Unmet training SCS needs: Are fellows getting enough cases?

[drusso]

---

Members don't see this ad.

https://www.ncbi.nlm.nih.gov/m/pubmed/30674697/

In light of the opioid epidemic, are we as a field doing everything we can to get more practitioners trained in neuromodulation?


Spinal cord stimulator education during pain fellowship: unmet training needs and factors that impact future practice.
Pak DJ, et al. Reg Anesth Pain Med. 2019.
Show full citation
Abstract
BACKGROUND AND OBJECTIVES: With a growing need for non-opioid chronic pain treatments, pain physicians should understand the proper utilization of neuromodulation therapies to provide the most comprehensive care. We aimed to identify the unmet training needs that deter physicians from using spinal cord stimulation (SCS) devices.

METHODS: Internet-based surveys were fielded to fellows enrolled in pain fellowships during the 2016-2017 academic year accredited by the Accreditation Council for Graduate Medical Education and past pain fellows identified through pain medicine societies and SCS manufacturers.

RESULTS: Current fellows were more likely to have received SCS training during fellowship compared with past fellows (100.0% vs 84.0%), yet there was variability in fellows' SCS experiences with a wide range of trials and implants performed. Forty-six percent of current fellows felt there was an unmet training need regarding SCS. Deficiency in SCS case volume was the most common barrier that was noted (38.5%), followed by lack of SCS curriculum (30.8%) and lack of faculty with SCS expertise (23.1%). Lack of training was a predominant reason for past fellows choosing not to use SCS devices postfellowship. The majority of current and past fellows (79.5% and 55.4%, respectively) strongly supported direct training of fellows by SCS manufacturers.

CONCLUSIONS: While SCS training during pain fellowship has become more universal, the experiences that fellows receive are highly variable, and most rely on industry-sponsored programs to supplement training deficiencies. Standardization of SCS procedures may also enable less experienced providers to navigate the SCS treatment algorithm.

© American Society of Regional Anesthesia & Pain Medicine 2019. No commercial re-use. See rights and permissions. Published by BMJ.

 

[Ducttape]

er, before we get too far...

are you saying that SCS is a "replacement" for opioids? if so, what evidence do you have that this expensive therapy is appropriate as such replacement?

beyond that, SCS should be taught but not as replacement

 

[DOctorJay]

er, before we get too far...

are you saying that SCS is a "replacement" for opioids? if so, what evidence do you have that this expensive therapy is appropriate as such replacement?

beyond that, SCS should be taught but not as replacement

not sure if this will work but worth a try
https://planion-cloud-convert.s3.am...7c3d23c0f8_1_3_salim_hayek_opioids_vs_scs.pdf

 

[drusso]

not sure if this will work but worth a try
https://planion-cloud-convert.s3.am...7c3d23c0f8_1_3_salim_hayek_opioids_vs_scs.pdf

That's a compelling case.

 

[Ferrismonk]

I have general surgeons doing stims in my area. It seems anyone with an ASC wants to put them in, training or not. That is the bigger problem in my opinion.

Also, Stims are for PLS, CRPS, or terrible radic that has failed everything else in a non-surgical candidate. It's not for multiple joint pain from RA or the guy with a history of crushed pelvis and a bunch of surgeries. Two different patient populations.

 

[Ducttape]

Dollars for Docs

$233K over 4 years. $51K in 2016.

and...
his talk:
1 study SCS vs. CMM showed NO CHANGE in opioid dosage or usage at 24 months.
HF10 showed decrease from 86 to 57%, but No control as to whether a comparable non-intervention group stopped COT. so cannot draw conclusion that SCS is better.
HF-10 vs. traditional SCS - no control of conservative care to see how many stopped COT
microdose IT pump does reduce oral use, but... im not sure that there is difference in overall MED (calculations ? include the IT->oral MED conversion factors...)

he himself admits that "neuromodulation ... may be an alternative to opioids" but "evidence is needed"...

 

[Agast]

This article is useless without numbers. A survey where someone says "I feel like I haven't done enough cases" is not the same as showing only 2 cases were done.

 

[unchockey21]

This article is useless without numbers. A survey where someone says "I feel like I haven't done enough cases" is not the same as showing only 2 cases were done.

And also when they were asked. I did 130+ trials/implants as a fellow. If you asked me then, I would’ve said I had done enough. If you had asked me after my first solo one in practice, I would’ve said “need more.”

