particulars

[medicineman1]

which programs are the best primers for interventional/pain? I'm sure this is somewhat subjective, although I'd love to hear your opinions?

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[Rehability]

UCLA has one of the few PM&R based interventional pain management fellowships in the country. There are 4 spots per year, 2 of which usually go to in-house residents based on statistics from recent years. As for residents coming from other programs, they are competitive applicants from top programs (the in-coming pain fellow is from RIC).

UCLA has incredible all-around teaching, arguably the best location in sunny southern California, exposure to multiple sites (7-8 in all), and VERY friendly attendinings. Most of all, the residents are HAPPY.

If pain is what you want to do, and as it stands I'm right there with you, take a serious look at UCLA. I'll be starting there in July....cant wait!

Good luck!

 

[axm397]

UCLA has one of the few PM&R based interventional pain management fellowships in the country. There are 4 spots per year, 2 of which usually go to in-house residents based on statistics from recent years. As for residents coming from other programs, they are competitive applicants from top programs (the in-coming pain fellow is from RIC).

You mean one of the current fellows is from RIC?

 

[paz5559]

UCLA has one of the few PM&R based interventional pain management fellowships in the country. There are 4 spots per year, 2 of which usually go to in-house residents based on statistics from recent years. As for residents coming from other programs, they are competitive applicants from top programs (the in-coming pain fellow is from RIC).

UCLA has incredible all-around teaching, arguably the best location in sunny southern California, exposure to multiple sites (7-8 in all), and VERY friendly attendinings. Most of all, the residents are HAPPY.

If pain is what you want to do, and as it stands I'm right there with you, take a serious look at UCLA. I'll be starting there in July....cant wait!

Good luck!

The Stanford fellow two years ago was offered the UCLA position, where he had served as a resident. He chose Stanford's PM&R program instead.

Dr. Aragaki, the current associate program director for the residency, is the most personable, smartest, most approachabl academician I have ever come across, and I believe she is involved with the pain program.

Food for thought

 

[tempperson]

i believe the most access would be achieve from harvard/spaulding. Sure they only have a 1 spot PM&R fellowship, but the number of residents who graduate there and do anesthesiology based pain is probably more percentage wise than any other place. I've heard of fellows going to beth israel (one of the top anesthesia pain fellowships), brigham&womens, mass gen, dartmouth, etc. The harvard name is great in the pm&r world, but tremendous in general. Anesthesiology based pain programs often judge a residency based upon the quality of the anesthesiology program at the institution, b/c they do not know as much about the PM&R program. Plus you get 10 mths of electives(6 mth in harvard/partners system, 4 mths outside), so you can audition all you want with the partners hospital and throughout the country. Auditioning is probably one the most important things to do for fellowship. No other rehab program even comes close in terms of elective time.

The best program to get a PM&R based pain fellowship is probably RIC, generally b/c of their great rep in the PM&R world. However, as I understand it, they do not send as many residents into anesthesiology based fellowships, and do not regularly have residents enter even the home northwestern pain program.

UCLA is solid. Typically, the program likes to take a couple of their own in their 4 fellow pain program. Works great if only 2 of 8 residents are interested, but its much harder to get an anesthesiology based program out of ucla. In the recent past, actually less than 2 of 8 residents have been interested in pain fellowship.

The best thing to do on the interview is to ask around to see how many residents entered pm&r based fellowships and how many did anesthesia based ones. Because anesthesiology greatly dominates the field, ideally a program should have grads in both types.
other good programs are uci, mayo, stanford, loma linda, ut san antonio where residents have done anesthesiology based pain

 

[axm397]

The best program to get a PM&R based pain fellowship is probably RIC, generally b/c of their great rep in the PM&R world. However, as I understand it, they do not send as many residents into anesthesiology based fellowships, and do not regularly have residents enter even the home northwestern pain program.

Obviously, there are pros and cons to anesthesia based vs PM&R based pain fellowships - but I know at least at RIC there is an atmosphere that promotes staying within physiatry to get fellowship training. The number of traditionally PM&R based (the distinction still exists now but not sure how it will change w the new ACGME reqmts) pain fellowships are limited and the competition is great since the number of PM&R applicants far exceeds the fellowship spots within PM&R.

