Pain vs Spine fellowships

[ml2001]

Before you all say not the same question again, please read my question. I was only able to find one post back in 2002 that tries to answer this question.

For a PM&R resident who is interested in a job that would let him/her practice outpt MSK/interventional pain/EMG-NCS, which fellowship would better train an outgoing PM&R resident: An interventional pain fellowship or interventional spine fellowship?

I'm still only a PGY-3 in PM&R, but I'm going through my pain rotation and started thinking about what my options are and which would be ideal for me?

My current pain rotation is under Anesthesia. It is turning into an eye opener. I never thought there would be much difference in a pain center regardless of whether it is run by Anesthesia or PM&R, but I'm starting to realize that I couldn't be more wrong? I just feel like I have already seen pts where they could have benefited from a MSK Physiatrist evaluation (comprehensive MSK exam, EMG-NCS) followed by medical treatment and physical therapy before going for injections, but instead pt ended up getting some form of steroid injection procedure during the first visit itself.

What has been the PM&R pain outpt attending's experience in this matter?

Thank you for your input in this matter

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[PMR 4 MSK]

You'd likely be better served with a spine fellowship.

Anyone can learn where and how to place needles into various parts of the human body. Many Anesthesia residents gets a leg-up on PM&R during training because they get a lot more needle time in the OR, while we do our 51st admit of the month for a 90 yo CVA. PM&R gets the advantage of more MSK training, in general.

The fully trained pain doc knows when to stick a needle into someone, and when to use other treatments like meds, PT, etc, as well as when to refer for surgery.

A very well-trained pain doc can come from PM&R or anesthesia (and sometimes other fields), and should be interchangeable or at least work well together.

My personal bias is that most Physiatrists should not be doing procedures requiring scalpels, as most PM&R residency programs have zero training in this. There are plenty of exceptions (e.g. several on this board), but I think you should have a lot more OR time than PM&R usually affords, if you plan on doing cutting and sewing as well as poking. You not only need to be technically proficient in placing implants, e.g., but must also be able to handle the complications. That's where the true skills lie.

 

[lobelsteve]

No scalpels? Did you think this thing was going to fall off on its own? It was almost in the way of a medial branch block, so it had to go. And yes, it got sent for pathology.

 

[PMR 4 MSK]

WTF is that?

 

[lobelsteve]

WTF is that?

Exophytic skin lesion. Benign. 3cm in diameter. Pedunculated.
4cc of 1% lidocaine with epi and a little battery powered cautery for touch ups. 11 blade to excise it at the base. It didn't bother the owner, except if his grandkids played with it because it would bleed. It had to go.

I took off a similar lesion on the PMR floor for a BKA patient who could not start with his prosthesis because he had a pedunculated schwanoma on his distal thigh. Whacked it off so we could fit him to start gait training. My attending OK'd it but said I could do it only if he was not on the floor at the time.

 

[ml2001]

You'd likely be better served with a spine fellowship.

Anyone can learn where and how to place needles into various parts of the human body. Many Anesthesia residents gets a leg-up on PM&R during training because they get a lot more needle time in the OR, while we do our 51st admit of the month for a 90 yo CVA. PM&R gets the advantage of more MSK training, in general.

The fully trained pain doc knows when to stick a needle into someone, and when to use other treatments like meds, PT, etc, as well as when to refer for surgery.

A very well-trained pain doc can come from PM&R or anesthesia (and sometimes other fields), and should be interchangeable or at least work well together.

My personal bias is that most Physiatrists should not be doing procedures requiring scalpels, as most PM&R residency programs have zero training in this. There are plenty of exceptions (e.g. several on this board), but I think you should have a lot more OR time than PM&R usually affords, if you plan on doing cutting and sewing as well as poking. You not only need to be technically proficient in placing implants, e.g., but must also be able to handle the complications. That's where the true skills lie.

