Realistic? Radiologists pursuing ACGME Pain Fellowship?

[xbox]

I'm finishing up a Neuroradiology Fellowship and was interested in Pain Management. I can hear the groans already, but hopefully someone will hear me out 🙂.

The pain experience that I received during fellowship -- if you can call it that -- consisted of mainly injecting sites that the orthopods or neurosurgeons wanted injected.

I want to be more comprehensive than that. I would like to be able to workup a de novo patient from start to finish. I hate the notion of injecting someone and sending them back to the referring doc for further management. It's very unsatisfying.

So, how realistic is it for a radiologists to enter a ACGME Pain fellowship? I don't know of any unfortunately.

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[lobelsteve]

None.

But there is a house in New Orleans.....

Charles April.

 

[drusso]

I'm finishing up a Neuroradiology Fellowship and was interested in Pain Management. I can hear the groans already, but hopefully someone will hear me out 🙂.

The pain experience that I received during fellowship -- if you can call it that -- consisted of mainly injecting sites that the orthopods or neurosurgeons wanted injected.

I want to be more comprehensive than that. I would like to be able to workup a de novo patient from start to finish. I hate the notion of injecting someone and sending them back to the referring doc for further management. It's very unsatisfying.

So, how realistic is it for a radiologists to enter a ACGME Pain fellowship? I don't know of any unfortunately.

I think that you could totally do it. This guy did:

http://radiology.ucsd.edu/faculty_staff/wwong.html

The new ACGME criteria state that base training in *ANY* specialty is acceptable. Can't wait until the pathologists and rad oncs start applying...

 

[emd123]

I'm finishing up a Neuroradiology Fellowship and was interested in Pain Management. I can hear the groans already, but hopefully someone will hear me out 🙂.

The pain experience that I received during fellowship -- if you can call it that -- consisted of mainly injecting sites that the orthopods or neurosurgeons wanted injected.

I want to be more comprehensive than that. I would like to be able to workup a de novo patient from start to finish. I hate the notion of injecting someone and sending them back to the referring doc for further management. It's very unsatisfying.

So, how realistic is it for a radiologists to enter a ACGME Pain fellowship? I don't know of any unfortunately.

Apply and see what happens. It all comes down to WHO YOU KNOW

 

[SleepIsGood]

When was the last time you did a good history and physical? Whend id you actually follow up with a patient CHRONICALLY? there's a personality trait inherent in you that made you do Rads. Not a bad thing, jus different from what it takes to see CHRONIC pain patients.

Who else is going to want to do pain? Like someone said pathologists? podiatrists? Where does it stop? LESIs by dentists?

 

[Aether2000]

Agree with Sleep is Good...why would you want to do that? The vast majority of radiologists are excellent technicians and very poor clinicians. You would be swimming upstream against the training of your own specialty, and unless you plan on specializing in pain medicine (unlikely having completed a neurorad fellowship), why bother with changing your entire field of medicine?

 

[geauxg8rs]

I think we are being a little harsh on our shadow chasing friend. The same questions sould apply to any of the gas passers (myself included). Why do you want to leave the comfort of the OR for the pain clinic? There is no chronic patient in gas either. I chose gas cause I wanted the furthest thing from clinic after exposure in med school. But in gas residency I felt like a technician more than a doc.
I came to realize after doing a pain rotation that what I hated was primary care but liked chronic pain (something I could help). I wouldn't be so quick to criticize the op intentions. Just my take on it.

 

[PsychoticNerve]

Ignore the haters and their unhelpful comments.

I know of one psychiatrist who did an ACGME accredited interventional pain fellowship and has a thriving practice.

I also know one internist who also did the same and is quite good with the needle and also has a thriving practice.

By all means, apply. As long as your board scores are good, you will be looked at.

 

[SSdoc33]

the reason you dont see many radiologists in pain is because you would need to do an extra year of training and generally take a significant hit in terms of salary. more training + less money doesnt seem all that attractive. but if its what you want to do, more power to you. also, im sure you could read all of your MRIs, which would be a nice bonus.

 

[Jcm800]

at least for now, Neuro Rad is WAY better...

more money, no (less) crazies, better hours, less headaches. If you wanna do pain, do it... but i cant see how someone that was attracted to Radiology would want THIS MUCH patient care. maybe a boutique blend, but the too are opposite in spectrum.

A disagree with the anesthesia comment, we still have pre-op clinics, we still see patients pre and post-op, we still do ICU stuff and have to deal with families, we and do pain rotations. Im not starting the which pathway is better (PMR is, hahah) im just saying that anesthesia is not devoid of patient contact...

but neuroradiology is awesome. Lets switch!

