How does one go into pain medicine?

[btpayne13]

After med school, is pain medicine a residency or fellowship? If it's a fellowship, what residency should one go into to do a fellowship in pain medicine?

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[Aether2000]

It depends on your goals. The easiest way is to become licensed to practice medicine is to do a one year internship after medical school, then set up shop to practice pain medicine in any one of the 35 states that allow licensure after one year of training. That way you can have more training than CRNAs but not waste time doing a residency program that is irrelevant to pain medicine. Another route would be to take a family medicine or genetics or internal medicine residency program (3 years) then apply for a pain fellowship. This will save you an extra year anesthesiologists, PMR, and neurologists spend slogging out their training for years and only then applying for a pain fellowship. Certainly a pain fellowship for those entering such a program in or after 2008 is desireable, but remember you will have the exact same capability to practice in an office setting as those with no residency or pain fellowship at all. This sad state of affairs is due to academicians not having standards for pain fellowships for nearly 2 decades, and tenaciously holding on to their control of pain programs.

 

[PMR 4 MSK]

Good one Algos!

But seriously, OP, it's not a residency yet. Fellowships are available to those who want advanced training to do true Pain Management - mostly advanced interventions and implants ATM, as well as better training in use of medications and other therapeutic modalities.

Almost all doctors treat pain - either as the chief complaint, or as a result of what we do to our patients. Pain Management is more of a state of mind than a true field so far. Some are just more qualified than others to do it.

 

[Mister Mxyzptlk]

I don't think I have ever seen such cynicism from you Algos. Can't say that I blame you but you've always been a "glass half full" guy as opposed to my "glass looks half empty but is really completely empty or will be shortly" philosophy.

I think taking the shortcuts described could blow up in your face. First of all, without the fellowship training you risk being denied privileges at facilities. Those with fellowship training can and do help write hospital by-laws and they keep out the competition from non-fellowship trained practitioners that way. I do a lot of office procedures but I still need facilities to do implants, pump trials, sick patients, etc.

It has been historically harder for PM&R grads to get pain fellowships than anesthesia grads. This is changing, but if a MSK-oriented specialty grad has had to crack the glass ceiling then an IM grad will have an even harder time.

I think it's worth the time and trouble to build as solid and bulletproof CV as possible. That means gas or PM&R, then an accredited fellowship. With those tickets you will not be denied anything based on credentials.

From a med-mal standpoint, the better your bona fides the better when you are defending yourself. I would rather tell a jury I did a fellowship and am board-certified than that I did an internship and then puttered around learning pain management wherever I could.

You might also get better rates on malpractice insurance with proper training. You might not be able to get coverage at all without it some day.

You can't predict the future. CRNAs might be doing pain injections routinely some day in which case Algos's wager will pay off. OTOH, if they start restricting pain management to board-certified practitioners or you can't get privileges somewhere or you can't get insurance you'll be screwed. IMHO it's worth a couple of years to be as secure as you can be.

One other consideration: How about taking the route that will make you the best pain doctor you can be?

 

[hyperalgesia]

Everywhere I have ever applied for credentialing or even state licensure, they always ask about Specialty Board Certification. Are there places in the country that this is still optional? Plus, to get on insurance plans they insist I am credentialed at a "network" hospital, which also always (in my experience) require boards. I just can't imagine trying to establish a career nowadays without specialty board certification/eligibility. It must be a very difficult life. I guess there may be areas of desperate need but certainly not something you want to hang your hat on.

 

[PMR 4 MSK]

Everywhere I have ever applied for credentialing or even state licensure, they always ask about Specialty Board Certification. Are there places in the country that this is still optional?

Yes, out here in the sticks.

 

[Aether2000]

Probably am cynical about this but the hypocrisy and intransigence of the current fellowship program directors holding an entire specialty back from advancement while at the same time opening the door to CRNAs, untrained PCPs, and even those with one internship year of training to call themselves pain physicians. The current system has 40% of those with "special qualifications in pain medicine" having been certified without any training at all in pain medicine and 56% more trained in programs that were not standardized to provide any rational level of competence assessment or adequacy. Only since 2008, 16 years after the first pain fellowships opened, have the pain programs adopted any standard curriculum. But guess what? They are still a joke. The requirement for interventional pain training in a pain fellowship is 20 procedures. Period. For the entire fellowship. I suppose I am just disgusted our illustrious leaders have not pulled their heads out of the sand and fail to realize the permanent damage their inaction and adoption of ridiculously low standards are causing.

