Sports medicine and neuromodulation

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nvrsumr

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I was at a Boston Scientific SCS course on saturday. Had some FPs in my cadaver group. They were super excited to learn retrograde lead placement and to start implanting to treat pelvic and rectal pain (they already do lumbar SCS). Supposedly they are doing celiac plexus neurolysis as well. They call themselves "sports medicine" doctors. Anyone else think the vast majority of interventional pain management procedures have nothing to do with sports medicine??

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I was at a Boston Scientific SCS course on saturday. Had some FPs in my cadaver group. They were super excited to learn retrograde lead placement and to start implanting to treat pelvic and rectal pain (they already do lumbar SCS). Supposedly they are doing celiac plexus neurolysis as well. They call themselves "sports medicine" doctors. Anyone else think the vast majority of interventional pain management procedures have nothing to do with sports medicine??

Dude, are you joking? FPs doing SCS and celiac neurolysis? I'm boycotting Boston Scientific if this is true.
 
Dude, are you joking? FPs doing SCS and celiac neurolysis? I'm boycotting Boston Scientific if this is true.


that pretty disheartening. on the other hand, im looking forward to performing my first CABG tomorrow......
 
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Yep, and some are taking the WIP certification exam also.
 
One complication and I'd testify in the criminal case.
It goes beyond med mal and civil when you are so far outside your scope.

But I guess I'd have to give up on liver transplants on weekends....


If BS comes by the office, I'll discuss it with them.
Went to a SJM (ANS) course this weekend.

12 Pain docs
2 Ortho spine
1 NS

No nurses, FP's, or other inappropriate trainees.
 
that pretty disheartening. on the other hand, im looking forward to performing my first CABG tomorrow......


Crazy, i just did an angiogram...

luckily the angio went fine, so I ll be putting the stent in later today... only problem is I have to put them on Plavix...
 
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If they have a complication, I wish them good luck in finding a defendants' expert witness to testify for them. They are clearly outside their scope of practice. Does the American College of Sports Medicine have any white papers on neuromodulation in athletes?
 
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Apparently this is part of their fellowship training, although clearly outside of their scope. BS is gonna say we are only selling it to docs - not our call who is qualified, especially since they can claim to be "fellowship-trained". Maybe the best way to address this is through the fellowship director?

drusso, could you PM me about your people you still know at UNTHSC@FW?
 
It seems you may be lacking some information in your posts. The physicians you are talking about have completed a 12 month ACGME accredited sports fellowship followed by a 12 month ACGME pain fellowship. That is a total of 24 months of fellowship training with eligibility to sit for both the sports and pain boards.
 
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The purpose of this type of training program is to prepare physicians to join sports and spine orthopedic groups and be able to handle all the non-surgical patients (fracture care, interventional pain, interventional joint, musculoskeletal ultrasound, MR/CT arthrography, sports injuries, etc.) This type of physician cannot be trained in one year. The only place, to my knowledge, to offer back-to-back integrated ACGME accredited sports and pain programs is John Peter Smith Hospital in Fort Worth.
 
The pain fellowship has adopted the position of the ACGME in that pain medicine is a multi-disciplinary specialty and as such, applicants are not discriminated against because of their primary specialty. Any specialty is welcome to apply, but to date, all graduates and current fellows have, or will complete, 24 months of training. The most common specialties are FP and PM&R, but we also have applicants from anesthesia, ER, IM, psych, and neuro. Our fellows learn SCS in their second year, and have completed 500-600 basic lumbar procedures before advancing to SCS. They also do lami paddle trials and implants with our spine surgeons.
 
It seems that a year of sports medicine training negates a year of pain medicine training. It also seems doing a family medicine residency negates ones ability to do any fellowship training, eh? I have noticed something in interviewing applicants for our programs, it is uncommon to have an applicant that has implanted stimulators in their residency program.

I wonder how many of our colleagues posting comments on this thread learned SCS implants in their residency programs.
 
With regards to finding an "expert witness" in the event of a complication, the only options we have are fellowship trained, board certified pain physicians and a fellowship trained, board certified spine surgeon. Hopefully that would be adequate.

