To ACGME or Not to ACGME

[staydin]

I feel many a sleepless nights coming on. Its the middle of my pgy-3 year, and all I have to show is the anxiety and apprehension about the specialty I have chosen and fellowship path I will end up taking. I though the hard part would be over after choosing my residency...but alas life has gotten more complicated.

Across the board this whole thing about ACGME accreditation regarding fellowhsips has been coming up. Of course, pain comes up always, however this seems to exist with all the subspecialties of the specialty; TBI, Edx, MSK, etc.

I guess what I am trying to boil down to, is my own selfish inquiry, why should I do a fellowship if I can't board in it? Guidance for this is better coming from my patients than some of the people who have given me advice. Its almost like its a big secret whatever the answer is, at least thats the impression I get from other residents when I ask for advice; which may be there own cooping mechanisms for their own insecurity about the stuff.

Advice, venting are all welcome.

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[Disciple]

There is no ACGME accreditation for Electrodiagnostics, TBI or MSK.

 

[chauffeur]

Orthopedic docs aren't boarded in spine after doing a spine surgery fellowship. This goes for all other surgical specialties (ophtho, etc.)

The biggest argument that people make is that you can't get privileges at a hospital to do procedures unless you're ACGME board certified in pain. Is there any truth to this? Maybe if you want to go into academics, but even then, this may not be true. For instance if you complete a spine fellowship at Penn, I imagine you could get a job there in the spine center or at the Cleveland clinic.

I spoke to people who just finished great spine fellowships and they have no problem getting privileges. If you do an anesthesia pain fellowship probably won’t get nearly as many spine procedures logged as you would in a spine fellowship. Also, you might not get the opportunity to do EDX in a pain fellowship.

On the other hand, if want to learn how to handle more chronic pain and everything from CA pain, CPRS, regional blocks, etc… a pain fellowship is the only way to learn those schools.

In the end you’re still fellowship trained.

 

[lobelsteve]

Exceptionally misguided to think that the two tracks are comparable in Pain Medicine. The ACGME fellowship will be much more beneficial from an insurane, credentialling, reimbursement, and opportunity standpoint.

Anyone who wishes to practice Pain Medicine should complete a fellowship that will allow ABMS subspecialty certification.

The Anes side is pushing hard to eliminate PMR docs from doing pain procedures in hospitals and ASC's, from getting fellowships, and next they will work on insurers to get PMR-Pain and all other non Anes-Pain providers ecluded from panels.

If you do not know why I say this, just move on. If you know of me- pass this on- or you will get cut out of the Pain specialty.

 

[ShrikeMD]

The decision to pursue fellowship training should hinge upon the likelihood that you would participate in a training experience that will provide unique benefits for many years to come. The issue of ACGME accreditation will mean little to the vast majority of patients referred to you. Conversely, academic physiatry programs that may be seeking/preferring fellowship-trained physicians for their program-director positions will know that there is no ACGME fellowship in certain subspecialties. In those areas (such as Brain Injury Medicine), the completion of a fellowship program (particularly with a highly regarded mentor) will likely place the candidate ahead of a non-fellowship trained candidate with a comparable experience background.

The issue of ACGME accreditation means more to the physiatric subspecialty than it does to the subspecialist. ACGME-accreditation basically designates the subspecialty as "official", or as "having arrived". The rules regarding # of fellowships/training programs required to "achieve" ACGME accreditation pose a formidable obstacle to some subspecialties; perceived conflict over "turf" and recruiting the cooperation/lack of opposition from other specialties is another obstacle. (Indeed, the neurologic subspecialties recognize these obstacles as a primary reason to pursue their own non-ACGME path to accreditation of their smaller subspecialties...including neurorehabilitation). I am fellowship-trained in a non-accredited subspecialty of PMR, and the lack of ACGME accreditation for my field of neurorehabilitation has not influenced my career opportunities. Having said this, I hope for a day when all major physiatric subspecialties have ACGME accreditation.

Finally, my comments regarding ACGME accreditation and its relative importance to the individual contemplating fellowship training assume that there is NO ACGME accreditation in that subspecialty. Obviously, if ACGME accreditation exists in that subspecialty, it seems foolish to pursue training in a non-accredited program.

 

[Disciple]

The Anes side is pushing hard to eliminate PMR docs from doing pain procedures in hospitals and ASC's, from getting fellowships, and next they will work on insurers to get PMR-Pain and all other non Anes-Pain providers excluded from panels.

