Bird in the hand for spine fellowship?

[buddy 2004]

Does anyone have any thoughts about this year's fellowships for spine and pain. Namely, since a few more programs have lost their ACGME accreditation, it pretty much comes down to the PMR spine fellowships versus the anesthesia pain fellowship (which are accredited).

This year the PMR Academy meeting is in September, and many spine programs will make their decisions by then. Unfortunately, the anesthesia programs don't even start interviewing until then, or even later. I don't know much about how the offers are made, but in reality do people only get one chance to decide on whether or not to take the position, or is it possible to defer until December?

The decision here is not so much "best spine program" versus anesthesia, but rather "average spine fellowship that offered you a spot" versus "wait to see what happens with the anesthesia apps". I suppose many people, including myself, have subconsciously made this decision already by applying to both. Do you think getting a lot of spine interviews makes for a very competitive anesthesia app? Just wondering.

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[nvrsumr]

Very tough call. I know I had a spine fellowship offer in desirable location(for me) that probably would have led to a partnership position but held out for and got a pain spot. Had a classmate wtih multiple pain spot offers who decided instead to go straight into private practice out of residency as an interventional spine guy. I dont think there is a right answer.

 

[axm397]

I decided going into the process that if I get an offer from one of my top 5 choices, I will take it regardless of timing, etc. I kind of knew when I sent out applications which ones I considered "safety" and which ones I really wanted. My top 5 list has both PM&R and Anesthesia programs. We'll see what happens but if I get an offer from one of my top choices, even before I start getting the later anesthesia interviews, I will take it.

I think competitiveness is hard to judge - a lot of it depends on what kind of schedule the fellowship programs are on. I think that RIC/Northwestern pain fellowship program hasn't even started offering interview yet. I have gotten interview offers from both PM&R and Anesthesia programs. Not sure if you can generalize that Anesthesia programs are on a later schedule than PM&R programs.

My situation is a little different from Buddy2004's because I only applied to ACGME accredited programs including the very few remaining accredited PM&R fellowship programs. (i.e. UCLA, VCU, Spaulding, Colorado, RIC/northwestern - and I suppose can count UMich although they are under the dept of Anesthesia)

 

[dc2md]

axm, LSU is pain fellowship is still technically a PM&R fellowship. The anesthesia and PM&R programs merged under the PM&R "title".

 

[Disciple]

I suppose can count UMich although Anesthesia has taken that program over)

I understand a merger, but "Taken over"?

How so?

 

[axm397]

I understand a merger, but "Taken over"?

How so?

sorry - I meant they seem to have taken over the application process. The PM&R coordinator is no longer in charge of receiving applications and the website for the fellowship is under the Anesthesia department. I changed the wording.

http://www.med.umich.edu/pmr/news/merger.htm

 

[Dr. Ice]

I just kinda wanted to extend this forum to ask if all those of you out there who have applied to PM&R Spine programs or "Sports/Spine" programs (accredited and/or non-accredited) have received interviews yet. Just curious as it is august 2 and I have only heard from 3 programs so far. I was thinking the interviews would be coming in by now since the AAPM&R meeting is pretty early this year. Anyway, just curious...

 

[axm397]

axm, LSU is pain fellowship is still technically a PM&R fellowship. The anesthesia and PM&R programs merged under the PM&R "title".

I didn't apply to LSU so I didn't list it but can you post a link to the fellowship? I only found this: http://www.medschool.lsuhsc.edu/physical_medicine/fellowship.asp and that only lists a musculoskeletal fellowship.

 

[dc2md]

I didn't apply to LSU so I didn't list it but can you post a link to the fellowship? I only found this: http://www.medschool.lsuhsc.edu/physical_medicine/fellowship.asp and that only lists a musculoskeletal fellowship.

exactly!! the program (after hurricane Katrina) hasn't really gotten up to speed on updating it's websites. i'm currently working on the regular PM&R residency site. i'll let the fellowship program know that they need to update the info they have online.

 

[truthnotBS]

axm, LSU is pain fellowship is still technically a PM&R fellowship. The anesthesia and PM&R programs merged under the PM&R "title".

Isn't Dr. Gould, the neurologist who doesn't believe injections/interventions have any role in pain management, the new fellowship director?

 

[Disciple]

sorry - I meant they seem to have taken over the application process. The PM&R coordinator is no longer in charge of receiving applications and the website for the fellowship is under the Anesthesia department. I changed the wording.

http://www.med.umich.edu/pmr/news/merger.htm

Hmmm... It seems that the strategy to kill the PM&R "pain" movement and to stifle the growth interventional Physiatry has been largely successful in a short period of time.


I'm certainly glad that the MSK/Spine guys/gals are now front lining the academy and seem to be trying to emulate the ISIS model for Musculoskeletal Physiatry.

The timing could not have been better.

 

[lobelsteve]

If our board does not step up to the plate and get an ABMS certified Pain Medicine Fellowship track through the ABPMR, we will go the way of the dodo. The few programs that remain will not be enough to support us, and the unaccredited programs will get squezzed out by credentialling and insurance committees.

If I were a resident, I'd be leaning on the leadership to make this happen ASAP.

 

[Taus]

If our board does not step up to the plate and get an ABMS certified Pain Medicine Fellowship track through the ABPMR, we will go the way of the dodo. The few programs that remain will not be enough to support us, and the unaccredited programs will get squezzed out by credentialling and insurance committees.

If I were a resident, I'd be leaning on the leadership to make this happen ASAP.

Why do you think the unaccredited programs will have these major problems?

I was under the (possibly naive...I'm only an MSIII..) assumption that it really doesn't matter. Articles such as this interview w/ Dr. Furman http://www.aapmr.org/resident/newslttr/060d.htm seem to lean in that direction also.

 

[ampaphb]

Hmmm... It seems that the strategy to kill the PM&R "pain" movement and to stifle the growth interventional Physiatry has been largely succesful in a short period of time.


I'm certainly glad that the MSK/Spine guys/gals are now front lining the academy and seem to be trying to emulate the ISIS model for Musculoskeletal Physiatry.

The timing could not have been better.

There is a huge difference between the MSK/Sports guys and the spine folks, and with the exception of Dr. Furman, no one else on the AAPM&R board is an interventionist. Admittedly, Dr. Press is our current President, and Dr. Micheo is also a mover and shaker, but let's look at the underlying presumption before we credit ourselves with having a greater role in positions of power:

Michael W. O'Dell, MD:

Associate Chief of Rehabilitation Medicine at NewYork-Presbyterian Hospital-Weill Cornell Center and Medical Director of the Inpatient Rehabilitation Medicine Center.
​

Michael F. Lupinacci, MD:

Serving as Medical Director for HealthSouth Rehabilitation Hospital of Mechanicsburg, Dr. Lupinacci is a physiatrist. He is the founder of PRISM Physicians of Rehabilitation, Industrial & Spine Medicine, P.C.
​

Lynn H. Gerber MD:

is currently the Director of the Center for Chronic Illness and Disability, and Professor of Rehabilitation Science at George Mason University in Fairfax, Virginia.
​

Leighton Chan, MD, MPH:

is the Medical Director of the UWMC Pulmonary Rehabilitation program.
​

Bruce E. Becker, MD:

received a grant to be used in development of support program for traumatic brain and spinal cord injury patients and families while at [FONT=Arial, Verdana, Helvetica, sans-serif][SIZE=-1][FONT=Arial, Verdana, Helvetica, Sans-serif][SIZE=-1]St. Luke's Rehabilitation Institute of Spokane, WA
[/SIZE].[/SIZE].​

M. Elizabeth Sandel, MD:

is the Medical Director of Kaiser Foundation Rehabilitation Center. She is also Chief of Rehabilitation Medicine at Kaiser Foundation Hospital in Vallejo. She is a graduate of Bucknell University and the Medical College of Pennsylvania. After residency training in Physical Medicine and Rehabilitation at Thomas Jefferson University Hospital in Philadelphia, she completed a fellowship in Brain Injury Rehabilitation at Magee Rehabilitation Hospital.
​

Kurt Hoppe, MD:

lists his interests as musculoskeletal rehabilitation, spinal cord injury medicine, disability and chronic disease healthcare public policy
​

William F. Micheo, MD:

[SIZE=-1]Director of Physical Medicine,. Rehabilitation & Sports Health at the University of Puerto. Rico School of Medicine
[/SIZE]​

David X. Cifu, MD:

His areas of expertise in PM&R include geriatrics, stroke, brain injury and multitrauma.
​

Steve M. Gnatz, MD:

Professor
Chief, Inpatient Medical Director, Loyola University
​

Seems to me the old inpatient guard remains in the VAST majority.

 

[axm397]

Having been part of board of governors meetings and conference calls, I have to defend the board members of the AAPM&R. (DRUSSO can give his perspective too) First of all, the AAPM&R is NOT an accrediting or certifying body. (that would be the ABPM&R - yes, the same organization that decided in its infinite wisdom to move our board exam to August so there would be less "cheating")

Many of the board members are very much in touch with the concerns of younger members of the AAPM&R and understand the trend within the field to move more towards MSK/Spine/Sports. (as evidenced by several surveys of PGY4s and young physiatrists) true - there are a few old school inpatient rehab types who may not "get it" - but I have to say I was pleasantly suprised by the majority of the board who understand the numerous economic, legislative, political, and other factors that influence our field and our residents.

