Mayo program

[kurt rambis]

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Hello everyone. I've been a faithful SDN PM&R forum reader for the past year or so. I've been extremely impressed by the level of professionalism and friendliness of everyone who has posted thus far. A special thanks to Drusso, Ligament, Stinky and Rehabdoc and to the newcomers Axm, M3 and Drvlad. Exellent work.

I have a quick question for Drusso and anyone else who can help out. How much "hands on" interventional PM&R experience does Mayo offer to its residents? I remember during my interview, some folks commenting on it but I can't remember the specifics on the types and quantity of procedures that you do there. I'm finalizing my rank list and this is a pretty crucial point in my decision making process. Any comments would be appreciated.

 

[axm397]

I remember coming away from my interview at Mayo with the impression that you don't get much hands on experience because of fellows. I think at most programs, you may get to do some of the lumbar interventions and trigger points. Most of the other procedures are more "shadowing" than hands on.


Out of all my interviews, I remember Stanford emphasizing that you actually get to do many procedures. UPenn also had an interventional physiatrist talk to applicants about how they get to do more than most programs as well. UMich is getting more fluoro suites and they implied that meant more procedures. I heard UCDavis is also big on procedures. I know Kessler has fellows and some of the residents said they didn't get to do as much. JFK - one of the chiefs told me he got to do A LOT. His log book was very impressive and he got a very competitive interventional spine fellowship in florida.

So compared to those programs, I remember feeling like Mayo wouldn't offer as much interventional opportunities if that is your focus. They did have a very impressive research facility and looked like they had lots of funding for research. Their sports program is also pretty strong from what I hear. Many of their residents also go on to get good fellowships within the Mayo system. (Anesthesiology based pain, etc.)

 

[drvlad2004]

I can't comment on Mayo. Drusso is the man to talk to. In terms of procedures, I found that San Antonio and UPenn residents, which both have outstanding pain rotations (notably in fluoroscopic-guided interventional spine), definitely get to "do" lots of procedures. I spent a day at Penn Radnor facility with the chief and one of the interventional spine specialists. The residents get to do a lot and 1:1 basis with the attending. Another attending, has a few fellows and thus the residents don't get to do as much with him.

With San Antonio, you have Dr. Walsh, who is current chairman of the ABPMR. He is a guru when it comes to interventional spine. Thr residents have said that they get to do lots of procedures.

JFK residents, starting at PGY3, get to do a lot of smaller procedures such as botox injections and joint injections. I did an elective at JFK and spent a fair amount of time with almost all of the board-certified pain specialists. I did get to see the residents get 1:1 supervision with the attendings. There is no fluroscopy suites at that rehab center. You would have to do an outside elective for that. The same goes for the majority of PM&R programs.

I don't think you will find many programs that will make you competent enough to perform many procedures. I think that is where the importance of the landing a pain fellowship and having elective time (Cornell-Columbia has NO ELECTIVE TIME!) comes into major importance when choosing programs.

Good luck🙂

 

[bobatea]

don't know much about Mayo. I agree with axm, though -- Stanford emphasized the hands-on procedures that they get to do. Along the East Coast, one of Emory's big selling points was the number of back injections, procedures that the residents got to do -- when one resident started a fellowship, she reportedly had done more injections than a fellow initially had.

Don't know if having more hands-on experience with stuff like this gives you an edge on getting fellowships, as much as more confidence and skills, though.

 

[bbbmd]

Dont know much about Mayo, but I find this discussion about PROCEDURES interesting. I am also interested in possibly pursuing pain or interventional spine in the future, but I dont see what all the "hype" is about finding a program that lets you do a lot of interventional procedures as a resident???

I agree that PM&R residents would benefit from a lot of hands on exposure, but remember that is not all that PM&R is about. In my opinion RESIDENTS-TO-BE should focus more on finding the MOST WELL-ROUNDED program out there. Afterall, you are first and foremost going to be a PHYSIATRIST and learning about basic PM&R topics during residency should be your priority...

Correct me if I am wrong, but I dont think that there is a PM&R program out there that will train a RESIDENT well enough to practice INTERVENTIONAL PHYSIATRY right out of residency without a fellowship??? I think all you really need in residency is exposure to all aspects of our broad specialty to peak your interest and then pursue a fellowship afterwards. More importantly, you should be able to practice GENERAL PM&R competently once residency is over.

Procedures are fun and I think I will be going in that direction also, but right now I want to learn all the other things that PM&R has to offer.... Just something for you graduating med students to think about! 🙄

 

[Stinky Tofu]

Originally posted by bbbmd
Dont know much about Mayo, but I find this discussion about PROCEDURES interesting. I am also interested in possibly pursuing pain or interventional spine in the future, but I dont see what all the "hype" is about finding a program that lets you do a lot of interventional procedures as a resident???

I agree that PM&R residents would benefit from a lot of hands on exposure, but remember that is not all that PM&R is about. In my opinion RESIDENTS-TO-BE should focus more on finding the MOST WELL-ROUNDED program out there. Afterall, you are first and foremost going to be a PHYSIATRIST and learning about basic PM&R topics during residency should be your priority...

