How to choose the right residency for pain?

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painfuldoc

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I'm thinking through my residency rank list. My end goal is interventional pain. What advice would you give someone who has sights set on a pain fellowship? What should I look for in a residency program? (I am a PM&R applicant). What residencies to avoid? Just go with the highest ranking program? Or would you say a lesser known program would also help me achieve my goal? Pls answer, I really do value your opinions.

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Go with the program with the strongest pain division. It is usually easiest to match at your home institution.
 
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Suggest thinking about what you want your practice to look like someday. Then find a fellowship that teaches the procedures/skills you will need. Some options - spine? inpatient? outpatient? oncology? HMO? Private? Academic? Research? That sort of thing. My fellowship (1984) was heavy on oncology pain which i almost never used later.
 
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I would caution you against putting exposure to pain as the greatest weight for program selection. I went in to PM&R convinced I would do inpatient SCI which ended up changing midway through PGY2. Just another thought
 
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PMR at Emory.

When I graduated there I had done 500 fluoro procedures, and got to participate in kypho and SCS. Pump management at Shepherd Center.

Things have changed there since I graduated and the PGY4 year is where you do all the interventional stuff.

...you do some earlier at the VA actually, but Emory Spine is PGY4 and I did all my elective time there as well.

I didn't learn anything in my pain fellowship about routine pain procedures bc I learned so much at Emory.

Also realize you may not like pain in the real world.

I pretty much knew I would do pain in 3rd year med school, but then at the Shepherd Center in Atlanta I wanted to SCI, then TBI, then back to pain, then Sports, and then Sports & Spine, and SCI again...

I went to Northwestern for a prosthetics and orthotics thing and then wanted to do something in that realm...

Pain was always there though, and it may sound trivial at first glance but doing an RFA on a 73 yo widow so she can garden is very satisfying.

I'm not changing the world and curing CA, but don't believe for a minute that managing degenerative spines in older ppl is insignificant...It isn't...
 
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I also was exactly like you, wanting to find a program that provided exposure to interventional spine. I knew 100% I wanted a pain fellowship prior to even starting residency. I was confined to the northeast so basically NYC and Philly. And none of them really provided that. I was pretty disappointed in the interview trial asking residents how much injection experience they get, and basically getting shrugs and blank looks back. Don’t know if things have changed in 5 years though. Go to the best program you can, do well, and hopefully the rest takes care of itself
 
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Keep in mind, NYU pain loves getting chinese and Jewish candidates, Cornell pain loves getting Indians
 
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Keep in mind, NYU pain loves getting chinese and Jewish candidates, Cornell pain loves getting Indians

So instead of ordering takeout they order residents?
 
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I'm thinking through my residency rank list. My end goal is interventional pain. What advice would you give someone who has sights set on a pain fellowship? What should I look for in a residency program? (I am a PM&R applicant). What residencies to avoid? Just go with the highest ranking program? Or would you say a lesser known program would also help me achieve my goal? Pls answer, I really do value your opinions.

Starting with the end in mind is a reasonable thing, but why is your end goal interventional pain as a resident? What's your backup plan?

If you're doing a pain fellowship, physiatry and anesthesia are better residency choices currently, but I'm not sure what will be best in 3-4 years when you're applying for a fellowship.

I would counsel ensuring there is a pain fellowship at your residency program of choice as that will help for letters, exposure, etc.
I would ensure that residents from your residency choices end up in pain fellowships. That's an easy thing to find out online on most websites or on interviews.

High ranking programs are generally high ranking due to research accolades and not necessarily because of training/education. I generally counsel to avoid that unless you want to be in academics, but if you're coming from a smaller medical school, it may be useful to aim up a tier.
 
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Look for signs that a program's leadership wants to treat pain as a mental illness and sacrifice patient well-being for the sake of "fighting the opioid epidemic." Do not apply to such programs. Look for institutions that are interested in treating the physical causes of pain, i.e. those investigating regenerative medicine.
 
Look for signs that a program's leadership wants to treat pain as a mental illness and sacrifice patient well-being for the sake of "fighting the opioid epidemic." Do not apply to such programs. Look for institutions that are interested in treating the physical causes of pain, i.e. those investigating regenerative medicine.