I think we missed the boat years ago when the RRCs met and came up with the ACGME accreditation requirements including having to learn things like intubation and other OR techniques that are clearly anesthesia biased. We are now dealing with the aftermath of that decision.

You would be suprised how many of the board members called out in the above post - have involvement in the field of pain management. For example, Dr. Cifu is the fellowship director for VCU's interventional pain program (which is one of the few accredited PM&R based pain fellowships left)
Dr. Lupinacci and Lanoff represent private practitioners and their interests - which include MSK/pain. Most of the academic types actually may be more up-to-date than some of the private practitioners since they actually SEE their residents pursuing fellowships in MSK/pain/spine. Dr. Gnatz's residency program (loyola) is probably pretty ahead of others in terms of interventional procedure exposure.

Dr. Cifu is going to be president 2007-8 and Dr. Micheo will be president 2008-9. If that's not a good thing, I dont' know what is. PASSOR members are still very active on the board and their "reintegration" efforts are because they think physiatrists interested in MSK/sports/spine are a much bigger group than they used to be so PASSOR interests = AAPM&R interests. the new journal should have more clinically applicable research within MSK/sports/spine in addition to inpatient rehab. It's really the inpatient rehab ppl who are feeling a bit left out these days.

We residents have been pretty vocal and our opinions are getting heard by the Academy. There's just no clear consensus on how to handle this issue. Should we be learning basic interventional procedures during residency so we can be "competent" in those procedures by graduation? (like EMGs) should interventional procedures be part of ACGME requirement for PM&R residencies? Can we take initiative so that when the next ACGME RRC cycle window comes along, we can take back some control/ have some input in the accreditation of pain fellowships? (like sports medicine) Internal politics at various academic institutions are probably key - the more respect and input a PM&R program has on its pain fellowship, the more ease with which PM&R applicants can land a fellowship spot. The more key anesthesia pain physicians exposed to the benefits of having PM&R components within their fellowships, the better.

the 2007-8 fellowship application cycle has probably been one of the toughest for PM&R applicants. Last year's applicants had to deal with a lot of uncertainty but many programs still had PM&R input and some slid into the last accredited spots in programs about to lose accreditation. This year, there are very few accredited PM&R spots and A LOT of change in a very short period of time with very little indication of how the internal political battles worked out. There's still a lot of confusion and uncertainty at many of the programs. Some traditionally anesthesia based fellowships seem to have set up "quotas" on how many PM&R applicants they will actually consider. Others have continued with their attitude of not considering PM&R applicants at all. Do I feel screwed? yes, a little bit. But fellowship is just like anything else in life - a lot of it is who you know and not what you know and more importantly who your letter writers know. Good interpersonal skills, long term relationships with key letter writers, good reputation within your residency program, will still get you far.

We at the RPC are working on a more user friendly fellowship database - hopefully with information on anesthesia programs that have accepted PM&R applicants, etc. The Academy is listening to us and you will see changes in the years to come. It's easy to point the blame on the "higher ups" and sometimes they do deserve it - but I have to say in this case, the Academy board members are not to blame - at least not all the blame.

 

[ampaphb]

Having been part of board of governors meetings and conference calls, I have to defend the board members of the AAPM&R. (DRUSSO can give his perspective too) First of all, the AAPM&R is NOT an accrediting or certifying body. (that would be the ABPM&R - yes, the same organization that decided in its infinite wisdom to move our board exam to August so there would be less "cheating")

Many of the board members are very much in touch with the concerns of younger members of the AAPM&R and understand the trend within the field to move more towards MSK/Spine/Sports. (as evidenced by several surveys of PGY4s and young physiatrists) true - there are a few old school inpatient rehab types who may not "get it" - but I have to say I was pleasantly suprised by the majority of the board who understand the numerous economic, legislative, political, and other factors that influence our field and our residents.

I think we missed the boat years ago when the RRCs met and came up with the ACGME accreditation requirements including having to learn things like intubation and other OR techniques that are clearly anesthesia biased. We are now dealing with the aftermath of that decision.

You would be suprised how many of the board members called out in the above post - have involvement in the field of pain management. For example, Dr. Cifu is the fellowship director for VCU's interventional pain program (which is one of the few accredited PM&R based pain fellowships left)
Dr. Lupinacci and Lanoff represent private practitioners and their interests - which include MSK/pain. Most of the academic types actually may be more up-to-date than some of the private practitioners since they actually SEE their residents pursuing fellowships in MSK/pain/spine. Dr. Gnatz's residency program (loyola) is probably pretty ahead of others in terms of interventional procedure exposure.

Dr. Cifu is going to be president 2007-8 and Dr. Micheo will be president 2008-9. If that's not a good thing, I dont' know what is. PASSOR members are still very active on the board and their "reintegration" efforts are because they think physiatrists interested in MSK/sports/spine are a much bigger group than they used to be so PASSOR interests = AAPM&R interests. the new journal should have more clinically applicable research within MSK/sports/spine in addition to inpatient rehab. It's really the inpatient rehab ppl who are feeling a bit left out these days.

We residents have been pretty vocal and our opinions are getting heard by the Academy. There's just no clear consensus on how to handle this issue. Should we be learning basic interventional procedures during residency so we can be "competent" in those procedures by graduation? (like EMGs) should interventional procedures be part of ACGME requirement for PM&R residencies? Can we take initiative so that when the next ACGME RRC cycle window comes along, we can take back some control/ have some input in the accreditation of pain fellowships? (like sports medicine) Internal politics at various academic institutions are probably key - the more respect and input a PM&R program has on its pain fellowship, the more ease with which PM&R applicants can land a fellowship spot. The more key anesthesia pain physicians exposed to the benefits of having PM&R components within their fellowships, the better.

the 2007-8 fellowship application cycle has probably been one of the toughest for PM&R applicants. Last year's applicants had to deal with a lot of uncertainty but many programs still had PM&R input and some slid into the last accredited spots in programs about to lose accreditation. This year, there are very few accredited PM&R spots and A LOT of change in a very short period of time with very little indication of how the internal political battles worked out. There's still a lot of confusion and uncertainty at many of the programs. Some traditionally anesthesia based fellowships seem to have set up "quotas" on how many PM&R applicants they will actually consider. Others have continued with their attitude of not considering PM&R applicants at all. Do I feel screwed? yes, a little bit. But fellowship is just like anything else in life - a lot of it is who you know and not what you know and more importantly who your letter writers know. Good interpersonal skills, long term relationships with key letter writers, good reputation within your residency program, will still get you far.

We at the RPC are working on a more user friendly fellowship database - hopefully with information on anesthesia programs that have accepted PM&R applicants, etc. The Academy is listening to us and you will see changes in the years to come. It's easy to point the blame on the "higher ups" and sometimes they do deserve it - but I have to say in this case, the Academy board members are not to blame - at least not all the blame.

Interesting, and a little disappointing, that you have drunk the Kool-aid to that degree, axm. Having spoken to your predecessor regarding this very topic, I will allow him to speak on his own behalf, but suffice it to say, I found his take on things far more exasperated, and somewhat disheartened by his experience, than your pollyannaish view.

Points of clarification -
1) Dr. Cifu is NOT the MCV fellowship director - Michael DePalma is (http://www.pmr.vcu.edu/directory/default.aspx).

2) Dr Lanoff does not sit on the Board of Governors (http://aapmr.org/academy/bogpublic.htm).

3) Barry Smith, our representative to the RRC when decisions were made regarding fellowship requirements, remains the Vice Chair of the PM&R RRC (http://www.acgme.org/acWebsite/RRC_340/340_comMemb.asp)

Oh, and when you speak with drusso, you might ask whose initiative it was to disband the RPC altogether.

The "listening" the Board of Governors do to residents is only enough to make us think we matter, but any initiatives that arise from resident ranks quickly get deferred to the infinite loop of "further study".

 

[axm397]

I think the new executive director has made a difference in the BOG and many changes have taken place in the past few years. The staff member who we think may have wanted to get rid of the RPC has no influence over the RPC anymore and we have a newly hired liaison.(my opinion) I have met with the exec director personally several times and have spent some time conversing with Joel Press and others on the board and I don't believe I am "tainted" or overly optimistic. I think there is a genuine interest to have residents have representation within the Academy. true - the RPC is smaller now- but the restructuring is in parallel to the restructuring of the Academy as a whole.

Cifu may not be the official director but my application was addressed to him: http://www.pmr.vcu.edu/fellowships/pain/default.aspx and applicants interview with him.

Lanoff is not on the BOG but he has attended BOG meetings and conference calls and has spoken up vocally about the needs of private practioners.

