Performance of Interventional Spine Procedures Be Core Training?

[fozzy40]

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Interesting point/counterpoint in this month's PM&R...thoughts?

Should Performance of Interventional Spine Procedures Be Part of the Core Training for PM&R Residency Training Programs?

 

[PMR 4 MSK]

Interesting point/counterpoint in this month's PM&R...thoughts?

Should Performance of Interventional Spine Procedures Be Part of the Core Training for PM&R Residency Training Programs?

If the field wants to survive, yes it should.

Inpt rehab is going extinct. Outpt rehab has little definition.

 

[bronx43]

If the field wants to survive, yes it should.

Inpt rehab is going extinct. Outpt rehab has little definition.

By "field" do you mean the subspecialty of Interventional Spine or PM&R as a whole?

Also, I thought inpatient rehab was the one that was expanding, and outpatient rehab was losing ground.

 

[PMR 4 MSK]

By "field" do you mean the subspecialty of Interventional Spine or PM&R as a whole?

Also, I thought inpatient rehab was the one that was expanding, and outpatient rehab was losing ground.

The field as a whole - PM&R.

Payment for inpt rehab is going to continue to be cut, as we have, as a field, failed to prove it's worth. It's a nice idea and we all believe it works, but the data to support it is not there.

When I started out in rehab, a CVA would stay up to 8 weeks, SCI up to 12, sometimes more. Amputees were there for a month regularly. How long do they get to stay now?

Also, when I started, it was Fee-for-service, now payment for rehab is one of the more complicated things Medicare has come up with.

Look at the journals and job boards - how many inpatient jobs do you see? Mainly only at academic centers. For now, they can continue to survive due to alternative revenue streams, or even operating at a loss if it helps the hospital/university overall.

 

[fozzy40]

I love inpatient and outpatient so this is my bias...

I am not as atuned on how reimbursement works so I don't know if its strictly that payment is becoming less. From a resident perspective, it does appear as though the criteria admission and payment for inpatient has definitely become stricter if anything. I'm at a big academic institution and our volume is a consistently high with the bread and butter SCI, CVA, TBI, etc. What is pretty rare is to see the joint replacement patients anymore unless they have some other comorbidities that require daily medical management i.e. infection, BP management, etc. If anything, the patients are transitioning from acute care to inpatient rehabilitation faster and coming sicker.

I definitely do not debate that their is trend towards fellowships with recent applicants predominantly in pain and sports medicine. However, I don't think it is because inpatient rehabilitation is "dying" or going away. I personally think that its more of a function that medical students are choosing career specialties with predictable work hours, high income, and/or that carry a perception of "prestige."

In my opinion, I think that inpatient rehabilitation is and will continue to be necessary in healthcare in some shape or form. The only way that it will "die" is if people stop getting older and/or hurting themselves. I can't predict how the system will pay those who work in an inpatient rehabilitation setting. At the same time, I think that forecasting future reimbursement is a problem across all specialties.

 

[Llenroc]

From our program 70% of graduates are going on to pain/spine/sports fellowships, most of them unaccredited. That to me means that our program, and PM&R in general is failing people. People are overeducated without having acquired enough skills from 6 years of college/graduate classroom instruction and 6 years of clinical instruction.

 

[fozzy40]

From our program 70% of graduates are going on to pain/spine/sports fellowships, most of them unaccredited. That to me means that our program, and PM&R in general is failing people. People are overeducated without having acquired enough skills from 6 years of college/graduate classroom instruction and 6 years of clinical instruction.

The article does bring up this issue in a roundabout way. From an outcome prospective, is a new goal of residency to create a curriculum where proficiency at interventional spine care or sports medicine is at a level where our graduates do not need fellowship training? In regards to the spine, what number of injections observed/performed defines "proficiency?"

I personally do think that there are weak areas in our curriculum. A couple of areas that I think is ABSOLUTELY missing from our curriculum are biomechanics, kinesiology, and motor learning. Sure we get snippets here an there but nothing truly dedicated in our didactics. I am generalizing but I suspect this is a deficiency in most PM&R residencies.

