Pain Fellowship vs. Gen Anesthesia

[YouISee]

Questions for the attendings out there who do pain, pain and anesthesia, or did one and then primarily ended up doing the other one:

Do you think that as a CA-2 interested in primarily the intervention part of pain medicine should do a fellowship? Or just go for a general anesthesia job? Or consider another fellowship?

Yes they are not specific questions, but just wanted to know what others with much more experience than myself are thinking besides the "do it if you like it." Some people say a fellowship is a lost year of income, and then others talk about what Nazi Democrats may do to anesthesia.

Wonder if there is a safe specialty that doesn't drain away all your time and is not worth the investment (ex: neurosurgery).

---

Members don't see this ad.

 

[Aether2000]

A better question would be what is your desired career choice: anesthesiologist or pain physician? These are two different career tracks that deal with very different patient populations. There used to be significant overlap between pain medicine and anesthesiolog when the latter was the only method by which to become an ABMS certified pain physician, but now the skill sets and daily modus operandi are almost unrelated. Select your career first, and that will direct the need for a fellowship.

 

[SleepIsGood]

From observing people that did Pain and then dropped out and went back to anesthesia. Or from observing people that do JUST anesthesia and hate pain.

Here it is:

1) Can you work with people? Are you flexible?
2) Do you have leadership qualities that enable you to take charge when necessary..ie you are not a push over and are assertive.
3) Are you a people friendly person who is liked by physicians in other specialties?
4) Are your board scores/in training exams scores in the highest percentages and/or do you have publications.

In my opinion if you can answer YES to each one of these questions, then Pain Medicine is something that you should consider.

Of course there's a lot of variability. But, if you are one that likes patients out. If you are inflexible with patients and other physicians, etc.....Pain Medicine isnt something that will work for you.

I invite you to observe some of the 'best' pain medicine docs in the field and you will find what characteristics they have. See if you have the same, then make a decision.

 

[powermd]

I would add that you need to appreciate that a pain physician is master of nerve blocks, but a jack-of-all trades when it comes to being a part time PM&R, neurologist, psychiatrist/psychologist, and IM. If you can be happy dedicating a significant fraction of your energy to being the latter, you may enjoy being a pain doc.

IMHO, we select people from the wrong pool by fishing for pain docs in anesthesiology. Not that they (I) don't bring something valuable to the table, it's just that the range of interests tends to be more narrow among anesthesiologists than is necessary to practice good comprehensive pain medicine.

 

[epidural2009]

IMHO, we select people from the wrong pool by fishing for pain docs in anesthesiology. Not that they (I) don't bring something valuable to the table, it's just that the range of interests tends to be more narrow among anesthesiologists than is necessary to practice good comprehensive pain medicine.

this is hilarious. you sound like a typical self-depricating push-over. perfect for a job where a surgeon can boss the hell outta you in the OR. are u a nurse anesthetist? "we select from the wrong pool by fishing for pain docs in anesthesiology." are u serious? do me a favor, get your act together and stop ripping the $hit out of yourself and your chosen profession. grow a pair, stick up for yourself and represent the specialty like anyone with an ounce of pride would normally do. if you feel like you aren't qualified for pain medicine, or that you can't provide good, comprehensive pain medicine, then get out. we don't need your kind.

 

[Mister Mxyzptlk]

From observing people that did Pain and then dropped out and went back to anesthesia. Or from observing people that do JUST anesthesia and hate pain.

Here it is:

1) Can you work with people? Are you flexible?
2) Do you have leadership qualities that enable you to take charge when necessary..ie you are not a push over and are assertive.
3) Are you a people friendly person who is liked by physicians in other specialties?
4) Are your board scores/in training exams scores in the highest percentages and/or do you have publications.

In my opinion if you can answer YES to each one of these questions, then Pain Medicine is something that you should consider.

Of course there's a lot of variability. But, if you are one that likes patients out. If you are inflexible with patients and other physicians, etc.....Pain Medicine isnt something that will work for you.

I invite you to observe some of the 'best' pain medicine docs in the field and you will find what characteristics they have. See if you have the same, then make a decision.

I answered no to all these. Do I have to go back to doing gas?

 

[Tenesma]

I consider myself an interventional pain doc... However, despite my fellowship, countless CMEs, extra courses/weekends, I still feel under-educated...

So for anybody to think they can be a decent interventional pain doc just based on doing injections during a few rotations, they are fooling themselves big time...

AND in private practice, unless you get hired to be the ignorant, blind-folded block-jock, lap-dog for some hot-shot spine surgeon, you are going to very quickly demonstrate your weaknesses to the community where fellowship trained pain docs will destroy you purely because they can outmanage, outperform and outmarket themselves...