Heidi Prather and other PASSOR members were present at the board meeting. (ex. Dr. Bagnall, Weinstein)

ampaphb, I think you are working off old information and although well intentioned, your accusations and blame really don't accomplish much. I believe I have served with the best interest of current and future PM&R residents as well as the field in mind and I may not agree with some of the historical events that have taken place and even with some of the BOG members but I am going to try diplomacy and conversation rather than alientating the board members. RPC members have gone on to serve on various AAPM&R committees and as we rise in ranks, we will have more say.

the bond that keeps us together is our identity as a physiatrist - our unique approach to patients and our committment to quality of life and function. Inpatient vs outpatient, MSK vs whatever subfield matter less. We need our payors and patients to recognize us for what we do, we need to produce more evidence/research to support what we do, and advocate in the political arena to secure funding and policies to help us grow.

 

[Disciple]

There is a huge difference between the MSK/Sports guys and the spine folks, and with the exception of Dr. Furman, no one else on the AAPM&R board is an interventionist. Admittedly, Dr. Press is our current President, and Dr. Micheo is also a mover and shaker, but let's look at the underlying presumption before we credit ourselves with having a greater role in positions of power:


Seems to me the old inpatient guard remains in the VAST majority.

True, however it seems PASSOR feels it has enough backing to impose its will on the academy,

to a certain extent.

This year's academy meeting is the first that I've seen with a "spine" track with a significant portion dedicated to research and the science behind interventions.

We can always do better and move faster, but at least it's a start.

It would be nice if some of the younger interventionalists would lend some support to PASSOR instead of contributing only to ASIPP, ISIS, NASS and AAPM, even if the AAPMR/PASSOR doesn't ideally represent their practice style/model.

 

[Disciple]

If our board does not step up to the plate and get an ABMS certified Pain Medicine Fellowship track through the ABPMR, we will go the way of the dodo. The few programs that remain will not be enough to support us, and the unaccredited programs will get squezzed out by credentialling and insurance committees.

If I were a resident, I'd be leaning on the leadership to make this happen ASAP.

After sitting through enough lectures (with unspoken underlying themes) at pain society national meetings, it's become clear to me that the pain academics see the increase in procedural utilization through rapid growth of Interventional Physiatrists, above other fields, as their greatest threat, second only to weekend warriors doing procedures. For example, you never hear anyone complain about Interventional Radiologists failing to practice comprehensive pain medicine or "cherry-picking" procedures.

Interesting how the Roundtable on the preservation of Interventional Pain Management at the ASIPP annual meeting this year included ISIS, NASS, AAPM, ASRA and ASA. PASSOR was notably absent. I'm assuming PASSOR was not invited.

The academy seems to be changing for the better within an acceptable time frame. However, these problems could be ended decisively, and the responsibility for that lies with the ABPMR. There is not a single interventionalist on the board. There is one EMG rep, one MSK/sports rep and the rest are department chairmen with inpt focus. Perhaps AXM could tell us if there's a liason between the academcy and the ABPMR.

One such board member does insurance UR and routinely denies my treatment requests for spinal injections in even the most appropriate patients because he thinks they don't work.

Regarding the pain accreditation negotiations, with what's going on now, it's clear the ABPMR was either ambivalent, naive or bullied into agreement.

Another shining example is the institution where I completed my residency. The gas pain fellowship is now using the PM&R, Neuro and Psyche departments to maintain accreditation, but still refuses to consider applicants from these specialites, including those from the departments who are helping them. Funny, the director of said fellowship will train Physiatrists (as evidenced by a recent course I attended) if he's paid by Medtronic, or other device company, to do so. So much for inter-specialty collaboration and good-will.

It matters not whether some sort of accredited fellowship track/certification is created or whether the residency guidelines are changed. The important thing is that something significant is done and done quickly.

 

[paz5559]

I think there is a genuine interest to have residents have representation within the Academy.

Representation, yes. Influence? How is that fellowship match drrusso and I worked so hard to implement doing? Still tabled, I would guess.

 

[axm397]

The fellowship match - the concept of having a "match day" for pain/MSK/spine fellowships - had a lot of support from PM&R fellowship directors (Press and Furman included) - BUT, since many of us are applying to both PM&R AND anesthesia fellowships, it would be hard for the AAPM&R RPC to influence the anesthesiologist fellowship directors to participate. And we ran into a legal issue - the Academy's legal council didn't think the AAPM&R should take the legal risk of endorsing a "match" - especially because the Academy is not an accrediting agency and wouldn't be able to host a match day process. There were too many unknowns - and then what ultimately killed the idea was the survey of PM&R residents who overwhelmingly responded that they would take a fellowship spot outside of a "match" if an offer came from their top choice program. If residents didn't want to agree to a "match", how can we ask fellowship directors to support the concept?

 

[paz5559]

The fellowship match - the concept of having a "match day" for pain/MSK/spine fellowships - had a lot of support from PM&R fellowship directors (Press and Furman included) - BUT, since many of us are applying to both PM&R AND anesthesia fellowships, it would be hard for the AAPM&R RPC to influence the anesthesiologist fellowship directors to participate. And we ran into a legal issue - the Academy's legal council didn't think the AAPM&R should take the legal risk of endorsing a "match" - especially because the Academy is not an accrediting agency and wouldn't be able to host a match day process. There were too many unknowns - and then what ultimately killed the idea was the survey of PM&R residents who overwhelmingly responded that they would take a fellowship spot outside of a "match" if an offer came from their top choice program. If residents didn't want to agree to a "match", how can we ask fellowship directors to support the concept?

I don't want to argue the specifics of the match, and so this will be my only post on the subject.

The concept of a fellowship match was brought to the AAP in conjunction with the AAPM&R. The NRMP, and to a lesser extent it's counterpart, the San Francisco Match, were on board as well. Thus the Academy's "legal risk" was nonsensical.

The issue with Anesthesiology was clearly recognized, and what was proposed was not a pure PM&R Match, but rather a joint PM&R/Anesthesia match for just that purpose.

Lastly, the whole purpose of a match is so that it is inclusive. Of course the residents would put self-interest above the general concept of a match. The whole reason this was brought to AAMP&R with the blessing of the program directors from AAP, and spearheaded by such luminaries as Dr. Smith and Dr. DeLisa was precisely because it was recognized that the only way a match could work was if the top programs signed on. The only way it was ever envisioned to be implemented was with the vast majority of programs participating, so that no one could back door the program without being in violation of the match agreement in the first place.

The powers that be didn't want a match, and found reasons to defeat the proposal. Once it was dead in the water, it was safe once again to support the concept, as they knew it would not be implemented.

 

[drvlad2004]

I just kinda wanted to extend this forum to ask if all those of you out there who have applied to PM&R Spine programs or "Sports/Spine" programs (accredited and/or non-accredited) have received interviews yet. Just curious as it is august 2 and I have only heard from 3 programs so far. I was thinking the interviews would be coming in by now since the AAPM&R meeting is pretty early this year. Anyway, just curious...

Dr. Ice,

I am in the same exact position as you. I have heard from only 3 Sports/Spine and Spine programs thus far. 2 of which will be 2nd interviews. It is already the first week of August. Oddly enough, all of my interviews are from the West and Midwest. I haven't heard anything from here in the East Coast yet. In fact, I did one rotation in Manhattan. However, they have not invited or reviewed the applications yet. Some of my fellow senior residents in my program are still waiting to hear from several programs.

I hope that this may the week where I get invited to more programs.

 

[Disciple]

Why do you think the unaccredited programs will have these major problems?

I was under the (possibly naive...I'm only an MSIII..) assumption that it really doesn't matter. Articles such as this interview w/ Dr. Furman http://www.aapmr.org/resident/newslttr/060d.htm seem to lean in that direction also.

Every group has their own agenda. It all depends on whose agenda you think is going to win out in the end. However, it's a double whammy for Physiatrists if we don't even have the backing of our own board.

 

[Disciple]

Dr. Gnatz's residency program (loyola) is probably pretty ahead of others in terms of interventional procedure exposure.

I think you can thank their program director Dr. Steiner for that. If I remember correctly from some rotations I had at Loyola (almost 3 years ago), some of the residents were upset that Dr. Gnatz wanted them to take more inpt call.

We residents have been pretty vocal and our opinions are getting heard by the Academy. There's just no clear consensus on how to handle this issue. Should we be learning basic interventional procedures during residency so we can be "competent" in those procedures by graduation? (like EMGs) should interventional procedures be part of ACGME requirement for PM&R residencies? Can we take initiative so that when the next ACGME RRC cycle window comes along, we can take back some control/ have some input in the accreditation of pain fellowships? (like sports medicine) Internal politics at various academic institutions are probably key - the more respect and input a PM&R program has on its pain fellowship, the more ease with which PM&R applicants can land a fellowship spot. The more key anesthesia pain physicians exposed to the benefits of having PM&R components within their fellowships, the better.

Maybe I'm already a little cynical from doing worker's comp and dealing with attorneys and insurers, but one thing I have learned is that interested parties, including doctors, will often disguise their agendas to make it appear as if their intentions are righteous. Regarding showing the benefits of PM&R, personally, I don't think that many of these pain departments actually care. Many of them still feel it is beneath them to prescribe pain medication or do anything other than inject or put in implants.

My feeling is that the intention of the gas RRC going into the negotiations was not one of mutual respect and collaboration but something along the lines of:

"OK, so here's the plan, we'll throw these guys a bone and give them figurehead representation in our faculty. In exchange we will be able to assimilate or shut down most of their fellowships and stop the creation of any new ones. The 15-30 programs we lose will be collateral damage. Thus, we will be able to control their numbers and retain control over the field".

