You just slid down to the bottom of the slippery slope with your "(or it is close)" qualifier statement. if you are aguing that a less qualified candidate should get a position because of their gender, as i believe you just did, than your selection criteria is inherently weakening the program and profession in general. i realize that this may pill over into an affirmative action debate, but you what you are saying is not logical or reasonable at this level.
PMR discrimination!
- Thread starter clubdeac
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You just slid down to the bottom of the slippery slope with your "(or it is close)" qualifier statement. if you are aguing that a less qualified candidate should get a position because of their gender, as i believe you just did, than your selection criteria is inherently weakening the program and profession in general. i realize that this may pill over into an affirmative action debate, but you what you are saying is not logical or reasonable at this level.
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DD300, you're exactly right . . . I am big and basically they did shut down a bunch of PMR pain fellowships while I was in residency or at least take their accreditation away! And just to catch you up, the whole landscape of PMR is changing, not just pain. PMR is a great field with a vast array of different avenues to pursue. The problem is, these avenues are increasingly eroding. Inpatient rehab - Medicare and the 75% rule has done a number on that one. Outpt sports medicine - was hot for awhile but with more FPs going into this and ortho dominating the market it's hard to find a niche. I could go on but basically pain seemed like the best fit and now I've got a bunch of red tape bull "$h-t" standing in my way.
"Sinai Hospital of Baltimore (Center for PM & R East York)- will not be ACGME accredited in '08 (from what I have heard)"
Michael Furman's fellowship program will likely no longer be affiliated with Sinai/Baltimore in 08. However, I have heard that he is probably going to be affiliated with another university hospital which allow him to keep his ACGME accreditation.
Michael Furman's fellowship program will likely no longer be affiliated with Sinai/Baltimore in 08. However, I have heard that he is probably going to be affiliated with another university hospital which allow him to keep his ACGME accreditation.
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If anybody can pull this kind of thing off, it will be Furman. Rooting for him.
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Seems unlikely, given that he is not in close proximity to any other University WITH a PM&R resdiency
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a far fetch- but 100 miles to philly
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I heard he was initially supposed to be affiliated with Hopkins but they were too much of a pain in terms of demands so he chose Sinai.
I read through the ACGME requirements and not sure if you necessarily need a PM&R residency - just two of neuro, PM&R, psych, Anesthesia, correct? Sinai only has PM&R which is the issue.
But I agree with lobelsteve -if anyone can pull it off, Furman can.
"Seems unlikely, given that he is not in close proximity to any other University WITH a PM&R resdiency"
Ok..so let me rephrase what I previously said...I KNOW for a fact that he IS going to be linked up with another institution that isnt exactly close to York. From what I hear, its close to a done deal. I heard this from a very, very reliable source in boston, so its probably true. Thats all Im gonna say, but dont be surprised if he keeps his accreditation in january '08.
AXM - you are correct. You need to have an affiliation with a university hospital with 2/4 residency training programs with a pain "subspecialty" ie psych, PM&R, neuro, anesthesia.
If he wants a "symbiotic relationship" so to speak...I dont think distance is going to be too much of an issue
Ok..so let me rephrase what I previously said...I KNOW for a fact that he IS going to be linked up with another institution that isnt exactly close to York. From what I hear, its close to a done deal. I heard this from a very, very reliable source in boston, so its probably true. Thats all Im gonna say, but dont be surprised if he keeps his accreditation in january '08.
AXM - you are correct. You need to have an affiliation with a university hospital with 2/4 residency training programs with a pain "subspecialty" ie psych, PM&R, neuro, anesthesia.
If he wants a "symbiotic relationship" so to speak...I dont think distance is going to be too much of an issue
Lobelsteve has made the comment that we can hear the door closing on Pain/PM&R. I think the fact that we are such a big part of pain medicine for being a fraction of just the folks that show up at ASA meeting is remarkable. I do not think this perhaps well minded but ill advised ACGME fellowship change is going to close the door. What worries me is that it is effectively closing the door to academic pain medicine to quality PM&R candidates. Fellowships need to live in a department and they are overwhelmingly going to hire their own. Overwhelmingly, anesthesiology has a broader wheel base than PM&R in most universities.
I work with an anesthesiologist. I am the better diagnostician. He is better with airway and acute. He has more experience with procedures (been doing it longer). Most of his procedural skills were picked up AFTER his fellowship where he basically learned bread and butter stuff. His departmental partners have threatened to quit working with him because of me. I am publishing, teaching and presenting - but their sitting on their anesthesiology butts is supposed to make them better than me.
