EMG fellowship

[topwise]

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Does anyone think it's worth it to do an EMG (neurophysiology) fellowship? I'll have 200-300 EMGs by the end of residency, but not much complicated stuff like ALS, myasthenia, etc. I'm not sure if I want to do those studies or not, but would an EMG fellowship make me more marketable?

 

[Disciple]

Only for an academic Neurophys position in a Neurology dept. Then again, I've never seen a Physiatrist in one of these positions.

 

[topwise]

The reason I brought this up is that I was telling my cousin, who is a neurologist in practice at an academic institution for many years, how much I loved doing EMGs. She thought that I should do the fellowship or else nobody would take me seriously as an EMG-er. But someone else on this board said that there was absolutely no point in doing an EMG fellowship if you're a physiatrist (and I would think an actual physiatrist would know better).

As I said, I am not hung up on doing complicated studies, but I want to be good at what I do. I get worried when I see attendings at my program who have been practicing a long time having to check textbooks in order to do any study beyond carpal tunnel or radiculopathy.

 

[PMR 4 MSK]

There's not that many real EMG fellowships. About the only reason to do one would be to increase your odds of being sub-specialty boarded in EMG, or to get more solid practice at them.

Since residency, I've done about 2000 - 3000 EMG's. I'm still learning things. Even routine "R/O CTS" still sometimes turns up some crazy stuff that I have to look up or ask someone.

Problem is, you do a fellowship, then you want to find a job where you get lots of referals for EMG's. Most places there's a lot of competion for them. If you get 4-5/week, you're doing well. Still got to fill the other 35 or so hours of the week.

If you'll have 2-300 EMG's that you have personally performed, not just reviewed or watched, you'll do fine right out of residency sans fellowship, especially if you come from a strong EMG residency (like San Antonio, Milwaukee).

 

[topwise]

Thanks for the responses. I will almost definitely have 200+ EMGs by the end of residency, but I can't say I'm in a program that's known for being particularly strong on EMGs. I think I'll feel comfortable with the basic studies, but I might not feel as comfortable for something slightly more complicated like a r/o myopathy.

Is there any benefit to being sub-specialty boarded in EMGs? At what point can you get boarded in general EMGs?

 

[Disciple]

I don't think you should take it as a sign of poor EMG skills in your attendings. The skills aren't any different for making electrodiagnoses of neuromuscular disease vs. peripheral nerve entrapment. It's just has to do with remembering the electrodiagnostic criteria for each condition, and of course your knowledge of the pathophys of the condition and your neuro-exam skills.

During residency I did half of my EMG training in the Neurology department. Do I remember the electrodiagnostic criteria for the spectrum of neuromuscular diseases? No. Do I think I could recognize the early recruitment and small motor units of Myopathic potentials, given a suggestive history? Yes. Just as a Neurologist may have done more R/O ALS, Myasthenia Gravis, etc. studies, a good Sports/Occ Med Physiatrist may be able to make a quicker diagnosis of, say, Axillary nerve entrapment in the Quadrilateral Space.

Second point is that certain types of studies traditionally get referred to Neurologists. Not because we have poor skills, but because
1. Many PCPs don't know what we do (discussed elsewhere)
2. Patients are referred for the entire work-up (lab work, neuro-exam) and possibly initial treatment

Third Point is that Physiatrists cannot become sub-specialty boarded in EMG. We can become certified through the ABEM, which isn't required for reimbursement through Medicare, Work Comp or private insurance. To take this exam, you now have to do at least 6 months EMG during residency, and an additional 200 studies independently in practice, or 400 EMGs in training (the initial 200, and then 200 with no assistance).

Neurologists can become sub-specialty boarded in Neurophysiology after an EMG/EEG fellowship. Physiatrists are not eligible for this certification, even after doing a Neurology Neurophys(EMG) fellowship.

 

[GQPMR]

Although you can't be board certified in Neurophysiology, you can however get board certified in Neuromuscular Medicine.

Check this thread out as there was a discussion of how to qualify for either the ABEM or Neuromuscular Medicine certification examinations.

http://forums.studentdoctor.net/showthread.php?t=491827

 

[topwise]

How do you prove you've done 200 EMGs? Also, we have 6 months of rotations that include EMGs but are not necessarily dedicated EMG rotations. Does that count?

 

[GQPMR]

How do you prove you've done 200 EMGs? Also, we have 6 months of rotations that include EMGs but are not necessarily dedicated EMG rotations. Does that count?

