Need for pain board certification if your a spine doc?

[wscott]

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Hey everyone,

I am strongly considering a fellowship with a non-ACGME accredited program that is taught by a senior ISIS instructor. I am confident that my education will be sound and I will leave the fellowship highly trained in spinal interventions. As an Osteopathic physiatrist, my goal is to incorporate interventional techniques into a continuum of rounded practice directed at treating patients with back, neck, and general musculoskeletal dysfunction.

As many of you know, there are only a handful of ACGME accredited PM&R programs in pain management and I am confident many of them will not even be able to offer the training I am seeking; particularly at the level of the fellowship I have already been offered. However, extraneous, nagging ...but important factors exist which irk me and place a seed of doubt into my decision to do a non-ACGME accredited fellowship, which now would prevent my participation in the pain boards.

There is a difference in training between a pain fellowship and a spine fellowship. I believe that residency trained, board certified PM&R physicians, who spend an additional year of quality fellowship to become proficient at performing interventional spine procedures, along with attaining the necessary knowledge to use them appropriately....should be alright to attain privileges, coverage, and get paid by insurance companies, etc. I want to primarily be an interventional spine and musculoskeletal doc, not a chronic pain doc.

I have heard accounts of some spine physicians having difficulty justifying themselves and their practice adequately to the satisfaction of some insurance payers, because they may not be board certified in pain management. I have heard of some difficulties gaining hospital privileges to perform procedures due to worries of increased liability coverage for non-pain board certified physicians wanting to treat the spine with spinal interventions.

Have you heard about such concerns? How do all those fellows taught by leading educators such as RIC, Wash U., Florida Spine, Spliman and others, many of whom are ISIS instructors, justify themselves to such challenges? “Doctor did you say your not board certified in pain medicine and you are treating this patients chronic back pain with interventioanl spine procedures?” said the lawyer.

Would you still consider a non-ACGME accredited fellowship with a wonderful teacher knowing you won't be able to sit for THE pain boards? Currently there are no Interventional Spine or musculoskeletal boards, so do all the others in my shoes share these concerns? Or are the instances above scattered and far between? What is the trend? Should there be concern about future difficulties finding desired employment? or other unforeseen difficulties?

I've done a good amount of research to date and I know there was a lot of discussion a while back on this subject in this forum, but I'd like to hear about the latest facts and experiences regarding these issues. Is being board certified in pain necessary for those physicians who want to do spinal interventions in their musculoskeletal practice?

What do you know about this?

Thanks for sharing.

 

[Aether2000]

Greely Company that publishes clinical white papers and also helps hospitals set up their credentialing systems, has statements that suggest board certification is one of the strongest tests to be used in credentialing. Most hospitals do not yet require certification in pain. Some insurers do, esp. HMOs, but who would want to be in an HMO?

 

[drusso]

I see three options for you: 1) You can do the MSK/Interventional Spine fellowship and sit for the "other" pain boards--the ABPM sponsored by the AAPM. 2) You can apply broadly to both ACGME PM&R and Anesthesia pain fellowship programs and see what comes up. There is certainly value in being cross-trained in the anesthesia approach to pain medicine. 3) You can do a MSK/Interventional Spine fellowship and fight your battles justifying why your general PM&R training plus fellowship experience qualifies you to do what you say you are already competent to do.

I think that moving forward ACGME accredited training is going to become increasingly more valuable. The ACGME does not like to accredit subspecialty training experiences that center on techniques or procedures only and instead emphasizes that a developed corpus of knowledge needs to exist in a particular field in order to justify it being labeled a true "sub-specialty." That's why there are no ACGME accredited EMG fellowships, but instead a recently approved fellowship in Neuromuscular Medicine sponsored by neurology and PM&R and open to candidates from both fields. Ditto for Pain Medicine. There are plans for other PM&R sub-specialty applications in Brain Injury Medicine (open to neuro and PM&R) and possibly Sports Medicine (open to PM&R and ??).