Boston Scientific supports the SCS training of all fellows in accredited pain fellowships, period. As far as Medtronic and St Jude/ANS, they are continuously trying to become more involved with the fellows, send them to courses, and schedule trials and implants (yes, even the ones that are FP trained). Frankly, I am getting tired of hearing reps in one part of the country stating "Boston is training FPs in Fort Worth to do SCS" as part of a marketing ploy to discredit Boston while their local reps (Medtronic/ANS) are in my office wanting to be more involved with the fellows and the fellowship.

They seem to selectively omit the fact these are pain fellows in a fellowship.
 
I would agree that most interventional pain procedures have nothing to do with sports medicine. Maybe we should create an additional 12 month training program for pain if that is a scope of service our graduates wish to do. Maybe we should integrate the two to produce a truly comprehensive interventional musculoskeletal physician. Wait, I think we did that already...

At the risk of being redundant, I can tell you Boston has not trained any physician at our program to do SCS unless they were an accepted pain fellow.
 
Anyone wishing to find out more facts about the sports and pain programs at JPS, or the training of our fellows, may contact me directly and I'll be happy to answer your questions.

Steven L. Simmons, DO
Program Director
UT Southwestern PM&R Pain Fellowship at JPS Hospital

Faculty
JPS Hospital Sports Medicine Fellowship Program

[email protected]
 
Dr. Simmons,

Thanks for your posts. Since your fellows are indeed in a pain fellowship (ACGME accredited at that), they were appropriate trainees at the workshop.

Kudos for taking the time to explain your program.

Whether FP is appropriate for a pain fellowship is another debate entirely.
 
Apologies.

FP to pain is viable and appropriate. That little bit of info was omitted in the beginning of the thread.

As far as paddles and laminotomy: I belive only the hospital you would like to do the procedure in would be able to certify you. That's why they call it credentialing. And I would think by asking for those privileges, you have a spine surgeon signing off or saying no.
 
As far as lami paddles, fellows are scrub in with our spine surgeon and implant the IPG. Our surgeon relies on us to tell him the appropriate place to place the paddle. With lami paddle trials, again we scrub with the surgeon and place extension leads while he cuts the lami. We trial the patient quickly and then come back and either implant the IPG or remove the extension leads if the trial fails. The paddle is removed by the surgeon 6 weeks later in the case of a trial failure. This has allowed us to be able to offer trials to all appropriate patients so far, even if they have had fusion surgery in the T spine or have rods/hardware, etc.. in the area.

Fellows do not cut the lamis. That is a procedure I consider outside their scope and would not certify any pain fellow to do so.

I do believe they need to be in the OR and participating to be sure the paddle is placed at the appropriate level, first assist the lami, and implant the IPG. I think this is necessary to assure good continuity of patient care when managing SCS with a lami paddle. This is the exact same way I do it in my private practice as well.
 
Dr. Simmons,

It does sound like your fellows are receiving adequate training. Unfortunately they did not present themselves as pain fellows and in fact they had the proctor at one table play a guessing game as to their specialty after running through Gas, PMR, NS, Neuro, Ortho, Rads.... they finally enlightened us and said FP and much afterwards that they were in a sports medicine fellowship in Ft. Worth.

I think a 24 month fellowship program might adequately make up for the complete lack of training related to pain or sports medicine in their primary field of FP.

Regards.
 
Obviously, the information as originally presented was incorrect. With the new multidisciplinary ACGME requirements *ANY* accredited specialty is a viable pathway to pain medicine not just the traditional big three (Anesthesia, PM&R, Psychiatry).

I did my internship at JPS and am more than familiar with the Family Practice residency program (probably among the top in the country), the sports medicine program (again, very good with the involvement of Dr. Simmons, Dr. Barber, the TCU athletic program, etc), as well as Dr. Simmons personally. So, this is legit: Yes, FP's can learn to do SCS as part of an ACGME-accredited pain fellowship and it is well within their skill-set to do so. So can psychiatrists, pathologists, and pediatricians for that matter...