 

[lobelsteve]

Probably am cynical about this but the hypocrisy and intransigence of the current fellowship program directors holding an entire specialty back from advancement while at the same time opening the door to CRNAs, untrained PCPs, and even those with one internship year of training to call themselves pain physicians. The current system has 40% of those with "special qualifications in pain medicine" having been certified without any training at all in pain medicine and 56% more trained in programs that were not standardized to provide any rational level of competence assessment or adequacy. Only since 2008, 16 years after the first pain fellowships opened, have the pain programs adopted any standard curriculum. But guess what? They are still a joke. The requirement for interventional pain training in a pain fellowship is 20 procedures. Period. For the entire fellowship. I suppose I am just disgusted our illustrious leaders have not pulled their heads out of the sand and fail to realize the permanent damage their inaction and adoption of ridiculously low standards are causing.

Ok. So let's figure out how to make ISIS a certifying board or entity? I'm assuming you need a few Senators, a few dept chairs, the director of the acgme, and the director of the abms. We'll need definitions, criteria, and a grandfathering mechanism that provides evaluation of competency. Start with a mission statement.

 

[Aether2000]

ABMS is definitely not on board and is overtly hostile to the prospect of a pain specialty or to any entity that is not part of its current core boards. Anesthesiology is hostile to anyone that would encroach on their paternalistic turf of pain, including control over pain fellowships. The ACGME wants all players to agree on a course of action, which in effect is being blocked by a filibustering group of fellowship chairs that prefer the status quo. ISIS is not an entity with a broad enough scope to stand as a certifying body for all of pain medicine while ASIPP has too many political axes to grind to be perceived as neutral and unbiased and becomes fixated on non sequitur issues that are not germane to the majority of pain physicians (eg. facility fee ASC reimbursement). So there are definitely challenges ahead....

 

[Jeff05]

"""current fellowship program directors holding an entire specialty back from advancement while at the same time opening the door to CRNAs, untrained PCPs, and even those with one internship year of training to call themselves pain physicians..."""

what? how are they doing that? seriously, i don't get it.

 

[lobelsteve]

ABMS is definitely not on board and is overtly hostile to the prospect of a pain specialty or to any entity that is not part of its current core boards. Anesthesiology is hostile to anyone that would encroach on their paternalistic turf of pain, including control over pain fellowships. The ACGME wants all players to agree on a course of action, which in effect is being blocked by a filibustering group of fellowship chairs that prefer the status quo. ISIS is not an entity with a broad enough scope to stand as a certifying body for all of pain medicine while ASIPP has too many political axes to grind to be perceived as neutral and unbiased and becomes fixated on non sequitur issues that are not germane to the majority of pain physicians (eg. facility fee ASC reimbursement). So there are definitely challenges ahead....

Then we start with state medical boards and make it a patient safety, public safety issue with procedures and opiates respectively. We can go public with some of the program directors actions that led to the narrowing of the field in the 2005 ACGME meetings that ripped the PIF.

If we can make it about patients, and not cronies or money- the public will support it, and the law will follow.

 

[Aether2000]

Jeff, the fellowship directors are into turf protection and have been for many many years. They don't want expansion into a full residency program since it would remove control from their department, would dry up some of the slave labor pool that is being used to take call in the OR, etc, would diminish the prestige of the program, would change the entire structure they have spent years setting up, would lend credence to the well known fact that you can't adequately train a pain physician to do pain medicine with a one year residency (since only a small fraction of what one does daily in anesthesiology and neurology, and to a less small fraction PMR practice and training transfer knowledge or skills needed to be a pain physician), a residency would diminish the value of a current pain fellowship if not make the current fellowship graduates and practitioners obselete, and would remove control and prestige from them personally. They also would have to finally acknowledge they do not have the breadth of knowledge to teach all aspects of a fellowship program and would have to recognize the current requirements (20 procedures per residency) is woefully inadequate, thereby torpedoing the value of education imparted to current and past fellows.
Therefore, they tenaciously hold on to the antiquated and outdated model of a full residency in anything followed by a completely unrelated one year training program, that is actually less than one year. They are pondering stacking on another year fellowship on top of the irrelevant base residencies, that ultimately will probably fail due to excess total training time with over half the total training time wasted in irrelevant pursuits. How relevant are the gene mutations that cause the development of polymucosaccaride diseases? Right! But under the current training scenerio, geneticists are permitted to enter a pain fellowship after becoming an expert in irrelevant gene mutations. Same for many other background residencies.