We keep logs of our EMGs (in fact, we kept computer logs of just about everything we did: procedures, inpatient consults, admissions, joint and spine injections, etc). These logs then have to be validated by the attending supervising them or your program director.

I have not gone through the ABEM certifying process, maybe someone who has recently gone through or is going through it can chime in. But just on cursory review of the ABEM website, there is no mention how this is to be documented. Maybe they are using the honor system???

 

[drvlad2004]

The reason I brought this up is that I was telling my cousin, who is a neurologist in practice at an academic institution for many years, how much I loved doing EMGs. She thought that I should do the fellowship or else nobody would take me seriously as an EMG-er. But someone else on this board said that there was absolutely no point in doing an EMG fellowship if you're a physiatrist (and I would think an actual physiatrist would know better).

As I said, I am not hung up on doing complicated studies, but I want to be good at what I do. I get worried when I see attendings at my program who have been practicing a long time having to check textbooks in order to do any study beyond carpal tunnel or radiculopathy.

I am not trying to be divisive but I always notice that it is the neurologist recommending an EMG fellowship. Truthfully, most neurology programs do not perform nearly as many EMGs as PM&R programs. IMO, I feel comfortable enough to do routine EMGs. More complicated neuromuscular disorders such as ALS would require me flipping through books like Preston or Dumitru. Since PM&R training programs offers more than an adequate amount of EMGs, you will be more marketable without the fellowship.

 

[topwise]

I am not trying to be divisive but I always notice that it is the neurologist recommending an EMG fellowship. Truthfully, most neurology programs do not perform nearly as many EMGs as PM&R programs. IMO, I feel comfortable enough to do routine EMGs. More complicated neuromuscular disorders such as ALS would require me flipping through books like Preston or Dumitru. Since PM&R training programs offers more than an adequate amount of EMGs, you will be more marketable without the fellowship.

I agree with what you say about neurologists. I kind of get the feeling that my cousin the neurologist (and other neurologists) think physiatrists suck at EMGs and look down on us. They can't imagine that our residency could possibly train us well enough to do EMGs.

I like the idea of getting extra training, but until I talked to her, I was really not excited about the idea of uprooting my family and getting paid less for a year to do a fellowship I might not even need.

 

[Disciple]

How do you prove you've done 200 EMGs? Also, we have 6 months of rotations that include EMGs but are not necessarily dedicated EMG rotations. Does that count?

The ABEM lists the requirement as equivalent of 6 months full-time training in Electrodiagnostics with 200 studies. I guess if your program director or primary EMG instructor signs the form, that should be good enough.

 

[Disciple]

More complicated neuromuscular disorders such as ALS would require me flipping through books like Preston or Dumitru. Since PM&R training programs offers more than an adequate amount of EMGs, you will be more marketable without the fellowship.

That's part of what I'm getting at. The studies for neuromuscular disease are not technically more complicated (There are exceptions. Most Physiatrists are not skilled at doing/interpreting Rep Stim and Single Fiber EMG), they just tend to be longer. It's the other stuff (the history, pathoyphys, physical exam) that you need to be up to speed on.

 

[PMR 4 MSK]

I agree with what you say about neurologists. I kind of get the feeling that my cousin the neurologist (and other neurologists) think physiatrists suck at EMGs and look down on us. They can't imagine that our residency could possibly train us well enough to do EMGs.

When the opposite is actually true...

 

[drvlad2004]

I agree with what you say about neurologists. I kind of get the feeling that my cousin the neurologist (and other neurologists) think physiatrists suck at EMGs and look down on us. They can't imagine that our residency could possibly train us well enough to do EMGs.

I like the idea of getting extra training, but until I talked to her, I was really not excited about the idea of uprooting my family and getting paid less for a year to do a fellowship I might not even need.

I would focus instead on other fellowships that would actually make you marketable such as pain/spine, neurorehab, TBI, SCI, sports, etc. Your cousin might have been doing some ego-tripping. At least in NY, most neurologists admit that they do not do a lot of EMGs. They focus on other areas.

 

[Disciple]

Although you can't be board certified in Neurophysiology, you can however get board certified in Neuromuscular Medicine.

Check this thread out as there was a discussion of how to qualify for either the ABEM or Neuromuscular Medicine certification examinations.

http://forums.studentdoctor.net/showthread.php?t=491827

As Physiatrists, I think we need to be careful about the misconception that a certification in Neuromuscular Medicine is a certification in EMG, which it was never designed to be.

