Programs with good interventional exposure

[midwestpmr]

Hi all, not new to the site but this is my first post. I have decided that I am going to pursue a residency in PM&R and was looking for some advice on which programs to look at that will suit me. There are three main things I am looking for in a program. 1) I would like good interventional exposure that does well putting residents into pain/spine fellowships and may have one of their own 2) A medium-smaller program 3)Faculty that like to teach and isnt focused on research (I dont want babied but I thrive off good teachers that like to teach and help people learn) Looking at the numbers I would qualify myself as an average PM&R candidate but feel PM&R is a field I will be able to thrive in.

Also, the main reason I am here asking these questions is that there is not a PM&R program at my institution so I have had little direction and the local PM&R docs are not recent grads or up on the residency programs. Due to this, I would like to set up atleast one rotation away and was looking for suggestions on places that would be great to rotate at. These may or may not be the same programs suggested in the top.

Thanks in advance for any help/suggestions!

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[dc2md]

LSU has a TON of interventional procedure exposure. And, we have an ACGME-accredited pain fellowship here. I also think it qualifies as a medium sized program (20 residents...going up to 22 next year). We definitely don't focus on research. And I think we're probably like every program in that not all of are attendings love to teach (but most do).

With that said, I think it's always best to rotate at the bigger-named programs if possible...just looks and sounds better to throw around during interviews. But remember if you haven't done a Physiatry rotation yet, make sure you get exposure to as many areas as possible (outpt MSK and inpt spinal cord/TBI at least...oh, and maybe some EMG/NCS exposure).

 

[axm397]

Feel free to add on

The programs with PM&R based/run pain fellowships:
Northwestern (1 spot per year)
UMich (now anesthesia but strong PM&R influence)
Spaulding
Colorado
VCU
UCLA

programs with anesthesia pain fellowships (or non-PM&R specialty) that have taken PM&R in the past
UPenn
Loma Linda
UCI
UCDavis
Stanford
UVa
Pitt
Jefferson
NRH????
Baylor / baylor and MD Anderson
U Wash
Mayo
UT San Antonio?
UTSW
LSU
Alabama?
Emory?

 

[Taus]

Feel free to add on

The programs with PM&R based/run pain fellowships:
Northwestern (1 spot per year)
UMich (now anesthesia but strong PM&R influence)
Spaulding
Colorado
VCU
UCLA
Temple (Falco) - to the best of my knowledge it has not lost AGCME accred.

programs with anesthesia pain fellowships (or non-PM&R specialty) that have taken PM&R in the past
UPenn
Loma Linda
UCI
UCDavis
Stanford
UVa
Pitt
Jefferson
NRH????
Baylor / baylor and MD Anderson
U Wash
Mayo
UT San Antonio?
UTSW
LSU
Alabama?
Emory?

 

[WaterAvatar]

what about Mount Sinai in NYC?

 

[dc2md]

maybe this list is a little off topic. the OP had some specific questions. axm, any advice for RIC rotations for this student?? or even UCLA (isn't that where your fellowship is now?).

also off topic slightly: the AAPM&R is going to start keeping a list of active fellowships (FINALLY someone is doing this). looking forward to it.

 

[Finally M3]

FWIW Michigan had a very strong interventional program for residents in the past; there have been some tweaks since I graduated, however.

 

[topwise]

FWIW Michigan had a very strong interventional program for residents in the past; there have been some tweaks since I graduated, however.

Yeah, Stanford strongly benefited from one of these tweaks.

 

[Taus]

FWIW Michigan had a very strong interventional program for residents in the past; there have been some tweaks since I graduated, however.

During my interview day this year, several of the residents said that the "hands-on" time in the spine center has declined significantly over the past few years due to attendings leaving and the presence of several fellows. That being said, the interventional experience offered there still seems stronger then the majority of programs I interviewed at. If it wasn't for the location, I would have had this program near the top of my list.

 

[axm397]

I got a good amount of hands on exposure during my residency because of the generous elective and selective time.(might be something you want to ask about during your interviews) Most of the SSRC and chronic pain rotation I spent observing the fellows but I did continuity clinic (2-3 hrs a week x 6 months average about 15 per 2-3 hrs) with an interventional PM&R guy and did a month of anesthesia pain at Northwestern. Just from those two things I had about 250 injections on my procedure log of which I performed about 100 including some cervicals and RFs. There are 4 elective months and 2 selective months so technically you could spend all your time doing anesthesia pain - some have done 2-3 months of it.
Other interventional electives include Ortho and Rheum (a lot of peripheral injections). We also had the option of doing MSK ultrasound for a month with the MSK radiologist. I did a month with the neuroradiologist reading brain and spine MRIs which has proven to be very valuable during my fellowship.

