ACGME vs unaccredited fellowship

[Cassowary]

1. Is there any purpose of doing unaccredited PM&R fellowships if a physiatrist plans on opening his own practice? What about for group practice?

2. If am interested in spine (maybe regenerative spine?), but there is no such thing as an ACGME accredited spine fellowship; would it be worth it do just do an unaccredited fellowship? If not, which ACGME fellowship is most in line with practice on the spine?

Thanks

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[Piebaldi]

1. Is there any purpose of doing unaccredited PM&R fellowships if a physiatrist plans on opening his own practice? What about for group practice?

2. If am interested in spine (maybe regenerative spine?), but there is no such thing as an ACGME accredited spine fellowship; would it be worth it do just do an unaccredited fellowship? If not, which ACGME fellowship is most in line with practice on the spine?

Thanks

This has been discussed extensively. There are different views of thought. You are correct there is no such thing as an ACGME accredited spine fellowship. All spine fellowships are non-accredited.
You can do pain which can be either accredited or not. There is not regenerative spine, the closest you will find is the Centeno-Schultz fellowship which is regenerative in nature. But I believe I have been told you need like 100 injections prior to the fellowshpi to be eligible.

 

[sdnuser001]

On a somewhat related note what is the advantage of doing a non ACGME spine over non ACGME pain fellowship? Seems like the latter would teach everything that the former would + extra procedures like sympathetic blocks and possibly med management exposure which could always come in handy. Is there something I am missing?

 

[bear2020]

On a somewhat related note what is the advantage of doing a non ACGME spine over non ACGME pain fellowship? Seems like the latter would teach everything that the former would + extra procedures like sympathetic blocks and possibly med management exposure which could always come in handy. Is there something I am missing?

The advantage of doing a non-accredited fellowship is the ability to build upon and advance many of the skills you learned in rehab residency. You will continue to perform EMG/NCS and musculoskeletal medicine in addition to learning how to perform interventional procedures. The other advantage is that you would essentially do this year round. An ACGME accredited position has requirements such as a month of Psych, Anesthesia, Inpatient Coverage. Etc.. which is required. In some of the non-acgme fellowships you may end up performing more procedures depending on the practice setup. Some fellowships may include regenerative medicine, ultrasound and tenex procedures.

It's extremely important to note that not all of the non-accredited fellowships are created equal. Read the forum reviews for the highly regarded fellowships and you could interview at some to get a feel. Most will be 2 day "interviews" where you just see what the day to day is like. Some fellowships may have a wider breadth of procedures than others. Some fellowships are not worth your time.

You need to decide if you want to practice Pain Medicine (with ACGME fellowship) and treat the wide ranging acute and chronic conditions that come with that including medical management,psych, etc. OR an interventional physiatrist who practices MSK med, does EMGs and performs interventional procedures for back and neck pain.

Think about it this way, if a hospital hires you as a pain physician they may expect you to manage opiates or patient's with cancer pain. Most non accredited docs would not only not feel comfortable with that, but they wouldn't be able to get hospital privileges for it anyway. Could you do an ACGME Pain fellowship and then practice essentially interventional spine? Sure. But in my humble opinion this kind of takes away from the pool of physicians we need to practice comprehensive pain management. You also may struggle to relearn EMG for a while. The paper will open doors for you career wise though especially in academics and competitive markets.

 

[SSdoc33]

1. Is there any purpose of doing unaccredited PM&R fellowships if a physiatrist plans on opening his own practice? What about for group practice?

2. If am interested in spine (maybe regenerative spine?), but there is no such thing as an ACGME accredited spine fellowship; would it be worth it do just do an unaccredited fellowship? If not, which ACGME fellowship is most in line with practice on the spine?

Thanks

WTF is regenerative spine?

if you plan on putting stem cells into discs A: you have to learn how to get in to a disc and B: you are going to have a lot of unhappy, poor patients

 

[Cassowary]

WTF is regenerative spine?

if you plan on putting stem cells into discs A: you have to learn how to get in to a disc and B: you are going to have a lot of unhappy, poor patients

I heard a pmr doc talk about it, seems interesting

 

[Eilat87]

I heard a pmr doc talk about it, seems interesting

Think he was being sarcastic. Jury is still out on regenerative disc stuff.

 

[cowboydoc]

WTF is regenerative spine?

if you plan on putting stem cells into discs A: you have to learn how to get in to a disc and B: you are going to have a lot of unhappy, poor patients

If you accept b, a isn't that important. Placebo will serve the same end.