What will happen to the field of "Interventional Spine?" Again, the ACGME will not accredit fellowships that focus narrowly on procedurally oriented training. Maybe it is time for a "Musculoskeletal and Spine Medicine" fellowship that would focus on the diagnosis and non-operative management of MSK and spine pathology. Some argue such training is part and parcel of PM&R. In which case, maybe the basic ACGME core PM&R residency competencies need to be re-tooled so that PM&R residency graduates are competent in basic axial lumbar injections upon finishing their residency. This seems to be what most PM&R residents actually want (and makes sense), but feel unprepared to do after completing their residency.

Any thoughts?

 

[Disciple]

I don't pretend to speak for all senior PM&R residents, but I would say that the above concerns weigh heavily on the minds of most of us, especially this year. There has been a mad scramble by Physiatry residents for accredited postions (both PM&R and Anesthesia) this year and unfortunately some us will be left behind. I don't see this trend reversing with the increasing number of high calibur med students coming in this year and the PGY 1-3s who will likely be applying for interventional pain-training positions in the coming years.

As this is only the second year that Physiatrists cannot take the pain boards without an accredited fellowship, this problem has not yet become overwhelming. What about in 5-10 years? Apparantly we didn't do enough or act quickly enough to accredit the majority of our programs during the time we were given for a "grandfather period". So, as I'm sure most of us prefer to prevent problems rather than fix them later, I think our academy needs to intervene.

The suggestions listed above are both great ideas, but if I remember correctly from a previous academy meeting, PM&R subspecialty certification in "Spine" will never happen due to opposition from Neurosurgery and Ortho, who amongst themselves cannot agree on guildlines for spine education.
So, that leaves the option of interventional training during our residencies. Yes, ideally this should be "part and parcel" to our core training, but as we all know, procedural training, like MSK/Spine/Sports training is all over the map with some residents never touching a spinal needle to some residents performing cervical transforaminals.

As was stated in a previous edition of the AAPM&R newsletter (maybe under the address by the president of PASSOR), Over 50% of Physiatrists list their focus to be MSK/spine/sports/interventional pain, etc.. with the vast majority of graduating residents (I'm assuming well over 60%) persuing jobs in the same. This point was reiterated during the PASSOR business meeting at this year's academy meeting.

So, how do we go about changing our core ACGME competencies? I really have no idea, perhaps Dr. Russo should comment. Maybe PASSOR should be the driving force behind this as they represent this arm of our specialty and will likely be reintegrated/assimilated, whatever, back into the academy in the next few years. PASSOR has published Physical Exam competencies lists and guildlines for interventional procedures, but these are not ACGME Core Competencies which each program is held accountable for.

There is only one thing that I'm certain of, and that is that it's a strange time to be coming up as a Physiatrist. If this is the direction our specialty is headed, then our academy needs to act quickly and decisively to best serve its future diplomats.

As a final point, if we are to amend our competencies, how extensive or encompassing should the changes be? Technically, many procedures besides ESI's can fall under the mantle of diagnosis and non-operative management of spinal disorders (e.g. RF, discography, etc.)

Food for thought.

 

[wscott]

I see three options for you: 1) You can do the MSK/Interventional Spine fellowship and sit for the "other" pain boards--the ABPM sponsored by the AAPM. 2) You can apply broadly to both ACGME PM&R and Anesthesia pain fellowship programs and see what comes up. There is certainly value in being cross-trained in the anesthesia approach to pain medicine. 3) You can do a MSK/Interventional Spine fellowship and fight your battles justifying why your general PM&R training plus fellowship experience qualifies you to do what you say you are already competent to do.

