Pain Medicine is an Official Subspecialty of Emergency Medicine

[Frazier]

I still am board certified in EM, as well as my subspecialty. I've maintained both going on 9 years, now. But I have very good news for you, my friend!

"Physicians certified by the American Board of Emergency Medicine (ABEM) who also hold an ABEM-issued subspecialty certificate are no longer required to maintain their core Emergency Medicine (EM) certification as long as they are participating in an ABEM-accepted Maintenance of Certification Program." - ABEM, 10/02/2018

Wise, per usual.

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[Katheudontas parateroumen]

This is a long thread so didn’t get a chance to read all of it.
I am an anesthesia resident and I’d say that although pain medicine was most likely from the world of anesthesiology, it honestly doesn’t make much sense. Yes, I do a lots of epidurals, spinals, nerve blocks, take care of acute pain in the OR and give lots of opioids.... but in all seriousness, what does anesthesia have to do with chronic pain management. I believe that helping chronic pain patients takes a great H&P especially physical exam and psychological training. All of which is generally not in the wheelhouse of anesthesiology. Personally, I think pain medicine makes most sense for PMR and family medicine. But probably historically anesthesia started the field and hence the strong bias. It always weirded me out when I hear anesthesia applicants say they are interested in pain. Like really? Our main area is critical care medicine and OR anesthesia. Has nothing to do with clinic or chronic conditions. Now, I’ll definitely get flack by saying this, and I’m all for protecting my field, but all honesty it’s the truth. So I’m glad people are going into different specialties. I just hope that these barriers in medicine become less. It does always feel like anesthesia gets the short end of the stick most of the time though haha.

 

[swamprat]

This is a long thread so didn’t get a chance to read all of it.
I am an anesthesia resident and I’d say that although pain medicine was most likely from the world of anesthesiology, it honestly doesn’t make much sense. Yes, I do a lots of epidurals, spinals, nerve blocks, take care of acute pain in the OR and give lots of opioids.... but in all seriousness, what does anesthesia have to do with chronic pain management. I believe that helping chronic pain patients takes a great H&P especially physical exam and psychological training. All of which is generally not in the wheelhouse of anesthesiology. Personally, I think pain medicine makes most sense for PMR and family medicine. But probably historically anesthesia started the field and hence the strong bias. It always weirded me out when I hear anesthesia applicants say they are interested in pain. Like really? Our main area is critical care medicine and OR anesthesia. Has nothing to do with clinic or chronic conditions. Now, I’ll definitely get flack by saying this, and I’m all for protecting my field, but all honesty it’s the truth. So I’m glad people are going into different specialties. I just hope that these barriers in medicine become less. It does always feel like anesthesia gets the short end of the stick most of the time though haha.

When I was a fellow me and my co-fellow whom was anesthesia both knew jack. Our PD went through spinal anatomy on fluorscopy and we couldn't answer any questions. She rolled her eyes and said "oh ****" - we both ended up fine. I agree - except with fact that anesthesia residents may have a lot of off service pain rotations to get a leg up (my cofellow did not) pain is its own specialty and really any physician can do well in it as long as they are motivated to learn. I will say 1 year is not long enough but my first and even 2nd year out as an attending pain MD I learned a TON. Heck still am but the fellowship gave me a nice base. Great field, no regrets.

 

[namethatsmell]

This is a long thread so didn’t get a chance to read all of it.
I am an anesthesia resident and I’d say that although pain medicine was most likely from the world of anesthesiology, it honestly doesn’t make much sense. Yes, I do a lots of epidurals, spinals, nerve blocks, take care of acute pain in the OR and give lots of opioids.... but in all seriousness, what does anesthesia have to do with chronic pain management. I believe that helping chronic pain patients takes a great H&P especially physical exam and psychological training. All of which is generally not in the wheelhouse of anesthesiology. Personally, I think pain medicine makes most sense for PMR and family medicine. But probably historically anesthesia started the field and hence the strong bias. It always weirded me out when I hear anesthesia applicants say they are interested in pain. Like really? Our main area is critical care medicine and OR anesthesia. Has nothing to do with clinic or chronic conditions. Now, I’ll definitely get flack by saying this, and I’m all for protecting my field, but all honesty it’s the truth. So I’m glad people are going into different specialties. I just hope that these barriers in medicine become less. It does always feel like anesthesia gets the short end of the stick most of the time though haha.

This post is totally true.

Like Birdstrike and swamprat (who both rock btw), I'm in the EM/Pain gang. When I was in fellowship, I had both co-fellows and attendings from anesthesia, pm&r, and neuro backgrounds. The program was one of the older ones and so coming from EM I was expecting to get a lot of flack, especially from the anesthesia folks. That didn't happen. Everybody was actually really chill and cordial and whenever my EM training did come up, the most common thing they'd say was "I could never do EM, it's too crazy." All the residency paths to pain really do have their own strengths/weaknesses, and I found all the stereotypes about these other fields as they pertain to pain to be untrue. In the real world nobody cares about what you did your residency in as long as you can do pain well.

 

[annchovee]

I'm graduating from an EM residency in 2022 and think I'd like to apply for a pain management fellowship in the upcoming cycle. I am so excited to see that there are folks that have walked that path before me. This is the first I'm hearing of it.

I am wondering about the concept of applying to all the programs to maximize the odds. I understand the concept, but this runs counter to what I've been told generally speaking, which is to apply more narrowly because "it's a small world" and you don't want to come across as disinterested in any individual program because of the number of programs you apply to. Does this make sense?

