How to overcome bias? i.e. Not only Anesthesia, PM&R, Neuro & Psych are eligible

[freddydpt]

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Hi Everyone,

I am a PGY 5 radiology resident, passionate about pain management, and currently applying for pain fellowships. I've sent out email inquiries to some program directors, who respond that they cannot accept a radiologist into their fellowship due to "ACGME regulations". However, this is a misunderstanding of what the ACGME accreditation status means. A common question that arises is whether or not a radiologist would be board eligible and of course the answer is yes, however, some program directors are still skeptical.

Below are links to two radiologists I've been in touch, both boarded in pain medicine, one through the ABPMR and the other through the ABPN.

https://www.abpmr.org/search_results.html?id=25927
https://application.abpn.com/verifycert/verifyCert_details.asp?p=172558

The Certification Booklet of Information for the ABPMR states:
"diplomates from other member Boards of the ABMS who have had appropriate training and experience in the area of Pain medicine may apply to the ABPMR for admission to the Pain medicine certifying process."

https://www.abpmr.org/boi/Cert_BOI.pdf

The rules state that the applicant to pain fellowships have to have graduated from an ACGME accredited residency and hold a primary ABMS certified board prior to entering fellowship.

http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/sh_multiPainPR707.pdf

There are also many other physicians in other fields, internal medicine is what I've noticed primarily, boarded through the ABPN.

Even the NRMP has the following on their site:
Pain Medicine includes comprehensive training in acute, chronic, and interventional pain management..... Programs accept residents trained in Anesthesiology, Neurology, Physical Medicine and Rehabilitation, and Psychiatry.

However, some programs routinely accept fellows outside of these four fields.

Can anyone else think of a way to overcome the biases or misunderstandings of the ACGME rules? I know I'm not the only radiologist passionate about pain management and I would love to make the process easier for future generations.

Thanks in advance for any suggestions! Have a great day!

(please only serious responses)

 

[emd123]

You're right. They're wrong. Likely they know it. Since 2007 any specialty can do Pain and be ABMS boarded with an ACGME fellowship.

If you really want to do this:

You won't overcome the bias; you need to side step it. Apply to as many programs as possible, preferably all of them (80-90+) expect a lot of rejections. At most programs, your different background will sink you. At others, it gives you an advantage since its unique (i.e. diversity). Don't shy away from your differences, own them and "sell it." Application numbers are your friend. Take a cadaver course. Get your ACLS card, to show some resuscitation skills. Focus on interventional radiology and highlight those skills. Get some psych, neuro, pmr exposure. Anything to prove you are developing clinical "hands on" skills. Be persistent, keep applying (even to programs that say they only take the big 4) and don't take no for an answer. Find people who've done it an focus on those fellowships, but still cast a wide net. If you're "good" you've got a shot. There are numerous threads here on people who were from specialties other than the big four who did ACGME fellowships and passed the ABA exam and are ABMS pain boarded.

I did it.

I hung my diplomas on my office wall last week (ACGME pain fellowship and ABMS pain subspecialty). Good luck.

 

[Aether2000]

First, drop the "Doctor of Physical Therapy" from your signatures...it is not something most real doctors find amusing or endearing...we think of it as professional padding of a CV. Secondly, you wanna play hardball and you received the responses in writing about the programs not accepting you because you are a radiologist, you have a case. I would start by pointing out to them the requirement they consider all applicants that have met the criteria. If they won't play ball, then have your lawyer send them a letter. If they continue to refuse to play ball, consider litigation. There may be many factors considered in candidate selection but it is definitely illegal to offer a level playing field for an ACGME pain fellowship candidacy.

 

[Dr. Ice]

Hi Everyone,

I am a PGY 5 radiology resident, passionate about pain management, and currently applying for pain fellowships. I've sent out email inquiries to some program directors, who respond that they cannot accept a radiologist into their fellowship due to "ACGME regulations". However, this is a misunderstanding of what the ACGME accreditation status means. A common question that arises is whether or not a radiologist would be board eligible and of course the answer is yes, however, some program directors are still skeptical.

Below are links to two radiologists I've been in touch, both boarded in pain medicine, one through the ABPMR and the other through the ABPN.

https://www.abpmr.org/search_results.html?id=25927
https://application.abpn.com/verifycert/verifyCert_details.asp?p=172558

The Certification Booklet of Information for the ABPMR states:
"diplomates from other member Boards of the ABMS who have had appropriate training and experience in the area of Pain medicine may apply to the ABPMR for admission to the Pain medicine certifying process."

https://www.abpmr.org/boi/Cert_BOI.pdf

The rules state that the applicant to pain fellowships have to have graduated from an ACGME accredited residency and hold a primary ABMS certified board prior to entering fellowship.

http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/sh_multiPainPR707.pdf

There are also many other physicians in other fields, internal medicine is what I've noticed primarily, boarded through the ABPN.