Now that is a bit of sour grapes-but my point is that it is really valuable to be truly multidisciplinary in this area because we all bring different stuff to the table. Can't we break bread and swill wine together and feel blessed that we get to do this!
I work with an anesthesiologist. I am the better diagnostician. He is better with airway and acute. He has more experience with procedures (been doing it longer). Most of his procedural skills were picked up AFTER his fellowship where he basically learned bread and butter stuff. His departmental partners have threatened to quit working with him because of me. I am publishing, teaching and presenting - but their sitting on their anesthesiology butts is supposed to make them better than me.
Now that is a bit of sour grapes-but my point is that it is really valuable to be truly multidisciplinary in this area because we all bring different stuff to the table. Can't we break bread and swill wine together and feel blessed that we get to do this!
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Pain medicine has been, and will continue to be a field dominated by anesthesiologists. PM&R pain physicians will become a rare breed. Most of the PM&R fellowships with few exceptions will disappear in the near future.
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Short of fudging, it seems difficult to imagine how any program could meet the requirements from a distance. Three years ago, Drs. Furman and Larry Frank "discussed" how a program could meet the then proposed requirements - Dr. Frank argued it was simply not feasible. Dr. Furman argued that the requirements spoke of exposure, not experience, in all of the different disciplines (wink wink, nod nod, say no more). It appears that loophole was closed prior to the requirements being finalized.
If a program were to claim they were abiding by the requirements, and then was found to not be doing so, but only claimed to to continue to be accredited, I suspect the fellows' accreditation and ability to sit for boards, in addition to the fellowship's accreditation, might be in serious jeopardy
ACGME Program Requirements for Fellowship Education in Pain Medicine (Effective: July 1, 2007)
Scope and Duration of Education
I. Institutions
B. Participating Sites
3. Only multidisciplinary programs will be accredited. A program in pain medicine will be accredited only if it is conducted in an institution that also sponsors residencies accredited by the ACGME in at least two of the following specialties: anesthesiology, neurology, physical medicine and rehabilitation, and psychiatry.
4. There must be an institutional policy governing the educational resources committed to pain medicine that ensures cooperation of all the involved disciplines. There may be only one ACGME-accredited pain medicine program within a sponsoring institution, and a single multidisciplinary fellowship committee to regularly review the program's resources and its attainment of its stated goals and objectives.
4. There must be an institutional policy governing the educational resources committed to pain medicine that ensures cooperation of all the involved disciplines. There may be only one ACGME-accredited pain medicine program within a sponsoring institution, and a single multidisciplinary fellowship committee to regularly review the program's resources and its attainment of its stated goals and objectives.
3. Clinical
Patient Population (Clinical Resources)
There should be, within the patient population, a wide variety of clinical pain problems. Such exposure is necessary for the development of broad clinical skills and knowledge required for a specialist in pain medicine. The program must be able to provide each fellow with the following clinical experiences:
a) continuity of care (longitudinal outpatient experience), including the managing chronic and cancer pain;
b) inpatient experience, including managing chronic and cancer pain;
c) experience managing acute pain;
d) exposure to interventional pain procedures; and,
e) a palliative care experience (longitudinal involvement with patients with pain who require palliative care).
Patient Population (Clinical Resources)
There should be, within the patient population, a wide variety of clinical pain problems. Such exposure is necessary for the development of broad clinical skills and knowledge required for a specialist in pain medicine. The program must be able to provide each fellow with the following clinical experiences:
a) continuity of care (longitudinal outpatient experience), including the managing chronic and cancer pain;
b) inpatient experience, including managing chronic and cancer pain;
c) experience managing acute pain;
d) exposure to interventional pain procedures; and,
e) a palliative care experience (longitudinal involvement with patients with pain who require palliative care).
