Congrats to Family Medicine - ABFM

[freddydpt]

As of today, Pain Medicine is now an official subspecialty of Family Medicine.

---

Members don't see this ad.

 

[emd123]

Pain is becoming more multidisciplinary every day.

 

[NJPAIN]

This is getting crazy. What's next - pathology??


Sent from my iPhone using SDN Mobile

 

[drusso]

As of today, Pain Medicine is now an official subspecialty of Family Medicine.

Send the link...

 

[Taus]

But at least now there is no way around completing an AGCME fellowship before being able to take the test correct?

 

[emd123]

But at least now there is no way around completing an AGCME fellowship before being able to take the test correct?

See, that's why I think this is good. The more specialties that have the option to do an ACGME Pain fellowship and ABMS boards, the less reason or justification to just hang a shingle and just call yourself "Pain Specialist." Obviously if you're a resident applying to pain, it increases the applicant pool and competition, but in my opinion, I think overall it's a good thing. If you want to be a Pain doctor, do an ACGME fellowship and pass the ABMS Pain boards. It's hard enough to become an expert in one year, let alone self taught. That's my opinion.

 

[emd123]

This is getting crazy. What's next - pathology??


Sent from my iPhone using SDN Mobile

Not pathology. Likely Rads, Peds and IM.

FM and IM see a ton of chronic pain and a few have already done ACGME fellowships and gotten ABMS boarded. Peds, maybe not so much in general peds but sickle cell, and pediatric cancer pain would be their argument. Rads obviously has the angle that they are experts at the imaging and have interventional exposure. Path? Eh...Doubt they'd apply for it. Seems like a stretch but who knows.

 

[Ducttape]

See, that's why I think this is good. The more specialties that have the option to do an ACGME Pain fellowship and ABMS boards, the less reason or justification to just hang a shingle and just call yourself "Pain Specialist." Obviously if you're a resident applying to pain, it increases the applicant pool and competition, but in my opinion, I think overall it's a good thing. If you want to be a Pain doctor, do an ACGME fellowship and pass the ABMS Pain boards. It's hard enough to become an expert in one year, let alone self taught. That's my opinion.

or it may result in many non-anesthesia/non-PMR residencies opening up their own "pain fellowship", under the auspices of the fellowship. a Peds or Int Med residency reviewing ACGME criteria may decide that they have the wherewithal to open their own fellowship, in a situation where the availability of interventional experience will be extraordinarily limited, along with the possible lack of historical knowledge regarding prior pain treatments that have failed - ie opioids.

dont laugh. the usual treatment in ER or office for chronic pain almost always ends in "take 1 pill every 4 hours as needed".

 

[NJPAIN]

Not pathology. Likely Rads, Peds and IM.

FM and IM see a ton of chronic pain and a few have already done ACGME fellowships and gotten ABMS boarded. Peds, maybe not so much in general peds but sickle cell, and pediatric cancer pain would be their argument. Rads obviously has the angle that they are experts at the imaging and have interventional exposure. Path? Eh...Doubt they'd apply for it. Seems like a stretch but who knows.

This is not good. There will be more guys with 10 thumbs who have never set foot in an OR or procedure suite and don't know one end of a needle from the other out there trying to make $$$ on procedures. They are not interested in pain certification to write meds. They want procedures. This is as bad a rheumatologists doing knee arthroscopy ( I'm told in some areas they do).


Sent from my iPhone using SDN Mobile

 

[Apollyon]

dont laugh. the usual treatment in ER or office for chronic pain almost always ends in "take 1 pill every 4 hours as needed".

The newer paradigm in the ED is "we don't treat chronic pain", and, in increasing numbers, the individual docs in the "pit" are getting institutional and medical society support in not treating, for example, "the fiber" (fibromyalgia) after "I ran out of pills, and you have to give me some because my doctor won't" (uh, no, I don't). However, there are still problems, including groups that say "we're working on a policy" (yeah, right, still waiting after 2 years), and the primary docs that you would swear were growing the opium poppy out back behind the office.

 

[freddydpt]

Not sure why so much negativity. Much of pain, acute and chronic, are treated in the primary care setting.

I've seen many family docs with fantastic procedural skills. It's about the education they receive. As of now the quality of a graduating board certified pain physician rests in the hands of academic pain departments with ACGME accredited fellowships. Those are primarily housed in anesthesia departments. I don't know of any new programs in the works in family departments.

 

[emd123]

The ACGME has required for a long time, that programs have all the specialties involved and follow the same ACGME requirements. So there really aren't any single specialty programs anymore and there haven't been for years now. Programs won't be able to start up without involvement from the core specialties. That's the whole point of bringing the other specialties within ACGME, so it can be unified. Any specialty has been able to do ACGME pain fellowships for years now. As far as I'm concerned, if you're FM, and you do a good fellowship besides anesthesia and PMR people, learn lots of procedures and the other things you need to, and pass the boards, you're fine with me. Not to mention the fact that by making FM "official" still makes it no easier for them to get a fellowship spot, anymore than it has been for psych residents, for years. But I get it though. People will see it as evidence the sky is falling. It may be, but not because of this.