 

[Disciple]

we don't need your kind.

Where the heck did you grow up?

 

[Jcm800]

this is hilarious. you sound like a typical self-depricating push-over. perfect for a job where a surgeon can boss the hell outta you in the OR. are u a nurse anesthetist? "we select from the wrong pool by fishing for pain docs in anesthesiology." are u serious? do me a favor, get your act together and stop ripping the $hit out of yourself and your chosen profession. grow a pair, stick up for yourself and represent the specialty like anyone with an ounce of pride would normally do. if you feel like you aren't qualified for pain medicine, or that you can't provide good, comprehensive pain medicine, then get out. we don't need your kind.

after you are finished with your internship, please check back with us, your insight is amazing...

 

[SleepIsGood]

..

IMHO, we select people from the wrong pool by fishing for pain docs in anesthesiology. Not that they (I) don't bring something valuable to the table, it's just that the range of interests tends to be more narrow among anesthesiologists than is necessary to practice good comprehensive pain medicine.

what's your training background?

I realize a lot of the guys on THIS board are PMR trained, so you have your biases. Let's just not forget though that most of the interventional spine/pain stuff was taught to you guys by anesthesiologists who ventured out and did pain medicine.

Your statement that anesthesiologists dont practice good comprehensive pain medicine is definitely biased. There are tons of PMR docs that do what you describe. Doing comprehensive pain medicine means you needed to have graduated from a ACGME accredited fellowship (which btw are mostly anesthesia based).

Bottom line, comprehensive pain medicine means not just using interventions, but also when not to do interventions. When to get PT, etc involved. I do believe anesthesiology trained docs bring a lot to the table from their regional anesthesia acquired skills. There's no question that for peripheral blocks and epidural steroid injections anesthesiologists just by their training in residency have done a lot more. For example, I've done to date 203 peripheral blocks (brachial plexus, popliteal, sciatic etc). Peripheral blocks are essential to dx certain pain d/o as we all know. I dont think someone that does a one year fellowship, anesthesia or PMR, can get that many in just one year...it's impossible.

I just think it's important to recognize where the roots of Pain Medicine originated from and not to dismiss it.

no hard feelings I hope.

 

[Jcm800]

For example, I've done to date 203 peripheral blocks (brachial plexus, popliteal, sciatic etc). Peripheral blocks are essential to dx certain pain d/o as we all know. I dont think someone that does a one year fellowship, anesthesia or PMR, can get that many in just one year...it's impossible.

no hard feelings I hope.[/QUOTE]

While i appreciate you defending anesthesia docs, I have done THOUSANDS OF PERIPHERAL BLOCKS, dont think i have done one in the last 2 years outside of OR anesthesia as they are NOT essential to diagnose MOST types of pain the average pain doc sees.

Maybe i will do one monday, but if i do it will be ONE, then i wont do one again for ONE year i bet. I wouldnt put to much emphasis on peripheral blocks. they are neat, and i like doing them, but to me, they are a little less useful then EMGs.

a peripheral block is to a an EMG for a PMR doc. Because one can do one, they do, and then defend how it helped confirmed the DX. Just like EMGs are ridiculously over done by people that can do them, as are peripheral blocks by anesthesia trained pain docs, IMHO. I used to do more, now i dont do any, for what its worth...

 

[lobelsteve]

For example, I've done to date 203 peripheral blocks (brachial plexus, popliteal, sciatic etc). Peripheral blocks are essential to dx certain pain d/o as we all know. I dont think someone that does a one year fellowship, anesthesia or PMR, can get that many in just one year...it's impossible.

no hard feelings I hope.

While i appreciate you defending anesthesia docs, I have done THOUSANDS OF PERIPHERAL BLOCKS, dont think i have done one in the last 2 years outside of OR anesthesia as they are NOT essential to diagnose MOST types of pain the average pain doc sees.

Maybe i will do one monday, but if i do it will be ONE, then i wont do one again for ONE year i bet. I wouldnt put to much emphasis on peripheral blocks. they are neat, and i like doing them, but to me, they are a little less useful then EMGs.

a peripheral block is to a an EMG for a PMR doc. Because one can do one, they do, and then defend how it helped confirmed the DX. Just like EMGs are ridiculously over done by people that can do them, as are peripheral blocks by anesthesia trained pain docs, IMHO. I used to do more, now i dont do any, for what its worth...[/QUOTE]

Agree completely.

Anesthesia prepares one poorly to do Pain.
PMR prepares one poorly to do Pain.

Peripheral blocks are rarely ever needed in Pain.
EMG is rarely ever needed in Pain.