RIC is also a little different from other programs it seems, as only 2 grads chose to pursue a pain fellowship out of 12 grads last year compared to almost 90-100% pursuing fellowships out of some of the other bigger academic programs. Many of the grads got excellent MSK/Pain jobs WITHOUT fellowships - most likely because of the RIC name, the alum network, and from the reputation of our MSK attendings. Our MSK education is phenomenal. As rehabsportsdoc can attest, the MSK ppl at SSRC spend A LOT of time and energy educating the residents with twice weekly lectures, anatomy sessions, physical exam modules, etc. We also rotate through the chronic pain center and SSRC for a total of at least 4 months if not more during our training. we also have 4 out patient therapy/clinic months allowing us time to shadow therapists and spend time with chiropractors. Couple that with 6 months of EMG training in the clinic, inpatient, MSK outpatient, VA, and neurology clinic settings, and we graduate with a very nice foundation of MSK knowledge and skills. We also have 4 elective months and some selective months. We have some great rotations with Ortho (NOT scut heavy, spending 1:1 time with Ortho attendings in clinic), Rheum, Neurology, and if we want, Anesthesia. We have some big names in the pain field and there's exciting research going on at the pain research center all the time. Drs. Addison, Harden, and Stanos are probably some of the top names within Pain, both Anesthesia and PM&R physicians seek them out to give lectures, sit on consensus committees, etc. Not to mention Press, Lento, Plastaras, Rehabsportsdoc , etc. etc. etc.

Many of the grads felt that they could work and get paid as an attending while being provided with enough "training" doing basic injections (mostly lumbar ESI) so why pursue a fellowship? the only reasons to pursue a fellowship according to one grad, would be if you really wanted to do riskier procedures like cervical injections, SCS, discograms, etc.. that we may not be routinely exposed to during residency.

I'm sure things will change as there seems to be more residents pursuing fellowships this year compared to last year. we'll see...

Anyways, this was just a long winded way of saying, looking at the how many grads go into Anesthesia based pain fellowships - as tempperson suggested - may not be the best way of assessing the quality of residency programs. Probably the better question is - How many people who WANTED to go on to fellowship training in pain/MSK/spine landed their top choice (or one of their top choices) fellowship?

 

[medicineman1]

forgive the ignorance- where is RIC and SSRC (which programs)? thanks

 

[drusso]

First, I think that choosing a program exclusively based upon fellowship plans is probably not a good idea. What you like and dislike about PM&R and medicine in general will likely evolve during your training. I would suggest assessing programs based upon their "breadth" and "depth" of opportunities.

Reputation matters, but less than you might think. I do think that programs that have good relationships with other departments in their institutions is a plus. PM&R programs where residents are exposed to both anesthesia-based and PM&R-based pain programs are ideal.

Every fellowship is different. There are advantages and disadvantages to training within versus outside of your specialty. Sometime it's nice to be exposed to "another way" of doing things.

 

[Taus]

forgive the ignorance- where is RIC and SSRC (which programs)? thanks

RIC- Rehabilitation Institute of Chicago
SSRC- Sports and Spine Rehab Center

 

[Disciple]

To the OP: To decide which programs are the best "primers" for interventional pain management requires you to be able to accurately forecast future trends.

Do you want to get your skills during residency and forego an extra year of training? Yes? Then I would ask the following questions during residency interviews.
-Is the PM&R dept linked to an academic Spine Center? Can I get hands on experience here?
-Is there a good relationship between the PM&R dept and the Anesthesia pain clinic? Will they let me get my hands on the needle?
-If not are there county and or VA rotations available where I can get hands on training?
-What about affiliations with private practice interventionalists?

I got a decent volume of injections during residency through multiple venues all the while being at a university hospital where Anesthesia had effectively blocked Physiatrists and possibly Interventional Radiologists from performing injections. This had less to do with specialty and more to do with an exclusive contract, which is not all that uncommon.

Additionally, the program should have dedicated Spine, Sports and MSK rotations so that you have the proper background to use your injections appropriately. By MSK rotations, I mean rotations where the attending devotes his practice to treating this patient population, not general PM&R with an occasional back pain patient walking through the door.

*Warning: I would ask the above questions when speaking with the chief or senior residents and not the chairman or PD.

Do you want to start your career with a comprehensive interventional skill set (including surgical implantations) and be pain board eligible? If this is the case then for all future intents and purposes you need to go to one of the highly interventional Anesthesia pain fellowships. In speaking with a few PM&R ACGME accredited fellowship directors (ambulatory based), several programs will be voluntarily withdrawing from accredited status due to the difficulty in meeting the new guidelines. With the new guidelines and the push toward one fellowship per institution, the growth of newly accredited PM&R pain fellowships is effectively over.

If the above is your goal then your PM&R residency needs to have a good relationship with the Anesthesia pain department (to conduct research or secure LORs) or a good number of elective rotations that will allow you to go to rotate at other university hospitals.

