Board Certification in Pain

[C Fiber]

Can someone please comment on board certifications in Pain Medicine? ABMS vs. ABPM? I noticed that many well-known attendings, pain docs are listed as board certified through ABPM. Is ABPM certification a must in competitive jobs?

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[Epidural]

There are many prominent Pain Physicians who only have board certification through the ABPM. However, I've been told that if you obtain board certification from the ABMS, you do not need to bother with the ABPM. In terms of eligibility, it appears as though you can sit for the exam without doing an ACGME-accredited Pain Fellowship. The exam is also open to a number of specialties. There was a previous discussion on this subject. I'd like to hear what those in practice have to say.

 

[drusso]

I think that its crucial that the field gets together on this issue. Part of the problem is defining the scope of practice of pain medicine and defining the core skills required for a such a practice. Even among interventionalists, some limit their practice to axial spine injections while other are far more encompassing. From a physiatric point of view, there was a good discussion at the last AAPM&R meeting in Pheonix on this issue:

Furman Talk

Also, this from the ASA:

Untangling the web of certification

I don't like the idea of fellowships becoming "balkanized" within individual anesthesiology, PM&R, or other departments. Clearly, multidisciplinary treatment and TRAINING have its advantages. Maybe creating pain medicine residencies is the solution afterall. Emergency Medicine, as an academic discipline and specialty, didn't exist before the mid-1970's. In a relatively short period of time, they have managed to create and expand their specialty to an admirable degree.

 

[neuropathic]

Can someone please comment on board certifications in Pain Medicine? ABMS vs. ABPM? I noticed that many well-known attendings, pain docs are listed as board certified through ABPM. Is ABPM certification a must in competitive jobs?

Let me try to clear this topic.

Pain medicine is not an ABMS specialty, therefore to be politically correct, there is no primary board certification for pain medicine. In order to be subcertified in pain medicine, you need to complete a primary residency in anesthesiology, PM&R, neurology or psychiatry. The exam is jointly run by the primary specialty board with ABPM.
In the past, people may be eligible to take the exam without doing an accredited pain fellowship as long as they have the required practical experience in pain medicine. Starting this year, everyone must complete an accredited pain fellowship to be eligible to take the board.

Again, ABPM is not an ABMS recognized board. Elliot Krames in SF is running a 2 year fellowship recognized by ABPM and allow you to take the board exam upon completion. I understand Elliot Krames has had fellows in different specialties outside of the 4 mentioned above.

Pain medicine subcertification is not a must for jobs, but there is no question you will be a more competitive candidate IMO.

 

[PainFellow]

It's true that pain medicine is not an ABMS specialty, however, the ABPM is eager to change that. In Feb., I attended the annual meeting of the AAPM. Reps from the ABPM were in attendance and reported that they are currently in the application phase for membership in the ABMS. It is their intent to eventually become a seperate and distinct specialty. Unfortunately, the application process is quite long and complicated and in fact they have already been denied once. However, they stated that it is common for specialties to be repeatedly denied until at some point their application is approved. They felt it might be as long as 5-10 years before they eventually gain approval. Probably, by that time there will also be pain medicine residencies.

 

[DigableCat]

http://www.asahq.org/Newsletters/2004/08_04/fishman.html

Medical licensure boards in California (1996) and Florida (1999) recognize the ABPM board certification as equivalent to ABMS board certification, and ABPM diplomates in the state of Texas have been determined to be qualified to advertise themselves as board-certified. But only those three states.

Which basically comes down to the question:

Does it matter if you are not board certified?

 

[DigableCat]

Let me try to clear this topic.

Pain medicine is not an ABMS specialty, therefore to be politically correct, there is no primary board certification for pain medicine.

There is no primary board certification in Pain Medicine, yet?

http://www.abms.org/approved.asp

But Pain Medicine is a recognized subspecialty by the ABMS. But only for Psychiatry/Neurology/Anesthesia/and PM&R.

 

[Aether2000]

Pain medicine is a poor stepchild of each of these specialties...it was an afterthought. Regardless of the fellowship status of pain medicine within each of these entities, the fact remains each specialty has their own views on what constitutes the subspecialty, sometimes in direct conflict with the philosophies of other specialties. Without an integrated approach, pain fellowships will continue to hold a myopic view of pain medicine, excluding critically important elements that their specialty cannot teach. The enormous diversity in training within the anesthesiology based pain fellowship programs is indeed enough to give one pause to consider why there is little consistency. The best fellowship is no fellowship: it is a residency in pain medicine.
Board certifications in pain medicine are currently from three sources however none can claim the high road.
ABMS Additional qualifications in Pain Medicine- there are different standards that have been applied over time with the inconsistencies that exist today perplexing. The ever expanding venues for subspecialization, each with a "grandfather clause" that permits those from outside their own specialty to become board certified without fellowship training dilutes the value and reliability of the board certification process. Also, anyone who completes a fellowship in pain medicine regardless of the quality or lack of educational standards is eligible for the ABMS examination in pain medicine.
ABPM is a worthy organization with an exam, but without a working fellowship sequence. There are scattered fellowships offered by the ABPM but these are generally through individual private practices. The ABPM has developed a residency curriculum for a full pain medicine residency.
IIP is the International Institute of Pain, affiliated with the World Institute of Pain (www.worldinstituteofpain.org) that holds a rather grueling examination including written, equipment ID, cadaver dissection structural ID, and a hands on cadaver interventional technique demonstration of proficiency with oral examination. Of the three, by far this has the most rigorous examination process, but the IIP lacks the infrastructure for wide scale training.
There are other certifications and exams such as the American Academy of Pain Medicine and the ABIPM but these do not have the weight of the above three certifications.