Kudos to Dr. Simmons and the JPS crew for "getting out in front."
 
Obviously, the information as originally presented was incorrect. "

I was not trying to stir something up. The participants presented themselves as FPs and took pleasure in the groups surprise. They did not mention they were in an ACGME pain fellowship but specifically stated a sports medicine fellowship.

I trained under a pain boarded and fellowship trained psychiatrist who did implants. He had originally started as ortho so had excellent surgical skills. In many ways he had much more to offer the "lifer" pain patient than I ever will. Of course the exception does not prove the rule.

Im sure when it was decided that any specialty (ie. occ med, aerospace medicine) could be accepted into pain fellowships it was for political expediency not because the powers that be thought these specialties provided relevant training to the practice of pain medicine.

This all being said a two year sports and pain ACGME fellowship sounds like it provides a unique training experience and I also congratulate Dr. Simmons for putting together such a program and not playing the sports medicine fellowship-interventional pain procedure training bait and switch that is happening elsewhere.
 
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I appreciate the support. I can understand the way this was originally presented may raise some eyebrows. I do not want Boston to get a bad rap due to misinformation. I can tell you this, both Medtronic and SJ/ANS know full well what the fellowship is and that it is an ACGME pain program, with 6 slots this year. ANS was in my office this week. If any reps come in your office and tell you that Boston is "training FPs in Fort Worth to do SCS" and failing to menition the whole pain fellowship detail, in an attempt to discredit Boston, they are being deliberately disceptive and I would appreciate an email letting me know about. ([email protected])

I expect people will have differing opinions regarding the structure of our training programs and what we are doing in FW. I just want them to have accurate information to form those opinions. I have no tolerance for deliberate misinformation as a marketing ploy. If this does happen, you may want to ask yourself if that is appropriate behavior from a company you are entrusting to take care of your patients and provide you with reliable information.
 
I have a friend (PM&R) who is going to the fellowship and he is excellent. I also applaud Dr. Simmons for taking the time to post and provide information on the fellowship. I think the fellows who attended the BS course should be educated on how to present themselves and talk about their training. They may consider themselves FP/sports fellows but from the standpoint of Boston Scientific and all those involved in the course, the reason why they were invited to train is because they are pain fellows at an ACGME accredited fellowship program. I hope that they are aware of this situation and understand that they need to be careful about how they label themselves and represent the fellowship. I was not at the course so I don't know the whole circumstance but even if they were joking, they should understand the bigger context of this discussion which is the problem of unqualified practitioners performing interventional procedures. (see discussions about FPs coding TPIs as facet injections, etc.)
 
I don't think our guys were being deliberately deceptive about their specialty per se, probably just cautious based upon past responses. I was not there, so I cannot comment directly, but I'm sure their intent was not to shock the group by announcing they were FP. Every course has the inevitable "what specialty are you" discussions around the cadaver. Occasionally I still go to courses to see what new things are being done and practice or refine new techniques. I have first assisted 70-80 lamis and implanted the IPGs, implanted a bunch of perc lead systems, and probably placed 150 or more trial leads in the 3 years I've been doing SCS. I don't say this to hang from the Empire State Building and beat my chest (or maybe those numbers are not that impressive), but the reaction I get when I announce I'm FP always prompts multiple questions and further detailed explanation. The reception I get is variable.

The thing I have found ironic is that in my residency, I scrubbed on more that 100 surgical procedures (opening and closing for the operating surgeons, primary on many c-sections, hernias, apps, etc..), rotated in surgery clinic doing post-op care, and rounded on pre-op and post-op patients in the hospital. Yet, some would view my training as less than adequate to implant SCS than someone that never touched a scalpel during residency. Frankly, I've found the experience I was able to get to be very helpful when I was learning SCS.
 
Dr. Simmons,

It does sound like your fellows are receiving adequate training. Unfortunately they did not present themselves as pain fellows and in fact they had the proctor at one table play a guessing game as to their specialty after running through Gas, PMR, NS, Neuro, Ortho, Rads.... they finally enlightened us and said FP and much afterwards that they were in a sports medicine fellowship in Ft. Worth.