When I interviewed at some gas programs back in '05, the above was reinforced through statements made point blank to my face.

Like I said above, it is my feeling that the ABPMR was either ambivalent, naive or bullied into agreement.

Bullied I can forgive, but not ambivalent or naive.

What many don't understand, and as I stated above, is that it doesn't matter which option is chosen (whether an accredited MSK/Spine fellowship track is created or if the decision is made to change the residency requirements/guidelines). What's important is that something significant is done to protect a large constituency of practicing Physiatrists.

It is a simple concept, yet complicated when you mix in the politics.

 

[dc2md]

Dr. Gnatz's residency program (loyola) is probably pretty ahead of others in terms of interventional procedure exposure.

We actually have the possibility of getting 3-4 months of interventional experience during our 4yr program...not too shabby eh?

 

[axm397]

I think you can thank their program director Dr. Steiner for that. If I remember correctly from some rotations I had at Loyola (almost 3 years ago), some of the residents were upset that Dr. Gnatz wanted them to take more inpt call.



Maybe I'm already a little cynical from doing worker's comp and dealing with attorneys and insurers, but one thing I have learned is that interested parties, including doctors, will often disguise their agendas to make it appear as if their intentions are righteous. Regarding showing the benefits of PM&R, personally, I don't think that many of these pain departments actually care. Many of them still feel it is beneath them to prescribe pain medication or do anything other than inject or put in implants.

My feeling is that the intention of the gas RRC going into the negotiations was not one of mutual respect and collaboration but something along the lines of:

"OK, so here's the plan, we'll throw these guys a bone and give them figurehead representation in our faculty. In exchange we will be able to assimilate or shut down most of their fellowships and stop the creation of any new ones. The 15-30 programs we lose will be collateral damage. Thus, we will be able to control their numbers and retain control over the field".

When I interviewed at some gas programs back in '05, the above was reinforced through statements made point blank to my face.

Like I said above, it is my feeling that the ABPMR was either ambivalent, naive or bullied into agreement.

#3 I can forgive, but not the other two.

What many don't understand, and as I stated above, is that it doesn't matter which option is chosen (whether an accredited MSK/Spine fellowship track is created or if the decision is made to change the residency requirements/guidelines). What's important is that something significant is done to protect a large constituency of practicing Physiatrists.

It is a simple concept, yet complicated when you mix in the politics.

I agree with you that something needs to be done to protect our future and that they really missed the boat during the RRC meetings. I think the AAPM&R is probably the most "progressive" PM&R organization (vs AAP, ABPMR, etc) so am hoping that they will produce some kind of change. Majority of AAPM&R members are in private practice so the Academy has to be in touch with market factors more so than the academic organizations. Having attended AAP meetings and seen what happens when residents and fellows (bbbmd, care to comment?) try to talk to PDs about getting more procedure exposure, etc. I decided to concentrate most of my efforts in the Academy and still try to continue to be involved with the AAP. As younger academics with strong interest in pain and MSK/sports/spine enter the picture, hopefully the residency programs will change. Rehab_sports_dr and bbbmd are pioneers in my mind - entering academic PM&R with a MSK/pain background. As residents keep pushing for more MSK/spine/pain exposure and continue to pursue fellowship training, the PDs will have to recognize that there is a demand for such training. Many PDs already realize that many of the top PM&R applicants are looking at things like procedure exposure, MSK/sports/spine training, etc. That's not to say we should neglect the inpatient side of rehab.

Also, in terms of procedure exposure - I think it's the quality of exposure that counts - not just the quantity. Ideally, being able to learn under fellowship trained interventionalists would be great. If there was a way to assess competence so PDs or preceptors can "sign off" on certain procedures, that would be better. During my intern year, I got "signed off" on certain procedures (central lines, etc.) after completing a set number of them under the supervision of experienced attendings then was able to perform them independently - something like that - standardized - would be nice. I would think basic lumbosacral procedures, SI joint, hip, and other peripheral join injections should all be part of a good PM&R residency training. MSK ultrasound would be a nice plus. I think many programs do have all of that and many residents go on to get private practice jobs performing those procedures without fellowships already - but having something standardized across the nation would be ideal. I guess we have to see what happens in the years to come.

 

[lobelsteve]

Also, in terms of procedure exposure - I think it's the quality of exposure that counts - not just the quantity. Ideally, being able to learn under fellowship trained interventionalists would be great. If there was a way to assess competence so PDs or preceptors can "sign off" on certain procedures, that would be better. During my intern year, I got "signed off" on certain procedures (central lines, etc.) after completing a set number of them under the supervision of experienced attendings then was able to perform them independently - something like that - standardized - would be nice. I would think basic lumbosacral procedures, SI joint, hip, and other peripheral join injections should all be part of a good PM&R residency training. MSK ultrasound would be a nice plus. I think many programs do have all of that and many residents go on to get private practice jobs performing those procedures without fellowships already - but having something standardized across the nation would be ideal. I guess we have to see what happens in the years to come.

Quality makes you competent to perform the procedure, quantity allows you to handle the complications.

Regulating procedures without a standard of care is not going to work. I have seen anes based PD's perform blind CESI's. I would not recommend doing, teaching, or allowing this to be performed on me. But it happens. and it rarely kills anybody. So whose technique becomes an issue and then the ego's get in the way of a politcal and economic fight. Outcome- Clusterfrig.

 

[drusso]

Wow...

Lot's of wheat and chaff in in these threads. I'll add my own purely opinion-based musing:

1) Interventional "insert anything here" does not equal pain medicine as a specialty. No single specialty adequately prepares a person for all aspects of the competent practice of subspecialty pain medicine. If you ask any of the "Pioneers" if they think that they could walk into the field today (at its current state of the art) fresh out of whatever their base training was, and practice safely and competently, they'll tell you "no."

2) Right *NOW* accreditation matters, but probably much less than you think. Don't know what the situation could be like in 10 or 15 years. If you do an unaccredited pain/spine/MSK fellowship, you can still be boarded via the ABPM. It's a legit board, though maybe not as "prestigious" as the ABMS. It's on the same rung as the AANEM.

3) Anesthesiology programs exist to train anesthesiologists though they may certainly choose to train anyone they wish. They don't owe physiatry any favors. Anesthesia departments are bigger and generally have more grant funding than physiatry departments so generally have more organizational clout...hence, they will likely muscle out PM&R if things continue as they are.

4) The fellowship match was an idea destined to die, but at least it died a loud, ugly, racuous death. I consider it valuable "road-kill" on the path to hopefully better things...

5) For reasons that still boggle me, there is a lot of ambivalency on the part of organized physiatry to the thought, promise, or threat of PM&R becoming a more out-patient oriented, procedurally-based specialty (I like to think of Dermatology as a specialty model for physiatry.)

I don't know why...I think that that it has generally to do with the fact that most academic physiatry departments are low on the food-chain in academic health science centers...this breads a very conservative, risk-averse leadership style that becomes perpetuated in the field. Also, how many of **YOU** (including **ME**) are willing to bring your fancy-shamancy interventional skills back to a po-dunk PM&R department and start teaching residents...for about 1/2 your private practice salary?? Pazz?? Disciple?? Buehler...

 

[ampaphb]

Wondered if anyone else noticed Dr. Furman's recent not to kind swipe at SDN http://www.aapmr.org/resident/newslttr/060d.htm which in releveant part said:

"Unfortunately, there are a lot of Web-based forums that put out too many opinions of a few very prolific individuals that may or may not be right. There are things on those forums that are totally based on hearsay. Examples include unsubstantiated listings of the “best” residencies or fellowships. When I’m asked about fellowships, I only know about the one I personally went to and the one I run. You really need to speak to the current and past fellows who trained there"
​

Odd, given that Dr. Furman trained current fellowship directors, and trained with others. Seems disingenuous that he wouldn't have an opinion, particularly when that is all that is being sought.

 

[Disciple]

5) For reasons that still boggle me, there is a lot of ambivalency on the part of organized physiatry to the thought, promise, or threat of PM&R becoming a more out-patient oriented, procedurally-based specialty (I like to think of Dermatology as a specialty model for physiatry.)

I don't know why...I think that that it has generally to do with the fact that most academic physiatry departments are low on the food-chain in academic health science centers...this breads a very conservative, risk-averse leadership style that becomes perpetuated in the field. Also, how many of **YOU** (including **ME**) are willing to bring your fancy-shamancy interventional skills back to a po-dunk PM&R department and start teaching residents...for about 1/2 your private practice salary?? Pazz?? Disciple?? Buehler...

What's frustrating is that there are already mechanisms in place that could be utilized for this purpose. There are PASSOR Guidelines for the performance of cervical/lumbar injections and musculoskeletal competencies. Yes, there would be logistical details that would need to be worked out, but what is really necessary is for someone at the ABPMR to press the "GO" button. Whether they would choose to change residency requirements or certify MSK/Spine fellowships is of less importance. If it proves too difficult to procure the necessary experience at all residency programs, then perhaps consider a dual pathway approach, either through residency or fellowship in the model of integrated plastics vs plastics fellowships. Granted, most residents would want to go to the intergrated programs, but that's a small price to secure the future of the profession.

