Sports/Interventional Spine vs. Pain Fellowships

[MSKmonky]

So what made you decide between a Pain and Sports/Spine fellowship? Did you find the job market to be challenging if you were a Sports/Spine fellow versus a Pain Fellow? Where there any employers that required the Pain Management title even though you do similar procedures.

Could a sports/spine fellow easily take one of the Pain Boards and fit that particular requirement?

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[bedrock]

There are dozens of threads on this, Do a forum search and you'll find this discussed many times.

Short answer, you'll definitely still be able to find a job with a spine or sports/spine fellowship, but an ACGME pain fellowship will give you much more flexible job options, particularly in major urban centers and highly desirable locations, where it's become very difficult to secure an interventional job without an ACGME pain fellowship.

There are other pain boards you can take besides the "real" one, the ABMS pain boards, but they also let chiros, naturopaths, and mid-levels take the other boards, so understandably, the other pain boards don't carry much weight. You can only take the ABMS pain boards after completing an ACGME accredited pain fellowship

Similarly, sport and spine grads can certainly find jobs that involved weekend warriors, high school sports, but it's very hard to become the team physician for a Division I university or professional sports team, without ACGME sports fellowship/board certification.

Simply put, you'll have more options in the future if you complete an ACGME fellowship. However, if you're not picky about where you live and/or you're determined to do a lot of both sports medicine and also spine care/procedures during your career, then go for sports/spine fellowship, but understand the restrictions that come with it.

 

[MSKmonky]

Excellent advice! thanks!

 

[PMR 4 MSK]

take whichever one describes what you want to do.

You want young, healthy, well-insured people? Go sport/spine. But you'll lose a lot of night and weekend time to covering games.

You want high dollar procedures, but whiny/demanding patients who usually have crappy insurance or government support? Go pain.

 

[ogp]

Sometimes it takes just being in the right place at the right time with the right people to help you find what you want. I know two residents (one from last year and one this year) that aquired sports positions during their 4th year of residency without doing a fellowship, or an ACGME fellowship for that matter, with orthopaedic groups that are the team physicians for two NFL football teams (Greenbay Packers and Baltimore Ravens). Doing a fellowship isn't always the answer. You have to know what you want and know the right people to help get you there. If doing a fellowship or an ACGME fellowship aids in that goal then do it.

 

[bedrock]

Sometimes it takes just being in the right place at the right time with the right people to help you find what you want. I know two residents (one from last year and one this year) that aquired sports positions during their 4th year of residency without doing a fellowship, or an ACGME fellowship for that matter, with orthopaedic groups that are the team physicians for two NFL football teams (Greenbay Packers and Baltimore Ravens). Doing a fellowship isn't always the answer. You have to know what you want and know the right people to help get you there. If doing a fellowship or an ACGME fellowship aids in that goal then do it.

So they work with the orthopedic group that has the team physician for those two teams. Not at all the same as being the team physician for those teams. I highly doubt that your friends have much say in the management of those athletes. I've worked with several NFL teams as a resident/fellow and I know how it works on the inside.

Could a high level professional athlete make it into your clinic if you didn't do an ACGME sports fellowship fellowship? Sure
Will it happen more than once in a blue moon, unlikely.

As I said, you can definitely see a smattering of sports med patients without an ACGME fellowship, mainly weekend athletes, and some high school team members. Plenty of general outpatient physiatrists do this and those sports patients are a nice change of pace from the usual spine and general chronic msk patients found in PMR clinics.

But it is extremely rare nowadays to regularly treat high-level athletes or have a clinic filled primarily with sports med patients, if you haven't done an ACGME sports fellowship. Those are the harsh realities.

 

[melancholy]

You'll want to inquire as to what breadth of patients are seen at various programs. There's nothing to say that you cannot improve your knowledge and experience of musculoskeletal injuries and associated interventions during a pain fellowship, but due to the inherent nature of the fellowship, you will naturally gain a lot more knowledge and experience in the management of pain and you will have to work harder and spend more time learning other topics of interest (i.e. practicing msk u/s) vs a sports/spine fellowship where you'll get more sports exposure. Obviously, your current background, interests, and motivation will play a factor in this.

I think Bedrock's distinction of a sports/spine fellowship vs an accredited sports fellowship is an extremely important point.

Where do your passions lie?