 

[SommeRiver]

And also when they were asked. I did 130+ trials/implants as a fellow. If you asked me then, I would’ve said I had done enough. If you had asked me after my first solo one in practice, I would’ve said “need more.”

You did a 4 yr fellowship?

 

[unchockey21]

You did a 4 yr fellowship?

Felt like it at times.

 

[SommeRiver]

Felt like it at times.

Can I ask what program you were a part of where one fellow did over 130 stim cases? The most I've ever heard of was 40 in a year for one fellow. Good training dude.

 

[unchockey21]

Can I ask what program you were a part of where one fellow did over 130 stim cases? The most I've ever heard of was 40 in a year for one fellow. Good training dude.

Wake Forest. Heard Rush was similar in numbers.

 

[Orin]

Yeah, needle jocks are perhaps not the best for training with if you didn't feel adequately prepared at 130+ cases.

I will say the opioid vs SCS question is interesting. If you look at studies focused on SCS prior to the CDC edict, like the SENZA study, their 80% pain relief got a 20% reduction in opioid usage. Now though, I'm sure all the studies will show dramatic reductions of 80% and 80% because of the change in physician attitudes, and the impetus to show a benefit in opioid reduction.

 

[SommeRiver]

Wake Forest. Heard Rush was similar in numbers.

Was this when Rauck was still affiliated with WF?

 

[Ducttape]

Yeah, needle jocks are perhaps not the best for training with if you didn't feel adequately prepared at 130+ cases.

I will say the opioid vs SCS question is interesting. If you look at studies focused on SCS prior to the CDC edict, like the SENZA study, their 80% pain relief got a 20% reduction in opioid usage. Now though, I'm sure all the studies will show dramatic reductions of 80% and 80% because of the change in physician attitudes, and the impetus to show a benefit in opioid reduction.

Yes but there is at least 1 study that shows a significant increase in opioid dose the year prior to implantation of stim...

 

[unchockey21]

Yeah, needle jocks are perhaps not the best for training with if you didn't feel adequately prepared at 130+ cases.

I think you missed the point. The timing of a survey question matters. I couldn’t have possibly learned more from doing another case in fellowship. But doing the first one of anything without back up will make you question yourself. I would say respondents at the end of fellowship would tend towards overconfidence and new attendings would tend towards underconfidence.

 

[unchockey21]

Was this when Rauck was still affiliated with WF?

Not sure what you mean. He still is.

 

[SommeRiver]

Not sure what you mean. He still is.

I interviewed to possibly become an attending there and I was told him and his group split off from WF.

Also if there are 6 fellows that's like 700+ cases and highly unusual.

 

[unchockey21]

I interviewed to possibly become an attending there and I was told him and his group split off from WF.

Also if there are 6 fellows that's like 700+ cases and highly unusual.

Yeah it’s a bit of a weird contentious marriage. He was formerly fully with Wake. Got fed up with university mismanagement and split to form Carolinas Pain Institute. But still associated with Wake and majority of fellowship is at CPI and not actually at WF Baptist.

As far as numbers go. It’s a high volume private practice regional referral center. 7 attendings, 1-2 midlevels per attending, 6 fellows. Multiple research studies relating to stim- Nevro, Saluda, BoSci, Stimwave. Referrals for implants coming in from several local docs who only do trials. Good relationship with several spine surgeons who referred specifically for stim trial prior to considering surgery. Stim numbers were high for sure but never dealt with any shady stuff typical of PP. For example, never did any 2 level b/l TFESIs, no shots for pills, less than 5 kyphos per fellow, less than 5 pumps between all of us over the year.

 

[SommeRiver]

Yeah it’s a bit of a weird contentious marriage. He was formerly fully with Wake. Got fed up with university mismanagement and split to form Carolinas Pain Institute. But still associated with Wake and majority of fellowship is at CPI and not actually at WF Baptist.

As far as numbers go. It’s a high volume private practice regional referral center. 7 attendings, 1-2 midlevels per attending, 6 fellows. Multiple research studies relating to stim- Nevro, Saluda, BoSci, Stimwave. Referrals for implants coming in from several local docs who only do trials. Good relationship with several spine surgeons who referred specifically for stim trial prior to considering surgery. Stim numbers were high for sure but never dealt with any shady stuff typical of PP. For example, never did any 2 level b/l TFESIs, no shots for pills, less than 5 kyphos per fellow, less than 5 pumps between all of us over the year.