 

[Ducttape]

we are bound to repeat the history if we do not remember experiences of the past. similar to pain, sports medicine had its heyday... where every residency program - particularly the ER ones - suddenly opened up a sports medicine fellowship pathway.

if i am correct, most of those fellowships are gone. looking at the MGMA dashboards, only Family Medicine: Sports Medicine is listed (im guessing all others fall into "non-operative orthopedics"?) what used to be the "hot" profession for ER docs is almost nonexistent.

 

[NJPAIN]

In an ideal world we would all love each other and be one big happy family. It's not an ideal world. Medicine is fiercely competitive. Are the subspecialties of IM such as Interventional Cardiology open to other specialties? I think that it is up to our primary specialty boards to give us exclusivity. You want to be a pain specialist? Then get in through one or two primary specialties - THATS IT! Don't like being a FM or ER doc? Retrain in a second specialty. I'd like to be an interventional radiologist. Wish I had gone that route. As an interventional pain specialist I do a lot of IR. I have the skills. However, if I want to do IR I need to retrain as a radiologist. Keeps me out of IR, keeps the number of IR docs limited, protects the board member's livelihood. I suspect that the motivation underlying this is MONEY. The fellowships gets lots of "bodies" for next to nothing, the boards get the fees for exams, etc. It is the job of our Boards to protect our way of making a living.

This is only a little less worrisome than CRNAs doing what we do. Perhaps a reasonable compromise would be to do something like Cardiovascular Disease. Have a subspecialty certificate in Pain Medicine (non-interventional) open to IM, FP, ER, Neuro, etc. and Interventional pain medicine open only to Anesth and PM&R. By allowing all of these specialties in we are more or less saying that you can teach a monkey to do what we do if you train them for a year. Do we really believe that? Then let's train the same monkeys to go coronary angiograms, PTCA, peripheral vascular stents, electrodiagnostics, etc, etc.

 

[freddydpt]

In an ideal world we would all love each other and be one big happy family. It's not an ideal world. Medicine is fiercely competitive. Are the subspecialties of IM such as Interventional Cardiology open to other specialties? I think that it is up to our primary specialty boards to give us exclusivity. You want to be a pain specialist? Then get in through one or two primary specialties - THATS IT! Don't like being a FM or ER doc? Retrain in a second specialty. I'd like to be an interventional radiologist. Wish I had gone that route. As an interventional pain specialist I do a lot of IR. I have the skills. However, if I want to do IR I need to retrain as a radiologist. Keeps me out of IR, keeps the number of IR docs limited, protects the board member's livelihood. I suspect that the motivation underlying this is MONEY. The fellowships gets lots of "bodies" for next to nothing, the boards get the fees for exams, etc. It is the job of our Boards to protect our way of making a living.

This is only a little less worrisome than CRNAs doing what we do. Perhaps a reasonable compromise would be to do something like Cardiovascular Disease. Have a subspecialty certificate in Pain Medicine (non-interventional) open to IM, FP, ER, Neuro, etc. and Interventional pain medicine open only to Anesth and PM&R. By allowing all of these specialties in we are more or less saying that you can teach a monkey to do what we do if you train them for a year. Do we really believe that? Then let's train the same monkeys to go coronary angiograms, PTCA, peripheral vascular stents, electrodiagnostics, etc, etc.

If one wanted to be an IR doc, for a many years there was a "DIRECT" pathway which was a shortened training period. In fact, for a long time, there was (probably still is) a shortage of IR physicians. This is why many of the image guided procedures have been acquired by other specialties... e.g. coronary angio and intervention was invented by IR. The field of pain medicine is seeing the need for interdisciplinary care and opening up avenues for diversifying the field and upping the anty for any physician to call themself a "pain medicine physician."

Regarding monkeys, I've talked to neurologists who think PM&R docs are monkeys when it comes to EMG/NCV, and OB/GYNs who think family docs are monkeys doing cesarean sections, etc. Other examples are vascular surgery vs. vascular IR or endovascular neurosurg vs. neuro IR. (I hold no strong feelings for any of these examples). But I think whether I do a TFESI, or a neurologist, or a physiatrist or a psychiatrist... a TFESI is a TFESI is a TFESI. One might argue that the "monkey" equivalent in medicine is the medical student... (no disrespect, I was one, too). As a medical student, I was PERFORMING vertebroplasties with IR docs. It wasn't hard to teach; it wasn't hard to learn.