Mmmhmmm...This'll go over well.
 
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Squirt some $tem cells in 'em
Those in the field who are denigrating stem cells are behind the curve, and failing in their fiduciary duty to their patients.
 
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Those in the field who are denigrating stem cells are behind the curve, and failing in their fiduciary duty to their patients.

I’m willing to entertain the first half of your thought, but what do you mean by the second? I’ve met too many patients who dropped $3-5k on stem cells and they still end up in my clinic.
 
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Those in the field who are denigrating stem cells are behind the curve, and failing in their fiduciary duty to their patients.
How does one provide stem cells to a geriatric woman on fixed income with multilevel stenosis who isn't a surgical candidate?

Where do the cells go; how do they get there?

Genuinely want to know - Not arguing.
 
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How does one provide stem cells to a geriatric woman on fixed income with multilevel stenosis who isn't a surgical candidate?

Where do the cells go; how do they get there?

Genuinely want to know - Not arguing.
I didn't say every individual is a candidate for regenerative medicine or that every doctor has to specialize in it. There will be those who aren't good candidates or for whom the procedures fail, and they will need to rely on conventional approaches. What I was attacking specifically is the mentality of "anything I didn't learn in medical school is snake oil," held by those who don't like science when it poses an economic threat to their current skill set.
 
Poorly worded. Anyone can make a baller amount of money by offering stem cells. You just have to ignore the large gaps in research and mind your abc’s.
 
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I didn't say every individual is a candidate for regenerative medicine or that every doctor has to specialize in it. There will be those who aren't good candidates or for whom the procedures fail, and they will need to rely on conventional approaches. What I was attacking specifically is the mentality of "anything I didn't learn in medical school is snake oil," held by those who don't like science when it poses an economic threat to their current skill set.
Fair enough on the general point, but the last part here (economic and science stuff) isn't accurate IMO.

In fact, I think science IS the reason there are skeptics.

The economic thing is confusing, especially considering your avg stem cell advocate is a chiropractor (goes back to the science thing).

I'm in support of whatever works by the way.
 
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Academic pain is different than real world pain. The politics/referral patterns/institutional inertia make it challenging for most academic pain physicians to offer the latest, greatest, newest therapies/technologies. I would suspect most fellowships aren't providing exposure to interspinous spacers, SI fusions, etc. I would suspect that the lack of insurance coverage makes it difficult to provide therapies like MSCs/PRP/biologics/etc in the inefficiencies of academia.

I would agree that anyone training in medicine needs to grow, but there is a need for trainees to understand what is snake oil and what is not. There's that old adage that 50% of what you learn in medicine will be wrong or inaccurate in 5 years, so we've got an obligation to keep learning, challenging, and improving our practices.

For what it's worth, I would probably ask more about turnover in faculty, industry relationships, opportunities for focused training on certain aspects, and things that help you understand the culture of a program such as how they treated their fellows during the pandemic.
 
Look for signs that a program's leadership wants to treat pain as a mental illness and sacrifice patient well-being for the sake of "fighting the opioid epidemic." Do not apply to such programs. Look for institutions that are interested in treating the physical causes of pain, i.e. those investigating regenerative medicine.
I was going to say that this is one of the most asinine statements I have read in a long time.

but the week is early, and I haven't browsed the Physicians only forum yet.
 
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Academic pain is different than real world pain. The politics/referral patterns/institutional inertia make it challenging for most academic pain physicians to offer the latest, greatest, newest therapies/technologies. I would suspect most fellowships aren't providing exposure to interspinous spacers, SI fusions, etc. I would suspect that the lack of insurance coverage makes it difficult to provide therapies like MSCs/PRP/biologics/etc in the inefficiencies of academia.

I would agree that anyone training in medicine needs to grow, but there is a need for trainees to understand what is snake oil and what is not. There's that old adage that 50% of what you learn in medicine will be wrong or inaccurate in 5 years, so we've got an obligation to keep learning, challenging, and improving our practices.