Several of the large influential procedurally based organizations (ISIS and even ASIPP) have a large Physiatry contingent, where such serious political action would create great internal strife within the organizations. NASS (the dominant spine surgical organization) holds cadaver courses and encourages spine surgeons as well as the Physiatrists they employ to become proficient at and to perform procedures.

Interventional Pain doctors are dependent upon referrals from surgeons and even Physiatrists (implants). Sure, the ASA and probably ASRA would like to take over, but you can only bite the hand that feeds you for so long before there is a backlash.

Take a look at these links to see the ASAs stance on the issue

http://www.asahq.org/Newsletters/2002/5_02/ventilations502.htm

http://www.asahq.org/Newsletters/2004/08_04/proCon.html

Take a look at the thread on Sports Accreditation to see what Physiatry is doing to protect our future.

 

[drrinoo]

Exceptionally misguided to think that the two tracks are comparable in Pain Medicine. The ACGME fellowship will be much more beneficial from an insurane, credentialling, reimbursement, and opportunity standpoint.

Anyone who wishes to practice Pain Medicine should complete a fellowship that will allow ABMS subspecialty certification.

The Anes side is pushing hard to eliminate PMR docs from doing pain procedures in hospitals and ASC's, from getting fellowships, and next they will work on insurers to get PMR-Pain and all other non Anes-Pain providers ecluded from panels.

If you do not know why I say this, just move on. If you know of me- pass this on- or you will get cut out of the Pain specialty.

I have to agree with Steve...these are unfortunately the realities of clinical practice. If you do a non-accredited fellowship, then you must do one at a program with a solid academic reputation, a diversity of attendings, and a non-malignant reputation---all you have to do is look at the credentialling application for any hospital and see what their requirements are--you will need a 'mentor' to sign off on your privileges...any falling out with a single mentor driven non-accredited fellowship...

If this non accredited program does not have a solid academic reputation, then why take the huge financial hit to learn 6-9 types of procedures, hire an attorney to review a complex contract, and no relocation costs....If the avg salary for that year is 35-45K, you have to factor in the costs of licensure, relocation to and away from the program, signing a non-compete, and the possibility of purchasing tail insurance.

Additionally, an ACGME accredited pain fellowship would enable you to have access jobs in anesthesiology based pain groups. These groups value vacation and generally command higher incomes than physiatrists--yes, your income is only as good as your negotiation skills, but these are general national and even regional trends.

 

[Disciple]

These groups value vacation and generally command higher incomes than physiatrists--yes, your income is only as good as your negotiation skills, but these are general national and even regional trends.

What would you attribute this to? Higher procedural volume? Greater procedural diversity?

 

[lobelsteve]

What would you attribute this to? Higher procedural volume? Greater procedural diversity?

It is an attitude that develops in training as a "shift" provider.
Anesthesiologists in the hospital are not felt to care for individual patients in the hospital setting, they are thought of as running cases over a certain time frame. The patient is seen for the anes service and becomes the responsibility of the surgeon when dc'd from PACU to floor.

My 2c on the issue. There is entitlement issues because the hospital based folks work shifts, not patients.

 

[drusso]

Steve,

Interesting ideas about shift work versus individual patient care duties and the politics of pain medicine, but...I have a different interpretation:

Until now, pain medicine has been a "pirate specialty" stealing a little of this and a little of that from regional anesthesiology, neurology, physiatry, neurosurgery, psychiatry, rheumatology, interventional radiology, orthopedics, etc. Who "owns" these things?? Obviously no one does...this hodge-podge of modalities provided unprecedented opportunities for a variety of practitioner to contribute to the field, stake a claim, and make a name.

In many ways, that was the way it was when OR anesthesia evolved too. Back before the standardized graduate medical training of physician-anesthetists, the anesthetist administering Ether could be have been a dentist, a nurse, a mid-wife, a medical student, a clergyman, or the hospital janitor. Over time, surgery became safe because anesthesiology became scientific and this science was invented, developed, and advanced by physician-anesthesiologists.

As you know, now, anesthesia has become so safe, that CRNA's, AA's, and graduate-trained dentists can provide the bulk of anesthesia services in small community hospital settings. Some small community hospitals don't even have a MD/DO anesthesiologist on staff; the services are provided solely by CRNA's. Anesthesiology, as a field, has responded by sub-specializing and looking for new frontiers...pain has always been there.

