PM&R Pain Medicine & Subspecialty Fellowship FAQ's

[charcot]

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.

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[paz5559]

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.

 

[hotwheel]

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.

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.

 

[Tenesma]

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.

 

[paz5559]

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

the top programs texas tech, BI deaconess, UCLA and others are all anesthesiology not PM&R

or

It also seems to me that the anesthesiology-based programs are more procedure oriented

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

Most PM&R pain people (who were fellowship trained) learned they WHY from Anesthesiologists during fellowship

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?

 

[Tenesma]

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

 

[Ligament]

"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

 

[Tenesma]

stanford has a pm&R and an anesth. pain program... two separate programs

 

[hotwheel]

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?

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).

 

[charcot]

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.

 

[paz5559]

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.

 

[charcot]

...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.

.... 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.

QUOTE]
PAZ-
Hey man, I was not putting out any disparaging comments. You are mistaken about my intention. I was, as others have pointed out, stating the current state of pain fellowships as being mostly anesthesia-based, and that most of the better programs seem anesthesia-based, and most of the fellows seem to be anesthesia-trained. This is all in the context of trying to find out where a non-anesthesia based person can fit in as a trainee in this exciting, inspiring and potentially lucrative field. I have heard that a PM&R person can go far, but should go into an anesthesia program. I'm simply trying to learn about the best ones.

 

[hotwheel]

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.

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.

COMMENTS CONTINUED ON NEXT QUOTE

 

[hotwheel]

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.

COMMENTS CONTINUED

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.

 

[paz5559]

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 *****", 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).

 

[drusso]

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."

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.

 

[hotwheel]

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, of if you feel your harangue must continue in public (misguided though it is), why not start a "beat up on PAZ", "PAZ is a *****", 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.)

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)

 

[PainDr]

Originally Posted by paz5559

"As for my response getting old, let me suggest that it may be old, but 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."

As a neurology resident going into interventional pain, I consider myself somewhat impartial. I have to disagree with the statement that anesthesiologists are not as well trained as physiatrists. I've worked with several very well trained anesthesiologists. Believe me...they know what they're doing. Also, I'm in the process of applying for fellowship and have carefully scrutinized quite a few programs. I must say I haven't been too impressed with MOST of the PM&R programs. Personally, I've been encouraged not to apply to them as most are not as well developed or nationally known as the Anesthesiology programs.

Also, someone mentioned that rehab residents are much better at EMG than neuro residents because we sometimes do less than one month of EMG. Just for the record, that's incorrect. AAN guidlines require a minimum of 2 months of EMG, but I don't know ANYONE who only does 2 months. Most people do at least 3-4 months. Additionally, the quality of training makes a great deal of difference. Are you learning from clinicians who are just fellowship trained or are you training with nationally known neuromuscular specialists? In the best situation you get both quality and quantity, but I doubt most physiatrists OR neurologists are fortunate enough to have that type of resident experience. My experience has been GREAT and it sounds like yours has too, but lets not delude ourselves into thinking that everyone is so lucky! I mean, if that were the case, there wouldn't be a need for neuromuscular fellowships!

 

[Finally M3]

Originally Posted by paz5559

"As a neurology resident going into interventional pain, I consider myself somewhat impartial.

Heh, isn't this statment re; a neurologist speaking about PM&R an oxymoron?



Sorry, I couldn't resist. You've been very professional in your postings, PainDr, and brought a lot to this discussion and our discussion board!

 

[Stinky Tofu]

Also, someone mentioned that rehab residents are much better at EMG than neuro residents because we sometimes do less than one month of EMG. Just for the record, that's incorrect. AAN guidlines require a minimum of 2 months of EMG, but I don't know ANYONE who only does 2 months. Most people do at least 3-4 months. Additionally, the quality of training makes a great deal of difference. Are you learning from clinicians who are just fellowship trained or are you training with nationally known neuromuscular specialists? In the best situation you get both quality and quantity, but I doubt most physiatrists OR neurologists are fortunate enough to have that type of resident experience. My experience has been GREAT and it sounds like yours has too, but lets not delude ourselves into thinking that everyone is so lucky! I mean, if that were the case, there wouldn't be a need for neuromuscular fellowships!

I can't speak for every program, but at least at Harvard and the institutions that the MGH/BWH fellows came from, it is not the norm to to 3-4 months. In fact, the Partners Neurology residents hardly ever spend time in the Neurophysiology lab (definitely less than two months on average) unless they are interested in doing a fellowship. The ones that do rotate through split their time between EEGs and EDX studies. On the other hand, we spend 4-6 months learning from the same neuromusclar specialists as the Partners Neurology residents do. This is in addition to the EDX studies we do on other rotations, our weekly EMG conferences, and the lectures we get.

