From EM to Pain? is it possible

[painfan]

Hi everybody,
I am a board certified EM physician, very interested in a pain fellowship.
Is this even possible?
Are there programs out there who take residents from non tradition pain related residencies?
Any advice would be appreciated.
Thanks in advance!

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[emd123]

Hi everybody,
I am a board certified EM physician, very interested in a pain fellowship.
Is this even possible?
Are there programs out there who take residents from non tradition pain related residencies?
Any advice would be appreciated.
Thanks in advance!

Painfan: Yes, its possible.

 

[Doctodd]

why would you want to?.....with reimbursements Pain is getting killed and ER medicine is protected by state laws so that the underserved get treated. In Florida ER docs are reimbursed by private insurance around 260% of Medicare by state law......although there are alot of Medicaid patients and i dont know what they pay. And you dont need to be contracted with any insurance companies so you should get paid usual and customary or 260%.

 

[Dr. Ice]

I agree..why the hell would you want to go into pain?!

 

[Sandpaper]

What's with the recent increase in random people wanting to do pain from other specialties? Neuro-radiology one day, ER the next.

Any pathologist want a stab at it?

And besides, you're already seeing pain patients in the ER. Just refill their Percocet and tell them to go see "pain management".

 

[PMR 4 MSK]

Wow, don't beat the guy down simply because he's ER.

Yes, you can. ACGME certification of a program includes the stipulation that they consider any candidate who has completed a certified residency. That doesn't mean they will accept them, as most tend to be anesthesia dominated.

Non-ACGME programs can take anyone they want.

You might find the pace of life better for you than ER. I know ER tends to cause a lot of "burnout" but keep in mind it happens in pain a lot also.

Also, although ER may pay well in some states, it doesn't in all. And pain payments are likely to go down, possible quite significantly.

However, do what makes you happy. If you are happy, salary doesn't matter.

 

[schiener]

Wow, don't beat the guy down simply because he's ER.

Yes, you can. ACGME certification of a program includes the stipulation that they consider any candidate who has completed a certified residency. That doesn't mean they will accept them, as most tend to be anesthesia dominated.

Non-ACGME programs can take anyone they want.

You might find the pace of life better for you than ER. I know ER tends to cause a lot of "burnout" but keep in mind it happens in pain a lot also.

Also, although ER may pay well in some states, it doesn't in all. And pain payments are likely to go down, possible quite significantly.

However, do what makes you happy. If you are happy, salary doesn't matter.

I agree, and more power to you. Can I ask the ?? about your decision to do this?

 

[SleepIsGood]

seriously...any pathologists our there?

As mroe and people from non anesthesia specialities start doing pain. The more complications there will be. Further, the more bad results and thus less reimbursements from insurance companies.

At a recent course. I especially do not think non anesthesia providers can pick up pain medicine in 1 year. Not only do you have to get the medical management down, one has to master the 'technical' aspects.

If you are at a place with many fellows, there's just not enough sheer volume at ANY program to pick up these procedures in one year. At a neighboring program, all the wet taps this year were from non-anesthesia fellows (with fluro guidance).

Also, for example, THIS IS NOVEMBER. I was at a meeting this year. A female participant who happened to be PMR trained at a workshop for SCS asked the proctor..."How do I know I am in the intrathecal space !".


SEriously. This is NOVEMBER of her fellowship and she does not know this and wants to place sharp objects next to people's spines! She has no business doing this in my opinion, and in the opinion of MANY people that heard her say this at the course.

 

[pmrmd]

seriously...any pathologists our there?

As mroe and people from non anesthesia specialities start doing pain. The more complications there will be. Further, the more bad results and thus less reimbursements from insurance companies.

At a recent course. I especially do not think non anesthesia providers can pick up pain medicine in 1 year. Not only do you have to get the medical management down, one has to master the 'technical' aspects.

If you are at a place with many fellows, there's just not enough sheer volume at ANY program to pick up these procedures in one year. At a neighboring program, all the wet taps this year were from non-anesthesia fellows (with fluro guidance).

Also, for example, THIS IS NOVEMBER. I was at a meeting this year. A female participant who happened to be PMR trained at a workshop for SCS asked the proctor..."How do I know I am in the intrathecal space !".


SEriously. This is NOVEMBER of her fellowship and she does not know this and wants to place sharp objects next to people's spines! She has no business doing this in my opinion, and in the opinion of MANY people that heard her say this at the course.

so the pmr lady was an idiot, clearly, however only an idiot generalizes that to all others in the field. i would give one of my lungs, kidneys, and left testicle to be the expert witness against you one day, you pompous douche.