The Neurologists' sub-specialty certification for EMG is the Neurophys certification. For Physiatrists, your ACGME EMG certification is your primary PM&R board certificate. The ABEM certification is can look nice on your resume, though I have applied to a few EMG services (who contract with private insurance/work-comp) who preferred ABEM certification.

The Neuromuscular Medicine certification is for Physiatrist or Neurologists who want to manage the complete care of these types of patients. To grandfather in as a Physiatrist, you would almost need to work part time in an MDA clinic for a couple of years.
As it stands, there are no PM&R Neuromuscular Medicine fellowships. In contrast there are 16 Neurology Neuromuscular Medicine fellowships vs. 90 Neurology Neurophys fellowships, with the Neuromuscular requirements including a substantial amount of clinic with possibly little additional electrodiagnostic training.

Personally, I don't see it being all that useful for the vast majority of practicing Physiatrists, especially those in MSK/sports/spine/pain.

 

[SSdoc33]

we have to be careful not to sell ourselves short. PM&R is the ONLY specialty that provides AMBS approved training for EMGs in residency. the ABMS is the highest certifying authority out there. to get separate ABEM certification, when it is only actually needed in rare circumstances (some large academic hospitals) makes all of the rest of physiatrists out there performing EMGs look like they are not as well trained. when in reality, the training in residency should be sufficient.

 

[Disciple]

we have to be careful not to sell ourselves short. PM&R is the ONLY specialty that provides AMBS approved training for EMGs in residency. the ABMS is the highest certifying authority out there. to get separate ABEM certification, when it is only actually needed in rare circumstances (some large academic hospitals) makes all of the rest of physiatrists out there performing EMGs look like they are not as well trained, when in reality, the training in residency should be sufficient.

"Should" being the important work here. There are still programs out there that provide poor EMG training (too much watching, not diverse enough pathology, too little rotation time). Personally, I think all Physiatrists should do some of their EMG training in Neurology Neurophys labs, for exposure to certain types of pathology. The ABEM is a great way to raise standards. The other option is for the RRC to crack down, but do you see that happening?

 

[olafa]

Actually UC DAVIS has a neuromuscular fellowship, I am not sure if there are others out there. It is for physiatrist.
http://www.ucdmc.ucdavis.edu/pmr/education/fellowship.html

a bit off topic, but they also have sports medicine fellowship.

As Physiatrists, I think we need to be careful about the misconception that a certification in Neuromuscular Medicine is a certification in EMG, which it was never designed to be.

The Neurologists' sub-specialty certification for EMG is the Neurophys certification. For Physiatrists, your ACGME EMG certification is your primary PM&R board certificate. The ABEM certification is can look nice on your resume, though I have applied to a few EMG services (who contract with private insurance/work-comp) who preferred ABEM certification.

The Neuromuscular Medicine certification is for Physiatrist or Neurologists who want to manage the complete care of these types of patients. To grandfather in as a Physiatrist, you would almost need to work part time in an MDA clinic for a couple of years.
As it stands, there are no PM&R Neuromuscular Medicine fellowships. In contrast there are 16 Neurology Neuromuscular Medicine fellowships vs. 90 Neurology Neurophys fellowships, with the Neuromuscular requirements including a substantial amount of clinic with possibly little additional electrodiagnostic training.

Personally, I don't see it being all that useful for the vast majority of practicing Physiatrists, especially those in MSK/sports/spine/pain.

 

[SSdoc33]

"Should" being the important work here. There are still programs out there that provide poor EMG training (too much watching, not diverse enough pathology, too little rotation time). Personally, I think all Physiatrists should do some of their EMG training in Neurology Neurophys labs, for exposure to certain types of pathology. The ABEM is a great way to raise standards. The other option is for the RRC to crack down, but do you see that happening?

i agree completely. good EMG training is clearly lacking in many programs. and i have VERY little faith in the RRC to make any meaningful improvements. nevertheless, we get more requisite training than anyone else out there. certainly more than chiropractors who take a weekend course and do 3 limb EMGs for unilateral CTS.

the ABEM does raise standards, but it is a shame that we can't have electrodiagnosis known as a physiatry stronghold. you dont see general surgeons doing fellowships in breast biopsies or appendectomies. it should be bread and butter that a physiatry grad can graduate and do a decent study.

just one more example of how we are a jack of all trades, but a master of none. do i hear "identity crisis" again???