 

[drusso]

Without an integrated approach, pain fellowships will continue to hold a myopic view of pain medicine, excluding critically important elements that their specialty cannot teach.

That hits the nail right on the head.

 

[gankaku]

I took both pain boards when I finished my pain fellowship. The American Board of Anesthesiology subspecialty certfication in Pain Medicine is, historically, the official one. As part of the ABA, it is sanctioned by the ABMS. It's more oriented to neuroanatomy and blocks than the ABPM exam. As an anesthesiologist, I thought it was a little easier than the ABPM. It was only half a day, instead of the ABPM's full day exam.

As far as credentialling goes, I think they both carry some weight. Hospital administrators probably don't know the difference. The ABPM is a bit of a wannabee, in my opinion - but they may well succeed in that. It's a well written exam, with broad emphasis on physiatry, psychology, and a generally broad view of pain medicine, not just procedures.

I was struck by how may foreign physicians were taking the ABPM test. Many people from non-anesthesia specialties are getting into pain medicine, presumably because there's lots of money to be made.

It's a strange perversion of our system that procedures pay and consultation doesn't. Unfortunately, this creates an unethecal system wherein pain doctors do procedures that aren't indicated.

Take, for example, the "series of three" epidural steroids issue. Private pain docs almost always do three epidurals, when frequently one will do. Why? because they'll get paid for three. The mother of one of my partners recently had three lumbar epidurals for pain just behind her greater trochanter (pain that turned out to be hip bursitis). She had a normal lumbar spine MRI. So she had neither the symptoms of lumbar radiculopathy nor the imaging to support it. What she did have was good insurance. Needless to say, the epidural steroid injections (three of course) didn't help.

The only ethical system for physicians is one in which their decisions don't change their paycheck. Anytime that there is a large difference in the money to be made based on one particular clinical decision (like implant a stimulator), then that decision making will be shifted in that direction. We're all human and all susceptible to these forces. I suggest finding a system where you can practice medicine without these forces at play. They're out there.

 

[defphiche]

The bottom line for me is that i wanted to enhance my PMR background with a pain focus and I felt a board certification made me legit. This must be a recognized board and the ABA has it while the ABPM does not. Now as an associate program director for a PMR pain medicine fellowship (ACGME approved), I want the fellow to be a leader. Moreover, I want to develop more PMR Pain Docs and to make them legit in the world, they need board certification that is recognized by the ABMS.

I understand the idea behind a pain residency, but as a PMR specialist, I can do more than pain medicine, I can do musculoskeletal medicine, EMGs, and Rehabilitation Medicine.

I am not trying to take anything away from my Anesthesia colleages. I fully appreciate all that is done by them, which is why our program has a rotation with 2 anesthesia pain trained doctors for half of the fellowship.

My interest in PMR lead me away from Anesthesia and Neurology. My interest in pain has allowed me to return to some of the anesthesia and neurology aspects that I liked.

 

[Aether2000]

It is laudable to attempt to achieve the most accepted certification status available. However since at least half of the 2,600 anesthesiology pain certifications granted were from those who never had fellowship training at all (just took an examination) and given that there is enormous variation within the quality of the fellowships themselves (there seems to be no operational standard), it does make one wonder what is the point of such a certification.
It is also certainly acceptable to engage in PM&R and pain medicine therapies. But just as plastic surgeons do not usually perform general surgery (although board certified in such) if pain medicine is to be a specialty, there will be increasing numbers of those who will solely practice that branch of medicine. Colon/rectal surgeons can perform thyroidectomies. but do not. Thoracic surgeons can perform mastectomies, but do not. Pulmonologists can treat rheumatic diseases but they do not.
Most physicians with subspecialty training are solely engaged in that subspecialty as a profession, and for good reason....it has been demonstrated that repetition and familiarity with a given procedure or area of medicine fosters improvement, while the corollary is that intermittent practice with fewer repetitions fosters poorer care. Obviously we have not arrived at that point in pain medicine yet because of the fledgling status of the specialty that has few practice boundaries and because the levels of training/competence are all over the map. There are boundary limits that physicians should observe when they are not practicing full time in a particular specialty.
But if I were coming out of medical school at this point in time and had the broad perspective on pain management that comes with years of experience, in lieu of a residency that does not yet exist I would have followed the path of PM&R with a fellowship in an interventional anesthesiology based program.

 

[drusso]

But if I were coming out of medical school at this point in time and had the broad perspective on pain management that comes with years of experience, in lieu of a residency that does not yet exist I would have followed the path of PM&R with a fellowship in an interventional anesthesiology based program.

