NASS Fellowships: Deal or No Deal?

[drusso]

Deal or no deal?

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[lobelsteve]

Tell her to stop callin me.

 

[Ferrismonk]

Unfamiliar with NASS fellowships. If I have the choice, only ACGME/AOA fellowship trained docs for me.

There are too many "unaccredited fellowship trained" docs out there for me to trust anyone else.

 

[Nodolor]

Problem is that I interviewed with all these ACGME fellowship trained Docs and they were he scariest DOCs out there doing pain in private practice.
🤮

 

[Gnarvin]

Problem is that I interviewed with all these ACGME fellowship trained Docs and they were he scariest DOCs out there doing pain in private practice.
🤮

I am assuming you didn’t do an ACGME pain fellowship. Without getting into it too much, I will just say that I’ve seen some things that alarmed me when observing procedures performed by both ACGME fellowship trained docs and non-ACGME fellowship trained docs. That being said, currently, I think graduating from an ACGME fellowship is valuable and everything being equal, I would want my parent to see an ACGME fellowship trained board certified pain physician.

 

[nvrsumr]

On the pmr board it appears that residents that didnt match into NASS are using acgme as backup.

 

[lobelsteve]

On the pmr board it appears that residents that didnt match into NASS are using acgme as backup.

 

[Ducttape]

false equivalence.

choices should be a NASS trained fellow vs ACGME fellow.

you will see as much or more alpha midlevels with NASS "trained" fellows.

 

[deleted472101]

I wouldn’t send my parents to a non-ACGME trained physician for anything.

cardiology
Nephrology
Colorectal surgery
Plastic aurgery
And definitely not pain.

We need to keep order in our own profession otherwise e are just a weekend course away from doing medicine all together.

 

[nvrsumr]

Would you rather pay a pmr nass doc 300k or anesthesia acgme 500k to do epidurals in your office suite?

 

[fathead88]

How is this even a question? There is effectively one credentialing board for the majority of medical education, the ACGME. This is consistent throughout most specialities.

The question regarding who to pay for doing epidurals in your office is completely irrelevant. The business people will want to pay for the least expensive option, often to the detriment of patient care. In anesthesia we are very aware of this. It’s a slippery slope between ACGME accredited fellowships, then non-ACGME, then NP/PA fellowships (which really do exist).

 

[Slowpoke]

On the pmr board it appears that residents that didnt match into NASS are using acgme as backup.

The individuals I know applying to NASS and Pain ACGME are casting a wide net for a # of reasons, and this should not be taken as superiority of one training paradigm vs another.

NASS fellowship training sites span reputable places including Hospital for Special Surgery and OSS (Furman's program)

 

[drusso]

Would you rather pay a pmr nass doc 300k or anesthesia acgme 500k to do epidurals in your office suite?

versus an ortho or neurosurg Alpha-Midlevel washed out of the OR?

 

[Ducttape]

The individuals I know applying to NASS and Pain ACGME are casting a wide net for a # of reasons, and this should not be taken as superiority of one training paradigm vs another.

NASS fellowship training sites span reputable places including Hospital for Special Surgery and OSS (Furman's program)

to be to the point, certification for a program in to a NASS fellowship (simple) and ACGME (onerous) are polar opposites and not comparable at all.


one route you can sit for an examination that is recognized throughout the country with no qualms. not so with the other route.



can you get good training at a NASS fellowship? are there great NASS fellowships?

absolutely and yes.


but the program paradigms are completely different.

 

[lobelsteve]

to be to the point, certification for a program in to a NASS fellowship (simple) and ACGME (onerous) are polar opposites and not comparable at all.


one route you can sit for an examination that is recognized throughout the country with no qualms. not so with the other route.



can you get good training at a NASS fellowship? are there great NASS fellowships?

absolutely and yes.


but the program paradigms are completely different.

Yes they are, and I would argue there are NASS programs superior for outpatient pain as compared to ACGME. No wasted time doing EMG and Psych. No wasted inpatient rotation.