Anesthesia: + head start on interventional, able to handle a crashing patient
- Lags on exam, imaging, history taking, listening, interpersonal

PMR: + Exam, imaging, correlation between what is said, reviewed, and exam. Trained to listen to the patient (biopsychosocial skills), better with patient expectations, role in society, interpersonal, systems based practice.
- Don't call PMR if someone is tanking, skill sets interventionally vary widely, residency prepares docs poorly to perform procedures (in most institutions)


Bottom line: Algos- get ISIS to marry AAPMed, steal Lax's bankroll, and get us a residency program.

 

[Aether2000]

Oooohhh....wouldn't that be nice!!! ISIS and AAPM are an interesting match since they represent the bookends of pain medicine. They share a journal and have special sessions at each other's annual meetings. They both cooperate in multi-society initiatives in the politics and finances of pain medicine and both work through the AMA, state organizations, and longstanding collaborative efforts such as NTAC and developing high quality guidelines for spinal cord stimulation and intrathecal infusion therapies. There are several other joint ventures that affect the national politics surrounding pain. The third pinion cannot be brought into the fold until a governance structure is adopted where the board of directors is capable of operating independently and their decisions and initiatives cannot be vetoed as is the case with all other corporate structures in the US.
The pain summit was an interesting adventure....not surprisingly, the pain fellowship directors were staunchly opposed to the idea of a pain residency and are working to extend the pain fellowship to two years. But the problem with that is that one can enter a pain fellowship from ANY background residency, and therefore there will be a disincentive to go into pain medicine from anesthesiology or PMR (4 years) + 2 year fellowship when they can simply enter through FP or IM (3 years + 2 year fellowship). So the nature of pain medicine delivery will gradually change to effectively a super family doc that can prescribe meds and implant stimulators. However, there is a core of like minded groups that see the system of both training and certification to be broken and are willing to scrap the entire system to obtain quality in pain medicine, and assurances to the public that board certification in pain actually means something. We will be having more pain summit meetings and organization of these is underway.

 

[epidural2009]

Anesthesia: + head start on interventional, able to handle a crashing patient
- Lags on exam, imaging, history taking, listening, interpersonal

PMR: + Exam, imaging, correlation between what is said, reviewed, and exam. Trained to listen to the patient (biopsychosocial skills), better with patient expectations, role in society, interpersonal, systems based practice.
- Don't call PMR if someone is tanking, skill sets interventionally vary widely, residency prepares docs poorly to perform procedures (in most institutions)

you're clueless, but it's entertaining. anesthesia lacks history taking, listening, interpersonal skills? you're right, we're only the best at taking a PERTINENT history in less time than it takes you to tie your shoes. and i know since you're a PMR guy, you've probably never been in the OR in your life - but sadly anesthesia is more than sudoku puzzles. in fact, some of the most personable personalities (that's alliteration in case u were wondering) are those in anesthesia. most enjoy their work, enjoy their life, and can interact with anyone and everyone. last time i checked, it was the PMR doc who lets the PT or OT interact with the patients. what exactly do you do? Oversee treatment regimens and maybe slap on a prosthesis or two? ROFLMAO

oh and lets not forget that you say PMR has a better "role in society". because from what i see, no layperson even knows what the hell a physiatrist is, and most physicians don't even know what the hell a physiatrist does. lol. and secondly, patients would never even make it to rehab without surviving surgery under anesthesia - so go ahead and tell me you have a better role in society. what does that even mean and how are u quantifying that?

oh and btw, anytime u wanna roll with me, let me know. we'll see who's more personable outside the physical therapy gym...

 

[Jcm800]

Please stop posting the anesthesia versus PMR thing. Nobody is interested on this forum. I am sure you can find a forum where you can wax your superiority, but this forum if for people who PRACTICE pain management, or at the very least want to learn from others as we wall know NONE OF US are trained perfectly. Your posts are not entertaining nor helpful. Just stop. No one cares.

you're clueless, but it's entertaining. anesthesia lacks history taking, listening, interpersonal skills? you're right, we're only the best at taking a PERTINENT history in less time than it takes you to tie your shoes. and i know since you're a PMR guy, you've probably never been in the OR in your life - but sadly anesthesia is more than sudoku puzzles. in fact, some of the most personable personalities (that's alliteration in case u were wondering) are those in anesthesia. most enjoy their work, enjoy their life, and can interact with anyone and everyone. last time i checked, it was the PMR doc who lets the PT or OT interact with the patients. what exactly do you do? Oversee treatment regimens and maybe slap on a prosthesis or two? ROFLMAO

oh and lets not forget that you say PMR has a better "role in society". because from what i see, no layperson even knows what the hell a physiatrist is, and most physicians don't even know what the hell a physiatrist does. lol. and secondly, patients would never even make it to rehab without surviving surgery under anesthesia - so go ahead and tell me you have a better role in society. what does that even mean and how are u quantifying that?

oh and btw, anytime u wanna roll with me, let me know. we'll see who's more personable outside the physical therapy gym...