You're right about the power or lack thereof of most PM&R departments. Most institutions who are lucky enough to have a PM&R department do the majority of their business through an inpt unit. So, it's in the faculty's best interest not to piss off the larger departments that may be helping to keep the beds full. Some of my more unpleasant memories from residency were of the continual pressures being brought down by other departments (PM&R is the only specialty where it's acceptable to call a non-emergent consult at 4:45 PM). On the other hand, there are program directors like Venu Akuthota (who is responsible for the newly formed spine track at the academy meeting this year) so I'm not sure that I buy that excuse. Many chairmen trained and practiced for years in a different PM&R environment, and likely have a "That's not Physiatry" or "Not in my specialty" type of attitude.

You'd think it would concern the leadership to see hordes of young Physiatrists over the past 10 years become interventionalists and then donate significant time and money to ISIS and NASS instead of the academy because the academy (until recently) is not useful to their practice model. I don't know about you but I didn't bother to renew my membership to the AAP when it came up for renewal this year.

As for teaching residents. I plan to, as an adjuct clinical instructor or 1-2 days a week at institution interested in getting an MSK/Spine program started. I don't think it would be for 1/2 my current salary though, as my salary is not doing so well at the moment (chalk it up to geographical variation, at least that's what I tell myself).

Minus the po-dunk thing as well.

 

[melancholy]

Wondered if anyone else noticed Dr. Furman's recent not to kind swipe at SDN http://www.aapmr.org/resident/newslttr/060d.htm which in releveant part said:

"Unfortunately, there are a lot of Web-based forums that put out too many opinions of a few very prolific individuals that may or may not be right. There are things on those forums that are totally based on hearsay. Examples include unsubstantiated listings of the “best” residencies or fellowships. When I’m asked about fellowships, I only know about the one I personally went to and the one I run. You really need to speak to the current and past fellows who trained there"
​

Odd, given that Dr. Furman trained current fellowship directors, and trained with others. Seems disingenuous that he wouldn't have an opinion, particularly when that is all that is being sought.

That's interesting. On one hand, I can relate to his comments on a different level - trying to inform medical students as best as possible about different residency programs. Granted, I had the opportunity to rotate through a few, interview at more, and currently attend one, there is still only so much you can get exposure to "first-hand" to feel comfortable telling other people about. Somewhere along the line, there are lots of disclaimers about taking things with a grain of salt.

On online forums, this can be both good and bad. This PM&R sub-forum has been invaluable to many folks who otherwise wouldn't have been able to make educated decisions regarding their future careers. The bad? Bits of incorrect information can spew forth in every direction. Also, the negatively-inclined vocal participants can certainly make some matters seem out of proportion. How often do we see one person write posts bashing a program or school when there are many others who are happy with things, but just don't post?

This being said, it sounds like Dr. Furman certainly has the connections to stay in the loop with various programs out there. Maybe his approach on advice-giving is heavily based on pushing applicants to search out the hard facts on fellowships from past/current fellows rather than pointing out differences between programs that may start the inevitable cascade of comparisons that we are prone to doing. Wouldn't this be a prudent approach to take in his position? (Sorry, I'm just conjecturing)

 

[Disciple]

1) Interventional "insert anything here" does not equal pain medicine as a specialty. No single specialty adequately prepares a person for all aspects of the competent practice of subspecialty pain medicine. If you ask any of the "Pioneers" if they think that they could walk into the field today (at its current state of the art) fresh out of whatever their base training was, and practice safely and competently, they'll tell you "no."

In my neck of the woods, there is a former Slipman fellow whose patients I get, usually after he's done several procedures on them. He doesn't advertise himself as a pain doctor and does not practice comprehensive pain medicine. I have no problem with that. At least what he does is (or supposedly is) evidenced based. What I take issue with are Physiatrists with little musculoskeletal training learning a few basic injections and then calling themselves Interventional Spine Specialists when what they are really doing is "Pain Medicine-Lite". It just makes the specialty look bad and is all the more reason for some sort of standardization or "quality assurance" if you will.

Interventional Radiologists don't practice pain medicine, even the ones who have narrowed their focus to interventional pain procedures. However, there aren't a whole lot of them and they certify their own fellowships/training programs, so it's not really an issue to the interventional pain community at large.

Even in the saturated geographical area I'm located in, 80-85% of Interventional Physiatrists do the "Interventional Spine" thing and the rest practice "pain medicine". We tried to put our musculoskeletal/spine skills under the pain medicine banner and we screwed it up. Let's be honest, most Interventional Physiatrists don't practice comprehensive pain medicine. Many of us work for surgeons or plan to work with/for surgeons (most of our interventional academic attendings do this and look at all the inquiries about this practice model on the pain forum). Many of us support ISIS and NASS (as opposed to APS/AAPM), have an aversion to prescribing opiates, using intrathecal therapies or doing anything inpt related. Should we say we're pain docs, sports docs and electrodiagnosticians with each Sports/Spine guy needing to carry around 3 subspecialty certifications even though his practice is only a little bit of each? Why not just say we're Physiatrists and have it mean something.

My opinion. Uplift/revamp PM&R training (by whichever methodology our elders see fit) and put an official stamp on it. The ever increasing numbers of Physiatrists with a MSK/Spine focus will raise our political clout to where it needs to be.

Problem solved.

And we can start worrying about more important things.

 

[drusso]

Let’s be honest, most Interventional Physiatrists don’t practice comprehensive pain medicine. Many of us work for surgeons or plan to work with/for surgeons (most of our interventional academic attendings do this and look at all the inquiries about this practice model on the pain forum). Many of us support ISIS and NASS (as opposed to APS/AAPM), have an aversion to prescribing opiates, using intrathecal therapies or doing anything inpt related. Should we say we’re pain docs, sports docs and electrodiagnosticians with each Sports/Spine guy needing to carry around 3 subspecialty certifications even though his practice is only a little bit of each? Why not just say we’re Physiatrists and have it mean something.

Hallelujah! Except we still can't decide what "physiatrist" means...

 

[drvlad2004]

Wow...

Lot's of wheat and chaff in in these threads. I'll add my own purely opinion-based musing:

2) Right *NOW* accreditation matters, but probably much less than you think. Don't know what the situation could be like in 10 or 15 years. If you do an unaccredited pain/spine/MSK fellowship, you can still be boarded via the ABPM. It's a legit board, though maybe not as "prestigious" as the ABMS. It's on the same rung as the AANEM.

3) Anesthesiology programs exist to train anesthesiologists though they may certainly choose to train anyone they wish. They don't owe physiatry any favors. Anesthesia departments are bigger and generally have more grant funding than physiatry departments so generally have more organizational clout...hence, they will likely muscle out PM&R if things continue as they are.

Good points as always by DRusso! I find it funny that a significant number of Anesthesiologists generally are not interested in pain management. Their starting salary often surpasses the starting salary as a pain specialist. However, over 90% of pain fellowships are through anesthesia. Also, I am surprised that no one on the PM&R forum has discussed two huge journal articles, from the AAOS and American Academy of Neurology. Each evidence-based medicine article had very damaging info about the use of lumbar epidurals. Reimbursements for spinal injections are alreading decreasing due to the growing numbers of EBM articles.

I still do not fully understand why it is necessary to do an accredited fellowship. Several job opportunities that I have seen are simply looking for a fellowship trained physiatrists? Personally I think that our specialty should keep that uniqueness of "Sports and Spine." I feel that doing an anesthesia-based pain fellowship does not allow me to incorporate EMGs and my OMM/MSKs as a fellow. I feel that I can get that through the PM&R sports/spine fellowships. Personally, I think that it is a great niche for those of us who enjoy treating athletes and active individuals to manage their acute pain.

 

[DigableCat]

I still do not fully understand why it is necessary to do an accredited fellowship. Several job opportunities that I have seen are simply looking for a fellowship trained physiatrists?

Of three jobs I'd been offered after I finished my fellowship, all of which were a combination of PM&R, Spine, and Pain, the pivotal deciding factor(other than the fact that I'm an awesome candidate ) was that I'd done an accredited fellowship.
Who was most concerned about my status: the anesthesiology department which had a voice in approving my privileges in the fluoro suite/OR.

 

[drusso]

I still do not fully understand why it is necessary to do an accredited fellowship. Several job opportunities that I have seen are simply looking for a fellowship trained physiatrists? Personally I think that our specialty should keep that uniqueness of "Sports and Spine." I feel that doing an anesthesia-based pain fellowship does not allow me to incorporate EMGs and my OMM/MSKs as a fellow. I feel that I can get that through the PM&R sports/spine fellowships. Personally, I think that it is a great niche for those of us who enjoy treating athletes and active individuals to manage their acute pain.

Fundamentally, I think that problem lies in the fact that no one believes in "Interventional Spine" as a bona-fide sub-specialty besides physiatrists, members of ISIS, and a handful of surgeons who want to employ them!

