Advanced procedures during fellowship

[Ravenclaw90]

Which advanced procedures are commonly being done in the PP world? I am trying to make a rank list of pain fellowships and am wondering how crucial it is. My goal is get as much exposure as possible, to maximize my own comfort and foundational training, but there are some programs that are better fits for me but don't offer kyphoplasty, for example. Now that you have the hindsight of experience in the real world after training, whether this is in academics or PP, what do you recommend we prioritize when creating a rank list?

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[lobelsteve]

Everything outside a tpi or joint is an advanced procedure. Especially when you see it go wrong.

 

[afob100]

Probably the most common advanced procedures in pp are SCS and kypho. No one does pumps - limited evidence for verteflex, peripheral stim etc (and insurance often doesn't cover it).

I would say that most pain docs do scs trials but refer out for implant. Some larger pain groups will have a couple of implant docs and all the other docs doing trials. You want to be doing a high volume of implants in pp if you want to stay good...so it makes sense to have other docs send you implant cases (difficult to generate that volume on your own).

 

[deleted284725]

This isn’t an endorsement of anything specifically but in pp you’ll see: stim/drg trial and implant, pns trial and implant, vertiflex, mild, kypho (intracept seems to be coming also) prp of various flavors, varicose vein ablations, SI fusion, minimally invasive lumbar fusion devices like minuteman and zip. I also saw a pain doc advertising “The O Shot” recently. I would say as long as you get decent exposure to permanent implants and pns (and kypho if possible) everything else you might do is learnable at a course pretty easily.

 

[swamprat]

there is not enough time in fellowship to become comfortably with the advanced procedures - SCS u will prob do the most of but def wont be comfortable doing implants. i do all my own implants now - i was very slow and worried when i first came out but i wanted to do them. now ive done skin to skin in 35 minutes before

 

[drusso]

Which advanced procedures are commonly being done in the PP world? I am trying to make a rank list of pain fellowships and am wondering how crucial it is. My goal is get as much exposure as possible, to maximize my own comfort and foundational training, but there are some programs that are better fits for me but don't offer kyphoplasty, for example. Now that you have the hindsight of experience in the real world after training, whether this is in academics or PP, what do you recommend we prioritize when creating a rank list?

Ask the reps in your area to hook you up with their KOL's and spend some time doing peer-to-peers. It's a win-win-win.

 

[Ferrismonk]

Honestly, just go somewhere where you get SOME stim exposure. Kypho, PNS, pumps, etc can all be learned later if you wish. Fellowship is about learning. Learn how to diagnose properly and how to steer a needle properly. Everything else can be learned later, especially if it has a rep selling something.

 

[Nodolor]

Ask the reps in your area to hook you up with their KOL's and spend some time doing peer-to-peers. It's a win-win-win.

Boooooo!

 

[Ducttape]

the most important thing is to be comfortable doing your base procedures - SIJ, ESI, TF, nerve blocks. it helps to obviously get some experience with advanced procedures, but...
dont the cart before the horse if focusing on the advanced procedures primarily.

in programs that don't do kypho, just ask to shadow whoever does the kypho. most times it is interventional radiology. do a 2 week rotation watching them. with your superior needle skills doing all those bread and butter procedures, you should be good to go.

I have met - at a SCS conference - a doc who literally could not give a toradol shot let alone any simple injection, but felt completely comfortable implanting a pump.



to answer your question - prioritize the bread and butter procedures, how do diagnose the patient and how to treat the patient after the procedures fail.

 

[Gnarvin]

I agree that the most important part of fellowship is building a good foundation of knowledge and good solid interventional technique. Most everything else can be learned after fellowship if you have a solid foundation.

That being said, if you are going to do your own implants/surgical cases, then I would recommend trying to find a fellowship that does a lot of surgical cases. There is no substitute for time in the OR and for the experience managing complications. You don’t want the first time you see a complication to be when you are on your own and you have no one to ask and you haven’t dealt with the problem before.

