Bird in the hand for spine fellowship?

[Disciple]

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> So, then, I would be interested in your assessment of how the speciality of physiatry has come to a place where many residents, who ostensibly fulfill basic ACGME core competencies by virtue of their time spent in training, are so woefully unprepared for actual clinical practice without the additional or remedial education you outline above?

IMO, the obvious answer is that the current didactic, clinical, and assessment structures are inadequate. Some ways they are:

DRusso, I wait excitedly to hear your thoughts, and the thoughts of any others.

Agree with most of your points.

To me, the most glaring problem is that many PM&R departments stay afloat by keeping their inpt unit full. Since there are no interns, PGY-2s through 4 do all the scut. Sicker patients are admitted leading to a higher work load. Education comes 2nd (Unfortunately, this is how many residents are turned-off to careers in inpt rehab early in their residencies).

With large inpt units, residents are often so busy making phone calls and answering pages that they don't get a chance to watch the patient in therapy, etc. With what little outpt time they are allotted, they are forced to choose between neuromuscular clinics or rotations in sports/spine/interventional rotations. This is often the cause of the necessary remedial training mentioned above by drusso.

I like your idea about adopting the IM model. However, IM has a hierarchy. Much of general inpt rehab functions like an extension of intern year. In contrast to IM, during an inpt rehab rotation, PGY-4s generally don't supervise PGY-3s and PGY-3s generally don't supervise PGY-2s. Several friends who have finished Medicine residencies have told me that most of their education came during PGY-2 and 3, when they were making decisions on patients, doing continuity clinic, etc.

Most of our programs are not large enough to support that type of hierarchy, so we must find another way. The use of midlevels is one solution. At first suggestion, this would not be cost-effective (midlevels are more expensive), unless the freed up resident generates income during his freed up time through, say, spinal injections or EMG. This may necessitate creation of a Spine Center, or at the very least, a spine clinic. Rather have the resident in neuro-rehab clinics? Fine. At the very least, the resident should be generating income through peripheral joint injections, trigger point injections, Botox for spasticity, or even just f/u visits (max 30 minutes). The typical 45-60 min PM&R office visits would have to be done away with. The idea is that the resident perform repetitions of valuable skills while also supporting the department by generating revenue.

There are solutions.


But it will take an openness to a fundamental change in philosophy (Recurring theme).

 

[axm397]

I think the same can be said for the fellowship programs. There are (I forgot who came up with this term- maybe DRusso) "families" of fellowships that share similar philosophies and skill sets.

One of the recent RIC grads called it the "circle of trust" (like in meet tha parents). It was kind of funny but true. the family, marriage, and cousin analogy does have some incestruous connotations though...

One issue with the family analogy is that most of the PM&R "families" do not have ACGME accreditation at this time. Perhaps in a few years we will start seeing ACGME sports medicine accreditation but for those residents who place value in accreditation (and that is another long discussion in itself) - we really don't have families right now.

I think my class has been hit with the consequences of the ACGME requirements. Last year's class slipped through into fellowship programs that had not made changes yet to comply with the ACGME requirements. This year, as late as July of this year, programs have started to change their structures - at least on paper. Fellowship directors have changed, and curriculum and training have changed. The residents applying this year can't rely on information from the past few years because even current fellows don't know what these changes mean. There are only a few accredited pain fellowships left with predominant PM&R influence. Some mergers have gone well, others are just on paper, and still others will likely combust. If past residents were looking at families, the class of 2008 residents are like foster children looking for foster families that won't abuse or abandon us and will help us get ready for the real world We also need to look at Anesthesia programs that have accepted PM&R residents in the past and a lot of that information is still word-of-mouth. One anesthesia program I applied to told me they had a "quota" for the number of PM&R applicants they would consider and interview.

In terms of the new sports medicine accreditation - the PM&R resident ACGME rep will be pushing the ACGME to make recommendations to the ABPMR to look at the sports medicine accreditation process and make sure our class and last year's class will not get lost. As it stands, current fellows and current PGY4s cannot be grandfathered in to take the sports medicine board exam AND there are no PM&R accredited sports medicine fellowships available YET. The world of family medicine sponsored sports medicine fellowships is also unknown territory for us.