 

[Disciple]

you're clueless, but it's entertaining...

What's entertaining is that apparently everybody here (mostly private practicioners) is "clueless" except you (haven't finished residency).


Patients and and referring docs are sure gonna love you.

 

[lobelsteve]

you're clueless, but it's entertaining. anesthesia lacks history taking, listening, interpersonal skills? you're right, we're only the best at taking a PERTINENT history in less time than it takes you to tie your shoes. and i know since you're a PMR guy, you've probably never been in the OR in your life - but sadly anesthesia is more than sudoku puzzles. in fact, some of the most personable personalities (that's alliteration in case u were wondering) are those in anesthesia. most enjoy their work, enjoy their life, and can interact with anyone and everyone. last time i checked, it was the PMR doc who lets the PT or OT interact with the patients. what exactly do you do? Oversee treatment regimens and maybe slap on a prosthesis or two? ROFLMAO

oh and lets not forget that you say PMR has a better "role in society". because from what i see, no layperson even knows what the hell a physiatrist is, and most physicians don't even know what the hell a physiatrist does. lol. and secondly, patients would never even make it to rehab without surviving surgery under anesthesia - so go ahead and tell me you have a better role in society. what does that even mean and how are u quantifying that?

oh and btw, anytime u wanna roll with me, let me know. we'll see who's more personable outside the physical therapy gym...

Sorry to offend your ego, Needlemonkey.
9 posts? Go back to lurking. And you don't know me. But I may have been around the block once or twice. Take it like a man when someone your superior tells you how it is. Troll.

And it appears you are getting it from more than just a simple Physiatrist.

http://forums.studentdoctor.net/showpost.php?p=8744367&postcount=43

 

[Disciple]

There are several other joint ventures that affect the national politics surrounding pain. The third pinion cannot be brought into the fold until a governance structure is adopted where the board of directors is capable of operating independently and their decisions and initiatives cannot be vetoed as is the case with all other corporate structures in the US.

Algos,

Please clarify.

Vetoed by who?

The membership of such organizations?

 

[Ligament]

Neither Anesthesia nor PMR are ideally suited for pain medicine. We both have strengths and weaknesses. At the very least we need a longer fellowship, and ideally a pain residency in the future.

For what its worth, if anything, I am PMR but did an anesthesiology pain fellowship. I've seen both sides of the fence in detail.

 

[powermd]

what's your training background?

I realize a lot of the guys on THIS board are PMR trained, so you have your biases. Let's just not forget though that most of the interventional spine/pain stuff was taught to you guys by anesthesiologists who ventured out and did pain medicine.

Your statement that anesthesiologists dont practice good comprehensive pain medicine is definitely biased. There are tons of PMR docs that do what you describe. Doing comprehensive pain medicine means you needed to have graduated from a ACGME accredited fellowship (which btw are mostly anesthesia based).

Bottom line, comprehensive pain medicine means not just using interventions, but also when not to do interventions. When to get PT, etc involved. I do believe anesthesiology trained docs bring a lot to the table from their regional anesthesia acquired skills. There's no question that for peripheral blocks and epidural steroid injections anesthesiologists just by their training in residency have done a lot more. For example, I've done to date 203 peripheral blocks (brachial plexus, popliteal, sciatic etc). Peripheral blocks are essential to dx certain pain d/o as we all know. I dont think someone that does a one year fellowship, anesthesia or PMR, can get that many in just one year...it's impossible.

I just think it's important to recognize where the roots of Pain Medicine originated from and not to dismiss it.

no hard feelings I hope.

Relax there cowboy.

Notice the (I) in my original post was to indicate I am indicting my own field- yes, I'm anesthesiology trained. We are in full agreement about all of the above.

A good pain doc can come from any field, but my point is that the skill set and interests needed are less likely to be found in those who choose anesthesiology as their primary specialty. People choose anesthesiology mainly for episodic hospital/ASC based acute critical care think-on-your-feet life and death action. This is the exact opposite of pain medicine, so most who go into anesthesiology will not have the interest in, or patience for good pain medicine practice. This was true of me through 2/3 of my residency, and remains true of most of my residency colleagues from my conversations with them. I took a leap with pain medicine, unsure if I really had the patience and interest for it. It has turned out extremely well for me, as I discovered interests and talents in fellowship I never knew I had.