Interesting. I still wonder if it is easier for someone from a procedural/ interventional background to learn all the non-interventional skills and knowledge required for the comprehensive practice of pain medicine versus someone from a non-interventional background to master the procedural skills?

 

[Aether2000]

Interesting question....there are two observations about pain fellows:

-The far less developed capabilities of history,physical examination, and clinic operations that are evident in anesthesiologists who have taken a one year pain training course in anesthesiology based programs

-The timidity of PM&R and neurology grads to tackle complex injections or advanced techniques and their uncertainty in airway management skills/emergency crash and burn scenerios.

So which would be easier to correct in a one year training program?

 

[C Fiber]

This is an interesting question indeed. More reasons why I think a Pain residency is in desperate need of development. Sorry to ones who oppose the idea.

Interesting question....there are two observations about pain fellows:

-The far less developed capabilities of history,physical examination, and clinic operations that are evident in anesthesiologists who have taken a one year pain training course in anesthesiology based programs

-The timidity of PM&R and neurology grads to tackle complex injections or advanced techniques and their uncertainty in airway management skills/emergency crash and burn scenerios.

So which would be easier to correct in a one year training program?

 

[SDN]

Why is IM or FM not a pathway to Pain Managment fellowship?

In practice, it seems these specialties manage the bulk of patients with chronic and acute pain. Additionally, in comparison with psychiatry, FM and IM would be equally (or I would argue more) skilled at procedures and management of complications. No knock on psychiatry, it's a great field -- I've just never seen a psychiatrist doing procedures.

 

[DigableCat]

In 1998, the American Board of Anesthesiology, joined with the American Board of Psychiatry and Neurology(one entity) after the boards decided to agree on one single standard of certification. People have long understood that pain management needs a multidisciplinary approach,with the psychological component as a factor.

Much like Neurology and PM&R have an advantage in physical exam skills, Anesthesology has an advantage with performing procedures and dealing with acute medical issues, Psychiatry brings an understanding of how to deal with the underlying psychosocial factors and mental illness that can sometimes affect optimal pain management, no matter how many pain killers you give or blocks you perform on the patient.

And just as PM&R cannot apply to FP sports medicine fellowships(despite the fact that I think we get much more musculoskeletal training during our residency) many things have to deal with politics.

Politics in medicine? Get outta here!

 

[paz5559]

OK, there seems to be a bit of confusion, so let me first timidly step into the fray by clarifying:

The ABA/AMPMR/ABPN subcertification is the only ABMS approved route

ABPM is an alternate board, which has certified many pain specialists with and without pain fellowship training. The current president of ISIS, for one, is AMPM, not ABA, certified. ABPM/AAPM is a member of the AMA House of Delegates, but is unlikely to be granted ABMS status, at least according to knowledgeable sources, anytime soon, despite their considerable political lobbying effort.

The problem with a non-ABMS board certification is that, unless one is knowledgeable regarding a particular field, it is difficult to distinguish between a legitimate organization like ABPM and one where you simply write a check and receive a certificate (i.e. American Academy of Pain Management - yes, they even have the same initials as the AAPM, which makes life even more confusing)

OK, so why is ABPM still important? In the world of Anesthesiology, I am not sure it is. In PM&R, however, we face the dilemma of interventional spine vs pain fellowships. I would argue that any resident who does not consider Slipman, Chou, Aprill, Prather, CINN, HSS, RIC, BI, FSI, Cole, Pauza, Stanford, Michigan's Spine fellowship, etc, solely because they are not ACGME accredited, is missing out on some of the best pain/interventional spine 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 in the ABA/ABPM&R/ABPN camp are just not borne out by the facts at present. Will you need ABMS Pain boards in future? Will ABPM boards carry equal weight? Who knows? Will you get better training in Oklahoma City (an ACGME accredited PM&R program) than any of the aforementioned places? What do YOU think? What I do know is that the vast majority of ABMS certified docs currently have no formal training, and got in under the grandfather clause, rather than through fellowship training of any kind.

Admittedly, Rob Widsor, Mike Furman, Frank Falco, et al have altered their training programs to now be ACGME accredited. But do you really think if you said you trained with Curtis Slipman, Charlie Aprill, Rick Derby, or Joel Press, anyone would say you were somehow lesser trained, or had inferior skills?

Lastly, and I know this is already far too long a rant, the last time I voiced my opinion, I was taken to task for using the terms pain and interventional spine interchangeably. I do not pretend to be a complete pain doc, nor do I have any wish to manage that huge field by myself. My fellowship training in interventional spine will enable me to diagnose and treat patients with issues amenable to interventional techniques of all kinds. My PM&R training will enable me to address appropriate medication management and physical therapeutic exercises and modalities appropriate for the specific pathology. I will be criticized for not wanting to be a "complete" pain physician, and that is a valid criticism. My solution is to work with an array of collegues who can manage the other aspects of pain I chose not to make the focus of my practice. Perhaps that makes me a spine doc, rather than a pain doc. Perhaps that is all semantics. I will leave that for you to decide for yourself.