Neurologists are certainly capable of becoming good Neurophysiologists, but from what I've heard from the residents and fellows, it would be difficult without a fellowship. On the other hand, Physiatrists don't necessarily have to do a fellowship. All PM&R residencies require you to do 200 studies prior to graduation and this is so that you will be eligible to sit for the AAEM's (American Association of Electrodiagnostic Medicine) exam.

For the average Neurology resident interested in doing both EDX studies and Interventional Pain, I think it would be difficult to do both without a fellowship in each.

 

[PainDr]

The minimum requirement is 2 months of dedicated EMG and 2 months of dedicated EEG (4 months total). Unless I'm mistaken, it is an ACGME/AAN requirement. We also do/interpret EDX studies on other rotations and have regular EMG lectures and conferences. However, both my chairman and program director are fairly well known neuromuscular specialists therefore, I'll concede that my program is probably somewhat unique in the amount and quality of EMG exposure.

I didn't realize that All PM&R residencies require you to do 200 studies prior to graduation. That's impressive. However, I was recently told by one of our fellows that the ABEM is changing it's eligibility criteria (I'm sure you meant the ABEM, as the AAEM doesn't have anything to do with confering board certification). The previous requirement of 200 completed studies is being revoked and in the future, only those with fellowship training will be allowed to sit for the boards. This is to go into effect in the next year or two. If this is incorrect, please let me know.

 

[drusso]

The minimum requirement is 2 months of dedicated EMG and 2 months of dedicated EEG (4 months total). Unless I'm mistaken, it is an ACGME/AAN requirement. We also do/interpret EDX studies on other rotations and have regular EMG lectures and conferences. However, both my chairman and program director are fairly well known neuromuscular specialists therefore, I'll concede that my program is probably somewhat unique in the amount and quality of EMG exposure.

I didn't realize that All PM&R residencies require you to do 200 studies prior to graduation. That's impressive. However, I was recently told by one of our fellows that the ABEM is changing it's eligibility criteria (I'm sure you meant the ABEM, as the AAEM doesn't have anything to do with confering board certification). The previous requirement of 200 completed studies is being revoked and in the future, only those with fellowship training will be allowed to sit for the boards. This is to go into effect in the next year or two. If this is incorrect, please let me know.

At Mayo we do a total of 6 months of EMG/EDX with our neurology colleagues. The neuro residents have an option of doing only four months and we have to do six months. Many of the neuro residents at Mayo are more interested in other fellowship opportunities--MS, stroke, movement disorders, etc. and tailor their experiences that way

The neurophysiology lab is a joint venture by Neuro and PM&R. I'll have to check with my program chairman about the 200 EMG requirement going away. She sits on the board of the AAEM. I do know that there is a push to further subspecialize EMG/EDX training as in some states physical therapists can do needle examinations as well as in the military. Scary. If even the best electrodiagnostician can miss ALS versus a polyradic or other "zebra EDX" finding how on earth will a PT make the call? It's not all carpal tunnel and L5 radics out there...

 

[Stinky Tofu]

As far as I know, that policy isn't going to change for the AAEM/ABEM. I would think that if the policy was going to change, they would probably mention it. I'm sure DigableCat would've heard about it as well since Dumitru and Walsh are at his program. I think that what you are referring to is the ABPN's (American Board of Psychiatry and Neurology) subspecialty certification in Clinical Neurophysiology. I remember one of the fellows mentioning this, but since I'm not a Neurology resident, I didn't really pay attention.

The resident should be exposed to patients with neuromuscular disorders at all levels of their training. While some aspects of this can be accomplished during their rotations on the in-patient service and resident clinics, it is recognized that many neuromuscular patients are seen only in sub-specialty clinics. The residency should provide rotations for all residents in neuromuscular clinics preferably the equivalent of 2-3 months during their residency. The adult neurology residents should be exposed to pediatric neuromuscular patients in a similar manner. It could be included as part of the 3 month pediatric neurology rotation.
A rotation in the EMG laboratory is an excellent way for residents to see a variety of neuromuscular patients, understand the physiologic aspects of these disorders, and learn when to order studies and how to interpret EMG results. It should be understood that the practice of electromyography requires extensive training and post-training experience. This is usually not possible to obtain during a short rotation during residency. Residents interested in performing EMG examinations in their future practice are encouraged to pursue further training in a fellowship.