One of the things I see as my strength is a demonstrated interest in opioid policy and how pain is treated in the emergency department, as it relates to addiction. In fact, until I started reading more about pain management, I was very excited about the prospect of applying for an addiction medicine fellowship, and may still do so. for people that have experience, like @Birdstrike , do you think this sort of non-anesthesia non-pain management experience would matter?

- @annchovee

 

[Frazier]

I'm graduating from an EM residency in 2022 and think I'd like to apply for a pain management fellowship in the upcoming cycle. I am so excited to see that there are folks that have walked that path before me. This is the first I'm hearing of it.

I am wondering about the concept of applying to all the programs to maximize the odds. I understand the concept, but this runs counter to what I've been told generally speaking, which is to apply more narrowly because "it's a small world" and you don't want to come across as disinterested in any individual program because of the number of programs you apply to. Does this make sense?

One of the things I see as my strength is a demonstrated interest in opioid policy and how pain is treated in the emergency department, as it relates to addiction. In fact, until I started reading more about pain management, I was very excited about the prospect of applying for an addiction medicine fellowship, and may still do so. for people that have experience, like @Birdstrike , do you think this sort of non-anesthesia non-pain management experience would matter?

- @annchovee

I see the line of reasoning and in this case it is still best to apply to as many programs as possible.

 

[Birdstrike]

I am wondering about the concept of applying to all the programs to maximize the odds. I understand the concept, but this runs counter to what I've been told generally speaking, which is to apply more narrowly because "it's a small world" and you don't want to come across as disinterested in any individual program because of the number of programs you apply to. Does this make sense?

I suppose it depends on how you look at it. If applying to more than only your favorite program implies you're not interested in that program and therefore hurts your chances, then I suppose the best approach would be to apply to only one. Those interviewing you could imply or think that even applying to ten programs is "too many" and shows you "have eyes for 9 other programs, how dare you, we'll take only those who apply on to our program or maybe one or two other." I don't think that way, but I suppose it's possible someone, somewhere on a fellowship admission committee might. I doubt it's many, but I don't know for sure.

On the other hand, you could say applying aggressively shows commitment to the field. "I want go here and only here, however, I have no guarantees and was advised to apply widely just in case. So I did." Any program that thinks you should give up a chance at a career in a field so you can apply to only their program to show loyalty, and therefore maybe not have a chance to take that career path at all, is probably not one worth going to.

Also, I think people on admission committees should be able to understand that being from a non-traditional specialty is another very valid justification for applying widely. "Although I know I'm just as qualified as applicants from other specialties, I have no guarantees as a non-traditional applicant that every program feels the same way and will act on it. Although I feel your program is by far the best fit for me, I was advised to apply widely, given my unique circumstances. So I did." In my opinion, that's reasonable.

That being said, do what works for you. My approach was before the Match even existed for Pain (I applied the last year before Pain was in the Match). So an attack plan of "Plan to apply everywhere until I get an offer," worked. Maybe there being a Match requires a different strategy, now? I don't know. But it's worth knowing how many programs are in the Match, how many aren't, and formulating the best attack plan that works for you.

Although it was my goal, I never got as far as being able to apply to all the programs. Since there was no Match, the process took many weeks. I got apps out to about 1/3 the programs in the country and started getting interviews. I paused applying and went on the interview trail. I got an offer as I started the second wave of applying to the next 1/3 of the countries programs. It was a solid program in a good location, so I accepted the offer on the spot, and stopped the process. It turns out I didn't have to apply to all the programs, but I had no way of knowing whether it would be program 1, 31 or 101, that would be the one that would bite. It certainly wasn't the first, second, or even tenth.

Do what works for you.

I was very excited about the prospect of applying for an addiction medicine fellowship...do you think this sort of non-anesthesia non-pain management experience would matter?

- @annchovee

I think any experience in addiction medicine is helpful, but not necessary, for a successful career in Pain Medicine.

 

[annchovee]

Thank you so much for your replies @Birdstrike and @Frazier . I feel like I'm flying blind and I'm very grateful for your insight.

I am wondering if you could speak to a finer point. I reviewed all of the websites (that were functional) of pain fellowships participating in the match this year. I wonder why EM is not present as one of the "welcome specialities."

I think EM graduates have a lot to offer, and I wonder why pain management fellowships haven't made it clear they'd welcome us. We confront psychiatric illness, acute and chronic pain, and are required to do procedures every day we work.

Are the leadership who review applications for pain management fellowships aware of the experience that typical applicants from EM bring to the table? Residents in psychiatry, anethesiology, etc. are typically welcomed as applicants to PM programs (if the websites I've reviewed are up to date.) EM is almost nowhere to be found. I don't understand. We're not *that* new.

I'm not complaining. But I do want to understand.

 

[Birdstrike]

Thank you so much for your replies @Birdstrike and @Frazier . I feel like I'm flying blind and I'm very grateful for your insight.

I am wondering if you could speak to a finer point. I reviewed all of the websites (that were functional) of pain fellowships participating in the match this year. I wonder why EM is not present as one of the "welcome specialities."

I think EM graduates have a lot to offer, and I wonder why pain management fellowships haven't made it clear they'd welcome us. We confront psychiatric illness, acute and chronic pain, and are required to do procedures every day we work.

Are the leadership who review applications for pain management fellowships aware of the experience that typical applicants from EM bring to the table? Residents in psychiatry, anethesiology, etc. are typically welcomed as applicants to PM programs (if the websites I've reviewed are up to date.) EM is almost nowhere to be found. I don't understand. We're not *that* new.