That's awesome. What's funny is you still felt you were lacking once you were out on your own. I did around 10 to 15 as a fellow. First case in PP I had a spine surgeon in our group scrub with me. He does paddles and has no idea how to do regular perc leads. It helped me not at all. He's done God knows how many paddles, but it wasn't a good experience for me. Like he only closes deep fascial layers and doesn't irrigate. Little things that aren't in keeping with the "guidelines."

Most educational experience of my career was my first two implant day by myself. On a Friday I did two implants one afternoon and both took me 2 hrs each...I don't have a PA to help me.

I think no matter how much training you have, nothing is like your first

 

[Rocuronium18]

So, which fellowship programs do you feel give residents a higher volume of SCS trials/implants than others? I’ve heard Rush, Wake Forest; any others on the list?

 

[dhcofc]

At UVA we did around 10-15 pumps each which I think gives you more surgical experience than SCS. Looking for a program that does a decent number of pumps also may be better than just looking for a high volume of SCS. It never hurts to have pump skills because I think it would be much harder to learn pumps than SCS if your program was weak in pumps.

 

[gdub25]

I went to Scott and White in Temple, TX. Highest volume SCS fellowship in the country on a per fellow basis. They only take two and both are in every SCS trial and implant. They do ~200 cases each year.

I agreee that we aren’t training our felllows very well. Need to do a better job, need to have a higher standard of what is acceptable when implanting as well.

 

[pain 9090]

Yeah it’s a bit of a weird contentious marriage. He was formerly fully with Wake. Got fed up with university mismanagement and split to form Carolinas Pain Institute. But still associated with Wake and majority of fellowship is at CPI and not actually at WF Baptist.

As far as numbers go. It’s a high volume private practice regional referral center. 7 attendings, 1-2 midlevels per attending, 6 fellows. Multiple research studies relating to stim- Nevro, Saluda, BoSci, Stimwave. Referrals for implants coming in from several local docs who only do trials. Good relationship with several spine surgeons who referred specifically for stim trial prior to considering surgery. Stim numbers were high for sure but never dealt with any shady stuff typical of PP. For example, never did any 2 level b/l TFESIs, no shots for pills, less than 5 kyphos per fellow, less than 5 pumps between all of us over the year.

Some of this information is a bit dated now. The WF pain fellowship leadership has gone back to WF faculty and facilities (in 2017). WF now has >10 pain faculty (anesth/pmr/neurology pain psychology backgrounds) and 3 new clinics. CPI docs, Rauck, Kapural and Gilmore, remain affiliated with WF and operate at WF facilities (and their own and the Novant hospital). The fellows continue to spend the majority of their time at CPI and continue to get a good experience there but get more and more exposure at WF with each year. SCS, IT and kyphoplasty volume are getting stronger as the new WF faculty do lots of these. WF faculty are ramping up cancer pain interventional management with pump, kyphoplasty and RF tumor ablation. The interventional experience is improved with more procedures (kypho, pump, tumor ablation, SCS) now that WF is now fully engaged and invested.

 

[deleted993114]

Spinal cord stimulator education during pain fellowship: unmet training needs and factors that impact future practice. - PubMed - NCBI

In light of the opioid epidemic, are we as a field doing everything we can to get more practitioners trained in neuromodulation?


Spinal cord stimulator education during pain fellowship: unmet training needs and factors that impact future practice.
Pak DJ, et al. Reg Anesth Pain Med. 2019.
Show full citation
Abstract
BACKGROUND AND OBJECTIVES: With a growing need for non-opioid chronic pain treatments, pain physicians should understand the proper utilization of neuromodulation therapies to provide the most comprehensive care. We aimed to identify the unmet training needs that deter physicians from using spinal cord stimulation (SCS) devices.

METHODS: Internet-based surveys were fielded to fellows enrolled in pain fellowships during the 2016-2017 academic year accredited by the Accreditation Council for Graduate Medical Education and past pain fellows identified through pain medicine societies and SCS manufacturers.

RESULTS: Current fellows were more likely to have received SCS training during fellowship compared with past fellows (100.0% vs 84.0%), yet there was variability in fellows' SCS experiences with a wide range of trials and implants performed. Forty-six percent of current fellows felt there was an unmet training need regarding SCS. Deficiency in SCS case volume was the most common barrier that was noted (38.5%), followed by lack of SCS curriculum (30.8%) and lack of faculty with SCS expertise (23.1%). Lack of training was a predominant reason for past fellows choosing not to use SCS devices postfellowship. The majority of current and past fellows (79.5% and 55.4%, respectively) strongly supported direct training of fellows by SCS manufacturers.