From what I gathered from a quick look at the AAN's website, it appears to be a suggestion rather than a requirement. The average Partners Neurology resident does not spend 2-3 months in the EMG laboratory; they'd rather spend their elective time pursuing other areas of interest and probably wouldn't want to be forced to spend that much time in the EMG lab.

 

[PainDr]

"From what I gathered from a quick look at the AAN's website, it appears to be a suggestion rather than a requirement. The average Partners Neurology resident does not spend 2-3 months in the EMG laboratory; they'd rather spend their elective time pursuing other areas of interest and probably wouldn't want to be forced to spend that much time in the EMG lab."

I suppose both my Chairman and Program Director could be wrong...I'll check into it.

 

[paz5559]

Reference was made earlier that PM&R REQUIRES that residents perform 200 EMG's during their residency. While individual programs may, the AAEM is the body that uses that benchmark in order for you to sit for their board certification exam.

I could be wrong, but I tried to read through the ACGME RRC requirements prior to posting this disagreement with the prior post, and I can't find any such requirement listed.

http://www.acgme.org/downloads/RRC_progReq/340pr703.pdf

Anyone who can find rules and regs I haven't stumbled across, please let me know.

 

[Stinky Tofu]

Reference was made earlier that PM&R REQUIRES that residents perform 200 EMG's during their residency. While individual programs may, the AAEM is the body that uses that benchmark in order for you to sit for their board certification exam.

I could be wrong, but I tried to read through the ACGME RRC requirements prior to posting this disagreement with the prior post, and I can't find any such requirement listed.

http://www.acgme.org/downloads/RRC_progReq/340pr703.pdf

Anyone who can find rules and regs I haven't stumbled across, please let me know.

I got this from the link you provided above:

7. The clinical curriculum must be written and implemented for the
comprehensive development of measurable competencies for each resident in
the following areas:

a. history and physical examination pertinent to physical medicine and
rehabilitation,
b. assessment of neurological, musculoskeletal and
cardiovascular-pulmonary systems,
c. determining disability evaluations and impairment ratings,
d. data gathering and interpreting of psychosocial and vocational
factors,
e. performance of electromyography, nerve conduction and
somatosensory evoked potential studies, and other electrodiagnostic
studies. In general, involvement in approximately 200
electrodiagnostic consultations per resident, under appropriate
supervision, represents an adequate number.
f. therapeutic and diagnostic injection techniques,
g. prescriptions for orthotics, prosthetics, wheelchairs and ambulatory
devices, special beds and other assistive devices,
h. Written prescriptions with specific details appropriate to the patient
for therapeutic modalities, therapeutic exercises and testing
performed by physical therapists, occupational therapists,
speech/language pathologists. It is necessary to provide for an
understanding and coordination of psychologic and vocational
interventions and tests.
i. familiarity with the safety, maintenance, as well as the actual use, of
medical equipment common to the various therapy areas and
laboratories,
j. a formal experience in evaluation and application of cardiac and
pulmonary rehabilitation as related to physiatric responsibilities,
k. the rehabilitation of children,
l. collaboration with other medical professionals and members of the
allied health team, including management techniques consistent with
the resident's team leadership role, and the treatment program
management role of the physiatrist,
m. geriatric rehabilitation,
n. prevention of injury, illness and disability
o. counseling of patients and family members, including end of life
care,
p. the importance of personal, social and cultural factors in the disease
process and clinical management,
q. the principles of pharmacology as they relate to the indications for
and complications of drugs utilized in PM&R, and
r. experience in the continuing care of patients with long-term
disabilities through appropriate follow-up care.

I'm not sure if this is a firm PM&R requirement, but at every program I interviewed, there would be some sort of mention about their residents having no problem meeting the 200 cases required. In retrospect, they may have meant the AAEM/ABEM requirement.

 

[DigableCat]

Unless I interpreted him wrong, this is what he says...

1. There is no intentions on making EMG fellowships required for PM&R residents to become ABEM certified. The fact that we have to do >200 during our residency makes up competent enough to sit for the exam.
2. Neurologists have to do a EMG fellowship to be able to sit for the boards. I'm not sure if they have to be ABEM certified to do EMGs(and it's highly unlikely). Although I hesitate to think how they could be done and interpreted with confidence. Half of the time, when I get an EMG consult from the Neurology service and I call the resident...they don't know exactly why they are ordering it or what they are looking for. It's more of a shot gun approach. Hoping something comes up positive.

 

[PainDr]

Stinky is right. Neuro residents must do a fellowship to get ABPN subspecialty certification. However, DigableCat is wrong. We are not required to do a fellowship to sit for the boards. We have the same 200 study requirement as you...something many programs could easily accommodate during elective time.