 

[painfan]

Hope everybody had a good thanksgiving!.

My sincere thanks to everybody for their replies (yes, even the negative ones!)

Its good to know that I can apply to any pain program, getting into one is an entirely different story

 

[SleepIsGood]

so the pmr lady was an idiot, clearly, however only an idiot generalizes that to all others in the field. i would give one of my lungs, kidneys, and left testicle to be the expert witness against you one day, you pompous douche.

I am stating what I saw. You insecurity and inferiority complex is quite apparent in your post.

FYI, the feeling is mutual. I would really like to be an expert witness when you pierce right through the cord with a 14G. "Doctor, how many epidurals did you do in residency? Doctor how many spinals did you do in residency. Your case log here shows that you did about 2 epidurals caths and about 20 ILESI during fellowship. Our expert witness did about 300 during residency and 100+ amount during fellowship. Do you really think you are as qualified as him to being doing these procedures? Do you think with 30 or so epidurals you are qualified into putting foreign bodies into people's epidural/spinal canals?"

Yah let's see which way the jury will swing

 

[Tenesma]

dude... i am starting to question whether you are really a fellow.... sometimes you sound like a 16 year old whose got something to prove...

 

[pmrmd]

I am stating what I saw. You insecurity and inferiority complex is quite apparent in your post.

FYI, the feeling is mutual. I would really like to be an expert witness when you pierce right through the cord with a 14G. "Doctor, how many epidurals did you do in residency? Doctor how many spinals did you do in residency. Your case log here shows that you did about 2 epidurals caths and about 20 ILESI during fellowship. Our expert witness did about 300 during residency and 100+ amount during fellowship. Do you really think you are as qualified as him to being doing these procedures? Do you think with 30 or so epidurals you are qualified into putting foreign bodies into people's epidural/spinal canals?"

Yah let's see which way the jury will swing

its not insecurity and inferiority. it has nothing to do with me. its a feeling that your hubris is undeserved and your assertions are made without experience to validate them, and amazingly you are too immature to realize it. i do like the imagination on the 14g harpoon and your courtroom dialogue, though, but realize that will only exist in that assumptive mind of yours. your 400 ESIs is child's play numbers to me, boy.

 

[emd123]

Sleep:

"news flash". Anesthesia no longer OWNS pain medicine. Get used to the competition. Many of the best and brightest in other fields are catching on that pain is a great field. Are you intimidated that the ER guy has treated thousands of chronic pain patients in his career, and done hundreds of lumbar punctures, lines , nerve blocks for wound repairs, intubations, sedations, joint aspirations/injections, neuro Patients, psych patients etc etc etc? None of this is relevant to pain medicine? Sounds like a pretty darn good background to me. You're insecure with your skills. The dog with the loudest bark has the weakest bite

 

[lobelsteve]

Sleep: you need a time out.


Get an away rotation with a PMR pain group. Catch your breath. You are getting attacked for saying stupid things and debasing any credibility you have or can create. Bite the tongue, go see what to do and not to do in a few clinics. You know nothing. I know 2% of all there it know about pain medicine and I'm 5 yrs post fellowship and read an hour a day.

 

[Prof Moriarty]

Beth Israel (NYC):
http://stoppain.org/for_professionals/content/information/painfellowship.asp

I know they've taken non-PM&R/anes-trained docs there in their medical track, including an IM doc. Not sure about EM but I think it's worth checking with them. And they have Knox Todd on staff, notable EM/pain guy.

 

[facets]

As a former anesthesiologist I am embarrassed by all the infighting between PMR and anesthesia. This divide and conquer mentality is what is allowing nurses to take over our field. A physician, regardless of background, is much more qualified to do pain management than a nurse.
We all have done and said stupid things and cannot generalize that to a whole speciality. As a matter of fact, the older I get, I realize I know less and less.

 

[SleepIsGood]

Clearly this forum is biased as there are more PMR folks on here than Anesthesia.

This is why I think it's important to give a fair and balanced viewpoint, or atleast the 'other view'.

PMRMD took issue with what I said. I did not GENERALIZE. read the post. I stated what I SAW. I stated what others at the course SAW with their own eyes.

There's no need for a 'timeout' or anything. The fact that someone is taking a 14G to a patient's spine without knowing where the spinal cord/intrathecal space is, is gravely concerning. I can tell you that anesthesia providers know when the subarachnoid space has been violated (even first year anesthesia residents), this is something we TRY to avoid whenever we do epidurals. This at the very least takes 3 years to get. Even at the end of my residency I was still learning new techniques.