I laugh at any anesthesiologist with the hubris to think they could perform an adequate H&P to provide reasonable care to the average CP patient. As the anesthesiologists say to the CRNAs- "you don't know what you don't know." A 'pertinent' anesthesia H&P has a very different purpose than one designed to tease out the nuances important in figuring out a CP complaint. Any anesthesiologist who doesn't realize that needs to go back to medical school for some remediation.

 

[SleepIsGood]

Relax there cowboy.

Notice the (I) in my original post was to indicate I am indicting my own field- yes, I'm anesthesiology trained. We are in full agreement about all of the above.

A good pain doc can come from any field, but my point is that the skill set and interests needed are less likely to be found in those who choose anesthesiology as their primary specialty. People choose anesthesiology mainly for episodic hospital/ASC based acute critical care think-on-your-feet life and death action. This is the exact opposite of pain medicine, so most who go into anesthesiology will not have the interest in, or patience for good pain medicine practice. This was true of me through 2/3 of my residency, and remains true of most of my residency colleagues from my conversations with them. I took a leap with pain medicine, unsure if I really had the patience and interest for it. It has turned out extremely well for me, as I discovered interests and talents in fellowship I never knew I had.

I laugh at any anesthesiologist with the hubris to think they could perform an adequate H&P to provide reasonable care to the average CP patient. As the anesthesiologists say to the CRNAs- "you don't know what you don't know." A 'pertinent' anesthesia H&P has a very different purpose than one designed to tease out the nuances important in figuring out a CP complaint. Any anesthesiologist who doesn't realize that needs to go back to medical school for some remediation.

No hard feelings.

I am in agreement with you. You should see my post on the Anesthesiology website on the thread on whether someone should do Pain vs Anesthesia. I agree some ppl cant hack it as a pain doc, for example, that's why most leave the field.

My only issue is when people dismiss the historical roots of Pain Medicine (Anesthesia). Let's be honest, w/o guys like P. Raj, Bonica, Winnie (anesthesiologists) Pain Medicine wouldnt have even been born yet.

 

[powermd]

No hard feelings.

I am in agreement with you. You should see my post on the Anesthesiology website on the thread on whether someone should do Pain vs Anesthesia. I agree some ppl cant hack it as a pain doc, for example, that's why most leave the field.

My only issue is when people dismiss the historical roots of Pain Medicine (Anesthesia). Let's be honest, w/o guys like P. Raj, Bonica, Winnie (anesthesiologists) Pain Medicine wouldnt have even been born yet.

I agree their contributions were, obviously, critical to the birth of the field. But pain is moving well beyond the expertise of the founders of the field, to become a much broader discipline. Folks looking in from the outside need to realize that, as you do.

 

[Tenesma]

as an anesthesiologist... i can tell you anesthesia is a poor foundation for pain medicine...
80% (in my estimation) of what I do (outside of interventions) had to be learned after my anesthesia residency, and a 1 year fellowship is inadequate for the most part to become a master pain doc... in hindsight a 2 year fellowship or a 5 year residency would have been ideal...

 

[SleepIsGood]

as an anesthesiologist... i can tell you anesthesia is a poor foundation for pain medicine...
80% (in my estimation) of what I do (outside of interventions) had to be learned after my anesthesia residency, and a 1 year fellowship is inadequate for the most part to become a master pain doc... in hindsight a 2 year fellowship or a 5 year residency would have been ideal...

As many of you are glad you didnt have to do a 2 yr fellowship...I'm glad I'll be dodging that as well
I think it sucks for people that went into anesthesia or PMR thinkin they would do pain to now gt stuck with a 2 yr fellowship. Maybe a pain residency would be better. however, if the dooms sayers are correct and pain med goes under, they wouldnt have a 'primary' specialty to rescind to.

 

[Disciple]

So,

It seems that there are 2 camps. The pain residency camp, led by AAPMed, and the establishment, which wants to keep things they way they are and just lengthen the fellowship to 2 years.

Question for the board,

Which approach is better for the specialty over the long haul?

As suggested above, in light of falling reimbursement and coverage for procedures, simply lengthening the fellowship may drive away residents, except those from primary care. Primary care physicians have first access to this patient population, so the specialty may evolve into a lesser reimbursed primary care subspecialty, ala Geriatrics.

On the other hand, a pain residency would improve consistency and quality of care, but with falling reimbursements and coverage for procedures, and without multiple specialties feeding into the pool of new pain doctors, would there be a sufficient number of trainees to meet the needs of the public?