Surely I don't need to tell you that programs vary greatly in their strengths and weakness. For example, I find it laughable that a neurologist would consult pm&r for an EMG, but if you tell me that's what's happening at your program, I suppose I'll take your word for it. I mean, after all, the pm&r residents at my program are the most worthless group I've ever seen and I wouldn't refer my worst enemy to them. So...I've seen first hand how an institution can have both strong and weak programs under the same roof.

 

[charcot]

Any word on top west coast pain programs? particularly in terms of breadth of training in interventions as well as didactics and collegiality amongs fellows and faculty.

By the way, Bonica's book is one of the most amazing textbooks I've come across in a very long time.

 

[DigableCat]

But...I stand corrected. As is sometimes the case.

American Board of Electrodiagnostic Medicine Eligibility Requirements

Training in Electrodiagnostic Medicine
A period of preceptorship in electrodiagnostic medicine that is coordinated with presentation of didactic material must be satisfactorily completed under direct supervision of an experienced electrodiagnostic medicine consultant, preferably an ABEM Board Diplomate. This preceptorship may be taken during and/or after an approved residency training program. The period of preceptorship must be at least 6 months fulltime,1 or equivalent thereto, with the first 3 months rigidly structured with regard to supervision. Any postresidency course of study in electrodiagnostic medicine must be conducted where there is an ACGME, AOA, or RCPSC recognized neurology or physiatry residency training program, or at a participating institution to a sponsoring institution that has been approved by the ACGME in order to qualify as a portion of the 6-month preceptorship. During these 6 months, at least 200 complete electrodiagnostic evaluations must be performed on separate occasions; these studies must be documented and interpreted.

Full-time equivalent: One month of full-time equivalent is defined as 160 hours

Independent Experience
Competency in electrodiagnostic medicine can only be achieved by performing and interpreting additional electrodiagnostic examinations. Candidates, therefore, must also document at least 1 year of experience following training during which they must perform 200 additional complete electrodiagnostic evaluations on separate occasions.


I get my 6 months and >200 EMGs easily. Don't know how easy it is for Neurology programs to do the same. Maybe what I was meant to understand is that Neurology programs typically do not receive the 6 months necessary, thereby making the EMG fellowship more of an option than say someone who is a PM&R resident.

Ready to be wrong...

 

[drusso]

For example, I find it laughable that a neurologist would consult pm&r for an EMG, but if you tell me that's what's happening at your program, I suppose I'll take your word for it. I mean, after all, the pm&r residents at my program are the most worthless group I've ever seen and I wouldn't refer my worst enemy to them. So...I've seen first hand how an institution can have both strong and weak programs under the same roof.

WOW, that's harsh. So, I'm just curious, what would you refer to PM&R as a neurologist? At Mayo both the neurologists and physiatrists run the EMG lab. The residents train side by side and we present cases to both PM&R and neurology attendings who are both fellowship trained electromyographers. Yesterday, I got a nice referral to my continuity clinic from a neurologist for "gait disorder" which turned out to be steroid-induced myopathy. Gee, I hope I wasn't worthless...more importantly, I hope that my input actually helped the patient.

 

[PainDr]

You're right, that was harsh. I just wanted to point out that it does seem that your neuro residents are really weak...just as our rehab residents are weak. I would NEVER confuse a myopathy with a gait disorder! That's disgraceful...that resident obviously doesn't know how to do a thorough neuro exam. If someone had some type of unusual movement disorder, I would refer to our movement disorders specialist. If someone had a steroid myopathy I would handle it myself. If, after a thorough w/u, I couldn't identify the etiology of a myopathy I would refer to our neuromuscular specialists. Personally, I only refer to PM&R for stroke, spinal cord or TBI rehab, or gait eval/training in someone at risk for falls (NPH, PD, dystonia, etc.).

 

[indytravl]

1. I'm interested in an Interventional Pain Medicine fellowship. Can anyone clarify the advantage of an ACGME-accredited program over a non-accredited one? When I spoke to Pain attendings, inluding one who graduated last year from Cleveleand Clinic program, they didnt give any ideas why to chose one over the other. I believe you can sit for the Pain Boards after completing either.

2. Does anyone have info on the Case Western fellowship? Is it a strong program with good didactics as well as procedure volume and variety?

3. Any programs in mid-Atlantic region (Virginia, West Virginia, Tenn, Kentucky, North Carolina) that anyone has further insights on?

4. Does anyone know about any Interventional Pain fellowship opportunities in the military and how they rate compared to civilian ones?

thanks, [email protected]

 

[Stinky Tofu]

The answer will depend on who you talk to. In the past, you could do a non-accredited fellowship, but that's changing starting this year. They've already changed the cutoff date once so I wouldn't be surprised if they changed it again. My suspicion is that you will start seeing more PM&R Pain programs apply for accreditation.

