Importance of Anesthesiology LORs

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sdnuser001

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I am a PGY-2 PMR resident who will be likely applying to the upcoming pain match. So far I have only worked with interventional PMR docs and my program doesn't have the ability to formally work with an anesthesia pain doc until fourth year and even then it's pretty minimal exposure and unlikely to be enough to get a LOR. How serious an issue is this? I could try to reach out to a local anesthesia pain doc but I would then be limited to shadowing as my program does not allow us to do any formal away rotations. I would assume you can't get a LOR from someone you only shadowed?

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Is this a real Q?
 
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You should be completely freaked out and lose many hrs of sleep per night bc you're simply not competitive if you don't have an LOR from an anesthesiologist.
 
You should be completely freaked out and lose many hrs of sleep per night bc you're simply not competitive if you don't have an LOR from an anesthesiologist.

Was it really worth the energy typing those words to produce such a worthless response? Save it next time.

A constructive response would be this: if you are interested in applying to some of the anesthesia based programs, it would be worthwhile to shadow the anesthesia pain physician as much as possible with the goal of obtaining a letter of recommendation. Additionally, it would be really worthwhile for you to try and present as many posters as possible between now and next year. If you are really motivated, it may even make sense to take a year off and apply for the cycle after next to really boost your resume. Finally, there are plenty of non accredited spine programs through pm&r, but it will be very difficult to weed out the bad apples since these programs are not standardized.
 
Agree with above. This is not a stupid question.

I’ve literally heard an anesthesia Pain fellowship PD say: the pm&r applicants need a letter from an anesthesiologist confirming they have “good hands”

The bias against pm&r is real.
 
I think the bias has decreased with decreasing reimbursement
 
I am a PGY-2 PMR resident who will be likely applying to the upcoming pain match. So far I have only worked with interventional PMR docs and my program doesn't have the ability to formally work with an anesthesia pain doc until fourth year and even then it's pretty minimal exposure and unlikely to be enough to get a LOR. How serious an issue is this? I could try to reach out to a local anesthesia pain doc but I would then be limited to shadowing as my program does not allow us to do any formal away rotations. I would assume you can't get a LOR from someone you only shadowed?
I understand your anxiety on this. I asked the same questions 8 years ago when I was applying, because being from an EM background and having been out of residency several years already, I had no letters of recommendations from any anesthesiologists, physiatrists or IPM physicians when I applied to fellowship. I ultimately bit the bullet and decided to get letters from people who knew me and my skills best: My Emergency Department Director, EM residency program director and a fellow EM doc (also Chief of Medicine at the time), all of whom I worked side by side with for nearly a decade. Ultimately I got in, but the fact that I had no letters from anyone in the Pain or Anesthesia world did leave me with a sense I was at a disadvantage.

My advice would be to get a couple of letters from people in the PM&R world who know you really well. Those letters sound best and are usually more persuasive anyways. Then, if you can, get one token Pain or Anesthesia letter from someone you may not know as well, but only if they can write you a decent one. If it's going to say, "I don't know this PMR dude/dudette who shadowed me for 5 seconds. -Sincerely, Famous Anesthesia Pain Guy" then you're better off sticking with sincere, quality letters from people that may not have the pedigree you wish they had.

Also, since there clearly is a bias against all non-anesthesia applicants, my advice is to try and overwhelm those odds with volume, by applying to every program in the country. As a non-anesthesia applicant, you cannot assume you're on a level playing field, until and unless you've been accepted to an ACGME fellowship. All 80-90 programs. You can always turn a program down or refuse to go to a place you matched at, but you can't create a fellowship offer out of thin air, that you never applied to.
 
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Was it really worth the energy typing those words to produce such a worthless response? Save it next time.

A constructive response would be this: if you are interested in applying to some of the anesthesia based programs, it would be worthwhile to shadow the anesthesia pain physician as much as possible with the goal of obtaining a letter of recommendation. Additionally, it would be really worthwhile for you to try and present as many posters as possible between now and next year. If you are really motivated, it may even make sense to take a year off and apply for the cycle after next to really boost your resume. Finally, there are plenty of non accredited spine programs through pm&r, but it will be very difficult to weed out the bad apples since these programs are not standardized.

Yes, it was worth the energy to type that out bc I don't care what you heard from some anesthesiologist. I am a PMR grad and didn't set foot around an anesthesiologist, had no LOR from one, and matched into my top anesthesiology-based pain program. Is there a PMR bias, or is it that your avg anesthesiologist has higher STEP scores and greater pain exposure than a PMR applicant? Is it that there are simply more anesthesia residents in the country? Possibly important that most pain programs are run by anesthesia departments where internal applicants typically get in?

If you are a well rounded applicant with good letters and good STEP scores you are golden. Write a good application letter. Submit ITE scores that are high regardless of whether or not the fellowship wants them. If your scores suck and you have no research, poor letters from attendings, and can't explain why you like pain in your essay...Well...

This Q reeks of the premed forums where ppl develop panic disorder bc they haven't published 17 papers as a college student.
 
I understand your anxiety on this. I asked the same questions 8 years ago when I was applying, because being from an EM background and having been out of residency several years already, I had no letters of recommendations from any anesthesiologists, physiatrists or IPM physicians when I applied to fellowship. I ultimately bit the bullet and decided to get letters from people who knew me and my skills best: My Emergency Department Director, EM residency program director and a fellow EM doc (also Chief of Medicine at the time), all of whom I worked side by side with for nearly a decade. Ultimately I got in, but the fact that I had no letters from anyone in the Pain or Anesthesia world did leave me with a sense I was at a disadvantage.

