PMR, Ortho, EMGs...

[pretenda]

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Do any Anesthesia trained pain guys do EMG/NCS? Im currently a gas resident and am hoping to expand my abilities before moving on to fellowship and was just wondering if anyone out there did any useful EMG, ortho, neuro or PMR rotations while they were still in residency.

 

[bedrock]

Do any Anesthesia trained pain guys do EMG/NCS? Im currently a gas resident and am hoping to expand my abilities before moving on to fellowship and was just wondering if anyone out there did any useful EMG, ortho, neuro or PMR rotations while they were still in residency.

No.

And that line of thinking is just like the other threads asking about teaching a graduated PMR doc some interventional procedures , who has no fellowship training in them at all. Not a good idea.

People who learn EMGs at a weekend course or a one-month rotation suck at them and you'll miss all kinds of diagnoses, and could be held liable.

The only way to properly learn EMGs is through a PMR residency or a EMG/neuromuscular fellowship.

IF you're a GAS resident wanting to learn some useful skills before a pain fellowship I'd recommend a month of spine surgery (including plenty of clinic time), spine or MSK radiology month, or a general ortho
clinic month, in that order.

 

[knoxdoc]

You have to go through a minimum of 3 months of formal training (we did 6-7) to have any clue how to do EMGs correctly. Many people still suck at them despite that. They are very anatomy/physiology/pathophysiology intense and it takes a long time to learn the technical components of the procedure. If you haven't done a Neuro or PMR residency and the local EMGers are aware of that, they will go out of their way to destroy your reputation with referring docs. I would forego the EMGs.

I gave an EMG talk to local PCPs and found out how difficult it was to even explain the very basics in one hour.

 

[pretenda]

interesting...thanks.

I was wondering how many months Neuro and PMR residents do of EMG to become proficient at it.

 

[Taus]

Most PM&R residences have 4-6 months and require > 200 studies. Doesn't mean that will make you proficient though. Neuro residencies are more variable with how much they do... some none...some a ton

 

[pretenda]

we basically have six elective months in our CA3 year so Im trying to think of what rotations would be best suited...Ill have already gotten a couple months of OB anesthesia, regional anesthesia, acute pain, and chronic pain done so what other rotations (6 months worth of added rotations) would be useful.

I understand you guys believe EMGs to be PMR "turf" but say you were starting a pain residency would you include these months in there? Ive seen the thread beginning to talk about a pain residency but what would you actually include rotation wise?

Anesthesia guys please chime in since we "run" 80-90% of pain departments and would probably be instrumental in starting a pain residency.

 

[bedrock]

IF you're a GAS resident wanting to learn some useful skills before a pain fellowship I'd recommend a month of spine surgery (including plenty of clinic time), spine or MSK radiology month, or a general ortho
clinic month, in that order.

.

 

[knoxdoc]

we basically have six elective months in our CA3 year so Im trying to think of what rotations would be best suited...Ill have already gotten a couple months of OB anesthesia, regional anesthesia, acute pain, and chronic pain done so what other rotations (6 months worth of added rotations) would be useful.

I understand you guys believe EMGs to be PMR "turf" but say you were starting a pain residency would you include these months in there? Ive seen the thread beginning to talk about a pain residency but what would you actually include rotation wise?

Anesthesia guys please chime in since we "run" 80-90% of pain departments and would probably be instrumental in starting a pain residency.

I think a month of EMG would be useful so that you know why its done, how its done, limitations, etc.

 

[hyperalgesia]

I agree with knoxdoc...

Also, if you do one month of it (with a qualified person), I think you will quickly realize it's not worth bringing it into your pain practice.

To do the study properly takes a LOT of time, experience, patience and concentration.

Anyone can buy a machine and stick the electrodes on and say, "Based on the numbers, the pt has carpal tunnel syndrome". But to be able to go through and eliminate elements of the DDx on the fly takes a LOT of experience.

IMHO, it's just not worth the time for you. You can do better sending your EMGs to an electromyographer and getting referrals for pain.

 

[Gauss]

for a rotation I would say EMG time would be torture. Watching EMG's is incredibly boring, I used to fall asleep. But doing them is a steep learning curve.

Do rads, look at spine imaging and MSK. Ortho, spine and sports. practice neuro exams, learn how to examine a hip and shoulder. maybe an addiction rotation

 

[Ducttape]

Neurology clinic / headache clinic.

Pm&r clinic.

MRI/ct rotation.

Spend time with practice managers of a pain clinic.

By far, in my opinion, the aspect of pain medicine that is never taught is how to start or run a business or office...

 

[emd123]

... the aspect of pain medicine that is never taught is how to start or run a business or office...

The greatest failing of all medical education. This is the reason we've completely lost our profession and are being rolled by the politicians, lawyers and insurance companies. We're all neurons and not enough backbone.