Not sure why many don't see this scenario similar to critical care, sleep medicine, sports medicine or hospice/palliative care. Who does critical care fellowship? IM/Pulm, EM, Anesthesia, Peds, Surgery. Who does Sleep Medicine? That list is too long to type out. Same goes for Hospice and Palliative Care. Remember who was late to the game for (non-operative) Sports Medicine? PM&R... that was previously limited to IM, ER, Peds and (mostly) FM, though some could argue PM&R is the most qualified.

I love the field of pain medicine and it requires a special kind of physician to care for patients' pain, sleep, mood and function, providing a variety of invasive and non-invasive interventions, but none of those domains or procedures are necessarily exclusive to any one primary field and certainly are NOT any more challenging than procedures performed in other fields. If anyone truly thinks that, then egos need to be checked at the door. You said you think it's the job of the board (I'm assuming anesthesia) to protect the way you make a living. I'd argue it's the boards' job to protect the integrity of the field and evolve along side. The field of pain changes dramatically on a yearly basis, but the board and training structure has remained fairly static. The fact that the ABA is now recognizing the contributions that ER, FM and Radiology can bring to the field in addition to Psych, Neuro, PM&R and Anesthesia only shows that walls are coming down and collaborative/interdisciplinary efforts can start to bloom.

Also, related to your post, you said if you don't like XYZ original specialty you chose and want to do pain, then retrain in another specialty. I know SO many people who have done that. Many chose anesthesiology to retrain with a full understanding that they HATED the OR but would tolerate it for three years in order to make themselves competitive for pain fellowship. That equals a lost residency spot for someone motivated to learn anesthesiology (waste of medicare dollars), a bitter, perhaps non-focused anesthesia resident, and lost valuable motivated time learning a desired field.

Just some thoughts and of course meant with the utmost respect to your opinions, as well.

 

[NJPAIN]

I admire your careful analysis of the situation, your enthusiasm and your optimism. I really hope that you are correct and that this is a good thing for everyone. I have watched this field evolve over the last 22 years in my capacity as a pain fellow (when there were so few fellowship trained pain physicians that everyone wanted to hire you), fellowship director and now private practitioner. From this experience I believe that the academicians who run our Boards live in a vacuum. They just want their programs to be BIGGER and BIGGER. The more fellows and residents they have the more power they have in their institution and in their respective fields. As they crank out more and more "trained" physicians they flood the field. Then no one can find a job and those of us in the field have to cut one another's throats as we fight over the crumbs. I remember in the mid 1990s when we trained so many anesthesia residents that our residents completing one of the top 5 residencies in the country were being offered $60,000/yr. Entry level RNs were being offered more. Then the field became so undesirable that we couldn't even fill half of our residency slots with American grads. So, we went overseas to recruit residents. We couldn't even communicate with them as most of them spoke little to no English. But, the chair wanted those slots filled. We filled as may as we could. The faculty wanted to throw many of them out as they were flat out dangerous but the chair insisted that we push them through. The numbers game produced a lot of really bad doctors. Unfortunately once they are trained and given the Board's stamp of approval no one knows the difference. They compete against the good doctors for the same jobs.

If I believed that the number of fellowship slots would remain static perhaps this wouldn't be a bad thing. However, I think that with all of these other primary specialties involved the number of trainees will increase and that will make things worse than it already is. The more of us there are the less valuable we become. Those making the decisions don't give a crap because it doesn't affect them.

 

[epidural man]

Having ER and FP do pain is nothing new. They used to get their board certification through PM&R. Now PM&R said they wouldn't do it anymore, so the other specialties said they would do it.

We have trained PM&R, Neurology, Psychiatry and anesthesia. They all have done very well and each bring something unique to the field. We are a better clinic having trained them and now having some of them as part of the fellowship faculty.

Having FM join those ranks will also benefit the field. It is short sighted to think otherwise.

Actually, it is the step in the right direction to get pain medicine as it's own specialty.

 

[deleted472101]

I think pain fellowships should be broken into clinical and interventional like NJ PAIN wrote above.

 

[freddydpt]

I think pain fellowships should be broken into clinical and interventional like NJ PAIN wrote above.

How do you feel that divide would help?

Personally, I don't understand how or why it would make a difference as long as the quality and quantity minimums are maintained during the fellowship year. Some programs already have "interventional" sub-tracks for their programs which call it that based on the amount of OR/Stim/Pump experience you desire during the program. Otherwise, all ACGME pain programs that I know of (and I literally researched ALL of them when I was applying) perform the bread and butter injections routinely as part of their program. If you start dividing "clinical and interventional" pain fellowships, then you'll start to see interventional docs know nothing about medications and clinical docs know nothing about procedures; the right hand won't talk to the left and the whole concept of interdisciplinary pain management goes out the window. Pain is a multimodality specialty where physicians have many tricks up their sleeve... that's part of what makes it so great.

