Pritzlaff's Doximitry Op_Ed on Pain Fellowship Match

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Op-Med

AAPM 2025: A Pivotal Meeting at a Pivotal Time for Pain Medicine​

By Scott G Pritzlaff, MD
April 14, 2025Original article
Original conference perspectives by Doximity members are published on Op-Med
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The 2025 American Academy of Pain Medicine (AAPM) Annual Meeting in Austin (April 3-6, 2025), with the theme PainConnect: Transforming Pain Care Together, came at a critical inflection point for the field. As our specialty faces a series of interconnected challenges, ranging from recruitment and workforce shortages to evolving clinical demands, this year’s meeting offered a timely and much-needed recalibration.

What stood out most was the meeting’s deliberate focus on foundational topics. Rather than centering solely on the latest devices or interventions, there was a strong and thoughtful emphasis on themes including medical education, buprenorphine treatment, peripheral neuropathy, imaging in pain diagnostics, and chronic headache care. These areas are cornerstones of modern pain practice and touch the lives of many of our patients. Re-centering on these core issues reminds us that cutting-edge care isn’t limited to what’s new—it also demands mastery of what’s essential.

Of note, were the sessions focused on education and workforce challenges. Pain medicine faces a recruitment lull unlike anything we’ve seen in over a decade. As detailed in our recent editorial, this year’s ACGME fellowship match left nearly 70 positions unfilled, with only 67.7% of programs successfully matching all offered positions. For a field that has historically been highly competitive, this represents a concerning shift—and a call to action.

And yet, amid these recruitment challenges, we are also witnessing an encouraging and important evolution. Pain medicine is attracting an increasingly diverse group of applicants in terms of training backgrounds and clinical perspectives. While anesthesiology has long served as the primary pipeline for pain fellowship applicants, we now see significant and growing interest from physicians with primary training backgrounds in physical medicine and rehabilitation (PM&R), neurology, emergency medicine, psychiatry, and even family medicine. This diversity is a strength. It brings new approaches to clinical care, enriches interdisciplinary collaboration, and reflects the multifaceted nature of pain.

That same spirit of inclusion was evident throughout the meeting. Sessions and panels frequently featured voices from across the care continuum: primary care physicians, advanced practice providers (APPs), mental health professionals, pharmacists, physical therapists, and trainees at every level. This broad representation mirrors how pain care is delivered in real-world settings—through teamwork, integration, and shared expertise. The AAPM meeting reminded us that our specialty is no longer confined to a single background or perspective. Pain medicine today is a multidisciplinary field, and our professional community is richer and more effective because of it.

Still, diversity alone is not enough. We must also ensure that fellowship training programs and institutional structures are ready to support this broadened interest. That means adapting curricula to include outpatient-focused training, building mentorship and research opportunities, and offering visibility to students and residents much earlier in their training. Social media, educational outreach, and national society initiatives must work in parallel to communicate the value and viability of a career in pain medicine—not just for anesthesiologists but for any clinician committed to caring for complex, underserved patients.

Despite the serious challenges outlined by the match data, I left Austin with a sense of cautious optimism. AAPM 2025 didn’t shy away from difficult conversations—but it also showcased the collaborative energy and problem-solving mindset that will be critical to moving the specialty forward. We are at a pivotal moment, but we are not powerless. With strategic investment in education, workforce development, and interdisciplinary support, pain medicine can continue to evolve, grow, and meet the ever-increasing demand for compassionate, evidence-based care.

Dr. Scott Pritzlaff is an anesthesiologist and pain medicine specialist at the University of California Davis. Dr. Pritzlaff has received institutional educational grants from Abbott, Medtronic, Biotronik, and Nevro, consulting fees from SPR Therapeutics and Bioventus, and royalties from Wolters Kluwer for UpToDate.

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Maybe it's because I am not an academician, but that seems like a whole lot of words to simply say he thinks the issue is a lack of advertisement about how great pain is, instead of looking at the real reasons trainees are losing interest. While I am sure he has a great career in pain medicine as evidenced by his numerous grants and consulting fees at a big name place, most of my co-fellows who wanted to stay in cities ended up in jobs I would never consider, making less than most any anesthesiologist. Even some of my PMR trained colleagues went back to PMR due to reimbursement, insurance, market saturation etc. It seems like addressing those issues would do far more than advertising. Maybe there should even be consideration of shrinking training spots if interest is down.