The program must integrate the following ACGME competencies into the curriculum:
a) Patient Care
Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows:
Fellows must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Fellows:
(1) will enter the fellowship in pain medicine with a range of different experiences. The pain medicine program must demonstrate separate, identifiable clinical experiences that provide the elements from medical disciplines essential to the practice of pain medicine. The clinical experience within the four disciplines outlined below may take the form of discrete clinical rotations, or may occur concurrently with the core clinical curriculum. This fellowship will vary from institution to institution based on the interests and expertise of the faculty who work directly in the pain clinic. The training experience must be provided by the pain medicine program and acquired by the fellow over the course of the program. The program must provide each fellow distinct clinical experience in each of the disciplines listed, with the exception of the fellow's primary discipline. The principal multidisciplinary elements of pain medicine education from the disciplines relevant to pain medicine are as follows:
(a) Anesthesiology
The fellow will demonstrate competency in:
The fellow will demonstrate competency in:
(i) obtaining intravenous access in a minimum of 15 patients;
(ii) basic airway management, including a minimum of mask ventilation in 15 patients and endotracheal intubation in 15 patients;
(iii) provider course in basic life support and advanced cardiac life support;
(iv) management of sedation, including direct administration of sedation to a minimum of 15 patients; and,
(v) administration of neuraxial analgesia, including placement of a minimum of 15 thoracic or lumbar epidural injections using an interlaminar technique.
(b) Neurology: The fellow shall be able to elicit a directed neurological history, perform a detailed neurological examination to include at least mental status, cranial nerves, motor, sensory, reflex, cerebellum examinations, and gait in fifteen patients. Faculty shall verify this experience in a minimum of five observed patient examinations. The fellow shall also become familiar with basic neuro-imaging, and identify significant findings, to include at least MR and CT of the spine and brain on a minimum of 15 CT and/or MRI studies drawn from the examples within the following areas: brain, cervical, thoracic, and lumbar spine. The fellow shall have an understanding of the indicators and interpretation of electro-diagnostic studies;
(ii) basic airway management, including a minimum of mask ventilation in 15 patients and endotracheal intubation in 15 patients;
(iii) provider course in basic life support and advanced cardiac life support;
(iv) management of sedation, including direct administration of sedation to a minimum of 15 patients; and,
(v) administration of neuraxial analgesia, including placement of a minimum of 15 thoracic or lumbar epidural injections using an interlaminar technique.
(b) Neurology: The fellow shall be able to elicit a directed neurological history, perform a detailed neurological examination to include at least mental status, cranial nerves, motor, sensory, reflex, cerebellum examinations, and gait in fifteen patients. Faculty shall verify this experience in a minimum of five observed patient examinations. The fellow shall also become familiar with basic neuro-imaging, and identify significant findings, to include at least MR and CT of the spine and brain on a minimum of 15 CT and/or MRI studies drawn from the examples within the following areas: brain, cervical, thoracic, and lumbar spine. The fellow shall have an understanding of the indicators and interpretation of electro-diagnostic studies;
(c) Physical Medicine & Rehabilitation: The curriculum should be designed to emphasize the performance of a comprehensive musculoskeletal and appropriate neuromuscular history and examination with emphasis on both structure and function as it applies to diagnosing acute and chronic pain problems and developing rehabilitation programs for them. This should include assessments of static and dynamic flexibility, strength, coordination and agility for peripheral joint, spinal, and soft tissue pain conditions. Fellows should gain an understanding of the natural history of various musculoskeletal pain disorders and be able to appropriately integrate therapeutic modalities and surgical intervention in the treatment algorithm. The fellow shall have an understanding of the indicators and interpretation of electro-diagnostic studies. Fellows must gain significant hands-on experience in the musculoskeletal and neuromuscular assessment of 15 patients, and demonstrate proficiency in the clinical evaluation and rehabilitation plan development of a minimum of five patients; and,
(d) Psychiatry: The fellow must carry out a complete psychiatric history with special attention to psychiatric and pain comorbidities, must conduct a complete mental status examination on a minimum of 15 patients, and must demonstrate this ability in five patients to a faculty observer. The program should provide educational experience in frequent psychiatric and pain co-morbidities, which include substance-related, mood, anxiety, somatoform, factitious, and personality disorders. The program should also provide educational experience in the effects of pain medications on mental status. The fellow must understand the principles and techniques of the psychosocial therapies, with special attention to supportive and cognitive behavioral therapies, sufficient to explain to a patient and make a referral when indicated. Faculty must be psychiatrists or clinical psychologists who have documented experience in the evaluation and treatment of patients with chronic pain.
(2) must have education in specific areas of pain medicine practice, and many of these experiences will be undertaken in parallel. As an example, the continuity experience will often be carried out while trainees are also gaining experience with inpatients and acute pain patients. The minimum time requirements apply to areas of practice that do require a minimum length of time to gain perspective on pain care.