 

[lobelsteve]

And yet there are those in our ranks who only do procedures for a living or others that just do opiate Rx. The more people that train, the more viewpoints there will be and the more watered down the field becomes. A residency is needed that would encompass all of pain. And it will never happen. Unless we go single payor and socialize pain medicine:

Manifesto of a madman:

Socializing pain medicine for the common good.

Pain physicians become employee's of the federal government.
Salary is 65-80% MGMA with no bonus, no work product/patient related ancillary income. Govt benefits and COLA.
VAMC type sovereign immunity form lawsuits.
Responsible for all Pain care outside of the acute ER or operative setting.

This includes opiate prescribing and interventional care.
Other physicians will no longer be able to Rx opiates outside of a 7 day course and 1 refill for any pain complaint. Surgeons can handle post-op pain per usual course.

Interventional care will be allowed only by pain physicians and not any other specialty. This would include outpatient VCF augmentation, SCS, ESI, Facet, SIJ, sympathetic blocks.

Minimum patient load would include 20 per day, max 30 per day.

Opiate prescribing issues will need a round table of experts for consensus. Dosing, drug choice, qty limits, due diligence
all need to be discussed and agreed upon.

Medicare is primary payor and all insurance companies would need to pay in a percentage of prior payments to the Pain Pilot program.

Would need a test region/locale to determine feasibility and logistics.

 

[freddydpt]

And yet there are those in our ranks who only do procedures for a living or others that just do opiate Rx. The more people that train, the more viewpoints there will be and the more watered down the field becomes. A residency is needed that would encompass all of pain. And it will never happen. Unless we go single payor and socialize pain medicine:

Manifesto of a madman:

Socializing pain medicine for the common good.

Pain physicians become employee's of the federal government.
Salary is 65-80% MGMA with no bonus, no work product/patient related ancillary income. Govt benefits and COLA.
VAMC type sovereign immunity form lawsuits.
Responsible for all Pain care outside of the acute ER or operative setting.

This includes opiate prescribing and interventional care.
Other physicians will no longer be able to Rx opiates outside of a 7 day course and 1 refill for any pain complaint. Surgeons can handle post-op pain per usual course.

Interventional care will be allowed only by pain physicians and not any other specialty. This would include outpatient VCF augmentation, SCS, ESI, Facet, SIJ, sympathetic blocks.

Minimum patient load would include 20 per day, max 30 per day.

Opiate prescribing issues will need a round table of experts for consensus. Dosing, drug choice, qty limits, due diligence
all need to be discussed and agreed upon.

Medicare is primary payor and all insurance companies would need to pay in a percentage of prior payments to the Pain Pilot program.

Would need a test region/locale to determine feasibility and logistics.

I agree that pain medicine needs its own residency for sure.

I agree with the opiate prescribing issues you stated.

Interventional care only by a pain physician? Not sure if I completely agree with that. May stunt innovation. For example, I think MR guided-focused US might be the next big diagnostic and therapeutic technique in pain medicine. Who would own/operate the MRI, modify pulse sequences, etc.? Might be difficult for a pain physician to learn that depth of MRI.

"The more people that train, the more viewpoints there will be and the more watered down the field becomes." - I disagree with that statement... depending on how you define "watered down."

 

[NJPAIN]

A residency in Pain Medicine would be ideal. You do 1 year of medicine, peds or surgery and 3 years of pain. You do a residency in another specialty, don't like it and want to do pain? - you need to do the entire 3 year pain residency. This keeps out those who are looking for a way out of their primary specialty because they don't like it or the $$$ was not what they hoped. That's the problem with the current structure. It's way too easy to bailout of another specialty and roll right into pain. What else is so easy?? It brings people in for all of the wrong reasons and floods the field with garbage. It wouldn't be so bad if the public was smart enough to distinguish the difference between a good pain doctor and a bad one. The primary doctors are no better at figuring out who is knowledgeable and well trained. The PCP will refer to whomever with take their chronic opioid dumps or who will pay them $10K/month to rent office space.

If we really limited who comes into this field we wouldn't be spending so much of our time on this forum discussing how much we hate primary care docs dumping patients on us but that we put up with it because otherwise they will send the "good" patients elsewhere. If there were fewer of us we would have much more power to control the appropriateness of patients sent to us and the type of treatment they receive. When fellowship trained pain doctors were as "rare as hound's teeth" 20 years ago being a pain doctor was more like being a neurosurgeon than in the current climate where a pain doctor is on the level of a chiropractor.

 

[emd123]

Having ER and FP do pain is nothing new. They used to get their board certification through PM&R. Now PM&R said they wouldn't do it anymore, so the other specialties said they would do it.

We have trained PM&R, Neurology, Psychiatry and anesthesia. They all have done very well and each bring something unique to the field. We are a better clinic having trained them and now having some of them as part of the fellowship faculty.