I'm not complaining. But I do want to understand.

There is historical bias against any specialty going into Pain, other than anesthesia. But that makes the other specialties no less official and no less qualified. Some programs may not know EM is a part of the specialty. Others may be actively trying to keep non-anesthesia medical doctors out (ironic, since they're fine with teaching nurses how to do their jobs, but I digress). Others may simply have outdated websites.

If I could get into a Pain fellowship in 2011, three years before Pain was even officially a subspecialty of EM, you can do it after it's been an official subspecialty for 7 years.

Proof from ABEM, you can do Pain.

Proof from ABMS, you can do Pain.

Keep in mind, it was the American Board of Anesthesia that in 2014 allowed any specialty board that wanted to bring Pain officially under their specialty, to make that known and to apply. Only EM, FM and Rads did so, and they were all granted. Interestingly, IM was prodded to do it by several of IM/Pain people that were grandfathered in, and ABIM turned it down. I'm not sure why. But now, IM is shut out permanently.

We pushed this in 2014. ABEM asked me, and I actually wrote the application letter that ABEM sent to ABA, although ABEM put the president of ACEP's signature on it so it would carry more weight. We pushed this issue hard, so people like you would be in better position, years down the road. But you've still got to run the ball across the goal line. Be aggressive, refuse to take no for an answer, and keep rattling the cage until you get in.

 

[Frazier]

Having rotated through pain during my palliative medicine fellowship, I will say that the several pain fellows I met all seem to be quite happy with their decision (and have nice employment lined up for July)... They feel like they are valued specialists (note: they are) and feel their work is important, meaningful, and makes a difference in patient lives. Important things! I wish the same for all my colleagues still grinding back in residency.

I did get a kick when one of the attending pain docs said "Ahhh, Palliative. You guys are great. Like a 'total person pain doc'. But all those feelings, and crying, dying and hand holding, noooo thanks(!!!)... here in interventional, man, we just do the cool ****!"

I took it as a compliment.

 

[namethatsmell]

We pushed this in 2014. ABEM asked me, and I actually wrote the application letter that ABEM sent to ABA, although ABEM put the president of ACEP's signature on it so it would carry more weight. We pushed this issue hard, so people like you would be in better position, years down the road.

You've previously alluded to aspects of helping with setting up the pathway for EM folks to get boarded in Pain...but I had no idea of this. So, so huge. Thank you, thank you, thank you for doing this.

FWIW, I worked my tail off in fellowship to not only get the most out of the year, but also to highlight that EM folks are worthy of being on the Pain field with them. Goal was to perhaps make it easier for future applicants coming from EM. By the end of my time there, multiple faculty were talking about the benefits an EM doc brings to the Pain table.

But you've still got to run the ball across the goal line. Be aggressive, refuse to take no for an answer, and keep rattling the cage until you get in.

Completely true. I went to big conferences to network, sent out letters of interest to a ton of programs, and applied as broadly as I could. Without all the work, I'm not sure I would have gotten in.

 

[Franzd'Epinay]

By the end of my time there, multiple faculty were talking about the benefits an EM doc brings to the Pain table.

What were they saying?

As a complete outsider, are there any things that we are better prepared for than the anesthesia grads?

 

[Birdstrike]

As a complete outsider, are there any things that we are better prepared for than the anesthesia grads?

The only thing they're better at is loss of resistance technique, which is 1% of Pain Medicine. Seriously. And if you already proficient at LPs, I can teach you loss of resistance (LOR) technique in an afternoon.

What you guys lack isn't the skills, it's the confidence to go for it. Dive into this like you dive into a room with a coding patient and you'll do great.

I'm telling you, I did EM for about 10 years and I've done Pain for about 10 years now. EM was way harder.

 

[Birdstrike]

What were they saying?

You didn't ask me, but I'll answer anyway. In my fellowship, they were impressed with the procedural skills I brought to the table (more than the PM&R, psych neuro people) and clinical skills (more than the anesthesia people) and most off all, they said I exuded a confidence that I can handle anything. EM prepares you for that. When clinic would get busy, some others would melt down. Me, I'd be thinking, "This is nothing compared to getting shelled in the ED," and I'd skip along with a calm smile, moving from room to room dealing with a finite number of people I knew weren't going to die or lose a limb.

 

[namethatsmell]

What were they saying?

As a complete outsider, are there any things that we are better prepared for than the anesthesia grads?

Well, Birdstrike beat me to it. They said, not surprisingly, pretty much what he said.

Some other brief examples to answer your questions (and that they commented on)...coming from EM we have:

The ability to take a pertinent/focused history, do a useful physical exam, look at labs/imaging...and then come up with a streamlined/pragmatic assessment and plan. And we can do it in a way that keeps patient care (and the clinic schedule) moving forward.

We actually know a decent amount of "medicine" that other fields don't necessary bring into fellowship. And it's useful.

We have, on average, perhaps the broadest procedural skill set coming into fellowship, and we're adaptable (as EM folks tend to be) to learning new ones pretty easily.

If something unexpected happens during a procedure (ie the patient vagels, etc)...you know what to do.

We're used to having challenging conversations with patients.


None of this is to insult anesthesia, pmr, neuro or the other fields that can train in pain. Every field brings different skills to a pain fellowship. In my fellowship I had co-fellows and attendings with base training in anesthesia, pmr, and neurology. I learned a ton from all of them, in part due to their residency backgrounds.


