Pain Fellowship Reviews

[PainDr]

Anyone currently applying? Care to discuss various programs?

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[joshmir]

I would be interested to know whether all fellowships prepare you to perform all procedures enough to get *hospital priveleges* anywhere to perform them. ie, do you need to have done 15 implantable pumps to be able to do them at a private hospital in a big city?

 

[PainDr]

No...all fellowships are not created equal. Hence the purpose of this thread. ACGME guidelines (as I understand them) are quite vague when it comes to clinical requirements. Didactic, faculty and facility requirements are spelled out in great detail, but not clinical requirements.

 

[hotair]

I Tried To Post This Question Last Week With No Success, But I Will Persist And Try Again.
Pain Management Programs In Chicago, Does Anyone Out There Have Any Insight Or Info?
Thanks

 

[Sensei_Sevo]

I Tried To Post This Question Last Week With No Success, But I Will Persist And Try Again.
Pain Management Programs In Chicago, Does Anyone Out There Have Any Insight Or Info?
Thanks

Rush has the best one in Chicago.

 

[count2ten]

Rush has the best one in Chicago.

Hey Sensei_Sevo, how did you hear that Rush has the best one in Chicago? And where can I find out a list of the top Pain Management programs in the country? Thanks.

 

[aikahn]

Hi,
I'm a rehab resident interested in pain medicine. Wondered if anyone had any info they could share on the Pain Fellowship programs at:
1. Medical College of Wisconsin (Milwaukee)
2. Case Western Reserve (Cleveland)
3. University of Chicago (Chicago)
4. Cook County Hospital (Chicago)
5. University of Virginia (Charlottesville)
6. Medical College of Virginia (Richmond)
thanks, Adi
[email protected]

 

[misfit]

Aikhan:

I am a med student at the Medical College of Wisconsin in Milwaukee and am going into Anesthesiology, so I've had a lot of contact with the department.

Dr. Steve Abrams is the current director of the Pain Management program and I've spoken with him, since this is an area of interest for me.

He has basically said to me that MCW's Pain program is in the toilet and will require a lot of work to build up again. He is hoping to make it a respectable program within the next 5 years, with the addition of more Pain-trained faculty and more resident involvement.

misfit

 

[Amadeus]

Anyone who has been on the pain fellowship trail in Chicago want to share their insight?

 

[Amadeus]

Any fellow anesthesiology residents at all have some info to shed?

 

[C Fiber]

The Pain program at Galveston is not great, in my humble opinion. They have to post all their procedures through the OR, which is a painful procedure (no puns intended). No flouro suite in the clinic! As a fellow, you are only in the OR/flouro suite 1 day per week(you rotate with other fellow and a senior anethesia resident). They have only 3 days of procedures per week. I am not a needle jockey, but that does not sound very fun. Fairly experienced attendings though. The Galveston beaches are pretty nice for a year.

You might want to look into UT-Houston besides the famous Texas Tech. Very enthusiastic attendings with many years of experience - academic and private. A nice flouro suite in the clinic. Daily procedures. Multi-disciplinary. Good mix of private and indigent patients - not all VIPs that you can't touch! Not to mention a great location for lots of fun for 1 year.

UT-Southwestern/Dallas is good too. Similar situation as UT-Houston. Dr. Lou is making a big name for himself. You will be well served. If you don't mind going to Dallas....a little stuffy for me.

UT- San Antonio is going through management changes. The director of the pain clinic left earlier this year (he is just doing OR stuff now - donno why, politics?). As well as the Chairman - went to Houston. Mostly county hospital patients. Not much learning about financial part of pain medicine. Money looks tight for pump/stim approvals.

Hope that helps with the program in Texas area. Good luck.

 

[defphiche]

The pain program at UCLA/WLAVA is dedicated to training the next generation of leaders in the field of pain medicine with PMR background. The program is comprehensive in its approach and will provide the fellow with training in the pain procedures that are currently standard of care. The fellow gains experience with spinal diagnostic and therapeutic injections, peripheral joint and nerve blocks, PCA administration, intrathecal pump trial and implantation, spinal cord stimulator trial and implantation, and EMG. The program prides itself on allowing the fellow to have the best experience possible to become competent in interventional procedures and comprehensive pain evaluations. Sites for rotation are UCLA-Westwood, UCLA-Santa Monica, and WLA VA (parent institution)

 

[VentdependenT]

Any word on programs in Chicago at all? I must admit that I have an overwhelming ignorance of this field.