 

[RUOkie]

I personally do think that there are weak areas in our curriculum. A couple of areas that I think is ABSOLUTELY missing from our curriculum are biomechanics, kinesiology, and motor learning. Sure we get snippets here an there but nothing truly dedicated in our didactics. I am generalizing but I suspect this is a deficiency in most PM&R residencies.

I'm sorry if this is going to sound harsh, but what the hell are they teaching you then?

Biomechanics, kinesiology, and motor learning are the lynchpins of physiatry!! If you know these topics well, you can do ANY aspect of PM&R and have the respect and admiration of your colleagues.

If you do not understand these topics, you will not, and people will send their patients elsewhere (ortho, FP sports med, anesthesia pain) Our forte is biomechanics and kinesiology.

 

[RUOkie]

If the field wants to survive, yes it should.

Inpt rehab is going extinct. Outpt rehab has little definition.

I agree that interventions should be part of the core training, but as I said above, Biomechanics are way more important. I also feel that MSK US should be as well.

 

[fozzy40]

We definitely "touch" on these topics in at my residency but I personally think that we need more. I can't speak for other residency programs but from my discussions with other residents (at other programs) this are also a deficient areas. I have taken it upon myself to pick up these things on my own but I absolutlely agree that these are areas that we should be VERY comfortable with.

If there are any other residents who have different feelings, please share!

 

[RUOkie]

We definitely "touch" on these topics in at my residency but I personally think that we need more. I can't speak for other residency programs but from my discussions with other residents (at other programs) this are also a deficient areas. I have taken it upon myself to pick up these things on my own but I absolutlely agree that these are areas that we should be VERY comfortable with.

If there are any other residents who have different feelings, please share!

I saw from another post that you are at RIC. Is Joel Press still there? Jeff Young? They know their mechanics better than most. It would hurt me to hear that you are being failed there. (The people I know from RIC finished over 10yrs ago)

 

[fozzy40]

Dr. Press is still here and is an amazing teacher. We have an EXCELLENT sport and spine lecture series that runs all year long in conjunction with our dissection course. All of this is resident driven with fellow and attending direction. I would say that a majority of discussions focus on origin and insertions versus forces, vectors, moment arms, and torques. However, when we do have a 1 month prosthetic and orthotic course which does touch on alot of this stuff. We do receive instruction on motor learning as it applies mainly to stroke while on the inpatient service.

I am not familiar with Dr. Young.

 

[RUOkie]

Dr. Press is still here and is an amazing teacher. We have an EXCELLENT sport and spine lecture series that runs all year long in conjunction with our dissection course. All of this is resident driven with fellow and attending direction. I would say that a majority of discussions focus on origin and insertions versus forces, vectors, moment arms, and torques. However, when we do have a 1 month prosthetic and orthotic course which does touch on alot of this stuff. We do receive instruction on motor learning as it applies mainly to stroke while on the inpatient service.

I am not familiar with Dr. Young.

You are learning biomechanics. Do not worry. The rest comes with clinical experience. If you truly understand how vectors and moment arms work with relation to muscular contractions, the rest will come. 👍

And it appears as if Jeff Young has retired from clinical practice. I discovered that he now runs a healthcare consulting co. He was (with Dr. Press) one of the early champions of MSK medicine, and the formation of PASSOR

 

[axm397]

fozzy has higher standards for himself than most residents I know 😀

Maybe it would be helpful for him to post exactly what kind of knowledge he wishes he had so the sdners can get an idea of what level biomechanics/kinesiology knowledge he is seeking. (i.e. concrete examples)

 

[PMR 4 MSK]

I agree that interventions should be part of the core training, but as I said above, Biomechanics are way more important. I also feel that MSK US should be as well.

Biomechanics seems to be the forgotten core of PM&R.