 

[Tenesma]

despite the feeling that more education is better - if i had to do it over again, i don't think i would have opted for a 2 yr fellowship

 

[Aether2000]

Excellent question. I think there are several variables that will drive the equation including the scope of practice of pain medicine physicians, whether we see ourselves as long term comprehensive treatment physicians or simply want to become board certified to stick needles into people. If the latter is true, then perhaps we should just stick to a one year fellowship and let the pediatricians/allergists/geneticists/family docs take over the specialty. If on the other hand, we want to foster research into the field, develop meaningful guidelines for practice, want to serve as a paradigm for comprehensive chronic pain treatment and diagnosis, then a one year fellowship or ABIPP certification is insufficient.

 

[SleepIsGood]

Excellent question. I think there are several variables that will drive the equation including the scope of practice of pain medicine physicians, whether we see ourselves as long term comprehensive treatment physicians or simply want to become board certified to stick needles into people. If the latter is true, then perhaps we should just stick to a one year fellowship and let the pediatricians/allergists/geneticists/family docs take over the specialty. If on the other hand, we want to foster research into the field, develop meaningful guidelines for practice, want to serve as a paradigm for comprehensive chronic pain treatment and diagnosis, then a one year fellowship or ABIPP certification is insufficient.

Just a side note...

There are already places like this. For example, the two that come to mind right now are "Harvard's Brigham and Women's" and "Stanford". Both are "center of excellence". Both places have in patient chronic pain services. Docs at those centers are not just consultants, but rather are the primary service for many of these patients. A true 'comprehensive' approach is taken there and one has to manage both pain issues and medical issues. I think this is what makes you a true Pain Physician.

I dont know if there are other programs like this, I'm sure there are a handful. At any rate, I think that experience will truly allow you to be a comprehensive physician and not just a needl jockey.

Personally, I would prefer a Pain Residency paradigm over adding more years to a anesthesia or PMR residency. however, the question again is, what happens if Pain med goes under. These grads dont have 'base' to fall on.

 

[Tenesma]

all ACGME accredited fellowships have to pretty much provide a "rounded" experience - it ain't just Brigham/Stanford that are doing this...

however the variations on the theme are a bit disturbing
at the Brigham (until just recently), the fellows managed ALL the PCAs in the hospital when they were on call... completely pointless from my point of view
at the Cornell (quad) program, the fellows would show up early to get most of the Thoracic epidurals started for operative cases... completely pointless from my point of view...
the list of inane responsibilities goes on and on...
when i did my Pedi Pain rotation at Children's (boston), the fellows managed all the PCAs as well including any other post-operative pain meds (including tylenol orders) - again makes no sense as to why that would be of any benefit in the real world.

then again, i had to take organic chemistry to get into med school... but that is another pointless conversation,.

 

[Jcm800]

when i was a resident we managed the PCAs on our pain rotations, what a dump. Of NO value. that was enough to almost deter me from doing pain, as i thought thats what pain would be, narcs, dumps and PCAs, and post-op epidurals. Glad i was only half wrong...

all ACGME accredited fellowships have to pretty much provide a "rounded" experience - it ain't just Brigham/Stanford that are doing this...

however the variations on the theme are a bit disturbing
at the Brigham (until just recently), the fellows managed ALL the PCAs in the hospital when they were on call... completely pointless from my point of view
at the Cornell (quad) program, the fellows would show up early to get most of the Thoracic epidurals started for operative cases... completely pointless from my point of view...
the list of inane responsibilities goes on and on...
when i did my Pedi Pain rotation at Children's (boston), the fellows managed all the PCAs as well including any other post-operative pain meds (including tylenol orders) - again makes no sense as to why that would be of any benefit in the real world.

then again, i had to take organic chemistry to get into med school... but that is another pointless conversation,.

 

[PMR 4 MSK]

So,

It seems that there are 2 camps. The pain residency camp, led by AAPMed, and the establishment, which wants to keep things they way they are and just lengthen the fellowship to 2 years.

Question for the board,

Which approach is better for the specialty over the long haul?

As suggested above, in light of falling reimbursement and coverage for procedures, simply lengthening the fellowship may drive away residents, except those from primary care. Primary care physicians have first access to this patient population, so the specialty may evolve into a lesser reimbursed primary care subspecialty, ala Geriatrics.

On the other hand, a pain residency would improve consistency and quality of care, but with falling reimbursements and coverage for procedures, and without multiple specialties feeding into the pool of new pain doctors, would there be a sufficient number of trainees to meet the needs of the public?

A pain residency would be better for the long haul, but with things being so iffy for reimbursement and the future of the field, having a primary residency to fall back on is the better short-term ideal.

