

And if it's purely for the reason of paperwork(as most of the programs you have listed above already have academic affiliation), then that shows a lack of motivation for reasons unknown to us. And before we decide any fellowship program, we should ask why?


BTW, there is a certain ACGME accredited PM&R fellowship that some friends of mine applied to that they were certainly NOT impressed with at all. And I'm surprised this program even has accreditation, given the fellows training at this program. And another ACGME accrediated PM&R program to me that has suspect ACADEMIC affiliation, as the hospital program that they claim to be affiliated with doesn't appear to have any residents rotate with them(I mean...kinda hard considering they are in different states). Probably affiliated purely for the purpose of acquiring ACGME accreditation.

Ultimately, you have to do what's best for you. Some of us have decided that regardless of whether it's ACGME or not, we have to CYA(cover your a**). The last thing a hospital will be able to use to deny me privileges to use their C-arm or the last thing an attorney will be able to use against me in a malpractice case is that I didn't complete a ACGME(read: Competent Standard of Care) fellowship. Shame it has come to that. Really.
 

neuropathic

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paz5559 said:
Any resident who does not consider Slipman, Aprill, Prather, CINN, HSS, RIC, BI, Falco, FSI, Cole, Pauza, Stanford, Michigan's Spine fellowship, etc, solely because they are not ACGME accredited, is missing out on some of the best training in the country, IMHO.

Though I agreed they are all good or even outstanding spine fellowships, there is a reason or reasons they are not ACGME accredited. ACGME has no interest in accreditating non-invasive spine training. Spine injections are not rocket science and most people don't need a year of training to learn how to do them IMHO. I do recommend residents to pursue fellowship training because it is important to have that added credentials to cover yourself and your patients.

I believe the few PM&R accredited pain fellowships are still quite different from the good Anesthesia based pain fellowships as the training is more comprehensive in true "pain management", covering the whole spectrum of acute, chronic, cancer pain. The PM&R pain fellowships may be more musculoskeletal and spine focus.
 

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Actually, both the quality and number of applications have already dropped from what I've been told. As many of you might know, there was a discussion on this very subject at the AAPM&R meeting.

I think it would be a mistake to underestimate the value of ACGME-accreditation and being eligible to take the Pain boards. Previously, I think the Spine fellowships were a much better option because you could still take the Pain boards; that avenue is over, however.

I agree that fellowships such as Slipman, Stanford (run by our graduate who did an ACGME-accredited Pain fellowship), Pauza, HSS (at least one graduate you've mentioned from this fellowship felt the need to do a second ACGME-accredited Pain fellowship to further his career), etc. are excellent. However, the fact is that we are always developing new procedures and discovering that others don't work as well as we thought it might. Fellowship is only one year and in 7-10 years, you'll probably be doing different things than what you learned during your Spine fellowship. While technology, procedures, and the liability landscape may change, your CV and subspecialty certification will not. Will hospitals, academic centers, and groups require subspecialty certification in the future? You put it best when you said "Who knows?".
 

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Stinky Tofu said:
Actually, both the quality and number of applications have already dropped from what I've been told. As many of you might know, there was a discussion on this very subject at the AAPM&R meeting.

I think it would be a mistake to underestimate the value of ACGME-accreditation and being eligible to take the Pain boards. Previously, I think the Spine fellowships were a much better option because you could still take the Pain boards; that avenue is over, however.

I agree that fellowships such as Slipman, Stanford (run by our graduate who did an ACGME-accredited Pain fellowship), Pauza, HSS (at least one graduate you've mentioned from this fellowship felt the need to do a second ACGME-accredited Pain fellowship to further his career), etc. are excellent. However, the fact is that we are always developing new procedures and discovering that others don't work as well as we thought it might. Fellowship is only one year and in 7-10 years, you'll probably be doing different things than what you learned during your Spine fellowship. While technology, procedures, and the liability landscape may change, your CV and subspecialty certification will not. Will hospitals, academic centers, and groups require subspecialty certification in the future? You put it best when you said "Who knows?".
1) Despite what Neuropathic has repetedly said, I really DON'T think even he/she believes you could train a monkey to do spine injections WELL. I also don't believe that in order to be a good interventionist you need to be a comprehensive pain management specialist. If I do 8-12 procedures a day, you can have ALL my fibromyalgics, (+) Waddells, inpatients, and yes, even my pumps and stims. Discography, transforaminals, sympathetic blocks, intradiscal procedures, vertebroplasty, kyphoplasty, and their progeny, will keep me fully occupied, and you can have all of my wacko patients with my blessing

2) I don't think ANY anesthesiologist I have met is as well trained in cervical transforaminal approaches as are physiatrists.

