Co-fellow fired

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To OP:

My suggestion. Since it is not accredited, finishing the program really means nothing. All you are trying to get is knowledge and skill. Spend two or three more months then bolt and get
PP pain job.

By the way, I sooooo disagree that credited vs nom is the same, and the argument against accredited (knowledge is knowledge) argument.

Think of it this way. I can study computer programming and be brilliant - maybe the best programmer on the planet. Some may hire me - but much more will hire me if I get a degree in programming and it will open many more doors. It’s true you can become just as skilled as those that went to an accredited program - but that really has nothing to do with why you may want to do an accredited program- just like someone may want to get a college degree even though they can likely learn everything without it.
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To OP. I'd suck it up and stay. It's one year apprenticeship and then you are on your own.

The real benefit of doing a non-accredited fellowship is that this guy actually runs a business. He is making money and not hidden behind the ivory tower. Take notes on how to do that because you won't learn that at "blah blah university." [ Guys, I'm not trying to minimize anyone who trains at academic, I'm trying to point out a potential advantage to training outside of academics.] Business as a whole is grossly neglected during training and physicians today are suffering because of that.

It's not only an opportunity to learn the clinical side of pain, you have an opportunity to learn how to operate a business and survive in this competitive business. I'd stay an extra six months to see if he can teach you business of running a medical practice
 
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Piebaldi said:
Right I get that. Again I am not expecting to be an expert from the bat. I have noticed that as I have gotten better, faster I have been allowed to do more - but there is so much to learn sometimes I worry that there wont be enough time to learn everything I want/need to. Thanks.
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You straight up won’t learn a lot of things... and that’s ok. Fellowship is about building a base that you can expand on throughout your career. If by the end of fellowship you still feel unprepared look for a job where you have a strong mentor who will continue to teach you.
 
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Just curious OP -

In this year of fellowship - where will you be doing your PM&R clinic rotation, your neurology rotation, and exposure to acute pain? How about palliative care and in-patient consults, and cancer?

What academic system is in place for the science part of pain that is ...oh so painful...to learn?

Cadaver work? Conferences? Multi-D rounds? Radiology exposure? Lectures?

I’m just super curious - I was thinking about what non-accredit means. If it is a rigorous program In the art and science of pain medicine, why not become accredited? Or if it’s just a place to learn to drive needles, you can learn that in three months at busy place. If that’s the goal, don't let a guy usurp you for 1 year.

Before regional became accredited, a lot of programs had trouble keeping people around for a full year because after about 6 months the fellows realized they knew the stuff and at this point they were just cheap labor so they would go get a real job with their new skills.

By the way - I tell my fellows - this year is for you to learn how to stick a needle anywhere. However, you need to spend the rest of your career learning not to stick needles in people. Not sure you'll get that “golden key that will never rust” at a non-accredited office.
 
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PMR’s chill said:
You straight up won’t learn a lot of things... and that’s ok. Fellowship is about building a base that you can expand on throughout your career. If by the end of fellowship you still feel unprepared look for a job where you have a strong mentor who will continue to teach you.
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I understand that - I don't expect to be an expert on everything by the time I graduate. But attending does a lot of stuff himself - even peripheral in clinic injections and is not allowing me to do them. He's very concerned about any negative outcomes or if everything is not perfect on spinal procedures, he takes the needle in a second - i need some time to get accustomed to thigns, get a feel for things. i am very cautious with things, and very conscientious about patient care, my limitations, etc. But it bothers me tremendously - i mean the point of a pain fellowship is to do procedures. he's not super receptive to things. but i am thinking, particularly since it's just me at this time, taht i will tell him - hey i need more procedure time. i don't want to waste my time this year. i want to make sure i get the most of it.
 
Baron Samedi said:
Maybe phrase it more along the lines of, "what is the timeline you envision for me to progress this year?"
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Before it was mentioned that things like thoracic procedures wouldn't be attempted until like 6months which seems excessive. Does it not? Granted I don't "need" to learn peripheral joint injections per se as I have done a ton during residency and granted I am allowed to do more stuff lumbar wise progressively - caudals, MBBs, RFAs, SI etc but I should be doing most of the injections - not just some of them. Am I wrong on this? Yes I get that I have not even been there 2 months and all, but i think I have progressed significantly, but certainly want to be able to do most things. There are certain things that I don't care if I get to do - discograms, stim trials, etc. But definitely feel a "conversation" is in order - I have learned a lot in terms of the business side as well which is helpful. But I want more procedural experience as well.
 