Also, I think in the future they will try and get some sort of accreditation for Spine fellowships if the trend is to require ACGME-accreditation for privileges. I don't think this will happen for some time because their will be too many people who will fight it.

I can't really answer your other questions.

From The American Board of Physical Medicine and Rehabilitation:

For candidates seeking qualification by way of training:
(available through 2006 examination)
■ satisfactory completion of 12 months of formal unaccredited training
in Pain Medicine, and
■ satisfactory completion of residency training required for general
certification prior to September 1, 2004.

After the 2004 examination, candidates applying or reapplying for admissibility
to the Pain Medicine examination will only be admitted by way of
training.

After the 2006 examination, candidates applying or reapplying for examination
in Pain Medicine must complete 12 months of training in an
ACGME?accredited Pain Medicine program.

 

[PainDr]

Hey Stinky...know anything about the pain fellowship? Also, what happened with the Tufts program? What's the scoop?

 

[Stinky Tofu]

Hey Stinky...know anything about the pain fellowship? Also, what happened with the Tufts program? What's the scoop?

The program apparently used to be located at Tufts/NEMC, but has moved to Caritas. I think they still have a strong affiliation with Tufts.

 

[Nanomed9999]

I am applying for PM&R residencies and am looking for programs with an emphasis on interventional procedures. An alternative would be a program with a good deal of elective opportunities.

I am definitely planning to do an interventional pain fellowship after residency.

1. What are the top programs with an emphasis on interventional procedures?

I've heard that Ohio State has good interventional emphaisis, while RIC, which is most definitely top tier, has a large number of electives.

2. To get into a top tier interventional pain fellowship (not spine fellowship), do you feel it's more important to go to a top tier program or to a program that may not be top tier, but has excellent interventional exposure.

Thanks very much for the feedback

 

[Finally M3]

When I interviewed last year I thought that UMich provided more intervential experience than OSU...at least that was the impression I left with.

OSU did provide a crapload of EMG experience, however.

 

[PainDr]

Anyone know anything about the Georgia Pain Physicians pain managment fellowship?

 

[DigableCat]

Anyone know anything about the Georgia Pain Physicians pain managment fellowship?

they've filled their spots already. Some friends of mine found out yesterday.

 

[Disciple]

I know that not all solid PM&R interventional spine fellowships are listed in the PASSOR fellowship guide.

In reading this thread and others I've seen LSU, U. of Mich., Harvard, Stanford, UVA, NRH, UC Davis and UMDNJ mentioned.


Anybody have any others to add?

 

[axm397]

You also have to check musculoskeletal and pain in addition to spine to get a full list of fellowships available. Off the top of my head, I would add Georgia Spine, Florida, Furman's (sinai of baltimore), and UPenn (slipman) fellowships to that list.

 

[Disciple]

Thanks.


Yeah, I've heard those names quite a bit.



I had just noticed that a number of good and/or new procedural based fellowships hadn't listed their programs through PASSOR.

 

[paz5559]

Thanks.


Yeah, I've heard those names quite a bit.



I had just noticed that a number of good and/or new procedural based fellowships hadn't listed their programs through PASSOR.

Just curious - which programs are you aware of that are not listed in the PASSOR directory? I ask becuase most of the ones you mentioned ARE listed (I suspect when you said UVA you ment MCV, but perhaps I am mistaken)

 

[Disciple]

Yeah, I don't see any of those listed.

I'm referring to the 2004 guide (the paper copy they send you in the mail.)



Why, is there another version on the AAPMR site?

 

[axm397]

Yeah, I don't see any of those listed.

I'm referring to the 2004 guide (the paper copy they send you in the mail.)



Why, is there another version on the AAPMR site?

yes - there is an electronic version where you can pick and choose various types of fellowship by location, etc.

here's the link: http://www.aapmr.org/member/felsearch.htm

 

[Disciple]

Just found it.



Thanks

 

[DigableCat]

The Future of Training and Education for Pain

 

[drusso]

The Future of Training and Education for Pain

I like this article so much that I'm making creating its own stikcy. I think that it nicely covers routine questions asked on this board.

 

[Spine Specialist]

Friends-

I am a PMR-based ACGME/Anes Pain fellow who is applying for jobs in academic practice Vs group practice in academic setting. How do i negotiate for percentage in procedures i am going to do after regular base salary? I hope you understand my question.

Any suggestions or advice from practicing pain folks or others will be really appreciated. Thanks!