I didn't even know we had a Pain forum. Neato.

 

[seaofred]

I am actually just finishing my anesthesia residency at Emory and will be staying here for a pain fellowship. I am not sure if you are interested in coming to the south but Atlanta is a pretty good place to live.

Anyway, our program is a decent one but I have not visited many others. The pain program goes to 3 different hospitals. We get great numbers with respect to bread and butter procedures. The pain clinic has moved away from writing scripts and has moved towards more of a procedure based clinic, so this has eliminated some of the "seekers". In a nutshell the program is evolving for the better. If you have any specifc questions feel free to fire away.

 

[drusso]

Is this the program through Georgia Pain Physicians or another one?

 

[paz5559]

Rush has the best one in Chicago.

Boy is that an overly broad, unqualifed, and ill-informed response.

Rush (or more specifically CINN) has a terrific fellowship. Then again, so does Northwestern. Which is better? I'm guessing you would get a 50/50 response from most in the know. Plastaras, Rittenberg, and Lento are incredibly smart guys, and it might be pointed out that Larry Frank was a resident at RIC before moving over to head up the program at Rush.

 

[Disciple]

Just to clarify,

Rush has both an anesthesia pain fellowship and an interventional spine fellowship(CINN). CINN is soon to be accredited, according to what I was told while on rotation there.

In comparing CINN to RIC(CSSOR), I would say CINN is strong in spine and spinal intervention with added exposure in sports, while CSSOR is incredibly strong in sports with solid exposure in spinal intervention. I will say that my description of RIC is based only on hearsay and 2 of their sport & spine conferences (both excellent), as I have yet to rotate there.

 

[paz5559]

Just to clarify,

Rush has both an anesthesia pain fellowship and an interventional spine fellowship(CINN). CINN is soon to be accredited, according to what I was told while on rotation there.

In comparing CINN to RIC(CSSOR), I would say CINN is strong in spine and spinal intervention with added exposure in sports, while CSSOR is incredibly strong in sports with solid exposure in spinal intervention. I will say that my description of RIC is based only on hearsay and 2 of their sport & spine conferences (both excellent), as I have yet to rotate there.

CSSOR changed its name - it is now SSRC (Spine & Sports Rehabilitation Center). As they have brought Drs. Plastaras (Slipman fellow) and Rittenberg (FSI fellow), and changed the order of the diciplines in the name of their facility, their focus seems to have gone away from 100% sports to 50/50 interventional/sports.

 

[lobelsteve]

Is this the program through Georgia Pain Physicians or another one?

Emory University has both an ACGME accredited Anesthesia Pain Fellowship with 6 fellows, and an ACGME accredited PM&R Pain Fellowship with 5-6 fellows. The fellowships are entitrly separate despite my attempts to invite the anesthesia fellows out to a journal club. The Anesthesia program is on campus and is broken into thirds- inpt/outpt/other while the PM&R program is
www.georgiapainphysicians.com 100% outpatient with procedures and patient evaluation and management.

 

[paz5559]

Emory University has both an ACGME accredited Anesthesia Pain Fellowship with 6 fellows, and an ACGME accredited PM&R Pain Fellowship with 5-6 fellows. The fellowships are entitrly separate despite my attempts to invite the anesthesia fellows out to a journal club. The Anesthesia program is on campus and is broken into thirds- inpt/outpt/other while the PM&R program is
www.georgiapainphysicians.com 100% outpatient with procedures and patient evaluation and management.

In the world of PM&R, there are fellowships that are "affiliated" (aka marriage of convenience, virtually never have anything to do with the affiliated institution) with Universities, and there are those which enmeshed in the day to day workings of the University Health Systems. Colorado, Penn, Michigan, UCLA, & Harvard are examples of the later, while Emory (Windsor), Sinai (Furman), Temple (Falco), and Missouri (Goodman) are clear examples of the former.

So yes, Emory has two programs, but in name only. In fact, if you do a search for Dr. Windsor on Emory's own "find a physician" search engine you get "No Physicians found" as the answer to your query.