Even the NRMP has the following on their site:
Pain Medicine includes comprehensive training in acute, chronic, and interventional pain management..... Programs accept residents trained in Anesthesiology, Neurology, Physical Medicine and Rehabilitation, and Psychiatry.

However, some programs routinely accept fellows outside of these four fields.

Can anyone else think of a way to overcome the biases or misunderstandings of the ACGME rules? I know I'm not the only radiologist passionate about pain management and I would love to make the process easier for future generations.

Thanks in advance for any suggestions! Have a great day!

(please only serious responses)

Dude..do you wanna switch? I have been dreaming about doing radiology..no fibro, no drug seekers, not as much govenment regulation, no crying work comp/auto patients with little ditzles on their MRI...

stay where you are man...

 

[Ducttape]

to be devil's advocate:

what can you show that proves that you have the clinical acumen to be a pain physician?

this is the conundrum facing pain programs. When they are interviewing candidates, they are not only looking for people who will be willing to work hard, but they are also looking for doctors who have a good knowledge base, interpersonal skills and clinical skills.

All pain specialists, regardless of their primary specialty, should be competent in pain assessment, formulation, and coordination of a multiple modality treatment plan, integration of pain treatment with primary disease management and palliative care, and interaction with other members of a multidisciplinary team.

there will always be a bias towards the "big 4". part of that is inherent to the backbone of the fellowship program itself.

A program in pain medicine will be accredited only if it is conducted in an institution that also sponsors residencies accredited by the ACGME in at least two of the following specialties: anesthesiology, neurology, physical medicine and rehabilitation, and psychiatry.

if you are like emd, you can clearly show that you have clinical acumen, having done Emergency Medicine, being able to do rapid quick and thorough evaluations of patients in pain. You might not have the technical skills, and those are hard to teach, but not impossible.

it is imperative that you show to them that you have the clinical skills and interpersonal skills to be a pain physician.do you have the technical skills (i dont know your experience with interventional radiology, most rad residents ive talked to said they felt okay but not great about their interventional skills - "the fellows get to do everything").

in my opinion - you have to prove that you belong, and the best way is to do lots of electives in pain medicine, and get as good letters of recommendations, support, maybe even phone calls from the mentor to a program director.

 

[specepic]

If I were I PD I would be very interested in someone with rads and PT background. Interesting and useful combo IMO. The DPT thing is a bit of a landmine, it is to your credit but be aware that some DPT's are seen as the enemy so tread carefully. I think it is more of a plus as you will have MSK skills most MD's won't have. DO's on the other hand will eat you for lunch 😀

 

[nvrsumr]

Pain electives, publish, do awesome on your inservice exams and your steps

I think having a rads would be a huge asset to a pain program as most anesthesia residents don't know which side is up on an MRI. I probably wouldnt put it that way to the pd....

Finally, you dont have to do a pain fellowship to have a pain practice... I know a number of rads who do interventional "pain"

 

[bedrock]

Yes but those rads suck as pain "doctors" because they only can drive a needle and have no clinical skills from a rad background

 

[Ducttape]

Yes but those rads suck as pain "doctors" because they only can drive a needle and have no clinical skills from a rad background

which may be why some programs may be hesistant to take a radiology resident as a pain fellow.

just saying...

 

[Tenesma]

hmmm. I don't know about rads doing pain...

there is really minimal clinical decision making exposure during the 5 years of residency... and 1 year of fellowship may not be enough to understand nuances...

if you are passionate about pain - do you mean passionate about procedures? in that case do IR and do some procedures here and there... if you are passionate about talking to patients then a rads residency may be poor preparation.

 

[Residentcool]

First, drop the "Doctor of Physical Therapy" from your signatures...it is not something most real doctors find amusing or endearing...we think of it as professional padding of a CV. Secondly, you wanna play hardball and you received the responses in writing about the programs not accepting you because you are a radiologist, you have a case. I would start by pointing out to them the requirement they consider all applicants that have met the criteria. If they won't play ball, then have your lawyer send them a letter. If they continue to refuse to play ball, consider litigation. There may be many factors considered in candidate selection but it is definitely illegal to offer a level playing field for an ACGME pain fellowship candidacy.

I think playing "hardball" is silly. A program does not have to accept you. I'm sure pain programs have more applicants than spots, and the last thing they want is a difficult candidate. It's farrrrr easier to take a gentle approach, perhaps point out how you would be a great fit for the program, why you are passionate about the field, why the different background may be an asset, etc. I agree with some that it seems a bit odd that a radiologist would go into pain. Perhaps apply to less competitive programs. There are certain programs that are far easier to get into than others. I think it's worth it to apply to all programs, and perhaps kindly educate the programs that suggest that they can't Iv you or something.