Thank you for a great response. Could someone please answer the following concerns:

• Are spine fellowship trained docs allowed to see all spine related issues including just med management or just only injections?
• Do spine programs integrate further training in EMG-NCS or just procedures?
• Can you get enough business just from spine interventions?
• Are spine docs allowed to deal with other joints like shoulder/knees since we come from a PM&R background?
• Are there any spine fellowships that are ACGME (excluding sports medicine/MSK fellowships)?

Thank you very much.....

-ML

 

[eljefe]

The problem with spine fellowships is the lack of ACGME accrediation. If you are interested in academics or practicing at a large tertiary care facility, anesthesia probably controls credentialing and will likely try to prohibit you from competing with them since you are not "ACGME fellowship" trained, even if your spine fellowship was top notch.


A spine fellowship is usually a better ideological fit for most PM&R residents, but you may wish you had that extra piece of paper that says ACGME on it down the road.

 

[ml2001]

The problem with spine fellowships is the lack of ACGME accrediation. If you are interested in academics or practicing at a large tertiary care facility, anesthesia probably controls credentialing and will likely try to prohibit you from competing with them since you are not "ACGME fellowship" trained, even if your spine fellowship was top notch.


A spine fellowship is usually a better ideological fit for most PM&R residents, but you may wish you had that extra piece of paper that says ACGME on it down the road.

I see what you are saying? Does this mean that most PM&R pain docs do ACGME pain fellowship just to have the ACGME certification and then they go back to practicing MSK/interventional pain doc?

Thank you again for the enlightenment

-ML

 

[bedrock]

Are spine fellowship trained docs allowed to see all spine related issues including just med management or just only injections?

of course you can. You're an MD, you can see whatever you want. But as a physiatrist you've had training in managing these patients not just injecting them

Do spine programs integrate further training in EMG-NCS or just procedures?

depends on program. Quite common to do EMG in many PMR spine fellowships and ACGME PMR based pain fellowships. Won't happen in anesthesia pain fellowships

Can you get enough business just from spine interventions?

spine interventions and EMGs can keep you plenty busy

Are spine docs allowed to deal with other joints like shoulder/knees since we come from a PM&R background?

duh, as an MD you can see whatever you want. Most physiatrists are comfortable seeing peripheral joints. Those patients do tend to be chronic, degenerative cases, etc. To attract and be ready for a clinic full of acute/subacute sports cases, you'll need a sports fellowship.

Are there any spine fellowships that are ACGME (excluding sports medicine/MSK fellowships)?

ACGME fellowship only in pain or sports.

Does this mean that most PM&R pain docs do ACGME pain fellowship just to have the ACGME certification and then they go back to practicing MSK/interventional pain doc

Many PM&R docs do this. If you want to do spine interventions and have the most job options when you finish, do a pain fellowship as ACGME credentialing is required for many jobs. You can still practice good spine/MSK medicine afterwards, just don't forget your PMR approach to spine and MSK care during your fellowship and take the time to work people up and incorporate various rehab strategies. You don't have to poke them with a needle as soon as they walk in the room just because you did a pain fellowship.

 

[ml2001]

While we are at it, can you guys comment on how hospitals would treat an ACGME sports medicine trained fellow compared to a ACGME pain fellowship trained fellow provided that both programs train the fellows in interventional spine procedures.
The reason I ask this is because there are ACGME sports medicine fellowships that do train their fellows in interventional spine procedures.

Thnx....


-ML

 

[lobelsteve]

While we are at it, can you guys comment on how hospitals would treat an ACGME sports medicine trained fellow compared to a ACGME pain fellowship trained fellow provided that both programs train the fellows in interventional spine procedures.
The reason I ask this is because there are ACGME sports medicine fellowships that do train their fellows in interventional spine procedures.

Thnx....


-ML

Sports and pain have little overlap. Sports guys would not priv at my hospital for spine procedures.

 

[SSdoc33]

The reason I ask this is because there are ACGME sports medicine fellowships that do train their fellows in interventional spine procedures.

Thnx....


-ML

which ones? maybe there are 1 or 2. either way, you are robbing peter to pay paul b/c you cant learn either adequately in less than a year.

 

[PMR 4 MSK]

Sports is a different animal than spine, and spine is much closer to pain management.

