Curious about pain medicine

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zislam159

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I've been very interested in doing pain management and have been trying to research but I have soo many questions. hopefully a nice soul, or souls, could help me :)

What is the difference between non acgme and acgme pain?
What is passor?
Does being nonacgme effect job opportunities?
How will nonacgme pain be effected in the future?
Does going to a pmr program without pain fellowship at the program limit me?
If I know I want to do pain is it better to go anesthesia rather than pmr, though I know I dont like the OR?

Bonus question:
Also what is difference between interventional spine and pain?

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I am a PGY-IV about to graduate and starting an unaccredited pain fellowship next month. There are many differences and similarities, the main difference being that accredited places are multidisciplinary and you spend time with neurology, psychiatry, anesthesiology and PM&R usually. They will have a mix of inpatient and outpatient rotations that varies a lot from program to program. The vast majority of unaccredited fellowships will not have any inpatient pain exposure at all and you are usually rotating on pretty much the same service the whole year instead of switching things up a bit. ACGME programs will also typically pay much better than unaccredited programs with better benefits as well as most of them are through large universities. The procedural variety varies a lot in both accredited and unaccredited programs. Some accredited places have a large volume, some spend a lot of time doing multi-disciplinary pain medicine and deal more with the prescription aspect with lower procedural volumes. Most unaccredited places have a fairly high volume (>1000) and some claim to have a super high volume (>3000), but that doesn't always mean you will be more skilled than the person who only did 750 in fellowship. At some of the high volume places their numbers are high, but they don't want to go home at 10PM, so if you are taking too long they will take the needle from fairly quickly from what I saw. Some places are really good at letting you struggle through it and become very skilled. Higher level procedures vary program by program quite a bit I found. For example, some places don't do pump or stim implants, while others do a lot. Some do kypho and some don't. Some do a bunch of ultrasound guided stuff, some do none. I will probably learn a several procedures that many other pain fellows won't, even though I will be at an unaccredited fellowship. Many PM&R based spine programs also have a heavy sports component that pain fellowships will not have. They typically don't do much/any narcotic management and there is usually a high EMG component. The multi-disciplinary stuff is important though and shouldn't be overlooked. part of my reason for bypassing the match besides really liking the program I will be at was that I felt my PM&R program gave me a a similar exposure to those aspects as a resident and I was able to use several electives to help increase this exposure. You have to interview and get exposure to these types of procedures in residency to figure which type of program would suite you best.

Passor as I understand it was an system that allowed fellows from unaccredited fellowships to get board certified, but is no longer in existence after pain fellowships became multi-disciplinary. Does coming from an unaccredited program affect your job choices? Yes it does. This depends on the area you want to practice and the type of practice you want to be in. Most academic places won't look at fellows from unaccredited programs, but many of the PM&R departments will depending on hospital rules. Many large orthopedic/neurosurgery practices don't care either and like people with the added sports and EMG capabilities. I didn't meet any people whom really had a tough time finding a job from unaccredited places, but I only interviewed at the more well known locations, so I can't speak for all of them. It is uncertain how unaccredited places may be affected in the future, but for the most part if you can prove you have the proper experience to do procedures, most people seem to be a able to do them, except at places that specify ACGME trained only. I have heard of some insurances giving people a tough time when it came to adding them to their plans over this as well, but I am not sure how prevalent that is. When it comes to selecting a program, if you want to do an accredited fellowship I would absolutely recommend going to a program that has either an Anesthesia based program that lets you rotate them or a PM&R program with its own fellowship. Places tend to be very friendly to their home residents, especially if they like them during their 3-4 years there. Even if you didn't want to stay there, having a letter from an academic pain attending from a fellowship that other PD's may recognize will help you a lot more than some random PM&R faculty that aren't well known in the field. Fellowships are competitive, and it's not getting any easier, so I would keep that in mind when it comes to the rank list. With that said you do not have to go to a program that has an accredited fellowship to match as I had a average amount of interviews for a PM&R applicant and I may have matched had I waited it out. That's the other difference, is that unaccredited places can offer you a spot when ever they feel like it, and that is typically before the match. I was offered my spot at the end of June when I was there and again formally at the end of July. A few places waited until September, but will want an answer before rank lists for the match are due. Some of these places are also very competitive as well, but most seem to take people whom seem smart and that they think are personable and will work hard for the year. Don't do anesthesia if you don't like it. Yes, they probably have better odds at matching, but if you go to a solid PM&R program and do well, you will likely be fine. It's not worth being miserable for 3 years just to get into a fellowship that you can get into from a different field that you enjoy.
 
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See attached from the purple journal.

Keep your options open. Don't do anesthesia if you don't like ORs.

If you want to do Pain from PM&R you have to plan early. Rotate with someone early in PGY3 so you can get a LOR by December. Apply on time. Work hard.
 

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Thanks so much for all the info! As someone very interested in pain mgmt but very disinterested in OR anesthesia this is super helpful

If you are disinterested in OR Anesthesia...this is a no brainer. I would never go to residency with an assumption to do a fellowship. Pain isn't a slam dunk. Do a residency that you feel you would be happy to do without a fellowship...but leaves the door open to the fellowship you are interested in.
 
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