Having trained in an academic anesthesiology department I was struck by the fact that, by and large, anesthesiologists see themselves as the ultimate "patient guardians of safety." They sit on hospital committees, develop treatment protocols, OR triage pathways, etc. It's a real ethic that permeates their programs. By extension, I think that anesthesiologists who practice pain medicine are attempting to establish pre-eminence, codify standards of training, track outcomes, and improve safety as the specialty did for OR anesthesiology 100 years ago. Where's physiatry??

Painting with a broad brush, organized physiatry has always been sort of passive in my view. How many physiatrists are as politically active as anesthesiologists at their hospitals, with their local, state, and national representatives, etc? Do you have any idea how much the ASA and other anesthesia groups give in political donations? Where's the physiatry PAC?

http://www.democracy-nc.org/moneyresearch/2007/AnesthesPAC.pdf
http://www.asahq.org/index.htm

How many physiatrists sit on key credentialing committees, are presidents of local medical societies, etc? Most physiatrists gravitate to the field for "plenty of money and relaxation," "no call," and "9-5." We're the specialty that's "all about the team," loathe to hurt others feelings or rock the boat. We're a specialty of part-time mommies, gym-rats, and Mr. Mom's. Remember, it's all about the lifestyle...

No doubt, this warm and touchy-feely attitude is wonderful for helping rehabilitate patients with devasting injuries, but it doesn't always work in the competitive health care market. So what happens: Neurologists run rehab units, PT's have "direct access" to the retail therapy market, chiropractors do EMG's and workman's comp...and anesthesia will define what is the standard of care for pain medicine.

Physiatry gives itself away over and over again. What's happening in pain medicine is just another variation on the theme. We can't blame others for our own lack of leadership or lack of pride in ownership. Physiatry will never be totally locked out of pain medicine, but you can expect it to take the same comfortable "me too" approach that we've always taken. And I think that's what everyone else is counting on too...

 

[PMR 4 MSK]

Fellowship makes you more attractive to employers and future (potential) partners, ACGME or not.

You can market yourself fellowship-trained whether it was ACGME or not.

You can become baorded in many subspecialties, like pain, with or without fellowship - ACGME or non-ACGME. There are several boards for pain.

However, states vary as to whether they accept these various boards. So if you get boarded by ABPM, your state might not allow you to advertise as such, and hospitals might not accept that as proof of training.

 

[lobelsteve]

Fellowship makes you more attractive to employers and future (potential) partners, ACGME or not.

You can market yourself fellowship-trained whether it was ACGME or not.

You can become baorded in many subspecialties, like pain, with or without fellowship - ACGME or non-ACGME. There are several boards for pain.

However, states vary as to whether they accept these various boards. So if you get boarded by ABPM, your state might not allow you to advertise as such, and hospitals might not accept that as proof of training.

Yes, you can do all of these things. But we do not practice in a vacuum. If I was hiring, I'd like to know the attendings who trained my candidate. I do not consider Board Certification from ABPMgmt real, and the ABPMed is real, but not recognized. ABIPP, WIP, FIP, etc are all money making schemes currently.

There is one real deal for credentialing with hospitals and insurance as well as when selling yourself as a candidate. Even this ABMS recognized ABA/ABPMR/ABNP candidate may have gotten really poor training- so none of this is a reflection on the candidates skills or knowledge.

Pain Medicine is a fragmented field that PMR will be losing a stake in over the next few years. I think this will lead to increased patient suffering at the hands of the politicos and their fat wallets, while the PMR guys will watch from the sidelines as opportunity vanishes. Paging Dr. Russo, Dr. Russo to the ACGME. I'm sticking my finger in the pot and swirling to try and make things right, but there are too few of us willing to defend the turf.

 

[Disciple]

It is an attitude that develops in training as a "shift" provider.
Anesthesiologists in the hospital are not felt to care for individual patients in the hospital setting, they are thought of as running cases over a certain time frame. The patient is seen for the anes service and becomes the responsibility of the surgeon when dc'd from PACU to floor.

My 2c on the issue. There is entitlement issues because the hospital based folks work shifts, not patients.

So, you’re pretty much referring to needle jockey model/mentality (brief patient contact, procedural emphasis, little to no patient f/u), leading to a greater number of patients screened for simple as well as advanced procedures and thus higher revenue generated, which is what I think generally accounts for the difference in average salary. Not all anesthesia pain groups practice this way, and, of course, there are some Physiatrists who do, but as Dr. Rinoo stated above, national and regional trends at least provide some idea of practice patterns.