 

[freddydpt]

If I were I PD I would be very interested in someone with rads and PT background. Interesting and useful combo IMO. The DPT thing is a bit of a landmine, it is to your credit but be aware that some DPT's are seen as the enemy so tread carefully. I think it is more of a plus as you will have MSK skills most MD's won't have. DO's on the other hand will eat you for lunch 😀

Thanks for your responses! It is interesting how the DPT might be considered a landmine. That never even crossed my mind! Any physician I've worked with, rather than thinking of it as a landmine, has asked me to "fix" their neck... or consult on a complicated MSK or Neuro patient. I've only received the utmost respect having that credential. The MSK/Neuro skills are there and fresh. I've rotated through a year long sports medicine continuity clinic elective that also included peripheral injections, in addition to doing pro bono PT work throughout residency. I also teach two courses (Neuroanatomy and Neurology) at University of Delaware (#2 program in the country).

Pain docs refer patients to physical therapy all the time. The benefit of the DPT (PT experience) is that I know the difference between effective PT vs. ineffective PT. I can also run a rehab center in the future and directly/closely supervise to make sure I see an appropriate response. Or, to put it a different way, I know what PT interventions will work with specific patients.

DO's are phenomenal! But, so many don't practice manipulation anymore, it's sad. I love to trade manual therapy tips whenever I work with one.

The radiology background is extremely beneficial for many reasons:
1) Looking at the imaging and recognizing more pain generators than a radiologist might not appreciate without strong history or physical exam data... Conversely, other disciplines might not understand nuances of imaging, technical limitations, implications for their procedures or other subtle findings.

2) Strong experience with multimodal image guided procedures: fluoro, US, CT and MRI. My fellowship next year at Jefferson will include a strong MSK US experience. The fellowship is in both Musculoskeletal and Neuroradiology.

Some of you guys are hilarious! So many stereotypes to overcome 🙂

I don't feel the need to justify a radiologist "not" being a doctor or "lacking" clinical decision making skills. I think most physicians can respect a radiologist's skills and unfortunately, based on some previous commentary, there is misunderstanding of what radiology residency encompasses. I've had 7 months of interventional radiology during residency where we carried our own inpatient service, admitting, rounding, managing and discharging as any other service would. However, every radiology service, not only IR, has their subset of procedural and patient management. Too many to even describe here.

What initially motivated me to enter radiology was a phenomenal interventional radiologist at GW. I ultimately didn't choose to enter IR because I've always felt passionate about pain management and never developed the same fondness for vascular procedures, GI intervention, interventional oncology, etc. With that said, I can't remember a day in residency when I didn't perform a history and physical exam that changed the course of a patient's hospital stay... so I'm unsure where the "lack of clinical decisions" comment stems from.

Thanks again for the comments, everyone! Super helpful!

 

[freddydpt]

I think playing "hardball" is silly. A program does not have to accept you. I'm sure pain programs have more applicants than spots, and the last thing they want is a difficult candidate. It's farrrrr easier to take a gentle approach, perhaps point out how you would be a great fit for the program, why you are passionate about the field, why the different background may be an asset, etc. I agree with some that it seems a bit odd that a radiologist would go into pain. Perhaps apply to less competitive programs. There are certain programs that are far easier to get into than others. I think it's worth it to apply to all programs, and perhaps kindly educate the programs that suggest that they can't Iv you or something.

I agree 100%. I'm not that "hardball" kind of guy. Much more laid back. 🙂

 

[Jcm800]

Dude..do you wanna switch? I have been dreaming about doing radiology..no fibro, no drug seekers, not as much govenment regulation, no crying work comp/auto patients with little ditzles on their MRI...

stay where you are man...

I totally agree! are you crazy. do a body imaging fellowship and move on with your life

 

[Residentcool]

I agree 100%. I'm not that "hardball" kind of guy. Much more laid back. 🙂

Dude, I think that it seems kind of odd that someone, after spending 5 years in a residency, would want to go into something completely different. Pain and rads are way way different. Most people who go into rads want to be away from patients as possible, pain is full of pt. contact. If you truly were interested in pain, why not do gas or PMR or neuro? I think that will be the million dollar question for programs.

Is it because of the job market situation? That should improve. I guess it does not make much sense for a person to go through a bunch of training in something like rads and then switch to pain. I'm sure that if you apply broadly you can find a pain fellowship. Does your hospital have a program? That would be the easiest thing.

 

[freddydpt]

Dude, I think that it seems kind of odd that someone, after spending 5 years in a residency, would want to go into something completely different. Pain and rads are way way different. Most people who go into rads want to be away from patients as possible, pain is full of pt. contact. If you truly were interested in pain, why not do gas or PMR or neuro? I think that will be the million dollar question for programs.