So what made you decide between a Pain and Sports/Spine fellowship? Did you find the job market to be challenging if you were a Sports/Spine fellow versus a Pain Fellow? Where there any employers that required the Pain Management title even though you do similar procedures.

Could a sports/spine fellow easily take one of the Pain Boards and fit that particular requirement?

I graduated from PM&R and have always had interest in msk/spine, however I wanted ACGME accreditation, a specific skill set and experience with many types of pain patients, and the structure of an accredited program I was familiar with for my education. I felt this combination would best meet my goals to become well-rounded and to develop a good foundation to build upon. In my job search, I feel like I have been a valid candidate at multiple types of practices from pain to orthopedic practices. Coming towards the light at the end of the tunnel, I predict I made a good choice for myself.

PM me if you have any other questions.

 

[lejeunesage]

take whichever one describes what you want to do.

You want young, healthy, well-insured people? Go sport/spine. But you'll lose a lot of night and weekend time to covering games.

You want high dollar procedures, but whiny/demanding patients who usually have crappy insurance or government support? Go pain.

Oh boy, this is cynical and dark... but I love it.

 

[Taus]

Oh boy, this is cynical and dark... but I love it.

Or.... do a pain fellowship w all its "fancy" procedures and agcme approval and then join a sports and spine practice where you don't have to cover games....

 

[cbest]

Or.... do a pain fellowship w all its "fancy" procedures and then join a sports and spine practice where you don't have to cover games....

Bingo - best of both worlds!

 

[Prof Moriarty]

take whichever one describes what you want to do.
You want young, healthy, well-insured people? Go sport/spine. But you'll lose a lot of night and weekend time to covering games.
You want high dollar procedures, but whiny/demanding patients who usually have crappy insurance or government support? Go pain.

Straight talk!



This is an interesting article: http://www.pmrjournal.org/article/S1934-1482(13)00370-5/abstract

I interviewed mostly at acgme pain progs. My buddy on the interview trail put it best: "The more pain interviews I go on, the less I want to do pain." I found as time went on, I agreed more and more. In fact, I think a lot of PM&R people on the pain interview trail feel this way. But they want "that paper" - the "legitimacy" that ACGME accreditation ostensibly brings.

I want to be a comprehensive musculoskeletal physician. When I brought up this concept at interviews, the anesthesiologists were like "Huh?" A little better at the PM&R-based places but still, this is not pain medicine.

I consulted a senior SDN member who's been out in practice for some time on the matter. He said: "I think that most medical students that choose Physiatry... do so with the purpose of becoming musculoskeletal doctors, but let themselves become tracked into “pain management”... and... as "pain management" continues to move away from opiates and procedures/fee for service, the typical "pain management" job will entail serving as medical director for a multidisciplinary pain program."

One PD on the interview trail asked me what ideas I had to fix pain medicine, because it clearly wasn't working. Because chronic pain patients don't respond (well) to meds and epidurals. Look on the pain forum and there's a ton of great clinical info, but unfortunately you'll also see a lot of early burn out; it can be a tough patient population.

I found myself halfway through the interview season strongly considering applying to the some of the better PM&R-based sports med programs that allow you to do interventional spine as well. This probably wouldn't work for everyone, but if you get good interventional skills in residency (we do), it could work. But after all the work I put into the pain and spine interviews, I figured one would work out and I'd have a hard time saying no just to hold out for a potential spot in the much later sports match. Plus I was tapped out. The process is exhausting and expensive.

I'm glad I applied to interventional spine & sports programs. I found a program doing really just what I wanted to be doing. The best of pain without all the crap and the best of sports without all the primary care (albeit, minimal elite/pro stuff, but that's not my thing).

Interesting thing I discovered along the way: the good Interventional Spine & Sports fellowships are *competitive*! I got way more pain interviews. As an example, UMich has excellent progs in both pain med (anes dept) and interventional spine (pm&r dept). I got invited to interview for pain, but not for spine. Certainly there are some crap non-acgme fellowships out there (acgme ones too, actually), but the good ones are highly competitive.

I do find it interesting that just a few years ago, a PM&R grad could grandfather into both pain and sports certification without a fellowship in either. I'd like to see a certification for interventional spine/MSK. What the heck happened to PASSOR? I think maybe those were the guys who grandfathered in. Politics. I was disappointed that some of the better spine/MSK fellowships jumped ship as well and joined the primary care sports match. PM&R sports doesn't really belong there, IMO.