Steve, you may have a point, and perhaps a combination of grass roots and big brother are in order here. Perhaps we can find a way to use Obama to achieve our goals. Anyone here have Obama's Blackberry number so I can send him a text message?

 

[emd123]

"since only a small fraction of what one does daily in anesthesiology and neurology, and to a less small fraction PMR practice and training transfer knowledge or skills needed to be a pain physician"

...quoting the above post. I'm a little confused. If anesthesiology, neuro and PM&R training does not prepare one to enter pain fellowship, then what does?

 

[Aether2000]

Anesthesiology and PMR and neurology give you a background that is largely not used in daily clinical practice of pain medicine therefore we need a residency program, not a fellowship. We are wasting valuable years of the lives of resident physicians needlessly.

 

[Buckeye Anes]

Anesthesiology and PMR and neurology give you a background that is largely not used in daily clinical practice of pain medicine therefore we need a residency program, not a fellowship. We are wasting valuable years of the lives of resident physicians needlessly.

That's not completely true...I made some great drinking/golfing buddies during residency. Also if you wanted to be taken seriously as a pain certifying board you should probably change the web address for ISIS...someting tells me "spinalinjection.com" may be viewed as biased

 

[Aether2000]

ISIS has no interest in becoming a certifying body or board, therefore there will be no change in the website URL. Aside from the great times we spent in a peripherally related residency hanging out and drinking...(oh, I could tell you some amazing stories ), I have collected surveys from many many fellowship trained pain physicians that attest the cumulative time spent in a full residency then a one year fellowship is partially being wasted. We would be much much better off with a one year anesthesia internship and 3 year pain residency. Although in one program that I was an assist. prof. for a few years, the nude pic done by the graduating class (men and women) of anesthesiology residents was quite amusing, and perhaps made up for the many repetitious perfunctory cases done by the residents.

 

[SleepIsGood]

That's not completely true...I made some great drinking/golfing buddies during residency. Also if you wanted to be taken seriously as a pain certifying board you should probably change the web address for ISIS...someting tells me "spinalinjection.com" may be viewed as biased

I agree with the above. SPINALINJECTION.com has a very bad connotation to it. I think it would be more credible with a 'softer' URL name.

In terms of credentialling etc. Arent there many societies that one can get 'boarded' by in pain. Back in the day it was just the ABA. Now doesnt ASIPP have their "ABIPP". I think Am Acad of Pain Med also has one (FAPM).

We can sit here and argue about which one is 'better'. My understanding is that hospital adms doesn't care as long as it's one of these 'boards'. Plus, let's say one is board certified in Anesthesiology and then pursues a ACGME Pain Fellowship. That individual already has one ABA board certification. Do hospitals realize that the ABA cert was in Anesthesiology and not in Pain Med?

The one thing I do agree with is that I dont think the answer is to increase residency time while at the same time 'fast tracking' nurses,etc. We're making our own obselete. I think there is value to having an anesthesia background for example. For example if stuff goes wrong in your podunk pain clinic (allergic rxn to contrast, or very bad bradycardia) you will quickly put on your Anesthesiologist hat and intubate, ventilate, give the proper RXs to resuscitate a patient. I dont think just doing a 1 year or 1 month anesthesia rotation will give you that ability to intervene in a second nature manner. After seeing a lot of poop hitting the fan in residency one quickly realizes how bad things can be if resuscitation isn't undergone quickly, calmly, and effectively..

 

[SleepIsGood]

That's not completely true...I made some great drinking/golfing buddies during residency. Also if you wanted to be taken seriously as a pain certifying board you should probably change the web address for ISIS...someting tells me "spinalinjection.com" may be viewed as biased

il ove your signature line...lol..what page is that on in the Hall book?