So that leaves a lot of unknowns and insecurity among us residents. I do agree with disciple that some of the "old school" PM&R types do seem to have personal issues with the field moving towards more outpatient MSK/spine models of practice. I happen to believe, as does some of the AAPM&R board members, that we may not be able to change all of those people (need to wait for them to retire), but we may be able to get some of them to come around by emphasizing how we are not abandoning the "physiatric approach to patients". The focus on proper neuromuscular physical examination, appropriate use of interventional procedures, consideration of quality of life and function issues, knowledge of assistive devices/P&O/medication, familiarity with biopsychosocial issues of the patient, and the use of effective physical and occupational therapy are all common threads that bind us physiatrists. Our field is small as is and further dividing within the field will only decrease our collective bargaining power and political voice. Plus, no one can predict the future. Economic factors are shifting and decreasing reimbursements will probably dissuade those that are PURELY pursuing MSK/spine for the $$ - which may even the field - if we are divided, in what shape would that put our field??

That's just my naive and idealistic point of view. 😉

 

[drusso]

One of the recent RIC grads called it the "circle of trust" (like in meet tha parents). It was kind of funny but true. the family, marriage, and cousin analogy does have some incestruous connotations though...

"Blood lines." Physiatry is still somewhat "tribal" in its training paradigm...

 

[drusso]

DRusso, I wait excitedly to hear your thoughts, and the thoughts of any others.

Gary

Many physiatry training programs are equipping residents with an outdated skill set...i.e. training residents for a job market that doesn't exist: Compare skills requested in the back of the Red and Blue journals with the typical set of skills residents master by the end of their base-specialty training to see what I mean.

For anyone interested in a research project, I have an instrument that can be used to "code" physiatry advertisements and determine what skills and abilities are "in demand" by geographic region, practice setting, etc. I would like to look at 5 years worth of data and assess "trends" of the market-place. These trends could then be compared to what graduating physiatrists can actually *DO* to reach a set of interesting conclusions...

 

[ampaphb]

I think the same can be said for the fellowship programs. There are (I forgot who came up with this term- maybe DRusso) "families" of fellowships that share similar philosophies and skill sets.

The family I am most familiar with is the RIC family of fellowships, that contain fellowship directors or faculty that trained at RIC, or share their philosophy and models. Those include Colorado, Utah, Wash U, Seattle, Geraci in Buffalo, Larry Chou in Philly, etc. Hopefully there will soon be similar ones in Arkansas and Kansas

My impression, and I may be wrong, having not been a fellow at RIC, is that injections CAN play a larger role, if that is what you want to focus on. Exposure to, and the ability to work with Dr. Rittenberg, a graduate of Florida Spine in Clearwater (another excellent, although purely interventional program, with an RIC grad, Lee Ann Brown, on faculty) enables one to have a broad exposure to interventional techniques if one so chooses. I know Brad Sorosky, a recent fellow, made that choice, although others have opted for other emphases.

The family of RIC fellowships teach a variety of interventional skills.

Based on their website, I didn't think Dr. Geraci's fellows got any procedural training (http://www.buffspine.com/services.cfm), but based on his PASSOR fellowship directory listing (https://www.e-aapmr.org/imis/passoronly/attachmt/07_PR_Fellowships.pdf) (p. 27) I could well be misinformed.

Dr. Prather's program teaches basic lumbar procedures, but avoids the neck altogether, from what I have been told. (https://www.e-aapmr.org/imis/passoronly/attachmt/07_PR_Fellowships.pdf) (p. 21)

Dr. Willik distinguishes between interventionists (i.e. needle jockeys, to use our vernacular) from "spine physiatrists", a usage , I believe, unique to the U of U. However, given that his PASSOR listing suggests spine makes up 1/3 of the fellowship content (p.35), it seems likely his training program is not terribly procedure-based.

Dr. Akuthota's program lists lumbar discograms, pulsed and continuous radiofrequency, in addition to the standard neck and back procedures, in the PASSOR fellowship directory (p. 9) leading me to believe his might teach the widest variety of procedures amongst the RIC family.

My point is that even the RIC "family" represents more than one kind of training. If you want to be an interventionist, doing procedures all day long, it may be that none of them are appropriate for you. If you want to be proficient, those programs that treat procedures as an afterthought might not be your cup of tea.

Just as there is a continuum of sports/spine/pain fellowships, with greater or lesser emphases on individual disciplines, there is a similar continuum within the families.