I think a 24 month fellowship program might adequately make up for the complete lack of training related to pain or sports medicine in their primary field of FP.

Regards.
I'm not sure where you are getting your information. Sports medicine is a part of most all FP training programs. Programs that have SM fellowships tend to do even more. Our residents cover games with our fellows and rotate in the sports clinic as well as in ortho. They do exercise treadmill testing on cardiology rotations. They do hundreds of pre-participation physicals. They round in the training rooms with our fellows. They see athletes in their clinics.

The Sports Medicine CAQ is ADMINISTERED by the ABFP to all other specialties that take it. PM&R has become the most recent board to join the Sports Med group, about a year now I think. Welcome, we are glad to have you! I was a big proponent of PM&R being accepted so our PM&R colleagues that graduated from the sports program could sit for the boards with no need to petition the ACGME/ABFP. That has now happened, so dual board certification for all of our PM&R graduates is a smooth administrative process.

The management of pain is a big topic in primary care. It is continuously address in our journals and the subject of dozens of CME hours yearly. Geriatric and palliative care are training areas in residency. Management of Schedule II substances is core training in our residency. FP is a member of the Hospice and Palliative care board. I could go on, but you get the point.
 
Im sure when it was decided that any specialty (ie. occ med, aerospace medicine) could be accepted into pain fellowships it was for political expediency not because the powers that be thought these specialties provided relevant training to the practice of pain medicine.

I think there are many other specialties that would disagree with you, like the Internal Medicine Board which administers the Hospice and Palliative Care board certification. Last time I checked, palliative care is part of pain fellowship training.

The ACGME has taken a firm, and I think appropriate, position that no specialty "owns" pain medicine. Many have something to offer. The fact that any specialty can be accepted into a pain medicine fellowship should further demonstrate the fact that the vast majority of skills a pain practitioner learns are a result of fellowship training, not residency.

Are you saying a pediatric specialist that trains in pain medicine has nothing to offer the specialty? I don't think I would agree with that statement.
 
I think there are many other specialties that would disagree with you, like the Internal Medicine Board which administers the Hospice and Palliative Care board certification. Last time I checked, palliative care is part of pain fellowship training.

The ACGME has taken a firm, and I think appropriate, position that no specialty "owns" pain medicine. Many have something to offer. The fact that any specialty can be accepted into a pain medicine fellowship should further demonstrate the fact that the vast majority of skills a pain practitioner learns are a result of fellowship training, not residency.

Are you saying a pediatric specialist that trains in pain medicine has nothing to offer the specialty? I don't think I would agree with that statement.


We are completing the circle here.

FP is inadequately trained for Pain.
PMR is inadequately trained for Pain.
Neuro is inadequately trained for Pain.
Psych is inadequately trained for Pain.
Anes is inadequately trained for Pain.

SO where is Algos, Perry, Turk, et al to get the AAPMed to finally wrestle this beast away from Anes and create the Pain Residency?

That is the only answer that will lead to improvements in overall patient care.
 
I think orthopedic surgeons are the only ones most qualified to do pain. Pain after surgery= RSD 100% of time. Easy peezy.
 
We are completing the circle here.

FP is inadequately trained for Pain.
PMR is inadequately trained for Pain.
Neuro is inadequately trained for Pain.
Psych is inadequately trained for Pain.
Anes is inadequately trained for Pain.

SO where is Algos, Perry, Turk, et al to get the AAPMed to finally wrestle this beast away from Anes and create the Pain Residency?

That is the only answer that will lead to improvements in overall patient care.


Amen.
 
Dr. Simmons,

I will have to respectfully disagree with you but do wish you the best with the unique training program you have put together.

Regards.
 
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I think there are many other specialties that would disagree with you, like the Internal Medicine Board which administers the Hospice and Palliative Care board certification. Last time I checked, palliative care is part of pain fellowship training.

The ACGME has taken a firm, and I think appropriate, position that no specialty "owns" pain medicine. Many have something to offer. The fact that any specialty can be accepted into a pain medicine fellowship should further demonstrate the fact that the vast majority of skills a pain practitioner learns are a result of fellowship training, not residency.