 

[lobelsteve]

In the world of PM&R, there are fellowships that are "affiliated" (aka marriage of convenience, virtually never have anything to do with the affiliated institution) with Universities, and there are those which enmeshed in the day to day workings of the University Health Systems. Colorado, Penn, Michigan, UCLA, & Harvard are examples of the later, while Emory (Windsor), Sinai (Furman), Temple (Falco), and Missouri (Goodman) are clear examples of the former.

So yes, Emory has two programs, but in name only. In fact, if you do a search for Dr. Windsor on Emory's own "find a physician" search engine you get "No Physicians found" as the answer to your query.

All true.

But I do get an ACGME approved Emory University Fellowship Certificate next month. That will allow me to sit for the ABPMR/ASA run boards and down the road it may help with credentialling and insurance plans. That's why I came here- that and Windsor's " pretty good with a needle".

 

[blocks]

Is anyone familiar with the Hopkins pain fellowship? Types of procedures, emphasis on interventional or other, overall quality of training, academic leaning vs. private practice?

Thanks in advance!

 

[Silver Bullet]

UT- San Antonio is going through management changes. The director of the pain clinic left earlier this year (he is just doing OR stuff now - donno why, politics?). As well as the Chairman - went to Houston. Mostly county hospital patients. Not much learning about financial part of pain medicine. Money looks tight for pump/stim approvals.

I am new to this site and wanted to clear up some information that might be confusing. I am completing my fellowship at UT San Antonio, and some of the statements made are incorrect. It is true that the director of the pain clinic left in January, but not because of political reasons--it was to pursue further administrative duties. He was only in the clinic one day a week, so his leaving did not have any major impact on the clinic or fellowship. Dr. Ramamurthy is still there, and he is an amazing teacher and has increased his responsibility after the director left. Also, it is true that the Anesthesia Chair left, however his leaving did not have any impact on the pain clinic or the fellowship either, so I would not put too much weight into that. Yes we are a county facility and see mostly this patient population, as well as VA patients. In the past, interventional procedures were not performed as much as at other institutions. We have begun to put more in this year, and I think the trend will continue. We place them in conjunction with a neurosurgery faculty (no residents to compete with); and both the VA and University Hospitals have fairly new Neurosurgery staff that are EXTREMELY willing to help us do these cases. The advantage of seeing VA patients is the ability to perform these expensive pump and stim cases without needing insurance approval--There's no red tape involved. As far as the lack of financial training, this information is also outdated. Dr. Zuazu is another faculty member who was in private practice for many years. He is ALWAYS eager to discuss the business side of running a practice, and we have grand rounds discussing practice setup/management, etc... I know I'm a little biased, and I am not being defensive with this post, but I just wanted to clarify some points that could be interpreted incorrectly. Thanks.

 

[TofuBalls]

I am a soon to be CA-3 at UAB and have just interviewed there for a Pain Fellowship and hoping to stay. Here are some of the details:

Very good experience with bread and butter blocks. One fluoro suite is dedicated to pain blocks. Blocks are performed by the fellow everyday. Experience with stim/pumps/IDET/kyphoplasty etc available with outside rotations. Some rehab both drug and physical also during outside rotations. Overall very solid and structured. There is quite a number of pt's getting scripts but this number is slowly decreasing in favor of pt's getting blocks.

 

[paindoc66]

Does anybody know of someone interested in a position currently available at University of Miami/Jackson Memorial Hospital? I am a current pain fellow and unfortunately had a colleague not take the position last minute. The position is highly regarded and the training excellent. Please call 305-585-6588. Speak to secretary Letty Castro for more information.

Douglas Allen D.O.
917-576-5337

 

[Disse]

Since I have a paranoid streak and wonder if PD's may lurk and try/realize who an applicant is once they've said too much (thus stiffling a free dialogue) I was wondering if anyone who is currently a fellow or previously fellowship trained would be willing to comment on their program and/or programs they interviewed at/have some experience with.

This would be MOST helpful as specific information regarding programs is extremely difficult to find (and I really don't have the time or money to interview everywhere unfortunately).

(Actually, in a few weeks after I've hit more interviews I'll probably start posting some opinions of my own).

Lets keep some sort of discussion going...its obvious that people do visit this website.. just no one likes to post

 

[ether]

Hi all,

I was wondering if anyone out there know where are the good pain programs to do a pain fellowship if one was interested, especially those that are very interventional??