Now, take the instance when a PMR, ER, pathology fellow tries to learn this in a 1 year fellowship. There's simply not enough volume at any program.

These are observations/facts. IF you are insecure with these facts, that's something you have to deal with. Dont try to blow them off as 'hubris'. IF people want to do spinal injections, then prove that you can. Dont just come into the field for the $$ and then ruin it for everyone else. Your misguided complications impact the ENTIRE profession. Complications happen. But there needs to be a certain 'baseline' competence that needs to be established.

 

[PMR 4 MSK]

I am stating what I saw. You insecurity and inferiority complex is quite apparent in your post.

FYI, the feeling is mutual. I would really like to be an expert witness when you pierce right through the cord with a 14G. "Doctor, how many epidurals did you do in residency? Doctor how many spinals did you do in residency. Your case log here shows that you did about 2 epidurals caths and about 20 ILESI during fellowship. Our expert witness did about 300 during residency and 100+ amount during fellowship. Do you really think you are as qualified as him to being doing these procedures? Do you think with 30 or so epidurals you are qualified into putting foreign bodies into people's epidural/spinal canals?"

Yah let's see which way the jury will swing

Oooh, oooh, me! Me! Me! My turn!

I sent a patient for IT pump placement after IT trial gave the best pain relief she'd had.

Fellowship-trained anesthesia pain doc put the catheter through the spinal cord just above the conus, breaking it off in the process - before or after. She wakes up screaming in pain, so he spends the next three says increasing the pump every few hours, until an MRI showed what he did.

Neurosurgeon testified that when he opened her up to fish out the broken cath, he could see the hole in her spinal cord and the necrotic tissue around it. He even gave pictures and video into evidence.

Given the pt was was in her 30's and working and now in a wheelchair, I'm guessing the settlement was in the $5M + range.

It can happen to anyone.

If you are going to spend your whole life looking to stomp on everyone you perceive as inferior to you, you are going to have a miserable life.

 

[SleepIsGood]

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[SleepIsGood]

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[Ligament]

At a neighboring program, all the wet taps this year were from non-anesthesia fellows (with fluro guidance).

Thats funny, cause all the wet taps I saw during my Anesthesia based fellowship were from my Anesthesia attendings and Anesthesia residents. I did not have one. Which means I was pretty lucky, but believe me having an anesthesiology residency behind you does not by any means make you infallible to producing unintentional wet taps. Doing non-fluoro guided epidurals has virtually NO useful benefit when learning how to do them with image guidance.

And by the way, your 300 non-image guided epidurals during residency has virtually no relevance to the practice of interventional pain management, because in this field, we use image guidance. In my PMR residency, I did almost 300 fluoro-guided epidural steroid injections, most TFESIs. That was relevant to my future career as an IPM physician.

I think folks from Anesthesia and PM&R backgrounds make equally good pain fellows, both with strengths and weaknesses. And sleep, you WILL have a complication or three during your career. Everybody will.

 

[pmrmd]

PMRMD took issue with what I said. I did not GENERALIZE. read the post.

Okay, lets read it again.

I especially do not think non anesthesia providers can pick up pain medicine in 1 year.

yes you did.

 

[Apollyon]

You are talking about the ER doc that gives a Rx for 180 oxycontin for back pain for a patient that now has to come to the Pain Clinic with the expectation that we need to refill his oxycontin?

Although your post is rife with jabs at EM (and I can counter each one - just like I don't have anesthesia in-house, so there's no one to "save" failed tubes - and, in my career? Zero), I shall take issue with this one.

Oxycontin #180? Really? For back pain? Even if a doc in the ED was dumb enough to do that, if the patient was opiate-naive, that would kill them; the chances of that naivete is slim, though, meaning someone else would have had to start the patient on that. Any clue as to whom that might be?

There is a pain guy here in town, but I don't know from which initial specialty he came to arrive at pain. He was on vacation for 2 weeks earlier this month, and his patients came out of the woodwork. How many times in your life have you lost your keys? Do I ever forget my insulin? Yet, the recurring theme of pain patients is "losing" their meds, or their meds were "stolen" (with a staunch refusal to call the police). It's remarkable how someone who is dependent on narcs can lose their lifeline - really remarkable. I had one of the pain doc's patients, who gets #240 MS Contin 30mg AND #390 (correct - nearly 400) Oxycodone IR 30mg per month. He "lost" his meds. The numbers he was Rx'd were backed up by a fax from the office. We have the option to fill all, half, or none of the patient's meds. This guy got a Utox and an Rx for #23 MS Contin - I told him he could either leave empty handed, or get his Rx for one day's worth, and the drug screen (+ for opiates and cocaine - despite his stating he hadn't had his meds in 5 days, and said the cocaine was just "wrong") faxed to the office. He chose the Rx.