CONCLUSIONS: While SCS training during pain fellowship has become more universal, the experiences that fellows receive are highly variable, and most rely on industry-sponsored programs to supplement training deficiencies. Standardization of SCS procedures may also enable less experienced providers to navigate the SCS treatment algorithm.

© American Society of Regional Anesthesia & Pain Medicine 2019. No commercial re-use. See rights and permissions. Published by BMJ.

I can tell you that they are not. I can see that the newly trained guys don't have enough experience with stim implants and seem to be afraid when you hand them sharp pointy instruments. Sometimes they don't even know the names of the instruments, so I cover for them and tell the nurse the name of the instrument a few times. It is sad, as stims are very easy and. for God's sake, they are SQ procedures (with the exception of the leads). It takes me 45-50 min to do a stim implant, which used to be average speed. Now I am considered "lightning fast" by the reps, which is a total joke. I am nothing special by a long shot and probably have the manual dexterity of a double amputee. All these take is initial good training AND LOTS OF REPS.

Most of the training programs tend to be so conservative that they minimize the use of stim, when they should be optimizing stim in their setting. What should they do? Farm out the fellows to the neurosurgeons so they can teach them to operate without fear. There is really nothing to hit with stims and guys are far to tentative when placing these. Too much time, too much mucking around- get in and get the hell out!

Oddly, I actually wanted to go back to my former training program as a staff to actually get those guys trained in implants and all the procedures they no longer teach, but they told me to "go to hell". My former mentor and chairman of the department (a very prominent and popular guy) is hated by the current chair and I am guilty by association.

I felt it was the least I could do and would probably be fun, even getting paid about 1/3 to 1/4th what I get paid now. Perhaps the training programs have become their own worst enemy and have become so conservative that they don't "push out the envelope". The training programs SHOULD be the ones researching and developing new techniques, but the opposite appears to be true.

I think I am moving in the next few months to a practice which hired a new guy from training and hired me specifically to ramp him up and show him all the BS I have accumulated through my career so I can make the guy fast and keep him out of trouble. It is my "last rodeo" and am looking forward to it, as it should be fun working with a youngster. I know as well that even at my career stage, there is a lot to learn and I can learn as well from a new guy. You just have to be very patient with them and build their confidence.

 

[deleted993114]

And also when they were asked. I did 130+ trials/implants as a fellow. If you asked me then, I would’ve said I had done enough. If you had asked me after my first solo one in practice, I would’ve said “need more.”

I would say 130 implants is a lot for one year.

 

[deleted993114]

Some of this information is a bit dated now. The WF pain fellowship leadership has gone back to WF faculty and facilities (in 2017). WF now has >10 pain faculty (anesth/pmr/neurology pain psychology backgrounds) and 3 new clinics. CPI docs, Rauck, Kapural and Gilmore, remain affiliated with WF and operate at WF facilities (and their own and the Novant hospital). The fellows continue to spend the majority of their time at CPI and continue to get a good experience there but get more and more exposure at WF with each year. SCS, IT and kyphoplasty volume are getting stronger as the new WF faculty do lots of these. WF faculty are ramping up cancer pain interventional management with pump, kyphoplasty and RF tumor ablation. The interventional experience is improved with more procedures (kypho, pump, tumor ablation, SCS) now that WF is now fully engaged and invested.

RF tumor ablation? I did not think that was the realm of pain management; however, that is pretty cool if the fellows are getting reps in that! What a valuable skill to have.

 

[callmeanesthesia]

RF tumor ablation? I did not think that was the realm of pain management; however, that is pretty cool if the fellows are getting reps in that! What a valuable skill to have.

Tumor ablation for vertebral body mets. Merit Medical (STAR Procedure) and Medtronic have systems. Did several as a fellow. It’s like a combination of a kyphoplasty and RF.

 

[deleted993114]

Tumor ablation for vertebral body mets. Merit Medical (STAR Procedure) and Medtronic have systems. Did several as a fellow. It’s like a combination of a kyphoplasty and RF.

That is very cool. We used to do kyphoplasty for isolated mets, but never an rf system in combination. When we stopped doing kyphoplasty, that kind of went out the window with it.

Sounds like a good procedure to have in your quiver.

 

[lonelobo]

Sounds like a good procedure to do in Fellowship

 

[Ducttape]

hired me specifically to ramp him up and show him all the BS I have accumulated through my career so I can make the guy fast and keep him out of trouble

so basically you are the backup quarterback...

the question is: are you going to be like last year's Tyrod Taylor, or Nick Foles?