My advice would be to get a couple of letters from people in the PM&R world who know you really well. Those letters sound best and are usually more persuasive anyways. Then, if you can, get one token Pain or Anesthesia letter from someone you may not know as well, but only if they can write you a decent one. If it's going to say, "I don't know this PMR dude/dudette who shadowed me for 5 seconds. -Sincerely, Famous Anesthesia Pain Guy" then you're better off sticking with sincere, quality letters from people that may not have the pedigree you wish they had.

Also, since there clearly is a bias against all non-anesthesia applicants, my advice is to try and overwhelm those odds with volume, by applying to every program in the country. As a non-anesthesia applicant, you cannot assume you're on a level playing field, until and unless you've been accepted to an ACGME fellowship. All 80-90 programs. You can always turn a program down or refuse to go to a place you matched at, but you can't create a fellowship offer out of thin air, that you never applied to.

Completely different situation considering you were out of residency and coming from a field that doesn't typically field pain doctors.
 
Completely different situation considering you were out of residency and coming from a field that doesn't typically field pain doctors.
Yes. Much different situation and a much greater long shot.
 
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Wow. I read this entire thing and thought we were talking about LOR syringes. Was very confused. I need to get out more.

I'm a recent PM&R grad. Having a letter from an anesthesia pain doc would definitely be helpful. Having said that, if you can't get one (I didn't), try to get one from a PM&R doc who is board certified in Pain. There's plenty of great non ACGME spine fellowship-trained PM&R docs, but if you're applying for Pain, you really should get one from a Pain doc.
 
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Yes. Much different situation and a much greater long shot.

Agreed, and my point exactly. Look what happened - You matched, and you had an even bigger hole to climb out of...

I never felt at a disadvantage, and my interview days were me and one or two other PMR applicants, and the rest anesthesia.

The number of anesthesia residents in the US outnumber PMR nearly 10 to 1. While we're doing TBI and SCI, they're doing anesthesia. What most ppl fail to realize (including the thread starter) is that the ENTIRE PMR residency is pain. Well, take out cardiac rehab. Everything in the PMR residency trains you to be a pain doctor.

You have to realize these facts and friggin market yourself correctly.

What are you good at? Physical exam and taking care of ppl with issues for which there is no cure. That's being a pain doctor. Make sure the programs know that in your essay. The anesthesia residents that so many ppl in PMR are scared of suck at the things that you're the best at...

Study hard and crush your ITE and STEP exams.

If you're a good candidate you'll match.

Having a LOR from an anesthesiologist means nothing.

Edit - At least you can bring up during a pain interview that you know that all leg pain isn't piriformis syndrome...Something happens in anesthesia residency where ppl graduate thinking all leg pain is either radicular or piriformis...

A physiatrist helps pts navigate periods in their life that are terrible and on many cases devastating. A C5 complete injury and you usher that pt from daily life with great employment and a family and now your wife is physically digging feces out of you? You sit down with that person and over the course of a few weeks in a rehab facility you send them back into society with a plan. You run team conference and coordinate multidisciplinary care. Anyone who can't see the value in all this and how it separates you from your peers is blind.
 
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agree with you about your perspective on PMR suggests that it is a field that is better suited for long term pain medicine. (FWIW I boarded in Eternal Med and much later Anesthesia)


yet......

why is it that 90% of chronic pain care, about 90% of what we do and bill for, about 90% of the posts here, are about the interventions and shots - which anesthesia is much more experience?


let me answer my own question - that's due to $$$. and that's were we "lost" Pain Management as a specialty.
 
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agree with you about your perspective on PMR suggests that it is a field that is better suited for long term pain medicine. (FWIW I boarded in Eternal Med and much later Anesthesia)


yet......

why is it that 90% of chronic pain care, about 90% of what we do and bill for, about 90% of the posts here, are about the interventions and shots - which anesthesia is much more experience?


let me answer my own question - that's due to $$$. and that's were we "lost" Pain Management as a specialty.

That's a question with an answer that is bigger than my little perspective. How many ppl here are under pressure from practice managers and CEO's to bill more and do more...we all are...Doesn't mean you do it, but I know way too many weak physicians who became doctors straight out of high school, college, med school, etc who never had a job before being a doctor, and bc of that they have no basis in the real world and they allow themselves to be run over by administrators and their peers (surgeons usually).

Also there is something in the current generation of young doctors who pay their loans only AFTER they got the big car and the house...They live on social media and see what their peers are doing and they want stuff...

I would say the opioid issue probably pushes people to inject more too.

Oh and not all PMR residents are behind in procedures. I did a lot of interventional spine stuff as a resident, and I'd put my procedural skills against any of my anesthesiologist cofellows any day of the week. I had done more stim as well. Lots of pump management and refills. Joint injections.

But in general you're right, and while some ppl feel labor epidurals aren't helpful for a pain doctor, I disagree entirely.

Anyone feel the culture in American society is one demanding immediate gratification and entitlement which negatively prognosticates successful pain management? Have spine surgery in India and you're getting Tylenol.
 
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