I think with interventions, you do need some quantity but it's the quality that counts. For example, one of my attendings taught me a very nice way of doing lumbar sympathetic blocks. He taught me in 5 minutes what many have not been able to teach me in months of doing injections. His method was fast, safe, and more importantly, consistently reproducible. Now it's one of my favorite injections. So with the right teacher and opportunity, you don't need as many numbers.

For the OP - in terms of rotating, I would decide on your top 5 choices and rotate at a couple of those programs. You said you are an average candidate - so you need to try to stand out during the rotations and get good LORs. Being too rigid in your choice of subspecialization within PM&R as a med student may not go over so well so I would be careful about over emphasizing your desire to get a lot of hands on procedures.

Also, I have to respectfully disagree about your point about faculty focused on research vs teaching. Some of the best faculty members are ones who do their own research and spend time advancing the field. I don't think you want a program without a focus on research. I feel like a program that has active researchers who publish and are "experts" on a topic would have more to offer its residents. Having leaders in the field at your program can help you get fellowships and possibly jobs later on. I know having a letter from a well known researcher in pain helped my application for fellowship. He was also a good lecturer and teacher.

Let me get off my soap box now. This is just my opinion so take it with a grain of salt. What worked for me may not work for you.

 

[ihaveaquestion]

what about Mount Sinai in NYC?

This is an interventional spine program under Dr. Herrera.

^^^Great response by axm397, but what else is new?

 

[chauffeur]

The University of Michigan is a medium sized program (6). The interventional exposure is still pretty strong, at least compared to what I've heard from other residents. They'll have 7 pure spine attendings starting this July, which is rare in a academic center as most are in an affiliated private practive. You can do procedures at different clinic sites. There are 3 ACGME PM&R Pain Fellows a year and several more ACGME Anesthesia Pain Fellows. Each year everyone who applies gets into an ACGME accrediated pain felllowship (Colorado, VCU, OHSU, Brigham, Spaulding, Mich, etc.) A few stick around as well.

 

[midwestpmr]

Thanks for all of your responses, they have been very helpful. I'll definately look further into Michigan and LSU. If any others pop into mind, please feel free to add them. I still want to leave my options open in PM&R but I know I want to make sure I get good interventional exposure to make sure one way or the other. As far as the researchers comment, I completely agree with what you stated. I have just had a few experiences in my career where attendings are more interested in their research than seeing patients and teaching, I was just looking to avoid those types of situations if anyone had those experiences. Some of the best teachers I have had were researchers, I was simply trying to avoid the former. Again, thanks for all the help! It has been quite trying without being able to get much help/advice from my home institution.

 

[dc2md]

midwestpmr, i definitely don't think LSU and Michigan belong in the same group. even though i love the training i'm getting at LSU, Michigan is supposedly a far superior overall Physiatry training program. and if all you're concerned about is getting into a pain fellowship, go for an anesthesia residency instead.

like axm said, many programs (like RIC) allow electives to pick and choose what extra areas you want to study in. LSU doesn't have that luxury unfortunately. but we have a TON of interventional experience built in.

 

[midwestpmr]

Thanks for the honesty regarding the programs. I did do some shadowing in both physiatry and anesthesia and I just really felt more comfortable and a better fit in physiatry. I guess my approach is to make sure I set myself up well to get into the hardest area of a possible field because it is easier to decide you dont want to do it than it is to decide the opposite and have to scrap to try and get into it. I do have an interest in pain but there are definately other areas of PM&R that interest me and I could see myself falling into.

Has anyone heard much about Loma Linda? I was told by a resident in PM&R that did medical school at my institution that Loma Linda was one that he wished he had looked into a little more.

 

[NYCRES]

anyone know about st.vincent's catholic medical center? is it good for interventional exposure as well?

 

[ampaphb]

I think with interventions, you do need some quantity but it's the quality that counts. For example, one of my attendings taught me a very nice way of doing lumbar sympathetic blocks. He taught me in 5 minutes what many have not been able to teach me in months of doing injections. His method was fast, safe, and more importantly, consistently reproducible. Now it's one of my favorite injections. So with the right teacher and opportunity, you don't need as many numbers.