Why this long damn story? Because that would happen each time if I was a candyman giving out nearly 200 Oxycontins for unsubstantiated complaints, and the place would be filthy with drug-seeking "patients". The pipeline is robust, and when a doc in the ED has a loose pen, the seekers come out like locusts.

I don't fault the EM doc for wanting to do pain management. I don't know why he would, but that's his choice. In areas I've worked, anesthesiology-pain have predominated in one, and PM&R-pain in another. Clients with Cluster B disorders were lacking in neither. I want as little to do with them as possible.

Oh, and even though I said I wouldn't, I'll swing at one more of your pitches in the dirt. When I was a resident, I saw the neurology resident try >10 times for an LP - the pt's back looked like the top of a salt shaker. If I can't get it in 2, I don't keep sticking. And I don't call anesthesiology (because I don't have them, and they don't generally do diagnostic tapping, as far as I know - isn't a "wet tap" a bad thing?).

 

[Jcm800]

my turn...


sleep, be quiet. Save these posts, and re-read them to yourself in 5 years...
the anesthesiology superiority will get you no where. some of the "best trained" docs have the worst hands.

despite your alleged amazing training and numbers (i did more procedures in private practice in 3 months than you did in 5 years of training ) you may be one of these guys that thinks he knows how to do procedures and still sucks at them.

Bottom line, procedures are not that hard. A monkey can do them. And a well trained monkey can be equally bad as an un-trained monkey.

 

[epidural2009]

Ok, so we all know that Sleep is correct. The problem is that most of you on here have little experience after your non-anesthesia residency and fellowships. You come on here looking for advice, cuz you don't know what you're doing. you think all the big shot pain guys on here (anesthesia trained of course) come on here to ask "where is the intrathecal space?" ha ha... that's comical.

PMR, EM, Psych, Occupational Medicine, Pathology, and Radiation Oncology should all be allowed to do pain, right? ha haha. actually i think a psychiatrist looking to do pain is a good one, cuz when was the last time a psychiatrist touched or examined a patient? let alone do a procedure? or handle a needle? or a scalpel? btw, doing ECT's dont count...

basically you guys are living in a fantasy world. why do you think insurance companies are cutting back reimbursements? because they THINK the procedures we do are B.S. or ineffective. Well of course they are when you have amateurs performing them. If you have a skilled provider, i.e. Pain Anesthesiologist, you get better patient care and better outcomes. That much is clear. i've seen this first hand. all these other unqualified physicians should do what they do best, and that's stick to their own speciality. if you want to do pain, then i have no problem with that. as long as you do your anesthesia residency and know how treat your IMMEDIATE complications. like when your patient "codes" on the table during a trigger point injection or during an LESI. knowing the letters ABC doesn't cut it people. and holding oxygen over their face and sitting a patient up won't help while you wait for EMS to arrive if they have no cardiac output...

stop lying to yourselves. please.

 

[emd123]

Ok, so we all know that Sleep is correct. The problem is that most of you on here have little experience after your non-anesthesia residency and fellowships. You come on here looking for advice, cuz you don't know what you're doing. you think all the big shot pain guys on here (anesthesia trained of course) come on here to ask "where is the intrathecal space?" ha ha... that's comical.

PMR, EM, Psych, Occupational Medicine, Pathology, and Radiation Oncology should all be allowed to do pain, right? ha haha. actually i think a psychiatrist looking to do pain is a good one, cuz when was the last time a psychiatrist touched or examined a patient? let alone do a procedure? or handle a needle? or a scalpel? btw, doing ECT's dont count...

basically you guys are living in a fantasy world. why do you think insurance companies are cutting back reimbursements? because they THINK the procedures we do are B.S. or ineffective. Well of course they are when you have amateurs performing them. If you have a skilled provider, i.e. Pain Anesthesiologist, you get better patient care and better outcomes. That much is clear. i've seen this first hand. all these other unqualified physicians should do what they do best, and that's stick to their own speciality. if you want to do pain, then i have no problem with that. as long as you do your anesthesia residency and know how treat your IMMEDIATE complications. like when your patient "codes" on the table during a trigger point injection or during an LESI. knowing the letters ABC doesn't cut it people. and holding oxygen over their face and sitting a patient up won't help while you wait for EMS to arrive if they have no cardiac output...

stop lying to yourselves. please.

ER docs don't examine patients, do procedures, use scalpels, needles and code people, or take care of chronic pain patients ? Practice on your own for 5 years as an attending then come talk to me.