For what it's worth, I would probably ask more about turnover in faculty, industry relationships, opportunities for focused training on certain aspects, and things that help you understand the culture of a program such as how they treated their fellows during the pandemic.

The Vanguard of Pain Medicine has always been private practice. Very few successful private doctors give it all up and are lured back into academia. Most of those who do have strong academic interests develop their own research divisions within their groups or practices.

It's just the way it is.
 
The Vanguard of Pain Medicine has always been private practice. Very few successful private doctors give it all up and are lured back into academia. Most of those who do have strong academic interests develop their own research divisions within their groups or practices.

It's just the way it is.
Or, some of them, including a fellowship program director, and also a medical director of Pain (at one particular “major” academic program in NYC) are paid up to 5-6 figure payments by industry. That could also be a motivator. This is all public record via a very easily searchable database by the way, for the skeptics.
 
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Or, some of them, including a fellowship program director, and also a medical director of Pain (at one particular “major” academic program in NYC) are paid up to 5-6 figure payments by industry. That could also be a motivator. This is all public record via a very easily searchable database by the way, for the skeptics.

The academic salaries can't compete to recruit the talent to build their programs.
 
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The academic salaries can't compete to recruit the talent to build their programs.
But why do a couple NYC academic institutions even allow these people to collect such huge checks from industry without scrutiny? Is it because no one else will take their job if they’re fired and thrown out?
 
Power.

my guess is that these individuals have such great power (part of that being prestige) that the academic institution finds it impossible to divest themselves from these individuals.

it all boils down to $$$$$
 
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My patient informed me her podiatrist is getting stem cell injections for her feet approved, and her copay is only $45. Pretty sure there's some fraud involved there, but she's pretty happy with the $45.
 
My patient informed me her podiatrist is getting stem cell injections for her feet approved, and her copay is only $45. Pretty sure there's some fraud involved there, but she's pretty happy with the $45.
...bc they're not stem cells.
 
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@Surgeontodd94 Current PM&R resident here-also knew I wanted pain on entry to PM&R-matched a top tier pain program for next year.

I'd agree that looking at PM&R programs with an internal pain fellowship/division is a good idea--especially if that pain group that you'll rotate with is high volume and they allow residents to assist/perform the procedures. Flexibility in the PM&R program to allow you to maximize your elective/exposure to your field of interest is also important. Some PM&R programs have several months of electives, others have a regimented schedule you can't really tweak much. As an aside, I'd argue having a strong MSK experience during your PM&R residency will also serve you well going in to pain especially a strong ultrasound training. The highest ranked PM&R programs (on Doximity?) do not always equate to those programs being best for everyones goals and many Anesthesiology pain departments aren't even aware of PM&R program Doximity rankings anyhow. Institutional name brand/anesthesia dept reputation is likely more important than that.

Was able to spend several months over the last few years with our pain division and feel very comfortable with many bread and butter pain procedures at this point as I wrap up residency. Done several hundred fluoro guided procedures with additional exposure to things like acute pain, peri-operative pain, SCS/DRG trials/perms, vertebral augmentation etc. This all led to strong pain LORs, early connections in the pain world and research opportunities. Also hoping that this exposure gained during residency allows me more time to focus on many of the more advanced procedural skills offered by the fellowship program I am headed to rather than having to spend tons of time learning basics of fluoro or needle driving. Of course there is always more to learn and I am fully expecting to do a ton of bread and butter regardless during fellowship, but it is nice having a solid foundation to build on for that already.
 
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many Anesthesiology pain departments aren't even aware of PM&R program Doximity rankings anyhow. Institutional name brand/anesthesia dept reputation is likely more important than that.
1+
 
Academic pain is different than real world pain. The politics/referral patterns/institutional inertia make it challenging for most academic pain physicians to offer the latest, greatest, newest therapies/technologies. I would suspect most fellowships aren't providing exposure to interspinous spacers, SI fusions, etc. I would suspect that the lack of insurance coverage makes it difficult to provide therapies like MSCs/PRP/biologics/etc in the inefficiencies of academia.