Having FM join those ranks will also benefit the field. It is short sighted to think otherwise.

Actually, it is the step in the right direction to get pain medicine as it's own specialty.

Agree.

 

[emd123]

A residency in Pain Medicine would be ideal. You do 1 year of medicine, peds or surgery and 3 years of pain. You do a residency in another specialty, don't like it and want to do pain? - you need to do the entire 3 year pain residency. This keeps out those who are looking for a way out of their primary specialty because they don't like it or the $$$ was not what they hoped. That's the problem with the current structure. It's way too easy to bailout of another specialty and roll right into pain. What else is so easy?? It brings people in for all of the wrong reasons and floods the field with garbage. It wouldn't be so bad if the public was smart enough to distinguish the difference between a good pain doctor and a bad one. The primary doctors are no better at figuring out who is knowledgeable and well trained. The PCP will refer to whomever with take their chronic opioid dumps or who will pay them $10K/month to rent office space.

If we really limited who comes into this field we wouldn't be spending so much of our time on this forum discussing how much we hate primary care docs dumping patients on us but that we put up with it because otherwise they will send the "good" patients elsewhere. If there were fewer of us we would have much more power to control the appropriateness of patients sent to us and the type of treatment they receive. When fellowship trained pain doctors were as "rare as hound's teeth" 20 years ago being a pain doctor was more like being a neurosurgeon than in the current climate where a pain doctor is on the level of a chiropractor.

#1-There's also lots of anesthesiologists and physiatrists that went into Pain to "bail out" of their specialties out of some level of dislike of their original specialties, in favor of Pain which they like more. So what? But you say that's okay for them but not for other specialties? That makes no sense. I'm hearing a lot of turf protection talk. I just shake my head when I hear the same people that trained nurses to do their jobs, don't think a physician who did medical school, a 3-4 year residency, and the same 1-year ACGME Pain fellowship, and passed the same ABA Pain exam can do the same job. It's just blatant, misplaced turf protection. A physician needs to spend 3 years doing OR anesthesia to treat chronic pain patients even though he did an ACGME pain fellowship and ABMS Pain boards, yet a nurse needs none of that to practice anesthesiology? That's absurd. You've for the cart before the horse.

#2-It's not "easy" to leave a non-traditional specialty and to into Pain. There's a HUGE bias against non-anesthesia people. You have to essentially be a superstar to overcome those odds as a non-anesthesia/non-PMR candidate trying to get into an ACGME pain fellowship. It's hard even for anesthesia residents even with the pro-anesthesia favoritism, and anti-non-anesthesia bias you admit you have, as a former Pain program director. So I think your fear of droves of non-anesthesia/non-PMR applicants flooding Pain fellowships is unjustified. That's not even to mention that no one has suggested any of this would even increase fellowship spots by even one position. It creates more competition for pain fellowship applicants, but does not add one more Pain doctor to the job market, than before.

#3-I agree, Pain needs a residency, but I have different reasons for thinking so. I practiced Emergency Medicine for 10 years before I did an ACGME Pain fellowship. I had seen tens of thousands of patients with every imaginable form of acute and chronic pain before my fellowship. I had seen patients with acute neck and back injuries, subacute injuries, all the way through patients who had pain 20 years after their injury. I had also seen lots of patients discharged from so called Pain doctors offices in the ER trying to abuse meds, plus countless addictive behaviors and overdoses. I had pushed narcan, intubated, and coded many a "pain physician's" patients and told family members their loved one had died due to their prescribed opiate addiction. That was the best "pre-Pain fellowship" education I could have ever had. I had way more experience with "pain" than a final year anesthesia resident. To exclude people like me from Pain, would be absurd. And for somebody like me to have gone back and have done an entire anesthesia residency to get into a Pain fellowship would have been *****ic. I would have spent 3 years learning what, loss of resistance technique? Give me a break. The portions of anesthesia that have any relevance to chronic pain care, I already knew. I already had done countless lumbar punctures. I already knew how to intubate people. I already had excellent procedural skills, including ultrasound, lines, intubations, experience reading spine films, resuscitation, sedation, suturing/wound-repair and more. I had diagnosed epidural abscesses, cauda-equina syndrome, and AAA's and cancers that presented as "chronic" pain. To have gone back and done anesthesia for me, would have been a laughable waste of time, since my goal was to do Pain, not OR anesthesia. Here's the big elephant in the room that no one wants to acknowledge: Pain as a specialty is completely different from general anesthesia, to begin with. They're miles apart. They're not even close. They're not even in the same building as each other. Most of these residents, from any specialty, don't know a darn thing about "pain," and 1 year isn't enough for any of them, anesthesia residents included. I would be in favor of a Pain residency. But let's be honest here, as I'm going to blow the lid off of this right now. The pro-anesthesia and anti-everybody-else bias in Pain, is about turf protection and nothing else.