Oh, and they did say my turkey sandwich was the best they'd ever had...clearly none of the other fields will ever compete with us EM folks in that regard.

 

[bravotwozero]

lol wut? Since when were EPs known for making good turkey sandwiches?

 

[Birdstrike]

Just got another email from an EM doc that found out they matched in Pain this year. Good program, too.

 

[hector10]

How important are step scores, cause mine are on the lower side unfortunately.

 

[Birdstrike]

How important are step scores,

For fellowships? I don't know. No one asked about them or mentioned them when I interviewed. I can't remember if they asked for them in applications, but I did send them. When I applied, my Step exams had been taken almost a decade prior. I think if I was on a fellowship admission committee I'd be looking at overall trends of success, more recent clinical performance and if looking at tests, more recent ones like in-training exams or specialty boards, which they did ask for.

 

[bravotwozero]

How did you go about finding a job after fellowship? Did you network using faculty or cold call?

 

[BoardingDoc]

lol wut? Since when were EPs known for making good turkey sandwiches?

I think that was a joke re: frequent fliers coming to the ed and requesting our ubiquitous turkey sandwiches.

 

[namethatsmell]

I think that was a joke re: frequent fliers coming to the ed and requesting our ubiquitous turkey sandwiches.

Yup, was my weak attempt at levity.

 

[bravotwozero]

how's the job market for pain right now, @Birdstrike ? Is your group hiring? has your patient volume returned to normal?

 

[Birdstrike]

how's the job market for pain right now, @Birdstrike ? Is your group hiring? has your patient volume returned to normal?

I don't have my finger on the pulse of the Pain job market since I'm not looking, but I hear from other people looking that COVID has made the Pain job market tight. My group is not hiring, although we probably could if we wanted too, for one of our other locations. I'm not busy enough to add someone where I'm at.

Pain has always been competitive and saturated in desirable locations, because there's a lot of fakers in Pain. You've got your meatheads who never did fellowships and aren't boarded claiming to be "Pain specialists." You've got chiro's, acupuncture and other alternative-medicine providers competing for the same patients. You've got CRNAs, PAs and NPs moving into the game in the states that allow it more than others. But usually there's enough achy old people anywhere, that you can slip into a market and start peeling patients away, especially if it's a growing area with new people moving in, you're fellowship-trained and boarded, and you allow yourself the time to build.

Our post-COVID volume has returned to normal.

Pain doesn't eliminate the problems all of Medicine faces. But it does allow you to live a normal life, reduce stress, work Derm hours for specialist pay, and 100% cure chronic shift-work, circadian-rhythm dysphoria. That's good enough to make it sustainable to career end, for me.

 

[Franzd'Epinay]

Pain doesn't eliminate the problems all of Medicine faces. But it does allow you to live a normal life, reduce stress, work Derm hours for specialist pay, and 100% cure chronic shift-work, circadian-rhythm dysphoria. That's good enough to make it sustainable to career end, for me.

Hypothetically, would you still have gone in to Pain if it was a significant pay-cut?

Would you do it for FM money? Peds money?

 

[Birdstrike]

Hypothetically, would you still have gone in to Pain if it was a significant pay-cut?

Would you do it for FM money? Peds money?

Yes, I would still have done Pain for the same pay, or a slight pay cut, for sure. If it was a significant pay cut, it would have made it a much harder decision since I owed much more than my house was worth at the time. That would have made a lifestyle downsize much harder. But knowing what I know now, I probably still would have, even for a significant pay cut. The repeated assault EM committed on my brain required all options that would allow me to have a normal life, remain on the table. I had to get out, before I stroked out. Although that's a catchy, funny phrase, I'm 100% serious when I say that. I had to break out. I had no choice.

I'm just not the same person I was, when I did EM. I'm way more relaxed. I'm not tired all the time. I'm not snapping at people all the time. I'm less negative minded, much more positive. But that's just me. Maybe I just wasn't cut out for it and other people are. I don't know. But I feel I'm a much better person for having done 10 years of it, but also much better for having been able to move on.

Being able to go to sleep at the same time every night and wake up at the same time every morning, combined with being on the same schedule as my family, trumps just about every other factor we could ever discuss. You just don't realize how messed up the circadian rhythm backflips make you, until you're out.

Or maybe I'm just a wimp, I don't know. Either way, it's all good, because my brain no longer feels scrambled and flogged.

 

[swamprat]

Just to tagon to bird strike - I’d like to add I make way more then my ER doc colleagues. And I work “9-5” which a lot of times is 9-4 or 330

 

[Birdstrike]

I'm going to start posting snippets of DMs on the subject, in case others have the same questions. Everything will remain anonymous:

"Going back to fellowship sounds tough to do"


My response:

When I was at your stage, recently post-residency + wife and kid #1 on the way, I too saw flashes of unsustainability in my EM career. I didn't even know a Pain fellowship was an option at that time. I had never even heard of an EM doc doing one. But I remember having thoughts of needing to transition into a less burnout-prone career path, at some point. But I didn't feel any sense of urgency about it until my first kid was schooled aged (5+) and with a second one in diapers. Once they were on a 9-5, and I was still on EM-circadian rhythm crazy-schedule, that's when the embers began to flame.

The game-changing trigger was when my wife finally got fed up with me complaining about EM, how unsustainable it was, and daydreaming about transitioning to something where I, and my whole family, could have a normal life. I said one day, "When I semi-retire, I should do something like Pain."

