Neurology and Pain

[Molly Maquire]

HI,

I see that many hospitals run pain clinics staffed by neurology.

Can anyone tell me what neurologists do with pain management? It has to be more than prescribing neurontin. Can you do the same procedures as gas guys who do pain fellowships?

thanks.

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[ajl102]

I have asked around about this and people seem to believe that pain procedures are still done by anesthesiologists, and that Neuro pain specialists do other work within a pain management department, presumably everything else besides the nerve blocks, rhizotomy, etc.

What their work is comprised of specifically I don't know. Also, what opportunities or obstacles exist to neurologists performing pain procedures - I have not gotten a clear answer.

 

[Kalel]

Neurologists do get referred patients with neuropathic pain or pain of a poorly understood etiology (eg fibromyalgia). There is of course a lot of overlap in places where pain clinics and the anesthesiologists who run them are. My understanding is that there are not enough pain clinics or pain specialists out there, so a lot of complicated pain patients end up being managed (sometimes inappropriately) by PCP's and neurologists still get referred a lot of chronic pain patients.

Neurontin (gabapentin) is the first line therapy for just about all forms of neuropathic pain with the exception of trigeminal neuralgia (where carbamezepine should be used first). Treatment failures of neurontin are often because providers and patients don't reach high enough levels of neurontin for the drug to be therapeutic. Besides neurontin, there are a lot of other drugs (TCA's, anti-epileptics, and surgical options) that require complicated management algorithms which would probably be better managed by pain specialists. I think that PCP's or non-pain specialists are more likely to put patients on oral opiod therapies that may temporarily "relieve" a patient's neuropathic pain but haven't been shown to be as effective as many of the other drugs we have out there and have the adverse effect of causing these patients who don't have nociceptive pain to become addicted. I saw one patient in a pain clinic who had fibromyalgia who was being managed by her PCP with a whopping 160 mg bid dosage of oxycontin!

 

[ajl102]

Again, is it possible for neurologists to do the procedures anesthesiologists seem to typically do - is there additional fellowship training available or needed?

If not, what do neurologists tend to do in a pain management department or practice?

 

[Finally M3]

Unless you get a lot of experience during your elective time, I think you need to do a fellowship to perform the kind of procedures you're asking about. However, rumor is that in the near future, only fellowship-trained clinicians will be able to perform/be reimbursed for some of the interventional pain procedures.

From a quick browsing of some of the fellowship programs listed on FREIDA, Gas PM&R Neuro and Psych residents can apply to fellowships. I thought it was more common for Gas and PM&R residents to go into the Pain programs, but I've only been exposed to two programs....

 

[PainDr]

Yes, neurologists can do interventional pain. The path is just like that for anesthesiologists and PM&R folks...we must do an interventional pain fellowship. No one (in any specialty) gets enough interventional experience during residency, so a fellowship is definately required. I think the confusion revolves around the fact that the vast majority of ACGME fellowships are run by anesthesiology. However, neurology and PM&R residents are welcome to apply. I'm a PGY-3 neuro resident who will be applying in July and am currently researching programs. So far everyone has been very encouraging and I've been told I'll have no problems finding a good fellowship. There are neurology pain fellowships, however all (but one-Univ of Georgia) are not ACGME approved. Also, most of them focus on medical management. Hope that answers most of your questions.

 

[ajl102]

Thanks PainDr, encouraging input. I am surprised to hear that as a neuro resident you will be applying into anesthesiology-run fellowships. I am guessing that these programs will be largely centered around the OR, and neurology residents never see any OR time at all. How do you expect to handle the adjustment? How do those running the fellowships view this issue?

 

[ajl102]

Asked around to a few anesthesia residents, no had heard of neurology residents doing anesthesia pain fellowships. Has anyone heard of this actually happening? There is infact only one neurology pain fellowship listed on FRIEDA.

 

[PainDr]

When you ask about OR time, what exactly are you asking? Interventional fellowships focus on interventional proceedures, not passing gas. In fact, ACGME guidelines prohibit fellows from performing OR anesthesia duties. Most interventional pain proceedures are performed not in the OR but in the fluoroscopy suite (which may be on the same floor/unit as the OR, or in an outpt surgical center). Since I've already spent a good amount of time actually doing these proceedures and already know my way around the fluoro suite, I don't anticipate any problems (and neither do any of the anesthesiologists I've worked with).