How on earth will a primary care physician decide between referring their patient to a "Pain Doc" versus an "Interventional Spine Specialist" or even an orthopod?? Let's say a family doc sends a patient with "back and leg pain" to a physiatry-trained Interventional Spine Specialist and the ISS decides that a procedure is not indicated (admittedly, probably a rare event for a ISS ) and the patient really has a PN. Does the ISS then send the patient to the Pain Doc for optimizing multi-modal pharmacology and treatment? Seems odd...

The distinction between Pain Medicine and Interventional Spine has been debated here before. I favor the definition of a pain specialist as a physician who desires to diagnose and treat *ANY* painful syndrome regardless of etiology: Cancer, headache, CRPS, acute/chronic injuries, shingles, entrapment neuropatheis, etc using all available treatment modalities including drugs, spinal interventions, implantable technology, physical modalities, and behavioral treatment. Thus, I think Pain Medicine is a broader focus than IS. I am also biased in believing that it is a focus uniquely suited to the physiatric skill set (coordination of care, DDx, long-term management, etc). I will leave it to a self-professed Interventional Spine Specialist to define their subspecialty and how it is distinct from Pain Medicine.

Now that Pain Medicine training has been consolidated into a new ACGME multidisciplinary fellowship (mostly based in university anesthesia departments), only time will tell to what extent physiatrists will continue to be involved in the practice of comprehensive pain medicine. (See related thread in Pain Rounds forum). It does appear that organized physiatry may be "giving up the ghost" of pain medicine in favor of MSK/Interventional Spine, which is odd because, historically, physiatrists were managing chronic pain with opioids, adjuvants, and injections before most anesthesiologists figured out how to do a TFESI!

As Disciple and others here have argued, perhaps one solution is to incorporate what is currently learned in Interventional Spine fellowships back into core PM&R residency training (basic neuraxial procedures, MSK medicine, and EMG). The dirty little secret in our field is that most MSK/Spine fellowships really exist to offer an opportunity for remedial education that is lacking in most PM&R residency programs. It is a little shameful that some physiatry residency graduates require doing fellowship in MSK/Spine in order to feel like the bona fide MSK specialists/experts that they are supposed to be!

Basic procedural competencies in neuraxial, EMG, and peripheral joint injections is what aspiring applicants to the field have always been looking for in selecting a residency program. Of course, ensuring this level of competency (to the public, stakeholders, and trainees) will mean drastically altering basic program requirements, overhauling curricula, and building new capacities in academic physiatry departments. It would probably mean closing some smaller programs that couldn't pass muster. I don't think that most PM&R department chairs are up to this challenge at this time and are still fighting more fundamental battles in their institutions for space, recognition, and resources.

And the beat goes on...

 

[Xardas]

Basic procedural competencies in neuraxial, EMG, and peripheral joint injections is what aspiring applicants to the field have always been looking for in selecting a residency program. Of course, ensuring this level of competency (to the public, stakeholders, and trainees) will mean drastically altering basic program requirements, overhauling curricula, and building new capacities in academic physiatry departments. It would probably mean closing some smaller programs that couldn't pass muster. I don't think that most PM&R department chairs are up to this challenge at this time and are still fighting more fundamental battles in their institutions for space, recognition, and resources.

And the beat goes on...

I would actually argue that larger programs by virtue of bureaucracy and bulk are harder to change.

I can tell you right off the bat that the large program I trained at has a lot of work to do to overhaul its criteria. In fact, the stodgy traditional programs with tons of inpatient rehab are harder to change than the small flexible ones where 1 or 2 new hires can make a huge change in the direction.

I am not fellowship trained although I am seriously considering it. While you mention that these skills should be ready upon graduating from residency I would differ a little and say that to some degree yes, but a 12-18 month fellowship concentrated say in msk/spine could allow a huge leap in a physiatrists' overall skills and knowledge, if done right.

The way I look at it is the non-standardization of a lot of these spine/msk fellowships, where admittedly some of them are done to keep a low paid doctor around versus more money on a mid level, is a key area that needs to be resolved over the coming years.

 

[Louisville04]

Of three jobs I'd been offered after I finished my fellowship, all of which were a combination of PM&R, Spine, and Pain, the pivotal deciding factor(other than the fact that I'm an awesome candidate ) was that I'd done an accredited fellowship.
Who was most concerned about my status: the anesthesiology department which had a voice in approving my privileges in the fluoro suite/OR.

1) I have seen several hospitals where the only way you can get privileges is if you work for a group that is already there. I think the groups are powerful enough where they won't let independent pain docs get privileges unless they are working for them.

2) Quite a few jobs are working in an ASC that is already owned by a group. So privileges will not be a problem.

 

[rehab_sports_dr]

Lots of great discussion in this thread. Some random comments:

1. I agree that the AAPMR has been more progressive and forward thinking than the ABPMR. There are likely several reasons for this.
a. The composition of the leadership of the AAPMR, as noted, has more MSK inclined physicians
b. The ABPMR has to be concerned with accrediting the body of knowledge as it currently exists, and therefore will have some lag time as they adjust to a growing literature.
That said, I think the ABPMR has moved inappropriately slowly. In meetings, I have heard some members voice their disbelief in the efficacy of interventional spine procedures. It is my impression that their opinions are not based on a thorough review of the literature, but on the practice patterns to which they've grown accustomed.
While the literature for many aspects of interventional spine medicine are not overly robust, that is true of many aspects of PM+R, and, as just one example, the literature supporting at transforaminal epidural for a lumbosacral radiculopathy, is stronger than much of the cannon of the PM+R literature.
c. The ABPMR has to be concerned not only in moving the field forward, but also continuing to certify the basic skills sets of the residents in all aspects of physiatry. An embarrassingly large number of residents graduate without what I consider basic skill and knowledge sets (e.g., the ASIA exam, how to write a wheelchair prescription, management of agitation in TBI). So the board has other fish to fry, and not just the advancement of novel and emerging treatments.

What would I do if I was made emperor and imperial ruler of physiatry?
Tough question. I think, as many others have alluded to, that ultimately the term physiatrist has to have some underlying uniform meaning. When a doc sends a patient to a physiatrist for a consult, it has to imply that they are capable of a full MSK assessment, the ability to prescribe assistive devices appropriately, write appropriate therapy prescriptions, feel comfortable with medication management, electrodiagnostic evaluation, reading and interpreting the appropriate imaging studies, and referring for the appropriate interventional spine procedures as necessary. I do not believe, as a field, we are there yet- I think many residents, even those passing the boards, are deficient in many of these areas, and the first priority of the board is addressing these core issues.

I am highly skeptical of the ability of most programs to train residents in basic lumbosacral interventional procedures and still meet these goals, since they aren't meeting many of the basic goals now even without having added the spinal procedures.

I think we should probably adopt the model of internal medicine. They have a core curriculum and accreditation that pretty clearly defines what it means to be an internist and what you can expect when you consult them. If you require a level of specialty care that requires additional training, you see a specialist whose skill set was defined WITHIN THE CONTEXT of what internal medicine thought was appropriate.
For example, gastroenterologists define what it means to be a GI fellow, rheumatologists define what it means to be a rheum fellow.
PM+R has to clearly define what it means to be interventional trained. Currently, their is a huge ambiguity as what the fellowship training means. As DRusso pointed out, the term Pain fellowship trained is something very distinct from the core principles of physiatry, and either we accept that as a distinct specialty, or have to very aggressively and actively act to redefine the accreditation and core skill set of an ACGME accredited pain fellow.
PASSOR was not uniform enough and did have enough monitoring to truly have a PASSOR fellowship mean something. The differences between, e.g., the Fuhrman fellowship in York and the Sports fellowship with Jay Smith at Mayo are too great for them to have a uniform and consistent meaning. Both fellowships, from what I've heard from past fellows are terrific, but they are obviously teaching such different things that to call them both PASSOR fellowships negates much of the clarity of what a PASSOR fellowship is.
I happen to like the ISIS guidelines and philosophy very much, and I think they best approximate what I think an interventional spine physiatrist should try to emulate. As of now, though, they don't really have an accrediting process for fellowships.

Anyway, enough for my ramble

 

[drusso]

When a doc sends a patient to a physiatrist for a consult, it has to imply that they are capable of a full MSK assessment, the ability to prescribe assistive devices appropriately, write appropriate therapy prescriptions, feel comfortable with medication management, electrodiagnostic evaluation, reading and interpreting the appropriate imaging studies, and referring for the appropriate interventional spine procedures as necessary. I do not believe, as a field, we are there yet- I think many residents, even those passing the boards, are deficient in many of these areas, and the first priority of the board is addressing these core issues.

I am highly skeptical of the ability of most programs to train residents in basic lumbosacral interventional procedures and still meet these goals, since they aren't meeting many of the basic goals now even without having added the spinal procedures.

So, then, I would be interested in your assessment of how the speciality of physiatry has come to a place where many residents, who ostensibly fulfill basic ACGME core competencies by virtue of their time spent in training, are so woefully unprepared for actual clinical practice without the additional or remedial education you outline above?

I have my ideas, but I'd like hear yours first...

 

[rehab_sports_dr]

> So, then, I would be interested in your assessment of how the speciality of physiatry has come to a place where many residents, who ostensibly fulfill basic ACGME core competencies by virtue of their time spent in training, are so woefully unprepared for actual clinical practice without the additional or remedial education you outline above?