She said, "Then do it now! What are you waiting for?"

That's when I started googling "Pain" "EM Pain" and poking around the Pain forum here on SDN. I emailed dozens of fellowship directors acting if EM physicians could do Pain fellowships. Most ignored me. Some said, "No. Sorry." One program emailed back saying, "Yes, EM physicians can do Pain fellowships. In fact, we have one in our program right now. Here's his contact info..."

My life would never be the same. All I can say to you is, my only regret about doing Pain, is that I didn't do it sooner. I was 39 when I started fellowship, with five and three year olds. Having been an attending for 8 years made it hard to go back. But it's never easy to take an 80% pay cut for a year, for anything.

I had a massive mortgage on a house worth less than I owed, student loan payment (still do, though not huge), two kids under 6, multiple pets, and ended up at a program in one of the most crowded expensive cities in America, which made living expenses that year, and the situation at large, even more impossible seeming. Then, the (#(*@-ers at the one last apartment in the city we got our hearts set on living in, demanded we pay the whole year of rent up front (!) because I couldn't prove I'd have enough income the fellowship year, to afford the apartment. I almost didn't do it. But I did. I wrote a check for $60K+ for the whole years rent, prior to moving up there. I worked dozens of extra shifts saving up money prior to fellowship and borrowed more money to make it happen. That's how bad I wanted out of the kiln of EM.

But that's just me. Whatever works for anyone; that's what they should do. But if you're going to do this, do it sooner rather than later. Do it when the time is right and when your spouse/significant other is on board with the whole plan, but don't wait so long the door closes.

But I get it. Life gets complicated. It really does. Kids make it tough, tough, tough. But I can't tell you how much better my family life is, having gutted out that one very tough year, knowing I never have to work a night, weekend or holiday again. I never have to be post-nights for my kid's birthday party, leave to work at 10pm on a holiday, or try to pop up after two hours of sleep and try to be smiling-involved mentally-present dad/husband/son/friend when I feel the weight of ED circadian rhythm dysphoria dragging my mood and personality down. But that's just me.

Do what's best for you!

 

[Birdstrike]

DM received:

"...one of the third year residents from my [EM] residency program just matched at his #1 choice for pain management..."

 

[Birdstrike]

Email received from Emergency Physician applying to Pain fellowships:

"Hi again,

I wanted to reach out and let you know I matched! Your article in ******* from years ago was one of the things that inspired and kept me motivated during this process. I know this will be a career altering move for the better, especially in light of the recent trends in EM employment. I give the deepest thanks to you and other EM/Pain docs like you for trailblazing before me so I can reap the benefits now.

-***** "

 

[Birdstrike]

Another private message received:

"Well, I matched! It took applying to virtually every program and I ended up at ***** ***** I will take it! Thank you so much for inspiring younger EM docs to go out there and try something new. I would have never even thought this was a possibility for me until I read your writings over the years. It's been such a long process looking back to when I first started messaging you about this in February 2017. Amazing how much time has gone by.

Looking forward to joining you among the ranks of EM to Pain docs!"

 

[Frazier]

I'm going to start posting snippets of DMs on the subject, in case others have the same questions. Everything will remain anonymous:

"Going back to fellowship sounds tough to do"


My response:

When I was at your stage, recently post-residency + wife and kid #1 on the way, I too saw flashes of unsustainability in my EM career. I didn't even know a Pain fellowship was an option at that time. I had never even heard of an EM doc doing one. But I remember having thoughts of needing to transition into a less burnout-prone career path, at some point. But I didn't feel any sense of urgency about it until my first kid was schooled aged (5+) and with a second one in diapers. Once they were on a 9-5, and I was still on EM-circadian rhythm crazy-schedule, that's when the embers began to flame.

The game-changing trigger was when my wife finally got fed up with me complaining about EM, how unsustainable it was, and daydreaming about transitioning to something where I, and my whole family, could have a normal life. I said one day, "When I semi-retire, I should do something like Pain."

She said, "Then do it now! What are you waiting for?"

That's when I started googling "Pain" "EM Pain" and poking around the Pain forum here on SDN. I emailed dozens of fellowship directors acting if EM physicians could do Pain fellowships. Most ignored me. Some said, "No. Sorry." One program emailed back saying, "Yes, EM physicians can do Pain fellowships. In fact, we have one in our program right now. Here's his contact info..."

My life would never be the same. All I can say to you is, my only regret about doing Pain, is that I didn't do it sooner. I was 39 when I started fellowship, with five and three year olds. Having been an attending for 8 years made it hard to go back. But it's never easy to take an 80% pay cut for a year, for anything.

I had a massive mortgage on a house worth less than I owed, student loan payment (still do, though not huge), two kids under 6, multiple pets, and ended up at a program in one of the most crowded expensive cities in America, which made living expenses that year, and the situation at large, even more impossible seeming. Then, the (#(*@-ers at the one last apartment in the city we got our hearts set on living in, demanded we pay the whole year of rent up front (!) because I couldn't prove I'd have enough income the fellowship year, to afford the apartment. I almost didn't do it. But I did. I wrote a check for $60K+ for the whole years rent, prior to moving up there. I worked dozens of extra shifts saving up money prior to fellowship and borrowed more money to make it happen. That's how bad I wanted out of the kiln of EM.

But that's just me. Whatever works for anyone; that's what they should do. But if you're going to do this, do it sooner rather than later. Do it when the time is right and when your spouse/significant other is on board with the whole plan, but don't wait so long the door closes.