 

[Ducttape]

it is not so much turf protection as protection of the specialty.

i would not go so far as to say that anesthesiology specialty is the best or should be the only way of getting into pain, but as of right now, it is the most common.

what my concern is is the dilution of the quality of the candidates via the establishment of new fellowships, and with some of these candidates not being vetted appropriately. if history repeats itself, multiple other specialties will start forming their own pain medicine fellowships, exactly like what happened to Sports Med in the 90s and even ER in the early 90s. the difference - ER held strong and would not recognize IM programs that decided to make ER fellowships or qualify for their boards. sports med fellowships popped up at multiple ER residencies. currently, ER as a profession is going strong. sports med? not so much.

freddypt, be careful what you ask for. if a monkey can be taught to do injections, then soon CRNA, NP, PA, LPN, med tech organizations will clamor to be allowed to do these injections, and without physician supervision. oh wait, some of those organizations are already pushing for that.

finally, emd, you didnt do anesthesiology residency so there is no way you can reasonably say that you do or do not know more because of not doing an anesthesiology residency.

i worked in ER longer than you, taught more years of ER residents than you were working in ER, and i found anesthesiology residency to be very informational about pain, particularly since at least 4 - in my case, 6 - months of a residency is in pain (acute and chronic). its not just about LOR. it is about disease process, other non-pill way of treating pain ( you obviously learned that opioid pills at least are not "good"), workflow, types of needles, running epidurals/testing them, comfort with neuraxial procedures and injecting medications, the anatomy of the spine, the mechanism of nerve blocks, medications used, ultrasound skills (which are completely different diagnostic vs. therapeutic), adjunctive meds, the study of pain itself. opioids are only a small picture of chronic pain. ER is not a great field to prep in itself for Pain. PMR? yes. Neuro, probably. Psychiatry? yes and no. FM? not so much.

 

[epidural man]

Ducttape,

I agree.

If I am a patient that has complicated cancer pain that may required a tunneled epidural that would be best served implanted to perserve longevity of the catheter, I want my pain physician to have this ability. Unfortunately, if everyone forms a "pain" fellowship, and they teach facet injections and epidurals and nothing else - it will be hard to tell who is that pain physician that has truly been taught ADVANCED invasive procedures, and has a good handle on all those things you mentionted. If you call yourself a pain phsyician, I think you should be the EXPERT on PCA management (both in the acute and chronic world), acute pain (both with catheters and other adjuvants), pharmacology of ALL agents including local anestheics - including how to treat overdoses, all neuraxial aspects of pain managament (spread of opioids in the epidural space, local anesthetics in the epidural and spinal space, etc) - which is all anesthesia based stuff.

However, I also think you need to be an expert on physcial therapy modalities for chronic pain and functional restoration and its management. I think you have to be an expert on the nervous system and most aspects pertaining the nervous system and pain. You have to understand the mind and body and how they piece together.

The field is too broad to come from one field, and try to get the rest in a year.

 

[freddydpt]

freddypt, be careful what you ask for. if a monkey can be taught to do injections, then soon CRNA, NP, PA, LPN, med tech organizations will clamor to be allowed to do these injections, and without physician supervision. oh wait, some of those organizations are already pushing for that.

Just to clarify, I never said a monkey could do these procedures (never implied it either). I was just saying that I don't think they are more complex than procedures performed by many other fields. I was trying to defend Family Practice docs as I've seen some very procedurally savvy FP's in my training.

 

[emd123]

it is not so much turf protection as protection of the specialty.

i would not go so far as to say that anesthesiology specialty is the best or should be the only way of getting into pain, but as of right now, it is the most common.

what my concern is is the dilution of the quality of the candidates via the establishment of new fellowships, and with some of these candidates not being vetted appropriately. if history repeats itself, multiple other specialties will start forming their own pain medicine fellowships, exactly like what happened to Sports Med in the 90s and even ER in the early 90s. the difference - ER held strong and would not recognize IM programs that decided to make ER fellowships or qualify for their boards. sports med fellowships popped up at multiple ER residencies. currently, ER as a profession is going strong. sports med? not so much.

freddypt, be careful what you ask for. if a monkey can be taught to do injections, then soon CRNA, NP, PA, LPN, med tech organizations will clamor to be allowed to do these injections, and without physician supervision. oh wait, some of those organizations are already pushing for that.

finally, emd, you didnt do anesthesiology residency so there is no way you can reasonably say that you do or do not know more because of not doing an anesthesiology residency.

i worked in ER longer than you, taught more years of ER residents than you were working in ER, and i found anesthesiology residency to be very informational about pain, particularly since at least 4 - in my case, 6 - months of a residency is in pain (acute and chronic). its not just about LOR. it is about disease process, other non-pill way of treating pain ( you obviously learned that opioid pills at least are not "good"), workflow, types of needles, running epidurals/testing them, comfort with neuraxial procedures and injecting medications, the anatomy of the spine, the mechanism of nerve blocks, medications used, ultrasound skills (which are completely different diagnostic vs. therapeutic), adjunctive meds, the study of pain itself. opioids are only a small picture of chronic pain. ER is not a great field to prep in itself for Pain. PMR? yes. Neuro, probably. Psychiatry? yes and no. FM? not so much.