3) The future of these procedures are surgicenters and specialty hospitals. As both of these will be for profit enterprises, they will NEVER deny you the right to generate revenues on their behalf. Ergo, do you REALLY think they WON'T privilege you?

4) Remind me again, where did Dr's el Abd at Spaulding, Plastaras at RIC, Lipitz, at LIJ (Past President of PASSOR), and Depalma at MCV (ACGME accredited programs all) train? Oh THAT'S right - that non-ACGME accredited program in Philly!

5) While I understand the fear of what the future may bring, in addition to looking good on paper, which I do not deny is important, what I believe is more important still is the decision making algorithm (ie who to do it on, and what to do, specifically) and needle skills necessary to access both the nerve root sleeve and the disc. While I entirely agree that procedures will change, what we inject, of what the tool will be, is secondary to being comfortable with the anatomy, the approaches, and the ability to get the instrument where it needs to be. THAT element of my training, at least to me, is paramount.
 

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You can also add Dr. Isaac (who won the Earl C. Elkins award) to the list of SRH attendings who trained with Slipman. Like I said before, I think his fellowship is excellent, but was a more attractive option when you were still eligible to take the Pain boards. In fact, since you mentioned Dr. El Abd, you should know that he did take the Pain boards and passed. Clearly, he saw the value in hedging against any changes the future might bring. In fact, I wouldn't be surprised if many of the others you've mentioned did the same thing.

I don't want it to be misconstrued that I am trying to discourage people from doing these fellowships. I just feel strongly that we should push to get these otherwise excellent fellowships ACGME-accredited. Not only would it be good for its graduates, but it would also be good for Physiatry in general. To accomplish this, we could either have them meet the requirements for an ACGME-accredited Pain fellowship program or push for the creation of an ACGME-accredited Interventional Spine fellowship. One of the concerns from people running these non-accredited fellowships is that they can no longer treat the fellows as attendings and have them bill independently. Every procedure would need to be supervised and for some of the people running these fellowships, that will ultimately hurt the bottom line. If people are still doing these fellowships, there's not as much of an incentive to change things. Anyway, there appears to be other factors in addition to the mounds of paperwork.

Lastly, I think that even at surgicenters and specialty hospitals, subspecialty certification could be an issue as well. Look at this post about an attending at a Children's hospital who had been practicing for 10+ years and was forced to do a fellowship. Unless you plan on opening your own surgicenter, being an attractive job applicant will still be important. Even in a group practice setting, those that have done an ACGME-accredited fellowship and have obtained subspecialty certification might be viewed as more attractive and less of a medico-legal risk. Ultimately, while your colleagues might not care, lawyers, hospital committees, and those determining reimbursements might. Irregardless of whether or not these things will happen or not in the future, I still think it's in the best interests of fellows and patients for a program to be accredited by the ACGME.
 

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Everyone is entitled to their opinion, here is another point of view.

paz5559 said:
1) Despite what Neuropathic has repetedly said, I really DON'T think even he/she believes you could train a monkey to do spine injections WELL.
On the contrary, if the da Vinci robot is assisting surgeries these days, I don't see why you can't train a "monkey" to do injections.

paz5559 said:
If I do 8-12 procedures a day, you can have ALL my fibromyalgics, (+) Waddells, inpatients, and yes, even my pumps and stims. Discography, transforaminals, sympathetic blocks, intradiscal procedures, vertebroplasty, kyphoplasty, and their progeny, will keep me fully occupied, and you can have all of my wacko patients with my blessing.
A good physician don't just keep doing procedures, you have to at least put half your effort to talk to your patients and show your concerns. There may be patients with complex psychosocial issues, but no one is a "wacko".

paz5559 said:
2) I don't think ANY anesthesiologist I have met is as well trained in cervical transforaminal approaches as are physiatrists.
You certainly have not met Gabor Racz, Leland Lou, Prithiv Raj, James Rathmell,...etc.

Good luck to you paz. The training is often what you made of it. It would still be an ongoing learning process after fellowships for everyone, whether it is the worst anesthesia program, or the best PM&R spine program. The difference is one is borad eligible and the other is not.
 