(a) Continuity experience will provide the fellow with supervised experience in the ongoing management of a diverse population of patients with chronic pain, including cancer pain. The experience must allow interaction with other specialists in a multidisciplinary model of chronic pain management. To this end, the pain medicine fellow must attend a supervised outpatient clinic, approximately weekly, throughout the year of the program. Fellows may be absent from continuity clinic experience only if the rotation site is more than one hour from the core institution. The maximum allowable time away may be no more than four months. This will provide a minimum of eight months experience (full-time equivalent of at least 60 half-days). Primary responsibility for 50 different patients followed over at least two months each must be documented.
(b) Inpatient chronic pain experience must be supervised on a pain team responsible for the assessment and management of inpatients with chronic pain including cancer pain. Patients may be seen through either a consultation team or while on a designated inpatient pain medicine service. To establish this experience, the fellow must document involvement with a minimum of 15 new patients assessed in this setting.
(c) Acute pain inpatient experience must be supervised in the assessment and management of inpatients with acute pain. To establish this experience, the fellow must document involvement with a minimum of 50 new patients.
(d) Interventional experience must be supervised, and the objectives include understanding the selection criteria for a broad range of interventions, understanding the risks and potential advantages of these interventions,
and obtaining exposure to the technical components involved in these interventions. It may be integrated with continuity experience or inpatient experience. To establish this experience, the fellow must document involvement with a minimum of 25 patients who undergo interventional procedures.
(e) Cancer pain experience must be a supervised, longitudinal experience in an ambulatory or inpatient population who requires care for cancer pain, and may be integrated with continuity or inpatient experiences. The objectives should include:
(g) Experience with the assessment and treatment of pain in children is strongly encouraged.
(h) Some programs will have faculty with extensive expertise in interventional pain medicine, and such programs are encouraged to provide an
expanded didactic and clinical experience in interventional pain medicine. Those programs offering advanced education in interventional pain medicine shall be required to demonstrate that they provide substantial supervised clinical experience in addition to that required within the core curriculum.
(b) Inpatient chronic pain experience must be supervised on a pain team responsible for the assessment and management of inpatients with chronic pain including cancer pain. Patients may be seen through either a consultation team or while on a designated inpatient pain medicine service. To establish this experience, the fellow must document involvement with a minimum of 15 new patients assessed in this setting.
(c) Acute pain inpatient experience must be supervised in the assessment and management of inpatients with acute pain. To establish this experience, the fellow must document involvement with a minimum of 50 new patients.
(d) Interventional experience must be supervised, and the objectives include understanding the selection criteria for a broad range of interventions, understanding the risks and potential advantages of these interventions,
and obtaining exposure to the technical components involved in these interventions. It may be integrated with continuity experience or inpatient experience. To establish this experience, the fellow must document involvement with a minimum of 25 patients who undergo interventional procedures.
(e) Cancer pain experience must be a supervised, longitudinal experience in an ambulatory or inpatient population who requires care for cancer pain, and may be integrated with continuity or inpatient experiences. The objectives should include:
(i) the understanding of a clinical approach to the treatments that comprise multidisciplinary cancer pain care, and
(ii) the understanding of strategies to integrate pain management into the treatment model. The fellow must document longitudinal involvement with a minimum of 20 patients.
(f) Palliative care must be a supervised longitudinal experience in an ambulatory or inpatient population that requires palliative care. The experience will include understanding a clinical approach to the multi-dimensional treatments that comprise palliative care, and an understanding of strategies to integrate pain management into this multi-dimensional treatment model. It may be integrated with continuity experience or inpatient experience. To establish this experience, the fellow must document longitudinal involvement with a minimum of 10 patients who require palliative care.(ii) the understanding of strategies to integrate pain management into the treatment model. The fellow must document longitudinal involvement with a minimum of 20 patients.
(g) Experience with the assessment and treatment of pain in children is strongly encouraged.
(h) Some programs will have faculty with extensive expertise in interventional pain medicine, and such programs are encouraged to provide an
expanded didactic and clinical experience in interventional pain medicine. Those programs offering advanced education in interventional pain medicine shall be required to demonstrate that they provide substantial supervised clinical experience in addition to that required within the core curriculum.
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Actually, physiatrists were doing chronic pain management long before anesthesiologists got into the game.
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You mean prescribing PT and OT for patients in chronic pain.