 

[pretenda]

So Spine Surgery Clinic, PMR Spine, PMR MSK, Ortho Clinic (Sports, Trauma, Etc), Radiology (Spine if feasible), Headache Clinic, possibly EMG month

My program has an intro to Anesthesiology Practice so hopefully that one helps with practice management. Appreciate the help.

 

[nvrsumr]

My fellowship(gas) was nice enugh to buy an emg machine for me(pmr) and set aside an afternoon a week to do studies. Some of the other fellows observed a few and I gave a couple powerpoints. I dont think you want /need to know much more.

 

[PMR 4 MSK]

I could teach any monkey/tech how to set up a basic UE screening exam - median and ulnar motor and sensories and a basic needle exam. I could teach them it in one weekend.

After 10 exams, they'll start to get an idea of what they are supposed to do.
After 20 exams, they'll start to see how to correct errors.
After 50 exams, they'll start to be confident in their abilities.
After 100 exams, they'll realize they know very little.
After 200 exams, they'll start to gain more confidence.
After 300 exams, they'll realize they have been missing so many things and mis-interpreting others.
After 500 exams, they'll think "Wow, I need a lot more formal training!"

EMG requires constant guidance to learn, for at least 100 hand-on cases, and at least 100 more cases reviewed. And then you are safe enough to diagnose many cases of CTS. Do a few hundred more and we'll let you diagnose a few other things.

Seriously, I've got at least 5,000 cases under my belt, and I'm still learning things all the time, and seeing things that make me go "WTF is that?"

 

[PMR2008]

I could teach any monkey/tech how to set up a basic UE screening exam - median and ulnar motor and sensories and a basic needle exam. I could teach them it in one weekend.

After 10 exams, they'll start to get an idea of what they are supposed to do.
After 20 exams, they'll start to see how to correct errors.
After 50 exams, they'll start to be confident in their abilities.
After 100 exams, they'll realize they know very little.
After 200 exams, they'll start to gain more confidence.
After 300 exams, they'll realize they have been missing so many things and mis-interpreting others.
After 500 exams, they'll think "Wow, I need a lot more formal training!"

EMG requires constant guidance to learn, for at least 100 hand-on cases, and at least 100 more cases reviewed. And then you are safe enough to diagnose many cases of CTS. Do a few hundred more and we'll let you diagnose a few other things.

Seriously, I've got at least 5,000 cases under my belt, and I'm still learning things all the time, and seeing things that make me go "WTF is that?"

Very true. I am at 200 and only now are things starting to make sense and I have a lot more confidence in my studies. I feel like I have a long way to go just like you said. Seeing a few emgs, doing a presentation, spending a month in an EMG lab etc are all barely good enough just to know when it is appropriate to order EMGs.

 

[Jcm800]

so what i took away from this, is if i do a weekend course, im good to go, right?

I could teach any monkey/tech how to set up a basic UE screening exam - median and ulnar motor and sensories and a basic needle exam. I could teach them it in one weekend.

After 10 exams, they'll start to get an idea of what they are supposed to do.
After 20 exams, they'll start to see how to correct errors.
After 50 exams, they'll start to be confident in their abilities.
After 100 exams, they'll realize they know very little.
After 200 exams, they'll start to gain more confidence.
After 300 exams, they'll realize they have been missing so many things and mis-interpreting others.
After 500 exams, they'll think "Wow, I need a lot more formal training!"

EMG requires constant guidance to learn, for at least 100 hand-on cases, and at least 100 more cases reviewed. And then you are safe enough to diagnose many cases of CTS. Do a few hundred more and we'll let you diagnose a few other things.

Seriously, I've got at least 5,000 cases under my belt, and I'm still learning things all the time, and seeing things that make me go "WTF is that?"

 

[Jcm800]

ive said this before, for pain management, EMGs are dumb, and grossly over-utilized because the doc who is seeing the patient with an obvious huge L5-S1 disc and PE exam findings that correlate, knows how to do it...

for other issues, neurological or otherwise, EMG can be reasonable, but the PMR guys that i know that do pain, all get EMGs before they inject, however obvious. Why? because they can...the same with the Neuro docs that send me a patient for the injection, AFTER the EMG, all when it is obvious...

in weird, confusing cases, maybe. but run of the mill? please.
now will follow all the responses from the various PMR docs about how THEY are different, their studies are quality, etc...

its the same as the anesthesia pain guys who will give a sciatic block for "sciatica", or a series of three ESIs, equally dumb.

as the reimbursement goes down, we will see less EMGs also...