 

[epidural2009]

ER docs don't examine patients, do procedures, use scalpels, needles and code people, or take care of chronic pain patients ? Practice on your own for 5 years as an attending then come talk to me. It's time for someone to tell it like it is. This forum has become a joke

EM docs... "jack of all trades, master of NONE". that's it emd123. not good at anything, but dip their paws into everything. tell me i'm wrong.

 

[Jcm800]

ignore the troll...

 

[Epidural]

I've gathered from your previous post that you consider BWH to be the best fellowship. I'm sure you know that Dr. Wasan (Psychiatry) and Dr. Soumekh (Neurology) provide valuable experiences for their fellows. Drs. Ross and Nedeljkovic have also had many Physiatrists in their program.

The same goes for MGH and in fact, they've trained many non-Anesthesia fellows (including Psychiatry) and have Dr. Gilligan (Emergency Medicine) and Dr. Wainger (Neurology) on staff. They also trained Dr. Mitra who is in charge of Stanford Interventional Spine Center.

I'm sure all of the pain physicians above would survive your "expert" testimony on the stand as I'm sure they'll find a colleague at Harvard to defend them and that person might have more experience and a better CV (medical school, internship, residency, fellowship, board-certifications, and publications) than you do. At the end of the day, if an ACGME-accredited fellowship program accepts and graduates a physician (irregardless of specialty) and he or she obtains board-certification, that's really all I personally care about. Frankly, it doesn't really matter what I think since I'm not a fellowship director and neither are you. CRNAs and physicians who have little more than a weekend course as experience is what concerns me the most.

 

[emd123]

I've gathered from your previous post that you consider BWH to be the best fellowship. I'm sure you know that Dr. Wasan (Psychiatry) and Dr. Soumekh (Neurology) provide valuable experiences for their fellows. Drs. Ross and Nedeljkovic have also had many Physiatrists in their program.

The same goes for MGH and in fact, they've trained many non-Anesthesia fellows (including Psychiatry) and have Dr. Gilligan (Emergency Medicine) and Dr. Wainger (Neurology) on staff. They also trained Dr. Mitra who is in charge of Stanford Interventional Spine Center.

I'm sure all of the pain physicians above would survive your "expert" testimony on the stand as I'm sure they'll find a colleague at Harvard to defend them and that person might have more experience and a better CV (medical school, internship, residency, fellowship, board-certifications, and publications) than you do. At the end of the day, if an ACGME-accredited fellowship program accepts and graduates a physician (irregardless of specialty) and he or she obtains board-certification, that's really all I personally care about. Frankly, it doesn't really matter what I think since I'm not a fellowship director and neither are you. CRNAs and physicians who have little more than a weekend course as experience is what concerns me the most.

Amen. Thanks for that refreshingly well though out and sourced post. All bashing of fellow Pain docs must stop. Its destructive to the field. Its equivalent to bigotry. One should be judged on his performance. The non-traditional applicants are having to interview and prove themselves to fellowship directors as much as anyone else. Above, Epidural has listed superstars in the field who are non-anesthesia. Obviously, by sheer numbers, there are many more who are from anesthesia. Someday, maybe later rather than sooner, there will be a Pain Medicine Residency. There has to be, eventually, if Pain is truly to come of age. Then we all with be extinct. Anesthesia/Pain, PM&R/Pain, Neuro/Pain, Psych/Pain, ER/Pain, Interventional Rad/Pain, IM/Pain, Whatever/Pain will no longer exist. The new Residency trained Pain docs will consider all of us washed up and extinct, unless we come together and support each other. If you've got your fellowship spot, or you're done with you're fellowship, what do you have to gain from bashing your colleagues? Nothing. No pathologist is going to take your ACGME Pain certificate from you. If you don't have one, its not owed to you. You've got to earn it. Referrals aren't owed to you. You've got to earn them by treating other doctors with respect and with good patient outcomes. Other specialties don't cannibalize each other like this. Its absolutely insane. Yes, there have to be standards. Going forward, the best we have right now is a 1 year ACGME accredited fellowship. Its not ideal, but its the best gold standard we've got. No, a weekend course alone is not enough. If an ER doc, or interventional rads doc or internist happen to impress a fellowship director (almost certainly an anesthesiologist) enough to get in, good for them. I can't imagine its easy getting a spot coming from non-traditional fields like those. These people must having incredible boards, extensive clinical experience, publications or have demonstrated a special interest in Pain Medicine or something. They're probably having to kill themselves to get in with all the prejudice against them.