 

[drusso]

Yes they are, and I would argue there are NASS programs superior for outpatient pain as compared to ACGME. No wasted time doing EMG and Psych. No wasted inpatient rotation.

Psych is useless in pain. #Notinyourhead #ShowmeyourModics #Yourdischurts

 

[fathead88]

ShowmeyourModics has to be the ultimate username for this forum

 

[deleted472101]

I read this as #ShowMeMoDics

 

[drusso]

I read this as #ShowMeMoDics

Get your head out the gutter.

 

[lobelsteve]

Psych is useless in pain. #Notinyourhead #ShowmeyourModics #Yourdischurts

Modic changes—Their associations with low back pain and activity limitation: A systematic literature review and meta-analysis

Previous systematic reviews have reported positive associations between Modic changes (MCs) and low back pain (LBP), but due to their narrow scope and new primary studies, there is a need for a comprehensive systematic review. Our objectives were to investigate ...

www.ncbi.nlm.nih.gov

Your favorite study

 

[myrandom2003]

No ACGME spine surgery fellowships, so do you only send to neurosurgery?

Acgme is standardized (though a 20 epidural quota is kind of silly) to an extent which is why it is deemed better. Other fellowships are all over the place and sometimes call themselves fellowships just to have indentured servants.

We have this argument on here frequently. If you want a well rounded pain experience, go for the acgme. Get your month of psych, anesthesia, pmr, Neuro, etc. if you want to work with primarily ortho or mak stuff, go the nass route. Nass is mostly pmr guys anyway, since many many acgme institutions prefer anesthesia grads, less spots for pmr. So the pmr guys just took their ball and play on a different court in the same playground.

 

[Dr. Ice]

I wonder how many acgme trained anesthesia pain docs use Furman’s atlas as a reference..he is an acgme certified doc, but the fellowship he came from would probably not be certified now. His own fellowship was acgme, but that got taken away from him. He is running his fellowship through nass now. Should his book get burned and banned? Most of his co authors in that atlas are also his former fellows...

 

[Tboned]

I did a NASS fellowship (only applied NASS cuz I felt it fit better for my goals and I had no interest in ACGME pain training-and no it wasn’t because I was not a competitive applicant). It wasn’t a weekend course. Feel very comfortable doing advanced procedures like SCS trials and Intracept. Completed it at a highly respected academic institution with highly respected and well known faculty. The whole year was highly focused on education. No bull scut work. Had a great experience and top notch training IMHO. No problems getting a job doing exactly what I wanted to do in a major metro and will easily be making more than the 300k mentioned on this thread. Zero problems getting privileges for everything I wanted to do at multiple large health care system/hospitals (my group is affiliated with all the big players across the metro I’m in given our size and there is always ppl chirping about this-it was a non-factor in my experience). Applicants should evaluate their goals and choose the training that fits the best, it’s not always ACGME. Don’t get me wrong, there are a lot of great ACGME pain docs, one of my partners went that route and she’s great.

the all inclusive/all exclusive talk only puts up walls/barriers and doesn’t facilitate moving forward to improve the status quo.

 

[Taus]

I trained in an agcme, anesthesia-based pain fellowship as a Pm&r doc. I currently teach at a NASS fellowship. For someone who wants a spine/msk practice the training can be ideal, but I believe can be highly variable between programs as discussed above.

 

[Tboned]

I trained in an agcme, anesthesia-based pain fellowship as a Pm&r doc. I currently teach at a NASS fellowship. For someone who wants a spine/msk practice the training can be ideal, but I believe can be highly variable between programs as discussed above.

I agree with the variability. There is a clear difference b/w top tier programs and those that are not.