Option #3-Do you want to learn bread and butter spinal interventions and possibly acquire a comprehensive interventional skill set but don't care about being pain board eligible? You can go to a non-accredited PM&R fellowship of which there are over 60. In this case having the proper residency "primer" is not so important.

Finally, factor your future practice environment into your decision.
Do you plan on working in a:

-Physiatry group (Rep and/or strong alumni network is important)
-Pain Group with Anesthesia (Rep is not important)
-Neurosurg or Ortho spine/sports group (Depends who is hiring you. The surgeons?-rep is not important. The Physiatrists?-rep is important)

 

[Disciple]

i believe the most access would be achieve from harvard/spaulding. Sure they only have a 1 spot PM&R fellowship, but the number of residents who graduate there and do anesthesiology based pain is probably more percentage wise than any other place. I've heard of fellows going to beth israel (one of the top anesthesia pain fellowships), brigham&womens, mass gen, dartmouth, etc. The harvard name is great in the pm&r world, but tremendous in general. Anesthesiology based pain programs often judge a residency based upon the quality of the anesthesiology program at the institution, b/c they do not know as much about the PM&R program. Plus you get 10 mths of electives(6 mth in harvard/partners system, 4 mths outside), so you can audition all you want with the partners hospital and throughout the country. Auditioning is probably one the most important things to do for fellowship. No other rehab program even comes close in terms of elective time.

The best program to get a PM&R based pain fellowship is probably RIC, generally b/c of their great rep in the PM&R world. However, as I understand it, they do not send as many residents into anesthesiology based fellowships, and do not regularly have residents enter even the home northwestern pain program.

UCLA is solid. Typically, the program likes to take a couple of their own in their 4 fellow pain program. Works great if only 2 of 8 residents are interested, but its much harder to get an anesthesiology based program out of ucla. In the recent past, actually less than 2 of 8 residents have been interested in pain fellowship.

The best thing to do on the interview is to ask around to see how many residents entered pm&r based fellowships and how many did anesthesia based ones. Because anesthesiology greatly dominates the field, ideally a program should have grads in both types.
other good programs are uci, mayo, stanford, loma linda, ut san antonio where residents have done anesthesiology based pain

This of course assumes that interventional training can only be acquired through fellowship training, and that interventional training is exclusively acquired through training in "pain-medicine".

 

[medicineman1]

great post disciple! If you dont my asking where did you train? If you were to do it over would you change anything? Do you think that approaching interventional pain management with physiatry as a base is becomingly an uphill battle vs. anesthesia base?

 

[Disciple]

If I were to do it over again, I would have been more focused on pain/musculoskeletal medicine from the beginning of residency without fear of offending attendings and/or senior residents. There is nothing wrong with knowing what you want.

That doesn't mean, however, that I would've shirked my repsonsibilities or appeared disinterested during other training opportunities. I've seen some residents go about things the wrong way and it led to some bad evaluations.

As it stands, anyone can do interventional procedures. There is absolutley no restriction on it whatsoever, except at some hospitals, and as I stated previously, this usually has to do more with exclusive contracts than it does with specialty or being pain boarded. The group I'm currently with has an exclusive pain contract with a hospital where I'll be doing procedures, and I'm not pain boarded. In reality, no one really wants to do their procedures in a hospital because of the reimbursement and the inefficiency. ASCs are purely for profit ventures and or course no one is going to stop you from doing procedures in your office.

The days of 100% accreditation for Physiatrists are over. Yes, a basal rate will matriculate to University gas fellowships annually, but the bulk mass of new Interventional Physiatrists will continue anyway. Will credentialing be denied with insurance carriers or medicare? I highly doubt it. There are only some 6,000+ pain docs in the country. Even with PCPs and CRNAs doing procedures, access is still limited. It would make no sense to restrict the second largest group of injectionists. If too many health care dollars are spent on interventional procedures, Medicare will simply cut the reimbursement, like they do with all overpriced procedures.

So to answer your question:

1. Anyone (regardless of specialty) can practice interventional pain management.

2. Anesthesia residents will always have a one-up on PM&R residents for Anesthesia pain fellowships.

3. I would not trade my PM&R training for anything. I would not have 3/4 of my skills (nonsurgical Ortho/manipulation/peripheral joint injections, sports med, EMG, spine, imaging interpretation, primer into musculoskeletal ultrasound) had I gone another route.