As far as what to choose... I think it depends on what you want to do professionally. If you want to be a pain physician, or you want to take a real pain medicine job down the line, then obviously pain is the best choice. If you want to be a MSK physician but have the ability to do spine procedures at an academic place where the Anes dept rules the roost, pain will probably keep your doors open too. But if you want to be an MSK physician and interventionalist, and you want to work in PP, or outside a saturated major metro, or at an academic place that understands the PM&R model to MSK medicine and interventional spine (Stanford, UMich, PENN, HSS, etc), then you will be best served in one of the good interventional spine/sports programs.

--

As an aside: as others have said, if you want to focus on pro athletes, be a NCAA team physician, etc, and don't care about high-end procedures, then go sports med. Ideally a PM&R-based sports med program, because most of the primary care progs target family med type skills and will prob not fit the bill, though there are notable exceptions.

 

[sloh]

Straight talk!



This is an interesting article: http://www.pmrjournal.org/article/S1934-1482(13)00370-5/abstract

I interviewed mostly at acgme pain progs. My buddy on the interview trail put it best: "The more pain interviews I go on, the less I want to do pain." I found as time went on, I agreed more and more. In fact, I think a lot of PM&R people on the pain interview trail feel this way. But they want "that paper" - the "legitimacy" that ACGME accreditation ostensibly brings.

I want to be a comprehensive musculoskeletal physician. When I brought up this concept at interviews, the anesthesiologists were like "Huh?" A little better at the PM&R-based places but still, this is not pain medicine.

I consulted a senior SDN member who's been out in practice for some time on the matter. He said: "I think that most medical students that choose Physiatry... do so with the purpose of becoming musculoskeletal doctors, but let themselves become tracked into “pain management”... and... as "pain management" continues to move away from opiates and procedures/fee for service, the typical "pain management" job will entail serving as medical director for a multidisciplinary pain program."

One PD on the interview trail asked me what ideas I had to fix pain medicine, because it clearly wasn't working. Because chronic pain patients don't respond (well) to meds and epidurals. Look on the pain forum and there's a ton of great clinical info, but unfortunately you'll also see a lot of early burn out; it can be a tough patient population.

I found myself halfway through the interview season strongly considering applying to the some of the better PM&R-based sports med programs that allow you to do interventional spine as well. This probably wouldn't work for everyone, but if you get good interventional skills in residency (we do), it could work. But after all the work I put into the pain and spine interviews, I figured one would work out and I'd have a hard time saying no just to hold out for a potential spot in the much later sports match. Plus I was tapped out. The process is exhausting and expensive.

I'm glad I applied to interventional spine & sports programs. I found a program doing really just what I wanted to be doing. The best of pain without all the crap and the best of sports without all the primary care (albeit, minimal elite/pro stuff, but that's not my thing).

Interesting thing I discovered along the way: the good Interventional Spine & Sports fellowships are *competitive*! I got way more pain interviews. As an example, UMich has excellent progs in both pain med (anes dept) and interventional spine (pm&r dept). I got invited to interview for pain, but not for spine. Certainly there are some crap non-acgme fellowships out there (acgme ones too, actually), but the good ones are highly competitive.

I do find it interesting that just a few years ago, a PM&R grad could grandfather into both pain and sports certification without a fellowship in either. I'd like to see a certification for interventional spine/MSK. What the heck happened to PASSOR? I think maybe those were the guys who grandfathered in. Politics. I was disappointed that some of the better spine/MSK fellowships jumped ship as well and joined the primary care sports match. PM&R sports doesn't really belong there, IMO.

As far as what to choose... I think it depends on what you want to do professionally. If you want to be a pain physician, or you want to take a real pain medicine job down the line, then obviously pain is the best choice. If you want to be a MSK physician but have the ability to do spine procedures at an academic place where the Anes dept rules the roost, pain will probably keep your doors open too. But if you want to be an MSK physician and interventionalist, and you want to work in PP, or outside a saturated major metro, or at an academic place that understands the PM&R model to MSK medicine and interventional spine (Stanford, UMich, PENN, HSS, etc), then you will be best served in one of the good interventional spine/sports programs.