 

[lobelsteve]

I agree with the above. SPINALINJECTION.com has a very bad connotation to it. I think it would be more credible with a 'softer' URL name.

In terms of credentialling etc. Arent there many societies that one can get 'boarded' by in pain. Back in the day it was just the ABA. Now doesnt ASIPP have their "ABIPP". I think Am Acad of Pain Med also has one (FAPM).

We can sit here and argue about which one is 'better'. My understanding is that hospital adms doesn't care as long as it's one of these 'boards'. Plus, let's say one is board certified in Anesthesiology and then pursues a ACGME Pain Fellowship. That individual already has one ABA board certification. Do hospitals realize that the ABA cert was in Anesthesiology and not in Pain Med?

The one thing I do agree with is that I dont think the answer is to increase residency time while at the same time 'fast tracking' nurses,etc. We're making our own obselete. I think there is value to having an anesthesia background for example. For example if stuff guys wrong in your podunk pain clinic (allergic rxn to contrast, or very bad bradycardia) you will quickly put on your Anesthesiologist hate and intubate, ventilate, give the proper RXs to resuscitate a patient. I dont think just doing a 1 year or 1 month anesthesia rotation will give you that ability to intervene in a second nature manner. After seeing a lot of poop hitting the fan in residency one quickly realizes how bad things can be if resuscitation isn't undergone quickly, calmly, and effectively..

Young, cocky, and stupid.... Those were the days..

 

[SleepIsGood]

Young, cocky, and stupid.... Those were the days..

Nice tactic, diverting from the topic at hand. Try your hand in politics ever? No disrespect.

 

[Buckeye Anes]

Sleepisgood....careful saying anything not praising PM&R around this place...apparently it makes you young, cocky and stupid...apparently being on the ISIS board now comes with a side of arrogance. I will agree with algosdoc that I feel a good portion of my anesthesia training is not applicable to what I am doing now so it may not be a bad idea to create a 1 and 3 or atleast 2 and 2 program. Of course this idea will have to be bounced around for another 10 years or so before it MIGHT happen.

 

[lobelsteve]

Sleepisgood....careful saying anything not praising PM&R around this place...apparently it makes you young, cocky and stupid...apparently being on the ISIS board now comes with a side of arrogance. I will agree with algosdoc that I feel a good portion of my anesthesia training is not applicable to what I am doing now so it may not be a bad idea to create a 1 and 3 or atleast 2 and 2 program. Of course this idea will have to be bounced around for another 10 years or so before it MIGHT happen.

Putting people to sleep is not pain. While you were off saving lives in the ICU, us PMR guys were learning spinal imaging and how to examine the patient. But we have several separate threads relating to PMR vs Anes and going into pain. Part of the problem is that a few of the (rathmell) Anes folks threw PMR programs under the bus to keep their department$ happy.

 

[SleepIsGood]

Sleepisgood....careful saying anything not praising PM&R around this place...apparently it makes you young, cocky and stupid...apparently being on the ISIS board now comes with a side of arrogance. I will agree with algosdoc that I feel a good portion of my anesthesia training is not applicable to what I am doing now so it may not be a bad idea to create a 1 and 3 or atleast 2 and 2 program. Of course this idea will have to be bounced around for another 10 years or so before it MIGHT happen.

Yah I've heard/seen on here. I think most readers will see the 'bias' of what's on this board for the most part (PMR, ISIS). Also automatically calling people names,etc.

People always make the claim about physical dx,etc. It's important, no question. However, in this day and age, at these meetings they tell you its about the skill set one has. Also YOUR ability to read imaging, interpret them, and do something about them.

In my area there's a Pain Mgt Group owner that was talking to me about his group's dynamics. 3 Anesthesia guys, 1 PMR. They had to let the PMR go because according to him, the guy just took too long and did more examining then he did interventions. His clinic would get backed up. RNs/MAs got pist off because they were staying late,etc. The other docs were pist because the fluro room would be backed up.

Obviously he's not saying be a needle jockey. But he was highlighting to me the importance of being 'efficient' and be 'focused'-atleast in private practice.