If I'm not qualified to make any judgements about anesthesiology, because I didn't do an anesthesia residency or take the anesthesiology boards, then you're no more qualified to speak of emergency medicine since you didn't do an EM residency or take the EM boards.

 

[lobelsteve]

If I'm not qualified to make any judgements about anesthesiology, because I didn't do an anesthesia residency or take the anesthesiology boards, then you're no more qualified to speak of emergency medicine since you didn't do an EM residency or take the EM boards.

Wait ER got a residency program?

Guess Clooney and Goose really did do a good job.

 

[Ducttape]

If I'm not qualified to make any judgements about anesthesiology, because I didn't do an anesthesia residency or take the anesthesiology boards, then you're no more qualified to speak of emergency medicine since you didn't do an EM residency or take the EM boards.

actually, no. i was a assistant professor in emergency medicine at an academic teaching program. i know what goes on and what is taught in EM residency - i taught guys like you what you know about EM.

i missed grandfathering the EM boards by 3 months. i decided not to take the alternate boards, because, prophetically, i thought that they would be useless.

 

[emd123]

Bottom line: this is old news. Any specialty has been able to do ACGME pain fellowships and take the pain boards since 2007. While these threads always degenerate to "my specialty is better" bickering, it's wasted breath. The hope to go back in time and start reversing the trend, and taking specialties away from Pain, to get back to one specialty dominance, is futile. In fact, more and more specialties will be added from here on out, likely rads, peds and IM, next. The ACGME, ABMS, and even the ABA, ABPMR and ABPN have all signed on to these changes along the way. Ultimately, Pain will be unified under a residency and it will make the point moot. But until then, people can be free to debate back and forth which specialty is better. I'm okay with that.

 

[emd123]

actually, no. i was a assistant professor in emergency medicine at an academic teaching program. i know what goes on and what is taught in EM residency - i taught guys like you what you know about EM.

i missed grandfathering the EM boards by 3 months. i decided not to take the alternate boards, because, prophetically, i thought that they would be useless.

Wait. As a side note, how many specialties have you practiced? Primary care, ER, anesthesia and Pain?

 

[Ducttape]

if you must know... Eternal Medicine residency.
Emergency medicine career, 15 years.
Anesthesiology residency, no clinical practice.
Pain fellowship, and Pain medicine career, on its 5th year.

yes im an old f%#t

 

[NJPAIN]

It's ALL about turf. Don't forget, most of us earn a living doing this. I believe that it is up to us and our board(s) to protect our turf. Just because this business is medicine doesn't mean we all have to hold hands, sing "I'd like to teach the world to sing in perfect harmony" on a mountain top and welcome everyone into the field. Protecting your turf is human nature and an important part of surviving in business. If this were my hobby I would love the diversity.

 

[emd123]

It's ALL about turf. Don't forget, most of us earn a living doing this. I believe that it is up to us and our board(s) to protect our turf. Just because this business is medicine doesn't mean we all have to hold hands, sing "I'd like to teach the world to sing in perfect harmony" on a mountain top and welcome everyone into the field. Protecting your turf is human nature and an important part of surviving in business. If this were my hobby I would love the diversity.

That's fine, as long as you concede to me the piece of turf I rightfully earned.

 

[bedrock]

NJ is hotly contested turf in pain medicine I hear.

 

[NJPAIN]

I sucks like everywhere else.


Sent from my iPhone using SDN Mobile

 

[Paddington]

If we really limited who comes into this field we wouldn't be spending so much of our time on this forum discussing how much we hate primary care docs dumping patients on us but that we put up with it because otherwise they will send the "good" patients elsewhere. If there were fewer of us we would have much more power to control the appropriateness of patients sent to us and the type of treatment they receive. When fellowship trained pain doctors were as "rare as hound's teeth" 20 years ago being a pain doctor was more like being a neurosurgeon than in the current climate where a pain doctor is on the level of a chiropractor.

In America, every idiot and his brother already has a pain practice. If you're in any city, any village, you can't go left or right without passing some sort of pain clinic within a few hundred feet.

I'm skeptical as to how throwing Pain open to as of yet even more specialties is going to be of benefit, other than somehow this makes some folks feel good about themselves about being in such an egalitarian field open to anyone with no relevant qualifications whatsoever. This is exactly, 100% the opposite strategy pursued by all other fields in medicine. But I fail to see how participating in such a peculiar social experiment is going to feed one's family.

