Number of procedures in fellowship

[90dayMD]

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What's a reasonable/standard/average number of procedures to do in fellowship?
Is there a required amount to do?

What about things like Vertiflex, kyphos, etc - do you all get exposure to those in fellowship?

 

[BobBarker]

I probably was part of 40-50 kyphos as a fellow. Usually placing one side and the attending the other. Vflex might not have good exposure in most fellowships.

 

[90dayMD]

I probably was part of 40-50 kyphos as a fellow. Usually placing one side and the attending the other. Vflex might not have good exposure in most fellowships.

Ok. What about the other part of the question in terms of numbers of procedures.

 

[gdub25]

I went to arguably the highest volume fellowship in the country at the time, I did over 100 stim trials and also over 100 stim implants during the year. I did over 1000 epidurals and over 1000 medial branch blocks, over 400 RFAs. I did 20 pump implants and 27 kyphoplasty, only handful of DRG cases but then again it had just come to market the last few months of my fellowship. Vertiflex wasn’t around at all. I’m still very involved in the fellowship program and interviewing incoming fellows every year, we typically see most fellowships doing around 10 stimulator trials or implants per year and procedural volume of 200 to 400 of each of the bread and butter cases, 100 or so RFA. anything less than these numbers and it’s probably a weaker procedural fellowship.

 

[90dayMD]

I went to arguably the highest volume fellowship in the country at the time, I did over 100 stim trials and also over 100 stim implants during the year. I did over 1000 epidurals and over 1000 medial branch blocks, over 400 RFAs. I did 20 pump implants and 27 kyphoplasty, only handful of DRG cases but then again it had just come to market the last few months of my fellowship. Vertiflex wasn’t around at all. I’m still very involved in the fellowship program and interviewing incoming fellows every year, we typically see most fellowships doing around 10 stimulator trials or implants per year and procedural volume of 200 to 400 of each of the bread and butter cases, 100 or so RFA. anything less than these numbers and it’s probably a weaker procedural fellowship.

When you say 200-400 of each bread and butter case, do you mean like 200-400 of each type of epidural for example, and 100 or so RFA per lumbar spine - cervical, thoracic, lumbar, so like 300RFA per site, or do you mean total - so a combo of the 3 levels?

Just trying to get ideas of what's adequate.

 

[BobBarker]

No, not many thoracic RF’s at all. I do less than 12 per year in a busy enough practice.

 

[90dayMD]

No, not many thoracic RF’s at all. I do less than 12 per year in a busy enough practice.

Ok, that makes sense. But again when the above poster mentioned 200-400 bread and butter epidurals, for example, do they mean 200-400 per section, so 600-1200 (given cervical, thoracic, lumbar)? just an example I guess. or do they mean total (200-400 total epidurals).

 

[gdub25]

I meant 200-400 ESIs total, combination of cervical, thoracic, and lumbar. About 200-300 MBB in total as well, combination of mostly lumbar, some cervical, and very few thoracic most likely. 100 RFA total as well.

 

[90dayMD]

I meant 200-400 ESIs total, combination of cervical, thoracic, and lumbar. About 200-300 MBB in total as well, combination of mostly lumbar, some cervical, and very few thoracic most likely. 100 RFA total as well.

Ok, thank you for clarifying that I almost stroked out when I read that lol, thinking it was normal to do so many of each! I have been told by a number of attendings that fellowship is kind of like a base, and some of my attendings mentioned that they weren't great when they graduated and developed skills over 2-3 years. I fear that I won't be super great when I graduate.

 

[Orin]

I fear that I won't be super great when I graduate.

You're not supposed to be super, great, or super great. You're supposed to be safe and competent.

Skill takes time, practice, and effort. They're providing a base, a sounding board, and you do all the rest. The key is to be a humble, hypercritical sponge with a short memory those first few years.

You'll learn a lot when you're doing this without someone watching you.
Be critical and honest with yourself about what you do right/wrong/etc, and allow yourself some grace when you mess up, but try not to maim anyone.

The dangerous ones are those that don't realize their weaknesses, overestimate their skills, and ignore their mistakes.

 

[BobBarker]

You will continue to improve over your first 10 years in practice. I am completing my fifth year and continue to grow and improve.

 

[SommeRiver]

You'll never be satisfied in your technical skills, and that's probably a good thing IMO.

 

[90dayMD]

You're not supposed to be super, great, or super great. You're supposed to be safe and competent.

Skill takes time, practice, and effort. They're providing a base, a sounding board, and you do all the rest. The key is to be a humble, hypercritical sponge with a short memory those first few years.

You'll learn a lot when you're doing this without someone watching you.
Be critical and honest with yourself about what you do right/wrong/etc, and allow yourself some grace when you mess up, but try not to maim anyone.

The dangerous ones are those that don't realize their weaknesses, overestimate their skills, and ignore their mistakes.

 

[90dayMD]

Yeah definitely agree on this. Thank you.

 

[iwumd07]

I did about >400 epidurals, >400 MBBs, >150 RFAs, a ton of TPIs, peripheral joint injections, and ultrasound-guided stuff (including peripheral nerve blocks and peripheral RFs), and about 15-20 each of SCS and intrathecal pumps (trials and implants) during fellowship. No Vertiflex (or any other interspinous process devices--no insurance coverage), no kyphoplasty (surgeons did them at our institution), no MILD (no insurance coverage). We had 5 fellows and each fellow did procedures 1 day/week.