 

[RoloTomassi]

What makes a good pain doc? IMO:

-good diagnostician: thorough history and PE, appropriate ordering and interpretation of diagnostic tests, broad ddx, thinking outside the box, putting it all together with critical thinking

-medical knowledge: textbook/studies knowledge, treatment decision making, complication management

-technical skills: accuracy and safety of procedures, broad skill set

-environment: time, staff, equipment, resources to do the above

-personal: cares enough and ethical enough to do the above, integrity not compromised

ACGME not the only place to learn the above, and ACGME does not insure the above

 

[NJPAIN]

I've said it before and I will say it again; there needs to be ONE ROUTE INTO A SPECIALTY. To the best of my knowledge multiple routes do NOT exist in other fields. You can certainly get excellent procedural training in these NASS fellowships as well as not so great training. Same for ACGME. For me the issue is what multiple routes of entry into training do to the field long-term. What is does is OVER-TRAIN and FLOOD the field. It produces a massive amount of high volume needle monkeys to satisfy the desire of orthopedic and neurosurgery groups to create massive revenue from assembly line procedures. It makes it difficult for well-trained and thoughtful pain physicians to compete in the market. More importantly, it takes our entire specialty in the direction of providing a mindless form of assembly line "injection therapy" and "fuse this-fuse that" masqueraded as genuine pain medicine.

 

[Dr. Ice]

There are bad apples everywhere regardless of training. That’s the problem

 

[NJPAIN]

To suggest that only acgme training can make you a thoughtful pain doc is just plain false. I have encountered several acgme trained docs who are thoughtless, needle and stim monkeys who are ironically the ones whoring themselves out on LinkedIn taking selfies with reps being the first implanter in their territory of whatever new fancy toy is out there now

Clearly nothing is 100%. However, if you chose a fellowship based upon the fact that the "useless junk" like psych, peds, acute pain and inpatient are eliminated you are perhaps going to have a less well rounded experience. My training perhaps had way too much psych/behavioral focus but I learned some of my most valuable lessons used daily from a guy named Bill Fordyce. There is value to rotating through other hospitals, working with docs from other specialties, etc. I don't know how you get that in most of these NASS fellowships. You can certainly argue that is useless and irrelevant to outpatient pain practice but I don't think it is.

Some of this is analogous to SLobel's " it's the person not the drug" ----> it's the person not the program.

All of this aside, do we need MORE programs to train MORE pain docs???

 

[lobelsteve]

I've said it before and I will say it again; there needs to be ONE ROUTE INTO A SPECIALTY. To the best of my knowledge multiple routes do NOT exist in other fields. You can certainly get excellent procedural training in these NASS fellowships as well as not so great training. Same for ACGME. For me the issue is what multiple routes of entry into training do to the field long-term. What is does is OVER-TRAIN and FLOOD the field. It produces a massive amount of high volume needle monkeys to satisfy the desire of orthopedic and neurosurgery groups to create massive revenue from assembly line procedures. It makes it difficult for well-trained and thoughtful pain physicians to compete in the market. More importantly, it takes our entire specialty in the direction of providing a mindless form of assembly line "injection therapy" and "fuse this-fuse that" masqueraded as genuine pain medicine.

So what about NS vs OSS? Two routes to same thing: ACDF, fusion, discectomy, etc.

 

[fathead88]

It looks like the objective of this thread has been met.

We all know that training alone does not make one a good doctor. The Harvard undergrad, Harvard med school, Harvard Neurosurgery grad is not automatically a better doctor than the state school undergrad, Caribbean med school, community residency program graduate. I think we can all think of examples of academic attendings that you wouldn’t want your family member to see.

I think the thread poll question undermines the value of the physician. No, we should not equate ANY of our colleague’s expertise with that of an NP/PA. We are physicians first and pain specialists second. If you want the best care , be seen by a pain physician.

Between crnas/PA/NPs that open there own practices to insurance companies denying SI joint injections and approving oxycodone and the other myriad issues out there, maybe we should stop the infighting within our own specialty because there are plenty of threats from the outside that are much more pressing than where your 5th year of postgraduate training was at.

 

[RoloTomassi]

So what about NS vs OSS? Two routes to same thing: ACDF, fusion, discectomy, etc.

Also EMG (neuro and PMR), non-op sports (family and PMR)

 

[nvrsumr]

I interviewed at furmans when acgme accreditted. Basically one dude in an ortho practice with a fluoro suite associated with a med school that wasn’t in same city. Sorry, not a fellowship.

