PM&R Pain Medicine & Subspecialty Fellowship FAQ's

Discussion in 'PM&R' started by drusso, Jul 13, 2002.

  1. drusso

    Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    From time to time, students inquire about the path to becoming a pain medicine specialist. Basically, pain medicine is sub-specialty accessible through fellowship-level training in either anesthesiology, PM&R, neurology, or psychiatry.

    The ACGME is largest accrediting organization for residency programs and fellowships. There are a multitude of quality fellowship programs in the country in a variety of settings, but those approved by the ACGME are viewed by hospitals and third-party payors as having attained a specified level of quality education and training.

    ACGME rules specify that an institution cannot have the same kind of fellowship offered in more than one academic or clinical department. Thus, when the field of pain medicine started out most fellowships were housed within anesthesiology departments and the field of anesthesiology came to dominate pain medicine. However, physiatrists and other specialty trained physicians are eligible to apply to any pain medicine fellowship regardless of its academic affiliation within an institution. Below is an updated list of ACGME-approved pain fellowships housed specifically within PM&R departments. I've also included a couple non-ACGME approved "interventional physiatry" fellowships that offer similar training. Please let me know if there are others that I've over-looked.

    LIST OF ACGME APPROVED PM&R RUN PAIN FELLOWSHIPS:

    [3410531003] VA Greater Los Angeles Healthcare System Program
    Greater Los Angeles Veteran Affairs Health Care System
    11301 Wilshire Boulevard (w117)
    Los Angeles, CA 90073
    Pain Management (PM) Quynh Pham, MD (310)268-4935
    [email protected]

    [3410713011] University of Colorado Program
    University of Colorado
    1635 North Ursula Street
    Anschutz Outpatient Pavilion, 4th Floor
    Aurora, CO 80045
    Pain Management (PM) Venu Akuthota, MD
    (720)848-1980
    [email protected]

    [3411222008] Emory University Program/Georgia Pain Physicians
    2550 Windy Hill Road, Suite 215
    Marietta, GA 30067
    Pain Management (PM) Robert E. Windsor, MD (770)850-8464
    (770)850-9727

    [3412312007] Sinai Hospital of Baltimore Program
    York Center for Pain Management and Rehabilitation
    2901 Pleasant Valley Road
    York, PA 17402
    Pain Management (PM) Michael B. Furman, MD, MS (717)848-4800
    (717)755-9618
    [email protected]


    [3412412004] Harvard Medical School/Spaulding Rehabilitation Hospital Program
    Harvard Medical School/Spaulding Rehabilitation
    125 Nashua Street
    Boston, MA 02114
    Pain Management (PM) Alec Meleger, MD (617)573-2178
    (617)573-2769
    [email protected]


    [3412521006] University of Michigan Program
    University of Michigan
    1500 E. University Drive
    Ann Arbor, MI 48109
    Pain Management (PM) J. Steven Schultz, MD (734)937-7210
    (734)936-7048
    [email protected]

    [3412812012] University of Missouri-Columbia Program
    University of Missouri-Columbia
    52 Medical Park East Drive, Suite 115
    Birmingham, AL 35235
    Pain Management (PM) Bradly S. Goodman, MD
    (205)838-3900

    [3414112010] Temple University Hospital Program
    Temple University
    139 East Chestnut Hill Road
    Newark, DE 19713
    Pain Management (PM) Frank J. Falco, MD
    (302)369-1700

    [3414813005] Baylor University Medical Center (Oklahoma City) Program
    St. Anthony North Ambulatory Surgery Center
    6205 North Santa Fe Avenue, Suite 200
    Oklahoma City, OK 73118
    Pain Management (PM) Michael J. Carl, MD (405)427-6776
    (405)419-5646

    [3415121001] Virginia Commonwealth University Health System Program
    Medical College of Virginia/VA Commonwealth Univ. Program
    P.O. Box 980661-0677
    Richmond, VA 23298
    Pain Management (PM) David X. Cifu, MD (804)828-0861
    (804)828-5074
    [email protected]

    UC Davis Pain Program (sponsored by the Anesthesia Dept)
    University of California, Davis Medical Center
    Scott Fishman, MD and Gagan Mahajan, MD
    916-734-6824

    LIST OF INTERVENTIONAL PHYSIATRY FELLOWSHIPS

    Curtis Slipman, M.D.
    Director, The Penn Spine Center
    Chief, Division of Musculoskeletal Rehabilitation
    Associate Professor, Department of Rehabilitation Medicine
    Ground Floor White Building
    Hospital of the University of Pennsylvania
    3400 Spruce Street
    Philadelphia, Pennsylvania 19104
    (215) 349-8062
    [email protected]

    Univ of Penn Interventional Physiatry Fellowship

    Gregory E. Lutz, MD, Chief of Physiatry for Hospital for Special Surgery
    Hospital for Special Surgery
    535 East 70th Street
    New York, NY 10021
    [email protected]

    Raj Mitra, MD, Director of the Interventional Spine Center
    Stanford University Medical Center
    900 Blake Wilbur Drive
    W1001
    Stanford, CA 94305

    Stanford Interventional Spine Center

    Andrew Haig, MD
    University of Michigan Spine Program
    The Spine Program
    325 E. Eisenhower Parkway
    Ann Arbor, MI 48108
    734-998-6644

    University of Michigan Spine Program

    Gerard Malanga, M.D., Program Director
    Sports and Musculoskeletal Medicine
    Department of Physical Medicine and Rehabilitation
    University of Medicine and Dentistry New Jersey

    University of Medicine and Dentistry New Jersey
     
  2. One program that I believe is ACGME-accredited is the combined Anesthesiolgy-PM&R pain program at UC Davis in Sacramento, CA. The Pain Program is run by a board-certified Psychiatrist/ Internist with Anesthesiology training and the fellowship director is a PM&R doc. It is a great combination. I believe they take 2 PM&R and 2 Anesthesiology residents each year.

    Scott Fishman, MD and Gagan Mahajan, MD
    University of California, Davis Medical Center
    916-734-6824

    Moderator's Note (6/3/04): The ACGME-approved fellowship at UC Davis is not formally dually sponsored by the PM&R and Anesthsiology departments. (Gagan Mahajan--personal communication). However, they do interview and accept applicants from all sponsoring specialties on a competitive basis.

    --DR
     
  3. axm397

    axm397 SDN Moderator
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    What is the difference between fellowships in pain management, interventional spine, and musculoskeletal?
     
  4. drusso

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    Pain management offers comprehensive training for the the diagnosis of a variety of pain syndromes (malignant, nonmalignant, RSD, trigeminal neuralgia, etc) and usually geared toward an interventional approach. These programs are usually in anesthesiology departments.

    Interventional spine focuses on diagnosis and treatment of spine conditions. There is usually an interventional component, but the interventions are limited to the axial spine. No bier blocks, sympathetic ganglion blocks, etc.

    Musculoskeletal fellowships are broadly-based training experiences in musculoskeletal medicine emphasizing diagnosis and nonoperative management of a variety of common musculoskeletal problems. There is usually some training in sports medicine, occ medicine, spine, EMG, and pain management. There is also usually an emphasis on musculoskeletal radiology too.
     
  5. rehabdoc

    rehabdoc Member
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    I would like to start this thread since many of PM&R resident are interested in pain management and or spine care. Obviously there is a huge market for this branch if physiatry these days. Almost 50 percent of the jobs offered in the red or blue journal are combination of interventional pain/spine-EMG and musculoskeletal medicine.

    So should I choose a pain fellowship or a spine fellowship? The answer is quite easy it depends on the area of interest, these two sub-specialties have some common procedures but besides that they are quite different.