--

As an aside: as others have said, if you want to focus on pro athletes, be a NCAA team physician, etc, and don't care about high-end procedures, then go sports med. Ideally a PM&R-based sports med program, because most of the primary care progs target family med type skills and will prob not fit the bill, though there are notable exceptions.

Wow I'm a 4th year going into PMR. Thank you so much for writing that post!!

 

[Gauss]

Straight talk!

I do find it interesting that just a few years ago, a PM&R grad could grandfather into both pain and sports certification without a fellowship in either. I'd like to see a certification for interventional spine/MSK. What the heck happened to PASSOR? I think maybe those were the guys who grandfathered in. Politics. I was disappointed that some of the better spine/MSK fellowships jumped ship as well and joined the primary care sports match. PM&R sports doesn't really belong there, IMO.

Certification without training is meaningless in competitive markets. Anyone with knowledge will see through that in the hiring process unless you have an amazing reputation and copious amounts of publications.

The fellowship paths have diverged - I no longer like the term interventional spine / sports. They have become very different fields and really should be separate.

 

[sloh]

Certification without training is meaningless in competitive markets. Anyone with knowledge will see through that in the hiring process unless you have an amazing reputation and copious amounts of publications.

The fellowship paths have diverged - I no longer like the term interventional spine / sports. They have become very different fields and really should be separate.

could you elaborate on the differences? thanks!

 

[j4pac]

I would also like to get some insight on employability. I love MSK/Sports Med. I also like Spine and it is a tool I would like to have, but it is not what I would want to do on a full-time basis. I would like a multidisciplinary MSK/EMG/Sports Med clinic. Is it reasonable to just plan to go straight into practice after residency, or is it becoming more difficult to get jobs without fellowship. I would eventually like to practice in the Jacksonville, Tampa, or Pensacola areas.

I may completely change my mind during residency and decide to do something different...inpatient...who knows. But I am just trying to get opinions on the outpatient side as of now.

 

[RUOkie]

I would also like to get some insight on employability. I love MSK/Sports Med. I also like Spine and it is a tool I would like to have, but it is not what I would want to do on a full-time basis. I would like a multidisciplinary MSK/EMG/Sports Med clinic. Is it reasonable to just plan to go straight into practice after residency, or is it becoming more difficult to get jobs without fellowship. I would eventually like to practice in the Jacksonville, Tampa, or Pensacola areas.

I may completely change my mind during residency and decide to do something different...inpatient...who knows. But I am just trying to get opinions on the outpatient side as of now.

That really depends upon how you feel after residency. Most people who do general MSK practice do not do fellowships. But they are necessary if you are planning on interventional spine or team coverage sports med. I didn't do a fellowship and you described my practice. Northern Fla should have opportunities

 

[Prof Moriarty]

Certification without training is meaningless in competitive markets. Anyone with knowledge will see through that in the hiring process unless you have an amazing reputation and copious amounts of publications. The fellowship paths have diverged - I no longer like the term interventional spine / sports. They have become very different fields and really should be separate.

Most of those people are well-established and not looking for a job. Some did MSK fellowships and now are PD's at PM&R pain or sports med progs.

could you elaborate on the differences? thanks!

Look at Cleveland Clinic as an example. They have the following fellowships:

• pain medicine (anes)
  
• spine medicine (neuro)
  
• sports medicine (primary care, under ortho dept)
  
• MSK medicine (ortho/rheum)

Stanford has:

• pain (anes)
  
• interventional spine (ortho/PM&R)
  
• sports medicine (ortho/PM&R/primary care)

UMich has:

• pain (anes)
  
• interventional spine (PM&R)
  
• sports (family med)

On the other hand:

• PENN still calls theirs spine & sports MSK medicine.
• HSS still calls theirs spine & sports medicine.
• OSS (Furman's prog in York, PA) still calls it interventional spine & sports medicine.
• Mt Sinai Beth Israel still has: "sports, spine & msk medicine."
• UWisc is "pain and MSK."
• Mt Sinai still calls it sports & interventional spine, though they joined the sports match this year (really too bad IMO).