 

[drrinoo]

this is tangential....but relevant to pain medicine

I have always wondered about the practice of non-evidence based medicine in other specialties, where all the practitioners have more or less identical backgrounds with respect their training and have accepted to ignore rules of ethics

e.g., where is the evidence for aesthetic plastic surgery...and I am not talking about those patients with true deformities....or for that matter spinal fusions for 'back pain'....or cosmetic dentistry....they don't seem to have significant moral dilemmas with respect to their practices and have convinced patients that their treatments are going to improve their 'quality of life'...

why then all the debate of about lack of evidence and intraspecialty criticism...i.e., challenging each others qualifications and back ground to practice pain medicine

the reason was suggested by a colleague at a meeting...the barriers to entry to practice pain medicine are low...hence there are many different players in pain medicine....additionally there are many many competing view points and there are multiple ways to practice pain medicine...the irony, is that there is very little usable evidence in pain medicine and we expend energies criticising each other for lack of evidence...and as a result, the true evidence based pain practitioner cannot use any tools to practice pain....

so by virtue of the fact that our specialty is 'democratic'....we are fighting for a voice and we are fragmented enough that any time a pain treatment is denied by insurers/workmen's comp/etc..(whether interventional. physical therapy, psychology), we stand back and don't care or fight with one another....and thus, all the tools that we may employ to fight pain....are taken away from us....by the FDA, DEA, independent reviewers, health insurance companies...and in truth, they are not wrong for denying treatment

I don't think most other specialties have these dilemmas since they all orginate from the same fold....and they may exercise their right to practice non-evidence based medicine, but this will only be known to people within their field and not outside their field...whereas in our specialty, our individual approaches to pain treatment can easily be criticised and it is.

one analogy about this issue is something I read about in the economist.....the Yangzte river was dammed in order the generate electricity for most of China and 1.2 million people had to be resettled....whether it was right or wrong.is a different issue...it took not a democratic process, but almost a totalitarian decision for this type of 'progress'

can you imagine something like this happening in the US or other democratic countries

similarly, I sometimes wonder whether the 'democratization' of pain practitioners....is beneficial or deterrent to the advancement of our specialty...the irony is that pain management is a sorely needed specialty and yet, the democracy in our field could be interfering with progress

 

[drusso]

...the barriers to entry to practice pain medicine are low...hence there are many different players in pain medicine....additionally there are many many competing view points and there are multiple ways to practice pain medicine...the irony, is that there is very little usable evidence in pain medicine and we expend energies criticising each other for lack of evidence...and as a result, the true evidence based pain practitioner cannot use any tools to practice pain....

So true...Reminds me of the quip, "The beatings will stop when the morale improves..."

 

[paz5559]

this is tangential....but relevant to pain medicine

I have always wondered about the practice of non-evidence based medicine in other specialties, where all the practitioners have more or less identical backgrounds with respect their training and have accepted to ignore rules of ethics

e.g., where is the evidence for aesthetic plastic surgery...and I am not talking about those patients with true deformities....or for that matter spinal fusions for 'back pain'....or cosmetic dentistry....they don't seem to have significant moral dilemmas with respect to their practices and have convinced patients that their treatments are going to improve their 'quality of life'...

why then all the debate of about lack of evidence and intraspecialty criticism...i.e., challenging each others qualifications and back ground to practice pain medicine

the reason was suggested by a colleague at a meeting...the barriers to entry to practice pain medicine are low...hence there are many different players in pain medicine....additionally there are many many competing view points and there are multiple ways to practice pain medicine...the irony, is that there is very little usable evidence in pain medicine and we expend energies criticising each other for lack of evidence...and as a result, the true evidence based pain practitioner cannot use any tools to practice pain....

so by virtue of the fact that our specialty is 'democratic'....we are fighting for a voice and we are fragmented enough that any time a pain treatment is denied by insurers/workmen's comp/etc..(whether interventional. physical therapy, psychology), we stand back and don't care or fight with one another....and thus, all the tools that we may employ to fight pain....are taken away from us....by the FDA, DEA, independent reviewers, health insurance companies...and in truth, they are not wrong for denying treatment

I don't think most other specialties have these dilemmas since they all orginate from the same fold....and they may exercise their right to practice non-evidence based medicine, but this will only be known to people within their field and not outside their field...whereas in our specialty, our individual approaches to pain treatment can easily be criticised and it is.

one analogy about this issue is something I read about in the economist.....the Yangzte river was dammed in order the generate electricity for most of China and 1.2 million people had to be resettled....whether it was right or wrong.is a different issue...it took not a democratic process, but almost a totalitarian decision for this type of 'progress'

can you imagine something like this happening in the US or other democratic countries

similarly, I sometimes wonder whether the 'democratization' of pain practitioners....is beneficial or deterrent to the advancement of our specialty...the irony is that pain management is a sorely needed specialty and yet, the democracy in our field could be interfering with progress

I am not entirely certain why your conclusion from that premise would not be raise the barriers to entry (ie. have ISIS/ASSIP/NASS/ABA/ABPMR/(insert your favorite governing body here) certify adequacy of technical skills, rather than impose a totalitarian regime, as your Yangzte river example seems to indicate.