    As pain specialist you not only will manage spine related painful syndromes but also will deal with other pathological issues with pain and their symptoms. You have to have the knowledge of medical and interventional pain control. You have to combine your rehab skills and integrate the interventional and non-interventional skills to manage pain. Your referral sources are spine specialists, which have completed diagnostics and therapeutic interventions without significant help and are looking into more sophisticated pain management like spinal cord stimulator or implantble Intrathecal pumps or pure medical pain control. PCP's , other rehab docs and orthopedic groups are your other major referral source. Your work would be hospital or clinic based and interventions are done in clinic or in the surgical-center or OR. All implantble devices are done in the OR. You could generally train in a pain fellowship which is ACGME accredited which makes you eligible to sit for pain boards. There are many pain fellowship around the country both ACGME and non-ACGME. Some are rehab based which seems to be more interdisciplinary and provide broad base pain training. Physiatrist, psychiatrist and Anesthesiologist compete for the pain fellowships in the country and the competition for the good fellowships are quite tough. Financially you will do quite well and the amount is based on your skills, aggressiveness in interventional aspect, practice style and set up, location, insurances and private vs. academics. Range of income is from 130K academic in metropolitan with incentives to 500k in private practice and up.

    A spine specialist to most part will only concentrate on pathological spine issues in more depth. Their knowledge of spine is vast and they are skillful in diagnosing different spine diseases. They complement this part of their practice with performing EMG. Their referral sources are other PMR or Ortho docs to most part. They do market themselves as interventionalist and to most part refer chronic pain situations to pain specialists. There is generally a good working relationship between spine and pain specialist since more sophisticated spine procedures are often done by spine docs like Vertebroplasty and Nucleoplasty. Many pain specialists now perform similar procedures as well to expand the clinical skills. The spine specialists generally work in spine centers and or in private groups with neurosurgeons or orthopedic practices. Interventions are done at spine center or OR. Some procedures like Vertebroplasty is generally done in OR setting. There is no ACGME for spine fellowships yet. Some are PASSOR certified which are the better programs. There are many good and some excellent spine fellowships around the country almost all rehab-based programs. Competition for the best programs are generally tight but since you are only competing within the PM&R specialty, there is a chance that if you are a good resident, you will be able to secure a position. Financially you will also do excellent. Range is similar to pain. If you choose to perform EMG then your income obviously will increase in both specialties.


    As an interventional pain fellow interested in many aspects of pain, I love what I do but you should know it is not that easy. Population of patient with chronic / acute pain is a very though population. There are many layers to their problems many of which are psychosocial and difficult to manage. Certainly the burnout rate in pain management is high for this reason and many pain clinicians tend to do it part time. You should be comfortable taking care of difficult patients, have a solid knowledge of anatomy, have a good training in pain and spine procedures and be efficient to become an overall well rounded and successful pain doc. You can't claim to be a pain specialist and only do injections and not manage patients medically. So many physiatrists tend to choose spine fellowships to avoid the chronic pain population, which in theory is good idea but there are may limitations to how far you could be helpful with the injections and eventually many of the patients will end up moths later in pain centers.

    There are many good programs around the country and recommending one over the other is sometimes tough. My only advise is to look into the structure and look at how broad base is the program. Programs, which only do injection type interventions, are missing a big chunk of other pain management techniques and the strictly medical management programs are obviously missing procedures skills. Cancer pain exposure, Inpatient pain exposure, Acute pain exposure, chronic pain exposure, headache management, musculoskeletal medicine and interventional pain management including pumps and stims all should be incorporated in a well balanced curriculum which is compatible with ACGME requirement.

    Same is valid for a good spine program. Look at all the aspects of the program including EMG skills, interventions, medical management, Disc and Bone interventions and so forth. Look for PASSOR approval as well.

    Personally I advise you to do an elective in a pain clinic as well as a spine center to get a feeling what it is all about. They are both excellent career choices. Both are major help to patients and are on cutting edge of medical science with more sophisticated procedures they can offer.

    Please feel free to expand the discussion.:clap:
     
  6. drusso

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    PASSOR Web Page

    PASSOR is an official council of the American Academy of Physical Medicine and Rehabilitation, founded to address the specific needs of musculoskeletal physiatrists. It sponsors procedural workshops and as well as educational events as well as maintains a database on PM&R-based fellowships (largely non-ACGME approved) in musculoskeletal medicine, sports medicine, and interventional spine.

    Residents or medical students interested in musculoskeletal medicine and/or pain medicine should consider joining.
     
  7. daphilster

    daphilster Junior Member
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    Ok the next logical question is this:

    Who gets the best spots in pain fellowship since they are available to psych residents, pmr, anesthesiogists? and what criteria do PD's use to judge applicants? reputation of their program, LORs, research, etc? You don't exactly have "grades" anymore in residency right?

    My guess would be the anesthesiologist would have the edge since most pain programs are run by anesthesiology dept. Do programs typically reserve x amount of spots for psych residents, pmr residents, etc??
     
  8. Stinky Tofu

    Stinky Tofu Registered User
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    The PM&R Pain fellowships are open to PM&R residents only. There are several Pain fellowships that are jointly run and they save a certain number of spots for PM&R and for Anesthesia. Many Pain fellowships are run by Anesthesia and these fellowships would be easier to obtain as an Anesthesia resident. That being said, many of the top Anesthesia fellowships (MGH, BIDMC, BWH, Children's, Mayo, etc.) like to take both PM&R and Anesthesia residents because they can learn a lot from each other as well. Whether you choose PM&R or Anesthesia as your route to Pain Management, I don't think you'll have much of a problem getting a Pain fellowship. I think the important thing to figure out is which type of residency will prepare you better for the type of Pain practice you want. If you want to do a lot of Interventional Pain/Spine procedures, I think PM&R or Anesthesia would be a better route. Check out the thread below for different perspectives on the route to Pain Management:

    http://forums.studentdoctor.net/showthread.php?threadid=107433

    All of the things you mentioned are important to obtaining a fellowship (research, LOR, and reputation of your residency program). Connections also play a large part in the selection of fellows as does impressing them on an elective rotation.
     
  9. freelancewriter

    freelancewriter Senior Member
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    I'm surprised that no one has mentioned palliative medicine and pain management. Your dealing with dying people, so there is definitely a different dynamic. There is a spiritual aspect to it, to be sure. I would think some folks interested in pain management would be interested in a palliative medicine fellowship, but maybe haven't been exposed.

    From what I've read, palliative medicine fellowships are open to PM&R and Neuro residents. I think they might be open to an even broader range than that.

    I did a Google search and stumbled across a fellowship directory on the American Academy of Hospice and Palliative Medicine (AAHPM) site. Lots of fellowship programs. The only program I saw on the list with a link was Marshfield Clinic www.marshfieldclinic.org/palliativefellowship. To quote their site, "The Fellowship is open to applicants BC/BE in Internal Medicine, Family Practice, Neurology, or Physical Medicine & Rehabilitation."

    Not sure if any palliative medicine programs are (yet) ACGME-accredited. Many of these programs started with grant funding in the last year or two, so I suspect it's a relatively new fellowship offering.

    I'm not a med student/resident/physician - that may already be obvious - but am very interested in the med school-residency-fellowship process. I lurk on these boards a lot, and post occasionally. (We all need a hobby.)

    Please give me some insight on the differences with "traditional" pain management and palliative medicine. Two things seem obvious:
    1. Dying people
    2. Large spiritual component

    What else?
     