 

[Taus]

I feel like most of those former pain/spine programs that are now agcme sports... Are really just a guise to offer boarding in something, as can no longer offer agcme pain. If credentialing for interventional spine procedures is a concern(occasionally valid) I can't see how sports boards helps

I of course have my biases- I did an anesthesia based pain fellowship. I see some sports stuff and do EMGs, where my residency training has been sufficient. I'm not a true sports doc, see about 80% spine and do some higher level procedures ie all cervicals, stim, disco. For me this training has been perfect. For others it wouldn't be if want true high level sports stuff.

 

[mjakec]

I'm the current PM&R Pain fellow at the University of Colorado. Historically, this fellowship allowed you to sit for both the pain and sports boards but recently had to choose one or the other. They stuck with the ACGME pain accreditation but the fellowship didn't change.

My typical week includes 2 days of spine clinic, 1 day of sports clinic, 2 days of spine procedures-lumbar, cervical, RFA's, and 1/2 day of US and 1/2 days of EMG.

I also cover 4 division 1 sports teams throughout the year.

For me, this is a great combination of interventional spine, sports, EMG, and US.

I just signed my first job contract which will essentially be the same thing- outpatient MSK/spine, spine procedures, EMG, US, and will be be 1 of 5 physicians covering a university's sports programs and 5 local highschool football teams.

I had a hard time figuring out which fellowships to apply for and ultimately applied to non-accredited spine and accredited pain (which ended up back-firing since the non-accredited spine fellowships offer positions before the pain match-it was still good to see what was out there) I did not like any of the anesthesia pain fellowships-mostly chronic pain management in clinic and inpatient pain consults.

I liked some of the non-accredited spine programs but the combination of what UC's Pain fellowship offered was the best combination for me and most mirrored what I wanted to be doing long term.

I made a list of the skills/training I wanted to get out of fellowship before interviewing -it's an extra year of training and it needs to be worth your investment.

 

[Taus]

Agreed that sounds ideal. And unique at Colorado.

 

[sloh]

If any more current residents and attendings could offer advice, that'd be awesome as well

 

[Prof Moriarty]

Duuude, you gotta be some lucky genius from Colorado and do your residency at Mayo/UWash/RIC to score a spot at UC. That program sounds pretty sweet. It's basically a spine & sports program with pain accred.

 

[Gauss]

I feel like most of those former pain/spine programs that are now agcme sports... Are really just a guise to offer boarding in something, as can no longer offer agcme pain. If credentialing for interventional spine procedures is a concern(occasionally valid) I can't see how sports boards helps

This is true and those fellowships should lose their accreditation. Interventional spine falls under pain, not sports

 

[The JockDoc]

This is true and those fellowships should lose their accreditation. Interventional spine falls under pain, not sports

I disagree that spine procedures fall only under the pain fellowship umbrella. An epidural steroid injection is just an injection at the end of the day. For example, a lot of specialties perform other injections into knees and shoulders without claiming ownership over them. Certain specialities may be arguably more skilled in how they use them through their treatment plans, but a knee injection is the same if its performed by ortho, rheum, FM, or PM&R, as long as proper training has been undertaken. The same can be said about spine injections.

 

[The JockDoc]

This is a question that has been debated again and again on this forum if you look at old threads. The problem is that the round peg of physiatric MSK/sports/spine treatment model unfortunately has never fit the current ACGME sports or pain fellowship square holes. There’s some give and take between accreditation and fellowship philosophies that varies markedly from program to program.

For those considering between the two, I highly recommend evaluating each fellowship on a case by case basis by first figuring out what you want to do. For myself, I enjoy taking care of the sports population, though I don’t necessarily care about cherry picking elite athletes. I also like general MSK and to a certain extent, spine. In my career, I’d like my potential schedule to look something like this: hand paresthesias, a runner with a chronic hamstring tendinopathy, an acute lumbar radic, salter-harris fracture, and a sports concussion.

FWIW, I’m in one of those ACGME accredited PM&R “sports” fellowships that trains spine, and even US (how dare they!) procedures. If I didn’t have the sports fellowship-related experience, I wouldn’t be terribly adept at taking care of the concussion (particularly if it was a peds pt), and definitely not the fracture. Likewise, I am more comfortable with the acute radic with my spine training, and I can do the necessary injection. I’ve also got US skills that enable me to inject the hamstring, should that be in the plan.