My perspective is clearly limited as a brand new attending. I am interested to hear other's thoughts. But at least at my big-name training center, a lack of advertising about pain was not the issue.
 
Maybe it's because I am not an academician, but that seems like a whole lot of words to simply say he thinks the issue is a lack of advertisement about how great pain is, instead of looking at the real reasons trainees are losing interest. While I am sure he has a great career in pain medicine as evidenced by his numerous grants and consulting fees at a big name place, most of my co-fellows who wanted to stay in cities ended up in jobs I would never consider, making less than most any anesthesiologist. Even some of my PMR trained colleagues went back to PMR due to reimbursement, insurance, market saturation etc. It seems like addressing those issues would do far more than advertising. Maybe there should even be consideration of shrinking training spots if interest is down.

My perspective is clearly limited as a brand new attending. I am interested to hear other's thoughts. But at least at my big-name training center, a lack of advertising about pain was not the issue.

Saturation? Most pain docs are booked out 2-3 months. Things have only gotten worse since the Modic change epidemic and cluneal neuralgia scourge.
 
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Saturation? Most pain docs are booked out 2-3 months. Things have only gotten worse since the Modic change epidemic and cluneal neuralgia scourge.
Paradoxically you're both correct. I just signed in a "desirable" geographic area. Jobs are very hard to come by. That said, wait times for patients remains high. The only way I can think to explain it is that most doctors are unwilling to risk opening their own practice despite market conditions being favorable for doing so. Groups that are hiring then also benefit by allowing them the opportunity to both A: expand due to large patient volume and B: pay below market rates for those new docs because of the aforementioned job market.

I was very close to opening my own practice before I signed with my group which offered very fair compensation.
 
Paradoxically you're both correct. I just signed in a "desirable" geographic area. Jobs are very hard to come by. That said, wait times for patients remains high. The only way I can think to explain it is that most doctors are unwilling to risk opening their own practice despite market conditions being favorable for doing so. Groups that are hiring then also benefit by allowing them the opportunity to both A: expand due to large patient volume and B: pay below market rates for those new docs because of the aforementioned job market.

I was very close to opening my own practice before I signed with my group which offered very fair compensation.

FYI, AI is making it simple to open your own practice. These days, everything operational can be done on your phone. I mean everything: Practice management, scribe, billing, payroll, HR, compliance, account payable, compliance, on-call, etc.
 
FYI, AI is making it simple to open your own practice. These days, everything operational can be done on your phone. I mean everything: Practice management, scribe, billing, payroll, HR, compliance, account payable, compliance, on-call, etc.

I think the challenging part of opening a practice is getting on insurance panels. That was and still is my hesitation. With that being said I brought in > 800 last year so not sure why I would do it unless things change. I mean I guess the prize at the end of the tunnel/career would be to sell out to PE or something and get a big check but not sure how often that occurs for smaller solo or 2-3 doc practices.
 
Saturation? Most pain docs are booked out 2-3 months. Things have only gotten worse since the Modic change epidemic and cluneal neuralgia scourge.
I have been on the Frontlines since the mid to late 2000s fighting the scourge of society---si joint pain and cluneal neuralgia

It has been a hard endeavor all these years and it does wear on you but we keep fighting on because this new epidemic of modic changes for real
 
I think the challenging part of opening a practice is getting on insurance panels. That was and still is my hesitation. With that being said I brought in > 800 last year so not sure why I would do it unless things change. I mean I guess the prize at the end of the tunnel/career would be to sell out to PE or something and get a big check but not sure how often that occurs for smaller solo or 2-3 doc practices.
yeah that doesn't occur for smaller practices.. This PE prize that some folks see as a future certainty is really not
 
What happened to those fellowships that are outside of the ACGME? How are they doing?
 
Saturation? Most pain docs are booked out 2-3 months. Things have only gotten worse since the Modic change epidemic and cluneal neuralgia scourge.
There are certain markets that are oversaturated with pain docs, like the one I'm in. I know several docs who are working multiple jobs because they can't get busy.
 
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There are certain markets that are oversaturated with pain docs, like the one I'm in. I know several docs who are working multiple jobs because they can't get busy.
This is true for me, major metro area in the northeast. About 2.5 years in, on pace for like 7000 RVU (updated values), but at least I have schedule flexibility and do it in 3.5 days 830-4 with an hour lunch. I am working EM shifts on the side to supplement. Not complaining given the state of full time EM particularly around me.
 