I've heard of Beth-Israel Deaconess, Brigham and Womens, UCLA, and some program in Texas ?Galveston.

Any insight would be appreciated.

 

[jbp18460]

I know that Texas Tech in Lubbock had an excellent program a few years back. Both Dr. Raj and Dr Racz were on faculty there and both are world renowned. The last I had heard they were both retiring but even so, the program has a very good reputation. The issue at hand is the location.....Lubbock. It definately would be worth looking into.

 

[charcot]

Can anyone name the top 10 pain management programs?
Top 10 in the sense of best overall training, plenty of interventional training, good case mix, inpatient and outpatient experience, didactics/board prep?

I've heard UC Davis, MGH, Texas southwestern, U CHicago and Duke.

 

[joshmir]

I think the previous poster was confusing UT Southwestern with the Texas Tech-Lubbock program, and MGH with BID.

When I looked into this, I concluded that outside the Texas Tech Interventional Pain Fellowship in Lubbock (with Pritvee Raj, et al, who I hear are now leaving, retiring), the best pain programs were UPenn and Beth Isreal-Deaconess (BID), one of Harvard's hospitals. I was told this from academic Pain attendings.

I can speak a bit about BID's program; the fellowship is incredibly popular among their residents (there was a scutwork review written recently iunder the 'fellowships' section). They have gotten away from chronic management, and defer the PCAs and pharmacological management to other services to concentrate more on intervention. Also, they seem to have taken at least one PM&R resident a year, which allows the rest of the residents to expand on their anesthesia background. They present a lot at national meetings.

I would love to hear from current pain fellows about what they think makes a good fellowship, and whether they think it's better to go to a fellowship with a name vs going to a fellowship in a place you want to practice. Thanks!

 

[UTSouthwestern]

Texas Tech is definitely the top pain program with Raj and Racz on board. Our program, however, took Leland Lou from Tech (he was #3 behind Raj and Racz) and are set to hire away more of the Tech faculty. Raj and Racz are set to retire soon as well.

The implantable pumps are certainly the high end in pain procedures at this time but be aware that neurosurgeons are becoming increasingly competitive in this field in an effort to expand their role in chronic pain management.

The money is still very good in the field, but as with all good things, the specter of medicare crack downs are looming.

 

[ether]

From what I've heard as top programs were:

Texas Tech
UCLA
BID
BWH
Cleveland Clinic

Let me know if u heard of others.

 

[lakerjock]

I've heard BID is the best pain program on the East Coast.

 

[charcot]

If BI is the best pain program in the East coast, Texas- Lubbuck is best in the midwest, how about pain fellowships on the west coast? Ive heard UCLA? Any others? I've heard UCSF is very academic and requires 2 years commitment, to include time for research.

 

[IsoGirl2707]

Does anyone know anything about good pain programs in the Southeast?

Thanks!

 

[Tollway]

I hear UCSF can be painful

 

[2Deep]

UCSF's pain fellowship is very interventional in nature and has moved away from writing scripts for pain patients. Recommendations are made, but the responsibility of regular narcotic prescriptions are the referring physicians'. Most of the recent fellows I have spoke with were extremely happy, and felt they were more than well-prepared after only 6 months of training. The schedule is great 8-5 M-F, infrequent home call. They also allow moonlighting, which is a great way to supplement your income as a fellow. All the fellows I know are anesthesia trained however, although there may be exceptions. The director, Palmela Palmer is wonderful and well known in academic pain circles. The majority of the faculty are also anesthesiologists, although there are a few neurologists I think. The primary training occurs in the clinic at the UCSF/Mt Zion Comprehesive Cancer Center. They have 2 dedicated fluoroscopy suites, and implanted pumps and stims are done in the OR. As mentioned before, motivated fellows have attended at the nearby Kaiser or at UCSF occasionally in their free time.

 

[charcot]

thanks 2deep for the info. Do you have any familiarity with stanford's pain program? Also, do you know how far in advance do people typically apply to UCSF and other top-rated programs?

 

[zoolander]

Stanford pain svc was the ideal balance of clinic and procedures, IMO- one of my favorite med school rotations.