 

[fozzy40]

fozzy has higher standards for himself than most residents I know 😀

Maybe it would be helpful for him to post exactly what kind of knowledge he wishes he had so the sdners can get an idea of what level biomechanics/kinesiology knowledge he is seeking. (i.e. concrete examples)

Haha...you're right🙂

Here are a couple of things that I wanted to know that I thought were important from a biomechanics standpoint ended up learning in a round about way:

- Open Chain vs. Closed Chain: Aside from knowing the difference, what is why is their a difference in force going through the joint proximal to the distal or fixed segment?
- Vertebral body fusions: Why does the rate of degeneration increase above and below the segments fused?
- Knee and ankle joint coupling: How and why is important to know that the ability to control motion at the ankle (not strength necessarily) have direct implications on the knee?
- Elbow pain in the throwing athlete: what is the importance of external/internal rotation ratio in regards to lateral vs. medial elbow pain in the throwing athlete?

As you can tell, I was the annoying kid that always asked "why?" However, I really feel that this is what separates us from the pack.

I found out the answers on my own. Perhaps most residents don't ask these questions or want to...I argue that they should be asking these secondary and tertiary type questions😀

 

[RUOkie]

Haha...you're right🙂

Here are a couple of things that I wanted to know that I thought were important from a biomechanics standpoint ended up learning in a round about way:

- Open Chain vs. Closed Chain: Aside from knowing the difference, what is why is their a difference in force going through the joint proximal to the distal or fixed segment?
- Vertebral body fusions: Why does the rate of degeneration increase above and below the segments fused?
- Knee and ankle joint coupling: How and why is important to know that the ability to control motion at the ankle (not strength necessarily) have direct implications on the knee?
- Elbow pain in the throwing athlete: what is the importance of external/internal rotation ratio in regards to lateral vs. medial elbow pain in the throwing athlete?

As you can tell, I was the annoying kid that always asked "why?" However, I really feel that this is what separates us from the pack.

I found out the answers on my own. Perhaps most residents don't ask these questions or want to...I argue that they should be asking these secondary and tertiary type questions😀

Ok, you will be just fine.👍

3 or 4 yrs ago, there was a shoulder course at the AAPMR meeting. It was far and away the best lectures I have ever been to at an AAPMR meeting. We spent HOURS discussing the throwing/serving athlete.

All of your questions will come to you in time. You are still a resident, and all of them were very high level questions.

 

[MSKalltheway]

Here again, those are the kinds of things I thought we should be learning about during our training, lol

 

[SSdoc33]

if there is one thing that residency taught me, it is that if you want to know/learn something, you are gonna have to figure it out for yourself. the standard physiatrist is generally lacking many areas (generalization). he trul outstanding one are few and far between

 

[PMR 4 MSK]

if there is one thing that residency taught me, it is that if you want to know/learn something, you are gonna have to figure it out for yourself. the standard physiatrist is generally lacking many areas (generalization). he trul outstanding one are few and far between

We physiatrists tend to be either Jack-of-all-trades and master of none, or master of one trade, and screw the rest. 😀

 

[MedBronc23]

I think learning how to perform interventional procedures should be part of our residency training. I know when I interviewed that the ability to get hands on time with interventional procedures before I considered a Pain or Sports/Spine Fellowship played a huge role of where I went. Many programs...including some of the top tier names...were not allowing interested residents any procedural time/exposure beside watching. This definitely steered me away from them even if they were solid in other aspects. In my opinion, if you do not train where they are letting you at least try these procedures because fellows/staff get them all, you are leaving residency with a handicap.

I think 1 month mandatory exposure to interventional procedures as curriculum would be a step in the right direction. Many people here in the midwest where I am doing my pre-lim year still have no clue the at we can do these procedures (as well and or better because of our increased MSK/neuro/anatomy knowledge) like Anesthesia Pain Docs do. This fact has allowed me to peak the interest of many of my students intersted in pain medicine/spine. In fact many people are surprised when I tell them that we do procedures at all. People like doing procedures. This is one of ours, and we should teach it and require some proficiency in performing bread and butter transforaminals etc.

I guess what I am saying is it would only add a positive aspect to our identity and give us an edge in the pain/spine/interventional patient population. Despite what changes come in healthcare, I think keeping in step with the procedural world we live in now and exposing residents in PM&R to these techniques/procedures in a mandatory curriculum manner like we do with EMGs and NCS would only benefit us in the long run.....


and now the responders to say that is what fellowship is for. I disagree. Fellowship is about perfecting skills and honing them, mastering a knowledge base on one area, not being exposed to it for the first time. It would be like not requiring internists to know how do central lines even though they may not work in PULM/CRITICAL Care.