 

[Jeff05]

i think that a 2 year fellowship will deter many from entering the field and so will a full residency. perhaps incorporating pre-fellowship tracks into existing residencies (structured "electives") would be a more feasible option.

i do think, however, if the field is to continue to grow (read - we actually come up with stuff that really works) more academic research is needed (injecting PRP into everything to find the next ESI-like holy grail does not qualify as real research).

also, who would you have manage acute pain? Just let PAs and NPs take over that too? i think having pain divisions maintain control over in house pain management is CRITICAL to the survival of our specialty. that's the stuff, no matter how insignificant you find it (or boring/not pertinent during fellowship/residency), inpatient services help to build a departments reputation with physicians and pay the bills.

i think that in the not so distant future our compensation will decrease even further. acs based and individual pain practices will be hit, hard. those affiliated with hospitals (who can provide services to said institutions)will survive.

 

[Axehandler]

I think you guys are all missing the best comprehensive pain fellowships currently offered are Palliative Care. They are multidisciplinary, involve diverse pathology, have great pharmacolgy and are whole patient centered. Add a few months in interventional proceedures and you have a great foundation.

 

[foxtrot]

I think you guys are all missing the best comprehensive pain fellowships currently offered are Palliative Care. They are multidisciplinary, involve diverse pathology, have great pharmacolgy and are whole patient centered. Add a few months in interventional proceedures and you have a great foundation.

How do you find out who offers palliative care fellowships? I spent some time doing palliative care medicine when I was a fellow and I agree with this. It really is an up and coming field.

With regard to who does pain best, it is irrelevant because it is now a multispecialty field. What pain practitioners need to do is work together for better research, a 2 year fellowship, and better reimbursement. I trained in an anesthesia based fellowship and I still feel like I have a ton to learn. I have met PM&R docs who have excellent exam skills but who are scary to watch with a needle. I have met anesthesiologists who are great with needles but who are poor with the physical exam. It all boils down to the type of physician you want to be. If you are someone who is constantly evolving and learning, you are going to do well no matter what residency background you came from. So it is pointless to pit one side against each other. Both PM&R and anesthesia bring different skill sets to the table. The ideal practices have both anesthesia and PM&R trained physicians working together but those can be hard to come by.

 

[SleepIsGood]

How do you find out who offers palliative care fellowships? I spent some time doing palliative care medicine when I was a fellow and I agree with this. It really is an up and coming field.

With regard to who does pain best, it is irrelevant because it is now a multispecialty field. What pain practitioners need to do is work together for better research, a 2 year fellowship, and better reimbursement. I trained in an anesthesia based fellowship and I still feel like I have a ton to learn. I have met PM&R docs who have excellent exam skills but who are scary to watch with a needle. I have met anesthesiologists who are great with needles but who are poor with the physical exam. It all boils down to the type of physician you want to be. If you are someone who is constantly evolving and learning, you are going to do well no matter what residency background you came from. So it is pointless to pit one side against each other. Both PM&R and anesthesia bring different skill sets to the table. The ideal practices have both anesthesia and PM&R trained physicians working together but those can be hard to come by.

maybe you guys know more bou this. But I've heard Pall Care is really hard to'infiltrate' since oncologists are very territorial about referring these pts out. They believe in some instances they can manage pain (and get paid for this) instead of referring out. What's been your experience..in NON academic settings.

 

[Jeff05]

I think you guys are all missing the best comprehensive pain fellowships currently offered are Palliative Care. They are multidisciplinary, involve diverse pathology, have great pharmacolgy and are whole patient centered. Add a few months in interventional proceedures and you have a great foundation.

i disagree.
much of palliative pain management involves titration of opiate/benzo/etc for end-of-life management. also, not sure about diversity of pathology (mostly cancer). there is just no experience in bread and butter general pain management (one of the institutions in my fellowship has a pall care fellowship).

i do think that having a palliative care rotation may be useful for a pain residency, if that ever comes around.

 

[Aether2000]

My experience is that the oncologist becomes the primary care physician at the end of life and they believe strongly in medicating the patient into oblivion is adequate desireable. Unfortunately they have also convinced the patients they need nothing but a cocktail of liquid morphine (cheap) and valium (cheap) to take away all the ills of the world. Pain medicine referrals are not even in their vocabulary, representing to the oncologist one further failure in their treatment after their chemo and radiation has failed. Patients are denied access to intrathecal therapies and other pain medicine techniques. Of course most patients don't need pain medicine referrals and many pain physicians wouldn't accept cancer patients unless they can stick needles into their spines, so we are partially responsible for the oncologist's dismal attitudes towards us.

