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We had a speaker on Thursday last who was trained in surgical anesthesia, but now manages a chronic pain clinic. He was truly a fascinating individual who seems to have a challenging practice, and when I spoke with him of my interest in this and related fields, he told me that anesthesiology was the way to go, because: "you spend five years learning how to stick needles in people's backs," a practice he emplys a great deal in managing his severe pain patients. My question is this: do the current PM&R residents/docs do much pain management in this sense? Or do you devote more time to pure rehab medicine, delaing with a more acute level of patient.

Also, is there any training in intrathecal techniques? Enough to where you would feel comfortable if called upon to administer? Or do physiatrists generally not deal with chronic pain patients without 'rehabilitable' injuries?

Just curious, any words would be helpful.
 
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In most practices it is the PM&R guys who do more of the chronic pain management and the anesthesia guys do the acute pain, cancer pain, sympathetically-mediated pain stuff. There's a lot of overlap. A PM&R physician who does a pain fellowship will have more than plenty of skill when it comes to "putting needles in people's backs"---or as it is termed in pain circles "being a needle jockey." Knowing how to put a needle somewhere is a fundamental skill, but what it equally important is knowing "why to put a needle somewhere" or "WHY NOT to put a needle somewhere". Through conversations with several pain physicians, most have commented that anesthesia-trained pain docs are woefully under-educated in musculoskeletal medicine---the majority of pain complaints. Moreover, they lack EMG training and interpretation, musculoskeletal radiology, and other skills that are bread and butter PM&R skills.

I'm not knocking anesthesia guys, they have been pioneers in the field. But, increasingly, PM&R trained pain physicians are being recognized has having more of the "total package." That said, pain is a very complex and very broad field and multiple specialties---PM&R, anesthesia, psych, neuro---all bring something important to the table.
 
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As an aside, I was flipping through the latest journal AAPMR puts out and who's name did I spy? :laugh:
 

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I would have to agree that different specialities bring different skills to the field. Personally, I chose neurology. We get great training in EMG/NC, musculoskeletal medicine and various central and peripheral pain syndromes. I'd say at least half the pts presenting to a general neurology clinic do so because of pain (back pain, head ache, painful neuropathies, RSD, etc.). Actually, I'm surprised more neurologists don't go into the field. Also, I would agree that "putting needles in peoples backs" is not a difficult skill to master. Of course, as a neuro resident, I could do lumbar punctures in my sleep, so learning epidurals was a snap! Now having said that, I'll also admit that neurology training doesn't teach you squat about regional anesthesia or malignant pain. But that's what fellowship is for. By the end of training, everyone has a pretty equal knowledge and skill base.:D
 

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i agree that pain is a very multi-faceted field - and I think PM&R, neurology, psychiatry, palliative medicine, all bring great points of view to the table...

but i would stay away from the broad generalizations that PM&R does the chronic pain with anesthesia doing acute, cancer, etc...
because that isn't true...

nor is the statement: "anesthesia-trained pain docs are woefully under-educated in musculoskeletal medicine---the majority of pain complaints".

pain is one of the few truly multi-disciplinary fields, and if PM&R provides such a great pain education, then why even do a fellowship???

the point: pain fellowship (at most good programs) will teach you everything you need to know to manage a complicated pain patient.... PM&R can bring their rehab, EMG skills to the table... Neurology can bring their in-depth understanding of the nervous system, EMG skills to the table... Psych can bring their understanding of mental health (which definitely plays a role) to the table... Anesthesia can bring their understanding of pain and procedures to the table.

bottom line: stigmatized patients finally get specialized help.

so no more anesthesia bashing...
 

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As a person seeing firsthand both an ANES trained fellow and a PM&R trained fellow both starting out in the same program last July...I can truly say that it was obvious that the PM&R fellow was by far the better prepared of the two. That is not to say that the ANES fellow was not able to improve his physical exam skills over the year...but wouldn't it be so much easier if you had that background to begin with?

It's not all about the injection...it's why you're doing the injection and whether you are doing it for the right diagnosis. An epidural steroid injection won't cure anything if you haven't figured out that the pain is really from his SI joint.
 