Correct me if I am wrong, but I dont think that there is a PM&R program out there that will train a RESIDENT well enough to practice INTERVENTIONAL PHYSIATRY right out of residency without a fellowship??? I think all you really need in residency is exposure to all aspects of our broad specialty to peak your interest and then pursue a fellowship afterwards. More importantly, you should be able to practice GENERAL PM&R competently once residency is over.

Procedures are fun and I think I will be going in that direction also, but right now I want to learn all the other things that PM&R has to offer.... Just something for you graduating med students to think about! 🙄

I agree that the goal of every program should be to train a well-rounded Physiatrist, but the reality is that not everyone is interested in being well-rounded. PM&R is such a broad field that some feel you wind up doing a lot of rotations in areas that you have no interest in. I know a few graduates of our program who did not want to do a fellowship, but wanted to do Interventional Spine procedures right out of residency. I've seen PGY-4s from our program create a mini-fellowship and jump right into doing procedures after graduation. I think it might be more difficult in the future to get privileges without a fellowship, but that doesn't mean you can't learn how to during residency. Also, knowing how to do these procedures doesn't hurt when you rotate at a place you want to do a fellowship at.

 

[drvlad2004]

Originally posted by Stinky Tofu
I know a few graduates of our program who did not want to do a fellowship, but wanted to do Interventional Spine procedures right out of residency. I've seen PGY-4s from our program create a mini-fellowship and jump right into doing procedures after graduation. I think it might be more difficult in the future to get privileges without a fellowship, but that doesn't mean you can't learn how to during residency. Also, knowing how to do these procedures doesn't hurt when you rotate at a place you want to do a fellowship at.

BTW, what's the story with non-accredited pain fellowships that soon must be accredited. As of now, I'm not strongly interested in pain management. I want to use my OMM skills more often. I was told that, within 2 years, that all pain fellowships must be accredited. Is that true?

Interventional Spine procedures right out of residency? If I did that, I would be begging for a malpractice suit.

 

[bbbmd]

Personally, I wouldnt want to risk being sued if I were to cause a spinal abscess after performing an ESI right out of residency just because I did a "few" of them during my training... Without a "fellowship" under your belt, I think our friends the ATTORNEYS would have a field day on you...

I do agree there are physiatrists out there, not fellowship trained, doing these procedures, but times-a-changing and from my understanding fellowships are the wave of the future... At present, physiatrists working in interventional pain/spine can sit for the pain boards after 2 years of focused practice, but I think this is about to change. I skimmed through an article in THE PHYSIATRIST a month ago and unfortunately do not know the details... There are published job openings in THE PHYSIATRIST and many of them look for either an experienced pain doc or ones that are fellowship-trained to join orthopedic practices, I have yet to find an opening that says "RECENT grad for pain practice wanted". I just think that it is in MY best interest to pursue fellowship training in pain/spine rather than just relying on the PASSOR workshops and the PAIN/SPINE rotations I get in residency. But, too each his own...

When I started my PGY2 year, I didnt think that I would like spinal cord, I did a good rotation and STILL DO NOT LIKE spinal cord. I didnt think I would like TBI, I did a rotation in it AND LOVED IT- Now I am considering TBI and Spasticity Management over PAIN/SPINE... I have a couple more years to go to decide, but at least I know I will have tried it all!!! But like STINK, if you KNOW FOR SURE that PAIN/SPINE is for you (like I once thought) then by all means rank the PROCEDURALLY BASED programs FIRST!!!

BTW... By procedures I mean... IDETs, RFA, Spinal Facet blocks, vertebroblasties and spinal stim.... All Physiatrists should be able to do the "simpler things" (inject peripheral joints and trigger points) out of residency- that's just bread and butter!!!!

 

[drusso]

Interventional experiences are available for PM&R residents at the Mayo Clinic. We can rotate through the anesthesiology pain clinic (where several of our attendings practice) and also pursue experiences in Scottsdale and Jacksonville.

Now, that said, you have understand that certain "cultural" factors about the Mayo system impact the kinds of experiences you can have here. Mayo believes in super-specialization. When you're a rotating resident on the pain service you *WILL* get proctored and trained in doing interventional procedures. But, when you rotate off the service, you're done---that's it. It's the same way with our EMG training. We do six months of solid EMG's---day in and day out---side-by-side our neurology colleagues and attendings. But, once you finish with EMG you're done. If you have a patient who needs an EMG when you're on a different rotation, then you send them to the EMG lab where one of your colleagues who's on that rotation that month does it. It's not like a private rehab hospital where if you feel like your spinal cord injury patient needs botox shot you take them to a procedure room and do it or you do a bedside EMG to evaluate a plexopathy. At Mayo you send them to the Botox or plexopathy clinic respectively. It's just the "Mayo way..."

 

[Stinky Tofu]

I think the opportunity to sit for the Pain boards without doing an ACGME-accredited fellowship ends in 2005. I plan on doing an Interventional Pain Fellowship as well, so I'm certainly not saying a fellowship has no benefit.