IMO, the obvious answer is that the current didactic, clinical, and assessment structures are inadequate. Some ways they are:
1. Too little time spend in outpatient clinic.
2. The decisions determining where residents spend their clinical are not driven exclusively by educational need, but by other factors as well (e.g., coverage issues).
3. Medical directors and PR staff not clearly enough defining what is appropriate for a physiatrist. Every time we see a patient outside our scope or practice, or that is better assessed by a physician extender, that is less time we are defining our core values and skill set.
4. Residents are often not aware of the full clinical skill set. For many residents, it simply has never occurred to them that they should know how to write a power wheel chair prescription, or to write a SLP prescription for someone with aphasia and dysphagia
5. The resident teaching structure does not match the specialties teaching objectives and core competencies. If the specialty considers the management of agitiation in a TBI population a core skill, then residents need that exposure. If residents should be able to read a hip x-ray, than they need sufficient exposure
6. Resident rotations are often chaotically structured, so so much energy is devoted to acclimating to the logistics of the rotation, and not enough to learning the core and clinical skill sets of the rotation
7. Not all attendings stay as current as they should. In his hard to teach novel and emerging technologies if the mentors are up to date.
8. Residents aren't held accountable for their development of core skills. Part of this is that the assessment tools can, at times, be non-existant, poorly designed, clumsy or time consuming to administer, or too infrequent. Often, even for well designed assessment tools, the residents are resistant to participating in self-assessment. This is a road block I have encountered many times as a mentor, and it is excruciatingly frustrating for teachers. The residents have to assume some culpability- if they want to exposed to novel and emerging information and techniques, they have to open to the people training them to assess the way they teach.

DRusso, I wait excitedly to hear your thoughts, and the thoughts of any others.

Gary

 

[DigableCat]

Wondered if anyone else noticed Dr. Furman's recent not to kind swipe at SDN http://www.aapmr.org/resident/newslttr/060d.htm which in releveant part said:

"Unfortunately, there are a lot of Web-based forums that put out too many opinions of a few very prolific individuals that may or may not be right. There are things on those forums that are totally based on hearsay.
​

Odd, given that Dr. Furman trained current fellowship directors, and trained with others. Seems disingenuous that he wouldn't have an opinion, particularly when that is all that is being sought.

I find it odd that he would take a not too kind swipe at SDN at all given that there isn't much available in the way of information other than a few choice websites. Unless he is an anonymous poster on here who provides anything useful, I think he hardly has reason to have any disgruntlement at all. Many things in life are based on hearsay. You think everyone who thinks Harvard is a great university actually attended Harvard? Does that make Harvard less great?
I wonder if it's hearsay that some fellowships, not to be named, are so inbred that in order to get a fellowship spot there you better be connected...

I for one have been very happy to have the opportunity to exchange ideas and opinions with others whom at some point had the same questions that I did when I was a medical student and resident.

 

[axm397]

I find it odd that he would take a not too kind swipe at SDN at all given that there isn't much available in the way of information other than a few choice websites. Unless he is an anonymous poster on here who provides anything useful, I think he hardly has reason to have any disgruntlement at all. Many things in life are based on hearsay. You think everyone who thinks Harvard is a great university actually attended Harvard? Does that make Harvard less great?
I wonder if it's hearsay that some fellowships, not to be named, are so inbred that in order to get a fellowship spot there you better be connected...

I for one have been very happy to have the opportunity to exchange ideas and opinions with others whom at some point had the same questions that I did when I was a medical student and resident.

I actually did that interview and he knows I am a co-moderator of this forum. I think his big concern was about threads that attempt to "rank" programs - whether it be residency programs or fellowships. he felt that choosing a fellowship should be a personal decision and there are many variables to consider and to have an artificial ranking system based on a few people's opinions didn't help the situation. If you read the rest of the article, he mentions how an applicant needs to decide what he/she wants from a fellowship and what the purpose of doing a year of fellowship would be for that person then go on to choose the right programs for him/her. I do agree with that. I think someone like rehab_sports_dr who was looking for as much academic exposure and experience as possible would really take advantage of a program like the one at RIC with its exposure to many mentors and various academic opportunities (teaching, research, etc). Someone else might benefit more from a Furman type fellowship where you learn about private practice and other business aspects of MSK care and procedures. I wanted a program with a comprehensive pain medicine curriculum and exposure including exposure to headache, cancer pain, CRPS, etc. Others may only want to concentrate on the spine and interventional procedures or sports medicine. So I think in his defense, I don't think he was taking a swipe at all of sdn - just trying to make the point that these forums are full of opinions and people should make their own decisions ultimately - which I think happens on this forum.

 

[dc2md]

WOW, this is the best tread yet. it's great learning about all the politics of PMR. thanks guys.

 

[drvlad2004]

I actually did that interview and he knows I am a co-moderator of this forum. I think his big concern was about threads that attempt to "rank" programs - whether it be residency programs or fellowships. he felt that choosing a fellowship should be a personal decision and there are many variables to consider and to have an artificial ranking system based on a few people's opinions didn't help the situation. If you read the rest of the article, he mentions how an applicant needs to decide what he/she wants from a fellowship and what the purpose of doing a year of fellowship would be for that person then go on to choose the right programs for him/her. I do agree with that. I think someone like rehab_sports_dr who was looking for as much academic exposure and experience as possible would really take advantage of a program like the one at RIC with its exposure to many mentors and various academic opportunities (teaching, research, etc). Someone else might benefit more from a Furman type fellowship where you learn about private practice and other business aspects of MSK care and procedures. I wanted a program with a comprehensive pain medicine curriculum and exposure including exposure to headache, cancer pain, CRPS, etc. Others may only want to concentrate on the spine and interventional procedures or sports medicine. So I think in his defense, I don't think he was taking a swipe at all of sdn - just trying to make the point that these forums are full of opinions and people should make their own decisions ultimately - which I think happens on this forum.

I agree with with most of what Furman had to say. It was an excellent Q&A article. This thread does exemply the struggle that our specialty has in identifying ourselves as "Pain/Interventional Spine specialist" and "Sports Medicine" physician, chiefly due to lack of accreditation. I am soon looking forward to when we have ACGME PM&R sports fellowships. There should be no reason that our specialty won't adjust in having more ACGME accredited pain fellowships. I think it is more of a matter of us being confident that we can compete and coexist with the other specialties in Sports Med and Pain.

AXM397, did you meet one of our former residents from Nassau during your interview with Furman? He is currently a fellow there now. He is awesome!

It is amazing that during this time of interviews/electives, each fellowship PASSOR program has a lot of major differences, especially with some programs heavily emphasizing lumbar ESIs/transforaminals. Fewer programs actually do thoracic and cervicals. I find it exciting that we are using MSK ultrasound and more programs like mine are starting to get into it.

It is great hear people openly discussing this big issue here.

 

[Disciple]

I still do not fully understand why it is necessary to do an accredited fellowship. Several job opportunities that I have seen are simply looking for a fellowship trained physiatrists? Personally I think that our specialty should keep that uniqueness of "Sports and Spine." I feel that doing an anesthesia-based pain fellowship does not allow me to incorporate EMGs and my OMM/MSKs as a fellow. I feel that I can get that through the PM&R sports/spine fellowships. Personally, I think that it is a great niche for those of us who enjoy treating athletes and active individuals to manage their acute pain.

Just from personal experience, not being granted privileges based on your pain board or fellowship accreditation is just one thing on a long list of things that can be used to keep you out of a hospital. If an established pain group is already at your chosen hospital and is worried about competition, they will find multiple ways to block you from getting priviledges. It’s called “economic credentialing”.

If you decide to go out on your own, there is a nice way to get around this problem that many Physiatrists employ. Get your priviledges through the rehab dept. and then sign up with an ASC or do office based procedures.

If you join a group and they have privileges at a hospital, then obviously those who hired you will support your application. If they happen to use/own an ASC or have an in-office fluoro suite, you’re all set.

Regarding the Sports/Spine thing, I agree with you. However, we cannot just be a bunch of self-proclaimed experts, especially when the Sports/Spine clinical skills and knowledge are so inconsistent amongst Physiatrists as a whole. The ABPMR needs to create quality assurance measures and certification if we are to have any credibility.

 

[Disciple]

Fundamentally, I think that problem lies in the fact that no one believes in "Interventional Spine" as a bona-fide sub-specialty besides physiatrists, members of ISIS, and a handful of surgeons who want to employ them!

Most of drusso's post cut to save space...

1. Regarding Interventional Spine vs Pain Medicine: The term "Interventional Spine" implies that IS specialists have some special skill or knowledge about the spine. Those of us familiar with pioneer Interventional/Spine/MSK Physiatrists such as Slipman, Windsor, Dreyfuss, the Saul brothers, Joel Press, Stan Herring, Michael Geraci and second generation Heidi Prather, etc. likely support this view. Unfortunately, when I speak of "those familiar", it usually means Physiatrists, of which there are few. How are patients and the rest of the medical community to know if Dr. X, "Interventional Physiatrist/Spine Specialist" possesses the skills of those mentioned above, or if Dr. X did 28-30 months of inpatient work in residency followed by some weekend injection courses?