Are you saying a pediatric specialist that trains in pain medicine has nothing to offer the specialty? I don't think I would agree with that statement.

Steve,

Because nothing else like it exists in the country, I think that it would be interesting to have you do a presentation at the Association of Pain Program Directors (APPD) Annual Meeting. Maybe you already have. They usually meet at the ASRA annual conference.
 
The ACGME has taken a firm, and I think appropriate, position that no specialty "owns" pain medicine. Many have something to offer. The fact that any specialty can be accepted into a pain medicine fellowship should further demonstrate the fact that the vast majority of skills a pain practitioner learns are a result of fellowship training, not residency.

Are you saying a pediatric specialist that trains in pain medicine has nothing to offer the specialty? I don't think I would agree with that statement.

Surely you can't think that a pathologist, dermatologist, opthalmologist are good candidates to be pain physicians?
 
We are completing the circle here.

FP is inadequately trained for Pain.
PMR is inadequately trained for Pain.
Neuro is inadequately trained for Pain.
Psych is inadequately trained for Pain.
Anes is inadequately trained for Pain.

SO where is Algos, Perry, Turk, et al to get the AAPMed to finally wrestle this beast away from Anes and create the Pain Residency?

That is the only answer that will lead to improvements in overall patient care.


BTW,


I contacted the ABPMR to see who they would be sending to the AMA Pain Residency Summit going on this month.



Apparently, they're not sending anybody.


:wtf:
 
For reasons I don't understand, organized physiatry is walking away from pain medicine...

Old timers holding on to the last vestiges of inpt rehab as the only "true" aspect of PM&R. If they ignore the newer trends in the field long enough, everything will return to how it used to be, right? I mean, that thought process worked well for dinosaurs, didn't it?
 
Dr. Simmons,

I will have to respectfully disagree with you but do wish you the best with the unique training program you have put together.

Regards.

I think we can conclude this with respectfully "agreeing to disagree". Nothing wrong with that in this type of forum. I think we do need to do that with mutual respect and appreciation for each others training and dedication.
 
Steve,

Because nothing else like it exists in the country, I think that it would be interesting to have you do a presentation at the Association of Pain Program Directors (APPD) Annual Meeting. Maybe you already have. They usually meet at the ASRA annual conference.
Hey Dave

I don't mind presenting our programs to anyone that has an interest in what we are doing. I don't know if we have something that doesn't exist anywhere else. I have not seen it anywhere else yet, but there may be other places doing it that I don't know about. There seems to be many PASSOR programs that are integrating the sports/musculoskeletal/pain training but I don't know if any of them have fellowships that lead to dual board certification. Most of the pain program directors will be from an anesthesia background so I am not sure if this would be the best venue to discuss versus presenting at your PM&R annual meeting, I would certainly be interested in presenting there.
 
Respectfully, I believe ophthalmologists probably have a far more reasonable argument to being appropriate for pain fellowship than do FP's. Theirs is an inherently surgical specialty, and as such, they have surgical training in the core of their residency, while at best, it is a peripheral part of an FP's training.

FP's neuromusculoskeletal training again, are at best peripheral, and no where near at the level of that of either a physiatrist or a neurologist.

Their axial procedural experience is in no was equivalent to that of an anesthesiologist's.

I am not qualified to perform a hand surgery fellowship, an orthopaedic spine fellowship, nor a functional neurosurgical fellowship, even though my training in physiatry peripherally touched on all of those areas. I take issue with the notion that any but the rarest FPs (and Dr. Simmons, you may well be the exception to the rule) is in anyway prepared appropriately by his or her residency training to evaluate and treat, either medically or procedurally, pain patients at the level that a physiatrist, neurologist, psychiatrist, or anesthesiologist is at the end of his or her residency; just as I am in no way adequately prepared to "cut the lami."