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whoopdeedoo... PM&R can do a better physicial exam ... I bet a neurologist can do a better neuro exam, and an orthopod can do a better joint/skeletal exam... gimme a break.

by they way, where do you think most PM&R pain specialists got their training??? at anesthesia programs... even the directors of the current ACGME-approved pain programs were all trained by anesthesiologists.... I can only pray for them that their PM&R training during residency made up for the inadequacy of their attendings during their pain fellowship :)

and regarding the regurgitated line of: anesthesia can do the procedure but they don't understand the why nor do they know how to make the correct diagnosis... that is a bunch of hogwash... do you realize that most if not all techniques (based on diagnosis) were developed by anesthesiologists and neurosurgeons???
the only group of physicians this statement applies to are the interventional radiologists doing pain procedures based on referrals from spine-surgeons and orthopods.....

by the way, i am just curious: what do you do when you place your patient on the table for a diagnostic SI joint placement, and just as you insert the needle into the skin the heart rate falls to 20 and the patient becomes unresponsive... what do you do when you do a BIER block and there is a large leak of local anesthetic into the systemic circulation and the patient starts having short runs of v-tach....

so from my point of view: i have seen PM&R fellows, Neurology fellows and Anesthesia folk doing their pain fellowship... they all have their strengths and their weaknesses.
 

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Get aggressive much?

Dude, I'm only speaking from experience. And when I'm doing my pain rotation with an anesthesiology resident and I have to explain to him how to check for posterior facet dysfunction or the Spurling test for cervical radiculopathy...it just reinforces my point.
 
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Originally posted by Tenesma


by the way, i am just curious: what do you do when you place your patient on the table for a diagnostic SI joint placement, and just as you insert the needle into the skin the heart rate falls to 20 and the patient becomes unresponsive... what do you do when you do a BIER block and there is a large leak of local anesthetic into the systemic circulation and the patient starts having short runs of v-tach....

Woh, slow down cowboy! I'm not saying that advanced airway management and ACLS shouldn't be a part of pain fellowships! I'm not saying that anesthesiologists are not competent pain practitioners...I was seriously considering anesthsia residencies because I really liked the regional techniques. Can't we all get along?
 

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Originally posted on Physician's Online:

1fb0fe9: Although I was originally trained as an Anesthesiologist, I have practicied "Pain" exclusively for the past 8 years and I agree completely with the last post. I had to learn a lot of musculoskeletal medicine under the gun of practice and it is better to do so under the protection of a residency. Also, quite frankly, I have been terribly disappointed in the quality of medicine I see my collegues in "Pain" practicing who started out in Anesthesia. My observation is that the PM&R docs practicing "Pain" are simply more knowledgable and have better judgement. I don't see them doing crazy things like laser percutaneous discectomy when they can't even do a competent physical exam and correctly manage a herniated disc.

12c3393: If you plan on practicing pain medicine, I reccomend a physiatry residency, and an interventional pain managment fellowship. It doesn't take long to learn where and how to stick needles in someone, but it does take a while to learn musculoskeletal medicine, which is what the majority of pain managment deals with. In anesthesia residency, you don't learn squat about musculoskeletal medicine. You learn how to intubate people and place lines. The only thing that I use from my anesthesia residency is my comfort with deep sedation for the rare instance that I need it. Otherwise it was a waste of 4 years. Also, I definetly did not learn all there is to learn about pain medicine and musculoskeletal medicine in my one year of pain fellowship. The fundamentals take time to learn. Learning how to stick needles in people doesn't take long.

529537: I may be unpopular here, but Pain Management (i.e. interventional) is the perview and should remain the perview of the Anesthesiologist. We are the ones that started this business and we are the best at it.

But, what anon 12c and 1fb said is correct. If you want to be a full fledged Pain Medicine Specialist, you can do it from anywhere. What this specialty really needs is more Psychiatrists specializing in Pain Medicine. Most of what you do with your patients is talk to them, reinforce that their is someone out their who actually believes them. That is worth more to them than anything.

No matter what you choose, you'll have to learn a lot on your own. If you choose Anesthesia, you'll have to learn good people and physical exam skills. If you choose PM&R, you'll have to learn procedural skills. What good is all the diagnostic skills if you can't put the needle where it belongs. My choice, if you are considering a procedurally based pain office, is to do Anesthesia. You are abviously motivated sincy you're asking as a student. I'll bet you have the people skills and can learn the physical exam skills along the way much easier than the procedural skills. Thats my 2 cents.

982cff: I have already completed 3 years anesthesiology and year of Pain fellowship (by the way my co-fellow was PMR doc) Now I am in practise 50% pain and 50% Anesthesia since last 2 yrs. I do full gamet of Interventional pain procedures. I am wondering by doing Neuro or PMR I can also get training in EDX and spine imaging.

c1c63b: If you want to be a block-doc - anesthesia
If you want to practice full spectrum pain management and be mediocre at sticking needles in people - PM&R. Having seen "interventional physiatrists" and "interventional anesthesiologists" practice, anesthesiologists are better at sticking needles in people and physiatrists are better at musculoskeletal medicine

18ed41b: If you are interested in pain - no pun intended - then go the anesthesia route. However, if you are interested in spine and musculoskeletal then you have no choice but to go the physical medicine route.