  10. islander

    islander Junior Member
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    Hey all - I'm a (soon-to-be) neuro resident who may be interested in pain. It seems as if anesthesiology or PM&R are the 2 best ways to get a pain fellowship, but I wasn't specifically interested in pain while selecting a residency. If I still want to do a pain mgmt fellowship 3 years from now, is it reasonable to think that an anesthesiology-run fellowship SOMEWHERE would be attainable? I'll be coming from a strong neuro program, & already have a bunch of research credits on various neuro/psych topics (papers, chapters, abstracts, etc.); I assume clinically I'll do well in residency and get good LORs, and will do pain electives during residency... As I said, I'm not shooting for the stars; just curious if entry to the field through some pain fellowship somewhere is feasible. Thanks for any opinions.
     
  11. rehabdoc

    rehabdoc Member
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    neurologists actually do well when it comes to pain fellowships and many of well respected rehab based or anesthesia based programs do take neurology residents as their fellows. good luck.
    rehabdoc
     
  12. paz5559

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    I am curious what your thoughts are for a pecking order of anesthesia based interventional pain management fellowships

    I know I tend to think of Slipman, Furman, HSS, Falco, Windsor, Stanford, CINN, and maybe Utah and Colorado as the top that are PM&R run.
     
  13. drvlad2004

    drvlad2004 Senior Member
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    Is there any type of sub-specialty certification specifically for interventional spine once you are done with fellowship?
     
  14. paz5559

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    You can sit for the ABA (Anesthesia) Pain Boards, so long as they keep grandfathering in non-ACGME acredited programs. However, that tests an array of skills beyond what is generally taught in an Interventional Spine Fellowship.

    PASSOR has talked about creating a sub-specialty boards, but that is still in the early planning stages.

    AAPM also offers pain boards, but to date, these are not ABMS acredited, so it is unclear what the point of taking them is.

    Bottom line is, since you will likely do these in a surgi center, you will not need to get hospital privaledges to perform these procedures.. Even if you do, I know of no one who has needed pain boards to be on an insurance pannel or to get privaledges yet. That may be coming in the future, but not at this point.

    Hope that helps
     
  15. rehabdoc

    rehabdoc Member
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    Well, I am not quite sure about the order of fellowships you mentioned.
    some of those are pain and some are spine fellowships. It depends on your interest.

    Slipman is a good high volume spine program but it not as nearly comprehensive as pain specialty can offer you. so if spine is all you want to do, it is very good choice.

    Windsor, furman and Falco I believe provide a broader based exposure to procedures offered especially at Atlanta. you cant go wrong with them. Last I know, Falco was not ACGME.

    The one program that people don't know much about and is quite comprehensive and has tremendous interventional exposure including implantable pain devices is at Spaulding. Its ACGME, It is a hybrid of spine and pain management , faculty are both Anesthesia interventionalist, PM&R interventionalist (couple of Slipman trained are there too), has headache training by experts and common lectures with MGH pain fellows. I think in the rehab based program, the curriculum is the most comprehensive one and you get a Harvard degree out of it as a bonus.

    FYI, the pain management board is common board between PM&R, Anesthesia and neurology. so if you are from ACGME program and sit for it, your boards is accepted regardless which program you are from. Spine fellowship people can sit for the boards till 2005 and after that, they cant become board certify in pain unless they do a fellowship. Hopefully a spine subspecialty will be created for them.

    One other small info for stinky, PM&R pain fellowships (ACGME) are not forced to take PM&R fellows only. they are allowed take many of the specialities including internal med, peds, Psych,anesthesia, neurology, and PM&R. obveiosly they prefer to have a bright rehab fellow but if better candidate come, they are legaly free to choose.


    good luck to the future specialists.
     
  16. paz5559

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    pain - spine - sports is semantic continuum (yes, I know it is more extensive training, but when spine fellowships call themselves interventional pain management, and when all three can also be lumped into musculoskelletal, the distinction gets pretty fuzzy, at least to me).

    Currently there are 7 ACGME acredited PM&R pain programs (http://www.abpmr.org/certification/pm_fellowships.html). However acreditation is only required to take the pain boards after 2006, and that deadline has been extended several times in the past, so it may well be extended further again in future.
     
  17. paz5559

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    I wondered if someone could give me advice as to the reputations, stengths, and weaknesses regarding the Anesthesia and Anesthesia/PM&R jointly run Pain programs?
     
  18. paz5559

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    A few additional items since I last posted:

    I spoke to a recent graduate of the UC Davis residency. She advised that the program typically takes two PM&R and two Anesthesia residents yearly. Despite it's "joint" nature, it seems the vast majority of the training offerd is through the Anesthesia department, and the fellowship director is an anesthesiologist. You take ER call, which the fellows were not happy about, and cover an in patient service, which I suspect is probably typical for most pain fellowships. However, there was a high dropout rate, so that the fellows felt overworked during the time this recent graduate was there. One particular fellow became pregnant during the fellowship, and no accomodation was made regarding her radiation exposure, and she therefore went through her 8th month being exposed. I know Dr. Davis has a role in the program, and he is clearly a huge plus, but from what I was told, there were certainly issues that anyone considering the program should look into before committing a year.

    New Topic - I spoke to the ABPM&R today about the temporary criteria that currently enable fellows at unacredited fellowships to sit for Pain Baords. The American Board of Anesthesia has advised the ABPM&R that no further extensions will be granted for unacredited programs. Also, the deadline to ahve completed your residency to sit for the pain boards will not be extended. So the bottom line is, if you finish your residency after August 31, 2004, or if you complete 12 months of your fellowship after August 31, 2006, you can only sit for the ABA pain boards if you have completed an ACGME acredited fellowship.

    Hope that is helpful, and please don't hesitate to PM me if you have any questions
     
  19. paz5559

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    Clearly I am now talking to myself, but I got two interesting emails today I thought I would share. I particularly mention these two programs becuase when I spoke to the head of our Neurology pain center at LSU, he mentioned these as two of the very top pain fellowships in anesthesia:

    1) UCSF: I should tell you that typically we don't consider non-anesthesia residents for candidacy for our program. The reason for this is that because of the high volume of invasive procedures we do in our clinic, we prefer anesthesia residents, who have been trained in nerve block techniques as well as airway management. however, if the pool of anesthesia resident applicants is sparse, and/or if your credentials are exceptional, you may be considered for an interview.

    I know this sounds discouraging; apparently there are other pain fellowships throughout the country with a similar policy. I would urge you to apply regardless if you are interested in our program.

    2) University of Washington (annonymous report from current PM&R resident:
    "The anesthesia program here is not very strong.

    The only anesthesiologist doing interventional work is a private practice
    guy from the eastside one day a week. There are ?3 fellows, all
    scavaging for whatever they can do, and spending a lot of time sitting
    around. I also think they take anesthesia call, which would not be a
    pretty site for a rehab doc.

    Overall, doesn't sound like a good deal."

    Food for thought.
     
  20. Spine Specialist

    Spine Specialist Passion for Spine
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    Hi Dr.Mahajan-

    Thanks for your input in this PMR forum. I am a PMR resident joining Pain Medicine Fellowship starting July,2004.
    What is your take on physiatrists joining Pain medicine fellowship?
    Can u recommed some books and give me some advice to become a good pain specialist? As you said one year fellowship will roll very quickly. How can i make use of that one year to maximun learning?
    Thanks :)
     
  21. paz5559

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    I certainly may have been mis-informed, although the source of my information was a PM&R resident at UC Davis during the relevant period. Clearly, I will defer to Dr. Mahajan's presentation of the facts.