I think at this point the discussion is moving in circles. You've gotten the same message from multiple people in this thread and are choosing to progress how you want. Why ask for advice if you won't consider it? Maybe think about that and it may give you some insight as to why your attending is keeping you on a short leash.
 
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Baron Samedi said:
I think at this point the discussion is moving in circles. You've gotten the same message from multiple people in this thread and are choosing to progress how you want. Why ask for advice if you won't consider it? Maybe think about that and it may give you some insight as to why your attending is keeping you on a short leash.
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Yes, I have listened to the advice and taken it to heart - I was simply trying to answer your question.
 
Perhaps the slow progress is to ensure you stick around for the entire year.

Were you aware of this progression during the interview process? Has this changed since you started? Was the other fellow on the same pace as you?

Stroke the dude’s ego, tell him how excited you are to learn the more advanced procedures and ask what the specific time course is. Also reach out to last years’ fellows and get their input as well if you haven’t already.


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DOctorJay said:
Perhaps the slow progress is to ensure you stick around for the entire year.

Were you aware of this progression during the interview process? Has this changed since you started? Was the other fellow on the same pace as you?

Stroke the dude’s ego, tell him how excited you are to learn the more advanced procedures and ask what the specific time course is. Also reach out to last years’ fellows and get their input as well if you haven’t already.


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Yes I have thought of that as well actually - I was just wondering how others do it kind of. Do other fellows not do cervical/thoracic type procedures until later in the year? Is that normal or not? The other fellow was on the same pace as me yes and actually slightly slower. I think I am planning on talking to him gently -I have been asking a lot more questions, etc. and being more "aggressive." Other fellows have gotten lots of procedures - I met some when I interviewed. I simply don't know the timeframe.
 
Piebaldi said:
Yes I have thought of that as well actually - I was just wondering how others do it kind of. Do other fellows not do cervical/thoracic type procedures until later in the year? Is that normal or not? The other fellow was on the same pace as me yes and actually slightly slower. I think I am planning on talking to him gently -I have been asking a lot more questions, etc. and being more "aggressive." Other fellows have gotten lots of procedures - I met some when I interviewed. I simply don't know the timeframe.
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Yes, it's normal. I went to an ACGME program. First day, the attendings had his/her gloves on and did the whole thing. I progressively did more and more until I was (relatively) independent. Any half decent doctor is not going to let you do a cervical early in fellowship. If they do, it means they don't respect the procedure. I am 1-2 years out of fellowship, and the thought of letting a fellow who is just a few months in do a cervical terrifies me. The more experience you gain down the road, you'll be thankful that they let you do them at all 6 months in. The injection is not the hard part. If you understand fluoro extremely well, including strange contrast patterns (CLO in particular - what happens if you cross midline? what happens if you are more lateral than you think?), then you will be fine, no matter how much or how little hands-on you get during your fellowship. If you are gaining anything from the fellowship, stay. If not, leave. You can learn things even from ****ty doctors.
 
MD87 said:
Yes, it's normal. I went to an ACGME program. First day, the attendings had his/her gloves on and did the whole thing. I progressively did more and more until I was (relatively) independent. Any half decent doctor is not going to let you do a cervical early in fellowship. If they do, it means they don't respect the procedure. I am 1-2 years out of fellowship, and the thought of letting a fellow who is just a few months in do a cervical terrifies me. The more experience you gain down the road, you'll be thankful that they let you do them at all 6 months in. The injection is not the hard part. If you understand fluoro extremely well, including strange contrast patterns (CLO in particular - what happens if you cross midline? what happens if you are more lateral than you think?), then you will be fine, no matter how much or how little hands-on you get during your fellowship. If you are gaining anything from the fellowship, stay. If not, leave. You can learn things even from ****ty doctors.
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Thank you for your advice. I am learning a tremendous amount overall - I thinkback to day one where I knew very little, and to this day, I think I have made leaps and bounds in terms of overall knowledge, understanding things, the whys and hows, etc. Attending can be very intimidating but i hae recently figured the more I ask, the more I'll learn. The pain program at my residency hospital had a limited number of procedures that were done by resident, and here there are so many more that I sometimes feel overwhelmed and like I will run out of time in order to learn everything. But you guys are right - perhaps I am spazzing out too much. I'll let things rest and see how they go. Thanks dudes.
 
