Ideal number of procedures for a pain fellow?

[Ligament]

Friends,

I'd like to hear from current and former fellows and attendings here. What is considered the minimum number of procedures to be done at a good pain fellowship? Yes I'm aware technique and selection is vitally important as well, but if we are talking pure numbers? 500? 1000? 1500? Thanks.

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[Aether2000]

Typically one would like to have a minimum of 35,000 injections during a fellowship. Nah, just kidding... I don't know of minimum standards since most pain programs vary so much in their philosophical tilt...

 

[Ligament]

Good one algos LOL

Typically one would like to have a minimum of 35,000 injections during a fellowship. Nah, just kidding... I don't know of minimum standards since most pain programs vary so much in their philosophical tilt...

 

[lobelsteve]

I can do most ESI's, lead insertions, and SNRB's with my eyes half shut. The only ones that count are the ones that are too difficult to get with ease. The best descriptor is performing a TF-ESI in a 24 y/o male vs a 80 y/o osteoporotic female that has had a 360 fusion and has BMP impairing your ability to steer into the foramen. It's like having a new fellow start with retrograde lead placement- it won't fit down that way just yet.

Men / boys

 

[neuropathic]

I can do most ESI's, lead insertions, and SNRB's with my eyes half shut.

That's great. Learning how to advance SCS leads with eyes half shut is really cool.

Now, back to the question. I think a good fellowship would give their fellows 1000 TPIs.

 

[C Fiber]

donno about the smaller procedures, but you need about 10 stim implants to get credentialed in a hospital. About the same for pump implants.

 

[Disciple]

My fellowship will likely give me decent experience in basic and advanced procedures. I would like to start my own practice the first year after fellowship. Variations in training philosophies aside, can anyone give me an approximation of procedural exposure/experience goals to shoot for during the fellowship that will allow me to practice independently afterward i.e. average #'s for procedures x,y and z for hospitals, ASCs and insurance credentialing?

I would like to offer my patients as many options as possible.

 

[lobelsteve]

The numbers do not mean a lot. Some fellows acquire skills very rapidly and are able to do pumps and stims after 4 months of training, others do not have the full grasp of it at 12 months but are fine doing the basics.

After 20 ESI, FJNA, FJNB, etc- most people should be comfortable performing these on most any spine.

Like I was saying before- the numbers are not a reliable way of gauging your skill level. 20 easy SCS lead placements does not prepare you for an extremely difficult case. 5 difficult lead placements might make you an Ace.

 

[paz5559]

The numbers do not mean a lot. Some fellows acquire skills very rapidly and are able to do pumps and stims after 4 months of training, others do not have the full grasp of it at 12 months but are fine doing the basics.

After 20 ESI, FJNA, FJNB, etc- most people should be comfortable performing these on most any spine.

Like I was saying before- the numbers are not a reliable way of gauging your skill level. 20 easy SCS lead placements does not prepare you for an extremely difficult case. 5 difficult lead placements might make you an Ace.

Steve, no one outside of REW's practice call them FNJBs or FNJAs - they are MBBs and RF respectively (oh, and just for the record, they arent SNRBs either!)

 

[bbbmd]

can anyone give me an approximation of procedural exposure/experience goals to shoot for during the fellowship that will allow me to practice independently afterward i.e. average #'s for procedures x,y and z for hospitals, ASCs and insurance credentialing?

Any answers for this??? For fellows starting in July, this would be a good guide for us. I understand that "feeling comfortable" with a procedure is individual, but Id like to know NUMBERS for CREDENTIALING purposes:

IT pumps:
SCS:
Stellate, Gasserian, Celiac Lumbar plexus blocks:
Epidurals (all types):
MBB/Facet blocks:
RFAs (all types):
IDETS:
Perc disc decomp:
Kypho/Vertebroplasties:

Others- intercostal blocks, bier blocks, etc....

Im going to learn these procedures and the current fellows say they are comfortable with all of them, so I am assuming that I will be too. My question is: How many do I need to log for CREDENTIALING purposes??? Makes no sense to feel "comfortable" and not being able to get credentialed to do them!

 

[bbbmd]

For the attendings/graduating fellows on this forum:

Are there any procedures soon-to-be fellows should be aggressive about learning- state of the art, cutting edge ones- to be more marketable when looking for a job??? Other than being well-rounded, I hear Kypho/Vertebroplasties and disc decompressions are attractive for employers. Any thoughts???

 

[paz5559]

For the attendings/graduating fellows on this forum:

Are there any procedures soon-to-be fellows should be aggressive about learning- state of the art, cutting edge ones- to be more marketable when looking for a job??? Other than being well-rounded, I hear Kypho/Vertebroplasties and disc decompressions are attractive for employers. Any thoughts???

Kyphos do noty get reimbused in an ASC setting, so they are only attractive to a hospital-based practice

PDDs and IDETs are rarely reimbursed, so you need to base your need to be proficient in these procedures on what your payer mix is willing to pay you to do.

Discography should also be another procedure you are proficient with by the time you out of fellowship, IMHO

 

[lobelsteve]

Steve, no one outside of REW's practice call them FNJBs or FNJAs - they are MBBs and RF respectively (oh, and just for the record, they arent SNRBs either!)

But there are no medial branches at L5 or S1, just a dorsal ramus and a lateral branch. Just to be technically confusing.

Why no SNRB? I think it would be a TFESI but distal to the foramen and without steroid. Of course we merge the terms for acronyms sake.

TF-ESI does not roll off the tongue like Snurb. Nor does MBB sound as good as fajinbee (FJNB)

 

[Ligament]

But there are no medial branches at L5 or S1, just a dorsal ramus and a lateral branch. Just to be technically confusing.

This factoid was a common "pimp" question on the PM&R pain fellowship interview trail, particularly amongst those docs that trained under Windsor. Heads up guys.