I think that moving forward ACGME accredited training is going to become increasingly more valuable. The ACGME does not like to accredit subspecialty training experiences that center on techniques or procedures only and instead emphasizes that a developed corpus of knowledge needs to exist in a particular field in order to justify it being labeled a true "sub-specialty." That's why there are no ACGME accredited EMG fellowships, but instead a recently approved fellowship in Neuromuscular Medicine sponsored by neurology and PM&R and open to candidates from both fields. Ditto for Pain Medicine. There are plans for other PM&R sub-specialty applications in Brain Injury Medicine (open to neuro and PM&R) and possibly Sports Medicine (open to PM&R and ??).

What will happen to the field of "Interventional Spine?" Again, the ACGME will not accredit fellowships that focus narrowly on procedurally oriented training. Maybe it is time for a "Musculoskeletal and Spine Medicine" fellowship that would focus on the diagnosis and non-operative management of MSK and spine pathology. Some argue such training is part and parcel of PM&R. In which case, maybe the basic ACGME core PM&R residency competencies need to be re-tooled so that PM&R residency graduates are competent in basic axial lumbar injections upon finishing their residency. This seems to be what most PM&R residents actually want (and makes sense), but feel unprepared to do after completing their residency.

Any thoughts?

Response:



Dr. Russo, thanks for your response to this confusing ordeal with making my decision for a fellowship position. I am, however, a little confused about your first option suggested, that is, in regards to "the other pain boards". Could you or anyone else elaborate on this?

So, there are two possible boards available? I have heard this, but I am admittedly confused and I have had difficulty getting a definitive explanation about the significance of all this. Correct me if I am wrong

ABPM is the American Board of Pain Medicine, correct? I don't see any connection to this board from the AAPM (American Academy of Pain Management) on their website or visa versa. What's their affiliation? How and why did this board get started? Is it recognized by hospital credentialing committees, insurance companies, and the legal environment as being adequate to practice pain? Or is it B.S. which I've heard. It seems it will have to suffice for all those fellows signing up for Non-ACGME accredited fellowships, RIC, Florida Spine, spliman, Michigan state, Wash U., HSS, etc....boy, that's a lot of affected and surely, high qualified people.

What's THE board which requires completion of an ACGME accredited fellowship? I believe this is the board exam written by the American Board of Anesthesiology, which has also recently been made eligible to Neurology, and PM&R. The board which, up until this year, most all other future fellows including myself would have been taking to satisfy "the requirements".

Is there a real difference between these two? Does the fact I'm accepting a non-ACGME accredited fellowship this year make my qualification as a physician any different this year from last years fellow? Of course not, but how will taking "the other boards" instead affect this specialty board certified and fellowship trained physiatrist? Can I be treated equally by insurers? Credentialing committees? Payers? Colleagues? Patients? Lawyers? Jurors?

Dr. Russo, as for the other two options....2) I think it's too late to apply for alternative ACGME accredited fellowship programs. (Do you disagree and know of openings?) From what I have heard most have made their decisions already, and frankly my wallet could not handle another round of interviews.
3) Responding to option three.... well I guess I will have to fight some battles, but I should hope larger organizations/powers-that-be will help me protect my desire to simply treat patients with above standard care and attention….but I’m not that naïve.

Please help with your knowedge of these issues and also ask your mentors about it as well.

 

[paindefender]

Do yourself a favor by doing an ACGME accredited fellowship. ABMS board certification is the way to go. Other "Pain Boards" are not recognized by many hospitals and insurance carriers. Other "Pain Boards" were created for those who do not have the credentials to get ABMS certification or for ABMS guys who like to have a lot of titles.

 

[Ichi]