 

[SleepIsGood]

My experience is that the oncologist becomes the primary care physician at the end of life and they believe strongly in medicating the patient into oblivion is adequate desireable. Unfortunately they have also convinced the patients they need nothing but a cocktail of liquid morphine (cheap) and valium (cheap) to take away all the ills of the world. Pain medicine referrals are not even in their vocabulary, representing to the oncologist one further failure in their treatment after their chemo and radiation has failed. Patients are denied access to intrathecal therapies and other pain medicine techniques. Of course most patients don't need pain medicine referrals and many pain physicians wouldn't accept cancer patients unless they can stick needles into their spines, so we are partially responsible for the oncologist's dismal attitudes towards us.

This is exactly what I've heard. Unfortunately, I feel as though these pts are unnecessarily and unfairly not able to benefit of intrathecal pumps...especially if they have a 'longer' life expectancy in relative terms.

 

[Prof Moriarty]

From my elective rotation at an academic medical center...

Prominent palliative care diagnoses are:

• Cancer
• CHF
• COPD
• Dementia

Pain management figures prominently but the palliative care service acts independently of the pain management service. Pain management service seemed less interested in the end-of-life cases, although occasionally both services are consulted on the same patient. Palliative is a consult service and the primary team retains control, although it often allowed/encouraged the palliative care service to place the orders, especially with regard to increasing dosages/potency of opiates. It seems most physicians are not as comfortable with these.

While pain is a prominent issue for many, SOB, delirium, aspiration, anxiety, family dynamics, advance directives, medical proxy, and a host of other issues, along with the patient's (usually) complex medical condition are also at the fore.

As noted by others, a general observation: it seemed the primary teams (most often oncology or ICU) got the palliative care consult late in the game. Palliative care is not synonymous with end-of-life, but it seems many docs (understandably) make that association.

 

[Axehandler]

Our institution's palliative outpatient clinic is full of sickle cell patients, post-thoracotomy syndromes and LBP. You would be amazed how "pain" docs don't want anything to do with these people even after the cancer is cured.

 

[lobelsteve]

Our institution's palliative outpatient clinic is full of sickle cell patients, post-thoracotomy syndromes and LBP. You would be amazed how "pain" docs don't want anything to do with these people even after the cancer is cured.

What area are you? There are always kind pain docs willing to help.

SML

 

[Tenesma]

the referrals i do get from oncologists are usually for patients who aren't dying despite narcotic dose escalations and are suffering from a) constipation b) delirium or c) both...

palliative medicine should be integrated into a pain residency...

 

[lobelsteve]

the referrals i do get from oncologists are usually for patients who aren't dying despite narcotic dose escalations and are suffering from a) constipation b) delirium or c) both...

palliative medicine should be integrated into a pain residency...

I have about 10 active oncology patients. One is for rib mets and RF to the intercostals, neuropathic pain, etc. One for a gasserian for jaw pain (met s/p XRT with exposed bone when I look in her mouth). One is for neuropathic pain mgmt to tolerate CTX for Myeloma. A few for thoracic pain s/p thoracotomy. A nice guy who really needs hospice for metastatic melanoma.
A feel more important when writing opioids for some of these folks. Maybe like I'm helping them more.

 

[SleepIsGood]

the referrals i do get from oncologists are usually for patients who aren't dying despite narcotic dose escalations and are suffering from a) constipation b) delirium or c) both...

palliative medicine should be integrated into a pain residency...

I think most pain fellowships have this integrated in them NOW.

 

[Jcm800]

i do get some good oncology referrals. i put 10 or so pumps in these patients last year, 5 have died...

most of the time the are on deaths doorstep, but sometimes, if its a full moon, they call me early in the care...

 

[FollowTheMoney]

Is there anyone who can provide some insight regarding this thread in 2018?

After discussing this topic with numerous colleagues in both pain and anesthesia it appears that the money has dried up for pain physicians who are employed/working for someone or young grads and that the only ones making the big money now are people with long well established practices. It appears daunting to start up your own practice in this climate of debt and it appears that if you don’t want to work in the middle of nowhere the market is going to be saturated. My understanding is you can still make 300-400k in pain but you have to work pretty hard for that money and the whole situation is not as glamorous as it used to be. Obviously the overall lifestyle is good and the autonomy speaks for itself.

Meanwhile, the anesthesia job market seems great overall and there are a lot of jobs with 400+ In PP to do general in desirable locations. If you work for a Hospital specifically or a big group covering a busy center you won’t have much autonomy, but it seems to be offering more overall compared to Pain. Also I’ve noticed a lot of people are doing general anesthesia despite a pain fellowship.