 

[hyperalgesia]

This case was closed years ago by the ACGME, ABA, ABPMR and ABPN. There are just a few kids still running around shooting their cap guns.

 

[PsychoticNerve]

As an attending at an institution that churns out pain physicians I've seen good technical skills from all backgrounds. But I gotta say, the anesthesia guys are generally better. The learning curve for non-anesthesia is steeper. And the quality of PM&R residencies and the fellow's exposure to pain medicine prior to fellowship is sometimes very sketchy. For the anesthesia fellows, it's a given that they've already had at least two months (some have had six months) since it is a requirement for anesthesia residencies.

Lately we're letting in more physiatrists and my blood pressure in the procedure suites have steadily risen. Can't even watch them trying to draw up meds. Besides, if a patient has a vagal episode during a procedure, I can trust the anesthesia trained fellows to calmly handle it, while the PMR guys are sucking their thumbs somewhere in a corner.

The fault lies with anesthesiologists for letting the cat out of the bag, just like they let pulmonary take over the ICU. Pain medicine is like an ugly wart to many anesthesia departments anyway, so it is not hard to see why other specialties are able to muscle in. Pain really should be its own specialty so we can stop bickering over who's better.

 

[Apollyon]

As an attending at an institution that churns out pain physicians I've seen good technical skills from all backgrounds. But I gotta say, the anesthesia guys are generally better. The learning curve for non-anesthesia is steeper. And the quality of PM&R residencies and the fellow's exposure to pain medicine prior to fellowship is sometimes very sketchy. For the anesthesia fellows, it's a given that they've already had at least two months (some have had six months) since it is a requirement for anesthesia residencies.

Lately we're letting in more physiatrists and my blood pressure in the procedure suites have steadily risen. Can't even watch them trying to draw up meds. Besides, if a patient has a vagal episode during a procedure, I can trust the anesthesia trained fellows to calmly handle it, while the PMR guys are sucking their thumbs somewhere in a corner.

The fault lies with anesthesiologists for letting the cat out of the bag, just like they let pulmonary take over the ICU. Pain medicine is like an ugly wart to many anesthesia departments anyway, so it is not hard to see why other specialties are able to muscle in. Pain really should be its own specialty so we can stop bickering over who's better.

What sticks out from your post to me, though, is that the point of fellowship seems to be lost. A friend of mine is a neuroradiologist, and she came into her fellowship program from the outside, with a lot of internally trained radiologists. The PD said that incoming fellows had variable levels of training/experience/ability, but the fellowship mission was to make sure all, irrespective of with what they came, left at the same level.

If the anesthesiology folks are better at the end, then the fellowship is not up to snuff. However, I have to qualify that, because you're not talking about people from different facilities trained in the same primary specialty, but from different specialties. I mean, a tiger and a housecat are both felines, but you're not going to confuse one with the other. If you conflate multiple specialties, you're going to come up with differently trained folks. See also the Department of Critical Care at Pittsburgh - taking IM, anesthesiology, EM, and general surgery. If you look at the rotation schedules, they're all the same. So, if the standard is X,Y,Z for pain fellows, and the PM&R and anesthesiology folks both make X,Y,Z, then that's what it is. If anesthesiology also brings A,B,C to practice, but it's not required for pain fellows, you can't hold it against the PM&R people if they don't have A,B,C.

 

[PMR 4 MSK]

As an attending at an institution that churns out pain physicians I've seen good technical skills from all backgrounds. But I gotta say, the anesthesia guys are generally better. The learning curve for non-anesthesia is steeper. And the quality of PM&R residencies and the fellow's exposure to pain medicine prior to fellowship is sometimes very sketchy. For the anesthesia fellows, it's a given that they've already had at least two months (some have had six months) since it is a requirement for anesthesia residencies.

Lately we're letting in more physiatrists and my blood pressure in the procedure suites have steadily risen. Can't even watch them trying to draw up meds. Besides, if a patient has a vagal episode during a procedure, I can trust the anesthesia trained fellows to calmly handle it, while the PMR guys are sucking their thumbs somewhere in a corner.

The fault lies with anesthesiologists for letting the cat out of the bag, just like they let pulmonary take over the ICU. Pain medicine is like an ugly wart to many anesthesia departments anyway, so it is not hard to see why other specialties are able to muscle in. Pain really should be its own specialty so we can stop bickering over who's better.

IF a PM&R resident has had less than 2 months of pain, he went to the wrong program and has no idea if s/he likes pain or not. Were I a fellowship director, I would not accept someone with minimal exposure, anesthesia, PM&R or whatever.