    I would wonder how a "Combined PM&R/Anesthesia Pain Program", one of only seven ACGME accredited "PM&R" Pain Fellowships in the nation, could count itself in the realm of PM&R, present itself as a "joint" program, market itself to PM&R residents, and then accept only one out of a total of ten fellows who are PM&R trained during the past two calendar years. I guess in a fiercely competative fellowship, PM&R residents are just not as well-qualified as the 70% Anethesiologists or 20% Neurologists who did fill those positions.
     
  22. drusso

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    Dr. Mahajan,

    Thanks for your contribution to this discussion. I really appreciate it when you, Brian Davis, and others in PM&R/Pain/Spine/Musculoskeletal Medicine post your observations and suggestions. As has been reiterated on this forum very often, perhaps more by young physiatrists than by young anesthesiologists, pain medicine is indeed a multi-disciplinary endeavor requiring a broad set of skills and knowledge. Patients benefit from different perspectives.

    Keep posting as you feel appropriate. I've been working hard towards making this forum one of the leading informational resources for residents and medical students interested in PM&R and its subspecialties.

    --David
     
  23. Spine Specialist

    Spine Specialist Passion for Spine
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    I appreciate your reply Dr.Mahajan. Thanks a million! :)
     
  24. charcot

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    As a resident in PM&R, I am realizing more and more that there are few spots in anesthesiology-based programs that take PM&R grads. I am a solid resident from a solid PM&R rogram. I see that there is definately a bias towards anesthesia and neuro grads, particularly in interventional geared programs. This doesn't make much sense given that we do more EMG's than many neurology residents. I dont want to do meds management which is where we seem to be shunted and I am thinking about doing EMG's instead of pain.
     
  25. Stinky Tofu

    Stinky Tofu Registered User
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    Based on your post in the Neurology forum, I thought you were an aspiring Neurologist.

    I disagree regarding the bias towards Neurology, but I do agree that in general, Anesthesiologists have an advantage in securing Anesthesia-based Pain fellowships. In 2004, there were roughly 1300 spots offered in Anesthesia and 350 in PM&R. The fact that you see more Anesthesiologists in these programs is not surprising. I can only speak about my experience in the Harvard system and my impression is that we are welcomed at all the different fellowship programs. In fact, I've been told that they want PM&R residents in their fellowship programs. Every Spaulding resident that I know of that has wanted to do a Pain fellowship has gotten one. The Tufts and BU residents also seem to be getting Pain fellowships as well. Children's Hospital, BWH, MGH, and BIDMC all take PM&R residents and their fellowships are considered competitive.

    I agree that we do more EDX studies than Neurologists. At Partners, the average Neurology resident spends less than one month in the Neurophysiology lab. We spend 4-6 months at either MGH or BWH doing EDX studies. I'm not sure what this has to do with securing a Pain fellowship though. If you are interested in doing both EDX studies and Interventional Spine procedures, a Spine fellowship might be a better route.

    In summary, I think that Pain fellowships are still wide open to Physiatrists and if you want to do Interventional Spine, there are other routes you can take as well.
     
  26. paz5559

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    You make it sound as though there is a significant difference between Pain, Spine, and Interventional Pain Management.

    I may be wrong, but I would hazard a guess that most PM&R residents would prefer to be involved in a purely interventional fellowship. The problem is that there is no subspecialty certification for that area at present. The quandry we are faced with, as a result, is do I pursue the best respected, best most accademically rigourous fellowship with those who are leaders in our field (ie. Slipman, CINN, Falco, Aprill, Stanford, Florida Spine Institute, Hospital for Special Surgery, just to name a few) which are NOT ACGME accredited, and thus do not enable me to sit for the pain boards, or do I spend a year in a fellowship which may well be excellent, but is either too new to have a track record (MCV/VCU, Spaulding, Michigan), or whose focus is not primarily interventional (UC Davis, other Anesthesia fellowships).

    Furman and and Windsor are the only ACGME accredited, primarily interventional fellowships, but that is a grand total of 8 fellowship spots - by reputation, Windsor's is lagely practical, not a huge amount of research. Furman's is a more optimal mix of hands on and research - the only criticism is that it means you have to spend a year in York, PA.

    I would therefore argue that there needs to be either a PASSOR, ISIS, or NASS certification in interventional pain management. I, for one, don't want to do hospice. I don't want to do acute inpatient pain. I don't want to do headaches. I want to do procedures. At present, there is no ABMS certification, and there needs to be. ABA, and ABPMR Pain certification is all we have at present (neither AAPM nor ABPM are ABMS member organizations), and it does not meet the needs of a large segment of the new graduates in our field.
     
  27. paz5559

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    I am sorry, but when Dr. Mahajan spins things to his fellowship's advantage, it makes me see red. Phrases like "If all you want to do ..." and "If you want to be well rounded and knowledgeable ..." belie a non-objective bias which may help to recruit more residents to the his fellowship, but is disingenuous, and does a disservice to those who are not sure who to believe, especially on forums like this. I do not begrudge him the ability to shill for his program, but please label it up front as an infomercial, rather than a legitimate opinion from a responsible, reliable source.

    Opiod refill referrals - boy, isn't that the group of patients you want to build your practice around? Dr. Mahajan, they are all yours. By the way, you can have the fibromyalgics too, while you are at it. I would prefer to limit my practice to those I legitimately believe I have a good chance of actually providing pain relief to, rather than feeding their addiction or their supra-tentorial disease.

    The business model is clearly not just join a group of manage your own meds - a third option is to go into practice with a psychiatrist/neurologist/physiatrist with an interest in pain who can manage the meds while you build your interventional practice. Will you have to build your practice by doing good work for and marketing yourself to primary care physicians, neurosurgeons, and orthopedists? You bet. Does that make you any different from any other physician who strikes out on his own rather than joining a multi-specialty group? Not in the slightest.

    By the way, we won't be "getting away with" anything when we pursue spine practice over pain practice - we will be making a well-reasoned, legitimate choice. Dr Mahajan, I respect your position, and all the work you have done to rise to your lofty position, but suggesting to impressionable students and residents that your field is better than my field, that your choice is better than my choice, that your expertise serves your patients better than my expertise, smacks of elementary school recess playground immaturity, rather than rational discussion.

    Anesthesia fellowships, even the most interventionally-based amongst them (and here I can not speak for UC Davis specifically) suggest a series of three intralaminar injections for radicular low back pain. There is no basis for the series of three, and the literature clearly shows that transforaminal selective nerve root injections provide a great specificity in terms of diagnosis and treatment. Anesthesiology programs teach the intralaminar approach primarily. A greater sin yet is that they teach the loss of resistance technique, and often advocate doing blind epidural steroid injections. The literature shows this approach can lead to spinal, rather than epidural injections, and not being in the epidural space ~25-30% of the time. So of your 25 to 30 procedures a day (split amongst your 5 residents that comes to 5/day/resident, by the way) how many are done with fluoroscopic guidance. How many are caudal injections (the simplest procedure, one you can be trained for in about a week at the most)?

    Dr. Mahajan is right - learning to do a procedure IS easy. Learning how to do it WELL, safely, and for the appropriate indications is the hard part. Learning when NOT to do it is even harder.

    Reputations are built on years of quality practice, quality research, and presentations at national meetings. I am not quite sure why those are bad criteria to use when choosing a fellowship, so perhaps Dr. Mahajan can enlighten me on that score.