These may, at first blush, appear to be the same thing, but one is likely to be imposed from outside of at least some practioners' spheres, whereas if you could herd all the cats into one overarching governing body (yes, I know, Lax hates Nik hates Gabor hates Curtis) we might be able to function as a cohesive unit and not be at each other's throats the majority of the time.

Afterall:

"Democracy is the worst form of government except for all those others that have been tried from time to time."

- Sir Winston Churchill (House of Commons Nov. 11, 1947)​

 

[drrinoo]

OK, there seems to be a bit of confusion, so let me first timidly step into the fray by clarifying:

I've read this post...and personally I have some strong opinions on this subject...

there is no such field as 'interventional spine'.....the entire premise of this field is based on anatomic constructs/musculoskeletal physiology concepts of pain....the entire field considers neural structures to be passive structures that are affected only by the their immediate surroundings...e.g., a disc herniation with its pro-inflammatory component irritates a nerve and this nerve acts as a simple relay to the brain....treat the disc and the pain goes away....if it doesn't, then either (A) you didn't treat the disc herniation appropriately or (B) the patient has some non-physiological factors (malingerer, psychological problems) that interfere with pain relief


what about central and peripheral sensitization....for instance....what about neural tissue that acts in an autonomous fashion....what about the contributions of the sympathetic nervous system....pain processing neurobiology is completely ignored


certain tenets in interventional spine bother me...here is one for example, the entire concept of a selective nerve root block or a selective spinal nerve injection....is a bunch of b.s.

lets see...you block a nerve distal...yes, distal....to where the pathology occurs.......you get a positive response...what is your diagnosis? e.g., there is an L4/5 paracentral disc protrusion affecting the descending L5 spinal nerve...you do an 'L5 selective nerve root block'....you do your best to avoid transforaminal spread and you get pain relief....knock your self out an do a series of comparative local anesthetic blocks...(yet more b.s.)....you block the nerve distal to the site of pathology...get '50%' reduction in pain....

you tell the patient...we will now do a transforaminal ESI hoping to get medicaton to the L4-5 protrusion...but we may then have to do addl. diagnostic injections (e.g., facets/SI), in order of find the other pain generators.

the patient then says.....Dr....I read about a patient that had an AKA with phantom pain and the anesthesiologist got rid of the pain by doing a sciatic nerve block.....do I have phantom radicular pain?

no...no you don't, you have a disc herniation

Doctor, but I heard of many patients with asymptomatic disc herniations....couldn't mine be a red herring

No...I am an experience spine interventionalist and my physical exam and EMG findings confirm this

Dr. I thought you said my EMG and physical exam were normal...and that I have not a radiculopathy but a radiculitis


Well, your exam is not normal....your pain is in the same distribution as the dermatomal chart...but yes, otherwise you are right....you have no reflex changes, no myotomal strength deficits, and no sensory abnormalities

no sensory abnormalities....did you check for allodynia or hyperalgesia

no need to....

could I have radicular pain, as discussed by Kobayashi, due to reduced periradicular blood flow or sensitization of the DRG by glutamate...in which case, how did your diagnostic injection figure this out and why would you want to use steroids?

no comment

could the 50% reduction in pain be mediated by blocking the sympathetic nervous system

no...

doc, please explain this...during the first SNRB, you used 2% lidocaine which routinely blocks somatic and sympathetic fibers and the second time, you used 0.25% bupivacaine....is it possible that the first time you blocked all fibers, but the second time only the sympathetic nervous system...so is the 50% reduction in pain because I have sympathetically independent or sympathetically maintained pain?

er..., no.....and that is impossible, because my interventional spine preceptor says so....

Dr...I also heard that a common phenomenon during peripheral nerve blocks is that one can get immediate onset of neural blockade, even whe using local anesthetic with a delayed onset (bupivacaine)....many regional anesthesiologists attribute this to a conduction neuropraxia due to inejction of air/fluid....could this phenomenon also cause a false positive with your spinal injection

no....



....patients in pain want pain relief....the more you understand about pain and pain processing...the more you will understand the problems I have with interventional spine...I have published on this topic in a few recent articles...

there is no doubt that you will get excellent training whereever you go.....but remember, part of the appeal of many successful interventional spine practitioners is that they can opt out of managing failed backs, headaches, medicare patients with pan spinal arthropathy.....as a fellow coming out....you may not have all the choices of which patient you see.....I made a choice that I wanted to do everything in interventional pain...unfortunately, the more I have learned....the more I realize that pain management cannot fall into the Keep It Simple Stupid...interventional spine attempts to do this....in fact, the term 'interventional spine'....presupposes that a patient's pain complaints come from the spine....you cannot know this a priori and you cannot know this even with blocks....at best you can say that spinal structures contribute to this patient's pain to some certain extent.

limiting your clinical treatment repertoire to 5-6 types of spinal injections, referring to PT, and referring to psych....in my opinion is not comprehensive enough for the vast majority of patients...and the pain treatment environment is becoming very competitive with newer trainees having a complete skill set


early on in your practice....you will get failed backs...if you start saying you can not treat them....they will go somewhere else and your referring physicians may be disappointed....if you treat failed backs with TCAs, neurontin, PT, psych, caudal ESIs....and thats it....you will at best help <1% of them...even though that is what you believe is the scope of your practice


anesthesiologists historically have been behind the times with respect to physiatric knowledge...but that isn't true anymore....additionally, like regional anesthesia with respect to anesthesiology...musculoskeletal training in pm+r residency is extremely heterogeneous.