 

[bedrock]

The most important thing here is not to argue NASS vs ACGME but physician vs mid-level.

Our top priority should be ensuring that mid levels are not allowed to do pain procedures anywhere in this country. Once that is accomplished, then the above discussion will have more relevance.

 

[Agast]

One of the newer device companies came by a few years ago with a “pain doctor”, I guess his role was to talk to me and convince me to use the device. He was a family medicine/sports medicine guy who did a “spine fellowship” with a group I couldn’t even find on Google. But he sure was very confident and happy with himself.

It occurred to me that if a patient looked the both of us up, they would probably choose him because he certainly made himself sound good.

 

[drusso]

One of the newer device companies came by a few years ago with a “pain doctor”, I guess his role was to talk to me and convince me to use the device. He was a family medicine/sports medicine guy who did a “spine fellowship” with a group I couldn’t even find on Google. But he sure was very confident and happy with himself.

It occurred to me that if a patient looked the both of us up, they would probably choose him because he certainly made himself sound good.

The ACGME brand has been devalued. I fought tooth and nail to get a university affiliated ACGME-accredited Pain fellowship because I thought training quality mattered. Now, people are just as happy to train at a KFC.

 

[NJPAIN]

So what about NS vs OSS? Two routes to same thing: ACDF, fusion, discectomy, etc.

I don’t think this is the same. We have already made the cone portion of the funnel enormous; you can get a fellowship and sit for exam from ANY specialty. Now we have increased the throughput by increasing the number and type of fellowship. I believe spine you need ortho or NS training. You can’t even come in from another surgical specialty? What I don’t know is if there are NASS fellowships in spine that are not ACGME accredited.

I freely admit that I feel that this devaluates an ACGME fellowship. Many of us worked really hard to get those positions and then take and maintain certification. Now, it feels like this is a way to cut in on the line. Again, great docs and bad docs come from both directions but I think the journey needs to be similar for everyone. Tons of people who would be great surgeons don’t get a training spot and never become surgeons; does that that need to addressed similarly?

 

[NJPAIN]

The ACGME brand has been devalued. I fought tooth and nail to get a university affiliated ACGME-accredited Pain fellowship because I thought training quality mattered. Now, people are just as happy to train at a KFC.

Well said David as always.

 

[deleted472101]

What is taught in this NASS programs?

what is the breakdown?

Is there an exam and certification that has to be done every so often?

 

[bear2020]

I always find these discussions interesting. Not all of the spine fellowships listed on NASS are equivalent but this is no different than acgme pain. Some pain fellowships have good training and some have sub par training. Some are almost surgical and some have minimal interventional experience.

Most pain practices in the community (in a large metro area) essentially practice “interventional pain”. They do not do peds, inpatient consults, multidisciplinary psych and many are shying away from managing opiates. It sounds like they want to just practice spine.

Seems like the the field is too broad for one specialty to begin with. Maybe there should just be interventional and multidisciplinary.

 

[Disciple]

So what about NS vs OSS? Two routes to same thing: ACDF, fusion, discectomy, etc.

Same with hand surgery.

And total joints(There are fellowships, but generally for those who want to specialize in complex cases).

 

[RoloTomassi]

Same with hand surgery.

And total joints(There are fellowships, but generally for those who want to specialize in complex cases).

And cosmetic procedures-- plastics, ENT, derm overlap, appropriately.

Why so much in-fighting with pain when no one seems upset NSG/ortho spine and IR are doing pain procedures too?

 

[Disciple]

And cosmetic procedures-- plastics, ENT, derm overlap, appropriately.

Why so much in-fighting with pain when no one seems upset NSG/ortho spine and IR are doing pain procedures too?

Some people probably are upset, but clearly, nothing can be done about that.

I think if you’re talking about the totality of “Pain Medicine”, then yes, a unified training pathway is best. If talking solely about procedures, then yes, multiple pathways can yield the same result.

 

[PMR2008]

I did my fellowship in a Non-ACGME program that has since become ACGME. I personally think Pain should be a residency and not just fellowship.