As a 4th year resident in PM&R, of course, this was a big issue for me in choosing a fellowship. But my decision came down to personal preference in style of practice. I turned down an ACGME accredited pain fellowship and decided to accept a non-accredited MSK/Spine fellowship. I knew that I did not want to practice comprehensive pain medicine. I just knew I was more of a sports and spine guy. I don't want to start any Spine vs Pain flame war, but in my experience (as little as it may be) I saw the two practice styles to be very different. Of course there is overlap, but I realized in a pain fellowship (especially Anesthesia based) I would not see as many general orthopedic or sports pathologies.
Will my decision have negative ramifications in the future? Will I get rejected for previleges at certain facilities? Will I have trouble with reimbursement? I don't have the answer. I'll deal with it later if and when that does occur.
With all that said about myself, it is my opinion (ONLY AN OPINION), that if someone wants to practice comprehensive pain medicine or have a high volume interventional practice, he/she should do an ACGME accredited program. I really think it depends on what type of practice one wants to have.
Of course my fellowship isn't going to train me about inpatient pain consultations/procedures, cancer pain, cervical inj/pumps/stims etc........But I'm OK with that. Only thing I am confident of is that my future fellowship will provide me with the knowledge and skill to be an excellent comprehensive musculoskeletal physiatrist.

 

[drusso]

(snip) Only thing I am confident of is that my future fellowship will provide me with the knowledge and skill to be an excellent comprehensive musculoskeletal physiatrist.

I think that you make excellent points and most people would agree with you (at least in PM&R anyway). But, shouldn't your RESIDENCY TRAINING impart you with the skills in knowledge to be a comprehensive physiatrist? I think many PM&R graduates depend upon MSK/Spine fellowships to remediate inadequate residency training that overemphasized traditional neurorehab. I think therein the problem lies...

 

[Ichi]

I guess in my mind, there is a difference in knowledge and skill set between a comprehensive physiatrist and a comprehensive MUSCULOSKELETAL physiatrist. I guess better way to describe who I wanted to be is an EXPERT in musculoskeletal/spine physiatry. I agree completely, many PM&R programs overemphasize neurorehab and many graduates rely on fellowships to get their MSK/Spine education. But even with the large amount of neurorehab training at some programs, the issue may be similar for the other subspecialties in our field such as TBI or SCI. Of course one may get good enough exposure and training in their residency to go out and practice in any of the subspecialties of physiatry and do a good job. And eventually if one practices in a certain subspecialty long enough, I think one can develop the skills to be an expert in that subspecialty. However, I think most would agree that MORE of an ACCELERATED level of expertise could be gained by doing a fellowship. Of course there are some programs out there that may do a great job in training in MSK/Spine, but I still think it is difficult to be an expert, just out of residency, with the similar knowledge base of a sports trained orthopedist, or a spine trained surgeon. For instance this is true even if you look at our surgical colleagues. One only needs to observe the difference in fellowship trained orthopedists vs general orthopedists. Sports trained surgeons are usually much more slick with the arthroscopes and are more up-to-date on literature about sports medicine.
For myself, I wanted to be an expert in MSK/Spine where I could go toe to toe with the surgical subspecialists. Of course my view or definition of expertise may be very different from others. I think if I wanted to be a leader or an expert in pain medicine, I'm sure I would have accepted a different fellowship.

 

[singarac]

I guess in my mind, there is a difference in knowledge and skill set between a comprehensive physiatrist and a comprehensive MUSCULOSKELETAL physiatrist. I guess better way to describe who I wanted to be is an EXPERT in musculoskeletal/spine physiatry. I agree completely, many PM&R programs overemphasize neurorehab and many graduates rely on fellowships to get their MSK/Spine education. But even with the large amount of neurorehab training at some programs, the issue may be similar for the other subspecialties in our field such as TBI or SCI. Of course one may get good enough exposure and training in their residency to go out and practice in any of the subspecialties of physiatry and do a good job. And eventually if one practices in a certain subspecialty long enough, I think one can develop the skills to be an expert in that subspecialty. However, I think most would agree that MORE of an ACCELERATED level of expertise could be gained by doing a fellowship. Of course there are some programs out there that may do a great job in training in MSK/Spine, but I still think it is difficult to be an expert, just out of residency, with the similar knowledge base of a sports trained orthopedist, or a spine trained surgeon. For instance this is true even if you look at our surgical colleagues. One only needs to observe the difference in fellowship trained orthopedists vs general orthopedists. Sports trained surgeons are usually much more slick with the arthroscopes and are more up-to-date on literature about sports medicine.
For myself, I wanted to be an expert in MSK/Spine where I could go toe to toe with the surgical subspecialists. Of course my view or definition of expertise may be very different from others. I think if I wanted to be a leader or an expert in pain medicine, I'm sure I would have accepted a different fellowship.