To answer your second question, you must have spoken to residents who don't know what they're talking about. As previously mentioned, there is only one ACGME neurology program and a few PM&R programs. All the rest are anesthesiology based and open to residents from the following specialties: Anesthesiology, Neurology, PM&R, Neurosurgery, Psychiatry. Do a little research on the history of medical education and training in pain mgmt.

Last, but not least, yes...not only have I heard of this actually happening but know folks who've done it.

 

[daphilster]

Ok the next logical question is this:

who gets the best spots in pain fellowship? and what criteria do PD's use to judge applicants? reputation of their program, LORs, research, etc? You don't exactly have "grades" anymore in residency right?

My guess would be the anesthesiologist would have the edge since most pain programs are run by anesthesiology dept.

 

[PainDr]

I'll know more about this after going through the process, but my guess is that alot of it depends on the motivations of the applicant. Many (if not all) programs require a letter from the applicant explaining their reasons/motivations for choosing the specialty. Also, applicants must submit 3 LORs which can really help or hurt you, depending on how well you've performed and with whom you've worked. Lastly, residents ARE graded. Not only do we have monthly evaluations (we are graded in 10 different categories) but all specialties have a yearly RITE exam (Resident In Training Exam).

 

[ys]

A couple more questions for PainDr:

The fluoro experience you mention, is that part of most neurology programs or did you have to seek that elsewhere? And secondly how is the job market for neuro pain specialists? Nearly all the interventional pain jobs I see advertised are for anesthesiologists and some for PM&R.
Good luck with your fellowship interviews.

 

[Sohalia]

Hey,
I've mostly heard that if you want to do interventional pain, PM&R is a better route than neuro. How do you find a neuro program that will help you go into an interventional pain fellowship (i.e. ones in which you can get a little experience in fluoro, get good LORs from, etc.)
Thanks!

 

[PainDr]

First of all, I chose neurology because I enjoy it and found out early on that it was an accepted route to pain mgmt. The reason you don't see more neurologists going into the field is because most of them simply aren't into doing proceedures. There is certainly no lack of patients. I doubt many people realize most general neurologists routinely manage lots of pain pts... low back pain, failed back surgery, radiculopathies, painful neuropathies, headache, RSD, trigeminal neuralgia, etc. We get them from FM, IM, ortho and neurosurg. We manage them medically and send them to interventionalists when necessary.

Regarding hands on experience, I started doing elective interventional rotations as a student, then as an intern and now as a resident. From the beginning, everyone has been very encouraging. Although neurologists are not common in the field, they are certainly not unheard of. In fact, the interventionalists at my medical center say most research in the area comes from anesthesia and neuro (their statements...not mine). Regarding PM&R, it is a more known and popular route and they have several of their own programs. However, personally I was just never interested in rehab.

Regarding Sohalias' question: How do you find a neuro program that will help you? You don't have to "find" a program...it's an accepted neuro sub-specialty. Anesthesiology gladly accepts us into their fellowships. Actually, I discussed the issue with my PD during my initial residency interview. He was very encouraging and assured me I would get all the support and exposure I wanted. It hasn't been a problem at all.

Finally, the job market for neuro is very good. I only have to decide if I want a mixed practice or 100% pain. Many ads don't mention neuro because there are so few of us. I've been told (by recruiters) that if I want to do 100% pain I'll have all the same opportunities as anesthesia and PM&R. Hope that answers most of your questions.

 

[neurologist]

A "100% pain" job?!?!??!
YIKES!
A word to everyone on this thread: You really do need to have a certain mindset to go into pain medicine. I don't have it. Imagine spending 10 hours a day sitting in a room listening to patients tell you about their pain. Pain that has never gone away for 25 years no matter what anyone has done. Pain that will never go away no matter what YOU do (except in VERY rare cases). Multiply that 10-hour day by the rest of your career. Do that every day of your life.
To deal with this, I suspect you have to be either SUPER-empathetic or be able to just completely divorce yourself from all feeling. Me, I would just kill myself if I had to deal with that day in and day out. My practice is about 30% chronic pain and that's more than enough for me!