But I get it. Life gets complicated. It really does. Kids make it tough, tough, tough. But I can't tell you how much better my family life is, having gutted out that one very tough year, knowing I never have to work a night, weekend or holiday again. I never have to be post-nights for my kid's birthday party, leave to work at 10pm on a holiday, or try to pop up after two hours of sleep and try to be smiling-involved mentally-present dad/husband/son/friend when I feel the weight of ED circadian rhythm dysphoria dragging my mood and personality down. But that's just me.

Do what's best for you!

This is a tremendous resource for readers.

 

[dchristismi]

Been there. Done that. Picked Birdstrike's brain. Made the leap.

Ditching my FACEP this year for HMDCB.
No regrets.

 

[Birdstrike]

Been there. Done that. Picked Birdstrike's brain. Made the leap.

Ditching my FACEP this year for HMDCB.
No regrets.

 

[Birdstrike]

1. I noticed that for a lot of the PM&R pain guys, they seem to market themselves as being able to provide many PM&R services (EMG etc) in addition to typical pain stuff. Did you feel underprepared to enter pain practice right after fellowship?

I did not feel underprepared. EMGs are considered like a procedure and I think the PM&R people put that out there as if to say, "Here's one more procedure I can do." But it's only a drop in the bucket. EMGs aren't that usual, that often, for pain. Maybe when history and MRI disagree to such an extent I need a tie-breaker to make a diagnosis, I'll order an EMG. But they're also operator dependent. So I don't order many. And when I do, I just refer them to a non-Pain PM&R or neuro person. Plus, some of those PMR guys leading with "I do EMGs" may not be fellowship Pain-trained. And there may be multiple procedures they don't do, so they throw out the EMG thing. I wouldn't worry about it.

If you do a fellowship, you'll be way way more prepared than a huge amount of non-fellowship people out there that claim to be "pain doctors." And there's not really a big market for "general PM&R services" in most Pain practices, that I can see. Outpatient Pain and general PM&R are as different as outpatient Pain and sitting in an OR running halothane on a surgical patient, that is, completely different.

2. How marketable would you say an EM pain guy is compared to the PM&R or Anesthesia pain guy? This is another concern I have.

If you went to an ACGME Pain program that does lots of procedures, and you pass the boards, you'd be equally marketable as a PR&R or Anesthesia Pain person. You might be more marketable, if they were not fellowship trained or went to a fake fellowship, which is not an insignificant number of people claiming to be 'pain specialists.'

3. Do you do any SCS/implants or kyphoplasties? Can you touch (just briefly) on what procedures you primarily do in your practice?

Thanks again!

I did many SCS trials and implants in fellowship. But currently, I do spinal cord stimulators trials, but not implants. The trials are temporary stimulators you can place under fluoro, in office. Implants require an OR either at a hospital or ACS. If you want to be a surgeon, you'll do trials and implants. If you don't want to be a surgeon, you'll do only the trials.

I also do kyphoplasties. Those can be done in hospital, ACS or in office. I do the easy ones, medically stable, in-office in my fluoro suite. Anything more difficult, bad lungs or higher in the spine than I'm comfortable with, I send to on of the ortho spine or neurosurg guys I know. Again, I have no desire to ever set foot in a hospital again, be a cowboy, or get 'surgeon calls' at 2 am. I'm happy to let someone else be the hero. Been there, done that.

My fellowship did tons of procedures, literally everything and then some. But kyphos were the one thing I wished we had more of. For some reason, IR took most of them. So, after fellowship, I had one of the kypho reps fly me to Tampa to do a cadaver course to hone my skills. After a year of learning all the other procedures, kypho was easy to learn. It's a really cool procedure. I wish I got more of them. But they're fun and work really well.

I also do lots of cervical and lumbar epidural steroid injections, facet nerve blocks, joint injections (shoulder, hip, knee, wrist, hand, sacroiliac, ankle), tendon/tendon sheath injections, occipital nerve blocks, radiofrequency nerve ablations (lumbar, cervical, knee), sympathetic nerve blocks, trigger point injections, joint bursa injections, and others.

I feel like if I do make the leap, I'll probably just have to take whatever fellowship I get (obviously always the case with the match, but I doubt I'll get my pick of fellowship).

Maybe or maybe not. This was how I approached it: My plan was to a apply to every program in the country. But since this was before Pain being in the Match, it was a rolling process. I had sent out 30 something applications when I started getting interviews. I paused applying temporarily and flew around the country to a hand full of interviews. I took the first offer I got, at a solid procedure-heavy program in a big city.
When I got the call I was on an ED shift, and I jumped up and down in the back hallway of my ED fist pumping and thanking the heavens like a crazy person, because I knew the day had come I could have a normal life again. I then stopped my search. I then worked more shifts than I ever did in my life the next 6-7 months to save money, so that the last day I left my ED, would be the last shift I ever had to work in an ED, ever again.

I did get credentialed with a locums company near my program and the ED director there said I could have shifts, but I never took any. Life was too good, at that point, to do that.

P.S.
The day-to-day practice of Pain has so little to do with the day to day practice of the base specialties the whole "who's better suited for Pain" conversation is actually kind of dumb. Pain training is best viewed more like a 1-year, crash-course residency, than a fellowship continuation of anything. And that goes for all the specialties.

To the extent you base specialty does matter, there are two things that do help: General procedural skills and clinical diagnostics. EM lines up very well on both fronts. EM physicians' only disadvantages are, being late to the Pain game, and a general refusal to ever imagine themselves as useful outside of the walls of an ED.