    Again, the basis of the post Dr. Mahajan used as an excuse to once more advertise the virtues of his program was not to suggest that non-ACGME accredited fellowships would allow one to sit for the pain boards after this year, but rather to point out the glaring need for an interdisciplinary organization, without an agenda of the type so blatantly epitomized by Dr. Mahajan, to serve as arbiter of who gets to pursue interventional pain management. Dr, Mahajan suggests, and the ACGME requires, that one needs to be trained in the management of inpatient pain, hospice pain, cancer pain, and non-interventional headache management, hypnosis, acupuncture, and relaxation techniques, in order to be a good interventional pain management specialist. I beg to differ. To pack that all into a year of training, AND pretend that you will be as adept at IDET, percutaneous discectomy, discography, kyphoplasty, and vertebroplasty, as well as neurological ablative technologies like RF, cervical and lumbar zygaphohyseal joint and transforaminal injections will not make you well-rounded, it will make you a jack-of-all-trades, master of none.

    Gee, I guess I have a bias after all. The difference is, I don't couch my bias to pretend that I am giving good advice. You agree with me? Great! You want to do a pain fellowship instead? Good for you! I do not pretend to know what is best for you, dear reader. My point is, neither does Dr. Mahajan.
     
  28. Tenesma

    Tenesma Senior Member
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    it kind of freaks me out to see a program director go to such pains to advertise his program.... If the fellows or residents from UC Davis were on this board (and thus still fit under "student" doctor/doctor-in-training) then their comments i think would be far more welcome....

    If Dr. Mahajan would like to contribute I would suggest more along the lines of what a program director is looking for in applicants and so on... not infomercial mode...

    In the meanwhile, after reading this thread, all I can really assume is that there must be some serious insecurities at a program to have the director in every posting (5 total - and counting) push UC Davis.
     
  29. kingyogurt

    kingyogurt Junior Member
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    I think Dr. Mahajan is doing a great job sharing his knowledge with us. Life is a long journey of collecting information, and we should always welcome others to share their stories. Of course I am just a medical student right now so I am sure I will get ignored :D (j/k)
    Side Note: Dr. Mahajan I will be doing a 4th year rotation at UC Davis in Pain Medicine soon and I was wondering if you could recommend a review book for a medical student?
     
  30. paz5559

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    I was and am amazed and appreciative that a PD like Dr. Mahajan would take the time to address the concerns of PM&R resdients and potential residents, particularly since only 1 PM&R resident has successfuly obtained a fellowhip positon at UC Davis in the past two years (ie. 1/10, or 10% of the successful candidates).

    Dr. Mahajan will , of course, give us the standard answer "more qualified applicants than we have positions available." I dont know about you, but to me, that rings about as hollow as the "We are sorry to inform you ..." letter most of us got from some college or med school we didnt get into. They AREN'T sorry, and Dr. Mahajan, you and I both know that they were not deemed as well qualified, in some manner, real or imagined, legitimate or not, or they would have been your fellows over the past two years.

    I would be more appreciative if he were to post objectivley, however, given his stature, rather than skewing his perspective to the point where it looses any hint of legitimacy.

    Actions speak louder than words - if you think highly enough of potential and current PM&R residents to take the time to post here on SDN, then perhaps we are also worth taking at more than a 10% clip into your fellowship.
     
  31. charcot

    charcot Member
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    What are the top programs that focus on interventional pain managment?
    I also have less interest in med refills, acute inpatient care, or palliative care.
    I think I am becoming more and more interested in developing a surgi-center that provides comprehensive outpatient interventional pain management.
     
  32. daelroy

    daelroy Senior Member
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    Couple of questions.

    1. How many years is the pain fellowship after completing a PM&R residency?

    2. Is this "interventional pain fellowship" associated with anesthesiology or PM&R? If is associated with anesthesiology, then I take it is more difficult for physiatrist to match into this fellowship?
     
  33. charcot

    charcot Member
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    My understanding is that Pain management is a 1 year fellowship. It is offered either by anesthesiology depts (90%) or PM&R depts (10%).
    The anesthesiology based programs seem to be open to all resident types, anesthesia, neuro, PM&R. PM&R-based programs seem to be only for PM&R residents.

    It also seems to me that the anesthesiology-based programs are more procedure oriented, blocks, epidurals, neurolysis, cord stimulators, etc where as PM&R is mostly blocks but in the context of a musculoskeletal examination and understanding of pain.

    Finally, the top programs texas tech, BI deaconess, UCLA and others are all anesthesiology not PM&R and most fellows did anesthesia.
    I only point this out because I heard that the best private practice jobs go to people trained at top programs (makes sense), assuming they leave academia.
     
  34. paz5559

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    Let's see, how many ways can someone be wrong in a three paragraph post? So far, I give honors to Charcot:

    Anesthesiology programs generally offer Pain Management fellowships, which include management of acute pain (ie. ER coverage, inpatient consults), hospice, cancer pain, psychopharmacology, and a whole host of non-interventional foci.

    Interventional procedures, despite what anyone says, are not easy to do WELL. They are fraught with potential complications, as evidenced by the recent rash of deaths and complications from cervical transforaminal injections. That being said, the hardest part of interventional pain management is determining, in advance of the injection, who is the candidate most likely to receive benefit from the procedure. My personal perception is that the majority of anesthesiology fellowships train technicians, whereas the majority of PM&R fellowships focus at least as much on the rationale for the injection as the technical aspects. In short, it is the process that is the hardest part - who to inject, where to inject them, and most important of all, who NOT to inject, either becuase their pathology requires surgical intervention, psychological intervention, or the intefvention of the legal profession (i.e. patients whose priority are their secondary gain isssues).

    Lastly, a little history: no institution can have more than one pain fellowship, interventional or otherwise. PM&R was late to the game, and so most of the programs in the "name" institutions were started by Anesthesia (it should also be noted that not every top institution even HAD a PM&R program, so it would be doubly hard to start a fellowship in that setting.) None the less, the membership of the Interventional Spinal Injection Society is about 35% PM&R, and 65% Anesthesia. The membership of the Board of Governors is 50-50, and NEITHER Nikolai Bogduk NOR Charles Aprill are either specialty (Bogduk is an anatomist, Aprill is a radiologist). The Saal brothers have been prominent members (ok, HATED prominent members, but prominent none the less) of NASS for years. Kevin Pauza won NASS's Outstanding Paper Award thgis past year for his paper on IDET. Joel Press is the incoming President of NASS. ALL of the aforementioned are prominent PM&R docs, NOT anesthesiologists.

    The bottom line is, get the best training. I personally think I am more apt to get that with Curtis Slipman, Michael Furman, Rob Windsor, FSI, CINN, CSSOR, HSS, Frank Falco, MCV, the University of Michigan, Spaulding, Stanford, etc, etc, etc. On the other hand, lots of important interventional pain mangement specialists (Way Yin, Ray Baker, Rick Derby) are well-trained anesthesiologists, and clearly extrodinarily talented interventionists. Way and Ray do their research with Paul Dreyfuss, and Rick just brought Yung Chen into his practice. Want to know what those two men have in common? PM&R training.

    The one number you did say, although I would love to know your source, that sounds about right, is the 90-10 split - there are lots more anesthesia positions than there are PM&R positions. As a PM&R resident, however, I would argue that just makes ours more sought after, competative, and less easily obtained.
     
  35. hotwheel

    hotwheel Junior Member

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    When I signed onto this forum, this is what I saw in the bylaws:

    "The Student Doctor Network is dedicated to developing and maintaining a friendly online community, where members of all ages and backgrounds feel relaxed and comfortable. Like any community, The Student Doctor Network has certain standards. When members join our forums, they agree to abide by these rules. To remain a part of the Student Doctor Network community, members must be considerate to others. Repeated violations of these standards may result in a member being barred from entry or participation in community forums."