Is it because of the job market situation? That should improve. I guess it does not make much sense for a person to go through a bunch of training in something like rads and then switch to pain. I'm sure that if you apply broadly you can find a pain fellowship. Does your hospital have a program? That would be the easiest thing.

I think your assumption is that I am "switching" fields. Pain fellowship was the plan from the beginning (I wrote about it in my radiology essay). I couldn't see myself doing a primary specialty I didn't absolutely love. Ultimately, it came down to PM&R vs. radiology. I loved radiology: the procedures, efficiency, technology and patient contact. Ultimately, I felt that chronic pain is a diagnostic dilemma and some of the best diagnosticians in medicine are radiologists. That was the path I decided on in medical school after rotating through all four other disciplines and I made a very educated decision!. In retrospect, I would have made the same decision again! I love my residency, fund of knowledge, skill set and what I can do for my patients.

Pain medicine and radiology are not way different. Many of the fluoro guided procedures practiced in pain medicine were invented by radiologists. This is why you see many radiologists practicing pain management who are not boarded in pain or attend ACGME fellowships. It's because many feel confident in their training to pursue clinical practice after a Neuro, MSK or IR fellowship. There are literally thousands of research and textbook publications written by radiologists as well as pain management workshops instructed by radiologists all over the world. The pain medicine field is extremely closely tied to radiology.

Despite popular belief, "most" people who go into radiology LOVE working with patients! (myself included) Radiology is full of patient contact... it's just not contact regularly observed by most other fields. I make it a regular habit to call a medical student or intern on a team to observe our patient care, i.e. when we're asked to perform a procedure.

I am not worried about the radiology job market in the least. I went to a very strong residency and will be attending a very strong fellowship. All graduates from both programs have gone on to amazing jobs. I'm applying for pain fellowship because it will help me reach my potential as a pain physician. That's ultimately why any of us do any fellowship, right?

 

[DOctorJay]

2) Strong experience with multimodal image guided procedures: fluoro, US, CT and MRI. My fellowship next year at Jefferson will include a strong MSK US experience. The fellowship is in both Musculoskeletal and Neuroradiology.

working with Lev? Sweet!

 

[Residentcool]

I think your assumption is that I am "switching" fields. Pain fellowship was the plan from the beginning (I wrote about it in my radiology essay). I couldn't see myself doing a primary specialty I didn't absolutely love. Ultimately, it came down to PM&R vs. radiology. I loved radiology: the procedures, efficiency, technology and patient contact. Ultimately, I felt that chronic pain is a diagnostic dilemma and some of the best diagnosticians in medicine are radiologists. That was the path I decided on in medical school after rotating through all four other disciplines and I made a very educated decision!. In retrospect, I would have made the same decision again! I love my residency, fund of knowledge, skill set and what I can do for my patients.

Pain medicine and radiology are not way different. Many of the fluoro guided procedures practiced in pain medicine were invented by radiologists. This is why you see many radiologists practicing pain management who are not boarded in pain or attend ACGME fellowships. It's because many feel confident in their training to pursue clinical practice after a Neuro, MSK or IR fellowship. There are literally thousands of research and textbook publications written by radiologists as well as pain management workshops instructed by radiologists all over the world. The pain medicine field is extremely closely tied to radiology.

Despite popular belief, "most" people who go into radiology LOVE working with patients! (myself included) Radiology is full of patient contact... it's just not contact regularly observed by most other fields. I make it a regular habit to call a medical student or intern on a team to observe our patient care, i.e. when we're asked to perform a procedure.

I am not worried about the radiology job market in the least. I went to a very strong residency and will be attending a very strong fellowship. All graduates from both programs have gone on to amazing jobs. I'm applying for pain fellowship because it will help me reach my potential as a pain physician. That's ultimately why any of us do any fellowship, right?

But ultimately you want to do pain, right? So you won't be practicing rads right? Or you want to do both? It seems weird that you would do 6 whole years of a residency to end up practicing pain. So you want to do pain after your MSK fellowship, so 7 years training? Just saying. And while you do have a good rationale and may be good at it, I personally think it will come across as strange and that may be part of the "bias" that you are experiencing.

It's as if I do general surgery and then I want to do a dermpath fellowship or something. It just seems odd. Good luck with it though, I'm sure you'll get a program to bite.

 

[specepic]

Thanks for your responses! It is interesting how the DPT might be considered a landmine. That never even crossed my mind! Any physician I've worked with, rather than thinking of it as a landmine, has asked me to "fix" their neck... or consult on a complicated MSK or Neuro patient. I've only received the utmost respect having that credential. The MSK/Neuro skills are there and fresh. I've rotated through a year long sports medicine continuity clinic elective that also included peripheral injections, in addition to doing pro bono PT work throughout residency. I also teach two courses (Neuroanatomy and Neurology) at University of Delaware (#2 program in the country).