If you are letting a fellow do a procedure and s/he doesn't know how to handle a complication before even going in there, that is the attending's fault, not the fellow's. If they don't know how to set up the meds and you let them do the procedure, you have similarly failed in your endeavor.

However, your obvious disdain for all doctors non-anesthesia renders your post useless.

 

[hyperalgesia]

I agree with PMR 4 MSK. Also, I continue to be amazed by the fixation some have on technical skills and it frankly suggests that other skills are lacking. Look, some people were never meant to hold a needle or a scalpel or whatever. But I've seen as many of them going into surgery in spite of their inability as not. Manual dexterity is more genetics than training.

 

[PsychoticNerve]

IF a PM&R resident has had less than 2 months of pain, he went to the wrong program and has no idea if s/he likes pain or not. Were I a fellowship director, I would not accept someone with minimal exposure, anesthesia, PM&R or whatever.

If you are letting a fellow do a procedure and s/he doesn't know how to handle a complication before even going in there, that is the attending's fault, not the fellow's. If they don't know how to set up the meds and you let them do the procedure, you have similarly failed in your endeavor.

However, your obvious disdain for all doctors non-anesthesia renders your post useless.

But not useless enough for you to read and comment on it.

Generalizations are sometimes instructive: It is probably sunny in Santa Fe right now. Inuits are short. Danes are tall. PMR fellows in my program have a steeper learning curve. Like it or not, this generalization holds. Now, that may not apply to you Mr. Hot Shot Physiatrist, but it's telling that you are thin skinned about it.

While it's also true that I'd rather not take someone who has no pain experience, I'm not the program director (yet), and the ACGME is pushing us to accept more non-anesthesiologists. So I make do with what we have. Generally speaking the anesthesia guys have higher board scores and are more proficient procedurally speaking. I can trust them to do inpatient consults without having to hold their hands. Can't say the same about non-anesthesia. At the end of the one year, hopefully, all the fellows are equally good, but sometimes you gotta wonder.

Apollyon makes the case that training programs should turn out equally well trained pain physicians. No quibbles there, but they have such disparate levels of prior experience that not all pain fellows are made the same. The non-anesthesia people struggle mightily in the beginning. Some still do and we're half way thru the fellowship. I'm not commenting on whether they will be kick ass private practitioners; I'm simply reflecting on what I have to deal with in the fluoro suite and during inpatient consults.

I understand that this is a PMR heavy pain forum and there are sensitivities to tip-toe around, but hey, it is what it is.

 

[axm397]

@psychoticnerve: your program is probably not very selective then. If the anesthesia fellows have higher board scores, why are you taking the PM&R fellows with the lower scores and lower aptitude? The top pain fellowships get the top candidates period, whether it be PM&R or anesthesia. But then again, the top PM&R candidates get the top fellowships so maybe your fellowship is not top tier so you are only seeing the mediocre PM&R candidates? Is it possible that, as an anesthesiologist, you just don't know which PM&R residencies are the top programs and are going based on what institution has the best anesthesia residencies?


I did a month of anesthesia (OR), a month of pain (anesthesia based clinic), and a month of PM&R pain as a med student, a month of pain with anesthesia and a month of spine (away rotation) as an intern, did 2 months of chronic pain, 6 months of 1/2 day procedure clinic with a physiatrist, 2 months of anesthesia pain clinic with procedures, and 2 months of "sports and spine" clinic with interventions during residency. (extra credit for 1 month of neuroradiology) I then went on to an ACGME accredited pain fellowship.


Also, the "quality" of applicant depends on what skill set you are looking for and value - Would I expect an anesthesia fellow to know how to perform EMG/NCS, read films, do a good musculoskeletal and neurological exam (including looking at spine alignment, pelvic obliquity, leg length, gait, etc), know when to appropriately prescribe DMEs, know what type of physical therapy works best for what condition, and know how to handle basic non-surgical orthopedic conditions? probably not. And because anesthesia residents do not know how to do EMGs, read films, and perform a good neuro exam, some PM&R and other specialty based ACGME accredited pain fellowship attendings have told me they don't really want to consider anesthesia candidates. And same goes for spine surgery and ortho practices looking to hire "pain" docs - they rarely hire anesthesia pain. That's why most anesthesia pain docs practice in a group with each other. So i guess it depends on your perspective. let's not get into another pissing match here - it's getting kind of old.

How hard is it really to put a needle on a target? I saw medical students performing TFESIs with supervision by the end of a 4 week rotation. I saw a very smart monkey on TV the other day - he figured out how to bend a wire hanger to fish out some food in a narrow bottle. Kind of similar, no?