I have read all the replies, and the question is of "ACGME--TO BE or NOT TO BE" is a good one as it may affect ones practice style as well as reimbursement in years to come.

As a physiatrist now in a ACGME pain fellowship, I had this very same question 1 year ago. As interested as I am in MSK, spine as opposed to simply chronic pain, the mystery of the future is too much. If pain is headed toward it's own residency program, and there is current ACGME board for these procedures, and one has decided to take a year of their life to learn them with skill then it makes only too much sense to go that route. No program will offer everything, however, only certain ones will offer a certification which as far as I'm concerned is a major obstacle that third party payers, academic appointments, and other pain specialists who may not want a physiatrists doing these procedures, will look at strongly. If you cannot get enough MSK training out of your residency (which is a problem in itself for many residency programs) then a MSK/Spine fellowship may be on value but not in leiu of an accredited fellowship in my opinion.

I think the best bet for the physiatrist who is more interested in spine over chronic pain, is to try for one of the pmr accredited fellowships, many of which have a heavy emphasis on MSK and spine. You may not get the stims, pumps, kyphoplastys, or advanced procedures, but you will still get the EMG training, MSK evaluation, and Spine emphasis more part and parcel to the physiatrist in the first place. Furman's fellowship, UofM, UVA, Denver Colorado all are accredited and still give the physiatrist EMG training, and some MSK training as well.

You may have to round out your fellowship with outside courses, or work with ortho, FP, or sports PMR while in your fellowship (if you have the resources) to give you that boost MSK experience your looking for.

At the Uof M pain fellowship, our great asset is the continued EMG training, Ortho MSK, Spine Clinic we recieve outside of course chronic pain experience and spine intervention (similar to most other fellowships). It really is a good fellowship, would highly recommend it.

 

[Kvetch]

There is a bias in some hospital systems against a non-ACGME fellowship without regard for the individual and their accomplishments or talents and ability, and it is quite dis-heartening. (Especially in light of the fact that the bulk of pain interventionalists haven't even done a fellowship at all!)
This "belief " and trust in the ACGME and similar mercenary organizations is a sx of the greater ill of the growing bureaucratic control of medicine in general. ACGME (and the medical specialty boards I would add) is just another business - another self proclaimed "accreditation" business - a private enterprise - that's found a way to make HUGE profits from leeching off the medical field and driving up costs and making themselves appear as "official" agencies of some credulity - horsepucky - they're just a dang profiteering business who couldn't care less about you and your patients well being. They are driven by greed and controlled by special interests like any bureaucracy. And in fact they are doing more harm than good to the quality and variety of training of medical residents across the country. Many excellent free-standing residency programs with innovative ideas and methods and fresh approaches with regional relevance have been shut down due to the ACGME and the RRC behemoth. This has served only to create a generic, controlled and controllable "product" out of previously free-thinking, innovative, and caring physicians of yesterday. And now the very idea of private-practice medicine - like the affordable neighborhood doc who knows his patients personally for a lifetime - is being threatened by socialized government run medicine. I hope all the hospital employed physicians and institutionalized physicians in Universities, are not falling into this mentality completely. For if they are we will see the rapid decay of the entire field.
I urge a REVOLT by all the young docs out there - you are becoming a rarity, and in demand - stand up for yourselves - go into private practice - avoid 3rd party payors - do fee for service only - and don't do the damn boards! And join the AAPS not the AMA.
Thanks for listening to (reading) my rant.

 

[mid|ine]

Sounds like someone couldn't secure and ACGME accredited spot to secure a AMBS Board certification ;-)

 

[kdlymes]

I will tell you by experience, to contract for some of the insurances you will need board certification. My wife does all my contracting and a few years ago we ran into this exact problem. My recommendation is that you do it. Your competitors can use it against you.