Respectfully, I think you need both. As a med student, and quite honestly, even as a resident, you simply don't know who's good and who isn't amongst your staff until you have watched a large number of pain docs.

As a resident at LSU, I got to see a number of fellows train with Dr. Aprill, and saw how variable their skills were. I also got to work with a number of the other local injectionists in New Orleans. Then I spent a week each with Drs. Slipman, Derby, Dreyfuss, Lutz, and the physicians of the Florida Spine Institute. Then I did a fellowship with Drs. Windsor and Lobel. Then I joined Dr. Aprill in practice, and re-learned the way he does things, this time with a far greater appreciation for the nuances of the procedures.

With enough exposure to enough different docs, you can decide for yourself whose approach works best for you. No one doc does everything well (although I'm sure we each think we do). Quite honestly, there are things a number of people I spent time with did that I conciously DON'T do, and that was just as useful a lesson.

Quantity of exposure is not sufficient, if it is taught by bad teachers or poor technicians. Quantity IS important, becuase the first 100 of each procedure, you wont appreciate the little things. Quantity is also important becuase you need to see complications, atypical responses, ande how to both keep and stay out of trouble.

AXM's SSRC experience was extraordinary not only because she got to do reasonable numbers, but also because Plastaras, Lento, Rittenberg, and fellows like Rehab Sports Doc, etc, are some of the best teachers in PM&R. Numbers are important, but WHO you train with is as important as how many you do. A one man show fellowship (eg. Furman, Cantu, Depalma) is reasonable, but only if you go in knowing you lose something when you don't get the benefit of multiple perspectives.

 

[DrGucciGal]

The University of Michigan is a medium sized program (6). The interventional exposure is still pretty strong, at least compared to what I've heard from other residents. They'll have 7 pure spine attendings starting this July, which is rare in a academic center as most are in an affiliated private practive. You can do procedures at different clinic sites. There are 3 ACGME PM&R Pain Fellows a year and several more ACGME Anesthesia Pain Fellows. Each year everyone who applies gets into an ACGME accrediated pain felllowship (Colorado, VCU, OHSU, Brigham, Spaulding, Mich, etc.) A few stick around as well.

Echo-ing this point. We are exponentially increasing the number of spine interventionalists here at U of Mich. So the interventional experience (as well as overall residency) is tops!

 

[axm397]

Respectfully, I think you need both. As a med student, and quite honestly, even as a resident, you simply don't know who's good and who isn't amongst your staff until you have watched a large number of pain docs.

You're right - when I was a student and even as a resident, I didn't have enough experience to know who's good and who's not. Only after you spend some time with a teacher do you see how well their outcomes are and how well their techniques work for you. There are many ways to do procedures and some are better than others. Exposure to complications and how to handle them is also KEY to preparing you for the future.

I have seen residents take their few hundred procedures from residency and open shop right after residency. It works for some but I have seen catastrophic career ending complications happen to some of those people and a shrewd lawyer will question your training. When you have a good fellowship director defending your training and expertise, it can help your case.

As a resident or a student, probably the best thing to do is to seek out many teachers. Go to conferences, rotate, shadow, talk to people with different training and find out how they do things. Take what works and throw out the rest. Interventional exposure comes in different forms. If you spend hours watching and doing injections but don't know the basic neuroanatomy, H&P, imaging interpretation, etc. you are not going to do well.

 

[drusso]

Respectfully, I think you need both. As a med student, and quite honestly, even as a resident, you simply don't know who's good and who isn't amongst your staff until you have watched a large number of pain docs.

As a resident at LSU, I got to see a number of fellows train with Dr. Aprill, and saw how variable their skills were. I also got to work with a number of the other local injectionists in New Orleans. Then I spent a week each with Drs. Slipman, Derby, Dreyfuss, Lutz, and the physicians of the Florida Spine Institute. Then I did a fellowship with Drs. Windsor and Lobel. Then I joined Dr. Aprill in practice, and re-learned the way he does things, this time with a far greater appreciation for the nuances of the procedures.

With enough exposure to enough different docs, you can decide for yourself whose approach works best for you. No one doc does everything well (although I'm sure we each think we do). Quite honestly, there are things a number of people I spent time with did that I conciously DON'T do, and that was just as useful a lesson.