 

[specepic]

I always find the argument interesting that anesthesia is the better background with 'dealing with complications' a primary rationale. Ok, I'll admit that an anesthesiologist can handle an airway situation better than me. Will this eventually be an issue-yes it will. Has it ever been an issue after 4 months of rotations as a resident, one year of fellowship and a 1/2 year of practice-no, not once. Thats why I do my procedures in a hospital where people are around that know these things. Why don't we worry about this with any other specialty doing procedures, using sedation?

A variety of specialties can be successful in pain, including anesthesia. A good PM&R pain doc learns from anesthesia colleagues and vice versa. A good program picks good applicants and shapes them. At the end of that year I would wager most PM&R have not learned to be anesthesioogists and most Anes trained have not really honed a solid MSK/Neuro assessment beyond the very basics. The specialty is better by having a mix of these people.

 

[emd123]

More and more super bright IM, ED, FP, and IntervRad docs are getting into really competitive fellowships because they know that Pain is a great field. As time goes on, with Obama-care eating away at reimbursements for ALL specialties like a cancer, I think Pain will still remain competitive.

 

[axm397]

pain is not really the holy grail. reimbursement has been going down every year. honestly, by the time ppl hear it's the "holy grail", its old news and timing is wrong. need to find the next best thing BEFORE anyone else finds it and jumps on the bandwagon

derm on the other hand... people pay cash for

not sure how many ppl u could convince to pay cash for injections. pills maybe. marijuana probably. injections? not really.

should've become an orthodontist. ppl drop thousands on invisalign

 

[Apollyon]

ppl drop thousands on invisalign

My orthodontist said that Invisalign was developed by Madison Avenue, and not primarily by dentists. He said that Simpli5 (Simplifive) was superior, because it was from dentists/orthodontists from the ground up.

Maybe because it had advertising guys behind it that they're so successful.

 

[Jcm800]

More and more super bright IM, ED, FP, and IntervRad docs are getting into really competitive fellowships because they know that Pain is a great field, i.e., good money, regular hours, little call. Its the holy grail of medicine: specialist pay AND live a normal life. Why work 60 hours per week as an internist while taking night, weekend and holiday call for $190,000? Why see an uninsured chronic pain patient at 4am on a holiday weekend in between codes in the ER and not get paid, when you can do an ESI at 10am on Monday and get paid, every time? Why get called in at 3am for an emergent angiogram as an interventional radiologist and lose so much sleep your whole week is ruined, again? As time goes on, with Obama-care eating away at reimbursements for ALL specialties like a cancer, the premium will be less on money and more on specialties where you don't have to sacrifice the important things in life. Fields like Pain and Derm are going to get even more ultra-competitive.

i cannot wait to hear the tune you are singing in two years (after the fellowship and then after a year of practice...)

The grass aint always greener. Many people that don't do ER would say that IT is the "holy grail". Good money, 12 shifts a month, no responsibility after the shift is over, you leave on time, hospital contracts and subsidies, no chasing referrals. I hope you really love it, otherwise, you will be going back to do a radiology residency...

 

[emd123]

i cannot wait to hear the tune you are singing in two years (after the fellowship and then after a year of practice...)

The grass aint always greener. Many people that don't do ER would say that IT is the "holy grail". Good money, 12 shifts a month, no responsibility after the shift is over, you leave on time, hospital contracts and subsidies, no chasing referrals. I hope you really love it, otherwise, you will be going back to do a radiology residency...

You're right, the grass isn't always greener on the other side. Its just different shades of brown. And yes, Pain isn't the holy grail, neither is any other specialty or any other career. I know, that's why its called "work". Just various choices of tin cups, plastic cups, paper cups; no holy grail. Radiologists get tired of looking at x-rays all day. Dermatologists get tired of skin. Anesthesiologist get tired of gas. Pain docs get tired of chronic pain. Oh well.

 

[Jcm800]

You're right, the grass isn't always greener on the other side. Its just different shades of brown. And yes, Pain isn't the holy grail, neither is any other specialty or any other career. I know, that's why its called "work". Just various choices of tin cups, plastic cups, paper cups; no holy grail. Radiologists get tired of looking at x-rays all day. Dermatologists get tired of skin. Anesthesiologist get tired of gas. Pain docs get tired of chronic pain.



Radiologists get tired of looking at x-rays all day. Dermatologists get tired of skin. Anesthesiologist get tired of gas. Pain docs get tired of chronic pain. Oh well.

exactly, this is why i said, i hope you love it, or its just a lateral move. if its something you enjoy, then do it. But to do it for the logistics, i would say run. ER isnt so bad. Pain is good most of the time, but oi vey, the patients...