 

[Birdstrike]

Apparently this thread is working. Private message I just got.

You see the smack being talked on the “Graduating fellows” thread on the pain forum? Somebody said the future of pain was looking bad due to EM residents applying for fellowships. Lol

Keep it up, EM folks!

 

[sloh]

The day-to-day practice of Pain has so little to do with the day to day practice of the base specialties the whole "who's better suited for Pain" conversation is actually kind of dumb. Pain training is best viewed more like a 1-year, crash-course residency, than a fellowship continuation of anything. And that goes for all the specialties.

To the extent you base specialty does matter, there are two things that do help: General procedural skills and clinical diagnostics. EM lines up very well on both fronts. EM physicians' only disadvantages are, being late to the Pain game, and a general refusal to ever imagine themselves as useful outside of the walls of an ED.

Looks like there's going to be some turf wars haha. It's a dog eat dog world.

Graduating fellows....any advantage of going into PP instead of hospital employee?

Almost nobody I know has signed yet. Overwhelmingly, the jobs I've come across have been: 1) Brand new(ish) offices in the middle of nowhere, where practices from more saturated areas are looking to capture a new piece of the market. The group will wine and dine you at the central location in a...

forums.studentdoctor.net

 

[Birdstrike]

Looks like there's going to be some turf wars haha. It's a dog eat dog world.

Graduating fellows....any advantage of going into PP instead of hospital employee?

Almost nobody I know has signed yet. Overwhelmingly, the jobs I've come across have been: 1) Brand new(ish) offices in the middle of nowhere, where practices from more saturated areas are looking to capture a new piece of the market. The group will wine and dine you at the central location in a...

forums.studentdoctor.net

Yep, lol. I remember muckin' it up with them over there 10-11 years ago when thinking about applying. It bothered me then, but doesn't now. I got in and I've been doing just fine in private practice for almost a decade now, and the same people are over on that forum slingin' poo at each other, Lol . I'll stay out of it and let them keep all the poo-poo for themselves. In the meantime, I'm too busy opening all the "Thanks Birdstrike, I got in!" DMs between procedures. Most of them couldn't get into fellowships, so they sling dirt at the people they think took their spots.

 

[avalon10]

I did not feel underprepared. EMGs are considered like a procedure and I think the PM&R people put that out there as if to say, "Here's one more procedure I can do." But it's only a drop in the bucket. EMGs aren't that usual, that often, for pain. Maybe when history and MRI disagree to such an extent I need a tie-breaker to make a diagnosis, I'll order an EMG. But they're also operator dependent. So I don't order many. And when I do, I just refer them to a non-Pain PM&R or neuro person. Plus, some of those PMR guys leading with "I do EMGs" may not be fellowship Pain-trained. And there may be multiple procedures they don't do, so they throw out the EMG thing. I wouldn't worry about it.

If you do a fellowship, you'll be way way more prepared than a huge amount of non-fellowship people out there that claim to be "pain doctors." And there's not really a big market for "general PM&R services" in most Pain practices, that I can see. Outpatient Pain and general PM&R are as different as outpatient Pain and sitting in an OR running halothane on a surgical patient, that is, completely different.


If you went to an ACGME Pain program that does lots of procedures, and you pass the boards, you'd be equally marketable as a PR&R or Anesthesia Pain person. You might be more marketable, if they were not fellowship trained or went to a fake fellowship, which is not an insignificant number of people claiming to be 'pain specialists.'



I did many SCS trials and implants in fellowship. But currently, I do spinal cord stimulators trials, but not implants. The trials are temporary stimulators you can place under fluoro, in office. Implants require an OR either at a hospital or ACS. If you want to be a surgeon, you'll do trials and implants. If you don't want to be a surgeon, you'll do only the trials.

I also do kyphoplasties. Those can be done in hospital, ACS or in office. I do the easy ones, medically stable, in-office in my fluoro suite. Anything more difficult, bad lungs or higher in the spine than I'm comfortable with, I send to on of the ortho spine or neurosurg guys I know. Again, I have no desire to ever set foot in a hospital again, be a cowboy, or get 'surgeon calls' at 2 am. I'm happy to let someone else be the hero. Been there, done that.

My fellowship did tons of procedures, literally everything and then some. But kyphos were the one thing I wished we had more of. For some reason, IR took most of them. So, after fellowship, I had one of the kypho reps fly me to Tampa to do a cadaver course to hone my skills. After a year of learning all the other procedures, kypho was easy to learn. It's a really cool procedure. I wish I got more of them. But they're fun and work really well.

I also do lots of cervical and lumbar epidural steroid injections, facet nerve blocks, joint injections (shoulder, hip, knee, wrist, hand, sacroiliac, ankle), tendon/tendon sheath injections, occipital nerve blocks, radiofrequency nerve ablations (lumbar, cervical, knee), sympathetic nerve blocks, trigger point injections, joint bursa injections, and others.


Maybe or maybe not. This was how I approached it: My plan was to a apply to every program in the country. But since this was before Pain being in the Match, it was a rolling process. I had sent out 30 something applications when I started getting interviews. I paused applying temporarily and flew around the country to a hand full of interviews. I took the first offer I got, at a solid procedure-heavy program in a big city.
When I got the call I was on an ED shift, and I jumped up and down in the back hallway of my ED fist pumping and thanking the heavens like a crazy person, because I knew the day had come I could have a normal life again. I then stopped my search. I then worked more shifts than I ever did in my life the next 6-7 months to save money, so that the last day I left my ED, would be the last shift I ever had to work in an ED, ever again.