if I were a betting man....get training in an ACGME fellowship and get your pain boards thru the ABMS

 

[drrinoo]

I am not entirely certain why your conclusion from that premise would not be raise the barriers to entry



I disagree with raising barriers to entry at this juncture...physiatrists have already been tortured with this concept...a number of anesthesiologists have blocked the ability of physiatrists to acquire the skill sets they needed whether in a fellowship or at a community level or they blocked privileges at hospitals..

personally, I believe the creation of societies such as ASIPP, WIP, AAPM, APS, ISIS have done more to repair wounds between specialties as compared to the AAPMR or the ASA...at least, these organizations have gotten us all in the ring...if some of us still choose to pick fights so be it...but it is better than creating walls between anesthesiologists, physiatrists, radiologists, neurologists, etc..

I am happy that the current crop of physiatrists, anesthesiologists, and pain specialists are far more collegial and have a collective sense of belonging compared to the events that wents on 10-20 years ago.

Hopefully, the current crop of trainees, such as you, can lead us into a future with consensus building and friendship...then collectively, we can create guidelines as to what pain training should be...so rather than artificially creating barriers to entry that are controlled by some group of individuals....have all stakeholders define criteria and have future trainees focus on a common mission as to what a pain physician is

 

[paz5559]

... there is no doubt that you will get excellent training whereever you go.....but remember, part of the appeal of many successful interventional spine practitioners is that they can opt out of managing failed backs, headaches, medicare patients with pan spinal arthropathy.....as a fellow coming out....you may not have all the choices of which patient you see.....I made a choice that I wanted to do everything in interventional pain...unfortunately, the more I have learned....the more I realize that pain management cannot fall into the Keep It Simple Stupid...interventional spine attempts to do this....in fact, the term 'interventional spine'....presupposes that a patient's pain complaints come from the spine....you cannot know this a priori and you cannot know this even with blocks....at best you can say that spinal structures contribute to this patient's pain to some certain extent.

limiting your clinical treatment repertoire to 5-6 types of spinal injections, referring to PT, and referring to psych....in my opinion is not comprehensive enough for the vast majority of patients...and the pain treatment environment is becoming very competitive with newer trainees having a complete skill set


early on in your practice....you will get failed backs...if you start saying you can not treat them....they will go somewhere else and your referring physicians may be disappointed....if you treat failed backs with TCAs, neurontin, PT, psych, caudal ESIs....and thats it....you will at best help <1% of them...even though that is what you believe is the scope of your practice


anesthesiologists historically have been behind the times with respect to physiatric knowledge...but that isn't true anymore....additionally, like regional anesthesia with respect to anesthesiology...musculoskeletal training in pm+r residency is extremely heterogeneous.


if I were a betting man....get training in an ACGME fellowship and get your pain boards thru the ABMS

I would think it only reasonable, in the interests of full disclosure, to point out that drrinoo first did an interventional spine fellowship himself, before going on to do an anesthesiology-based pain fellowship. Also, given that he is a current fellowship director at that same ACGME accredited anesthesia-based pain fellowship, applicants reading this thread might want to factor that into his objectivity.

I will be glad to also point out that I am not objective in this matter either, as I will be starting with Dr. Charles Aprill as his interventional fellow later this year (no, the fellowship is NOT ACGME accredited), so my opinions are clearly equally biased in the other direction.

 

[DigableCat]

I feel that everyone agrees that Pain Management(spinal or otherwise) involves a multidisciplinary approach. As Dr. Rinoo could have easily taken the ABPM&R pain exam and gotten grandfathered in(like many have opted to do as this is the last year), I think it's interesting that deciding that an "interventional spine" fellowship, left him feeling less than fully prepared to optimally manage patients.

But ultimately, it comes down to each individual fellowship program. And that means choosing a fellowship wisely to ensure that you are receiving all the skills necessary to treat your patient population appropriately.

Having the accreditation behind your name certainly doesn't hurt though...

 

[drrinoo]

I feel that everyone agrees that Pain Management(spinal or otherwise) involves a multidisciplinary approach. As Dr. Rinoo could have easily taken the ABPM&R pain exam and gotten grandfathered in(like many have opted to do as this is the last year), I think it's interesting that deciding that an "interventional spine" fellowship, left him feeling less than fully prepared to optimally manage patients.

Since my personal attributes and training are the subject of this discussion, I will address some of the above raised questions.