What I am saying is that a fellowship doesn't necessarily make you more proficient at doing facet blocks or ESIs. A Spine fellowship isn't necessarily focused on doing a ton of procedures either. We have a rotation here where you can probably do 4-5 spinal injections per day. Volume and letters of recommendations can play a significant role in obtaining privileges at a hospital. One of our graduates two years ago got hired at the MGH Spine Center out of residency. He left our program a couple of months ago to join the Steadman-Hawkins Clinic in Colorado. This clinic is world-renowned and I think they could've easily found someone who completed an ACGME-accredited fellowship. There are also courses available from ISIS on how to do these procedures. I do agree that fellowship training might be the wave of the future for privileges, but this doesn't mean that lawyers will have a field day and that you can't be just as proficient as someone who did a fellowship.

With regards to jobs, I'm not saying that someone out of residency is on equal footing when compared with someone who has more experience or has done a fellowship. What I am saying is that when you've done 100 spinal procdures on your own, you have letters vouching for you from prominent Interventionalists in the field, you've completed spine injection courses, and you have published papers on the subject, you would be considered competitive out of residency. I've also seen ads where a practice will hire you and train you for the first six months to do the procedures and then you are on your own. I agree that these procedures should be limited to ESIs, facet blocks, and maybe RFAs. You definitely need a fellowship to do vertebroplasties/kyphoplasties, to perform IDETs, or to implant spinal cord stimulators. Many just want to do ESIs and facet blocks though. Lumbar ESIs and facet blocks are relatively simple and safe. They are no more dangerous than a LP and we certainly don't require a fellowship to do LPs. If you do the facet blocks and ESIs under fluoroscopy (I don't know anyone who doesn't anymore) and you've taken pictures that show proper placement, many wouldn't worry too much. Also, as part of the consent, you've already informed the patient about the risks of the procedure.

I am not saying that one should look for a program that focuses on procedures, but it is nice when the opportunities are available in the form of electives. I am also not encouraging people to forgo fellowship training. I think a fellowship is a good idea, but not because you can't become proficient at ESIs, facet blocks, TPIs, joint injections, and RFAs without it.

 

[jeeva]

Hey all, I know this thread started as a Mayo question, but since it appears to have switched gears to a more general topic I just wanted to add my 2 cents. (Bear in mind I'm just an intern and haven't even started "real" resdency yet so take it for what it's worth)

I admit to being among the many people riding the new wave of interest in pm&r, namely pain and interventional spinal procedures. And yes, when I first began looking for programs to train at, I desired one that would give me greater exposure to performing procedures as a resident. But the further I got along in the process, the more I discovered how truly broad and diverse the field is, and there is much to be learned in a seemingly short amount of time. What I finally realized was that while I say I am interested in pain/spine now, my interests may change along the way. After all, they have before (I don't know about the rest of you but I certainly wasn't thinking about pm&r when I started med school---I didn't even know it was a specialty! 😳 )

I guess what I'm saying is for those finalizing their rank lists now, don't sacrifice a solid broad-based exposure to all areas of the field. Ask yourselves whether you would still receive top-notch training/exposure/volume in other subspecialties within pm&r if, for some unforseen reason, you decide down the road that interventional pain and spine are not for you. There are a number of programs out there that meet these criteria--don't immediately count any of them out just because they won't get you 100 ESI's as a resident.

But if you're 150% sure about what you want to be doing post-residency, then all the power to you and best of luck, my friends!🙂

 

[bbbmd]

Nicely said Jeeva... Looking forward to meeting you in a few months!!! STINK, I agree with you 100%- just wanted to point out, to those contemplating their rank order, that doing procedures during residency is definitely IMPORTANT, but should not be the only thing they consider...

Well, this is from the PASSOR newsletter re: pain medicine requirements: (vol 7, No.1)

"If you plan to take the pain medicine exam and you completed residency training for general certification prior to Sept 1, 1998 your last opportunity to take the exam without completing a fellowship is 9/11/04"...

"As outlined by the AAPM&R's website, the educational req in pain medicine currently can be fulfilled by either:

1.) Satisfactory completion of 12 months in an ACGME-accredited Pain Medicine Fellowship;

OR

2.) Under temporary criteria as follows:

-for candidates seeking qualification by way of practice:
* completion of 24 months of full time practice in pain medicine, and
*satisfactory completion of residency training required for general certification prior to 9/1/1998.

(Credit will be granted only for pain medicine practice occuring within the last 8 years immediately preceding the deadline for the receipt of the application to the examination.)

-for candidates seeking qualification by way of training:
* 12 months of formal training in pain medicine
* satisfactory completion of residency training required for general certification prior to sept. 1, 2004

# After the 2004 exam, admissibility to the exam can only be attained by way of training

# After the 2006 exam, candidates applying or re-applying for exam in pain medicine must complete 12 months of training in an ACGME-accredited pain medicine program."


I guess this answers the question about the need for an ACGME-accredited fellowship to take the pain boards.

 

[drvlad2004]

Thanks for the explanation, bbbmd!