    So paz5559, I would like you to share with the rest of the residents and medical students of this forum why you feel it necessary to devalue someone else's opinion with giving out "honors...about ...how many ways can someone be wrong in a three paragraph post?"

    I would also like the moderator of this forum, Dr. Russo, to speak up about how inflammatory statements like paz5999's contribute to the overall "positive" purpose of this forum.
     
  36. Tenesma

    Tenesma Senior Member
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    pazzz... come on... using the old line of anesthesia folk being technicians, and PM&R are the only people to understand the WHY behind a procedure, is getting very, very old.

    Most PM&R pain people (who were fellowship trained) learned they WHY from Anesthesiologists during fellowship - so tone the rhetoric down. Plus Charcot is a young member of SDN and deserves a chance without you sounding so condescending.
     
  37. paz5559

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    I guess the best way to respond to Hotwheel would be to suggest that, when you disparage my field, you disparage me, and all of the other PM&R docs I work with. Implied condescention in statements like
    or
    deserve correction, and I feel I did nothing other than that in the entirety of my post. Quoting one sarcastic comment out of the cotext of the whole, and then taking the "I'm gonna tell mommy" tattletale approach by invoking the help of the forum moderator in no way deminishes the veracity of what I said - Charcot was wrong, and I spent 5 paragraphs explaining WHY he or she was wrong - I did not merely flame him/her.

    As for Tenesma, I have read your comment
    in prior posts. Forgive me, but you just plain wrong about that. Most of the PM&R patriarchs DEVELPOED the field, and are thus not fellowship trained in the first place (Slipman, Windsor, Dreyfuss, Bogdok, Aprill), or trained with the aforementioned (Furman, Falco, Plastaras, members of the Spaulding & MCV staff).

    As for my response getting old, let me suggest that it may be old, but is is also true to suggest that anesthesiologists do not, on the whole, tailor their approach to the patients symptomatology. You have chronic back pain? You get three epidural intralaminar injections, period. MAybe floroscopically guided, maybe not. Always intralaminar, NEVER transforaminal (which is the more effective technique (Clin Rheumatol. 2003 Oct;22(4-5):299-304; Pain Digest 1999; 9:277-285) IS there any evidenced reason why top stick with the less effective technique? Nope. In fact, the literature shows that the loss of resistance technique employed by most anesthesiologists, when done blindly can lead to spinal, rather than epidural injections, and not being in the epidural space at all ~25-30% of the time. Evidence based medicine, Tenesma. I have the literature on my side on this one. Unless you have contrary references you would care to share?
     
  38. Tenesma

    Tenesma Senior Member
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    pazz - nobody is arguing the literature with you - in fact at MGH all ESIs are done fluoroscopically (even though they don't all get reimbursed with the fluoro coding).

    You are citing the literature incorrectly - the randomised controlled study your refer to, compared fluoro-guided transforaminal vs. blind intra-spinous.... that is a poor way of looking at it. It should have been a comparison between fluoro-guided transforaminal vs fluoro-guided intra-spinous (no good literature as far as that is concerned - yet...)

    and i don't understand how there is any condescention implied by stating that the top interventional programs are primarily anesthesia based. That is a fact based on historical development of the field, it doesn't imply that PM&R is unable to have a top interventional program. In fact there are some very good interventional PM&R pain programs (they just don't have the national reputation yet).

    If you look at most interventional PM&R pain programs - their directors (unless they were grandfathered-in) trained at anesth. programs (ie: Raj Mitra at Stanford).

    it sounds like, to me, that you should spend some time in a good pain clinic and observe what anesth. pain docs actually do, instead of making large generalizations
     
  39. Ligament

    Ligament Interventional Pain Management
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    "Lastly, a little history: no institution can have more than one pain fellowship, interventional or otherwise."

    I dont know where that info comes from. I can tell you for a fact that the University of Michigan has TWO separate pain fellowships. One is run by PM&R, and takes two fellows per year. The other is run by anesthesiology and takes two per year.

    Maybe some regulations have changed? Best, Ligament
     
  40. Tenesma

    Tenesma Senior Member
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    stanford has a pm&R and an anesth. pain program... two separate programs
     
  41. hotwheel

    hotwheel Junior Member

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    There you go again, paz5559...disrespecting others! If you actually take the time to READ my initial quote, no where in there did I disparage Physiatrists.

    Here's what I said, and I'll say it again:

    "So paz5559, I would like you to share with the rest of the residents and medical students of this forum why you feel it necessary to devalue someone else's opinion with giving out "honors...about ...how many ways can someone be wrong in a three paragraph post?"

    I would also like the moderator of this forum, Dr. Russo, to speak up about how inflammatory statements like paz5999's contribute to the overall "positive" purpose of this forum."

    By the way, I am a Physiatrist...and proud of it. So your comment that "when you disparage my field, you disparage me, and all of the other PM&R docs I work with" makes even less sense when placed in that context. As far as getting the moderator involved?why not? Your response further supports my initial comment. I am in agreement with one of the other participants that your statements are just plain condescending.

    And Pain Digest? Truthfully, I?ve not met any pain practitioner (academic or private) who quotes articles from this journal. Personally, I?m used to reading Pain, Pain Medicine, The Clinical Journal of Pain, Journal of Pain and Symptom Management, Spine, JAMA, NEJM, Anesthesia and Analgesia, Regional Anesthesia and Pain Medicine, etc.

    Anyway, I took the liberty of pulling the abstract from the other article you cited in Current Rheum, 2003, as that probably carries more weight in academic circles. I?ve copied the abstract verbatim for everyone to read:

    ABSTRACT: A prospective, randomised, double-blind study was carried out to compare the respective efficacies of transforaminal and interspinous epidural corticosteroid injections in discal radiculalgia. Thirty-one patients (18 females, 13 males) with discal radicular pain of less than 3 months duration were consecutively randomised to receive either radio-guided transforaminal or blindly performed interspinous epidural corticosteroid injections. Post-treatment outcome was evaluated clinically at 6 and 30 days, and then at 6 months, but only by mailed questionnaire. At day 6, the between-group difference was significantly in favour of the transforaminal group with respect to Schober s index, finger-to-floor distance, daily activities, and work and leisure activities on the Dallas pain scale. At day 30, pain relief was significantly better in the transforaminal group. At month 6, answers to the mailed questionnaire still showed significantly better results for transforaminal injection concerning pain, daily activities, work and leisure activities and anxiety and depression, with a decline in the Roland?Morris score. In recent discal radiculalgia, the efficacy of radio-guided transforaminal epidural corticosteroid injections was higher than that obtained with blindly-performed interspinous injections.


    Seriously, is this what you consider substantive research that withstands the the rigorous criteria of evidence-based medicine? I certainly don?t, and I would be embarassed to quote this to my colleagues as an article that proves the ? evidence is on my side.? This article has numerous flaws, the least of which are the following:
    1. It is NOT a double-blinded, prospective, randomized placebo-controlled study. It is only a prospective, randomized placebo-controlled study.
    2. Only 31 patients were enrolled
    3. Less than stringent inclusion/exclusion criteria were used
    4. Comparison of a fluoro-guided technique with a non-fluoro guided-technique

    I respectfully suggest you do some further reading and come back to this forum with something more substantial? perhaps, give us the abstract as well. There is stuff out there, but my guess is you will find that most (but not all) of the procedures done in by pain practitioners (Physiatrists or Anesthesiologists) are not supported by strong research, ie randomized, double-blinded, placebo-controlled studies with large populations. Even look in the Cochrane data base. None-the-less, this does not negate the fact that many patients obtain pain relief with associated functional improvement from these various procedures.

