I agree with the AAPMR/PASSOR focus away from pain and more to the spine/MSK, but have felt that this is short sighted. The UCLA WLA VA program is trying to be competitive with Anesthesia based programs with all aspects of pain medicine training. There is a strong emphasis on intrathecal pump implantation and management with dorsal column stimulation trials and implantation, but obviously, there is a flair of PM&R with the training (EMG, MSK, and Rehabilitation). I think this is what makes the UCLA WLA VA program unique.
I had hoped more PM&R programs would become accredited, but with the change of focus on a 'single' program at an institution, the PM&R training has combined with most of the Anesthesia programs. For example, the EMG aspect is lost, which for a PM&R physician, is an important tool to use for patient evaluation. The UCLA WLA VA program is unique because it is based out of the VA which is why it is a program separate from the UCLA Anesthesia Pain program. The fellow will rotate at UCLA for 6 months out of the year and 6 months at the VA.
The UCLA WLA VA PMR program is not a 'spine intervention' or 'MSK' program but has strong features of both embedded in the training. If your focus is on spine only, this is not your program. If your interest is in all aspects of pain training, which will of course include the spine, then the UCLA WLA VA PMR Pain Medicine Fellowship will hopefully fulfill all of your goals.
The reason PM&R programs gotstiffed was a politcal coup by Rathmell. Our representation at the RRC meeting was silent and many of the PD's did not know about the changes until after they were being made.
My opinion of the anesthesia training programs is low,as is my opinion of the PM&R programs. None address the need of the US population which is to have a multidisciplinary pain center provide for all aspects of their care.
Not a pill mill, not a needle jockey who sends them back to their PCP with recommendations, not a psychobabble three times a week. It should all get done in one place, under one tax id, and not to make money at the expense of patient care. This is currently not the case in almost all of the "Pain Clinics" in the US.
The Pain paradigm is broken and no one wants to fix it, they all just want a bigger slice of the $$$.
We can propose a pain residency, but who will stop the money grubbers from doing 40 epidurals on Friday when the OR is slow, the stim weenies who think PN of DM warrants a 4 octrode trial, and the docs who rapidly titrate opioids in an effort to get them reasdy for IT meds.
Ben Crue should be required reading for Pain Fellowship.
I'm ranting....and disenfranchised.
The AAPM&R conducted several surveys first amongst member Physiatrists and then residents looking at career choice/practice focus. The decision was made to focus toward Spine/MSK versus "pain". In my opinion the AAPM&R (pushed by PASSOR), is trying to best and accurately represent the wants and needs of its membership.
The vast majority of Interventional Physiatrists practice in MSK practices, surgical groups or Spine centers. The reason I think a lot of Physiatrists train in Anesthesiology based pain fellowships is because the ABPMR will not provide them with what they need via an "Interventional Spine" model, i.e. standardized procedural training to supplement the non-operative management of orthopedic conditions of the spine. Many Physiatrists training in Anesthesiology based pain fellowships go on to practice in surgical groups or musculoskeletal PM&R groups (take several of the inquiries on this forum as an example). Assuming said Physiatrist had good MSK/Spine training in residency, then he/she likely uses a small fraction of the skills learned during a 12 month multi-disciplinary fellowship in their spine based private practice, which would be the interventional skills minus intra-thecal implants. The region in which I practice (metropolitan area in a saturated state) is densely populated with Interventional Physiatrists. I cannot think of a single one off the top of my head who implants and manages intra-thecal pumps, manages headaches (non-cervicogenic), pelvic pain, non-spinal cancer pain, etc. whether they possess the proper training or not. Those with the largest practices certainly do not. The situation is similar in 2 other cities (2 of the top 4 US cities by population) in which I have lived.
Interventional Radiologists do not practice pain medicine, but do undergo standardized procedural training and obtain certification through their own fellowships. There are some who have a fondness for Vertebro/Kyphoplasty and spinal injections. By the reasoning supported by the 4 core pain RRCs, shouldn't they be doing a pain fellowship? What about surgeons? Let's say a neurosurgeon does alot of spine work, implants some pumps and stims and now wants to add a few injections to his repertoire. Should he/she have to do a pain fellowship or would it be acceptable to learn from an experienced colleague? (The Smith & Nephew course I attended on IDET a couple of years ago was taught by the chairman of the Ortho dept at a large surgical hospital). Wouldn't a pain fellowship for a surgeon in this situation be a complete waste of time?
Would we even be having these issues if the ABPMR put its stamp on musculoskeletal Physiatry?
As a parallel example, I consider myself a competent electromyographer. Even though most of my studies are done to screen for radics and peripheral nerve entrapments, with some review I feel confident I could do a proper electrodiagnostic study to confirm Neuromuscular Disease (ALS, Myotonic Dystrophy, etc.) Does that mean I should be capable of managing that condition long-term? Should I even be expected to manage the rehabilitative aspect or should that be referred to a Physiatrist with extensive longitudinal experience with these types of patients.
If you look at all the Pain Medicine/Spine/Interventional Pain Management organizations we subscribe to, we have:
ISIS-Guys who like to do procedures
ASIPP-Guys who like procedures and money
AAPM-Guys interested in pain who favor a more balanced approach
NASS-Surgeons, and then Interventional Spine guys who work for/with surgeons or have a large referral base from surgeons
APS-Guys who like neurobiology and the psychosocial aspects of pain
ASRA-Anesthesiologists who like the OR/pain clinic hybrid model
PASSOR-Physiatrists who are into non-surgical orthopaedics and who may supplement with some spinal procedures
Think of all the practicioners in these organizations (Gas, Physiatry, Neuro, Primary care, Psyche, Spine surg, Rads), all the patients they treat, and how many of them actually practice comprehensive pain medicine. Is everyone of them a pain doc? If so does that mean that each practitioner who does not practice comprehensively is providing substandard care? Is it realistic to think that we can take all the relevant knowledge from Anesthesiology, Physiatry, Neurology and Psychiatry, condense it into 12 months of training and spit out pain docs with the same skill set, level of competency and uniform knowledge base? With the relative shortage of pain docs in this country and hypothetically taking some of the above specialties out of the picture, who is going to treat all their patients?
Is it realistic to think that you can take a physician, train him/her for 12 months and equip that physician with the tools to evaluate, diagnose and effectively treat all types of pain with all types of interventions, medications and modalities from the moment a patient's pain starts up until and on a continuing basis after it becomes chronic?
The value of multi-disciplinary pain management is well documented, but is it realistic that this be the standard for every community pain practice in every state? Perhaps, the expensive full scale multi-disciplinary pain clinics should be left to the tertiary and quaternary referral centers. As stated above, the number of pain docs in this country does not meet the current need. So should E&M be OK for PCPs, but expensive procedures be referred out? For Physiatrists, in part, the ABPMR is to blame for not standardizing or performing some sort of quality assurance to the interventional training of Physiatrists.
So let's be honest about the real motive behind proposing a multi-disciplinary 12 month fellowship as a viable substitute for a pain-residency. Over-utilization of procedures.
The most simple solution is to let nature take its course and to let the reimbursements fall.
When the reimbursement for pumps fell, many with large pump practices stopped providing this service. Now, those who continue to implant a high volume of pumps generally are dedicated to it and do it well.
Let the reimbursements fall, most of the unethical behavior will stop and those abusing the system will leave. Auto-regulation. Of course, this path is not favorable to those who stand to lose from it, and thus, we have the current solution which is a poor patchwork attempt at improving the current situation.