We should have a required set of procedures including EMGS, NCS, joint injections, fluoro injections...thoughts?

 

[fozzy40]

I am currently at a program where residents do not have as much experience actually performing spine injections. However, we do have the opportunity to set up an elective with anesthesia to perform such injections. I suspect that many other programs likely have a similar opportunity to gain this type of exposure.

What number of procedures does one gain "proficiency?" One of the authors does make this point that the 200 EMG requirement is somewhat arbitrary. Does having 200 lumbar epidurals and/or 1 month of mandatory experience make one proficient AND safe to perform them after residency?

Furthermore, is producing graduates that no longer need fellowship training to gain such proficiency a new goal for our residencies? I have friends who are currently practicing and very comfortable doing injections. However, something has to give and they admittedly have weaknesses in other areas. Perhaps PM&R residency should be longer?

Thoughts?

 

[PMR 4 MSK]

I am currently at a program where residents do not have as much experience actually performing spine injections. However, we do have the opportunity to set up an elective with anesthesia to perform such injections. I suspect that many other programs likely have a similar opportunity to gain this type of exposure.

What number of procedures does one gain "proficiency?" One of the authors does make this point that the 200 EMG requirement is somewhat arbitrary. Does having 200 lumbar epidurals and/or 1 month of mandatory experience make one proficient AND safe to perform them after residency?

Furthermore, is producing graduates that no longer need fellowship training to gain such proficiency a new goal for our residencies? I have friends who are currently practicing and very comfortable doing injections. However, something has to give and they admittedly have weaknesses in other areas. Perhaps PM&R residency should be longer?

Thoughts?

The evolution of profiency in a procedure:

1st case - "OMG! So that's how it's done!"
5th case - "Ok, this is so easy, anyone can do it."
10th case - "Oops, what just happened?"
20th case - "Oh, that's what those are for!"
35th Case - "Ok, I really didn't understand this before, but now I'm really getting it."
50th Case - "Meh, I'm bored of this, gimme something new."
75th Case - "Holy Crap! I didn't know that could happen, I'm gonna have to go read more."
100th case - "Ok, I got it now. Cruise control."
118th Case - "AHHHHHHHH! WTF just happened?!?!?!? HELLLLLLLPPPPP!!!!!"
119th case - "Ok, it's been 6 months, I can try it again."
150th case - "I'm starting to feel comfortable with this again."
200th case - "I could teach this to a 12 year-old."
300th case - "I thought of a new way to do this."
324th case - "Whhooops! Guess I should go back to the old way..."
500th case - WTF, where's my book from residency? I've never seen that happen before..."

 

[SSdoc33]

The evolution of profiency in a procedure:

500th case - WTF, where's my book from residency? I've never seen that happen before..."

never SEEN this before? i didnt get a get out of here. they should teach you that in medical school. cancer, get outta here!

 

[rbvjl]

If anesthesiologists, interventional radiologists do IDET, vertebroplasty, percutaneous discectomy, why not properly trained physiatrist. Intervention training during residency training will be help in development of the specialty.

 

[fozzy40]

If anesthesiologists, interventional radiologists do IDET, vertebroplasty, percutaneous discectomy, why not properly trained physiatrist. Intervention training during residency training will be help in development of the specialty.

I agree that learning how to do more procedures makes graduates more marketable but I disagree that it will help with the development of the specialty.

Anesthesiologists are typically proceduralists which brings along a certain personality. They tend to be more focused on the technical aspects of procedures and acute medical care compared to physiatry which is focused on something almost completely on the opposite end of the spectrum. Marketing ourselves as proceduralists, in my opinion, is the wrong way to go because it takes away what makes us special: our ability to view the big picture and think outside the box. I love that there are physiatrists picking up these skills because I'd rather refer my patients to them compared to someone who has a hammer and treats my patients as nails.