 

[nvrsumr]

I would consider U of M's residency if you want exposure to interventional spine and MSK procedures. We have an ACGME accredited pain fellowship with 3 fellows located at our spine center. Fellows perform lumbar and cervical TFESI, SI, Median br blocks and RFA, discography, IDET(infrequently), nucleoplasty and EMGs.

Currently our residents perform between 25 to 300 hundred procedures in the fluroscopy suite during residency, depending on level of interest of course. One resident did over 500 2 years ago but that is not the norm(300 is high too but accurate). Resident procedures are mainly limited to the LS spine but I have done couple cervical facet injections and a stellate ganglion block. There is alot of MSK exposure-You will inject > 50 peripheral joints, nerve blocks, trigger points, Botox. Again this is dependent on your level of interest-if you love TBI, SCI, or Peds you can tailor your clinics more to serve these populations.

You also have 2 months of spine clinic, 2 months of electives and 2 months of dedicated research time with many opportunities to work on pain research projects and get published or present at national meetings(I will be a NASS next week).

Hope this is helpful and best of luck.

 

[Disciple]

If you dont my asking where did you train?

I trained at Rush. My experience was as follows:

Interventional training was done through Hines VA pain clinic, Cook County Hosptial pain clinic (ACGME fellowship here open to PM&R), Rush Ortho department and private practice Interventional Physiatry. An interested resident should be able to perform 200+ during residency. The procedures I performed included lumbar interlaminars, transforaminals, facets, medial branch blocks, SI joint, caudals, cervical interlaminars and an occasional Sympathetic block.

There is an Academic Interventional Spine Fellowship available, but as I stated above, the Anesthesia pain fellowship at Rush was not open to non-Anesthesiologists while I was there. With the new guidelines I expect this to change (this year or the next), just as I expect several other Chicago programs to open up. An educational stipend was provided which I used to attend NASS and ISIS meetings and a PASSOR Cadaver workshop. Last spring the Ortho dept hosted a free lecture and cadaver lab/workshop (sponsored by Smith & Nephew and proctored by ISIS and ASIPP instructors) on Radiofrequency Ablation, Percutaneous Disc Decompression, IDET and Discography that I was able to attend.

Spine training is through the Chicago Institute of Neurosurgery and Neuroresearch (CINN) and the Ortho dept. General MSK is done at the Cook County outpt clinic run by PM&R (peripheral joint injections and peripheral nerve blocks). Sports training is through the Ortho dept and U of I-Chicago Ortho/PM&R. EMG training is with the Neurology dept supplemented by Physiatry.

The basic Spine/Sports/MSK rotations are done during PGY-3. PGY-4 includes 2 months elective and 6-8 months selectives.

 

[tempperson]

I think from a practicality standpoint, if you want to be safe and be ACGME accredited, you've got to be thinking about anesthesia based pain. There are about 80-90 accredited fellowships, whereas PM&R only has 11. In addition, a higher percentage of the anesthesiology based fellowships will teach 'higher-end' procedures like spinal cord stimulators, intrathecal devices, IDET, percutaneous discectomy, vertebroplasty. Only the elite of the PM&R pain programs do this. Many PM&R pain programs focus more on injections. Finally, as drusso mentioned above, pm&r pain fellowships that are acgme accredited are having a tougher time.

Also in terms of not doing a fellowship, I've heard many PDs say that it is not wise even if you pushed many needles in residency. This is because there is not uniformity in training requirements during residency (ie you must haev this number of lumbar injections, facet blocks, cervical injections). Insurance may not reimburse in the future although this remains to be seen.

With this in mind, if I were applying to PM&R, and knew I wanted to focus on pain, I would focus on programs that had excellent relationships with anesthesia depts. And yes, I left out many programs, but I do remember mayo on the interview trail mentioned how their well established anesth pain program takes pm&r residents quite regularly.

 

[medicineman1]

From everything Im gathering here- if you know that you really want to do an interventional practice, and you are already in anesthesia training (and dont really like the OR setting), and in your heart you feel that you would gain a better comprehensive base doing physiatry- I might still be better off sticking with anesthesia due to the politics of the pain environment (anesthesia being the gorilla) as drusso point sout in another post? Not to mention that at this point for me, I might be delayed a year or worst case two- in switching?