Pain docs refer patients to physical therapy all the time. The benefit of the DPT (PT experience) is that I know the difference between effective PT vs. ineffective PT. I can also run a rehab center in the future and directly/closely supervise to make sure I see an appropriate response. Or, to put it a different way, I know what PT interventions will work with specific patients.

DO's are phenomenal! But, so many don't practice manipulation anymore, it's sad. I love to trade manual therapy tips whenever I work with one.

The radiology background is extremely beneficial for many reasons:
1) Looking at the imaging and recognizing more pain generators than a radiologist might not appreciate without strong history or physical exam data... Conversely, other disciplines might not understand nuances of imaging, technical limitations, implications for their procedures or other subtle findings.

2) Strong experience with multimodal image guided procedures: fluoro, US, CT and MRI. My fellowship next year at Jefferson will include a strong MSK US experience. The fellowship is in both Musculoskeletal and Neuroradiology.

Some of you guys are hilarious! So many stereotypes to overcome 🙂

I don't feel the need to justify a radiologist "not" being a doctor or "lacking" clinical decision making skills. I think most physicians can respect a radiologist's skills and unfortunately, based on some previous commentary, there is misunderstanding of what radiology residency encompasses. I've had 7 months of interventional radiology during residency where we carried our own inpatient service, admitting, rounding, managing and discharging as any other service would. However, every radiology service, not only IR, has their subset of procedural and patient management. Too many to even describe here.

What initially motivated me to enter radiology was a phenomenal interventional radiologist at GW. I ultimately didn't choose to enter IR because I've always felt passionate about pain management and never developed the same fondness for vascular procedures, GI intervention, interventional oncology, etc. With that said, I can't remember a day in residency when I didn't perform a history and physical exam that changed the course of a patient's hospital stay... so I'm unsure where the "lack of clinical decisions" comment stems from.

Thanks again for the comments, everyone! Super helpful!

To restate, a combo of DPT and rads is uncommon and fantastic. You will likely make a great pain doc based on your background, assuming you are not a kook, althnough that could be a plus in Pain. Don't give up, also keep in mind if pain does not work out you will rock doing IR/MSK US.

 

[Dr. Ice]

I totally agree! are you crazy. do a body imaging fellowship and move on with your life

1+

Lawyers have made sure the world will always need radiologists..defensive medicine and over imaging is here to stay. On the other hand, pain docs.......

 

[emd123]

But ultimately you want to do pain, right? So you won't be practicing rads right? Or you want to do both? It seems weird that you would do 6 whole years of a residency to end up practicing pain. So you want to do pain after your MSK fellowship, so 7 years training? Just saying. And while you do have a good rationale and may be good at it, I personally think it will come across as strange and that may be part of the "bias" that you are experiencing.

It's as if I do general surgery and then I want to do a dermpath fellowship or something. It just seems odd. Good luck with it though, I'm sure you'll get a program to bite.

This was a common question I faced. It's a fair question, but I think often a false assumption that someone is somehow flawed that they want to change specialties, or switch gears at some point mid career. As if everyone else knew at their pre-school graduation they wanted to be a pain doctor and asked for a spine model and copy of Bonica's Pain text instead of a dirt bike for their forth birthday. Give me a break.

Most human beings change jobs/careers/positions many times in a career, yet as doctors we pick at age 26 and can never switch gears? This is unrealistic and a reason so many docs are miserable. There's no freedom to change. Change is normal. Change can be refreshing.

Regardless, it's a fair question and you'll have to answer it in a way that shows you're not a chronic malcontent, burned out, floating around without focus or just "odd". The burden of proof is on you to show that your differences are an asset, not a liability, and that your reason for change is because you want to expand your skills, not run from another specialty (even if that's true).

Here's the way you should look at it. Doing the year doesn't replace one specialty for another, it gives you two different specialties to choose from, diversifies your skills and opens up options. As long as you don't mind giving up the year, it can only open up options for you. With all the uncertainties in the future of medicine, I find having the option of double board certification, and two specialties, pretty cool.

Considering more radiologists are being asked to work nights, weekends and holidays now, working Pain hours might not be a bad option to have.

 

[Residentcool]

This was a common question I faced. It's a fair question, but I think often a false assumption that someone is somehow flawed that they want to change specialties, or switch gears at some point mid career. As if everyone else knew at their pre-school graduation they wanted to be a pain doctor and asked for a spine model and copy of Bonica's Pain text instead of a dirt bike for their forth birthday. Give me a break.