 

[Neuron]

Originally posted by PainDr
Interventional fellowships focus on interventional proceedures, not passing gas.

 

[Neuron]

Originally posted by neurologist
A "100% pain" job?!?!??!
YIKES!
A word to everyone on this thread: You really do need to have a certain mindset to go into pain medicine. I don't have it. Imagine spending 10 hours a day sitting in a room listening to patients tell you about their pain. Pain that has never gone away for 25 years no matter what anyone has done. Pain that will never go away no matter what YOU do (except in VERY rare cases). Multiply that 10-hour day by the rest of your career. Do that every day of your life.
To deal with this, I suspect you have to be either SUPER-empathetic or be able to just completely divorce yourself from all feeling. Me, I would just kill myself if I had to deal with that day in and day out. My practice is about 30% chronic pain and that's more than enough for me!

I have to agree with this, but I guess if someone has been interested in it from med school through residency, maybe he's really good at it/really likes it. Plus maybe the interventional aspects help reduce the pain, no pun intended. I think pain is the only interventional area where Neurology has ACGME certified programs (at least one at the moment), and for someone who likes neurology but also like procedures, I guess that's one way to go. Hopefully as the endovascular wars settle, "interventional minded" neurologists will have more options.

 

[PainDr]

It's true that you have to have a certain personality for pain mgmt, but it's not as bad as neurologist describes. In fact, I think I'd shoot myself if I had that kind of practice! The truth is, there have been huge advances in medical and interventional mgmt and if you know what you're doing, you can help the vast majority of patients.

Part of the problem is the wide variety of skill seen among practitioners. There are many nonfellowship trained people doing pain mgmt and doing it poorly. Even among those who are fellowship trained, there are quite a few who just aren't very good at what they do. My facility is fortunate to have an amazingly well trained interventionalist so I've seen the level of knowledge and skill needed to be really effective.

 

[Sohalia]

Hi,
I was looking on the web for what sort of certification a neurologist specializing in interventional pain would hold. I found this document http://www.asipp.org/documents/fipp.pdf that says that one would need:

1.American Board of Psych and Neuro certification
2.American Board of Anesthesiology/Pain management certification (or American Board of Pain medicine certification)
3. Then you can apply for certification as a fellow of interventional pain practice which is offered by the World Institute of Pain-Section of Pain Practice

So my question is, for a US neurologist specializing in interventional pain, would you just need the first two in order to be considered fully certified, or should you really get certification specifically stating that you have training in interventional pain (i.e. something like #3). Does anyone know what the time scale would be for recertification for each of these 3 things?

Thanks!

 

[freelancewriter]

I'm surprised that no one has mentioned palliative medicine and pain management. Your dealing with dying people, so there is definitely a different dynamic. There is a spiritual aspect to it, to be sure. I would think some folks interested in pain management would be interested in a palliative fellowship, but maybe haven't been exposed.

From what I've read, palliative fellowships are open to PM&R and Neuro residents. I think they might be open to an even broader range than that.

I did a Google search and stumbled across a fellowship directory on the American Academy of Hospice and Palliative Medicine (AAHPM) site. Lots of fellowship programs. The only program I saw on the list with a link was Marshfield Clinic (www.marshfieldclinic.org/palliativefellowship). To quote their site, "The Fellowship is open to applicants BC/BE in Internal Medicine, Family Practice, Neurology, or Physical Medicine & Rehabilitation."

Not sure if any palliative programs are ACGME-accredited. Many of these programs started with grant funding in the last year or two, so I suspect it's a relatively new fellowship offering.

(I'm not a med student/resident/physician - that may already be obvious - but am very interested in the med school-residency-fellowship process. I lurk on these boards a lot, and post occasionally.)

 

[PainDr]

You only need the first two. Number 2 DOES certify that you have been trained in interventional techniques. I'm not sure what number 3 is...never heard of it. There are lots of organizations that offer "certification", but the only ones recognized by state/government officials and insurers are 1 and 2.

Regarding the last poster, a good interventional fellowship will also provide training in palliative care.