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Actually, treating the whole patient, not raping the healthcare system for dollars. But now there are PMR guys just as bad as the Gas guys where it is all about the money.
Chronic pain: PMR
Inpatient/Post-op pain: Anes
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Are you a Physiatrist, Paindefender?
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I think he is. He posts quite a bit on the pm&r board.
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More like
1. Treating post-op knee/spine/hip patients admitted to the rehab unit.
2. Treating phantom pain/post op pain in a new amputee.
3. Treating shoulder pain in a hemiplegic CVA patient.
4. Treating chronic neuropathic pain in a spinal cord injury patient.
5, Treating pain in a non-verbal TBI patient, that's been transferred to a rehab unit only to find out he has an unidentified fracture somewhere...(hand/forearm/ankle) or a UTI.
I never remembered as a resident calling a consult to help me out with these, until it was appropriate.
And we did a pretty good job of tapering down opiates and maximizing adjuvant medications prior to discharge instead of dumping these patients on their PCP.
Not to mention the outpatient referrals:
1. Treating nonsurgical hip/back/neck/knee/elbow/shoulder/ankle patients(with injections/medications/and YES even prescribing the appropriate PT/OT and not just "Eval and Treat")
2. Identifying peripheral neuropathies/entrapment neuropathies/radiculopathies via EMG/NCS and making recommendations.
On my fellowship interviews, I told people...I'd been a "pain physician" all along...I just hadn't realized it.
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On my fellowship interviews, I told people...I'd been a "pain physician" all along...I just hadn't realized it.
That's exactly right.
I think pain defender trolls the PM&R and his alias is probably drug dealer 3000 or whatever.
Regardless if they are one person, two people they both have nothing constructive to say. Don't bite the bait-
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I would rather work in Mcdonald's
"Short of fudging, it seems difficult to imagine how any program could meet the requirements from a distance. Three years ago, Drs. Furman and Larry Frank "discussed" how a program could meet the then proposed requirements - Dr. Frank argued it was simply not feasible. Dr. Furman argued that the requirements spoke of exposure, not experience, in all of the different disciplines (wink wink, nod nod, say no more). It appears that loophole was closed prior to the requirements being finalized.
If a program were to claim they were abiding by the requirements, and then was found to not be doing so, but only claimed to to continue to be accredited, I suspect the fellows' accreditation and ability to sit for boards, in addition to the fellowship's accreditation, might be in serious jeopardy"
I dont know what to tell you. All I know is what I heard. Perhaps you are right. Although I know that Furman seemed very positive that this was going to work out for him..."loophole" or no loophole. He had no reason to falsely be optimistic with me either. He is a very bright guy, and Im sure that if he has been through this in the past, he will be extra cautious this time around. Incidentally, the directors at this university affiliation do seem to have a good amount of political clout and do seem to be pretty "crafty" in their own right
If a program were to claim they were abiding by the requirements, and then was found to not be doing so, but only claimed to to continue to be accredited, I suspect the fellows' accreditation and ability to sit for boards, in addition to the fellowship's accreditation, might be in serious jeopardy"
I dont know what to tell you. All I know is what I heard. Perhaps you are right. Although I know that Furman seemed very positive that this was going to work out for him..."loophole" or no loophole. He had no reason to falsely be optimistic with me either. He is a very bright guy, and Im sure that if he has been through this in the past, he will be extra cautious this time around. Incidentally, the directors at this university affiliation do seem to have a good amount of political clout and do seem to be pretty "crafty" in their own right
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I don't disagree with anything you say - I would just be VERY cautious if I were an applicant, and ask lots of questions about "loopholes", and "crafty" programs, rather than ones that don't have to resort to such tactics. Afterall, Goodman's Birmingham, AL - Columbia, MO connection didn't pass the smell test with the ACGME.
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As a PM&R resident who applied to both Pain and Interventional programs this year, I definitely felt like there was discrimination, by Anesthesia pain programs, for PM&R candidates. I know, at my home institution, there is an unspoken quota for the number of PM&R candidates accepted for fellowship yearly ( 1 is the quota), and, given that the majority of Pain fellowships won't even interview PM&R candidates, that is actually pretty good. I've watched anesthesia candidates, with lesser credentials (I had good letters, research, presented a poster at a national conference, and was chief resident) obtain pain management positions with no problem. I think if you asked any PM&R resident who applied this year, they would echo my sentiment.