The concept of "family" ought to imply legacy, rather than indicating the training you get within that group will be similar.

I should also point out that Windsor/Furman/Falco/Cano/Lagattuta/Nieves is another family, as is Slipiman/DePalma (MCV)/Patel (Rochester), U of M/Benny (Baylor), Smith (Mayo)/Kraback (UW), and FSI/Rittenberg (RIC)/Thomas (Cleveland Clinic).

 

[gideon]

I want to say that I have found this thread to be very interesting. I appreciate everyone's input on this subject.

Personally, I have found my physiatry residency to be exhilirating at times, and then extremely frustrating at other times.

My questions are...
What is the outdated skill set we are being trained in?
What skills should we be trying to attain during residency?
What can residents do to get things changed?

When a physician consults a physiatrist...what should they expect the physiatrist (non-fellowship trained) to know?

 

[dc2md]

Yeah, I want to second gideon's question of, what can we do as residents to change our programs.

 

[dc2md]

Let me preface this by stating I'm only a PGY-1 and have only done two non-PMR rotations so far. BUT, during my ER rotation and during my current radiology rotation, it seems clear that most docs in the hospital (ER, IM, FM, NPs) refer ALL musculoskeletal cases to ortho instead of PMR...even the clearly non-surgical ones. Does anyone else see this happening in their hospitals??? There's an obvious lack on knowledge regarding PMR and what we do (can do). How can we change this within the hospitals?? Are ortho's really even wanting to deal with these "mundane" non-surgical MSK cases?? Wouldn't they be thankful to not have to deal with them?? Or am I missing a strong political force by ortho to keep MSK cases (even the non-surgical cases)??

 

[lucyz02]

k Dr. Geraci's fellows ....
Dr. Prather's program teaches basic lumbar procedures...

Dr. Willik distinguishes between interventionists (i.e. needle jockeys, to use our vernacular) from "spine physiatrists...

Dr. Akuthota's program lists lumbar discograms, pulsed and continuous radiofrequency....

Windsor/Furman/Falco/Cano/Lagattuta/Nieves is another family, as is Slipiman/DePalma (MCV)/Patel (Rochester), U of M/Benny (Baylor), Smith (Mayo)/Kraback (UW), and FSI/Rittenberg (RIC)/Thomas (Cleveland Clinic).

Good thread-

I agree there need to be a change; is seems programs are heavy on the inpatient relatively speaking. The non-inpatient rotations aren't srtictly outpatient and the "true musculoskeletal" training lacks form an academic standpoint. Often it's glazed over, or expected that resident pick it up along the way- continuity in this realm isn't what it could be at an optimal level.

Re: the sports/spine fellowships: it seems the vary on interventional exposure, those that have exposure is mostly lumbar which is fine as that seems to be a majority of the clinic visits anyhow. But, a sports/spine fellow is still NOT an interventional physiastrist because his/her training was not under the umbrella of pain programs---- so, were does that leave a fellow who did a sports/spine porgram looking to do a practice of musculoskeletal with the extension of some interventional procedures (obviously skills learned in fellowship) since they aren't "board elgible." Can fellows with this training actually (legally/insurance carrier-wise) utilize their skill-set attained in fellowship?? Seems difficult since there is no standard training.

Any thoughts appreciated?

 

[axm397]

But, a sports/spine fellow is still NOT an interventional physiastrist because his/her training was not under the umbrella of pain programs---- so, were does that leave a fellow who did a sports/spine porgram looking to do a practice of musculoskeletal with the extension of some interventional procedures (obviously skills learned in fellowship) since they aren't "board elgible." Can fellows with this training actually (legally/insurance carrier-wise) utilize their skill-set attained in fellowship?? Seems difficult since there is no standard training.

Any thoughts appreciated?

I'm a bit confused by your question. First of all, whatever one calls him/herself is what he/she is - there is no test you have to pass to become an official "interventional physiatrist". There are plenty of non-fellowship trained physiatrists who call themselves "pain specialist" or "interventional physiatrist". Board exams do not give you the right to do procedures. Hospital credentialing committees do. Sometimes, because of political factors, board certification is a requirement to become credentialed at that particular hospital - but this is not the case everywhere. I think Furman's article makes this point pretty clear.

