How many procedures is "enough"?

[Blitz2006]

Just wondering, as I cross the halfway point in fellowship, and start looking into the 2nd half.

By the end of fellowship, how many b&b procedures (Caudal, TFESI, Lumbar Sympathetic, cervical epidural) do you think is enough to be "comfortable"?

5? 10? 20? For each procedure

Obviously, I know this is subjective, but curious to hear some rough N values...

Thanks!

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[lobelsteve]

10 caudals. 100 mbb. 100 tfesi. 20 LSB.
CESI? Couple thousand so far. If I ever feel comfortable I will stop doing them.

 

[dhcofc]

If you’re asking you haven’t done enough to be “comfortable.” Stay cautious and continue to learn once you’re on your own.

 

[Blitz2006]

If you’re asking you haven’t done enough to be “comfortable.” Stay cautious and continue to learn once you’re on your own.

I hear ya. Just wanted some rough values to gauge, since I'm a numbers guy.

But I obviously agree with you.

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[dhcofc]

I would also urge you to always question the “way you were taught” and continually learn new ways to do procedures and figure out why others do procedures differently. I do most procedures quite a bit different than I did in fellowship when I had to do it the way an attending wanted it done. So even when you’re “comfortable” don’t be afraid to try different ways. When you eventually figure out how YOU want to do things you’ll become much more comfortable.

 

[SommeRiver]

You know what's funny? The procedure that is going to cause you the most trouble in the real world is the TFESI.

The reason is you will take their simplicity for granted, assume they will always take 5 minutes, and you'll overbook them.

Mr Smith's severely gross back isn't going to look right, the facet is going to keep stealing your contrast, now it's vascular flow, next thing you know it has been 20 min and you're behind...

You can never do too many TFESI in training.

Edit - Also do NOT rely on loss of resistance in a cervical ESI. Early contrast administration and I'd start that habit now in training if I were you.

 

[paindoc007]

You know what's funny? The procedure that is going to cause you the most trouble in the real world is the TFESI.

The reason is you will take their simplicity for granted, assume they will always take 5 minutes, and you'll overbook them.

Mr Smith's severely gross back isn't going to look right, the facet is going to keep stealing your contrast, now it's vascular flow, next thing you know it has been 20 min and you're behind...

You can never do too many TFESI in training.

Edit - Also do NOT rely on loss of resistance in a cervical ESI. Early contrast administration and I'd start that habit now in training if I were you.

That’s funny to me. Start the habit training now as a fellow.

My attendings at my acgme accredited pain fellowship would not let me do ANYTHING outside of how they believed a procedure should be done. I asked nicely about various approaches, and my attendings would get so annoyed, and take it that I wasn’t comfortable doing the procedures.

I had several friends in other fellowships across the country; and I don’t feel like I was alone in that. There isn’t a lot of “let the fellow be independent and think out the problem themselves” kind of training nowadays

 

[SommeRiver]

That’s funny to me. Start the habit training now as a fellow.

My attendings at my acgme accredited pain fellowship would not let me do ANYTHING outside of how they believed a procedure should be done. I asked nicely about various approaches, and my attendings would get so annoyed, and take it that I wasn’t comfortable doing the procedures.

I had several friends in other fellowships across the country; and I don’t feel like I was alone in that. There isn’t a lot of “let the fellow be independent and think out the problem themselves” kind of training nowadays

I'm not suggesting doing things outside of the norm, but if you've done a lot of CESI you've had those cases where there is no loss of resistance, and if you're dumb you can hurt someone. Early contrast and a lot of radiation will keep you safe.

TFESI...Usually L4-5 on a back that really sucks can steal your soul and make you wonder why you ever decided to do the procedure in the 1st place.

Edit - I put a dot of contrast when I perfectly KNOW I'm posterior during a CESI. I move a millimeter and dot it again. I use a LOR syringe by the way. That dot of contrast if you get a good loss can show epidural spread by itself. I still prove it with more contrast though. My fellowship was accredited too, but no attending had any issues with that, bc I'm not doing anything wrong. A residency attending taught me that, and I haven't changed it, nor will I.

Contrast is the ONLY reliable thing you can use for safety.

 

[dhcofc]

Contrast is the ONLY reliable thing you can use for safety.