When it comes down to it, I think that the academy is responding to what most Interventional Physiatrists have in their hearts, to treat Orthopaedic patients and to supplement with interventional procedures. Whatever the reason why, I don't think it's completely financially driven as the salary a Physiatrist may earn from a surgical groups is likely to be lower than the income he could attain from a fully interventional pain practice.

To provide some historical backround for those who are med-students or those in training who may not know the whole story: During the 1980's-early 1990's, when it came to physicians who would treat spinal pain, there were surgeons, anesthesiologists (in the hospital), and opiate clinics. Stim was in its infancy, ESIs, SIJ and facet injections were done blind, disc procedures were not in wide use, etc. Physiatrists specializing in MSK/Spine were very rare, and Physiatrists and those from other specialties generally were not considered for pain fellowships. In 1993 ISIS and PASSOR formed, with many of the first Interventional Physiatrists taking great interest in both organizations. Physiatrists began to work for spine surgeons and assimilated some of their knowledge. ISIS is not a "pain medicine" organization, but is focused on the science behind the biomechanics of the spine and spinal injections. Academic pain departments and most "pain" practicioners lagged in this knowledge base, and thus, for a time, Interventional Physiatrists or Interventional Spine Specialists may very well have had what was considered special knowledge/skills/evaluative abilities pertaining to the spine. 2000-07, everyone is doing fluoro-guided everything, many private practice pain guys have refined their physical exam skills, academic pain departments are now assimilating Physiatric knowledge as well as that from Neurology, PASSOR has outgrown its special interest group frame and many of the most Interventional of Physiatrists have abandoned the AAPMR and definitely the AAP in favor of ISIS, NASS and ASIPP (organizations that support their practice models). So, today, the ball is back in the court of the Interventional/Spine/MSK Physiatrists. As with any other professions, those providing a service need to be able to justify their existence, or become extinct. Similary, the hybrid of OR Anesthesia/Part Time Pain Doc is the parallel to the Interventional Spine specialist who treats acute/subacute spine only and performs limited interventions. Can Physiatrists take it up another level and again demonstrate special knowledge/skills on a consistent basis? It's up to the ABPMR. So, is Interventional Spine/Physiatry just a watered down/limited version of Pain Medicine, or can IS/Spine Surgery be the equivalent of Primary Care Sports Med/Ortho Sports? I would say that it can, but it's up to us to demonstrate, with some consistency, the knowledge base and skill set that would justify IS as a bonafide sub-specialty.

Slipman's new book Interventional Spine has a chapter or forward on the future of Interventional Physiatry. I'm looking forward to reading what he has to say on the matter.

2. Regarding the ability of the Pain Medicine specialist to diagnose and treat painful conditions of any etiology with all non-surgical treatments/modalities: Ideally, this would be possible. But, how many Physiatrists do any of us know who have this skill set? None? 1…2…maybe? Short of a Pain Medicine residency, a 12 month fellowship program will not be sufficient. The 12 month pain fellowships with PM&R, Neuro and Psyche rotations isn't going to cut it. Just as an example, one particular university pain fellowship is now having their fellows rotate with a Physiatrist I know personally who is not fellowship trained, knows little if anything about MSK or the Spine and has not done an EMG in the past 2 years (sounds like 3 months of time that could be spent reading films with a Neuroradiologist or in an Occ Med clinic evaluating patients).

There is a relative shortage of pain doctors in this country. Is it realistic to think we can fill that void with pain docs with a standardized skill set similar to the most highly interventional (all types of interventions)/spine/MSK trained "pain" Physiatrist? Or is this just a speed bump on the way to a pain medicine residency or the demise (a few more years of reimbursement cuts) of interventional pain management?


3. Regarding the progression of residency training and skill acquisition: It is clear that some academic PM&R departments have the necessary faculty/affiliations in place while others do not. Short or putting an MSK guy/gal in every chair position, there are going to be more than a few programs that struggle to make the necessary changes. If we are innovative, we will find ways around the problem. For those programs on the right track, Great! continue to evolve. For those programs that can't make the changes and survive, fine. We can still help those residents. Set up an ABPMR certification that can be met through residency or 6-12 months of approved ABPMR fellowship. Obviously, residents who are stuck in another 6-12 months are not going to be happy, but the bigger issue of establishing our expertise and protecting the specialty will be resolved.

 

[Disciple]

Lots of great discussion in this thread. Some random comments:

1. I agree that the AAPMR has been more progressive and forward thinking than the ABPMR. There are likely several reasons for this.

b. The ABPMR has to be concerned with accrediting the body of knowledge as it currently exists, and therefore will have some lag time as they adjust to a growing literature.
That said, I think the ABPMR has moved inappropriately slowly. In meetings, I have heard some members voice their disbelief in the efficacy of interventional spine procedures. It is my impression that their opinions are not based on a thorough review of the literature, but on the practice patterns to which they've grown accustomed.
While the literature for many aspects of interventional spine medicine are not overly robust, that is true of many aspects of PM+R, and, as just one example, the literature supporting at transforaminal epidural for a lumbosacral radiculopathy, is stronger than much of the cannon of the PM+R literature.

Just my experience, but I think alot of grumpy Physiatrists have chips on their shoulders when it comes to interventional pain management procedures. I have not heard the term "needle jockey" used in a derogatory fashion by any specialty more than Physiatry.

One particular member of the ABPMR does UR for an insurance company and denies my injection requests, no matter what the clinical scenario.

In my opinion, in many cases this resistance seems to stem from some kind of bitterness more than it does the medical literature.

For example, you rarely hear anyone arguing over the efficacy of knee injections for OA or their ability to prevent/delay TKA.

If basic spinal injections were not being over-utilized, you wouldn't hear a peep from anybody.

I am highly skeptical of the ability of most programs to train residents in basic lumbosacral interventional procedures and still meet these goals, since they aren't meeting many of the basic goals now even without having added the spinal procedures.

You should ask Ligament how his residency did this.

I happen to like the ISIS guidelines and philosophy very much, and I think they best approximate what I think an interventional spine physiatrist should try to emulate. As of now, though, they don't really have an accrediting process for fellowships.

THe ABPMR does have tools at its disposal to make this happen. PASSOR has published well written musculoskeletal competencies that could be easily converted. Guidelines for for basic spinal injections were contributed by Kevin Pauza, who as we know was a contributor to the ISIS Guidelines. PM&R residencies or certified fellowships could mandate that these guidelines be utilized when teaching spinal injections, but that in addition, instruction may include other current, established variations of the technique in question.

 

[rehab_sports_dr]

Quick comment on rankings:

I totally agree with Fuhrman that the idea of ranking programs is at times a bit silly, and distracts from the more important question of fit. This opinion has been voiced strongly by myself and others on this forum.

However, rankings still serve a purpose. For example, when I was a medical student at Stony Brook, I had absolutely no idea where to start the process. We had no department of PM+R in my medical school, so I talked to a local program, which didn't give me a very good sense of the field. I talked to recent graduates, but my medical school at that time only graduated one PM+R candidate per class of 120 every year.

Many of the schools as I targeted early on, I ended up leaving unranked, and had I had a starting point for discussion, I would not have even bothered interviewing at those programs.

I happen to think the tier concept (I know paz has used this effectively in the past) is a useful framework. It approaches objectivity to set up a tier of the large, elite, nationally recognized programs (The RIC, Baylor, Kessler, Seattles, Mayo etc. of the world. Some might put Michigan, Ohio State, Spaulding in the mix). Doesn't matter the exact details- it is clear that they are one type of program.

Then you have another tier of smaller, less well established programs that nonetheless have developed strong reputations in recent years (e.g., Indiana, Charolette, Virginia, Pittsburgh, JFK, etc).

I think this kind of tiering gives a sense of a starting point to the discussion.

I think the same can be said for the fellowship programs. There are (I forgot who came up with this term- maybe DRusso) "families" of fellowships that share similar philosophies and skill sets.

The family I am most familiar with is the RIC family of fellowships, that contain fellowship directors or faculty that trained at RIC, or share their philosophy and models. Those include Colorado, Utah, Wash U, Seattle, Geraci in Buffalo, Larry Chou in Philly, etc. Hopefully there will soon be similar ones in Arkansas and Kansas

There are other families, which I am sure others are more quailifed to comment on, including the Windsor family, the Slipman family, the Fuhrman family, etc. Then their are Anasthesia Pain fellowships, which are a whole different family (and maybe a totally different branch off the evolutionary tree)

I think if I was a prospective fellow, I would say the starting point in the discussion is figure out which family as a whole most matches your goals. Perhaps you are on the fence, and you apply to programs in a few different families. And then you interview, and try to figure out which of the cousin programs within that family best meet your needs. And then you hope, pray, and network and hope you get married into the family.

Anyway, this is my long winded way of saying that rankings per se can be misleading, but residents and medical students need some structural framework to know how to approach what is a complex and nerve wracking decision process. If feedback from others who have gone through it before can help, then I think that is useful.

Final thought: I also definitely agree that some effort is needed to try to stay as objective and fact based as possible. There are certainly times the forums degenerate with inaccurate information that obfuscates people's needs for understanding