Another question- if I were to interview at PM&R programs for a July 2008 spot, would my logic for switching be weak? and without a strong background in PM&R would I even be competitive at this point?

thanks

 

[Disciple]

I think from a practicality standpoint, if you want to be safe and be ACGME accredited, you've got to be thinking about anesthesia based pain. There are about 80-90 accredited fellowships, whereas PM&R only has 11. In addition, a higher percentage of the anesthesiology based fellowships will teach 'higher-end' procedures like spinal cord stimulators, intrathecal devices, IDET, percutaneous discectomy, vertebroplasty. Only the elite of the PM&R pain programs do this. Many PM&R pain programs focus more on injections. Finally, as drusso mentioned above, pm&r pain fellowships that are acgme accredited are having a tougher time.

Also in terms of not doing a fellowship, I've heard many PDs say that it is not wise even if you pushed many needles in residency. This is because there is not uniformity in training requirements during residency (ie you must haev this number of lumbar injections, facet blocks, cervical injections). Insurance may not reimburse in the future although this remains to be seen.

With this in mind, if I were applying to PM&R, and knew I wanted to focus on pain, I would focus on programs that had excellent relationships with anesthesia depts. And yes, I left out many programs, but I do remember mayo on the interview trail mentioned how their well established anesth pain program takes pm&r residents quite regularly.

What is your definition of "elite" for PM&R pain fellowships? Just about all 11 of them are either ambulatory or VA based with the ambulatory based programs being of higher volume interventionally. Take a look at the list of non-accredited fellowships in the PASSOR guide, you'll find alot of programs (many of which are well regarded within the PM&R world) that offer training in advanced techniques.
Medtronic, ANS and Advanced Bionics could care less if you're pain boarded. They will send you to Cadaver courses, provide 1 on 1 training at your clinic and even set you up to spend time at the practices of well published pain docs. Same for Stryker (Vertebroplasty). Procedures such as IDET/Nucleoplasty/Decompressor, though exotic sounding, are not difficult. If you can access the disc i.e. discography, then you can perform these procedures. The approach is the same.

Regarding the performance of injections without doing a fellowship. Yeah, when I was in residency, several faculty members told me the same thing. Ironically, none of them were interventionalists. If you ask around, I'm certain you'll find very few PDs who practice interventional pain management, and fewer still that are able to formulate well informed opinions on the subject.

The insurance issue worries alot of people, but frankly, I've never seen a case of this happening, and don't know how this paranoia got started in the first place. If net billing for procedures gets too high, access won't be cut, the reimbursement will.

There is an innate danger in choosing a PM&R program based soley on its relationship with the Anesthesia department. When reimbursements get cut in the near future and injections become much less profitable, some part-time gas/pain docs may opt out and return to the OR. If you're a Physiatrist with poor skills other than what you learned in your Anesthesia fellowship, you'll have nothing to fall back on.

 

[medicineman1]

Disciple- so whats your point? Again sounds to me, that if you want to do interventional pain management- hands down anesthesia is the way to go? It seems to me from reading all the threads and posts that the leadership in the field is extremely weak, and getting worse? What it comes down to is politics, and the PM&R folks have given it up? Not inspiring!

 

[Disciple]

The PM&R leadership is there, I suppose our leading interventionalists just don't have enough "seniority" if that makes any sense.

To sum it up:

You can become a highly skilled interventionalist through either specialty, with some additional skills acquired through PM&R training. Will politics have dire ramifications for the future thus restricting the ability of Interventional Physiatrists to practice? Highly unlikely.

Is it impossible?

No.

So weigh your options. If security is important to you, go with Anesthesia. If the skills that PM&R offers are appealing to you (whatever you may plan to do with those skills) then go that route.

 

[axm397]

The PM&R leadership is there, I suppose our leading interventionalists just don't have enough "seniority" if that makes any sense.

Without sharing too much information - I can tell you that the AAPM&R leadership is very aware of these issues and understand that the field is moving more towards Musculoskeletal outpatient type practice. I agree with disciple that the interventionalists and MSK specialists within PM&R are definitely "up and coming". I think you will start noticing a change in the way the Academy serves its members in the near future.

I think the Academic people tend to be more "old school" - especially older inpatient based academic physiatrists and their opinion, although valuable in terms of respecting the history of the field of PM&R, may not be as relevant or even realistic.

I have spoken to many physiatrists in private practice outpatient settings and they all agree that fellowship training is not necessary to perform procedures (especially lumbar ESI, joint injections, etc.) - especially if you get sufficient exposure and education during residency. If you want to do riskier procedures and want to have the additional safety net of being able to claim fellowship training or board certification in a malpractice situation, then fellowship would be a good idea.

It sounds to me though, that medicineman's highest priority is financial success. If that is the only goal, and anesthesia/PM&R is just a stepping stone to get to that goal, then I would recommend anesthesia.