Quantity of exposure is not sufficient, if it is taught by bad teachers or poor technicians. Quantity IS important, becuase the first 100 of each procedure, you wont appreciate the little things. Quantity is also important becuase you need to see complications, atypical responses, ande how to both keep and stay out of trouble.

AXM's SSRC experience was extraordinary not only because she got to do reasonable numbers, but also because Plastaras, Lento, Rittenberg, and fellows like Rehab Sports Doc, etc, are some of the best teachers in PM&R. Numbers are important, but WHO you train with is as important as how many you do. A one man show fellowship (eg. Furman, Cantu, Depalma) is reasonable, but only if you go in knowing you lose something when you don't get the benefit of multiple perspectives.

I agree. That's why I enjoy attending some of the cadaver workshops and even some of the more "basic" skill-labs. I always pick up something new.

 

[dc2md]

I agree. That's why I enjoy attending some of the cadaver workshops and even some of the more "basic" skill-labs. I always pick up something new.

found out today, the leg bone is indeed connected to the knee bone

 

[Llenroc]

Is there a bone in the boner?

I've been thinking about asking in the Ortho forum.

http://www.youtube.com/watch?v=zeUtCxe-xDg

 

[njdevil]

At the Jefferson residency, you are required to rotate with the Anethesia department for one month of pain, many choose to use elective time with them as well. They have taken physiatry residents regularly and in the last 2 years, they have taken 3 of our own out of 6 total spots for there ACGME accredited fellowship.

As a resident, you also are required to work with physiatrists (who recently wrote the Archives 2008 study guide on Chronic Pain) in the orthopaedic department (Rothman Institute) for 2 months in which there are several interventional physiatrists to work with, again many choose to use elective time with them as well. They have a PASSOR approved fellowship but do not take a fellow every year.

There are 4 months of elective time. 2 of which you are free to rotate in or out of system, many go to tryout rotations for fellowships. 2 months are senior elective in which you stay in system.

 

[Nico47]

It seems that most of our applicants consider Loyola (Maywood, IL -just outside Chicago) because of the interventional exposure it provides, with little competition over procedures since it's a small program.

Then there's the rest of the applicant pool that has yet to discover us, as we are a little fish in a large sea. So please pardon my blatant promotion of Loyola PM&R in this setting, I'm just trying to get the word out.

This is what a PGY-4 had to say in response to the thread:

"During interventional pain clinic we are taught by the Chief of Anesthesia himself how to prep, proper needle placement and visualizaiton under fluoro including cervical epidurals, lumbar caudal ESI, selective nerve block injection, interlaminar ESI's, intra articular facet joint injections and medial nerve branch blocks as well as sacroiliac joint injections. We are trained and expected and are able to take the patient all the way from examination and determination of what there likely pain generator is, consenting them, determining any contraindications to prepping them in the OR and of course the procedure itself. There are 2 months required of this.

One of our recent grads went on to do an ACGME accredited fellowship and returned as an attending interventional physiatrist. In addition to the above injections which he does on a regular basis, we also learn how to perform intra articular hip injections under fluoro, become very competent in performing transforaminal ESI's as well as participating in radiofrequency ablation of the medial nerve branch of the lumbar region from time to time as well. During this rotation, we also continue to hone our EMG skills since this is part of the rotation. There are 2 months required of this as well.

We have 2 months of electives if the previous pain experience is not enough to further strengthen and/or expand our abilities.

In addition to interventional we are trained for one month in a comprehensive interdisciplinary chronic pain rehabilitation program where we learn how to manage pain from a completely different perspective. This rotation incorporates acupuncture and diagnostic ultrasound as well.

The competency in pain management that one obtains in this residency is incredible and unique. Our training is such that it makes us excited and gravitate naturally toward the field of pain medicine with many of our graduates going on to be interventional physiatrists."

I'm a PGY-2 and thus my experience is not as extensive, but already I've been pleased with the following at Loyola:

- Weeks of anatomy during which interventional physiatrists have joined us in the cadaver lab to demonstrate how and where injections should be performed.

- An organized competency training program that involves getting signed-off on injections using models first followed by actual patients.

- The incorporation of ultrasound in our MSK clinic for injections and the ease of accessing this device (you can practice with the machine whenever you like, so long as you return the key. . . or else the VA police WILL come after you. Lesson learned).

- The opportunity for EMG-guided procedures (i.e. botox) during elective months.

I hope this was helpful.