 

[Disciple]

Actually UC DAVIS has a neuromuscular fellowship, I am not sure if there are others out there. It is for physiatrist.
http://www.ucdmc.ucdavis.edu/pmr/education/fellowship.html

a bit off topic, but they also have sports medicine fellowship.

You'll have to wait 'til these are accredited for it to help things.

 

[drusso]

the ABEM does raise standards, but it is a shame that we can't have electrodiagnosis known as a physiatry stronghold. you dont see general surgeons doing fellowships in breast biopsies or appendectomies. it should be bread and butter that a physiatry grad can graduate and do a decent study

Absolutely correct. I call the "Napolean Dynamite" physiatric training doctrine: Employers like physiatrists with skills--EMG skills, interventional skills, MSK skills, ultrasound skills, medical director skills, etc.

 

[melancholy]

Actually UC DAVIS has a neuromuscular fellowship, I am not sure if there are others out there. It is for physiatrist.
http://www.ucdmc.ucdavis.edu/pmr/education/fellowship.html

a bit off topic, but they also have sports medicine fellowship.

Thanks for bringing this point up. I haven't been monitoring the forums lately. Our NMM fellow said there was actually quite a bit of interest at the AAP down in Anaheim this past year compared to the sports medicine fellowship (which I believe is in the process of getting ACGME accreditation)

From my limited experience in residency, having an MDA clinic that residents actively participate in, then performing EMGs throughout all three years of residency gives quite a few opportunities for exposure to using electrodiagnostics as an important component of the work-up for such diseases. Again as someone mentioned above, it is not significantly different from a technical standpoint, but the H&P as well as approach to the exam is what folks likely need to be "up to speed" with.

 

[tanoli10]

Hi
i am a physiatrist . i have recently passed certification Exam of ABEM and awarded certificate of recognition . I have not done USMLE . is there anyway i can get a fellowship in EMG in USA , canada or anywhere else . pl advice

 

[Ludicolo]

Hi
i am a physiatrist . i have recently passed certification Exam of ABEM and awarded certificate of recognition . I have not done USMLE . is there anyway i can get a fellowship in EMG in USA , canada or anywhere else . pl advice

I can only speak for US fellowships.

You have to be ECFMG certified in order to perform any type of medical care in the US, which includes performing EMGs during a fellowship. In order to be ECFMG certified, you have to take/pass the USMLE. Most fellowships prefer individuals who have graduated from an accredited US residency program as part of their pre-requisites. Now take into consideration that most EMG fellowships here are run through neurology departments, so any non-neurologist applying for these fellowships would already be at a relative disadvantage.

If I may ask, what are your reasons for pursuing a US fellowship? Are you looking to eventually start practicing in the US? Because in this case a fellowship by itself (without the US residency) would not allow you to be board eligible/certified in PM&R, which may make practicing in the US difficult.

However, an outstanding, exceptional, international physician might convince a given hospital or program to petition for an exemption to the above. So I guess the ultimate answer to your question is that it depends on your credentials. But just having passed the ABEM exam in and of itself probably isn’t enough.

 

[tanoli10]

thanks for your reply . The reason for pursuing fellowship in EMG is to be in a educational environment for some time so as to consolidate my skills and the reason for EMG fellowship in USA is ,that probably USA is the only place where these fellowship are in sufficient number so the chances of getting a fellowship are more . I will be grateful if you or someone else can guide me of any opportunities outside USA in countries where mode of teaching is English

You have to be ECFMG certified in order to perform any type of medical care in the US, which includes performing EMGs during a fellowship. In order to be ECFMG certified, you have to take/pass the USMLE. Most fellowships prefer individuals who have graduated from an accredited US residency program as part of their pre-requisites. Now take into consideration that most EMG fellowships here are run through neurology departments, so any non-neurologist applying for these fellowships would already be at a relative disadvantage.

If I may ask, what are your reasons for pursuing a US fellowship? Are you looking to eventually start practicing in the US? Because in this case a fellowship by itself (without the US residency) would not allow you to be board eligible/certified in PM&R, which may make practicing in the US difficult.

However, an outstanding, exceptional, international physician might convince a given hospital or program to petition for an exemption to the above. So I guess the ultimate answer to your question is that it depends on your credentials. But just having passed the ABEM exam in and of itself probably isn’t enough.[/QUOTE]