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Don't take this the wrong way but you've got much better things to do with your time than post here right now.

You're a fellow.
Make this year count.
Go read.
 
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I was with one attending who wouldn't let me do cervical epidurals. I didn't understand it then. I got it now. Simply too dangerous and scary of a procedure, thin ligamentum flavum or possibly none at all with gaps. Don't take it personally. The whole getting pissed part about menial things and not allowing you to do US procedures is ridiculous though. Find elsewhere, esp if its non-accredited.
 
i mean the point of a pain fellowship is to do procedures.

um, no.

the point of a pain fellowship is learn on whom to do a procedure, and why not (over why).


btw these are issues you should have addressed before signing on to this fellowship, by talking to previous fellows.
 
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Ducttape said:
i mean the point of a pain fellowship is to do procedures.

um, no.

the point of a pain fellowship is learn on whom to do a procedure, and why not (over why).


btw these are issues you should have addressed before signing on to this fellowship, by talking to previous fellows.
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Isn't that the truth? Best advice I ever got from a director and attending was telling me that anyone can do our procedures. Seriously, if you train a mechanic or a plumber, eventually they can do it and figure it out. The trick is, learning how, when, why, and to whom to do it to. Otherwise, we're just a mindless block jock. Pain Management is to skillfully gather your most probably diagnosis from a thorough history, physicial, and appropriate imaging. Also, understanding the medications you give, being safe, and preventing paralysis, stroke, death, injury, etc. The rest is easy - and by that I mean procedure.
 
Plus, looking back now that I'm an attending, if I had a fellow underneath me - I wouldn't have them touch a needle at all the first month. You have to demonstrate to me fluoro anatomy, risks, verbally tell me your approach, pharmacology, different pathologies, etc. Then after the first month, I would allow Lumbar MBBs and Facets, followed by a Caudal. Progressing to Lumbar TFESIs and LESIs. Cervical MBBs/Facets would be the next step at the 6 month mark, and to tell you the truth, I don't think I would ever trust a fellow with CESI - just too dangerous and risky of a procedure. I would definitely hawk that fellow and go CLO and tell them, to slowly enter the space or start squirting contrast slowly once Spino-laminar line is reached. Just my preference.

Why? Problem is some people know they're in training and they have that safety net - versus an attending who doesn't. So they'll be more aggressive and not care as much. Not putting my neck on the line for that; unless I get sovereign immunity.
 
Skrillex said:
Plus, looking back now that I'm an attending, if I had a fellow underneath me - I wouldn't have them touch a needle at all the first month. You have to demonstrate to me fluoro anatomy, risks, verbally tell me your approach, pharmacology, different pathologies, etc. Then after the first month, I would allow Lumbar MBBs and Facets, followed by a Caudal. Progressing to Lumbar TFESIs and LESIs. Cervical MBBs/Facets would be the next step at the 6 month mark, and to tell you the truth, I don't think I would ever trust a fellow with CESI - just too dangerous and risky of a procedure. I would definitely hawk that fellow and go CLO and tell them, to slowly enter the space or start squirting contrast slowly once Spino-laminar line is reached. Just my preference.

Why? Problem is some people know they're in training and they have that safety net - versus an attending who doesn't. So they'll be more aggressive and not care as much. Not putting my neck on the line for that; unless I get sovereign immunity.
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So how do people learn things like cervical ESIs etc?
 
Baron Samedi said:
Cervical ESI is my least favorite procedure I do tbh
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Yes I get that completely- I certainly don't think I'd enjoy cervical procedures in general. I'm asking in general how newbies learn these procedures.
 
I did CESI as a resident.

If you're going to volunteer to teach fellows you need to teach fellows and the CESI is part of the curriculum.

My fellowship we weren't coddled into harder and harder procedures. You were put on inpt, procedures, clinic, etc.

I mean really, you have to get your hands on the needle. You wait until month 6 to teach them something and by the time the year ends they've done 10 and sent out into the community to hurt someone.

Teach when to do or not to do something, and ensure they're ethical but no matter what they will be sticking people so you have to show them how to do it.
 