I actually don't think ACGME accreditation ensures uniformity of training either - there is a huge spectrum of ACGME accredited pain fellowships in this country. The board exam is a written exam - it does not test competence with procedures.

 

[Louisville04]

My questions are...
What is the outdated skill set we are being trained in?
What skills should we be trying to attain during residency?
What can residents do to get things changed?

1) There seems to be an emphasis on inpatient pm&r during residency. Most of the jobs advertised are for outpatient with injection skills.

2) Procedure skills such as epidurals. Most of the older attendings don't do epidurals.

3) If your department is not heavy on intervention, try to use an elective to rotate with an anesthesia pain clinic where you can get hands on experience.

 

[Disciple]

Yeah, I want to second gideon's question of, what can we do as residents to change our programs.

You need to be active under your chief resident, and your chief resident needs to be the point man.

While in residency (senior year) I called around and around and around and searched through multiple opportunities for our residents until good hands on interventional rotations were found.

2 years later, those rotations are now core rotations.

So, it's pretty much up to you.

Grass roots effort.

 

[Disciple]

Let me preface this by stating I'm only a PGY-1 and have only done two non-PMR rotations so far. BUT, during my ER rotation and during my current radiology rotation, it seems clear that most docs in the hospital (ER, IM, FM, NPs) refer ALL musculoskeletal cases to ortho instead of PMR...even the clearly non-surgical ones. Does anyone else see this happening in their hospitals??? There's an obvious lack on knowledge regarding PMR and what we do (can do). How can we change this within the hospitals?? Are ortho's really even wanting to deal with these "mundane" non-surgical MSK cases?? Wouldn't they be thankful to not have to deal with them?? Or am I missing a strong political force by ortho to keep MSK cases (even the non-surgical cases)??

ER, IM, FM docs don't refer to us because they aren't trained to refer to us. They don't know what we can do, and their academic attendings don't know what we can do. They are trained to refer to ortho.

So it's up to you to educate them. During residency, our department used to do biannual grand rounds/PM&R 101 lectures for the IM and FP departments (targeted toward interns and PGY-2s)

However, once you've won them over and they refer somebody, you need to be able to deliver the goods, and that is the responsibility of your/all or our training program(s).

 

[lucyz02]

I'm a bit confused by your question. First of all, whatever one calls him/herself is what he/she is - there is no test you have to pass to become an official "interventional physiatrist". There are plenty of non-fellowship trained physiatrists who call themselves "pain specialist" or "interventional physiatrist". Board exams do not give you the right to do procedures. Hospital credentialing committees do. Sometimes, because of political factors, board certification is a requirement to become credentialed at that particular hospital - but this is not the case everywhere. I think Furman's article makes this point pretty clear.

I actually don't think ACGME accreditation ensures uniformity of training either - there is a huge spectrum of ACGME accredited pain fellowships in this country. The board exam is a written exam - it does not test competence with procedures.

More or less I was more curious for what the future holds, (ofcourse no one has a crystal ball) were would a sports and spine fellow who has the interventional training fit into the future dilema everyone is trying to predict, re insurance carriers/ ASC privledges etc.... without that "official" title of having the pain boards & an ACGME fellowship to back it up??

 

[Disciple]

"Blood lines." Physiatry is still somewhat "tribal" in its training paradigm...

We really need advance past this type of stuff.

"After 28 months of punishment on the inpt floor, I finally earned the right to learn from master Dr. X, the ancient Physiatric secrets of curing back pain by watching someone walk up and down the hall"

Gimme a break.

As if we're passing down some secret, highly guarded information from master to pupil. This is the sort of thing perpetuates the remedial training model. Physiatrists shouldn't need to seek out master so and so to learn injections, and then train with master so and so to learn advanced biomechanics. This is supposed to be American medicine from an established medical specialty. With other specialties it's generally "I served as a fellow at (blank) University", with fellows from various programs generally having acquired the same skill set. Well, then again, you may hear an Orthopod say he/she trained with Jim Andrews or Lewis Yocum or something, but those are surgeons, and they certify their own fellowships.

Granted, each fellowship has its own focus/philosophy. Like other specialties, and to improve our own specialty, each fellowship/residency needs to teach the same core skills to a certain level (procedural/biomechanical knowledge). The differing program philosophies of each fellowship can be added on top of the core curriculum.