Also, don't forget to focus on the actual diagnosis of pain. I live in a city that is chock full of interventional pain physicians, and few listen to or examine a patient. Almost every new patient I see has seen a few other pain physicians, and 'nothing has ever worked' (also, I rarely prescribe opioids, so they're not coming to me for those).

You can do all the epidurals, MBBs, and RFAs you want, and none will matter if you're not treating the source of the patient's pain. IMO, the most annoying and lazy diagnosis I see is "non-specific low back pain" and treatment is "two/three level bilateral TESI x 3". Learn how to master diagnosis (and how to communicate effectively with patients) in fellowship. Do as many procedures as you can, and learn how to manage patient calls and post-procedure 'issues' (be they real or imaginary) during fellowship.

 

[90dayMD]

You'll never be satisfied in your technical skills, and that's probably a good thing IMO.

I did about >400 epidurals, >400 MBBs, >150 RFAs, a ton of TPIs, peripheral joint injections, and ultrasound-guided stuff (including peripheral nerve blocks and peripheral RFs), and about 15-20 each of SCS and intrathecal pumps (trials and implants) during fellowship. No Vertiflex (or any other interspinous process devices--no insurance coverage), no kyphoplasty (surgeons did them at our institution), no MILD (no insurance coverage). We had 5 fellows and each fellow did procedures 1 day/week.

Also, don't forget to focus on the actual diagnosis of pain. I live in a city that is chock full of interventional pain physicians, and few listen to or examine a patient. Almost every new patient I see has seen a few other pain physicians, and 'nothing has ever worked' (also, I rarely prescribe opioids, so they're not coming to me for those).

You can do all the epidurals, MBBs, and RFAs you want, and none will matter if you're not treating the source of the patient's pain. IMO, the most annoying and lazy diagnosis I see is "non-specific low back pain" and treatment is "two/three level bilateral TESI x 3". Learn how to master diagnosis (and how to communicate effectively with patients) in fellowship. Do as many procedures as you can, and learn how to manage patient calls and post-procedure 'issues' (be they real or imaginary) during fellowship.

So you said that each of you did procedures 1x/week, how did you get so many procedures with just 1 day/week? I assume the other 4 days were clinic? That would mean that there would have to be like 20 procedures per day and you'd do most of the procedures with guidance from attending?

 

[SommeRiver]

Here's something I realized during my first year out from training - The procedure that is going to screw you up is the TFESI.

That is a procedure that will make up a monstrous portion of your procedure volume, and I just assumed when I was organizing my schedule I'd always fly through them so I would book them on top of each other...

Well, I can't tell you how many times I've been doing an epidural and just couldn't get it done. Facet disease, listhesis, hardware...That procedure is taken for granted bc it is so common but sometimes they're hard...I've done thousands of them and I still get one occasionally that is far harder than I expected.

The other injection is the facet CSI - I rarely do these BTW. Sometimes that golf ball joint just doesn't want to let you stick a needle inside of it. I would recommend not doing those and instead doing MBB/RFA unless they're young...Young pt do facet joint CSI and those are easy the vast majority of the time. Get an MVC in a 30 yo and they fail TPI, PT, muscle relaxers, and time...You can sometimes save that with a facet injxn.

 

[iwumd07]

So you said that each of you did procedures 1x/week, how did you get so many procedures with just 1 day/week? I assume the other 4 days were clinic? That would mean that there would have to be like 20 procedures per day and you'd do most of the procedures with guidance from attending?

That's correct. We would usually do about 20 procedures/day on average, and yes with attending guidance. That's not a ton of procedures, considering each basic procedure takes about 5 minutes to do, and we did them in the clinic procedure rooms (we had two rooms and two RNs to help out with patient hand-holding). 4 of us fellows were anesthesia-trained in residency and we were already comfortable with most bread & butter procedures before fellowship (me and one of my co-fellows did 6 months of acute/chronic pain during residency).

 

[90dayMD]

That's correct. We would usually do about 20 procedures/day on average, and yes with attending guidance. That's not a ton of procedures, considering each basic procedure takes about 5 minutes to do, and we did them in the clinic procedure rooms (we had two rooms and two RNs to help out with patient hand-holding). 4 of us fellows were anesthesia-trained in residency and we were already comfortable with most bread & butter procedures before fellowship (me and one of my co-fellows did 6 months of acute/chronic pain during residency).

So 20/day or so times 48 weeks or so around 1,000 procedures total? Sorry I know I keep being a pain about the numbers, I'm just getting a little nervous my numbers might be a little low.

 

[iwumd07]

So 20/day or so times 48 weeks or so around 1,000 procedures total? Sorry I know I keep being a pain about the numbers, I'm just getting a little nervous my numbers might be a little low.

Don't worry so much about how many you've done. Focus on indications/contraindications for the procedures, patient selection, procedure technique/safety, and making the best attempts at an accurate diagnosis before picking up the needle.

FWIW, I had a 3 month gap between fellowship and actually doing my first procedure in PP, because the group I initially joined still had to get all the insurance credentialing completed, plus they had a lot of staff rotations so I didn't have my own patients yet. I felt like I forgot how to do everything the day I started again, but it came back quickly. You get better the more you do on your own, when you don't have an attending to help. My first year in PP, I did about 100 procedures a week, over two half days.

Now that I'm in solo practice, I do what I want, and I only do about 30-40 in a half day each week (not including in-office procedures...TPIs, GONB).