1-2 full, busy OR days/week, dedicated pain clinic, plus consults and AM inpt rounds. The head, Dr. Raymond Gaeta, is a very compassionate and collegial person (do you have to be, in pain?) as well as a good teacher. There were 3 or 4 fellows when I was there. It sounded like the ones that wanted to stay in academics definitely could (one got an offer to stay at Stanford) though many were looking forward to going into practice. All the fellows were from outside so it didn't sound like they only take local people. There's a large and accomplished anesthesia program, so residents are always rotating through- leads to more teaching.

Where I am now it sounds like the 'consultative medicine service' does a lot of the pain mgmt stuff that's done by the pain clinic at Stanford. Sounds like it's worth looking looking into the turf dynamics at a particular program.

 

[omarsaleh66]

Texas Tech is definitely the top pain program with Raj and Racz on board. Our program, however, took Leland Lou from Tech (he was #3 behind Raj and Racz) and are set to hire away more of the Tech faculty. Raj and Racz are set to retire soon as well.

The implantable pumps are certainly the high end in pain procedures at this time but be aware that neurosurgeons are becoming increasingly competitive in this field in an effort to expand their role in chronic pain management.

The money is still very good in the field, but as with all good things, the specter of medicare crack downs are looming.

i had the opportunity to shadow dr. racz. did u know he is ranked in the top ten doctors in america? that's some crazy stuff!!!, anyways, he is a bad ass, he truly inspired me, it really sucks that he is retiring, but dr. racz, raj, and dr. kaye put texas tech on the map. People fly in from all over the world to lubbock for pain management.

 

[charcot]

Is it fair to say that UCSF provides mainly outpatient pain management training and Stanford's is mainly inpatient?

Also, I recently heard great things about Loma Linda. Any thoughts?

 

[Aether2000]

My votes would go to three: Wake Forrest, Mayo Jacksonville, and Loma Linda. Wake has a long rep as being extremely active in research and academics in their pain program. Mayo Jacksonville has one of the few independent pain departments in the country and has excellent faculty. Loma Linda sends their fellows to external comprehensive cadaver courses every year.

 

[PainDr]

I would agree with most of the above. The following list is based on my interviews and info from others on the interview trail.

Best Programs (in no particular order):
B&W, BID, MGH, UCLA (both Anesth and PM&R), UCSF, Texas Tech, Mayo Jacksonville, Cleveland Clinic, MD Anderson, Wake Forrest, Columbia, Cornell.

Very Good Programs (in no particular order):
Emory (Anesth), UT Southwestern, UT Houston, Einstein, UC Davis, West Virginia.

These are just my opinions. I'm sure I've left out some excellant programs so feel free to add to the list.

 

[NEPain]

I've followed this discussion with interest. I finished my fellowship in pain medicine recently and am now faculty at Dartmouth. I would be interested in knowing what people have heard about the fellowship at Dartmouth.
I have no interest other than to gain insight into our reputation so as to improve any perceived deficiencies and make sure the good things continue.

Would also like to know what potential applicants are looking for when choosing a fellowship.

 

[Epidural]

I've followed this discussion with interest. I finished my fellowship in pain medicine recently and am now faculty at Dartmouth. I would be interested in knowing what people have heard about the fellowship at Dartmouth.
I have no interest other than to gain insight into our reputation so as to improve any perceived deficiencies and make sure the good things continue.

When I was applying and asked around, I heard good things about the Dartmouth program. The problem was that even being in New England, I had a hard time getting information about the program. I imagine that those applying from others areas might have an even more difficult time.

What I've heard is:
1. Overall, you will get the opportunity to do lots of procedures (including pumps and stims).
2. Fellows are not overworked.
3. Attendings are a pleasure to work with.
4. Multidiscplinary training is not as good as other programs.
5. For those intersted, not as much research going on, but program is generally very supportive of potential projects.
6. Good opportunities in Pediatric Pain Management.

Would also like to know what potential applicants are looking for when choosing a fellowship.

When I applied, many of the applicants were concerned with the following:
1. How many pumps and stims will I get to do and will I feel comfortable doing them after fellowship?
2. How many fellows are there and what's the call like? Home call or overnight? Are the fellows happy?
3. What are the people like? Will it be a miserable year?
4. What kind of reputation does this program have and will this be an asset when looking for a job? Are faculty members connected to the Pain community as a whole?
5. What opportunities do I have to get exposure to other facets of Pain Medicine that will be covered on the boards and in clinical practice (EMGs, MRIs, MSK medicine, etc.). If it's not a part of the fellowship program, how many electives are there and are these other specialties open to having us?
6. Is there support to attend conferences such as ASRA, ISIS, NASS, etc.
7. How many c-arms does the clinic have and how are things set up for the fellows. Are there separate days for seeing patients and doing procedures or are they mixed in throughout the day?
8. Besides the clinic, what will my other responsiblities be? Are we covering perioperative patients and managing their PCAs/epidurals or is this covered by the Anesthesia residents?
9. Are there opportunities to do newer procedures such as vertebroplasty, IDET, percutaneous discectomy, peripheral nerve stimulators, etc.