Most human beings change jobs/careers/positions many times in a career, yet as doctors we pick at age 26 and can never switch gears? This is unrealistic and a reason so many docs are miserable. There's no freedom to change. Change is normal. Change can be refreshing.

Regardless, it's a fair question and you'll have to answer it in a way that shows you're not a chronic malcontent, burned out, floating around without focus or just "odd". The burden of proof is on you to show that your differences are an asset, not a liability, and that your reason for change is because you want to expand your skills, not run from another specialty (even if that's true).

Here's the way you should look at it. Doing the year doesn't replace one specialty for another, it gives you two different specialties to choose from, diversifies your skills and opens up options. As long as you don't mind giving up the year, it can only open up options for you. With all the uncertainties in the future of medicine, I find having the option of double board certification, and two specialties, pretty cool.

Considering more radiologists are being asked to work nights, weekends and holidays now, working Pain hours might not be a bad option to have.

I'm not saying that it's a bad option for OP, I"m just saying that I think many PDs will find this weird and that's why it may be that the OP is facing some difficulty. If he wants to go into pain I think that's a fine option for him, but it may be more difficult than usual.

 

[Ducttape]

have you done a rotation in a pain clinic? id say that is the key - with great evals.

if you are not going to go the traditional route, you have to show a program director why he has to take a bigger chance on hiring you for a year vs. hiring the "safe" choice of an anesthesiologist or PM&R doc, who spend at least 2-4 months in residency in the pain service, and who can be traditionally vetted by fellow pain attending colleagues.


fyi, being able to interpret images, i would say, occupies a max 10% of the time spent on pain pts. and fluoro injections are a small part of pain management. much more time is spent on pharmacology and psychology - are you comfortable with these specialties? let me guess, radiology residency is exquisitely geared towards these specialties...

 

[Aether2000]

Inevitably it is more difficult for radiologists to be considered for a pain fellowship, however application and initial consideration is not supposed to be based on background specialty at all....zero. This is an ACGME requirement adopted by all the pain programs and is not subject to interpretation by program directors. Any program director that explicitly states a radiology background is insufficient for their program is in violation of ACGME rules, and can have their program stripped of fellowship certification, and probably should have this done. Either they play by the rules they themselves adopted or they need to have their program closed. This is not simply sour grapes- it is overt discrimination that is specifically prohibited, and therefore in a court of law is an illegal act.
On the other hand, if all applicants are given interviews, then the program director selects the best applicants from the pool presented, then this process is perfectly legal. In this case, it would be rare for a radiologist to be admitted to a pain fellowship due to lack of appropriate experience and training.

 

[specepic]

Inevitably it is more difficult for radiologists to be considered for a pain fellowship, however application and initial consideration is not supposed to be based on background specialty at all....zero. This is an ACGME requirement adopted by all the pain programs and is not subject to interpretation by program directors. Any program director that explicitly states a radiology background is insufficient for their program is in violation of ACGME rules, and can have their program stripped of fellowship certification, and probably should have this done. Either they play by the rules they themselves adopted or they need to have their program closed. This is not simply sour grapes- it is overt discrimination that is specifically prohibited, and therefore in a court of law is an illegal act.
On the other hand, if all applicants are given interviews, then the program director selects the best applicants from the pool presented, then this process is perfectly legal. In this case, it would be rare for a radiologist to be admitted to a pain fellowship due to lack of appropriate experience and training.

It think it is much too strong to state that rads 'lacks appropriate exp and training for Pain'. That is why there is a fellowship. We had a rads in my program and he was very strong in the fluoro suite, and did fine in clinic. He was one of the stronger fellows overall at a good program. This candidate is not only rads but a DPT. All things equal, if I was a PD I would jump at a chance to take him.

 

[Aether2000]

If you think about what radiologists, esp diagnostic radiologists do, they are as a group, among the poorest candidates for a pain fellowship. Their physical exam is lacking on virtually every patient, they rarely actually talk to the patient to obtain a valid history, and they rely extremely heavily on technicians to do the bulk of patient contact in their jobs. They rarely experience emergency resuscitation situations, know virtually nothing about medications except what they read on their list of medications to be stopped prior to a MRI or CT, and are very one diminisional in their diagnostic abilities that are limited only to radiological means. Functional restoration is completely foreign to them since they never engage in these modalities in their patients. Psychiatric illnesses are a complete mystery to them since they neither diagnose nor treat these entities that are integral to chronic pain. Actually an allergist would be a better candidate than most radiologists to become chronic pain physicians. Unless one has the idea that mindless block jock = pain physician.