    Finally, I agree with Tenesma. You need to spend time in a good pain clinic, but specifically an Anesthesia-based pain clinic, before you start casting broad generalizations about them. I will agree with you, however, that some of the PM&R based pain clinics have a well-established reputation of excellence...others do not (but maybe with time they will).
     
  42. charcot

    charcot Member
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    It is so wonderful to see such enthusiastic postings, and I appreciate all of them. No offense is taken by the postings. I am new to the forum and I am trying to learn about this specialty. As I read the postings I learn more about the field, and some of the personalities who make up the specialty. I would still like to hear more discussion on the top programs, particularly west coast and east coast. (I hope I don't offend any midwesterners). I can appreciate the importance of comprehensive pain management training, including the pathophysiology of pain and the logical selective use of interventions. I am trying to find out which programs will teach the above mentioned and provide didactics on the conceptual basis for pain medicine, as well as hands on training in the interventions, a good mix of outpatient, inpatient, and hospice.
     
  43. paz5559

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    I will do this in stages, ?cause I am getting it from all sides

    To answer the most egregious error first, hotwheel, had you taken the time to note what I was quoting, it was from charcot's original post, not your response. It was he/she who I felt was disparaging the field, and like it or not, I am entittled to take humbrage, just as you, and all contributors to the field are entittled to pile on when you dislike me, my lopinon, or my perspective.

    Once again, just so you are clear, I did not respond to you, hotwheel, except in the sense that I responded BECAUSE of your post. Had you taken the time to read what I wrote, perhaps you would have noticed that. I responded to charcot's post the first time, and my comment "when you disparage my field, you disparage me, and all of the other PM&R docs I work with," I referred to his disparaging comments. Your response referred to my characterization of him/her, and I EXPLAINED why I had responded as I did. I hope that is helpful, and clarifies what I thought would have been obvious to the keen reader.

    Also what I would have assumed was obvious was the distinction between condescension and sarcasm. My intent was for the latter. That you read it as the former may speak to your lack of insight, or my lack of subtlety. Your call. In any case, not cause to call for banning me, which is clearly an over reaction, whether you recognize it or not.

    Like him or hate him, Laxmaiah Manchikanti is a prominent member of the field of interventional pain management. (For those not aware, Dr. Manchikanti is the President and Executive Director of the American Society of Interventional Pain Physicians). I do find it interesting that you fail to list The Spine Journal, the official publication of the North American Spine Society, and JBJS, but instead list medical resources like NEJM and JAMA. Perhaps if you ahd taken the time to read what I have posted, you might see I was making reference to INTERVENTIONAL Pain Management, rather than the totality of the field of Pain Medicine.

    Having attended last years meetings of NASS, ISIS, AAPM, and AAPM&R, I find it comical that your ONLY standard is the gold one of double-blinded, prospective, randomized placebo-controlled. Exactly ONE paper was presented meeting that criteria last year relating to interventional pain management, and Kevin Pauza's paper regarding IDET was the winner of NASS's Outstanding Paper Award, in part BECAUSE of the difficulty involved in such a study. In it, he screened in excess of 4000 potential participants to end up with an N of 64. Thus to be critical of an N of 31 demonstrates your lack of familiarity when it comes to the trials and tribulations of research related to placebo, or sham procedures.

    But let?s go further. Assume for sake of argument, you were able to recruit sufficient participants. How do you propose that you would blind the investigator? After all, he is the one who would be performing the procedure, and would thus HAVE to know which procedure he was to perform on each patient. And lastly, just to nit pick, when comparing two efficacious procedures, you compare them against each other, not against a placebo. The ethics of sham procedures are dubious at best, and no IRB would allow you to perform them when the point of the study was to determine which of two procedures that have demonstrated efficacy provide better relief.
     
  44. charcot

    charcot Member
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  45. hotwheel

    hotwheel Junior Member

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    Now please allow me to address YOUR most egregious errors:

    You see, when your lead sentence is ?I guess the best way to respond to Hotwheel would be to suggest that, when you disparage my field, you disparage me, and all of the other PM&R docs I work with? I naturally assume you?re talking about me. Either I can?t read or you were confused about which name you wanted to insert. Your call.

    As for your statement being sarcasm, if that is your intent then so be it. Keep in mind, then, that such statements are left open to the interpretation of the reader. Your call.

    As for the Spine Journal and JBJS, yes , I agree they are reputable journals. As you will read in my list of journals, there is an etc at the end. I?m not going to list every single journal that I find reputable, as there are many of them.

    And with respect to being an interventionalist, if the only journals you are quoting for evidence based medicine are Pain Digest and Clinical Rheumatology then you?re missing out on a lot of interventional studies that are reported in some of the journals I listed. And yes, some of the other ones overwhelmingly (and in some cases, exclusively) have articles with a non-interventional bias. But that is a part of pain management?even interventional pain management, whether you believe it or not. And what's up with the inuendo about being an interventionalist as it relates to reading (or not reading in your case based on my interpreation of your statement. Your call.) NEJM and JAMA. In case you didn't know it, even NEJM accepts research from interventionalists. In 2000 (volume 343, #9), Kemler et al published an article on spinal cord stims and complex regional pain syndrome. In my opinion, stims are about as interventional as things get in this field.

    And to use your saracastic term ?comical? (I?m giving you the benefit of the doubt on this one and am not taking offense to the word as you used in your response to me), I would use it this way: for someone who presents him/herself as an aspiring Interventionalist, why are you quoting literature from a Rheumatology journal? The study was certainly not done by people prominent in the field of interventional pain management as far as I know. Gosh, they couldn?t even find >31 patients for their study. Either the authors are ?dabbling? in pain management or they have a very slow clinic. And so being critical of an N = 31 is, I feel, justifiable. Where is the statistical power with an N = 31? And answer this for me: do you think it is ethical (and nervermind, safe) to be sedating a patient for a procedure so that he/she forgets what procedure is being performed? That's what these authors of your quoted study did. Anyway, in my opinion, it is still a weak study on numerous fronts. However, I encourage you to read the article in it's entirity, and then tell the rest of us why you think this is a strong study that meets your criteria for evidence-based medicine.

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  46. hotwheel

    hotwheel Junior Member

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    As for the gold standard of research being a randomized, double-blinded, prospective, placebo-controlled study? that is a fact. The lack of such a standard is why the results of many pain studies are fraught with errors in interpretation and conclusions drawn. And not being able to blind the researcher makes this even more difficult.