Digable Cat and PAZ....would you be comfortable with your skill set...if you got called in the middle of the night to place a thoracic epidural for acute rib fractures....would you be comfortable in performing an interscalene catheter if the surgeons call you for post-total shoulder pain....if a patient presents with acute blindness secondary to a Hollenhorst plaque with a recent MI...could you perform a blind superior cervical ganglion block with 10-12 cc of 0.25% bupivacaine/fentanyl/lidocaine?.....if a patient presents with intractable oral cancer after you have performed trigeminal ganglion neurolysis, sphenopalatine neurolysis, high dose oral analgesics...would you feel comfortable consulting a neurosurgeon to place an intracisternal catheter for opioid analgesia and manage their dosing in the ICU.....would you feel comfortable putting an HIV/Hep C pt. with cirrhosis who demands a demerol PCA....would you feel comfortable performing a dye study in a patient with an intrathecal catheter/pump that is getting 25 mg/day of dilaudid and 3% bupivacaine....would you feel comfortable removing an intrathecal catheter with a granuloma when the neurosurgeons say they don't want to be involved....would you feel comfortable placing a spinal cord/dorsal root entry zone stimulator at T12-L1 for groin pain.....could you place a caudalis nucleus stimulator for atypical facial pain...would you feel comfortable scrubbing in with the orthopedic surgeons in your clinical practice and showing them how to appropriately place a peripheral nerve stimulator lead and show them how to place an interposition graft and perform post-op programming....would you feel comfortable placing a permanent transsacral S4 electrodes for fecal incontinence...would you feel comfortable performing glossopharyngeal RFTC in a patient with a pacemaker?....would you feel comfortable performing thoracic sympathetic RFTC for hyperhidrosis...would you feel comfortable placing a patient on intrathecal ziconotide?..would you feel comfortable performing an anterior thoracic sympathetic RFTC on some one with a C7-T5 posterior fusion...would you feel comfortable placing a revision spinal cord lead in one that has fractured...say over a 14 gauge angiocatheter...would you feel comfortable in telling an anesthesiologist how to dose a spinal in an OB patient with diffuse CRPS that has an IT pump/scs and 3 peripheral nerve stimulators...would you feel comfortable managing chronic angina with a high thoracic spinal cord stimulator....would you feel comfortable placing a depomorphine into the epidural space....these are just a sample of some of the problems I have experienced as a faculty member/fellow

our fellows feel comfortable doing all of the above and everything in a spinal injection fellowship or regional anesthesia fellowship.....if you read raj's practical imaging for pain book, we do all of those procedures...also all physiatrists should check out the website by Hadzic and Vloka at www.nysora.com you should be able to perform these procedures, if you want to run an acute pain service

I wanted to be a pain specialist
I recognized my knowledge deficits and I addressed them.

both of you are more than welcome to visit our institution, if you still have any doubts about whether additional knowledge is useful or not.

if you are confident that your physiatric knowledge will sufficiently prepare you for the vast majority of pain patients...acute, chronic, cancer...so be it...I wish you the best.

remember, patients present with pain...it is simple and you are a doctor that treats pain...that is simple

pain specialists do not have an identity crisis like physiatrists do...in having to explain what we do....this is important

if you promote yourself as pain specialist...you will see every variety of patient...and you can do some good.

if you are exclusively a spine specialist...then make sure your front staff are educated on which patients you can see and which ones you don't see.

 

[C Fiber]

"A man's pride shall bring him low: but honour shall uphold the humble in spirit." Instead of mocking each other's credentials, I wish we can have more meaningful conversations. You should be proud there there are people like Dr. Shah to bridge the gap between anesthesiologists and physiatrists.

 

[DigableCat]

Dr. Shah,

Anyone who knows me on the forum, knows that I have been an advocate of doing a Pain Management fellowship(and specificallly those that are ACGME accredited in order to sit for the boards). I myself, preferentially choose to do a ACGME accredited PM&R Pain Management Fellowship for some of the reasons you've listed above.

If you felt that I was questioning your qualifications or motivation for doing an additional fellowship, that was not the case.

This being said, do I feel that I will be able to do most of those procedures listed above with a one year fellowship? Not likely, as some of those procedures appear to overlap with those gained in a Regional Anesthesia fellowship , which are not open to PM&R residents.

I plan on being a board accredited pain management doctor with a physiatric approach after my training. Hopefully this will be enough. If I can't provide what they are requesting, I will kindly refer to someone who can.

 

[neuropathic]