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The ACGME will not accredit training experiences that only focus on technical skill acquisition. Indeed, one of the many requirements for becoming an ACGME-recognized sub-specialty is that it must be demonstrated that there is in existence a sufficient body of knowledge (ie academic/cognitive base) that goes beyond what is traditionally learned in a residency curriculum. This is the driving rationale for a fellowship...that is, that there is just "not enough time to learn it all..."

This why it has taken Neuromuscular Medicine (which will include six-months of EMG training in it core competencies) so long to come into its own. EMG'ers have been board certified by the AANEM, a bonafide non ACGME board, for decades. But, it is only relatively recently that the practice of electrodiagnostic and neuromuscular medicine has progressed substantially beyond doing and interpretting a procedure in the eyes of the ACGME. Now, most electromyographers not only perform and interpret various electrodiagnostic tests, but also make specific recommendations regarding a wide variety of neuromuscular disorders including what genetic tests to order, where to perform a biopsy, etc. With this scope of practice in mind, the ACGME recognizes the need for a Neuromuscular Medicine fellowship

It's my understanding that there has been very preliminary discussions about increasing the breadth of ACGME fellowships offered under the ABPMR umbrella. Currently, Pain, Peds, SCI, and very soon Neuromuscular Medicine are solely sponsored or co-sponsored by ABPMR. Two other potential fellowship programs include an Acquired Brain Disorders (ABD) program and Interventional Spinal Therapeutics (IST). ABD will likely include in its core competencies the comprehensive management of spasticity including chemodenervation and IST will, of course, include needle work. The success of these applications will hinge upon how well the sponsors can demonstrate a cognitive/academic base.

Relatedly, the whole ACGME Pain Medicine program requirements and core competencies are under review this year and the general feeling among those involved in the that group's RRC is that Pain Medicine needs to be broader in its scope so the focus is not on interventional skill acquisition only.

So, the way I read the tea leaves is as such: It depends what you want to do and where you want to do it. If you want to practice bread and butter musculoskeletal medicine away from an academic setting and only do selected interventional techniques in the lumbar spine and pelvis, you can probably get by without a formal ACGME-approved experience. Since, diagnostic and therapeutic axial spine injections are included in the core training of PM&R, you will have a good leg to stand on in terms of credentialing with your non-ACGME approved fellowship. If, however, you want to practice the full spectrum of Pain Medicine---malignant pain, cancer, chronic pain, inpatient/catheter management, etc---the ACGME fellowship looks like the route to go.

How all this will exactly play out remains to be seen.
 

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drusso said:
The ACGME will not accredit training experiences that only focus on technical skill acquisition. Indeed, one of the many requirements for becoming an ACGME-recognized sub-specialty is that it must be demonstrated that there is in existence a sufficient body of knowledge (ie academic/cognitive base) that goes beyond what is traditionally learned in a residency curriculum. This is the driving rationale for a fellowship...that is, that there is just "not enough time to learn it all..."

Two other potential fellowship programs include an Acquired Brain Disorders (ABD) program and Interventional Spinal Therapeutics (IST). ABD will likely include in its core competencies the comprehensive management of spasticity including chemodenervation and IST will, of course, include needle work. The success of these applications will hinge upon how well the sponsors can demonstrate a cognitive/academic base.

From talking with Dr. Nicolas E Walsh, my Chairman and President of the ABPMR: At this time, there is not going to be any type of accredited fellowship in Interventional Spine in the near future(nor does he expect there to be). From reasons stated above, approval from ABMS, as well as turf battle policies that would be fought with the surgical subspecialties (namely Ortho and Neurosurg).

There was a rather interesting discussion I had with him recently on how PM&R was able to come to an agreement with American Board of Anesthesiology that enabled PM&R to become Board Certified in Pain Medicine. Trust me, alot of politikin was going on.

If we as a specialty expect to be taken seriously and respected, especially by Anesthesiology, we have to be prepared to be trained in all aspects of pain medicine. Both the medical management as well as the interventional side. Patients benefit most from a comprehensive multidisciplinary approach that includes medication management, psychological intervention, functional restoration in the form of therapy, and WHEN NEEDED spinal intervention. If you can get all of that from a "SPINE FELLOWSHIP", that's great.

The peds pain, the cancer pain, the headaches, and yes...even the dreaded fibromyalgia: whether you chose to accept those patients into your practice when you're done is up to you. But every one of those cases during your training will be a learning opportunity and will teach you how to approach the simplest to the most complex "back pain" patient. And don't you want to know the most for optimally managing your patients.

Stinky and Drusso won't say it, but I will. Just do the dang ACGME fellowship! It's a win-win situation. ;)

Just my thoughts anyway.
 