Now, I pose this question. Is it wrong to "look out for your own"? (e.g. Anesthesia preferring Anesthesiologists for these pain positions.) One could argue yes, given the "multidisciplinary" nature of pain management, but practically speaking, I cannot fault anesthesia for preferring its own. The problem is PM&R DOESN'T "LOOK OUT FOR ITS OWN". We dropped the ball re: pain management in the respect that we watched basically all of our pain fellowships go non-accredited, and the PM&R leadership did nothing about it.
Also, in regards to developing the Interventional Spine specialty, not much has been done: it's still not an ACGME fellowship, not enough education has been done for PCP's/Hospitals/Insurance Companies, and many times, interventional physiatrists are at the mercy of ortho for jobs/referrels. The main thing that illustrates the fact that PM&R doesn't look out for its own, is the fact that, even if you did a ACGME Pain fellowship, the starting salaries are, by enlarge, lower than anesthesia ACGME Pain physicians. Why is that? Well, Anesthesia pain groups offer the anesthesiogy Pain physicians what there worth, while ortho AND PM&R groups offer lower salaries.
Face it, we did it to ourselves. I can only hope that our leadership tackles these issues in the future.
Now, I pose this question. Is it wrong to "look out for your own"? (e.g. Anesthesia preferring Anesthesiologists for these pain positions.) One could argue yes, given the "multidisciplinary" nature of pain management, but practically speaking, I cannot fault anesthesia for preferring its own. The problem is PM&R DOESN'T "LOOK OUT FOR ITS OWN". We dropped the ball re: pain management in the respect that we watched basically all of our pain fellowships go non-accredited, and the PM&R leadership did nothing about it.
Also, in regards to developing the Interventional Spine specialty, not much has been done: it's still not an ACGME fellowship, not enough education has been done for PCP's/Hospitals/Insurance Companies, and many times, interventional physiatrists are at the mercy of ortho for jobs/referrels. The main thing that illustrates the fact that PM&R doesn't look out for its own, is the fact that, even if you did a ACGME Pain fellowship, the starting salaries are, by enlarge, lower than anesthesia ACGME Pain physicians. Why is that? Well, Anesthesia pain groups offer the anesthesiogy Pain physicians what there worth, while ortho AND PM&R groups offer lower salaries.
Face it, we did it to ourselves. I can only hope that our leadership tackles these issues in the future.
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NOPE: Rathmell did it to us and pre-selected our member at the RRC-PIF rewrite committee. I do not believe a PD from an accredited PMR program was invited.
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Wasn't our RRC rep Barry Smith? I thought he was both PD and Chair at Baylor Dallas.
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There is no ACGME spine surgical certification, so don't expect there to be a spine certification for Physiatry. It appears that the PM&R leadership is going for the next best thing (read mission statement of PASSOR), which is not necessarily based on the fellowship model, but does require and somewhat of an overhaul of typical PM&R residency training.
Regarding starting salaries, you have to look at the specifics of typical practice models. Surigical groups will offer lower salaries by default, so that lowers the average when taking into account all the Physiatrists who are going to sign up with surgical groups.
Many anesthesia groups will provide both pain management as well as OR coverage. As a Physiatrist, you can't participate in that part of the equation, and thus generate less income. You may be able to make up some of that with EMGs, but that's if the group wants that to be a component of the practice.
Finally, stand alone PM&R MSK/Spine practices generally have lower procedural volume as well as procedural diversity compared to typical interventional pain practices. There is less of a chance that the PM&R group will have shares in a facility.
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Clubdeac and other residents are freaked out about this because when youre in residency, the sky is always falling.
FYI-short version-In the 1990s, Physiatrists began to focus on non-operative management of orthopedic conditions, a bulk of which was spine with spinal injections. This was all fine, until utilization for pain procedures skyrocketed, in part due to high volume spine centers, as well as other physicians getting all their training through weekend courses.
The academic pain programs said, What the *$#%!, this has got to stop or the specialty is ruined. Thus, the ACGME reforms. Which, as they as written, do have some unrealistic goals but good intentions behind them, but, yes, the 1 fellowship per institution thing is a purely political move.
At this point, the ABPMR should have looked things over and said fine and then gone off and done their own thing. I think they are finally starting to realize this and are acting accordingly. Either that or the membership complained.