As stated above, Dr. Rinoo has suggested opening our minds to this type of philosophy. The financial advantages to individual Physiatrists practicing in this model are apparent but would be detrimental to the field over the long term if this became the norm. If Physiatrists are to cement our place as the experts in musculoskeletal care, over the long term, this is an area where we need to take the moral high-ground (I know, tell that to someone with kids and a heap of med-school debt). Physiatrists are supposed to be the polar opposite of the shift worker that you’ve described above. I’d be more in favor of advanced level MSK with CAQ in procedures than the alternative, and think that in this case the PM&R leadership has made the right decision.

 

[Disciple]

Where's physiatry??

How many physiatrists sit on key credentialing committees, are presidents of local medical societies, etc? Most physiatrists gravitate to the field for "plenty of money and relaxation," "no call," and "9-5." We're the specialty that's "all about the team," loathe to hurt others feelings or rock the boat. We're a specialty of part-time mommies, gym-rats, and Mr. Mom's. Remember, it's all about the lifestyle...

No doubt, this warm and touchy-feely attitude is wonderful for helping rehabilitate patients with devasting injuries, but it doesn't always work in the competitive health care market. So what happens: Neurologists run rehab units, PT's have "direct access" to the retail therapy market, chiropractors do EMG's and workman's comp...and anesthesia will define what is the standard of care for pain medicine.

Physiatry gives itself away over and over again. What's happening in pain medicine is just another variation on the theme. We can't blame others for our own lack of leadership or lack of pride in ownership.

As a specialty, to clearly and decisively chart where we're going, I think we need to start by being completely frank and honest about what we're doing and more importantly, why we're doing it.

By and large, Physiatry shown had little interest in supporting the training and practice of Physiatrists as "Interventional Pain Physicians", the image of which arose through the advent and financial profitability of fluorscopically guided injections.

IMO, the ABPMR capitalized on the opportunity to sponsor the pain subspecialty certification process because Physiatrists have always been involved in the management of chronic pain from a rehabilitation/functional restoration/non-interventional model, and that at the time, it made sense to use the vehicle of becoming a sponsoring specialty of pain medicine to promote this philosophy. I think a prime example of what our leaders likely had in mind was the RIC pain program (pre-anesthesia merger). The ABPMR has put forth support for "pain medicine" proportional to the number of Physiatrists who want to practice in this model.

If we are to be completely honest, pain certification from the late 90's to present then became/was used as a pathway for Physiatrists to facilitate our practices in spine and orthopedic care in lieu of a certification that did not exist that would have more appropriately represented this type of practice. How many Physiatrists do you know that practice comprehensive pain medicine vs. all those you know that do spine/general orthopedic care combined w/ sports medicine? How many Physiatrists do you know that were trained to practice comprehensive pain medicine and then went on to spine/sports/MSK practices? What ever the proportion is, it's significant. Ironic that the few Physiatrists that truly want to do comprehensive management of chronic pain through a day rehab/functional restoration type of model (likely the original intent of our pain board sponsorship) often do so quite skillfully without fellowship training.

Even our most renown/published Physiatric interventionalists practice in the interventional spine model (Ironic, I think most graduating pain anesthesiologists want to practice in a procedurally expanded version of this model as well) which, IMO, embodies the reason you haven't seen political backing by Physiatry in the specific arenas you've mentioned above. Where does our lobby go? Inpt rehab (75% rule), Spine, athletes with disabilities, restricting scope of practice for PTs/Chiros, etc. Classic PM&R stuff/philosophy. Where are our members? ISIS, NASS, ASIPP, ACSM. Where are they not? APS>>ASRA>AAPM.

Simply put, the jack-of-all trades multi-disciplinary interventional pain specialist idealized by the academic pain departments didn't fit what we were doing (Square peg, round hole), and with the way things have turned out, it clearly took some time for us to figure this out, or to decide what to do about it. Certification in spine was considered and didn't happen. So, they revamped the AAPMR, are reintegrating PASSOR, sponsored the sports med boards, created the new journal and now the ABPMR is considering CAQ in procedures. Whether they're trying to undo mistakes of the past, or were just slow to react, this is the game plan that's been laid out. I think we do have pride in ownership, or at the very least are developing it in the MSK/Spine, and soon, the sports arena. It's where most of our Type A guys/gals reside.


I'm skeptical but hopeful.


Hopefully we have enough "gym-rats" to make it happen.

