When making decisions about fellowships, what to do?, who the best is, or even how to structure you residency training prior to fellowship, residents/med students (including those recently matched) need to get an accurate view on the role of Physiatry in the medical community and how that role is perceived by patients and other physicians as of 2007.
First of all, what is Interventional Physiatry/Spine? Most will say that it is a Physiatrist who takes care of patients with Orthopadic spinal pain through conservative measures including the use of some basic injections. But, what is the scope of these procedures? What can be expected in terms of technical competency? What is the knowledge base? Personally, I think this term should be done away with/discouraged unless our field chooses to fully embrace and define it.
To say Slipman has the best interventional spine fellowship may be accurate from a certain line of thinking. One has to remember that in the early to mid 90's, Physiatrists were lucky to get any MSK/Spine training at all during residency, much less get quality MSK/Spine training. In that era virtually no Physiatrists got to do spinal injections during residency. So, if you wanted to become an interventionalist back then, you had to do either a gas fellowship (essentially closed to Physiatrists in the 90s), or train with a Physiatrist who was brave enough to have started performing interventional pain procedures. Slipman, Windsor, Saul brothers, Dreyfuss, Lagattuta were probably the frontrunners here. Concerning the research contribution from the Physiatry world regarding interventional pain management procedures, the greatest contributions have likely come from Slipman and Dreyfuss, thus the reputations.
Fast forward to 2007. Knowing some Physiatrists that trained at Slipman's program, I have been told that his fellows do a good volume of MSK type EMGs, use algorithms heavily weighted on evidenced based treatments, learn to read spinal CTs/MRIs, only perform transforaminals (no interlaminars) and that the fellows themselves do not perform the Vertebroplasties or Percutaneous Disc Decompressions. You will also participate in his ongoing research.
Regarding the procedures, what if you already logged 200-300 transforaminals during residency? What if you did 8-12 months in sports/spine/MSK? What if you did over 400 EMGs during residency and learned to read MRIs? A whole brutal year of fellowship to log 10+ RFs and 10+ discograms? Would any interventional spine program still be the best? What if you've decided that after fellowship you don't want to work for a surgeon or be an employee of a "spine center" and now realize that you don't know how to implant stims or do sympathetic blocks. What if you want to live in a desirable area that is saturated with pain interventionalists such that you cannot feasibly treat only spine patients. What if cervical transforaminals really fall out of favor. Uh oh, you never learned how to do cervical interlaminars or how to use epidural catheters.
As Physiatrists, here is how we would like to be perceived by patients and other physicians:
-Superior knowledge of anatomy, kinesiology, functional biomechanics and rehabilitation of the musculoskeletal system and spine combined with sound interventional and electrodiagnostic skills leads to a complete diagnosis and greater functional outcomes in a conservative, cost effective manner.
Now, the perceived reality:
-Physiatrists do alot of nothing during residency. When they go out into practice, they get snatched up by Spine/Neurosurgeons to take care of alot of the easy conservative care to keep the patients in the practice and to write the scripts for PT. They can also do some basic injections but their technical skills are all over the map and in general they really struggle with anything more advanced. I would not trust my community Physiatrist to do anything to my or my patient's neck. If the patient absolutely needs it, I guess Ill refer them to the pain doc down the street.
Now, I'm exaggerating, but unfortunately, in most community settings the perception in scenario B is the reality. An example from real life. The other day I saw a new pt in the clinic. She was a "low back and total body pain" patient with heavy psychological overlay. She had been referred by a Physiatrist for evaluation for an intrathecal pump trial. The referring Physiatrist is an interventional spine guy. He saw the patient for consult only, before referring to our group. The funny thing is, I consider myself a spine guy as well. I just happen to work in a pain group. Being a spine specialist, he should have something unique to offer the patient or some special insight into her diagnosis and rehabilitation right? Well, needless to say, the patient was quite disappointed/unimpressed with the referring Physiatrist and in her consultation with me, referred to him as a PT with an MD. This type of situation tends to happen every now and then from various referral sources.
So, whats the real point of this long winded post? Physiatry has advanced considerably since the late 80s to mid 90s. Many Physiatrists no longer have to go through an entire residency devoid of MSK/spine/interventional training and then train for another year with 1 of a few Spine/MSK experts to become an expert themselves. A higher standard is expected today. If you want to call yourself a spine guy or Interventional Physiatrist to justify a boutique type practice, then so be it, but you better have some special/far advanced skills to offer that are quite evident to patients, surgeons, PCPs, pain docs. For quite some time now, Physiatrists have been touting our approach MSK/Occ med/Spine and Pain Management as superior without insuring that the majority (>50% at least) of new grads can deliver the goods.
By reintegrating PASSOR, creating a spine track at the annual meeting and renaming the AAPMRs journal, The Academy has made it clear that it wants Physiatrists to be known as the de facto experts in non-operative spine and musculoskeletal care. Whether we have the commitment and drive to make good on these lofty goals remains to be seen. Handing down new ACGME requirements through the ABPMR would likely be the necessary final step. You want to be competitive and help the academy achieve its goals (regarding spine care in particular)?, then get as much MSK training as you can during residency. If your program offers poor MSK/spine training and/or no funding to attend the right conferences, then agitate for change. Follow up your base training with a gas fellowship at places like the Cleveland Clinic or Hopkins, or a highly interventional procedurally diverse PM&R fellowship like Windsors. For those newly matched, things are likely to have evolved even further when you look for fellowships in 2010.
