Though I cannot speak for anybody else. In my opinion our leadership has made a mistake in the concessions they have made regarding pain medicine training. Under new ACGME guildlines (correct me if I'm wrong), there will be one pain fellowship per institution with faculty representation of 2 or 3 of 4 core specialties (Anesthesia, PM&R, Neurology, Psyche). Rotations in each of these four disciplines is mandatory and the sponsoring institution must house residency programs for 2 of the aformentioned core specialties. Supposedly, each fellowship will be held accountable to these standards at their next ACGME site review. This should open doors for Physiatrists and Neurologists at all programs. After all, what kind of Physiatrist or Neurologist is going to agree to be on a pain faculty for a fellowship that does not accept residents from their specialty? Of course this sounds good "in theory", but we all know about politics in medicine. On the flip side, accreditation of any new PM&R pain fellowships will now be extremely difficult and may stop completely. Physiatric fellowship directors now attempting to get their fellowships accredited must find a hospital without a pain program and then fulfill these new requirements in addition to providing experience/exposure in pediatric pain, cancer pain, etc.
What will happen at institutions with two fellowships? Will they merge? Will spots get cut? From what I've seen, some programs are merging already, with Anesthesia keeping their spots and PM&R keeping their spots. So again, this does not help us.
So what I think will happen is that the growing number of Physiatrists able to practice pain medicine (something we possess almost all of the clinical tools for) will be effectively surpressed/contained, fluctuating on a year to year basis depending on the size of the applicant pool by Anesthesia.
For a number of years now, Physiatrists have been able to grandfather into ABMS certification through spine fellowships or practice. Anesthesia was able to do their fellowships, we were able to do ours. Certification was not a problem. Now that this has ended, give it ten years when there will be a rapidly growing number of non ABMS certified Physiatrists serving a whole lot of patients and there may be a huge problem. This is where I believe our leadership may have been a bit short sighted.
Another point of contention is that I believe we are unofficially forcing many of our new graduates primarily interested in advanced musculoskeletal medicine and non-operative spine care into "pain" fellowships, where a substantial amount of their one year fellowship (4-8 months) may be spent managing PCAs, inpt pain consults, palliative care, etc. While I believe that we Physiatrists make excellent pain docs, I do not believe that interventional procedures should be solely the domain of those who focus on the entire scope of "pain".
So, a solution I believe is feasible is to update our core ACGME PM&R residency guildlines. Make musculoskeletal/spine training more standardized and add a requirement for experience with/exposure to basic fluoroscopically guided spinal injections (Lumbar ESIs, MBBs, facets), perhaps even a required number of injections performed under supervision. Benefits I see from this would be three fold.
1. ACGME accrediatation would become a non-issue. All physiatrists would be ABMS certified to wield a needle (through our residency training).
2. Physiatric representation in pain medicine would be much larger and stronger through sheer numbers.
3. Those wishing to become comprehensive pain specialists would still have that option, through fellowship training. Those wanting to be musculoskeletal/spine specialists would not be forced into it, and would have the option and skills to enter musculoskeletal practice after their PGY-4 year (the difference between an attending and fellow salary are nothing to sneeze at!).
Once upon a time, someone thought EMGs important enough put a training requirement into PM&R residencies, then later with an attached number of studies (200). As a result, all Physiatrists should be able to perform basic electrodiagnostic studies and few feel a need for EMG fellowship training. Our represention in the world of electrodiagnostics is strong, and we by and large have a very collegial relationship with Neurology. Perhaps it is time to make the same change with interventional training. After all, Physiatry is already strongly represented within organizations such as ISIS, NASS and ASIPP. Now, I realize that such a change would probably need support from PASSOR and ultimately the leadership of the AAPMR, but if you think about it, many of the current leadership of PASSOR at its inception ('93) were at a stage in their careers where many of us on this forum are today. PASSOR's original goal was to make musculoskeletal medicine prominent within the specialty of PM&R. They have accomplished this. There is much more to do and now it's our turn to contribute.
Regarding a pain medicine residency, in the latest issue of the AAPM newsletter, it looks like they are actually going through with this, starting with the creation of a residency review comittee (RRC). Good for them, I hope they see this through however many years it takes.
Email ligament for his two cents.