Along with contralateral oblique...

 

[SommeRiver]

Along with contralateral oblique...

Yep.

 

[Blitz2006]

I'm not suggesting doing things outside of the norm, but if you've done a lot of CESI you've had those cases where there is no loss of resistance, and if you're dumb you can hurt someone. Early contrast and a lot of radiation will keep you safe.

TFESI...Usually L4-5 on a back that really sucks can steal your soul and make you wonder why you ever decided to do the procedure in the 1st place.

Edit - I put a dot of contrast when I perfectly KNOW I'm posterior during a CESI. I move a millimeter and dot it again. I use a LOR syringe by the way. That dot of contrast if you get a good loss can show epidural spread by itself. I still prove it with more contrast though. My fellowship was accredited too, but no attending had any issues with that, bc I'm not doing anything wrong. A residency attending taught me that, and I haven't changed it, nor will I.

Contrast is the ONLY reliable thing you can use for safety.

So is it wise for the first few months out to only do ILESI...and avoid TFESI (Lumbar)?

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[NJPAIN]

Some great advice above. Don't be afraid to use contrast early and check image frequently. No one wants to over radiate themselves and the patient but doing any kind of procedure and using 3 seconds of fluoro time is like trying to park a car with your eyes closed. If you have an elderly patient population and you know and care about the difference between an epidural and an epidermal you are going to run into more than a few 20 minute TFESIs.

 

[SommeRiver]

So is it wise for the first few months out to only do ILESI...and avoid TFESI (Lumbar)?

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No, you should do what is correct in any situation.

 

[Ducttape]

So is it wise for the first few months out to only do ILESI...and avoid TFESI (Lumbar)?

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maybe the first couple of weeks, but no longer than that. that's more for getting comfortable with all the extraneous stuff - new staff, new needles, new equipment, c arm, etc.

after that, then dive right in, but initially book extra time for CESI and difficult procedures. and when you are starting, you probably will have extra time available. so you can go slow.

thing is, the longer you wait, the more you will find reasons not to incorporate those procedures as part of your standard regimen, and the less comfortable you will be with them in the long run.

 

[DOctorJay]

Agree with booking extra time. Get comfortable in your new environment with your new team before you get stressed about keeping on schedule.


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[geauxg8rs]

I would press my attendings to teach me a different way to do a bread and butter procedure.

 

[callmeanesthesia]

TFESI...Usually L4-5 on a back that really sucks can steal your soul and make you wonder why you ever decided to do the procedure in the 1st place.

Amen to that. Just did a couple procedures on scoliosis arthritic osteoporotic 80+ year old ladies. Takes 3x as long because you can’t even see the bone spurs blocking your needle’s path...

 

[Orin]

No, you should do what is correct in any situation.

What's the correct indication for a TFE$I over an ILESI, other than the almighty $?

I would agree the appropriate approach is for residents/fellows to ask about other approaches and techniques. The latitude to do novel approaches comes with time and comfort both for the learner and the teacher, which unfortunately is harder with the increasing focus on metrics and profitability even in academic settings.

 

[SommeRiver]

What's the correct indication for a TFE$I over an ILESI, other than the almighty $?

I would agree the appropriate approach is for residents/fellows to ask about other approaches and techniques. The latitude to do novel approaches comes with time and comfort both for the learner and the teacher, which unfortunately is harder with the increasing focus on metrics and profitability even in academic settings.

What?

Is this another instance in the forum where someone references dollar signs for unclear reasons?

My point is that you should do what is correct for the pt in any given situation - Don't avoid things for fear of being slow if it is the right thing to do.

Also, I don't see that anyone here is recommending novel approaches for anything.

 

[Orin]

What?

Is this another instance in the forum where someone references dollar signs for unclear reasons?

My point is that you should do what is correct for the pt in any given situation - Don't avoid things for fear of being slow if it is the right thing to do.

Also, I don't see that anyone here is recommending novel approaches for anything.

My bad. No high quality data for TFESI over ILESI in majority of indications except for reimbursing better.

For some people, CLO, a different view, or using a different needle is "novel." A lot of people don't wander far from the way they were taught.

 

[Blitz2006]

So follow up question

How can I get better in the upcoming year as a new attending in an academic setting?

