Well, I was recently browsing through the American Pain Society's newsletter which details the new ACGME program training requirements. It's a good read:
http://www.ampainsoc.org/pub/bulletin/fall07/training.htm
Some interesting observations beginning with the very first sentence:
Until the advent of formal training programs in pain medicine 15 years ago, training in pain medicine was carried out through informal fellowships under the tutelage of self-trained experts, such as John J. Bonica, who developed the field (Rathmell & Brown, 2002).
Bonica developed the field? Single-handedly???
Bonica was indeed a major figure in pain medicine. But at the same time John Bonica was working, practicing, and laying the ground-work for multidisciplinary pain clinics across the country, a whole cadre of physiatrists were also at work diagnosing, treating, and rehabilitating people with persistent painful injuries. Many of the basic components of the multidisciplinary pain clinics and training model that Dr. Bonica espoused were straight out physiatric clinics that Dr. Bonica visited and was exposed to during his training in New York City and during his service in the US Army.
In fact, within medicine, the development of a multidisciplinary specialty centered on the diagnosis, treatment and rehabilitation of people with painful and disabling conditions predates Bonica by at least a couple of decades and begins with Howard Rusk, Frank Krusen, and Henry Betts. Now, this article is not meant to be a history lesson in pain medicine, but it seems to ignore some very important contributions by non-anesthesiologist pain practitioners toward developing the field of multidisciplinary pain medicine. Their story starts with Bonica. The problem is that these earlier practitioners did not think of themselves as "pain specialists." They took a broader view of what they did and were called physiatrists.
The article then moves to review
the history of the development of the ACGME guidelines for subspecialty training in pain medicine. At the conclusion of this historical analysis, the authors frame the central question for training in this field, "the question to consider was, 'How could training pain medicine specialists be improved to eliminate the tremendous lack of consistency in what is offered from one pain subspecialty clinic to another?'"
Fundamentally, this is a question of
standards.
The article then moves to recap some recent events within the last two to four years familiar to many posters on PainRounds. In fact, some of them were involved in the process. It would be interesting to hear from them, if, from their perspectives, the authors
got the story right.
The new proposed standards that emerged are now currently the ones under which ACGME-accredited pain fellowship programs function:
Changes Established by 2007 ACGME Program Requirements for Fellowship Training in Pain Medicine (ACGME, 2007)
Only one ACGME accredited Pain Medicine fellowship program will be approved per institution.
The required didactic curriculum has been completely revised to incorporate the IASP Core Curriculum for Professional Education in Pain as the core of the curriculum.
All trainees will be required to gain verified exposure to all four parent specialties: anesthesiology, PM&R, neurology, and psychiatry, through defined clinical rotations with minimal documented clinical experience in each discipline.
While all programs will be required to expose trainees to the range of interventional pain modalities available for pain treatment, a subset of programs may offer expanded training in interventional pain medicine through an established "Advanced Interventional Track." Suggested features of this track include the following:
An expanded didactic curriculum on interventional pain medicine
Minimum suggested numbers of interventional procedures for each trainee
A requirement that program directors complete a final summary letter detailing
The specific interventions with which each trainee has demonstrated competence.
One of the most important changes is the development of the Advanced Interventional Track for selected pain fellowships. It seems to be that the purpose is to delineate between programs that offer EXPOSURE to various interventional pain treatments versus those that offer PROFICIENCY. I think it remains to be seen how this change will be implemented. It seems to suggest that some pain fellowships will have the track and others won't. For those that do, perhaps there will be 2 non-advanced slots and 1 advanced slot? Perhaps there will be some competition among fellows completing the standard 12 month fellowship for the additional 6-12 months of advanced interventional training? I don't know...
Still, according to the authors, the real benefit of this is for hospital credentialing, "This new requirement should serve as an invaluable aid to hospital credentialing committees as they grapple with credentialing new physicians (Lubenow & Rathmell, 2005)"
While this reform process has been nominally multidisciplinary, it has been largely *driven* by academic anesthiology-trained pain practitioners in tertiary care settings. This is laudable as I doubt that physiatry-trained pain practitioners would have had the clout to get around to the question of standards any time soon and carry the process foward on their own. It does, however, reveal a bias. How could it not?
At the very least, I think that bias could be summarized and restated as, "The standard for training in multidisciplinary pain medicine should be that the trainee trains in an academic anesthesiology department (in fact is preferably an anesthesiologist though mechanisms will allow for the consideration of others) in a tertiary-care medical center." It's not necessarily a bad bias, but certainly different from the direction in which many physiatric post-residency fellowship training opportunities have gone.
These opportunities have developed into "Interventional Spine" fellowships. These fellowships tend to be non-academic or private practice based, physiatric-based, and single-specialty and see an overlapping population of patients seen in traditional pain clinics. Setting aside the question of the merits of IS as a distinct sub-specialty compared to pain medicine,
I wonder what will be the future of IS given the biases outlined above? Moreover, it seems to me that organized physiatry has almost completely surrendered its claim to the history of pain medicine and has chosen to invest in the interventional MSK/Spine training model almost exclusively. I think that ampaphb keeps track of the latest number of ACGME-accredited versus non-accredited PM&R fellowship numbers and can quote them off the top of his head!
Only time will tell if this gamble pays off for physiatry. But as defphiche, drrinnoo, lobelsteve and others can tell you, I think it has some pretty steep political costs associated with it.