 

[swamprat]

I agree that the most important part of fellowship is building a good foundation of knowledge and good solid interventional technique. Most everything else can be learned after fellowship if you have a solid foundation.

That being said, if you are going to do your own implants/surgical cases, then I would recommend trying to find a fellowship that does a lot of surgical cases. There is no substitute for time in the OR and for the experience managing complications. You don’t want the first time you see a complication to be when you are on your own and you have no one to ask and you haven’t dealt with the problem before.

I will argue that sometimes u have no choice. My first job out my partner . well coworker but great guy did cases with me we both learnesd from eachother and a lot.

 

[10KHertz]

If you can do a kypho you are likely capable of discograms. Good to be able to do the later for future therapies (intradiscal).

 

[Ferrismonk]

Ask the reps in your area to hook you up with their KOL's and spend some time doing peer-to-peers. It's a win-win-win.

I thought only washed up family docs were my "peers"?

 

[futureSuperStar]

Say I really want intrathecal baclofen pumps to be part of my practice, can this be done even if a lot of exposure isn't obtained during fellowship? How do you go about getting referrals?

 

[afob100]

You would need to go to courses/work with the medtronic reps to get good at implanting/managing them.

Then you will need to network in private practice- ideally with a large oncology group and/or PMR/rehab group for pump referrals. Pumps are becoming more rare these days. In any given area, there are usually only 1 or 2 docs that manage them - usually in academics.

Outside of oncology and spasticity, no use for pumps for the average pp pain doc

 

[Gnarvin]

Say I really want intrathecal baclofen pumps to be part of my practice, can this be done even if a lot of exposure isn't obtained during fellowship? How do you go about getting referrals?

If you think you want to do pumps on your own when you are done, you should do a fellowship that does a lot of pumps. You might change you mind about doing a lot of pumps on your own after managing them during fellowship.

 

[nopain1234]

Honestly, just go somewhere where you get SOME stim exposure. Kypho, PNS, pumps, etc can all be learned later if you wish. Fellowship is about learning. Learn how to diagnose properly and how to steer a needle properly. Everything else can be learned later, especially if it has a rep selling something.

Then what’s the point of a fellowship?

 

[Ferrismonk]

Than what’s the point of a fellowship?

Honestly, just go somewhere where you get SOME stim exposure. Kypho, PNS, pumps, etc can all be learned later if you wish. Fellowship is about learning. Learn how to diagnose properly and how to steer a needle properly. Everything else can be learned later, especially if it has a rep selling something.

 

[Status Sciaticus]

You would need to go to courses/work with the medtronic reps to get good at implanting/managing them.

Then you will need to network in private practice- ideally with a large oncology group and/or PMR/rehab group for pump referrals. Pumps are becoming more rare these days. In any given area, there are usually only 1 or 2 docs that manage them - usually in academics.

Outside of oncology and spasticity, no use for pumps for the average pp pain doc

If you think you want to do pumps on your own when you are done, you should do a fellowship that does a lot of pumps. You might change you mind about doing a lot of pumps on your own after managing them during fellowship.

Do pumps reimburse at a decent level in PP? I would imagine that would be the reason why its done primarily at academic centers?

Then what’s the point of a fellowship?

tO lEaRn To tAkE cArE oF tHe pAtIeNt. Or ArE yOu OnLy iN iT fOr FiNaNciAl gAiN?! ----- some attendings when I told them I was looking mostly at intervention heavy program than primarily bread and butter programs.

 

[geauxg8rs]

This isn’t an endorsement of anything specifically but in pp you’ll see: stim/drg trial and implant, pns trial and implant, vertiflex, mild, kypho (intracept seems to be coming also) prp of various flavors, varicose vein ablations, SI fusion, minimally invasive lumbar fusion devices like minuteman and zip. I also saw a pain doc advertising “The O Shot” recently. I would say as long as you get decent exposure to permanent implants and pns (and kypho if possible) everything else you might do is learnable at a course pretty easily.

Lol. My beavis and butthead like brain couldn’t get over the O shot immediately followed by permanent implant.