People who know the fields, know the difference.

I found this discussion on POL relevant to the questions raised in this thread. I've worked at the Spine Center at MGH and NEBH and plan to do rotations at BWH and MGH in the Pain Center. I think Tenesma is right in that all the different specialties bring something to the table. I do feel that the fact that we can do a much better neuromusculoskeletal exam is important, but its degree of importance lies in what type of practice you want. Our training in performing EDX studies and interpreting imaging studies is also extremely important to the management of a certain subset of pain patients out there. This is the reason that MGH has both a Spine Center and a Pain Center because certain patients are better managed at one or the other even if the procedures done at each do overlap. MGH's Pain Center website also has a link to SRH's Pain Program and the Anesthesia-run fellowship has taken several of our graduates into their fellowship. This demonstrates to me that we each bring something unique to the broad field of Pain Management and hence I've often seen referrals between the three centers.

During residency, the best rotation we have to learn Interventional Pain procedures is with an Anesthesiologist because of the sheer volume and variety of procedures he does. In terms of technical skills, some of the best that I've worked with are the Neuroradiologists that trained at or work at MGH. Physiatrists are better at diagnosing the source of a patient's MSK complaints and providing a broader spectrum of conservative care. I think each group has a certain type of pain practice that they want and probably wouldn't want to do what another group does. I feel fortunate that my residency will provide me with exposure to the different types of practices out there and this will help me to develop my own approach, send appropriate referrals, and help me decide which type of fellowship I want to pursue.
 
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More from Physicians Online (POL: www.pol.net) about this very topic. Apparently, we've generated some discussion among our attending/staff colleagues:


Anon_746515 on 03/05/04 11:13 AM

I am physiatrist, doing 100% non-surgical spine practice. I did a two-year fellowship in musculoskeletal, spine and sports medicine and is pain boarded through ABA. I work with a renowned conservative spine surgeon. We read X-rays, MRIs ourselves and often discuss with the radiologists about their readings.

I have seen many anesthesiologists doing pain management who are big on needles but have no clues to their diagnoses. Most of their impressions after a very poor hitory and physical examination is 'multifactorial low back pain'. These are the pain specialists that end up doing one dozen facet joint injections on one patient at one sitting and then go ahead with RF abaltion of bilateral MBBs for all those levels.

Or, they do series of epidurals irrespective of outcome. To me they may be excellent in maneuvering their needles, but by putting needles where it was not needed, make themselves and others, including the patients, more confused. It is like having weapon in your hand and you know how to kill, but do not know who is your friend or foe.

I do not want to generalize. There are good docs and not so good docs in every specialty and as Dr. Soriano mentioned, every specialty, by virtue of their training have their strength and weakness at certain faculties. We should not look down upon other specialties based on their weakness, rather look into ourselves and see what we are lacking in managing our patients and try to gather skills from other specialties for a more gratifying practice.

If you are a good doc, know what you are doing and your patients like you, you do not need to fear other docs taking your practice.

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Anon_18ed41b on 03/06/04 07:12 AM

Anon 746515:

I have a similar background as a PM&R residency followed by an orthopedic fellowship performed in an Orthopedic Dept with Spine Surgeons - and practice as you. My clinical interests are pretty much limited to spine and EDX and I'll be sitting for the EDX boards next month. I am a member of NASS, ISIS, and the AAEM.

I do not consider myself a pain physician, but an interventional physiatrist. I do not want to bear the pain moniker as, more often than not, my observation has been that chronic pain is a much more psychosocial than biological phenomenon and I am still not convinced even after having worked in an internationally recognized multidisciplinary chronic pain clinic- that specialty physicians have a meaningful role in its management let alone treatment. Moreover, as I eluded earlier, interested observers - insurance companies, health epidemiologists, occupational health clinics, etc. - are coming to equate the "interventional pain management designation" with a practice pattern - expensive and anecdotal - that I do not want to be associated with.

However, as a concession to the 'turf' war I plan to sit for the ABPM&R sponsored pain boards. This is not due to the salience of the material to my practice or my interest in "pain" but merely out of recognition of the turf wars between a small specialty - PM&R - and a much larger specialty - Anesthesia. I do not buy the Spine = Pain argument put forward by the pain tribe; why not chest pain? Pain for me is a symptom, not a disease, and as a physician my focus will always be on the treatment of the underlying disease.

For the studentdoctor.net residents: in the end, evidence, outcomes, and continued education should be your guiding principles. Those practioners who are trying to take an evidence-based, nosological approach, to spine and musculoskeletal problems will be more familiar with the etiology and natural history of the diseases they treat and this will lead to measurably better outcomes.(1, 2) With that in mind, you need to think about your fellowship training carefully.