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Piebaldi said:
Yes I get that completely- I certainly don't think I'd enjoy cervical procedures in general. I'm asking in general how newbies learn these procedures.
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CESI is a legit procedure and I take them very seriously but they're just another intervention that you have to know how to do.

They're sketchy looking at times, and sometimes the needle crosses over the midline and weird patterns occur with your contrast so you need to know how to do it.

This is a non accredited fellowship so the entire situation is weird. He will let you do more the further you get but accredited programs typically throw you in the deep end. Mine did...
 
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First; this is not an ACGME vs. non-accredited fellowship thread. There is plenty the OP can learn in a non-accredited fellowship that may be superior in real life, such as business practice and how to treat private practice patients.

When I did my pain fellowship, I was selected as one of two fellows.

My co-fellow never showed up and I was told on day one that I was on call 24/7. I lived a 45 min drive a way.

That was an ACGME fellowship attached to a major cancer hospital where we were running epidural catheters, IT pumps, neurolytic blocks. Lots of high dose opioid prescriptions. I was the first PM&R based fellow in an Anesthesiolgoy department and almost everybody was mad I was there.

THAT was a very stressful situation.

Your fellowship does not manage opioids, no acute patients, all private practice. No inpatient cancer pain. Your call is VERY EASY.

I've been on 24/7 call in outpatient private practice for 10 years. Its not bad.

Also, almost no way your co-fellow got fired for a minor medication error. There is more you have not been told.

Just take the call and be done with it in a few short months.

Also; sounds right that she is not having you do cervcial and thoracic stuff just yet. 2 months in you shoudl be doing lumbar stuff and progressing up the spine in another month or so.
 
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I can’t believe we are still talking about how to learn to do a CESI.

The best way is do an accredited fellowship. If you can’t or won’t do this then... read, ask questions, gain your “program” director’s trust over time and then get your hands dirty. Realize that the “director’s” way to do CESIs may (likely) not be the best way to do a CESI.

CESIs are not hard at all. In fact I find them easier to perform on the majority of the population (elderly) because they simply have less degenerative changes at C7-T1 than they likely do at L5-S1. I can’t remember the last time I had a hard time accessing the interlaminar space for a CESI (but at times lumbar ESIs are very challenging if the interlaminar space is limited or degenerated).

Here is my FREE tutorial on how to do a CESI my way (one of several right ways):

1. Identify the C7-T1 interspace. It’s the interspace right above the T1 lamina of the vertebral level that has a rib going to it.

2. Decide if you want more injectate to be injected on the left or right side (which side does patient have radicular pain that is worst?)

3. 1% lido for skin wheal

4. Place 18g tuohy (more crisp LOR feel) or 20g tuohy (less crisp LOR feel) through skin wheal approximately 2-3mm lateral to the midline (ensure spinous processes are midline). Advance it carefully no more than 2-3cm before checking depth with contralateral oblique to ensure you’re not too deep. Advance tuohy near (2-3mm shallow to) the ventral interlaminar line (the line connecting the ventral parts of the lamina in contralateral oblique).

5. Connect LOR syringe with saline (crisp LOR feel) OR use omnipaque (less crisp LOR but immediate location feedback on fluoro). Feel for LOR just like lumbar.

Caution: Use contrast as the LOR fluid once you develop great feel and won’t squirt in too much LOR fluid and ruin your fluoroscopic images. Also realize with a smaller tuohy it may not give great LOR feel compared to an 18g because it’s more viscous than saline.

6. Once you’ve reached the epidural space you will have LOR, a good epidurogram in contralateral oblique and a good pattern on AP (fat globules, non myelogram like spread).

7. Inject appropriate medication of choice.

Pro tips: As you’re advancing the needle tightly grip THE SHAFT right at the skin to ensure the needle can NEVER lurch forward inadvertently. NEVER advance the tuohy without protecting against it going to deep. NEVER push the needle in without fingers on the shaft preventing it from going in too far. If you have to in obese patients, tent the skin down along the needle to grip the needle to ensure it won’t advance too far.

THE ABOVE UNDERLINED TIP IS THE MOST IMPORTANT STEP HERE!!!

Pearls: Contralateral oblique means oblique 45-50 degrees AWAY from the side the TIP ends up on (draw line on the true midline and if the tip is to the right of the line then oblique left).

If ANYTHING is not right and you don’t understand what you’re feeling/seeing/thinking then ABORT! It’s better to live to fight another day.