In California in the metro areas, there's actually waiting lists to get into see a PCP. I know someone in LA whose in their 20's, up until recently healthy, with "good insurance", but now with GI issues who can't get into see a PCP because the waiting lists are so long. They keep going into the ER with severe episodes and being told to follow up with their PCP, and yet they can't get a PCP. We actually need PCP's in America doing Primary Care stuff. People are suffering from lack of access to PCP's. Meanwhile, nobody has actually ever died from not being stuck with a needle or not getting oxycodone. Why do we need more people doing Pain, when there's already an insane oversaturation of Pain providers?

 

[Ducttape]

there is an oversaturation of Pain providers, but there is a significant dearth of board certified - in Pain Management - physicians

 

[NJPAIN]

In America, every idiot and his brother already has a pain practice. If you're in any city, any village, you can't go left or right without passing some sort of pain clinic within a few hundred feet.

I'm skeptical as to how throwing Pain open to as of yet even more specialties is going to be of benefit, other than somehow this makes some folks feel good about themselves about being in such an egalitarian field open to anyone with no relevant qualifications whatsoever. This is exactly, 100% the opposite strategy pursued by all other fields in medicine. But I fail to see how participating in such a peculiar social experiment is going to feed one's family.

In California in the metro areas, there's actually waiting lists to get into see a PCP. I know someone in LA whose in their 20's, up until recently healthy, with "good insurance", but now with GI issues who can't get into see a PCP because the waiting lists are so long. They keep going into the ER with severe episodes and being told to follow up with their PCP, and yet they can't get a PCP. We actually need PCP's in America doing Primary Care stuff. People are suffering from lack of access to PCP's. Meanwhile, nobody has actually ever died from not being stuck with a needle or not getting oxycodone. Why do we need more people doing Pain, when there's already an insane oversaturation of Pain providers?

APPLAUSE



Sent from my iPhone using SDN Mobile

 

[Raddoc123]

Having ER and FP do pain is nothing new. They used to get their board certification through PM&R. Now PM&R said they wouldn't do it anymore, so the other specialties said they would do it.

We have trained PM&R, Neurology, Psychiatry and anesthesia. They all have done very well and each bring something unique to the field. We are a better clinic having trained them and now having some of them as part of the fellowship faculty.

Having FM join those ranks will also benefit the field. It is short sighted to think otherwise.

Actually, it is the step in the right direction to get pain medicine as it's own specialty.

How does getting more co sponsors lead to pain medicine becoming it's own specialty??

 

[drcrispmd]

Appointments for pain medicine prescriptions take up too many appointment slots especially being the new doc in a small town. It does make it difficult for patients with other issues or those needing to establish get appointments. I think I have ran off some of our "pain patients" because I wanted to imaging because we didn't have records from their "injury" 20 years ago and a drug screen before anymore meds. I would love to say I do not do any chronic pain meds but I work for a rural clinic and we see a lot of patients with no insurance.

In America, every idiot and his brother already has a pain practice. If you're in any city, any village, you can't go left or right without passing some sort of pain clinic within a few hundred feet.

I'm skeptical as to how throwing Pain open to as of yet even more specialties is going to be of benefit, other than somehow this makes some folks feel good about themselves about being in such an egalitarian field open to anyone with no relevant qualifications whatsoever. This is exactly, 100% the opposite strategy pursued by all other fields in medicine. But I fail to see how participating in such a peculiar social experiment is going to feed one's family.

In California in the metro areas, there's actually waiting lists to get into see a PCP. I know someone in LA whose in their 20's, up until recently healthy, with "good insurance", but now with GI issues who can't get into see a PCP because the waiting lists are so long. They keep going into the ER with severe episodes and being told to follow up with their PCP, and yet they can't get a PCP. We actually need PCP's in America doing Primary Care stuff. People are suffering from lack of access to PCP's. Meanwhile, nobody has actually ever died from not being stuck with a needle or not getting oxycodone. Why do we need more people doing Pain, when there's already an insane oversaturation of Pain providers?

 

[emd123]

How does getting more co sponsors lead to pain medicine becoming it's own specialty??

I think the more specialties that have skin in the game that can advocate for Pain at the ABMS and ACGME level, help this. Being isolated like a one or two specialty island makes the specialty less strong as it is with more ox pulling the cart.

 

[Ducttape]

no, emd. the more access there is for any specialty to get into a subspecialty, there becomes less interest overall in making that a unique specialty.

how does allowing every tom, dick and harriet (to be politically correct) the ability to do a pain fellowship after going through a primary residency encourage the primary residencies to advocate for a different and new residency, one that would prohibit their former residents to not apply for their primary residency and apply for the new one?

to wit - if FM, IM, Peds, Surgery, etc. all allowed ER fellowships, the development of an ER residency would stalled and quite possibly never had occurred.