 

[thiswonthurtabit]

On a somewhat related note what is the advantage of doing a non ACGME spine over non ACGME pain fellowship? Seems like the latter would teach everything that the former would + extra procedures like sympathetic blocks and possibly med management exposure which could always come in handy. Is there something I am missing?

It depends on what kinds of patients you want to cater to. If you do spine instead of pain you can easily defer/avoid referrals for some of the difficult beasts such as chronic abdominal and pelvic pain since you are 'just a spine guy'. If you're interested in treating a broader spectrum of pain conditions beyond spine the pain fellowship isn't a bad idea.

 

[RM38]

I work for a private practice pain group that has hired several people from Sport and Spine fellowships which I think was a big mistake. They are great with spine and joint issues but typically they really are not comfortable managing things outside of that at all depending on what they were exposed to. They are usually not comfortable/knowledgable with med management and often times have no idea how to taper high dose opiate patients or deal with somebody that has a pump. They also have more difficulty addressing other issues such as psych stuff that is very prevalent in chronic pain patients. In my next group(mix anesthesia and PM&R pain) I would likely not hire somebody from one of these programs if I have any input and I did an unaccredited fellowship. I strongly argree ACGME fellowship opens more doors than non-accredited spot. If you don't do EMGs in fellowship you can always relearn them and you should do plenty of spine stuff in fellowship. Some of the unaccredited places teach you to arthrograms which may be attractive to ortho groups if they have their own MRI machine. The most important thing is you can always do a pain fellowship and then just drop all of the other stuff and just be a "spine guy" and do zero med management if you want, but I think it is much harder to do the opposite.

 

[Eilat87]

I work for a private practice pain group that has hired several people from Sport and Spine fellowships which I think was a big mistake. They are great with spine and joint issues but typically they really are not comfortable managing things outside of that at all depending on what they were exposed to. They are usually not comfortable/knowledgable with med management and often times have no idea how to taper high dose opiate patients or deal with somebody that has a pump. They also have more difficulty addressing other issues such as psych stuff that is very prevalent in chronic pain patients. In my next group(mix anesthesia and PM&R pain) I would likely not hire somebody from one of these programs if I have any input and I did an unaccredited fellowship. I strongly argree ACGME fellowship opens more doors than non-accredited spot. If you don't do EMGs in fellowship you can always relearn them and you should do plenty of spine stuff in fellowship. Some of the unaccredited places teach you to arthrograms which may be attractive to ortho groups if they have their own MRI machine. The most important thing is you can always do a pain fellowship and then just drop all of the other stuff and just be a "spine guy" and do zero med management if you want, but I think it is much harder to do the opposite.

I would agree. I'm currently a spine fellow applying for jobs. I do not feel at all comfortable with narcotics management as I didn't have much exposure during my training (primarily orthopedic practice). I would say half of employers out there want the shiny ACGME accreditation. And the other half don't know or don't care. Especially when you're talking to a surgical practice, a lot of spine surgeons don't know about this stuff. They only care if you can do the procedures they want you to do.

 

[sdnuser001]

I would agree. I'm currently a spine fellow applying for jobs. I do not feel at all comfortable with narcotics management as I didn't have much exposure during my training (primarily orthopedic practice). I would say half of employers out there want the shiny ACGME accreditation. And the other half don't know or don't care. Especially when you're talking to a surgical practice, a lot of spine surgeons don't know about this stuff. They only care if you can do the procedures they want you to do.

What factors should go in when choosing an unaccredited fellowship? Depth/breadth of procedures? Academic over private practice? And should you choose a location near where you want to settle or not necessarily due to non-compete clauses?

 

[drusso]

If you accept b, a isn't that important. Placebo will serve the same end.

There's a great Regen Spine course coming up in November:

https://interventionalorthopedics.org/physician-education/

 

[RM38]

What factors should go in when choosing an unaccredited fellowship? Depth/breadth of procedures? Academic over private practice? And should you choose a location near where you want to settle or not necessarily due to non-compete clauses?