In sports, you mostly see young, health adults with good insurance who are go-getters, motivated and get better quickly, or go to surgery and get fixed, rehab it and then get back to sports.

Spine - middle-aged to older, less well insured, less motivated, often chronic problems. Some need surgery.

Pain management - Mostly young, uninsured/Medicaid and old/medicare, not at all motivated to get better, few do get better, many have surgery and then come back to you because it didn't work.

Also in sports, you are expected to give a lot of your time for free attending high school and college sporting events, in case anyone gets injured. Some of our sports guys are covering 4-5 events per week during some seasons. The expected quid-pro-quo to get those injured athletes to be your patients may not happen.

Then you sometimes get contracted to cover minor pro sports teams, and they often expect free treatment, free physicals, free MRIs and Xrays, etc. Move up to the big leagues and you get to pay them to be the team doctor.

In sports, orthos can make $1M, due to all the knee and shoulder scopes they do. The non-operative guys divy up the scraps.

 

[VApmrdoc]

Great synopsis PMR 4 MSK, and of course don't forget dragging residents and medical students with your fellow to do the physicals and high school/college team coverage "with" you.

Not sure if its ACGME accredited (but I think it probably is), there is a fellowship in Interventional Spine and Sports Medicine at Hospital for Special Surgery in NY. Uou can find out more information about how they do it if you want something to compare.

SSdoc33 comments on this below but here is the website link http://www.hss.org/11943.asp#11
And it does not appear to be ACGME accredited... they do say PASSOR accredited for what it's worth.

 

[SSdoc33]

Not sure if its ACGME accredited (but I think it probably is), there is a fellowship in Interventional Spine and Sports Medicine at Hospital for Special Surgery in NY. Uou can find out more information about how they do it if you want something to compare.

not accredited

 

[axm397]

PASSOR doesn't exist anymore and they never accredited anything. They "recognized" some fellowships but that really doesn't mean much anyway. (i.e. hospital credentialing, etc.)

 

[ml2001]

Not to bring an old thread to life, but why is it that ACGME is such a big deal for hospitals/insurance companies only for pain specialists. I was talking to couple of my GAS buddies who mentioned that even they have couple of fellowships (ex: regional anesthesia) that are not ACGME.

I'm not arguing that ACGME pain fellowship is the best option, but was just wondering why only pain fellowships.

Thank you...

-ML

 

[PMR 4 MSK]

Not to bring an old thread to life, but why is it that ACGME is such a big deal for hospitals/insurance companies only for pain specialists. I was talking to couple of my GAS buddies who mentioned that even they have couple of fellowships (ex: regional anesthesia) that are not ACGME.

I'm not arguing that ACGME pain fellowship is the best option, but was just wondering why only pain fellowships.

Thank you...

-ML

Elitism...

 

[avatar]

which ones? maybe there are 1 or 2. either way, you are robbing peter to pay paul b/c you cant learn either adequately in less than a year.

That's crap. There are plenty of Sports fellowships that train their fellows in interventional techniques. This includes many of the top, ACGME-accredited ones such as RIC. These fellows go on to have extremely successful careers in both academics and private practice doing both sports and spine, and are involved and highly respected in the national multidisciplinary spine associations such as NAAS and ISIS.

I also disagree with the posts that pain, sports, and spine practitioners have little overlap in patient and payer mixes. For my 2 cents, we see MANY of the same types of patients and perform many of the same procedures. The difference is in ideology and approach towards these patients.

I have depending on the occasion labeled myself as either a "sports and spine" doc or a comprehensive musculoskeletal specialist. I for one am glad that I am NOT an "interventional spine" or pain practitioner. If someone sends me a neck pain patient that turns out to be shoulder, or back pain that turns out to be SIJ or hip, I am not going to turn them away because I am a spine doc. Furthermore, I will not label myself an interventionalist because I am not a proceduralist, or to use a more derisive term, a "needle jockey". There is a subtle but very real difference in the way that an "interventionalist" approaches the use of injections compared to that of a musculoskeletal specialist. I use interventional techniques to supplement my care of the patient, but it does not define my practice.