I did get credentialed with a locums company near my program and the ED director there said I could have shifts, but I never took any. Life was too good, at that point, to do that.

P.S.
The day-to-day practice of Pain has so little to do with the day to day practice of the base specialties the whole "who's better suited for Pain" conversation is actually kind of dumb. Pain training is best viewed more like a 1-year, crash-course residency, than a fellowship continuation of anything. And that goes for all the specialties.

To the extent you base specialty does matter, there are two things that do help: General procedural skills and clinical diagnostics. EM lines up very well on both fronts. EM physicians' only disadvantages are, being late to the Pain game, and a general refusal to ever imagine themselves as useful outside of the walls of an ED.

“Outpatient Pain and general PM&R are as different as outpatient Pain and sitting in an OR running halothane on a surgical patient, that is, completely different”

This is just so not true. How would you know what general PMR is like?!? You clearly don’t.

 

[Birdstrike]

“Outpatient Pain and general PM&R are as different as outpatient Pain and sitting in an OR running halothane on a surgical patient, that is, completely different”

This is just so not true. How would you know what general PMR is like?!? You clearly don’t.

Why don’t you tell us...

 

[hector10]

I’m an intern
So I have emailed 35 program coordinators for a chance to do an elective rotation as a visiting resident and they all said they aren’t accepting rotators during covid.
so if I am to apply for a fellowship and start right after my third year of EM residency, I would have to apply during December my 2nd year.
How on earth do I get pain experience ..?
Any ideas

 

[Birdstrike]

I’m an intern
So I have emailed 35 program coordinators for a chance to do an elective rotation as a visiting resident and they all said they aren’t accepting rotators during covid.
so if I am to apply for a fellowship and start right after my third year of EM residency, I would have to apply during December my 2nd year.
How on earth do I get pain experience ..?
Any ideas

Email 35 more. Then 35 more. Then, try shadowing as many Pain docs as you can. Just cold call some in your area (I did). If all else fails, pay to take a Pain procedure cadaver course, if they're not also on hold due to COVID (ASIPP and SIS have good ones).

But you know what, if that all fails, just apply. That's what I did. I never had a 'pain rotation' prior to applying or starting fellowship. You know what I told them when they asked, "What's your experience in 'pain'?"

I told them that, "in years practicing EM I had seen thousands of patients, 70% of which have a chief complaint of some type of pain and 40% have an underlying chronic pain condition. Although my pre-fellowship pain experience isn't the traditional one, it's a very broad and unique experience in treating and evaluating a wide array of acute and chronic pain conditions, that will be a great base for Pain Fellowship training."

I also mentioned any experience I had in reading MSK films and CTs, using ultrasound for guidance, ED nerve blocks, intubation/sedation (the anesthesia guys liked that). I also had stories of patients that were blown off as being "drug seekers," who I didn't blow off and on whom I found life or limb threatening conditions.

It worked. I got in.

But just ask yourself this at the end of your next shift, "How many patients with some type of pain did I see in the past 10 hours, and how many did the anesthesia resident upstairs, while sitting in the OR?"

 

[Birdstrike]

You guys are letting Anesthesia residents, who don't want you as competition for fellowships, frame your mindset about this subspecialty of your specialty. "We own the specialty....no one's as good as us...only anesthesia should do Pain..."

DO NOT ALLOW YOUR COMPETITION TO SET THE RULES

You're constantly seeing patients with pain, all day, every day, in EM. Acute pain, chronic pain, and everything in between. While you may not be an "expert" in pain(yet), you sure see enough patients in pain to qualify as being able to obtain the training to be an expert. You know at least as much about presentations of pain than an anesthesia resident monitoring a patient that's asleep. Don't you?

If you allow someone else to frame your mindset on a situation, you're playing by their rules. Frame your own and play by your rules.

 

[Birdstrike]

Another one:

"Hey man,

I'm an ER ___ going into pain fellowship this July. Reading your posts is absolutely inspiring and providing me with a sense of relief. I'm ___years into ER, and getting absolutely burned out. I may reach out to you once in a while to get some advice during fellowship.

Cheers"

 

[Birdstrike]

Another one:

“Hey Birdstrike remember me??

My friend, holy crap we did it. I matched in pain from a 3-yr EM program. …couldn't be more stoked!”

 

[Birdstrike]

Another one:

"Hey just wanted to let you know I accepted an...offer at [ACGME Pain Fellowship]..."

 

[emergentmd]

Given current market conditions, is getting a pain fellowship worth the money? From what I can tell, it takes a while to get up a successful pain practice and competition in big cities can be fierce.

 

[DeadCactus]

 

[BoardingDoc]

Given current market conditions, is getting a pain fellowship worth the money? From what I can tell, it takes a while to get up a successful pain practice and competition in big cities can be fierce.

If you are willing to relocate to a "less desirable area," it can still be very lucrative. Like you said, however, compensation in big cities can be rather low. I would almost certainly be taking a pay cut going from EM --> Pain in my current area.

 

[GatorCHOMPions]

Starting compensation for my major metro area pain job is about on par with EM salaries in the area. Difference is, assuming things go decently, that is my floor whereas EM pay is rather stagnant. The ceiling is much higher than local EM pay. Finding the job was pretty tough, much harder than getting an EM job, however.