If I remember correctly from the last annual meeting, PASSOR was to conduct a survey of fellowship programs comparing content, focus, etc.

Anyone have an update on that?

 

[Disciple]

For anyone interested in a research project, I have an instrument that can be used to "code" physiatry advertisements and determine what skills and abilities are "in demand" by geographic region, practice setting, etc. I would like to look at 5 years worth of data and assess "trends" of the market-place. These trends could then be compared to what graduating physiatrists can actually *DO* to reach a set of interesting conclusions...

You taking the lead on this?

 

[lobelsteve]

Talk til you are blue in the face, you cannot fix it.

The money prohibits change at this time. If reimburesement can fall off enough to start closing existing ACGME PM fellowships through anes dept's, then the time will be right to "reassess" pain training.

As older threads have shown, we do need a Pain Residency focusing on regional anesthesia, MSk physiatry, interventional spine, and Psych.
It would be 1+3 and include anes, PMR, psych, ortho, NS, and Neuro-Headache.

Ain't gonna happen. Everyone in practice has too much to lose to make changes.

Also, even the Chief should not be too aggressive inrequesting change in a residency program. If anyone was out in Hawaii at the AMA a few years ago, you heard me testify on the floor.

 

[Disciple]

If anyone was out in Hawaii at the AMA a few years ago, you heard me testify on the floor.

I wasn't there. What happened? Short version is fine.

 

[Finally M3]

That's odd; we get a ton of MSK referrals from PCPs, some to the point where I wonder why they are referring them. One would think that PCPs would jump at the chance to inject subacromial or trochanteric bursae in their offices: quick visits, easy procedures, happy patients.

Maybe it's a regional thing, because my wife's FP program, most of the residents hate any MSK problem and refer out as well.

 

[DigableCat]

I still do not fully understand why it is necessary to do an accredited fellowship. Several job opportunities that I have seen are simply looking for a fellowship trained physiatrists?

Another reason why.

Also, some facilities (for example...my hospital) now require fellowship training just to get privileges. Additionally, I know of at least one insurer who requires not just fellowship training, but ACGME fellowship training. I only found out because this particular carrier was refusing to add me to their approved provider list because "my fellowship wasn't ACGME accredited". Of course, they were wrong. I gave them the documentation they asked for and by the end of the day I was on their list, but it's pretty obvious it was a policy designed to decrease expenditures for interventional procedures.

The carrier that required ACGME fellowship training was Preferred Community Choice (PPO) and Community Care (HMO). They're a local carrier out of Tulsa.

 

[buddy 2004]

So to follow up on this thread, since I started it. I got an offer for fellowship with Dr. Windsor, who has a spine program that is no longer accredited. I have two anesthesia programs that are accredited in more desirable cities, but they don't make their decision for a few more weeks. Any advice on what to do? I would be happy with the procedures in his program, but I do get the feeling that teaching is second to volume of procedures at Dr. Windsor's clinic. I am a believer that in a purely outpatient practice, I will not have to struggle to get hospital priveleges. Will his reputation carry me far enough?

Thanks for your replies.

 

[paindefender]

So to follow up on this thread, since I started it. I got an offer for fellowship with Dr. Windsor, who has a spine program that is no longer accredited. I have two anesthesia programs that are accredited in more desirable cities, but they don't make their decision for a few more weeks. Any advice on what to do? I would be happy with the procedures in his program, but I do get the feeling that teaching is second to volume of procedures at Dr. Windsor's clinic. I am a believer that in a purely outpatient practice, I will not have to struggle to get hospital priveleges. Will his reputation carry me far enough?

Thanks for your replies.

Ask Steve

 

[Louisville04]

So to follow up on this thread, since I started it. I got an offer for fellowship with Dr. Windsor, who has a spine program that is no longer accredited. I have two anesthesia programs that are accredited in more desirable cities, but they don't make their decision for a few more weeks. Any advice on what to do? I would be happy with the procedures in his program, but I do get the feeling that teaching is second to volume of procedures at Dr. Windsor's clinic. I am a believer that in a purely outpatient practice, I will not have to struggle to get hospital priveleges. Will his reputation carry me far enough?

Thanks for your replies.

Can you wait for the other programs to make a decision? Even though you may not need hospital privileges, it would be easier to carry your ACGME certificate than a notebook full of all the procedures you did in an unaccredited program.