 

[ihaveaquestion]

I will leave the debate of Sports/Spine vs. Pain alone, but according to the ACGME website there are 8 accredited sports medicine fellowships through PM&R. In addition, most of these programs probably take 1 candidate yearly. As far as musculoskeletal medicine training there is no doubt that RIC is amongst the best. They were in the process of applying for accreditation a few months ago.

One year is a short amount of time for fellowship. I am not sure if SSdoc33 was entirely off the mark when stating that in a "pure" ACGME-accredited sports medicine fellowship there is less exposure to advanced interventional spine procedures. This is not a knock on sports medicine in any way - just a different clinical focus is all.

That's crap. There are plenty of Sports fellowships that train their fellows in interventional techniques. This includes many of the top, ACGME-accredited ones such as RIC. These fellows go on to have extremely successful careers in both academics and private practice doing both sports and spine, and are involved and highly respected in the national multidisciplinary spine associations such as NAAS and ISIS.

I also disagree with the posts that pain, sports, and spine practitioners have little overlap in patient and payer mixes. For my 2 cents, we see MANY of the same types of patients and perform many of the same procedures. The difference is in ideology and approach towards these patients.

I have depending on the occasion labeled myself as either a "sports and spine" doc or a comprehensive musculoskeletal specialist. I for one am glad that I am NOT an "interventional spine" or pain practitioner. If someone sends me a neck pain patient that turns out to be shoulder, or back pain that turns out to be SIJ or hip, I am not going to turn them away because I am a spine doc. Furthermore, I will not label myself an interventionalist because I am not a proceduralist, or to use a more derisive term, a "needle jockey". There is a subtle but very real difference in the way that an "interventionalist" approaches the use of injections compared to that of a musculoskeletal specialist. I use interventional techniques to supplement my care of the patient, but it does not define my practice.

 

[lobelsteve]

That's crap. There are plenty of Sports fellowships that train their fellows in interventional techniques. This includes many of the top, ACGME-accredited ones such as RIC. These fellows go on to have extremely successful careers in both academics and private practice doing both sports and spine, and are involved and highly respected in the national multidisciplinary spine associations such as NAAS and ISIS.

I also disagree with the posts that pain, sports, and spine practitioners have little overlap in patient and payer mixes. For my 2 cents, we see MANY of the same types of patients and perform many of the same procedures. The difference is in ideology and approach towards these patients.

I have depending on the occasion labeled myself as either a "sports and spine" doc or a comprehensive musculoskeletal specialist. I for one am glad that I am NOT an "interventional spine" or pain practitioner. If someone sends me a neck pain patient that turns out to be shoulder, or back pain that turns out to be SIJ or hip, I am not going to turn them away because I am a spine doc. Furthermore, I will not label myself an interventionalist because I am not a proceduralist, or to use a more derisive term, a "needle jockey". There is a subtle but very real difference in the way that an "interventionalist" approaches the use of injections compared to that of a musculoskeletal specialist. I use interventional techniques to supplement my care of the patient, but it does not define my practice.

As a Pain Medicine Specialist, my 2c.

Sports guys do not get the same training as Pain guys. Some overlap for sure, but no way would I let my mom go to a Sports guy for a blown disc or axial neck/back pain. As far as SIJ, hips- needs fluoro for placement, U/s is a possibility, but when they kill off guidance codes....Knees and shoulders are bread and butter of PMR, if you didnt get a few hundred injections of each and how to eval- your PMR program failed you.

If you are a spine guy- and cannot offer TFESI, disco, SIJ, MBB, RF, SCS, kypho or vertebroplasty, GRC- then you should defer to those who have better training. An remember, as we have learned from our Anesthesia trained brethren- anyone can learn to do the procedure, they just can't learn on who needs what procedure.

Sport, spine, pain. It is up to each practitioner to determine their comfort levels in what they do and what they don't do. Be very clear in your practice as to your limits, and don't cross the lines of your comfort zone. My website lists what I do. If you need a lami, I cannot help.