 

[sdnuser001]

What is taught in this NASS programs?

what is the breakdown?

Is there an exam and certification that has to be done every so often?

I am doing an academic NASS style fellowship but also applied to ACGME. There is a lot of variety between the NASS fellowships and the curriculum is not exactly clear. Ie there are some fellowships that are heavy sports and just a sprinkle of lumbar procedures (like Wash U) vs. others that are at private practices and are heavy pain/interventional. I would hope in the future that NASS comes up with minimum requirements for various types of bread and butter procedures. I understand some of the concern that NASS fellowships could cause market over saturation but the issue is that there are still not enough ACGME spots for PMR grads. I know various anesthesia residents with low scores and red flags that matched ACGME vs PMR residents with better stats who did not.

 

[MindtheGlottis]

What is taught in this NASS programs?

what is the breakdown?

Is there an exam and certification that has to be done every so often?

NASS programs can be divided into 2 main categories: Academic & Private practices. Some are more sports heavy than others.
- Academic has the benefit of a GME and more structured didactics (tend to be associated with PM&R residencies). Examples include: Stanford, Cleveland clinic, WashU, HSS, Vanderbilt, University of Utah.
- Private practices have the most variation. Some are great like (Furman, Desert Spine) and others are more of an apprenticeship style of fellowship. Some are in larger surgical practices and others are spine & sports clinics. This may be where NASS gets a bad reputation, however will prepare physicians to run well in private practices wherever they may practice. A lot of these practices have SIS instructors or follow SIS guidelines which they proud themselves behind and teach. These fellowships are still superior to some no name non accredited pain fellowship, but have its limitations.

Fellowship overviews can be see here
- As are pain fellowships, there's some variations with procedures done
- ALL: Standard procedures like lumbar ESI, MBB, RFAs, SIJs, etc
- MOST: Cervical procedures like ILESI, MBB; Genicular RFAs; US guided MSK injections (intraarticular)
- SOME: Cervical TFESI, SCS trials (no implants), Intracept, regenerative med (PRP), EMG, Sports coverage/clinics, diagnostic MSK US, vertebral augmentation usually with neurosurgery, rarely MILD
- Time is exclusively spent on the outpatient clinics with some having call covering inpatient rehab. Clinics are mostly interventional spine/MSK based, however some are more sports heavy, some time can be spent with neurosurgeons/ortho spine surgeons, strictly PM&R clinics, and pain.

Goals of fellowship are to train spine specialist and refine the MSK knowledge from PM&R residency with the job prospects in outpatient spine & MSK practices. Attendings are primarily PM&R and fellows are all PM&R from my knowledge. Opioid management is not taught and practices are very clean, the focus on adjuvant therapies. There's no APS, cancer pain, psych/neuro/anesthesia rotations. Fellows can sit for the AAPM or AISIP boards. Job opportunities appear great and can include many academic opportunities.

The field of pain is developing rapidly - the more collaboration we have between different specialties will ultimately lead to better patient outcomes. It's clear we still have lots of room for improvement in improving function and quality of life for all our patients.

 

[Dr. Ice]

It is funny how people don’t complain about IR doing pain. Those guys don’t even know how to spell physical exam, and yet pmr docs and nass are crucified in a hot moment

 

[nopain1234]

Do you think insurance companies will recognize NASS fellowships in the same fashion they do ACGME fellowships?

 

[Dr. Ice]

I have a hard time believing that if you are trained by docs who are internationally renowned in interventional spine care, whose contribution to the field cannot be denied, that insurance will deny you payment. But who knows. They should not pay IR docs or PAs/NPs. As stated so many times on here, our infighting will only lead to more chaos and “creep” from everywhere else. Tupac and biggie would have been much greater as a collaboration than as enemies. And even as enemies, they could have co existed and given each other respect to prosper

 

[Ferrismonk]

It is funny how people don’t complain about IR doing pain. Those guys don’t even know how to spell physical exam, and yet pmr docs and nass are crucified in a hot moment

I complain. But noone listens to me. ;P