The things you should be looking at are the variety of cases and the number of procedures done. If they only do spine related stuff and don't much in the way of advanced procedures like SCS, you likely would be limited in your skill set depending on your residency training. You never really know what a program will be like until you interview and you should go somewhere that fits what you think you want to to practice like. Just remember, the more narrow the focus, the less opportunity you may have when job searching. You can always decrease the scope of what you deal with as attending. Non-competes can be really be an issue, and if you really want to stay in that area, it should be discussed upfront. I am not sure how enforceable a non compete is on somebody only making like 50K that is technically a trainee, but you don't likely have the financial resources to find out. Academic places likely will not have a non-compete and may be looked at as more legit by some groups, especially if you want to do academics. I also only partially agree with the ortho group situation. I my area, most people working with Ortho did ACGME fellowship and would not hire otherwise. Likely because they want them doing much of the peri-op med management and are attracted to them bringing in higher volume of patients from pcp for basically everything MSK related and not just spine. Many Ortho groups do not want you doing any med management what so ever, and they are less likely to care. Many of them will want to know if you will do the procedures their way or not. This is especially true with cervical epidurals. They will expect you to do a cervical TFESI when ordered. Many programs do not teach those and many pain people including myself don't do them.

 

[Bostonspine]

I work for a private practice pain group that has hired several people from Sport and Spine fellowships which I think was a big mistake. They are great with spine and joint issues but typically they really are not comfortable managing things outside of that at all depending on what they were exposed to. They are usually not comfortable/knowledgable with med management and often times have no idea how to taper high dose opiate patients or deal with somebody that has a pump. They also have more difficulty addressing other issues such as psych stuff that is very prevalent in chronic pain patients. In my next group(mix anesthesia and PM&R pain) I would likely not hire somebody from one of these programs if I have any input and I did an unaccredited fellowship. I strongly argree ACGME fellowship opens more doors than non-accredited spot. If you don't do EMGs in fellowship you can always relearn them and you should do plenty of spine stuff in fellowship. Some of the unaccredited places teach you to arthrograms which may be attractive to ortho groups if they have their own MRI machine. The most important thing is you can always do a pain fellowship and then just drop all of the other stuff and just be a "spine guy" and do zero med management if you want, but I think it is much harder to do the opposite.

Just so your aware a lot of us don’t find it attractive to taper high dose opioids we did not start and I find dealing with the psych issues related with pain is more related to the individual than the fellowship training. That may have just been a method of dump those patients on you.

 

[RM38]

Just so your aware a lot of us don’t find it attractive to taper high dose opioids we did not start and I find dealing with the psych issues related with pain is more related to the individual than the fellowship training. That may have just been a method of dump those patients on you.

If you read through the pain forum I don't think any of us find tapering opioids is attractive and is certainly not something I enjoy doing. I am not an big advocate for chronic opioids in the non-cancer population and I manage my patients that are on medications with minimal doses. I am also not a pyschiatrist and I do not treat psych issues directly, but recognizing certain psych behaviors in chronic pain patients is important and takes some training to recognize and address. I do not accept med dumps from other practices. If the patient comes to me on meds, I do my own eval and discuss with the patient what I will or will not do for them. If they do not agree with my plan they are free to return to their previous practice or seek another opinion. Since this really a discussion about fellowship and job opportunities thereafter, my point on here is that different employers will have different expectations of physicians for that individual practice. The residents on here need to understand that where they train could impact their job opportunities when they finish and they need to think about that before they accept a fellowship spot. I personally wish I had stayed in the match as my job search would have likely been easier considering I was originally trying to live in a very saturated job market. I am about to start a new practice and hopefully the new group will be great, but I am moving farther away from family to do so. For some people, location is extremely important due to family issues and they need to know the advantages/pitfalls of the different training environments. I have seen first hand fellows come out of a sports and spine type fellowship and not be prepared to deal with some of the issues they would face in a traditional pain practice and how that affects both the employer and the physician negatively. It should be noted that my former practice universally manages meds conservatively and patients are not on high dose meds with the exception of a few cancer patients and it is was still a problem. My next practice is a multidisciplinary pain practice that has a PhD psychologist and we very carefully screen all patients. At my interview they were direct to discuss what I was and was not comfortable managing to make sure I was a proper fit for the practice. Due to my previous experiences I would not hire a fellow that did not have exposure to a more traditional pain environment if I have any say in the matter. Again, this should not be taken as insult to people that do sport and spine type fellowships. The other people in my practice were very smart and well trained and there are plenty of practices out there that would want people with their skill set. I would have let them do an epidural on me if I needed one. It was just very clear that the practice type was not a good fit and it created issues. Also there is some other liability issues surrounding med management that they usually do not understand like proper interpretation of LCMS, but that can be learned without much difficultly. At the end of the day, ACGME fellowship provides the most opportunity. I don't know of any job that would not hire somebody because they did one, but I do know of plenty that will not because they didn't.