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DigableCat said:
Stinky and Drusso won't say it, but I will. Just do the dang ACGME fellowship! It's a win-win situation. ;)

Just my thoughts anyway.
Thanks, Dig...I think that David St. Hubbins summed it up well...

"It's fine line between stupid and clever..."

David St. Hubbins
Lead singer and rhythm guitarist
Spinal Tap
 

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mupmr said:
Also, does anybody have any idea if Goodman's program in Alabama will be accredited?

It appears that Goodman's program in Alabama is now ACGME accredited, although it's through the University of Missouri-Columbia. I suppose the 630 miles between Birmingham, Alabama and Columbia, Missouri is quite inconsequential.
 

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DigableCat said:
It appears that Goodman's program in Alabama is now ACGME accredited, although it's through the University of Missouri-Columbia. I suppose the 630 miles between Birmingham, Alabama and Columbia, Missouri is quite inconsequential.
Dr. Goodman himself told me they were, indeed, accredited, but the ABPM&R website does not yet list them as such
 

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neuropathic said:
The training is often what you made of it. It would still be an ongoing learning process after fellowships for everyone, whether it is the worst anesthesia program, or the best PM&R spine program. The difference is one is borad eligible and the other is not.
I believe the 8 ACGME accredited PM&R programs might take issue with that
 

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paz5559 said:
I believe the 8 ACGME accredited PM&R programs might take issue with that

11, not 8.


Program Number / Name / Address Specialty Director Phone / Fax / Email
[3410531003] VA Greater Los Angeles Healthcare System Program
Greater Los Angeles Veteran Affairs Health Care System
11301 Wilshire Boulevard (w117)
Los Angeles, CA 90073
Pain Medicine (PM) Quynh Pham, MD (310)268-4935

[email protected]
[3410713011] University of Colorado Program
University of Colorado
1635 North Ursula Street
Anschutz Outpatient Pavilion, 4th Floor
Aurora, CO 80045
Pain Medicine (PM) Venu Akuthota, MD (720)848-1980
(720)848-2019

[3411031009] Georgetown University Hospital/National Rehabilitation Hospital Program
Washington Hospital Center
110 Irving Street, NW
Washington, DC 20010
Pain Medicine (PM) Malady S. Kodgi, MD (202)877-3442
(202)877-8194

[3411222008] Emory University Program/Georgia Pain Physicians
Emory University School of Medicine
2550 Windy Hill Road, Suite 215
Marietta, GA 30067
Pain Medicine (PM) Robert E. Windsor, MD (770)850-8464
(770)850-9727

[3412312007] Sinai Hospital of Baltimore Program
York Center for Pain Management and Rehabilitation
2901 Pleasant Valley Road
York, PA 17402
Pain Medicine (PM) Michael B. Furman, MD, MS (717)848-4800
(717)755-9618
[email protected]
[3412412004] Harvard Medical School/Spaulding Rehabilitation Hospital Program
Harvard Medical School/Spaulding Rehabilitation
125 Nashua Street
Boston, MA 02114
Pain Medicine (PM) Alec L. Meleger, MD (617)573-2178
(617)573-2769

[3412521006] University of Michigan Program
University of Michigan
Dept of PM&R
325 E Eisenhower, Suite 100
Ann Arbor, MI 48108
Pain Medicine (PM) J. Steven Schultz, MD (734)936-7201
(734)763-4224
[email protected]
[3412812012] University of Missouri-Columbia Program
University of Missouri-Columbia
52 Medical Park East Drive, Suite 115
Birmingham, AL 35235
Pain Medicine (PM) Bradly S. Goodman, MD (205)838-3900
(205)838-3906

[3414112010] Temple University Hospital Program
Temple University
139 East Chestnut Hill Road
Newark, DE 19713
Pain Medicine (PM) Frank J. Falco, MD (302)369-1700
(302)369-1717

[3414813005] Baylor University Medical Center (Oklahoma City) Program
St. Anthony North Ambulatory Surgery Center
6205 North Santa Fe Avenue, Suite 200
Oklahoma City, OK 73118
Pain Medicine (PM) Michael J. Carl, MD (405)427-6776
(405)419-5646

[3415121001] Virginia Commonwealth University Health System Program
Medical College of Virginia/VA Commonwealth Univ. Program
P.O. Box 980661-0677
Richmond, VA 23298
Pain Medicine (PM) David F. Drake, MD (804)828-0861
(804)828-5074