 

[Residentcool]

If you think about what radiologists, esp diagnostic radiologists do, they are as a group, among the poorest candidates for a pain fellowship. Their physical exam is lacking on virtually every patient, they rarely actually talk to the patient to obtain a valid history, and they rely extremely heavily on technicians to do the bulk of patient contact in their jobs. They rarely experience emergency resuscitation situations, know virtually nothing about medications except what they read on their list of medications to be stopped prior to a MRI or CT, and are very one diminisional in their diagnostic abilities that are limited only to radiological means. Functional restoration is completely foreign to them since they never engage in these modalities in their patients. Psychiatric illnesses are a complete mystery to them since they neither diagnose nor treat these entities that are integral to chronic pain. Actually an allergist would be a better candidate than most radiologists to become chronic pain physicians. Unless one has the idea that mindless block jock = pain physician.

That's a tad harsh don't you think? People who match into rads are some of the brightest in med school, given how competitive rads is. I doubt that the avg anesthesiologist or PMR doc knows a lot more about medications in general, and while I have much respect for both, anesthesiologists do 0 physical exam. PMRs don't deal with meds at all. Anesthesiologists only deal with a small # of drugs used specifically during anesthesia. Not sure how an anesthesiologist would really beat a radiologist in a PE? Might as well compare both to a pathologist or something. Psychiatrists also do 0 PE, yet they are candidates for pain fellowships.

Anesthesiologists also have very limited patient contact as well. If anything, I would say PMR probably has the best ability to be a good pain doc because they are up to their elbows in patient contact, rehab with pain patients, and PE.

I also think that psychiatrists would have far less aptitude in procedures vs. a radiologist, even though they do no PE and have 0 procedural experience, yet they somehow are able to land pain fellowships.

While not the "best" candidate, I think rads probably are certainly not the worst by any means.

 

[Ducttape]

That's a tad harsh don't you think? People who match into rads are some of the brightest in med school, given how competitive rads is. I doubt that the avg anesthesiologist or PMR doc knows a lot more about medications in general, and while I have much respect for both, anesthesiologists do 0 physical exam. PMRs don't deal with meds at all. Anesthesiologists only deal with a small # of drugs used specifically during anesthesia. Not sure how an anesthesiologist would really beat a radiologist in a PE? Might as well compare both to a pathologist or something. Psychiatrists also do 0 PE, yet they are candidates for pain fellowships.

Anesthesiologists also have very limited patient contact as well. If anything, I would say PMR probably has the best ability to be a good pain doc because they are up to their elbows in patient contact, rehab with pain patients, and PE.

I also think that psychiatrists would have far less aptitude in procedures vs. a radiologist, even though they do no PE and have 0 procedural experience, yet they somehow are able to land pain fellowships.

While not the "best" candidate, I think rads probably are certainly not the worst by any means.

as an internist and an anesthesiologist and pain physician and former practicing ED doc, i would argue multiple points with you regarding your view of anesthesiologists.

anesthesiology is perhaps the only physician specialty that requires, at least some time during training, intimate knowledge of pharmacokinetics, pharmacodynamics, and drug interactions. We are responsible for knowing almost all drugs, because any drug can have significant interactions with others and cause significant effects while under anesthesia. (not talking about DO training here -->) For ex., Int Med is probably the only other specialty that needs to know the potential effects of herbal medications. These are vitally important for the anesthesiologist.

second, anesthesiology requires a specific yet comprehensive exam regarding airway, cardiovascular and pulmonary systems. only ENT may argue they are equal in airway management. only ED can argue that they are as competent in emergency CV management.

in terms of PE, only anesth and PM&R residencies can state that they have required rotations in pain management, 2+ months, which includes physical exam of the chronic pain patient.


the anesth vs. PMR debate can be seen in both ways, and not worth arguing. both specialties bring unique perspectives to pain medicine, above and beyond any other specialty.

thats not to say that an individual candidate cannot be better than the average candidate from those 2 specialties.

 

[Residentcool]

as an internist and an anesthesiologist and pain physician and former practicing ED doc, i would argue multiple points with you regarding your view of anesthesiologists.

anesthesiology is perhaps the only physician specialty that requires, at least some time during training, intimate knowledge of pharmacokinetics, pharmacodynamics, and drug interactions. We are responsible for knowing almost all drugs, because any drug can have significant interactions with others and cause significant effects while under anesthesia. (not talking about DO training here -->) For ex., Int Med is probably the only other specialty that needs to know the potential effects of herbal medications. These are vitally important for the anesthesiologist.

second, anesthesiology requires a specific yet comprehensive exam regarding airway, cardiovascular and pulmonary systems. only ENT may argue they are equal in airway management. only ED can argue that they are as competent in emergency CV management.

in terms of PE, only anesth and PM&R residencies can state that they have required rotations in pain management, 2+ months, which includes physical exam of the chronic pain patient.


the anesth vs. PMR debate can be seen in both ways, and not worth arguing. both specialties bring unique perspectives to pain medicine, above and beyond any other specialty.

thats not to say that an individual candidate cannot be better than the average candidate from those 2 specialties.

