Pain vs. MSK/Spine vs. No fellowship

[KCN79]

So, as I'm halfway through my PGY3 year, I've come to the conclusion that I still don't know what I want to do with myself. I am considering 3 options:
1. Applying to Pain fellowships
2. Applying to MSK fellowsihips
3. Going directly into practice.

I've read the forums, talked with senior residents, fellows, and faculty, and still am no closer to a decision than before talking to anybody.

Things factoring into my decision:
-In reality, I don't envision myself wanting to do more than bread and butter spinal procedures, if I do spine procedures at all
-I would like to have the skill set that a Pain fellowship offers, but being labeled as a "Pain Doc" I feel like I would get chronic pain upon chronic pain thrust upon me as I started my practice.
-An MSK or spine fellowship would potentially offer training in more basic spine procedures, but what does the future hold for getting credentialed if you aren't a board certified pain physician?
-If I am comfortable with my MSK/spine training and am able to fulfill the "Credentialing Recommendations for the PM&R Specialist Performing Interventional Pain Management Procedures" with my residency training alone, what is the advantage of completing a fellowship (taking the answer to the previous question into account)?

I appreciate any input you all can offer.

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[Disciple]

-If I am comfortable with my MSK/spine training and am able to fulfill the "Credentialing Recommendations for the PM&R Specialist Performing Interventional Pain Management Procedures" with my residency training alone, what is the advantage of completing a fellowship (taking the answer to the previous question into account)?

Everything's relative.

If you go to one of the few residency programs that provides what was previously considered to be fellowship level training, then no fellowship is necessary.

If you go to a program that provides terrible MSK/interventional/EMG training, then a fellowship is definitely necessary.

Anything in-between and the decision can be difficult.

 

[lobelsteve]

Pain practices vary widely from pure MSk, to pure opioids, to pure spine.

Most of us are Spine>Msk>drugs and quite happy. If you do not fl the need to offer OR level services (SCS/PDD/Disco) then you should still do a fellowship in Pain because insurance companies may start limiting brad and butter to those with formal training. See the new PMR journal for contrast patterns and missed vascualr uptake....

 

[Finally M3]

Pain practices vary widely from pure MSk, to pure opioids, to pure spine.

Most of us are Spine>Msk>drugs and quite happy. If you do not fl the need to offer OR level services (SCS/PDD/Disco) then you should still do a fellowship in Pain because insurance companies may start limiting brad and butter to those with formal training. See the new PMR journal for contrast patterns and missed vascualr uptake....

To be fair about Matt and Zach's paper, those fellows in the study, if they were half-way through the prior manifestation of Michigan's PMR-based pain program, had performed over 500 injections a piece. The current combined Anesthesia/PMR program would have less than that for the entire year. Combine the fact that not everyone uses live fluoro with contrast injection, I think experience with the right training (live fluoro, really knowing what you are looking for w/ intravascular patterns, as well as experience, experience, experience) would trump some Pain fellowship experiences. I think everyone would concur that experience is the key factor to recognize what you are seeing.

Disclosure; I'm biased in that I chose a spine program over a pain program.

Disclosure2; I think the Pain certification helps in the job hunt; some places want you to be BC/BE for Pain specifically. Although I'm happy with the interviews I have set up thus far

 

[SSdoc33]

all the fellowships are different. some of the "msk" fellowships, as you put it, will give you more exposure to spine procedures than some of the "pain" fellowships. the reverse is also true.

 

[chauffeur]

i agree with the above.
i addition, look at some job postings in regions were you might want to work. more often than not, if you just want to do spine, msk and outpatient work, a fellowship will make you a stronger applicant and more marketable. most employers in nice parts of the country want someone who is fellowship trained to fit the job described above. of course there are exceptions. it seems that those rehab residents who don't do spine/pain/sports fellowships end up doing some inpatient work as well. possibly b/c they can't differentiate themselves from others in their practice group.

 

[lobelsteve]

Please consider that there are insurance companies that will not credential you as a interventionalist and some hospitals that will not credential you period if you do not have ACGME training.

Some insurances would credential you but only if you have hospital privilges.
Many ways to get shut out.

Pain is an evloving field and the battle for a residency program is under way.

 

[ampaphb]

-If I am comfortable with my MSK/spine training

You should not be. No matter the number of procedures you have done in residency, you have never had the opportunity to do enough DIFFICULT cases, get yourself into trouble, and figure out how to get yourself out of the woods. IMHO, no PM&R residency trains you adequately to do procedures, even the bread and butter kind.

 

[lobelsteve]

You should not be. No matter the number of procedures you have done in residency, you have never had the opportunity to do enough DIFFICULT cases, get yourself into trouble, and figure out how to get yourself out of the woods. IMHO, no PM&R residency trains you adequately to do procedures, even the bread and butter kind.

Even little stuff like oversedating an opioid naive patient and having to abort the procedure to roll the patient supine and increase O2, assess if they need to get bagged, and push narcan +/- flumazenil can make the difference.

I agree with above.
I've seen fellows do the above, inject into the ACL with Synvisc, perform cervcal pneumo-encephelograms, perform lumbar epidurencephelograms (the radiologist report said it could be blood unitl I told him what we did).

 

[Disciple]

I agree with above.
I've seen fellows inject into the ACL with Synvisc.

So, nobody should do knee injections without a fellowship?

 

[lobelsteve]

So, nobody should do knee injections without a fellowship?

I did not say or imply that.
No body should do knee injections without proper instruction beforehand.
If a PMR resident makes it through residency without ever injecting a knee, the problem lies within the program. If he does his first in fellowship after cutting his teeth on CESI, LESI, SIJ, RF, LSB, SCS and winds up in a ligament, it becomes my problem.

So nobody should do anything with the potential for injuring a patient without being taught how by a competent and experienced attending physician.

 

[Ludicolo]

Agree with the above. It's a great responsibility to stick a needle in someone. Education about procedures is not just about learning the regional anatomy and technical aspects. It's about knowing about the indications and contraindications. Knowing all of the possible outcomes and complications, and how to deal with them. Troubleshooting when things aren't going your way. Knowing your limitations and when to bail.

You should not be. No matter the number of procedures you have done in residency, you have never had the opportunity to do enough DIFFICULT cases, get yourself into trouble, and figure out how to get yourself out of the woods. IMHO, no PM&R residency trains you adequately to do procedures, even the bread and butter kind.

But do we let residents/fellows get into this situation? This is the rationale behind appropriate attending supervision. If something is going wrong - and an attending should certainly recognize this better than a resident or fellow - the attending needs to step in and do what’s right for the patient. At that point, the resident needs to step back, digest what went wrong, and observe how the attending problem solved and dealt with the situation. Debriefing should be done afterwards.

We learn from our mistakes as well as our successes. We learn from experience, just as much (if not more so) as from reading a book or journal article, or from a didactic session. And I personally feel I continue to learn through teaching. But it can be a difficult task - balancing the responsibilities of patient care and resident/student education. It’s one of the many things that makes my job challenging and stimulating.