 

[hyperalgesia]

I'm finishing up a Neuroradiology Fellowship and was interested in Pain Management. I can hear the groans already, but hopefully someone will hear me out 🙂.

The pain experience that I received during fellowship -- if you can call it that -- consisted of mainly injecting sites that the orthopods or neurosurgeons wanted injected.

I want to be more comprehensive than that. I would like to be able to workup a de novo patient from start to finish. I hate the notion of injecting someone and sending them back to the referring doc for further management. It's very unsatisfying.

So, how realistic is it for a radiologists to enter a ACGME Pain fellowship? I don't know of any unfortunately.

Pain is fairly satisfying mix of clinical evaluations and interventions, without (hopefully) the pressures of life and death patient management. Obviously it's not without its share of headaches and those are easily demonstrated on this forum. It would be cool if you could moonlight a little during fellowship to keep the money flowing and the rad skills alive. I think you would certainly be considered with your unique perspective and skill set. Go for it.

 

[youngdoc8205]

I believe you can, I'm not sure if you can from neurorad though, but many an IR do an interventional pain fellowship, in fact I think coming from that training paradigm makes you better for certain things, a la cancer pain: because you have more things to offer like samarium or strontium,anesthesia can't do it b/c you have to have a certain amount of experience with it to be a certified user that you get in radiology but not in anesthesia (though I'm sure there are exceptions to the rule)


and I dare say are technically more competent (don't flame me, but pretty much all rads residents get between 6-8 months of IR including pain procedures, and with the new training where the 4th year will pretty much be a fellowship they will have that much more experience) the only thing a pain fellowship will get you is to become well-versed in non-interventional treatment of pain, which is as, or more important then the interventional stuff;


I was briefly considering this and looked into it


to the haters: don't forget whose techniques you're using to practice "your" craft
know the history of your field before you start bashing others

 

[knoxdoc]

I hate the notion of injecting someone and sending them back to the referring doc for further management. It's very unsatisfying.

I really think we have a case of "the grass is always greener" here. I'm always debating whether I can add another half day of procedures just to stay out of the office. I'll be more than happy to hang out in the procedure suite and send my patients to you for their follow up. You may change your mind in a hurry.

Here are some questions you can chew on in the mean time to get ready:

"The injection worked great for 3 weeks but then wore off. I don't want any more injections or PT or surgery. Will you prescribe my Percocet?"

"The procedure helped, but I still can't work. Will you put me on full disability?"

"That steroid injection caused me to be impotent one month later. Why did you recommend we do that?"

"I had an injection yesterday and I am much worse. I need an off work slip for two weeks and demerol, because that's the only thing that helps."

"That epidural didn't work - I still have pain shooting down my leg. Why can't you just "burn the nerves" like someone else did for my friend. She is doing great and told me that's what I really need."

"I need a repeat injection and I can't get in until Friday for a shot? What am I supposed to do until then? Why can't we do it right now?"

"My chiropractor told me if I get more than one injection my bones will all disintegrate. Do you really think we should do another one?"

 

[jettavr6]

When was the last time you did a good history and physical? Whend id you actually follow up with a patient CHRONICALLY?

What if he wants to learn how to perform a thorough H&P, as well as learning about treating chronic pain patients?

We spend an awful lot of time attacking other specialities within medicine instead of collaborating. CRNA's, NP's, PA's need not lift a finger - we're implementing the divide and concquer strategy (against ourselves) for them.

 

[jettavr6]

Agree with Sleep is Good...why would you want to do that? The vast majority of radiologists are excellent technicians and very poor clinicians. You would be swimming upstream against the training of your own specialty, and unless you plan on specializing in pain medicine (unlikely having completed a neurorad fellowship), why bother with changing your entire field of medicine?

Agree with you on most of your posts, but aren't we over reaching with some generalizations here? One, how do we know that he is a poor clinician. And second, what if he enjoys pain and does plan on specialing in it. Maybe he can bring something to the table for all of us to learn. My .02cents.

 

[mid|ine]

MGH is pretty open to considering non-traditional pathways. Yes, it would be possible. But as previously stated, not exactly sure why you would do it.

 

[specepic]

I know personally of a rad who recently completed at a top tier pain fellowship. Sounds like you are well intentioned. Go for it.

 

[Aether2000]

The radiologists in my area do not touch patients unless absolutely necessary. In order to have a myelogram, they will not perform a history and physical exam, but want the PCP or pain doc to do it so they do not have to examine the patient. Interventional radiologists are different, in that they actually do have physical contact with the patient and talk to the patient. But how many radiologists talk to the patient before an MRI to determine a dermatomal pattern of pain? Our radiologists do not even see the patients before or after MRIs.
My point is, radiologists frequently develop very specific skill sets that do not include clinical diagnostics via history and physical exams, which are mainstays of pain medicine. It is not impossible to acquire these skills, but why would a radiologist who is gifted at placing coils in the brains of patients want to be bothered by listening to people complain all day about pain?