As I said, I respect anesthesiologists and what they do. My point is that to suggest that radiologists are the worst type of applicant for pain is way over the top. If I were a PD, I'd take someone from rads vs. someone from psych or medicine any day. What procedural experience do those docs have? Very little. Also while your statement about airway management is absolutely correct when it comes to anesthesiologists, pain is not doing airway management. I think anesthesiologists obviously have a tremendous amount of procedural experience which is necessary in pain obviously. And I do agree with you that both anesthesia and PMR are probably the 2 best specialties for pain. But again, I find it a bit harsh to suggest that rads would be the worst candidates, given the heavy procedural component of pain med. And I'm sure that any PE needed for pain management can be learned/relearned given that at the end of the day we are all doctors and have gone through med school, and obviously the point of a fellowship is to train the physician in the specific field.

 

[freddydpt]

If you think about what radiologists, esp diagnostic radiologists do, they are as a group, among the poorest candidates for a pain fellowship. Their physical exam is lacking on virtually every patient, they rarely actually talk to the patient to obtain a valid history, and they rely extremely heavily on technicians to do the bulk of patient contact in their jobs.

Huh? You are not describing myself nor any radiologist I know. I'm not sure how to respond.

They rarely experience emergency resuscitation situations, know virtually nothing about medications except what they read on their list of medications to be stopped prior to a MRI or CT, and are very one diminisional in their diagnostic abilities that are limited only to radiological means.

Sadly, contrast reactions occur. When they do, radiologists are all well trained to handle the situation. There are quite a few medications we administer during specific protocols, i.e. beta blockers and nitro for cardiac scans, CCK and morphine for nuclear scans, glucagon for enterographies and the list goes on. We also administer conscious sedation during various procedures (not only on IR, but also on other services). While on IR, when we are managing our floor patients, patients are on the same medications as any other. That includes our very sick patients undergoing TIPS and Denver shunts, as well as our UFE patients where we manage pain and nausea (among many other overnight complaints). I find many UFE patients also tend to be on antidepressants.

Functional restoration is completely foreign to them since they never engage in these modalities in their patients. Psychiatric illnesses are a complete mystery to them since they neither diagnose nor treat these entities that are integral to chronic pain. Actually an allergist would be a better candidate than most radiologists to become chronic pain physicians. Unless one has the idea that mindless block jock = pain physician.

Functional restoration experience depends on the radiologist. Many who practice pain management are well versed and discuss their patients with PT regularly. In fact, I have an idea for developing techniques in functional kinematic cross sectional imaging in the future... but that's a tangent. The knowledge of psychiatric illnesses go back to our inpatient management. You are right if you mean that radiologists have not rotated through psychiatry since medical school or intern year. It doesn't mean we don't encounter psychiatric illnesses on a daily basis that provide challenges to our procedures.

Thanks again for your comments algosdoc. They are enlightening.

 

[Ducttape]

i think you two are thinking about INTERVENTIONAL pain. a "real" pain doc does multidisciplinary pain management. Procedures can be taught in about a year (i.e. the difference between a CA2 and CA3 in anesthesiology), tho i wouldnt go so far as to say that Int Med/psych is "good" for pain.

to both of you, answer these questions:

How many radiologists write for a TCA/opioid/NSAID, with refills, and know the side effects of such?
How much of radiology residency involves monitoring a chronic state over years, no injections involved?
How much of a radiology residency is devoted to the devastating psychological effects of a chronic illness?


again to the OP - do pain rotations, lots of them. if you like what they are doing, then great. get great letters of recommendations/apply to those programs, and you'll get a fellowship, and i welcome your arrival.

if you really want to just do injections like a block shop - thats not pain medicine, and the field isnt for you.

 

[emd123]

Two years ago I would have jumped into this debate headlong, but I won't because it's not really and argument about "what specialty is best prepared for Pain," because there is no such specialty. Pain should have a residency, and be considered its own specialty. No specialty is ready for all aspects of Pain. Let's quit kidding ourselves.

How many prospective pain fellows or Pain physicians have coded someone else's young "chronic Pain" patient and told their completely unsuspecting family that despite all the narcan in the world, their child/brother/spouse/cousin is dead? That's something every candidate for a Pain fellowship should be required to have done, before fellowship and before being allowed to script chronic long term opiates. I think if more Pain physicians had this kind of experience going in, we might be in a much different place now with our opiod abuse epidemic. But strangely, this is not required before a Pain fellowship.

You can argue about who "owns" Pain, but which is well prepared?. There is no such specialty.

 

[Aether2000]

The majority of diagnostic radiologists are poorly prepared for pain fellowship, period. Interventional? Possibly....at least they touch the patients....