I would agree that anyone training in medicine needs to grow, but there is a need for trainees to understand what is snake oil and what is not. There's that old adage that 50% of what you learn in medicine will be wrong or inaccurate in 5 years, so we've got an obligation to keep learning, challenging, and improving our practices.

For what it's worth, I would probably ask more about turnover in faculty, industry relationships, opportunities for focused training on certain aspects, and things that help you understand the culture of a program such as how they treated their fellows during the pandemic.

There are select fellowships (not the expected ones) who provide exposure to the most advanced procedures like Endoscopic decompressions for herniated discs, spinal stenosis, facet cysts, epidural fibrosis etc. Along with SIJ fusion, Vertiflex and all the latest therapies etc. Academic pain medicine will still train the next generation of pain physicians and could be quite satisfying as a career if you have the right aptitude (minus big $$$$ of course)
 
A lot of these procedures are here today gone tomorrow. They require a lot of training and logistical ramp-up. While it may be cool to train in them, and potentially useful long term, they are likely to dissapear entirely. Remember coblation nucleoplasty?
 
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A lot of these procedures are here today gone tomorrow. They require a lot of training and logistical ramp-up. While it may be cool to train in them, and potentially useful long term, they are likely to dissapear entirely. Remember coblation nucleoplasty?

I thought my future was going to be IDET and percutaneous discectomies.
 
A lot of these procedures are here today gone tomorrow. They require a lot of training and logistical ramp-up. While it may be cool to train in them, and potentially useful long term, they are likely to dissapear entirely. Remember coblation nucleoplasty?

Endoscopic spine surgery is not a flash in pan like IDET, Biacuplasty and even perc discectomy where you operated only under fluoroscopic guidance without actually seeing or treating the pathology unlike using an endoscope where you see and treat the actual pathology inside the spinal canal. Spine endoscopy is the future of minimally invasive spine and is being adapted rapidly by NSGY by undergoing cadaver labs but since they were originally trained on the microscope so they are still coming to terms with holding the endoscope with one hand and wielding the instruments with other. There is still a window for pain docs to get trained and adopt Endoscopic spine before the surgeons take a stand and shut it down. ACNS and AANS have already petitioned NASS to clarify it’s position on this issue.
 
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Endoscopic spine surgery is not a flash in pan like IDET, Biacuplasty and even perc discectomy where you operated only under fluoroscopic guidance without actually seeing or treating the pathology unlike using an endoscope where you see and treat the actual pathology inside the spinal canal. Spine endoscopy is the future of minimally invasive spine and is being adapted rapidly by NSGY by undergoing cadaver labs but since they were originally trained on the microscope so they are still coming to terms with holding the endoscope with one hand and wielding the instruments with other. There is still a window for pain docs to get trained and adopt Endoscopic spine before the surgeons take a stand and shut it down. ACNS and AANS have already petitioned NASS to clarify it’s position on this issue.
Good luck getting credentials in a hospital for this.
 
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Can you do it an ASC?

Sure it can be done in an ASC. Also hospitals will credential you if you provide training certificate and blessing from your neurosurgeon and/or ortho spine Docs who will be on the credentialing committee (hardest part). If Endoscopic spine surgery is part of your fellowship training then your case logs will be enough to give you credentials anywhere
 
I didn't say every individual is a candidate for regenerative medicine or that every doctor has to specialize in it. There will be those who aren't good candidates or for whom the procedures fail, and they will need to rely on conventional approaches. What I was attacking specifically is the mentality of "anything I didn't learn in medical school is snake oil," held by those who don't like science when it poses an economic threat to their current skill set.
What is your degree? You don't sound like a Physician
 
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You can learn how to do procedures later. Being good at your base specialty has a lot to offer and makes you a better doctor. If I was a PD, knowing an applicant has done hundreds of procedures wouldn’t impress me. It just means you might have a lot of bad habits that need to be untaught.

evidence based Techniques that most folks consider the gold standard, such as SIS techniques are rarely taught or used by the fellowship docs out there.

just recently had an old school anesthesia pain doc tell me his “revelation” that he should get a lateral when doing cervical ESI to check depth instead of relying on LOR...
 
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