 

[PMR 4 MSK]

The radiologists in my area do not touch patients unless absolutely necessary. In order to have a myelogram, they will not perform a history and physical exam, but want the PCP or pain doc to do it so they do not have to examine the patient. Interventional radiologists are different, in that they actually do have physical contact with the patient and talk to the patient. But how many radiologists talk to the patient before an MRI to determine a dermatomal pattern of pain? Our radiologists do not even see the patients before or after MRIs.
My point is, radiologists frequently develop very specific skill sets that do not include clinical diagnostics via history and physical exams, which are mainstays of pain medicine. It is not impossible to acquire these skills, but why would a radiologist who is gifted at placing coils in the brains of patients want to be bothered by listening to people complain all day about pain?

The last time I ordered a CT myelogram, as the radiologist recommended in a pt with a pacemaker who's CT showed a mass in the canal, radiology then refused, saying the order had to come from a spine surgeon who would also be on call in case anything went wrong.

When we got a new set of radiologists a few years ago (contract change), the new group did vertebroplasty. I referred a pt and they said I needed to do the H&P, admit orders and be "on call" to admit the pt if anything went wrong. I sent the patient elsewhere and never sent another.

Doing my radiholiday as an intern, I watched the interventional guys and could have seen myself switching fields, but I knew that would require doing the match again and starting over, so I never did.

But I agree radiology is not normally seen as a field that gets clinical experience.

 

[xbox]

Thanks to everyone for your thoughtful responses, including those for and against. It's good to hear from both sides.

I will have to think about this more, as I would be a very atypical applicant and even more atypical graduate. I would probably be shunned from both Radiology and Pain practices and ultimately would have to go academics. Now going academics isn't a bad thing as that was my original intent: to focus on imaging pain and (hopefully) find a better way of assessing pain based on functional imaging rather than our current simplistic anatomical basis.

As a radiologist, I was hoping I'd be an interesting applicant to a Pain fellowship/department. I'd like to think technically I'd be able to bring CT-guided interventions, kyphos/vertebros, etc. to the table plus a more experienced perspective on the imaging front.

But, yes... I'd be sacrificing a year of 'attending' income to train in a fellowship that would ultimately pay less. Money isn't everything... I guess 😉

 

[Aether2000]

My, my...if you have the capability of developing practical pain imaging techniques, then you would advance the entire field far more than slogging away in the trenches in a specialty that is under constant financial and regulatory attack. Use your gifts and talents for the betterment of humanity.

 

[SleepIsGood]

Thanks to everyone for your thoughtful responses, including those for and against. It's good to hear from both sides.

I will have to think about this more, as I would be a very atypical applicant and even more atypical graduate. I would probably be shunned from both Radiology and Pain practices and ultimately would have to go academics. Now going academics isn't a bad thing as that was my original intent: to focus on imaging pain and (hopefully) find a better way of assessing pain based on functional imaging rather than our current simplistic anatomical basis.

As a radiologist, I was hoping I'd be an interesting applicant to a Pain fellowship/department. I'd like to think technically I'd be able to bring CT-guided interventions, kyphos/vertebros, etc. to the table plus a more experienced perspective on the imaging front.

But, yes... I'd be sacrificing a year of 'attending' income to train in a fellowship that would ultimately pay less. Money isn't everything... I guess 😉

CT guided?

Not saying you are this guy...but I saw a patient that had a CT guided L5/s1 interlaminar EPIDURAL steroid injection done by a radiologist. That's fraud in my opinion. No need for CT in a patient that was in his 30's with a WIDE open L5/s1 interspace.

What's next? CT guided Trigger Point?

 

[Jcm800]

CT guided?

Not saying you are this guy...but I saw a patient that had a CT guided L5/s1 interlaminar EPIDURAL steroid injection done by a radiologist. That's fraud in my opinion. No need for CT in a patient that was in his 30's with a WIDE open L5/s1 interspace.

What's next? CT guided Trigger Point?

not fraud...just ridiculous...

 

[Ligament]

The facility/technical fee for CT guidance pays much more than fluoro guidance. Hence the CT guidance.

 

[bedrock]

still a misuse of resources and significant unnecessary radiation exposure

Medicare should go after that before they try to bundle fluoro guidance for transforaminal ESI

 

[freddydpt]

I'm not sure why such animosity exists on this thread. I share xbox's desire to enter pain management and plan to manage the patient's pain with all aspects of treatment. I think many people forget radiologists also went to medical school, completed internship and performed, at least in my residency, 6 months of interventional radiology, required to complete H and P's, both inpatient and outpatient, round on our consults and our own service and only consult medicine as needed. IR is changing as a field to align more with a clinical model rather than a pure procedural one.