My final advice is from a mentor who’s motto was “Everything we do is elective” - meaning you can abort ANY procedure we do! Don’t forget that.
 
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painfree23 said:
Wat???? Everyday for 10 years? When do you travel/vacation/drink??
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Lol. That’s not “call”. That’s your office/local ED having your phone number in case a patient shows up. I do that as well, certainly don’t think of it as call though
 
paindoc007 said:
Lol. That’s not “call”. That’s your office/local ED having your phone number in case a patient shows up. I do that as well, certainly don’t think of it as call though
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That's my point. That is the same type of call the OP is facing for 8 months.
 
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In my 4 months of home call as a fellow, I came in exactly twice. One was to do a skin check for a pump site on an inpatient, the other was a questionable SCS implant infection in the ED. Both were straight forward. The vast majority of calls I got were people asking for blood patches for OB patients, in which case you just tell them to walk-in the next morning.

Nothing we do is so crazy that call should be unreasonable.
 
What do you do when you even show up for scs infection ? It’s a surgical fix anyway which is over our expertise...
 
painfree23 said:
What do you do when you even show up for scs infection ? It’s a surgical fix anyway which is over our expertise...
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Consult ID, determine if superficial infection or if deeper has a biofilm developed.
Determine if explant required. That is our job.
 
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painfree23 said:
What do you do when you even show up for scs infection ? It’s a surgical fix anyway which is over our expertise...
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Look at the incision and determine if it's an infection at all. Often times, it's not. If it's draining pus and the patient is toxic, it's coming out ASAP and you're getting the OR ready that night. Otherwise do what lobelsteve said.
 
Over our expertise? No, I’d say don’t do a procedure if you’re not comfortable managing a potential complication from it
 
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There is nothing complicated about explanting, culturing, and washing out an infection.

Literally the hardest part is the conversation at the bedside in recovery when the pt wants to know when you can put it back in...Fellowship can't teach that skill...
 
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SommeRiver said:
There is nothing complicated about explanting, culturing, and washing out an infection.

Literally the hardest part is the conversation at the bedside in recovery when the pt wants to know when you can put it back in...Fellowship can't teach that skill...
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6 mo, cleared by ID. And underlying risk gactors mitigated.
 
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I've had two pts drop their A1C over 3 points in the last 4 months bc I canceled their trials due to pre procedure labs.
 
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What do you do for patients on biologics (methotrexate, humira, imuran etc)? Do you hold those for trials for increased risk of infection?
 
painfree23 said:
What do you do for patients on biologics (methotrexate, humira, imuran etc)? Do you hold those for trials for increased risk of infection?
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I do now and don't care what others say. Had one infection and the guy was on MTX. No other identifiable risk factors
 
clubdeac said:
I do now and don't care what others say. Had one infection and the guy was on MTX. No other identifiable risk factors
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How long do you hold? Do u get letter from rheum saying it’s ok to proceed?
 
2 weeks... and yes first clear with rheum
 
Rheum patients I keep on their immunosuppressive agent. They are the only patients who get antibiotics during trial and try to keep as short as possible.

Had an insidious onset epidural abscess when I was a fellow in an RA patient on MTX. Presented 30 days post trial as staph bacteremia.


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No Pain All gain said:
Rheum patients I keep on their immunosuppressive agent. They are the only patients who get antibiotics during trial and try to keep as short as possible.

Had an insidious onset epidural abscess when I was a fellow in an RA patient on MTX. Presented 30 days post trial as staph bacteremia.


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No ABx during trial?
 
No evidence for abx during trial


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So update on all of this - I ended up resigning given that I did not feel I was getting what was necessary at this place. I was frustrated that there were no didactics, no journal clubs, no discussion of cases, and I was pressured to do more and more attending type duties without real teaching. Also attending and partner got into a stiff recently and he was threatening to potentially leave, which did not make me feel particularly secure. Just lots of bullying, instead of talking to me they woudl try to bully me and others into doing certain things, etc. Attending of course got upset with resignation, blamed me for the issues, told me how I did this or that wrong, and how it was me not the "program", etc. I was expecting more of a professional demeanor. Oh well. I think it was the right choice.
 
did you accept the other position before resigning?

I'm old school, I know. if I were to resign, I would have had the other option already set in stone, just in case that other program gets cold feet...
 
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