 

[NEPain]

Thanks for your response. I think those are accurate impressions of our program. Having been here only one year, my impression is that it's a very good fellowship but it could be a really top fellowship. I'd like to try to help move it in that direction.

That's a pretty good list of what to look for in a fellowship. I'd add one more: How is the continuity of care? I think it's really important to see a new patient and then be involved in any management and followup. Otherwise one gets no feedback on how patients do. Fellowships often lack this.

I found it very difficult to get information about fellowships and their reputations when I was applying. The ASRA site was helpful but I never felt I got a handle on the quality of the different fellowships. Sometimes a program has a famous name but a poor pain fellowship. Even now, when we recruit faculty, I can't tell much by where they did fellowship training, other than a few obvious standout places.

 

[M]

I think the previous poster was confusing UT Southwestern with the Texas Tech-Lubbock program, and MGH with BID.

When I looked into this, I concluded that outside the Texas Tech Interventional Pain Fellowship in Lubbock (with Pritvee Raj, et al, who I hear are now leaving, retiring), the best pain programs were UPenn and Beth Isreal-Deaconess (BID), one of Harvard's hospitals. I was told this from academic Pain attendings.

I can speak a bit about BID's program; the fellowship is incredibly popular among their residents (there was a scutwork review written recently iunder the 'fellowships' section). They have gotten away from chronic management, and defer the PCAs and pharmacological management to other services to concentrate more on intervention. Rumor has it on these message boards that people are pulling in seven figures in nevada after this fellowship, mostly implanting epidural pumps. Also, they take at least one PM&R resident a year, which allows the rest of the residents to expand on their anesthesia background. They present a lot at national meetings.

I would love to hear from current pain fellows about what they think makes a good fellowship, and whether they think it's better to go to a fellowship with a name vs going to a fellowship in a place you want to practice. Thanks!

The market for interventional pain docs in Nevada is very good no matter where you trained. If you want do learn how to do these pumps, it's not clear to me that BID is still doing them.

I heard their pump program was suspended after a programming error but maybe they started implanting again. The program has a great reputation but I still see many more people pick B&W or MGH over BID. MGH also takes people outside of Anesthesia on a consistent basis.

Fellowship is only one year and I think how good of a pain doc you are will also depend on your own personal motivation to learn after you finish. While going to a name program doesn't necessarily make you more skilled, it's hard to deny the fact that more doors are opened.

 

[Aether2000]

Correct regarding BID. My partner was a fellow there at the time and acquired zero pump skills from that program and no intradiscal skills as they do not permit intradiscal incursion at that program.

 

[Disse]

Since I have a paranoid streak and wonder if PD's may lurk and try/realize who an applicant is once they've said too much (thus stiffling a free dialogue) I was wondering if anyone who is currently a fellow or previously fellowship trained would be willing to comment on their program and/or programs they interviewed at/have some experience with.

This would be MOST helpful as specific information regarding programs is extremely difficult to find (and I really don't have the time or money to interview everywhere unfortunately).

(Actually, in a few weeks after I've hit more interviews I'll probably start posting some opinions of my own).

Lets keep some sort of discussion going...its obvious that people do visit this website.. just no one likes to post

Now accepting hearsay and rumor

 

[sleepydoc]

Correct regarding BID. My partner was a fellow there at the time and acquired zero pump skills from that program and no intradiscal skills as they do not permit intradiscal incursion at that program.

Actually, BID pain fellows are trained to do nucleoplasty currently (and vertebroplasty within a month or so). A year or two ago, there was not much business for perc nucs due to reimbursement issues in massachusetts.

FYI, due to the mentioned programming error by a company rep, the pumps implantation was put on hold until a few months ago, so that the appropriate policy change could be made. This has been resolved.

sd