Medicineman, not to sound harsh but you're already switching specialties and thinking about multiple options (family practice, anesthesia, PM&R, etc.)http://forums.studentdoctor.net/showthread.php?t=321104 and looks like as of a couple weeks ago, you were looking for open PGY2 spots in Anesthesia, and were even considering dentistry http://forums.studentdoctor.net/showthread.php?t=319825 and sounds like your priority is about making money http://forums.studentdoctor.net/showthread.php?t=319809, it really would be difficult for you to find a good position in PM&R because it is a SMALL field with limited positions compared to the number of applicants and PDs tend to be more conservative and looking for genuine interest in the field.

Anyways, good luck in your hunt for the financial success and security you desire...

 

[medicineman1]

AXM- interesting post. While your devout sentiment is appreciated you are only partially correct in evaluating my motive.

Firstly- I am in an anesthesia program and very unhappy ( mostly situational, although I do find the OR very repetitive, cold, and slow).

I am going to make a change. My long standing interest has been interventional pain management- I like the procedures, the practice environment, the multidisciplinary knowledge base required to succeed, and yes the potential for financial success.

While contemplating my change I am considering all options. I truly feel that if for whatever reason I couldnt get a fellowship I'd be happier doing physiatry- although unfortunately I have limited experience in this vast field, and I will lose a year, perhaps two making the switch. I genuinely think that PM&R would provide a stronger knowledge base/foundation in approaching pain, although a weaker technical skill set/and fewer opportunities secondary to politics.

I have transiently considered FP because of the entrepeneurship aspect, the outpatient experience, and most importantly for me - the geographic flexibility. It would be nice to be closer to my aging parents, and to be closer to my fiance's family as well. Ultimately the field is too vast, and yes the financial incentive is somewhat grim, and I need to focus on the longterm effect of my choice. I am 290, 000 dollars in debt between loans and credit cards- so yes- financial success is important to me.

If I could go back would I consider dental school where fellowship in (oral surgery, endodontics, periodontics, or orthodontics) could make me 500k per year for 4 days per week? hell yes I would! Would I encourage my kids to go to dental school over med school? hell yes!

At this point, I am very interested in the switch to PM&R and am attempting to get as much information as possible- I'm doing my homework. AXM - I do appreciate/find humor in your posting my previous posts in an attempt to disqualify my interst/statements! This is the wonderful world of medicine isnt it?

 

[Disciple]

Without sharing too much information - I can tell you that the AAPM&R leadership is very aware of these issues and understand that the field is moving more towards Musculoskeletal outpatient type practice. I think you will start noticing a change in the way the Academy serves its members in the near future.

So hopefully we'll be getting an update in Hawaii?

 

[rehab_sports_dr]

Much of this has been discussed extensively elsewhere, but I'll chime in with a few thoughts.

If I was a medical student interested in MSK medicine, I would think long and hard about choosing a program solely for the access to interventional procedures. They pay well now, and are the hot field now, but this is in part cyclical. There have been other hot areas in the past, and interventional spine may not always pay as well as it used to. I am sure there are docs who chased the easy money of sub-acutes and EMGs in the past who now regret that they have a practice scope that they don't really enjoy.

Second, if your goal is to do injections, then the training of PM+R will never be as efficient and comprehensive as anasthesia training. My roommate from internship went into anasthesisa and then a pain fellowship, and he clearly has better training as an injectionist. No matter how skilled a physiatrist becomes, we will never match their scope in some skills. Clearly, anasthesiologists have superior training in dealing with the complications of procedures.

So if a physiatrist is to have value, their primary value is in the things we do besides injections. Just as the anasthesiologists have better core training in procedures, we have better core training in neuromusculoskeletal examination and assessment.

So if your goal is to become the best injectionist possible, anasthesia is a better route. If your goal is to become a well rounded neuro-MSK doc who is able to judiciously use interventionals when appropriate, then PM+R is a better route.

As for which programs to apply to, I have my biases. I trained at UMNDJ-Kessler, and am doing my fellowship at RIC, so I obviously hold those two programs in extremely high regard, and think they provide terrific overall training.

When I was a resident at UMDNJ, I only directed the needle toward the spine once, although I observed ~100 epidurals. So if the goal was to get needle time, it was not a plus.