 

[PMR2008]

ive said this before, for pain management, EMGs are dumb, and grossly over-utilized because the doc who is seeing the patient with an obvious huge L5-S1 disc and PE exam findings that correlate, knows how to do it...

for other issues, neurological or otherwise, EMG can be reasonable, but the PMR guys that i know that do pain, all get EMGs before they inject, however obvious. Why? because they can...the same with the Neuro docs that send me a patient for the injection, AFTER the EMG, all when it is obvious...

in weird, confusing cases, maybe. but run of the mill? please.
now will follow all the responses from the various PMR docs about how THEY are different, their studies are quality, etc...

its the same as the anesthesia pain guys who will give a sciatic block for "sciatica", or a series of three ESIs, equally dumb.

as the reimbursement goes down, we will see less EMGs also...

I am not going to pretend to speak on behalf of all the electromyographers but in my practice EMGs have a role. EMGs can help differentiate plexopathies vs radiculopathies vs mypathies vs malingring vs mononeuropathies vs peripheral neuropathies vs chronicity when the symptoms, imaging and at times exam findings might be similar. I have always been taught that EMG is like an extension of the physical examination and not an alternative. There is no such thing as a cookie cutter EMG and it is a very dynamic test. I am sure PMR 4 MSK would have a lot more practical examples than I do. Just like any procedure, in the wrong hands and for monetary gain there is potential for abuse. So your statement "for pain management, EMGs are dumb" is an obvious over exaggeration and ignorant.

 

[Jcm800]

[ So your statement "for pain management, EMGs are dumb" is an obvious over exaggeration and ignorant.[/QUOTE]

you must be a dumb EMGer....


How about i fix my statement, ROUTINE use of EMG in pain management is dumb...
which is what i said in the body of my post. if there is some question, then maybe, bu i am talking about the "every patient that needs an injection, gets an EMG" practice that i think is crazy.

I also think that those that say EMGs are an extension of the exam are full of BS... its a saying that makes an EMG justifiable in anyone.

 

[PMR 4 MSK]

so what i took away from this, is if i do a weekend course, im good to go, right?

Yes, you can start doing them and billing for them. And if you do enough of them, in a few years, you might start getting correct diagnoses and not miss the important things. Assuming you also take refresher courses and read a lot.

ive said this before, for pain management, EMGs are dumb, and grossly over-utilized because the doc who is seeing the patient with an obvious huge L5-S1 disc and PE exam findings that correlate, knows how to do it...

for other issues, neurological or otherwise, EMG can be reasonable, but the PMR guys that i know that do pain, all get EMGs before they inject, however obvious. Why? because they can...the same with the Neuro docs that send me a patient for the injection, AFTER the EMG, all when it is obvious...

in weird, confusing cases, maybe. but run of the mill? please.
now will follow all the responses from the various PMR docs about how THEY are different, their studies are quality, etc...

its the same as the anesthesia pain guys who will give a sciatic block for "sciatica", or a series of three ESIs, equally dumb.

as the reimbursement goes down, we will see less EMGs also...

Agreed, EMGs are useless for pain. When someone is sent to me for EMG and the primary complaint is pain, not numbness or tingling, it is almost universally normal.

The point of an EMG is to either confirm or deny the presumptive diagnosis of nerve or muscle injury, not to go on a hunt for a mystery diagnosis. Sometimes odd things come up, but that's the exception. The correct use of EMG is "Is this CTS?" or "This patient presents with generalized weakness and has a high CPK. Is this myopathy?"

EMG has little role for Radiculopathy. Symptoms and MRI generally suffice for the dx. Sometimes, we find that instead of CTS, the pt has an acute radic, or vv.

 

[knoxdoc]

Mondays suck.

 

[Jcm800]

Yeah!!!! FOCK YOU TOO!!! who wants some!?!? who's next!!!! hahaha.
i dont think its mondays, but monday-fridays hahah



everyone, please note the wild orchid....

you must be a dumb EMGer....


How about i fix my statement, ROUTINE use of EMG in pain management is dumb...
which is what i said in the body of my post. if there is some question, then maybe, bu i am talking about the "every patient that needs an injection, gets an EMG" practice that i think is crazy.

I also think that those that say EMGs are an extension of the exam are full of BS... its a saying that makes an EMG justifiable in anyone.

Take an extra long road ride today - lots of hills/intervals. Mondays are getting to you man.[/QUOTE]

 

[101N]

ive said this before, for pain management, emgs are dumb, and grossly over-utilized because the doc who is seeing the patient with an obvious huge l5-s1 disc and pe exam findings that correlate, knows how to do it...

For other issues, neurological or otherwise, emg can be reasonable, but the pmr guys that i know that do pain, all get emgs before they inject, however obvious. Why? Because they can...the same with the neuro docs that send me a patient for the injection, after the emg, all when it is obvious...

In weird, confusing cases, maybe. But run of the mill? Please.
Now will follow all the responses from the various pmr docs about how they are different, their studies are quality, etc...

Its the same as the anesthesia pain guys who will give a sciatic block for "sciatica", or a series of three esis, equally dumb.

As the reimbursement goes down, we will see less emgs also...

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