So, this is not really about Pain Medicine. Its about control of procedures. Unless you want to stop all other physicians from prescribing opiates as well. Im all for PM&R reforms in parallel to the ACGME pain reforms. Its a win-win situation. Physiatrists (who over the past 15+ years have become an intergral part of the care of those with non-surgical musculoskeletal/orthopedic conditions) are able to protect themselves while the number physicians getting all their training from weekend courses is decreased.
Final comment about Pain Medicine. The current fellowship model is kind of like our healthcare system in general, trying to put a band-aid on something that instead needs an overhaul. In most community settings, Physiatrists and Pain Physicians co-exist peacefully and there is definitely enough work for everybody. Higher standards for both pain medicine and Interventional Physiatry would be ideal.
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Is there a way to tell this to the anesthesiologists in my town? When I came to town, I was the first PM&R to ask for interventional procedures at local hospitals. You would have thought it was the same as an FP asking to do cardiothoracic surgery! After many letters of support and other documentation, they finally gave it to me.
Two years later I asked to add another procedure, suddenly it was the same thing all over again. Once hospital even decided it needed to form a new committee to look at pain credentialing - amazingly only anesthesiologists on it...
Now, I'm not fellowship trained, but neither are 5 / 8 anesthesiologists here who practice pain. There is definately bias against PM&R here among the gas guys. The rest of the community appears to like me, however.
On a different note, I've talked to several PM&Rs for a position we're looking for. All did supposed fellowships, all non-ACGME. All but one do no more procedures than I do, one appears to do fewer than I. What this tells me is these PM&R non-ACGME programs they went to are not accredited for a reason - they're basically doing a year-long apprenticeship, picking up what they can.
Here's a question - if PM&R had more (any?) ACGME-accredited programs, would they give equal weight to an anesthesia applicant? I bet the bias would go the other way.
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Interesting...were these non-accredited fellowship "pain fellowships" or MSK/Spine? Any PASSOR-recognized programs?
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Not sure - none have gotten far enough for us to check - one not interested enough in the other (us or them) to warrant further investigation. Good questions to keep in mind, though.
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I think the best thing for PM&R is to develop the interventional spine with standards such that it can become an ACGME accredited fellowship. This would entail convincing the powers that be that interventional spine physicians are the experts of non-surgical neck/back pain, but maybe saying that ACGME Pain programs are experts in more esoteric/complex types of conditions (e.g. CRPS, Cancer pain, etc.) and maybe higher level procedures such as SCS and pumps.
I know that anesthesia groups always use the excuse that they pay anesthesia pain doctors more because of the ability to cover the OR, but knowing many anesthesia pain grads, most of them are doing strictly pain without OR or call coverage, and still getting offered more than their PM&R counterparts. So, although a good excuse, still an excuse. The point I was trying to make is that the PM&R groups try to lowball their own pain grads, even though PM&R pain grads can do pain procedures and EMG, not to mention good non-procedural management.
Also, I don't think the statement can be made that stand alone PM&R interventional spine practices have less procedural volume than anesthesia pain practices. You're right, they may have less procedural diversity, but I wouldn't think less procedural volume OR profitability. Tell that to Furman, Cano, Slipman, et.. Too many market factors are at work to make that statement.
Bottom line is, PM&R should focus its energy on taking care of its own, and not lowballing its own grads.
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I don't think it is lowballing, I think it is simple economics - stims, discos, veterbros, kypohos, and PDDs simply pay more, and it is not unreasonable to pay docs who can do those procedures more than docs who simply do bread and butter procedures.
Now if a PM&R doc can DO those procedures, then he should absolutely be pain at a rate equal to his anesthesia colleague - if not, then the differential is justified.
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That likely had to do with you being the first and those in charge unsure about how to judge your qualifications. As you've stated, eventually, they did give you priviledges. I think it's much worse in many academic institutions. Where I did residency, no one is allowed to do procedures (pain boarded or not) except faculty of the pain clinic.
Really, I think it's all about building relationships. Remember, Neurosurgeons were the first to do implants and had to agree (over time) for others to start coming into the OR. It looks like you've built those types of relationships in your community.
Regarding, the Physiatrists you're considering hiring, you have to remember, most PM&R fellowship aren't really pain fellowships. If they were, their scope would reach beyond orthopaedic conditions of the spine. I'd say they're Orthopaedically based fellowships supplemented by some spinal injections (what PM&R residency training is morphing into). I think the ABPMR has finally come to terms with this and is planning to certify accordingly.