On the other hand, when I was a resident there, I spent ~18 months, or half my residency, in some kind of MSK rotation. Working with mentors like Gerry Malanga, Pete Yonclas, Greg Mulford, Joe Rempson, Rex Ma, etc, were tremendous experiences. I had a great variety of exposures, from the classic occupational/work comp clinic with Todd Stitik and Pat Foye, to a more pure sports practice with Greg Mulford. The opportunities to cover games, go to national meetings, and learn from really smart people was tremendous. And when it came time to apply for fellowships, I felt like I was a very strong candidate. Of the 6 residents who sought fellowships, all got the ones they wanted, from pure pain fellowships to more academic sports and spine fellowships.

Now that I work at RIC, I think they also offer a tremendous exposure. The doctors at the SSRC (the sports and spine rehabilitation center) are all world class teachers and clinicians and very giving of their time. They have weekly residents lectures, journal club, sports and spine lectures, cadaver dissections, all on top of excellent clinical teaching. They have a dummy for practicing injections using the flouroscope, which certainly helps with the learning curve, both for the residents and the fellow. So while they may not get as much injection time as some other programs, they certainly are very well skilled as MSK docs upon finishing their training.

I cannot speak to the quality of other programs on a personal level. I will note that I have been extremely impressed with the quality of the residents and faculty I have met who have worked at UW-Seattle and Mayo.

 

[rehab_sports_dr]

> The PM&R leadership is there, I suppose our leading interventionalists just don't have enough "seniority" if that makes any sense.

I am not sure what that means. There are certainly many physiatrists who are well regarded in the leadership of ISIS, for example

 

[paz5559]

> The PM&R leadership is there, I suppose our leading interventionalists just don't have enough "seniority" if that makes any sense.

I am not sure what that means. There are certainly many physiatrists who are well regarded in the leadership of ISIS, for example

Actually, other than Paul Dreyfuss, there are no physiatrists in leadership positions at ISIS at the moment

 

[drusso]

Second, if your goal is to do injections, then the training of PM+R will never be as efficient and comprehensive as anasthesia training. My roommate from internship went into anasthesisa and then a pain fellowship, and he clearly has better training as an injectionist. No matter how skilled a physiatrist becomes, we will never match their scope in some skills. Clearly, anasthesiologists have superior training in dealing with the complications of procedures.

I think that I have to disagree with you here. I personally identify myself as a pain physiatrist--i.e. I'm interested in the symptomatic management and functional restoration of individuals suffering with, and disabled from, painful conditions regardless of etiology. At the conclusion of my fellowship I'll emerge with an identical skill set in the field of pain medicine as my anesthesia colleagues.

If had a done an anesthesia residency I would no doubt have differently valued skills, but I don't think that I'd be as well prepared for my intended scope of practice in pain medicine. I'm not dissing my anesthesia colleagues, and I don't want the thread to degenerate into a pissing contest, but anesthesia-trained pain physicians will tell you that the day-to-day practice of OR anesthesia in no way resembles the day-to-day practice of ambulatory pain medicine.

There is no perfect path to training in this field. That is why it is a sub-specialty. My anesthesia colleagues struggle with a lot of things that I find second nature and vice-versa. The field is much more diverse than most people realize. There are neurosurgeons, neurologists, OB/GYNs, pediatricians, interventional radiologists, psychiatrists, and orthopedic surgeons among many other specialists who consider themselves "pain doctors." This doesn't include hordes of primary care physicians practicing palliative medicine, addiction medicine, occupational medicine, etc. They all know things that I don't know. We're all better at different things.

My advice is that if Pain Medicine is really your calling, rotate in one of the three traditionally accepted specialties---anesthesia, PM&R, and Neuro---and see which one "fits" the best. Your entire agenda and interest could change during your residency. If you still choose to pursue pain medicine at the end of it then you'll be coming from a specialty with a place at the table. People may be intrigued or disinterested in your choice of specialty, but no one will begrudge you being there.

 

[Ligament]

I too am a physiatrist in an anesthesiology based pain fellowship. I would not give up my PM&R training for anything. I'm better at some things, the anesthesiologists are better at others in pain medicine. This really is a great subspecialty that truly NEEDS gas, PM&R, psych, neuro. Without some cross pollination, this subspecialty is dead in the water as fare as I am concerned.

For example, one of my anesthisiology attendings called me into the exam room this week to examine a patient to differentiate between a supraspinatus vs. biceps tendinitis vs. ac joint pain. I called in my anethesiology attending to tell me what to do with a leaking tunnelled epidural catheter running morphine and bupivicaine (he showed me how to localize the leak, decide to pull it, and cover with huge dose PO opioids).

You won't learn much about inpatient pain management, tunnelled catheters, SCS, pumps, sympathetic blocks/neurolysis, vertebroplasty, at many PM&R fellowships. Of course there are exceptions. Also, these procedures may not be important to you.