would you be comfortable with your skill set...if you got called in the middle of the night to place a thoracic epidural for acute rib fractures....would you be comfortable in performing an interscalene catheter if the surgeons call you for post-total shoulder pain....if a patient presents with acute blindness secondary to a Hollenhorst plaque with a recent MI...could you perform a blind superior cervical ganglion block with 10-12 cc of 0.25% bupivacaine/fentanyl/lidocaine?.....if a patient presents with intractable oral cancer after you have performed trigeminal ganglion neurolysis, sphenopalatine neurolysis, high dose oral analgesics...would you feel comfortable consulting a neurosurgeon to place an intracisternal catheter for opioid analgesia and manage their dosing in the ICU.....would you feel comfortable putting an HIV/Hep C pt. with cirrhosis who demands a demerol PCA....would you feel comfortable performing a dye study in a patient with an intrathecal catheter/pump that is getting 25 mg/day of dilaudid and 3% bupivacaine....would you feel comfortable removing an intrathecal catheter with a granuloma when the neurosurgeons say they don't want to be involved....would you feel comfortable placing a spinal cord/dorsal root entry zone stimulator at T12-L1 for groin pain.....could you place a caudalis nucleus stimulator for atypical facial pain...would you feel comfortable scrubbing in with the orthopedic surgeons in your clinical practice and showing them how to appropriately place a peripheral nerve stimulator lead and show them how to place an interposition graft and perform post-op programming....would you feel comfortable placing a permanent transsacral S4 electrodes for fecal incontinence...would you feel comfortable performing glossopharyngeal RFTC in a patient with a pacemaker?....would you feel comfortable performing thoracic sympathetic RFTC for hyperhidrosis...would you feel comfortable placing a patient on intrathecal ziconotide?..would you feel comfortable performing an anterior thoracic sympathetic RFTC on some one with a C7-T5 posterior fusion...would you feel comfortable placing a revision spinal cord lead in one that has fractured...say over a 14 gauge angiocatheter...would you feel comfortable in telling an anesthesiologist how to dose a spinal in an OB patient with diffuse CRPS that has an IT pump/scs and 3 peripheral nerve stimulators...would you feel comfortable managing chronic angina with a high thoracic spinal cord stimulator....would you feel comfortable placing a depomorphine into the epidural space....these are just a sample of some of the problems I have experienced as a faculty member/fellow

Well said. My utmost respect to the world class faculty and training at Lubbock. Although, most of the private pain physicians don't really deal with acute pain. I still think anyone would be blessed to have that kind of training in a fellowship.

 

[Aether2000]

Ditto. The educational experience at Lubbock represents an extreme outlier compared to all other programs. Accolades to Dr. Shah, Gabor, et al.

 

[paz5559]

Digable Cat and PAZ....would you be comfortable with your skill set...if you got called in the middle of the night to place a thoracic epidural for acute rib fractures....would you be comfortable in performing an interscalene catheter if the surgeons call you for post-total shoulder pain....if a patient presents with acute blindness secondary to a Hollenhorst plaque with a recent MI...could you perform a blind superior cervical ganglion block with 10-12 cc of 0.25% bupivacaine/fentanyl/lidocaine?.....if a patient presents with intractable oral cancer after you have performed trigeminal ganglion neurolysis, sphenopalatine neurolysis, high dose oral analgesics...would you feel comfortable consulting a neurosurgeon to place an intracisternal catheter for opioid analgesia and manage their dosing in the ICU.....would you feel comfortable putting an HIV/Hep C pt. with cirrhosis who demands a demerol PCA....would you feel comfortable performing a dye study in a patient with an intrathecal catheter/pump that is getting 25 mg/day of dilaudid and 3% bupivacaine....would you feel comfortable removing an intrathecal catheter with a granuloma when the neurosurgeons say they don't want to be involved....would you feel comfortable placing a spinal cord/dorsal root entry zone stimulator at T12-L1 for groin pain.....could you place a caudalis nucleus stimulator for atypical facial pain...would you feel comfortable scrubbing in with the orthopedic surgeons in your clinical practice and showing them how to appropriately place a peripheral nerve stimulator lead and show them how to place an interposition graft and perform post-op programming....would you feel comfortable placing a permanent transsacral S4 electrodes for fecal incontinence...would you feel comfortable performing glossopharyngeal RFTC in a patient with a pacemaker?....would you feel comfortable performing thoracic sympathetic RFTC for hyperhidrosis...would you feel comfortable placing a patient on intrathecal ziconotide?..would you feel comfortable performing an anterior thoracic sympathetic RFTC on some one with a C7-T5 posterior fusion...would you feel comfortable placing a revision spinal cord lead in one that has fractured...say over a 14 gauge angiocatheter...would you feel comfortable in telling an anesthesiologist how to dose a spinal in an OB patient with diffuse CRPS that has an IT pump/scs and 3 peripheral nerve stimulators...would you feel comfortable managing chronic angina with a high thoracic spinal cord stimulator....would you feel comfortable placing a depomorphine into the epidural space....these are just a sample of some of the problems I have experienced as a faculty member/fellow

our fellows feel comfortable doing all of the above and everything in a spinal injection fellowship or regional anesthesia fellowship.....if you read raj's practical imaging for pain book, we do all of those procedures...also all physiatrists should check out the website by Hadzic and Vloka at www.nysora.com you should be able to perform these procedures, if you want to run an acute pain service

I wanted to be a pain specialist
I recognized my knowledge deficits and I addressed them.

both of you are more than welcome to visit our institution, if you still have any doubts about whether additional knowledge is useful or not.

if you are confident that your physiatric knowledge will sufficiently prepare you for the vast majority of pain patients...acute, chronic, cancer...so be it...I wish you the best.

remember, patients present with pain...it is simple and you are a doctor that treats pain...that is simple

pain specialists do not have an identity crisis like physiatrists do...in having to explain what we do....this is important

if you promote yourself as pain specialist...you will see every variety of patient...and you can do some good.

if you are exclusively a spine specialist...then make sure your front staff are educated on which patients you can see and which ones you don't see.

why then all the debate of about lack of evidence and intraspecialty criticism...i.e., challenging each others qualifications and back ground to practice pain medicine

Physician, heal thyself