1. Klein, Ben J. PhD. Radecki, Richard T. MD. Foris, Michael P. MBA. Feil, Edward I. MD. Hickey, Martin E. MD. Bridging the Gap Between Science and Practice in Managing Low Back Pain: A Comprehensive Spine Care System in a Health Maintenance Organization Setting. Spine. 25(6):738-740, March 15, 2000.

2. Saal, Jeffrey A. MD, FACP. 1996 North American Spine Society Presidential Address. Spine. 22(14):1545-1552, July 15, 1997.

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Rinoo Shah on 03/06/04 04:39 PM

anon 18e..or shall we call you p.c, ....which BTW stands for politically correct [medicine] and does not represent the initials of an individual on the p.o.l. discussion boards with a portuguese namesake

your arrogance in these matters is stifling and what is particularly appalling is the stark dichotomy between some of your posts on the ISIS web site and on p.o.l.

in one recent ISIS post you describe a transdural L5-S1 discogram for a patient with a posterolateral fusion to help the referring physician decide if the patient is a candidate for an anterior interbody fusion or is 'nuts'..i.e., a candidate for psychological counseling.

I truly wonder how you can ethically convince a patient that this discogram is in the patient's best interest as well as an ALIF if positive...and tell the patient (based on your posts on p.o.l.) that SCS, lysis, intrathecal opioid, oral opioids, neurontin and other AEDs do not have sufficient evidence and are not in the patient's best interest..

there is no such thing as a spinal diagnostician nor interventional physiatrist...

diagnose what? if a patient doesn't have an analgesic or provocative response to your repertoire of 'spinal interventions'..which based on your posts are limited to your interpretation of evidence to discos, transforaminals and may be SIJs, or medial branch blocks...so if a patients pain cannot be reproduced or blocked with these interventions...then they would only benefit from psych...or if their pain is reproduced or blocked...and they don't reach a therapeutic endpoint..then they go to your REFERRING spine surgeon?

additionally, according to your ISIS posts percentage-wise you see a larger number of run-of-the-mill disc herniations...how did you develop such a cozy practice...do you turn a blind eye (selection bias) to patients you cannot help and dissuade them from seeing pain physicians in your community


this latter practice generates the scorn and ire of cadde5 against physiatrists...you see the easy to treat patients and dump the waste baskets on the pain physicians and then crib about there approach to treating them

you call interventional pain physicians 'goats'.....but as a 'spinal diagnostician' you appear to be a greater goat...fueling the spinal surgery business

In Merrill's article in Reg Anesth in 12/03...the estimated cost to medicare from interventional pain in 2001(excluding implants: SCS and IT pumps)...was about 370 million...he estimated that since medicare' share of physician fees was 21% then the costs to the USA overall, could be as high as 1.8 billion

...but take a look at his TABLE 3...out of this 370 million to Medicare...translaminar ESIs accounted for 130 million, transforaminals for 36 million, medial branch blocks 60 million, medial branch RFTC 13 million, and sympathetic 3 million,, there were extra dollars and cents for fluoroscopic guidance, epiduraography....but all in all the vast majority of costs were by spine interventions...very familiar to p.c.

now look at the spinal surgery business that p.c. is helping promote...according to Mirza and Deyo...implants alone for spine surgery generate 2 billion in revenue...the implants alone! cost health care more than most interventional pain procedures

now look at Figure 1...250,000 spinal fusion surgeries were performed in 2001 and that rising trend may outstrip total knees and hips...according to DEyo the average inpatient hospitalization (EXCLUDING THE SPINE SURGEON's FEES) is 34,000

250, 000 x 34,000 = 8.5 billion dollars...and with physician fees it may top 10-12 billion

I feel your relentless criticism of interventional pain is in the hopes of keeping your spinal diagnostic business alive...the last thing you would want is an interventional pain physician to spoil your cozy party with your spinal surgery colleagues...here is your motto

'lets keep the spinal diagnostic and spinal surgery business alive...shall we?'

your acceptance of chronic pain as less of a biological problem and your lack of respect of interventional pain physicians and the premier clinic founded by JJ Bonica and subsequently headed by J. Loeser further underscores your ulterior motives not to mention your ignorance in recognizing the vast achievements in our understanding of chronic pain over the past 50 years...you have no interest in the psychological aspects of pain apart from trying to protect your turf

p.c....doesn't stand for politically correct medicine but paul...it stands for...

pork chop for me (spinal diagnostician and spine surgeon) and nay for you (pain physician and pain patients)
 
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