 

[Ligament]

I concur more docs should joint the AAPS, great organization.

 

[myrandom2003]

as recently mentioned in a couple of posts here on the pmr forum as well as the pain forum about crnas performing pain procedures unsupervised and the FTC getting involved to review a rule by the Alabama state board that says only md's and do's, who needs board certification???

If CRNAs are able to perform interventional procedures without special boards, why is ACGME board certification so important to us? just playing devil's advocate... yes I do realize it is beneficial in the court of law, but seriously, if crnas dont need it, why do we?

and yes there are some insurances that dont credential you, but as long as BCBS, Aetna, MCR/MCD, and UHC, Tricare, and workers comp approve you, is it that big of a deal?

maybe someone more versed in the ways of the world can enlighten me...

regardless, given the choice, i would always pick an accredited fellowship and get the boards... just wish pmr had their own

 

[Kvetch]

Now, now - we docs need to stick together. I'm just pissed off and sick of the dang field being overrun by bureaucrats and us being told what when and how to do everything. And the more hard we are on ourselves, the more it seems nurse pracs and others just weasel right on in and try to supplant us. F the dang boards. I got board cert in my first specialty, but I've done 2 residencies and 2 fellowships and I'm tired and sick of test taking - which proves nothing. I know excellent docs who've never boarded, and I know many crappy head up their asses docs who are boarded and think the world of themselves - they just know the tricks of taking tests. You know the type. The type that's given us a bad name. Prima Dona University Sophists - who actually started the whole Board scam. No doc took "boards" in the not so distant past - just the academics - because of their dang over-competitiveness and damaged egos. Now we all pay for their folly.
The Art of Medicine is not yet completely dead. Find an innovative training program that's not yet been shut down by the ACGME / RRC - and join the AAPS - and go practice the Art of Medicine for your patients and community - the way it was meant to be practiced. Free market. Good docs will do well, bad profiteering docs will fail. It's as simple as that. And with a lot less overhead, and thus savings for all. The cost of medicine / health care will half overnight if we went back to cash only / fee for service. And I believe the quality would increase exponentially, because you could then afford the time with your patients to figure out whats going on properly. No more rushing to meet your quota and keep under budget. Pass the word along to the student docs. Private practice is not yet dead. The evil is not the doc - but the bureaucracy trying to control him. You don't need to be an employee. You'll be infinitely happier working for yourself with a new found freedom. Your pts will appreciate it too. People are willing to pay for quality care. I know I am.

 

[drpainfree]

I'm not sure what exactly is the definition of "physiatrist"...but last time I checked it's the equivalent of PM&R, not pain medicine.

So if you want to specialize in pain management, you should complete an ACGME-accredited pain management fellowship and be board-certified by American Board of Medical Specialties.

 

[jakalope]

I agree that ACGME is the way to go so you do not have any issues in the future....and out in the real world past residency/fellowship there are two pain boards....but only one is recognized TOTALLY (American Board of Anesthesiology Pain Medicine) and you need an ACGME accred. pain fellowship to sit for it. Complete it and you have no worrries with insurance or hospitals....

And when you say you are a "spine doc" i initially thought (from your title) that you were an Orthopedic spine surgeon, Fellowship trained Surgical Pain Medicine or a Neurosurgeon.....Careful how you word yourself at this point. Good luck with your endeavors.

 

[Finally M3]

I will tell you by experience, to contract for some of the insurances you will need board certification. My wife does all my contracting and a few years ago we ran into this exact problem. My recommendation is that you do it. Your competitors can use it against you.

Haven't had credentialling/contract problem yet...but we are a big ortho group so i'm probably small potatoes

As for competition...you'll be surprised how far bedside manner/clinical competence goes in getting referrals from family/friends of happy patients.

Would agree for those in training, tho, go ACGME if possible