 

[drusso]

Hopefully we have enough “gym-rats” to make it happen.

I'd like to help, but it cuts into my gym time.

 

[drusso]

Physiatrists are supposed to be the polar opposite of the shift worker that you’ve described above. I’d be more in favor of advanced level MSK with CAQ in procedures than the alternative, and think that in this case the PM&R leadership has made the right decision.

So, then what's your primary certification good for? Junior college transfer credit to another specialty?

Why not just incorporate actual specialty medicine skills (advanced MSK and CAQ in procedures) and training into the primary board certification in physiatry?

Does it really take 4 years to learn how to rehab a patient with an ischemic stroke? As my all time favorite Lebonese senior resident from residency used to say, "What's so hard? Just tell them to move around!"

 

[Disciple]

So, then what's your primary certification good for? Junior college transfer credit to another specialty?

I can just picture a 70 y/o Physiatrist reading that and then punching you in the face.


Your solution is the best solution, and clearly, alot of programs have been trying to hire MSK faculty over the past several years.

Short of abruptly changing PM&R residency requirements, it's going to take a while, and maybe the ABPMR doesn't want to put programs under the gun like that.

The question is, what do we do in the interim?

 

[ShrikeMD]

Proposal: Give the programs a longer range target. They can plan in advance. If they can't meet the requirements by the time of the target date, then they are placed on probation. If they can't meet the new requirements by the end of the probation period, then they shut down.

Personally, I would rather see fewer programs, with consistent, broad scope of excellent training, than just a few good ones and the rest in varying degrees of mediocrity.

 

[drusso]

Personally, I would rather see fewer programs, with consistent, broad scope of excellent training, than just a few good ones and the rest in varying degrees of mediocrity.

absolutely.

 

[MN1]

So, then what's your primary certification good for? Junior college transfer credit to another specialty?

Why not just incorporate actual specialty medicine skills (advanced MSK and CAQ in procedures) and training into the primary board certification in physiatry?

Does it really take 4 years to learn how to rehab a patient with an ischemic stroke? As my all time favorite Lebonese senior resident from residency used to say, "What's so hard? Just tell them to move around!"

Good old Dib.

 

[drrinoo]

Proposal: Give the programs a longer range target. They can plan in advance. If they can't meet the requirements by the time of the target date, then they are placed on probation. If they can't meet the new requirements by the end of the probation period, then they shut down.

Personally, I would rather see fewer programs, with consistent, broad scope of excellent training, than just a few good ones and the rest in varying degrees of mediocrity.

cutting back on pm+r programs defies logic....is it the quality of the programs or the core knowledge of pm+r?

scale back the programs and there would be fewer physiatrists; fewer physiatrists imply less visibility. As is...any MCO/health care organization can use a simple demographic analysis to determine the valuation of a physiatrist....

e.g # physiatrists/population in Fargo, North Dakota vs. #physiatrists/population in Brooklyn....let us see conduct a survey of our members with the ICD 9 diagnosis of CVA/TBI/SCI and determine their satisfaction with their care...if it is equivalent, then we may not need physiatrists....but let us be sneaky about it and curtail their reimbursements, so that they get priced out of the market.

physiatrists are the reason the PM+R is still alive and not because of high quality academic training programs. physiatrists that see patients in the community and provide service foment more respect from the field...

impressing other physicians in other subspecialties about our holier than thou academic reputations will not save PM+R. Ultimately, patients that seek out physiatrists will preserve the field....if a patient is seeking out a physiatrist, you can be sure it wasn't due some marketing effort from the AAPM+R...it was due to the hard work and dedication of practicing physiatrists in the community.

more visibility with existing training programs is imperative...ideally, pm+r programs should add procedural training in their programs (this could be an interventional procedure, osteopathic manipulation, or the direct delivery of physical therapy)....things patients want and not what we think patients need.