You're probably right that if PM&R had more ACGME certified programs of any kind, the bias would likely go the other way. Then again, if you're going to promote/tout the "multi-disciplinary" approach and make it a rule, then it is implied (good faith effort) that your trainees are "multi-disciplinary". If not, then leave things segregated and let everybody go about their business.
This was the whole justification behind shutting down PM&R pain fellowships. "Why have more than one fellowship per institution if one of them is already multidisciplinary?
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This was already considered by the PM&R leadership several years ago and found to be unfeasible. The choices are to promote non-operative spine specialists vs. specialists in the evaluation/management of the broad range of non-surgical orthopedic conditions. The PM&R leadership chose option B, maybe out of convenience, maybe because they thought it was the best decision. I don't necessarily agree with you regarding pumps/stims, as they are frequently used in community settings to treat chronic spinal pain. So long as proper training standards are implemented, I don't see why they shouldn't be part of spine fellowships.
I stand by my statement that stand alone PM&R groups/solo practices likely bring in, on the average, lower revenue (from procedures) due to lower procedural volume as well as procedural diversity.
If you open a rural practice, sure, you may able to get all the referrals for a large volume of basic injections. If you are setting up in any semi-populated area, you're going to be competing with all other interventionalists for these basic injections, while the other practicioners may be doing advanced stuff as well. I do know Physiatrists who were able to set up high volume bread & butter procedural practices in populated areas. However, that was 8-10 years ago and there are many more interventionalists now.
I believe Furman's group includes surgeons and anesthesiologists and Slipman is in an academic spine center (surgeon referrals) and has fellows who work pretty hard to generate all those injections, so these examples don't really apply. Cano I know nothing about.
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Oh, I get you. I don't know then. That's the good thing and the bad thing about medicine. Its great from a business point of view because it has high barriers to entry. Unfortunately if the landscape changes there are prohibitive switching costs. Good luck with your fight. With all the external forces squeezing medicine we are all being reduced to cannibalism. I'm just wondering what is going to tank anesthesiology!
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The other option is to equip Physiatry residency graduates with appropriate skills and training during their 4 year residencies that actually allows them to do what the specialty says it does in lieu of an "interventional spine fellowship:" Provide comprehensive non-operative MSK/Spine care including basic neuraxial procedures.
Pumps, stims, sympathetic blocks, etc clearly require a level of training and breadth and scope that even some anesthesia residency and even NEUROSURGERY programs lack so I think it is completely unreasonable to expect this from all but the most exceptional physiatry departments.
What most aspiring "interventional spine physiatrists" really want is to be competent in basic appendicular joint injections, SIJ, lumbar facets, and lumbar ESI procedures. These skills, combined with EMG and good MSK training would equip physiatry residency graduates to meet the needs of more than 80% of spine/MSK problems over and beyond what primary care does. What is really lacking is the will on the part of program directors, courage of conviction by ABPMR to ensure "truth in advertising", and institutional muster by department chairs to make these changes a part of the general PM&R curriculum.
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A. It would be a turf war with every anesthesia department at every institution
B. The gray-hairs on the board still believe that our mission remains inpatient first, EMG second and MSK third. Interventions are an afterthought
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I meant for that to be part of Option B. Of course, there has to be a transition period when programs are given time to get up to snuff, and for this reason I think MSK/Spine fellowships should linger on for a while longer. I think the ABPMR knows this and is planning on certifying in this manner (The New Physiatry, PM&R 2K, improved academy, new journal, etc.) not creating any kind of new sub-specialty. I'd heard some things. Maybe I should e-mail Barry Smith about this. Then again, maybe we're not supposed to know about any of it because it's still hearsay, like Kobe Bryant to the Bulls or who's gonna buy the Cubs.
I think learning about pumps/stims is entirely reasonable for most Interventional Physiatrists. In many cases we're going to end up refilling them, right? May as well learn about complications, med titration, etc. And what about all those spastic patients we're supposed to be helping as Physiatrists. That's fine if a Physiatrist has no intention of ever doing an implant, but we should at least know how to trial people. I was asked to supervise trials of intra-thecal Baclofen many times as a PGY-2 (inpt rehab), so it's only one additional step, and should be well within the scope of someone who has demonstrated proficiency in basic neuraxial injections.
Sympathetic Blocks? I thought injections like Stellates were some of the bread n' butter injections offered by academic pain clinics before the days of fluoro.