 

[NRAI2001]

Sports and pain have little overlap. Sports guys would not priv at my hospital for spine procedures.

What do spinal trained PM&R docs really do? Do they do invasive procedures? Or is it more of pain/medical-management of spinal related injuries?

The more I learn about the field of PM&R the cooler and cooler I realize it is

 

[lobelsteve]

What do spinal trained PM&R docs really do? Do they do invasive procedures? Or is it more of pain/medical-management of spinal related injuries?

The more I learn about the field of PM&R the cooler and cooler I realize it is

Spine and Pain are the same for most docs. Call yourself a Pain guy on a billboard and you'll attract a lot of addicts. Call yourself a spine guy, and you'll get a lot of bulged disc addicts.

If you are still down in Grenada, go to Grand Anse, tell Nick I said hi, then walk to Colin and Sue Folan's place (Taffy's) and give him a hug for me. I miss my life as a pirate. Just wait til you get to Bequia....

 

[SSdoc33]

That's crap. There are plenty of Sports fellowships that train their fellows in interventional techniques. This includes many of the top, ACGME-accredited ones such as RIC.

ok, long-haired, blue cartoon man (woman?). go ahead. list 'em. i'm listening. and by ACGME-accredited, i assume you mean ACGME SPORTS accredited.

 

[MSKalltheway]

ok, long-haired, blue cartoon man (woman?). go ahead. list 'em. i'm listening. and by ACGME-accredited, i assume you mean ACGME SPORTS accredited.

From the ACGME website, cuz I was bored:

UC Davis
Emory
Spaulding
Mayo
Wash U in St Louis
U of Puerto Rico
U of Wash - Seattle
MCW

 

[SSdoc33]

From the ACGME website, cuz I was bored:

UC Davis
Emory
Spaulding
Mayo
Wash U in St Louis
U of Puerto Rico
U of Wash - Seattle
MCW

UGH. follow the coversation, MSK. anyone can look up a list. i want to know the ACGME sports fellowships that also offer comprehensive spine interventional training.

 

[caedmon]

I'd say UW- Seattle has pretty good spine exposure.

Also University of Utah. I believe their PM&R sports/spine fellowship is accredited through family medicine (PM&R picks one per year). The fellow does quite a bit of sports and a lot of spine.

 

[MSKalltheway]

UGH. follow the coversation, MSK. anyone can look up a list. i want to know the ACGME sports fellowships that also offer comprehensive spine interventional training.

Easy bro, my bad, I obviously have nothing to offer there

 

[SSdoc33]

Easy bro, my bad, I obviously have nothing to offer there

my point is that VERY few ACGME sports programs offer comprehensive training in both sports and spine. the few spots that do, all the better, but thats hardly something we can hang our hats on as a specialty.

 

[bedrock]

UC Davis
Emory
Spaulding
Mayo
Wash U in St Louis
U of Puerto Rico
MCW

Sports fellows at Mayo don't do spine interventions
Sports fellows at Wash U & Spaulding don't do cervical spine interventions or any RF (A fellow's job options will be much more limited if he/she isn't trained in cervical procedures or RF)
Not sure regarding Davis, Emory, and MCW, but I believe they are in the same camp as Wash U & Spaulding so they are a ACGME sports fellowship + some spine but you're limited by the fact you can't treat the entire spine or offer common interventions like RF

I'd say UW- Seattle has pretty good spine exposure.

Also University of Utah. I believe their PM&R sports/spine fellowship is accredited through family medicine (PM&R picks one per year). The fellow does quite a bit of sports and a lot of spine.

UW and U of Utah represent two of the very few ACGME PMR sports fellowships that actually train their fellows in cervicals and radiofrequency ablations. At both programs you get plenty of lumbars and just enough cervicals and RF to be competent, but not a ton of cervicals/RF.

Very few ACGME sports fellowship truly train you to treat the entire spine. If you can't offer cervical epidurals and cervical/lumbar RF, you can't really claim you're a "spine expert" as cervical epidurals and RF are very common bread and butter spine procedures.