 

[lobelsteve]

Yah I've heard/seen on here. I think most readers will see the 'bias' of what's on this board for the most part (PMR, ISIS). Also automatically calling people names,etc.

People always make the claim about physical dx,etc. It's important, no question. However, in this day and age, at these meetings they tell you its about the skill set one has. Also YOUR ability to read imaging, interpret them, and do something about them.

In my area there's a Pain Mgt Group owner that was talking to me about his group's dynamics. 3 Anesthesia guys, 1 PMR. They had to let the PMR go because according to him, the guy just took too long and did more examining then he did interventions. His clinic would get backed up. RNs/MAs got pist off because they were staying late,etc. The other docs were pist because the fluro room would be backed up.

Obviously he's not saying be a needle jockey. But he was highlighting to me the importance of being 'efficient' and be 'focused'-atleast in private practice.

Oh please make it stop...anyone, anyone?

 

[SleepIsGood]

After med school, is pain medicine a residency or fellowship? If it's a fellowship, what residency should one go into to do a fellowship in pain medicine?

alright getting back to the topic...people on here are always trying to change the subject.

At the moment. Pain Med=a fellowship. There is a 'push' to make it into a residency, likely NOT going to happen anytime soon. I actually went to several ASRA conferences where PDs at programs tlked to residents and stated that this will perhaps occur, but not anytime soon.

In terms of what residency you should go into... Again, you will hear different opinions.

Here's the fact. Most ACGME pain fellowships CURRENTLY are under the auspices of the Department of Anesthesiology of their institution. Google, random Pain Fellowships nationwide and you will see this for yourself. At my interviews,there were SEVERAL times when I had to interview with the Chair of respective Anesthesiology Dept. Most places now will also have neuro, psych, pmr attendings in the "pain dept" usually to fulfill ACGME guidelines for a pain fellowship.

So read this. come to a conclusion. Hope that helps.

 

[eljefe]

It took me a little while to figure this out and it is obviously more complicated than this, but bear with me...

The major ideological difference between Anesthesia and PM&R regarding clinical approach is:

a) Anesthesia trained pain physicians consider themselves experts in treating literally-pain. Generally, their approach is entirely focused on pain alleviation. This often comes with the assumption that other treatable pathology has been ruled out prior to the pain clinic referral. While the pain is treated effectively faster, sometimes an underlying cause is missed.

b) PM&R trained pain physicians focus on trying to identify the underlying cause of the pain. Once a cause is identified, then they feel comfortable treating the pain. This sometimes leads to getting bogged down in diagnostics/additional consultations and a delay in pain alleviation when no clear cut cause of symptoms is ever identified.

Due to a), anesthesia trained pain physicians oftentimes get labeled as needle jockeys. Due to b), PM&R trained pain physicians get labeled as ineffecient zebra chasers.

In reality, physicians in a) and b) are both trying to help the patient in the best way they know how. The ideal pain physician knows when to further work up the patient and when to forego additional work up and treat the pain. This, I'm guessing, only comes with years of experience.

Just a thought--I may be wrong (it wouldn't be the first time).

Yah I've heard/seen on here. I think most readers will see the 'bias' of what's on this board for the most part (PMR, ISIS). Also automatically calling people names,etc.

People always make the claim about physical dx,etc. It's important, no question. However, in this day and age, at these meetings they tell you its about the skill set one has. Also YOUR ability to read imaging, interpret them, and do something about them.

In my area there's a Pain Mgt Group owner that was talking to me about his group's dynamics. 3 Anesthesia guys, 1 PMR. They had to let the PMR go because according to him, the guy just took too long and did more examining then he did interventions. His clinic would get backed up. RNs/MAs got pist off because they were staying late,etc. The other docs were pist because the fluro room would be backed up.

Obviously he's not saying be a needle jockey. But he was highlighting to me the importance of being 'efficient' and be 'focused'-atleast in private practice.

 

[PMR 4 MSK]

There is also the difference in personalities and interests that leads one to go in to anesthesia vs PM&R, and whether to stay within those fields primary, or join the nexus of "pain." In PM&R, we do tend to take more time and do "sit down and think about it" medicine. We very rarely make life-or-death decisions. I ran a code once for the 30 seconds or so it too the code team to arrive. That's about as close as I've come to that kind of medicine since internship.