    And to say I have a ?lack of familiarity with the trials and tribulations of research and placebos and sham and not getting IRB approval?, let?s get serious here. Did YOU actually read Pauza?s NASS paper of the year? And by the way, it was NOTa double-blinded randomized placebo-controlled prospective trial as you alluded to in your quote. It was a randomized, placebo-controlled, prospective trial (see abstract below, under "study design/setting")

    Here is the abstract from Pauza?s paper (which is listed on PubMed) for everyone to read:

    BACKGROUND: Intradiscal electrothermal therapy (IDET) is a treatment for discogenic low back pain the efficacy of which has not been rigorously tested. PURPOSE: To compare the efficacy of IDET with that of a placebo treatment. STUDY DESIGN/SETTING: Randomized, placebo-controlled, prospective trial. PATIENT SAMPLE: Patients were recruited by referral and the media. No inducements were provided to any patient in order to have them participate. Of 1,360 individuals who were prepared to submit to randomization, 260 were found potentially eligible after clinical examination and 64 became eligible after discography. All had discogenic low back pain lasting longer than 6 months, with no comorbidity. Thirty-seven were allocated to IDET and 27 to sham treatment. Both groups were satisfactorily matched for demographic and clinical features. METHODS: IDET was performed using a standard protocol, in which the posterior annulus of the painful disc was heated to 90 C. Sham therapy consisted of introducing a needle onto the disc and exposing the patient to the same visual and auditory environment as for a real procedure. Thirty-two (85%) of the patients randomized to the IDET group and 24 (89%) of those assigned to the sham group complied fully with the protocol of the study, and complete follow-up data are available for all of these patients. OUTCOME MEASURES: The principal outcome measures were pain and disability, assessed using a visual analog scale for pain, the Short Form (SF)-36, and the Oswestry disability scale. RESULTS: Patients in both groups exhibited improvements, but mean improvements in pain, disability and depression were significantly greater in the group treated with IDET. More patients deteriorated when subjected to sham treatment, whereas a greater proportion showed improvements in pain when treated with IDET. The number needed to treat, to achieve 75% relief of pain, was five. Whereas approximately 40% of the patients achieved greater than 50% relief of their pain, approximately 50% of the patients experienced no appreciable benefit. CONCLUSIONS: Nonspecific factors associated with the procedure account for a proportion of the apparent efficacy of IDET, but its efficacy cannot be attributed wholly to a placebo effect. The results of this trial cannot be generalized to patients who do not fit the strict inclusion criteria of this study, but IDET appears to provide worthwhile relief in a small proportion of strictly defined patients undergoing this treatment for intractable low back pain

    So did the authors screen 4000 patients? Yes (4253 patients to be exact), but it was a combo of referrals and a media blitz that brought the patients in. So let?s agree that 4253 people were ?screened? and whitled down to 1360 as it indicates in the abstract. So what? Some of these were patients whose only complaint was low back pain and did not even have an exam until they agreed to randomization. And then only 260 were eligible based on a clinical exam, and of these only 64 were enrolled in the study. Still a small number as far as I?m concerned. However, I commend the authors for doing this study and the laudable task of putting it together.

    Furthermore, I?m impressed with the placebo control: ?Sham therapy consisted of introducing a needle onto the disc and exposing the patient to the same visual and auditory environment as for a real procedure.? And by the way, that is how you do a sham treatment with the approval of the IRB! So, would you agree or disagree with your previous statement that ?the ethics of sham procedures are dubious at best, and no IRB would allow you to perform them when the point of the study was to determine which of two procedures that have demonstrated efficacy provide better relief.? Here you could try to get me on a technicality that the study did not compare two procedures, and that's fine with me. But one could plausibly say it was 2 procedures: that of IDET vs. merely sticking a needle into the patient and placing it onto the disc. But then answer this question: should the authors have even used a sham treatment in patients with a positive discogram, when the "alternative therapy" could be surgery? Oh and it looks like the conclusion of the study was not that forceful either, with 50% of patients obtaining no appreciable benefit. It probably reinforces why many (but not all, ie work comp especially) insurance companies continue to deny authorization for the treatment. Certainly, this is the type of study that should have been done before every interventionalist (physiatrists and anesthesiologists) jumped on the wagon of doing IDETs on everyone with a positive discogram. If you go back and read the earlier studies of some of the ?PATRIARCHS??2 of whom developed the procedure?and you will see that Pauza?s study probably supports much of the skepticism about the procedure when it first came out and the Saal brothers started publishing their data. But don?t mistake this for me believing IDET is invaluable?it is in the right patient. Certainly, surgical outcomes and outcomes research for LBP are not great either, but insurance companies have no problem paying for that.
     
  47. paz5559

    10+ Year Member

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    Quite a diatribe, hotwheel. Yet at the end of the day, you have still not suggested how it would be technically possible to accomplish what you have suggested is the only acceptable form of evaluating transforaminal vs. intralaminar epidural injections. I wait with bated breath for your proposed double-blinded, prospective, randomized placebo-controlled protocol. I for one believe you have set the bar impossibly high to then be able to throw darts with impunity, but perhaps you will prove me wrong.

    By the way, while an interesting discussion, I wonder if it hasn't been hijacked from its original mission of addressing "PM&R and Pain Fellowships"

    Why don't you PM me, or if you feel your harangue must continue in public (misguided though it is), why not start a "beat up on PAZ", "PAZ is a moron", or "Anesthesia is better than PM&R" thread? (That was sarcasm, by the way, just so nothing is "left open to the interpretation of the reader" in this instance).
     
  48. drusso

    Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

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    There is nothing wrong with spirited debate: It's interesting and introduces juniors/novices to this important topic. Let everyone just remember that this is a professional forum.
     
  49. hotwheel

    hotwheel Junior Member

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    paz, surely you jest about my not having answered your question about the "proposed double-blinded, prospective, randomized placebo-controlled protocol" for transforaminal vs. translaminar epidural injections. Look, you have not even answered any of my questions, especially the ones about the literature YOU posted in your comments. When you answer my questions, then I?m happy to answer yours. Until then?keep waiting with bated breath. Besides, my diatribe today is too long anyway!

    As for my setting the bar too high, don?t blame me on this one. The bar is set by the scientific/research establishment to keep unsafe procedures and drugs from coming to the mass market. So forgive me if I view the literature with a high level of scrutiny. Make no mistake, though, there are merits to many of the interventional procedures that are performed even though they don?t meet the ?gold standard?. To be clear, I?m not throwing darts with impunity. On the other hand, I'm not going to justify doing some of those procedures with the authoritative mandate of "evidence-based medicine" being on my side, when it is clearly not. (And as an aside, what do you think about research that is published by authors who are speakers for the products/devices they are testing? Should those studies be weighted equally with those studies where the authors have absolutely no bias?)

    As for hijacking the discussion and haranguing you in public...c?mon! Let?s just stick to the facts. You're the one that's quoting the literature being on your side. I merely pulled the Rheumatology study that I?m assuming you've read but never-the-less the results of which you clearly defend. I then read the article and posted the abstract for everyone else to view so they, too, can reach their own conclusions about the study?s veracity. (Note: I tried to get to Pain Digest, but unfortunately our library doesn't have access to that, it doesn?t exist in Pub Med/NLM, and I don?t have a subscription. So you?ve got me on that one, but once again I haven?t heard of Pain academicians quoting it ? and this includes AAPM&R, AAPM, ISIS, IASP, ASRA, or APS. (Missed the NASS conference, so I?ll have to defer to you on that one.) And as for Pauza's paper, I'd already read that one when it came out (And I forgot to mention in yesterday?s original post?while 64 patients were ultimately analyzed, the final data was only based on 56 patients). So, once again all I did was post the abstract..

    So really, the bottom line is this: misquoting and misrepresenting scientific articles as being something more than what they are, is in my opinion, an egregious error. Most of the research in the field of pain management, especially interventional pain management, should be reviewed with a keen eye. The scientific literature is littered with many studies, and it's up to the reader to recognize each studies limitations, as it ultimately is extrapolated to affect one's clinical practice.

    With respect to determining which are the best types of Fellowships, you list quite a few. But you also state that your ??personal perception is that the majority of anesthesiology fellowships train technicians, whereas the majority of PM&R fellowships focus at least as much on the rationale for the injection as the technical aspects.? Now, I respect your opinion and your right to put it out there in this forum like everyone else. I am not being sarcastic when I ask that I genuinely would like to know what forms your perception, as it is obvious that you have a clear bias is towards PM&R Pain Fellowships. (As for my bias, I have none as I?m equally receptive to both)
     

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