I do think you'd be trained to be a better "spine" focused pain doc at a PM&R fellowship if you did not already have a strong base from residency.

 

[Disciple]

> The PM&R leadership is there, I suppose our leading interventionalists just don't have enough "seniority" if that makes any sense.

I am not sure what that means. There are certainly many physiatrists who are well regarded in the leadership of ISIS, for example

It means that our leading interventionalists came up in the early, mid or late 90's. Not in practice long enough to change the direction of the field, though many of them are probably now starting to "come of age".

I could be wrong, but Joel Press will be probably the first MSK focused practicioner to become AAPMR president.

 

[Disciple]

If I was a medical student interested in MSK medicine, I would think long and hard about choosing a program solely for the access to interventional procedures. They pay well now, and are the hot field now, but this is in part cyclical. There have been other hot areas in the past, and interventional spine may not always pay as well as it used to. I am sure there are docs who chased the easy money of sub-acutes and EMGs in the past who now regret that they have a practice scope that they don't really enjoy.

Second, if your goal is to do injections, then the training of PM+R will never be as efficient and comprehensive as anasthesia training. My roommate from internship went into anasthesisa and then a pain fellowship, and he clearly has better training as an injectionist. No matter how skilled a physiatrist becomes, we will never match their scope in some skills. Clearly, anasthesiologists have superior training in dealing with the complications of procedures.

So if a physiatrist is to have value, their primary value is in the things we do besides injections. Just as the anasthesiologists have better core training in procedures, we have better core training in neuromusculoskeletal examination and assessment.

So if your goal is to become the best injectionist possible, anasthesia is a better route. If your goal is to become a well rounded neuro-MSK doc who is able to judiciously use interventionals when appropriate, then PM+R is a better route.

When I was a resident at UMDNJ, I only directed the needle toward the spine once, although I observed ~100 epidurals. So if the goal was to get needle time, it was not a plus.

To offer some counter-points:

1. It sounds like you're in favor of Physiatrists restricting their skill set i.e. becoming skilled at musculoskeletal evaluation but referring out for procedures. I think this is the wrong attitude to take if the field is to continue growth and expansion. As you've seen above, and in other threads, there are programs in existance that offer the full scope of training (the spine/sports/MSK, the high volume interventions and the requisite inpt training). I expect revision to many programs in the next 5 years. Check the summer issues of the Archives, there are quite a few adds for academic pain/spine/MSK (requesting inteventionalists specifically) Physiatry positions. Yes, Anesthsiologists will always be better at airway management/resusitation, but other than that we are able to acquire an identical interventional skill set. Physiatrists can do it all. I expect those graduating between 2000-2007/08 to be some of the first.

Wanting to perform interventional pain procedures does have to do with the reimbursement potential, but in many cases it is not all about the money. There are many attendings and residents who went into the Physiatry because they enjoy Sports, MSK, procedures, etc. On one end of the spectrum you have, say, something like outpt Peds rehab (Autisim, ADHD, CP, Spina Bifida, alot of involvement with social work, families, counselors, teachers, coordination of care, etc.)-don't misinterpret that this is not an important or valuable subspecialty, however. On the other end you have someone who does sports evals, EMGs, a large variety of interventional procedures and may even implant a pump/stimulator now and then. As an MS4 I realized that I would have to do various rotations during a PM&R residency and decided (similarly to many others I'm sure) that I would make this sacrifice to attain the career that I wanted.

2. It is easy to come out of our university programs/academic settings with an inflated view of the place Physiatry has in the medical community/community setting. In general, nobody still (including patients) knows what a Physiatrist is or does. Ortho and Neurosurg may associate you with injections/EMG, PCP's and Neurologists may associate you with supervising the rehab unit, Anesthesiologists may see you as a competitor. Everybody else, forget about it. The way to turn this around is to educate other medical professionals, to grow our numbers and to expand our skill set. Your support of PM&R fellowships is laudable. However, in the medical community, by and large, a PM&R fellowship means little from a recognition/familiarity standpoint. The real issue is that we can have outstanding fellowships and support MSK, pain or both, but without the full and vigorous support of our entire profession, it will fail.

3. In my opinion, watching a large volume of injections during residency is a collosal waste of time, better spent on Musculoskeletal exams or doing EMGs. Watching injections is not necessary to learn the risks, benefits, indications, complications etc. for a procedure. It is the hands on high volume repetition that is important for speed (essential for private practice) and safety.