For anesthesia, treating pain outside of surgical patients is a complete paradigm shift. It's a more long-term relationship, requires a clinic and clinical eval - full H&P different than a surgical patient, treatment plans and re-evaluations in the future. Most gas guys I've talked to like having very short-term relationships with the patients and knowing that for most of the relationship, the patient will be asleep.

For PM&R, "pain" is more of a conceptual shift in practice - whether to take on patients that are less rehab and more pain management, and whether to seek further training in advanced pain interventions (discos, vertebroplasty, pumps, stims, etc.) and whether to prescribe opiates.

We all bring something good to the table, and neither field is "best" at pain. Some individuals are better at some things than others. I know what my limits are and when to refer or surrender. Hopefully everyone does.

 

[specepic]

Yah I've heard/seen on here. I think most readers will see the 'bias' of what's on this board for the most part (PMR, ISIS). Also automatically calling people names,etc.

People always make the claim about physical dx,etc. It's important, no question. However, in this day and age, at these meetings they tell you its about the skill set one has. Also YOUR ability to read imaging, interpret them, and do something about them.

In my area there's a Pain Mgt Group owner that was talking to me about his group's dynamics. 3 Anesthesia guys, 1 PMR. They had to let the PMR go because according to him, the guy just took too long and did more examining then he did interventions. His clinic would get backed up. RNs/MAs got pist off because they were staying late,etc. The other docs were pist because the fluro room would be backed up.

Obviously he's not saying be a needle jockey. But he was highlighting to me the importance of being 'efficient' and be 'focused'-atleast in private practice.

Without knowing more about the situation, I would wager that the guy they fired is the one you'd want your mother to see, no? Wouldn't you want the guy to take his time rather than run through injection protocols?

Anyway-I've met great pain docs from a variety of backgrounds. The best ones, regardless of their prior specialty - are or become -- good physiatrists. By that I mean they have or develop good msk history/exam/imaging and focus on pt. function. I know plenty of anesthesiogy-pain docs who do this as well as anyone.

 

[Tenesma]

nice post specepic

 

[SleepIsGood]

Putting people to sleep is not pain. While you were off saving lives in the ICU, us PMR guys were learning spinal imaging and how to examine the patient. But we have several separate threads relating to PMR vs Anes and going into pain. Part of the problem is that a few of the (rathmell) Anes folks threw PMR programs under the bus to keep their department$ happy.

BTW..I've seen and heard Rathmell talk atleast 3 times at 3 different meetings. He's never thrown PMR under the bus. I dont even know the guy so it's not like I'm sticking up for him either.

 

[SleepIsGood]

There is also the difference in personalities and interests that leads one to go in to anesthesia vs PM&R, and whether to stay within those fields primary, or join the nexus of "pain." In PM&R, we do tend to take more time and do "sit down and think about it" medicine. We very rarely make life-or-death decisions. I ran a code once for the 30 seconds or so it too the code team to arrive. That's about as close as I've come to that kind of medicine since internship.

For anesthesia, treating pain outside of surgical patients is a complete paradigm shift. It's a more long-term relationship, requires a clinic and clinical eval - full H&P different than a surgical patient, treatment plans and re-evaluations in the future. Most gas guys I've talked to like having very short-term relationships with the patients and knowing that for most of the relationship, the patient will be asleep.
....

not sure if you know this. But as part of the ACGME guidelines, us in Anesthesiology must rotate through the Pain Clinic, something like 3 months. So we do have clinic. Also, a lot of places have PreOp clinics as well.

 

[Finally M3]

After med school, is pain medicine a residency or fellowship? If it's a fellowship, what residency should one go into to do a fellowship in pain medicine?

Anesthesia, PM&R, Neurology, Psychiatry residencies in order of most to least common. Technically, Pain fellowships are open residents of all fields, although many of the Anesthesia-based fellowships only take Anesthesia residents. Part of this is practical, in that fellows have some OR duties...

Gas v. PMR pissing match has been covered ad-nauseum on multiple threads.

Ultimately, with the practice environment being what it is, by the time you get ready to decide on going into Pain, the field may not be financially viable