 

[paindefender]

cutting back on pm+r programs defies logic....is it the quality of the programs or the core knowledge of pm+r?

scale back the programs and there would be fewer physiatrists; fewer physiatrists imply less visibility. As is...any MCO/health care organization can use a simple demographic analysis to determine the valuation of a physiatrist....

e.g # physiatrists/population in Fargo, North Dakota vs. #physiatrists/population in Brooklyn....let us see conduct a survey of our members with the ICD 9 diagnosis of CVA/TBI/SCI and determine their satisfaction with their care...if it is equivalent, then we may not need physiatrists....but let us be sneaky about it and curtail their reimbursements, so that they get priced out of the market.

physiatrists are the reason the PM+R is still alive and not because of high quality academic training programs. physiatrists that see patients in the community and provide service foment more respect from the field...

impressing other physicians in other subspecialties about our holier than thou academic reputations will not save PM+R. Ultimately, patients that seek out physiatrists will preserve the field....if a patient is seeking out a physiatrist, you can be sure it wasn't due some marketing effort from the AAPM+R...it was due to the hard work and dedication of practicing physiatrists in the community.

more visibility with existing training programs is imperative...ideally, pm+r programs should add procedural training in their programs (this could be an interventional procedure, osteopathic manipulation, or the direct delivery of physical therapy)....things patients want and not what we think patients need.

Direct delivery of physical therapy would be great

 

[drusso]

drrinoo,

I see your point, but the dirty little secret in PM&R is that there is a lot programatic variation relative to other specialties. The field is so broad that physiatry literally means different things in different parts of the country. We depend on our national associations and special interest groups to provide "remedial" education for a lot gaping holes in residency training. There are *STILL* programs that have trouble providing sufficient breadth and depth of EMG training let alone MSK training, pain medicine, or spine! I managed no chronic vents during my residency (except for some moonlighting), but at some programs this was "bread and butter."

The specialty of physiatry is about the same size as the specialties of dermatology and radiation oncology. These specialties are academically "lean and mean." ShrikeMD has many very good observations and arguments about the various "drivers" in the field in other posts. I would rather have quality over quantity.

 

[ShrikeMD]

With regard to drrinoo's comments about the logic of scaling back pmr programs, I would emphasize that it is not my intention to shrink the specialty or its programs, per se. My point of emphasis is improving the quality of resident (and fellowship) education. If forced to choose, I believe that the benefits of providing excellent training across the patient populations treated in our broad field in fewer programs is better than delivering a lesser quality of education in numerous programs.

If we return to the question posed in the original post, "why should I do a fellowship if I can't board in it?", a number of respected colleagues have opined here regarding various facets and limitations of physiatry/physiatric education that come to mind when addressing this deceptively simple question. Physiatry is a field that IS growing, albeit unevenly, reflecting the forces (market, government reimbursement [or lack thereof], interspecialty politics, academic, lifestyle, reputation/perception) that shape individual career choices as well as physician healthcare delivery as a whole. I believe that the drive toward subspecialization is one positive engine of that growth. While my own field of subspecialization is not musculoskeletal/pain medicine, its (msk/pain) importance to physiatry is abundantly clear to me, a physiatrist subspecializing in neurorehabilitation. Similarly, I would appreciate the assistance of my colleagues in physiatric pain mgt to help us neurorehab specialists to emphasize the importance of improving the quality of neurorehabilitation training at both the residency training level and fellowship training level.

We all advance with the improvements to care that are brought about by our best practitioners, specialists, and investigators. Conversely, we are all hurt by the ill repute associated with a few fellow physiatrists whose practices reflect lesser standards of care. The common pathway for both of these groups (best/worst) is the education system. Let us therefore strive to make the physiatric education system the best possible, at the residency and fellowship level. There are programs that do this well. Let us emulate them.

 

[lobelsteve]

Replacing the old gaurd is essential in saving the field of PMR. I'm glad that this has started to happen and hope this continues over the next few years.

 

[PainMaster]

Perhaps this has been mentioned before but I'm going to reiterate it here. For a long time, I've been conflicted between Anesthesia/PM&R. I have completed rotations in both and have come to understand their specialties, particularly what scientific disciplines are implemented. The anesthesiologist needs to understand physiology, pharmacology and anatomy. The physiatrist is primarily engrossed in anatomy and neuroanatomy. Furthermore, their practical medical practice is radically different. As a physiatrist, you are constantly treating pain, be it a trigger point injection, facet injection...whatever. The anesthesiologist intubates, loads drugs and is essentially the primary care physician for the patient throughout the surgery and unlike the urologist plays with his own****.

Having said this, where is the role of an anesthesiologist in treating MSK oriented pain? NONE!!! They anesthetize pts and provide analgesics using pharmacological principles in the OR. When was the last time they performed a thorough neuro exam? Let them install pumps and provide narcotic scripts for their chronically ill patients. That is not the role of pain management in physiatry oriented pain practice. It's acute pain and it is MSK in origin.

I'm hopeful that someone with power and influence will come across this and present it at the next pain conference and gain some support for PM&R.