FP's can certainly be accepted into pain fellowships per the ACGME, but let's be frank - that decision was reached for political expediency, and had little clinical justification
 
Respectfully, I believe ophthalmologists probably have a far more reasonable argument to being appropriate for pain fellowship than do FP's. Theirs is an inherently surgical specialty, and as such, they have surgical training in the core of their residency, while at best, it is a peripheral part of an FP's training.

ampa I respectfully disagree with you on this one. An FP resident would be infinitely better suited for a pain fellowship than an opthalmologist.

A surgeon does not a pain fellow make. By your logic, you might argue that fellowship trained spine surgeons would make good pain docs, and we all know that is impossible...;)
 
Respectfully, I believe ophthalmologists probably have a far more reasonable argument to being appropriate for pain fellowship than do FP's. Theirs is an inherently surgical specialty, and as such, they have surgical training in the core of their residency, while at best, it is a peripheral part of an FP's training.

Ampa, I'm going to play devil's advocate: Don't you think that this the the very same argument that organized anesthesiology used (and sometimes still uses) against physiatry? I think that we agree, that in the big picture, the procedural skills of pain medicine are probably the easiest to acquire with proper teaching.

I think that the big question still remains, "What is the best preparation for a career in pain medicine?" Your unique set of experiences in operative and non-operative specialties is probably most ideal.

But, realistically, I don't see why an FP with a 3 year residency and essentially a 24 month fellowship in MSK medicine and Pain doesn't approximate a *typical* 4 year PM&R or anesthesiology residency plus a 12 month fellowship. I'm certain that there are many aspects of a 3 year FP residency that are irrelevant to pain medicine, but so too with PM&R, Gas, and Neurology...Have you ever watched a neurology resident do a shoulder exam? Talk about painful...

I also agree that the "anything goes" ACGME compromise was really not in the best long-term interests of the specialty, but I think it was another example of our leadership asleep at the wheel.

My larger concern is that others will attempt to poorly emulate Dr. Simmon's program. There are a variety of unique factors that I think combine to make the Fort Worth program a "one of a kind" situation: A very strong, "unopposed," FP residency in a "House of God" county hospital, a strong and well-developed sports medicine fellowship, programatic support from UTSW PM&R, and a personal commitment among the trainers to program's success. It would be disappointing if FP residencies looking for revenue opportunities decided to open up primary care pain clinics and primary care pain fellowships.
 
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Hey Dave

I don't mind presenting our programs to anyone that has an interest in what we are doing. I don't know if we have something that doesn't exist anywhere else. I have not seen it anywhere else yet, but there may be other places doing it that I don't know about. There seems to be many PASSOR programs that are integrating the sports/musculoskeletal/pain training but I don't know if any of them have fellowships that lead to dual board certification. Most of the pain program directors will be from an anesthesia background so I am not sure if this would be the best venue to discuss versus presenting at your PM&R annual meeting, I would certainly be interested in presenting there.

Dr. Simmons,

I think you have the right idea here. The concept of what you're offering is what alot of PM&R residents and PM&R bound medical students are searching for.

Were you to present your training model at the AAPMR annual meeting, I think that during your talk you would get alot criticism (there would be many experienced Physiatrists who would not see the value of dual certification as a means within the current classification system to legitimize expertise in non-operative Orthopedic care).

However, after the room empties, you would have a line of educators asking how to set something up at their institution (even if only to emulate the concepts), and a line of residents wanting to apply to your fellowship.
 
These are all great discussions. I do not think this will be something that will be mass produced. I have discovered there is somewhat of a small pool of residents willing to dedicate 24 months to fellowship training. In addition, it takes twice the institutional resources to produce one fellow as compared to a 12 month track. (2 years of salary, benefits, etc.). We are certainly striving for quality, not quantity.

The FP board does not have any interest that I have seen in joining the pain board, but they will support their members if they do an appropriate fellowship. One issue I have seen is that there can only be one pain fellowship at an institution's site. If an anesthesia program is already in place, PM&R cannot have one at the same site. At the time I worked on the fellowship at JPS, anesthesia outnumbered PM&R programs about 10:1. I don't know what it is now.

I would like to continue our discussions in a week, as I will be on vacation and will have very limited access to the internet.
 
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