Can I ask to be shadowed by senior attendings while I'm doing a procedure I want to improve on (e.g TFESI, SCS trial, pump, etc)?

Do I keep going to cadaver courses? I find cadavers are good...but obviously nothing like the real patient.

Should I ask to Shadow colleagues?

Basically, my question is, how can I get better technically /interventionally/ surgically as an attending?


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[cbest]

Based on MacVicar’s review of lumbar TFESI in Pain Medicine in 2013 (I think), the data suggests that lumbar TFESI provides superior outcomes compared to ILESI. Only Candido’s paper suggests otherwise. Assuming I see adequate perineural fat around a nerve on MRI, I’ll typically select TFESI as plan A. If severe foraminal stenosis, I’ll do an ILESI.


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[lobelsteve]

Based on MacVicar’s review of lumbar TFESI in Pain Medicine in 2013 (I think), the data suggests that lumbar TFESI provides superior outcomes compared to ILESI. Only Candido’s paper suggests otherwise. Assuming I see adequate perineural fat around a nerve on MRI, I’ll typically select TFESI as plan A. If severe foraminal stenosis, I’ll do an ILESI.


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And despite 100,000procedures, Kenny still doesn't do an ESI correctly. Shameful.

 

[SommeRiver]

My bad. No high quality data for TFESI over ILESI in majority of indications except for reimbursing better.

For some people, CLO, a different view, or using a different needle is "novel." A lot of people don't wander far from the way they were taught.

I don't do too many LESI, as most of my lumbar epidurals are TFESI. I have no idea if one reimburses more than the other.

Edit - This shows the opposite, but I do not get into fees. I have no clue what epidurals reimburse, I hope to keep it that way bc I don't need to have money weighing on my decisions.

 

[Ducttape]

depends on office or facility based. makes sense for office based injections - Touhy needles and the like are a lot more expensive than spinal needles.


to get better - you need to do the procedures yourself. you have been shadowing attendings, doing things their way. watching them do procedures wont help your motor skills.

the only way to get better - make sure they schedule a day (or half day) that you do procedures just on your own without any resident or fellow.

 

[SommeRiver]

First few months unsupervised are important, and that's when you really become a doctor. Don't set yourself up for failure - Take your time, do it correctly, and don't assume anything will be easy.

 

[callmeanesthesia]

First few months unsupervised are important, and that's when you really become a doctor. Don't set yourself up for failure - Take your time, do it correctly, and don't assume anything will be easy.

And if you aren’t sure whether it’s safe to inject, don’t inject. It’s okay to abort a procedure if it isn’t working out.

 

[Pain_doc]

And despite 100,000procedures, Kenny still doesn't do an ESI correctly. Shameful.

?

 

[lobelsteve]

And despite 100,000procedures, Kenny still doesn't do an ESI correctly. Shameful.

?

No short catheter on needle for ESI to ensure tip is not moving during the push on the plunger during injection.

 

[Ligament]

You've done enough procedures when you become scared of them the second time around.

What I mean by this is as a fellow you are scared of them, as an early attending you loose your fear after a while, then as you go on you become scared of them again, as you've learned more about what can go wrong and heard or seen the horror stories. I think it is then that you've had enough exposure to get the full picture...

By "scared" I mean cautious/fearful/sceptical/respectful etc etc.

 

[SommeRiver]

You've done enough procedures when you become scared of them the second time around.

What I mean by this is as a fellow you are scared of them, as an early attending you loose your fear after a while, then as you go on you become scared of them again, as you've learned more about what can go wrong and heard or seen the horror stories. I think it is then that you've had enough exposure to get the full picture...

By "scared" I mean cautious/fearful/sceptical/respectful etc etc.

...and you realize your residency snd fellowship attendings acted like wimps all the time for a reason.

 

[NJPAIN]

You've done enough procedures when you become scared of them the second time around.

What I mean by this is as a fellow you are scared of them, as an early attending you loose your fear after a while, then as you go on you become scared of them again, as you've learned more about what can go wrong and heard or seen the horror stories. I think it is then that you've had enough exposure to get the full picture...

By "scared" I mean cautious/fearful/sceptical/respectful etc etc.

So true. Bravo!