How about we cut fellowship spots 30 percent.


They can work on a painresidency if they want but in the meantime let go of the cheap labor.

Soon we will see threads in here saying “I failed step 1 2 and 3 each 3 times. Didn’t do a residency, but can I get into a pain fellowship?”
 
How about we cut fellowship spots 30 percent.


They can work on a painresidency if they want but in the meantime let go of the cheap labor.

Soon we will see threads in here saying “I failed step 1 2 and 3 each 3 times. Didn’t do a residency, but can I get into a pain fellowship?”
the problem also arises from non-ACGME accredited fellowships like NASS where private practices are recruiting for 'fellowships' to bring in even cheaper labor.
 
the problem also arises from non-ACGME accredited fellowships like NASS where private practices are recruiting for 'fellowships' to bring in even cheaper labor.
That’s always been there.

My acgme paper is still worth something that a unaccredited program is never going to be able to provide.
 
How about we cut fellowship spots 30 percent.


They can work on a painresidency if they want but in the meantime let go of the cheap labor.

Soon we will see threads in here saying “I failed step 1 2 and 3 each 3 times. Didn’t do a residency, but can I get into a pain fellowship?”

Universities don’t want to cut fellowship spots because it’s giving up free money from the government and cheap labor for staffing acute pain services/giving attendings a “free NP” to see their patients for them in clinic.

Think back to your average academic pain doc - they don’t care about the future of the field as much as they care about having a Cush life.

It’s too early for us to see what happens to pain fellowships in terms of competitiveness. It will take a few years for things to settle.
 
I think it’s way less complex than written….

Anesthesia market is hot, paying extremely well.

Done.
Exactly this. Flip through gaswork or LinkedIn and the jobs that offer salary #’s are 30-40% lower than most anesthesiology jobs.

You can do a year of fellowship and come out for a PP job offer $300-375k range, with a “promise” of “building up” in 3-4 years.

Or you can take a job almost double that base in some situations right out of training.

You’re looking at a gross opportunity cost of $600-800k in most situations.
 
Im rads, but I don't get why pain isn't more popular. Seems like the income potential is massive if you scale up and own imaging centers and ASCs (yeah you need to work your tail off), and clinic visits are short, can employ midlevels, and the procedures are short and low risk (compared to a TIPS, thrombectomy, or any surgery). Seems like a great field if you're business minded
 
Im rads, but I don't get why pain isn't more popular. Seems like the income potential is massive if you scale up and own imaging centers and ASCs (yeah you need to work your tail off), and clinic visits are short, can employ midlevels, and the procedures are short and low risk (compared to a TIPS, thrombectomy, or any surgery). Seems like a great field if you're business minded
imaging centers dont make a lot of money as people assume.
Theres also large corporations and lack of familiarity with the field as well. For example, there are 5 different imaging center companies in my city that do imaging all day every day. Why would I try to compete with that rather than devote my resources to something in my lane, like more clinics and surgery centers?

Both the cost of an imaging center or a surgery center are pretty high, and the opportunity cost that can be invested elsewhere largely can make it a wash until 12-15 years down the line.
 
Yeah - I was actually looking at anesthesiology salary data on Marit recently, and while anesthesiology overall is doing well, anesthesia pain is one of the fellowships consistently pulling higher comp than general anesthesia (cardiac being another). I know a couple of my anesthesia pain friends are clearing >$800k. Doubt compensation is the main driver behind declining interest.
 
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The upside potential of pain medicine is undoubtedly higher than anesthesia but debt-ridden residents making a decision about pain vs anesthesia aren’t thinking 5-10 years down the line.

As mentioned earlier they’re thinking 350k out of fellowship vs 500-600k out of residency.
 
The upside potential of pain medicine is undoubtedly higher than anesthesia but debt-ridden residents making a decision about pain vs anesthesia aren’t thinking 5-10 years down the line.

As mentioned earlier they’re thinking 350k out of fellowship vs 500-600k out of residency.
also avg 3-5w vacation vs 9-12w vacation. With those same salaries you mentioned. so about 2x base salary and 3x vacation
 
also avg 3-5w vacation vs 9-12w vacation. With those same salaries you mentioned. so about 2x base salary and 3x vacation

Yes no doubt. For pain - less acuity of daily work, predictable schedule, no call, no weekend, no holidays.

But most anesthesia residents don’t care for pain anyway - they want to do anesthesia. This is the perfect market for them.
 
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