Also, many people have various backgrounds that lend themselves toward pain management. For myself, with a background of physical therapy, I loved seeing these patients. That's where I felt I made the biggest difference. However, when thinking about what would make me the best pain doctor, I thought, ultimately, chronic pain is a diagnostic dilemma and who receives the most intensive diagnostic training, uses advanced technology/procedural skills and still maintains a decent quality of life? The radiologist. I couldn't see myself going to anesthesia because I'm a big fan of the OR, the beeping and yelling really get to me 🙂

I've spoken to many radiologists who practice pain management, prescribing meds, coordinating care with PT, psych, acupuncture, etc. In fact, if you do Google search you'll find many pain management radiologists.

Try it out.

 

[Aether2000]

While there are certainly exceptions, we the practicing pain physicians have had to deal with radiology groups telling patients and PCPs that if there is a problem found on lumbar or cervical MRI, they will do the 3-4 insurance permitted injections, then they dump the patient back to the PCP for meds who dumps the patient on to pain medicine physicians. We do a slow burn everytime one of your brethren does not behave like a real doctor, and instead like a mindless greedy technician devoid of diagnostic skills other than what can be appreciated on MRI. We also are not impressed by the substandard care rendered by using CT guidance for injections. So while there are a few exceptions, there are many many more that use their position in radiology to read and diagnose and to treat with expensive and sometimes unnecessary injections, and do not follow up with these patients after they have dumped them.
John Fisk is an outstanding example of a radiologist turned pain physician and should be the paradigm against which all others are measured.

 

[lobelsteve]

While there are certainly exceptions, we the practicing pain physicians have had to deal with radiology groups telling patients and PCPs that if there is a problem found on lumbar or cervical MRI, they will do the 3-4 insurance permitted injections, then they dump the patient back to the PCP for meds who dumps the patient on to pain medicine physicians. We do a slow burn everytime one of your brethren does not behave like a real doctor, and instead like a mindless greedy technician devoid of diagnostic skills other than what can be appreciated on MRI. We also are not impressed by the substandard care rendered by using CT guidance for injections. So while there are a few exceptions, there are many many more that use their position in radiology to read and diagnose and to treat with expensive and sometimes unnecessary injections, and do not follow up with these patients after they have dumped them.
John Fisk is an outstanding example of a radiologist turned pain physician and should be the paradigm against which all others are measured.

Just saw a patient with right sided aching axial low back pain worse with extension and worse in AM. Constant, stiff. IR did series of 3 ESI and third one gave her leg a vacation for 4 hours (motor and sensory block). She presents to me for neck pain and asks what to do about neck and back as ESI did not work. Oy Vey.

 

[WaterRabbit]

Just saw a patient with right sided aching axial low back pain worse with extension and worse in AM. Constant, stiff. IR did series of 3 ESI and third one gave her leg a vacation for 4 hours (motor and sensory block). She presents to me for neck pain and asks what to do about neck and back as ESI did not work. Oy Vey.

Sounds like you're peeling the onion, so to speak. Seems to be typical w/ chronic intractable pain patients with the all-too-often cognitive problems. Part of the job, and something to think about when considering going into pain medicine. It can be frustrating for us, but equally, if not more so, frustrating for the pts. suffering.

Screening for drug seeking/diversion also goes with the territory, and these the ones I tire of. I want to help those in pain, not those looking to get high. Once in a while, we run into those who have both, and those cases are the most difficult IMHO.

We have to remember that we are all people. I worked with a patient who had >30 surgeries, complications from prior meds, is clearly still in severe pain after several procedures, and tried just about every modality for pain, and has had chronic health problems since childhood. This pt doesn't complain much (despite adverse reactions to meds/procedures), keeps scrips to a minimum, was a serious athlete that wants to get that back (or do what it takes to try to help other chronic pain pts.), has had some meds & procedures not go that well, yet is willing to try just about anything and has become well educated. These, and pts that return to normal lives are the people that make this all worth while.

Something to consider when deciding to go into pain medicine.

Not all pts. are going to respond well to treatment. Some handle this well, some do not.

Still others are going to be healed and go on their way.

I'm glad I obtained some practical experience before I decided on this specialty. It certainly gave me some perspective.

 

[PMR 4 MSK]

I think many people forget radiologists also went to medical school.

I think many practicing radiologists have forgotten that themselves. Like when they refuse to do a procedure until I provide them with the H&P they will put on the chart as their own.