All of those skills are not taught in one fellowship, unfortunately, so I’m one of those who was caught in between pain and spine. A problem with seeing only sports patients is that it comprises a relatively small patient population, albeit one I enjoy caring for. I wanted to be trained in spine because it’s so useful in the MSK world. Spine related pain is more common than any other joint pain and providing service to those patients can make it easy to generate some patient traffic.

What hasn’t been mentioned so far in this thread is that there is much to sports that is not taught in a pain or spine fellowship. Sports is not all MSK. Concussions are a good example. They can take a lot of clinical acumen to properly treat without just resorting to an impact test for clearance. If you want to see athletes and not just patients with pain, you should probably be trained to treat problems that athletes face. You won’t get that in a standard pain fellowship. Not to mention the fracture care, etc.

In the end, I’ve got a valuable set of skills that can be used to treat the wide variety of patients that I want to see. Others may have a different goal for their career, and therefore will have alternative paths more suited for them.

 

[Gauss]

I disagree that spine procedures fall only under the pain fellowship umbrella. An epidural steroid injection is just an injection at the end of the day. For example, a lot of specialties perform other injections into knees and shoulders without claiming ownership over them. Certain specialities may be arguably more skilled in how they use them through their treatment plans, but a knee injection is the same if its performed by ortho, rheum, FM, or PM&R, as long as proper training has been undertaken. The same can be said about spine injections.

That is not what I said. IMO strictly Interventional spine fellowships should not be falsely labeled as ACGME sports fellowships. If a sports fellowship chooses to train you in spine and spine interventions, it should not be the majority of the curriculum. I would say 1 - 1.5 days out of the week is typical. The downside is that you will not be as skilled an interventionalist compared to if you did a pain or say Lobel's fellowship. I see so many new grads that say they're interventional spine but can't do cervical or thoracic work. Then I see sports grads that do a half ass job with US, sideline coverage, concussions, and EMG. I blame these fellowships for that. If I see a UC pain or Mayo sports grad - I know what I'm getting.

 

[The JockDoc]

That is not what I said. IMO strictly Interventional spine fellowships should not be falsely labeled as ACGME sports fellowships. If a sports fellowship chooses to train you in spine and spine interventions, it should not be the majority of the curriculum. I would say 1 - 1.5 days out of the week is typical. The downside is that you will not be as skilled an interventionalist compared to if you did a pain or say Lobel's fellowship. I see so many new grads that say they're interventional spine but can't do cervical or thoracic work. Then I see sports grads that do a half ass job with US, sideline coverage, concussions, and EMG. I blame these fellowships for that. If I see a UC pain or Mayo sports grad - I know what I'm getting.

Right, you can only be good at so many things. I personally chose a primarily sports medicine fellowship with additional lumbar interventional spine procedure training, but I don't feel that my sports-related skills are necessarily lacking compared to if I went to a sports fellowship without learning the procedures. Yes, I don't intend on doing cervical/thoracic procedures. That's fine with me. Most patients require lumbar moreso than cervical procedures, and I can do a good job with my lumbar procedures if need be.

You bring up EMG competence too, but a pain fellowship won't fix that either. In fact, they can erode EMG skills since most pain fellowships (anesthesia based) don't include them.

You work with what's available to you. The reality is that there is no perfect fellowship for everyone within the pm&r sports/spine framework as it stands.

 

[j4pac]

For those considering between the two, I highly recommend evaluating each fellowship on a case by case basis by first figuring out what you want to do. For myself, I enjoy taking care of the sports population, though I don’t necessarily care about cherry picking elite athletes. I also like general MSK and to a certain extent, spine. In my career, I’d like my potential schedule to look something like this: hand paresthesias, a runner with a chronic hamstring tendinopathy, an acute lumbar radic, salter-harris fracture, and a sports concussion.

Let me know when your clinic opens, because I would love to work there.

 

[lobelsteve]

I disagree that spine procedures fall only under the pain fellowship umbrella. An epidural steroid injection is just an injection at the end of the day. For example, a lot of specialties perform other injections into knees and shoulders without claiming ownership over them. Certain specialities may be arguably more skilled in how they use them through their treatment plans, but a knee injection is the same if its performed by ortho, rheum, FM, or PM&R, as long as proper training has been undertaken. The same can be said about spine injections.

Wow, you sound like you know nothing about the history of pain/spine. Knee injections ever kill anyone? Paralyze? Stroke? Seizure? Anticoagulants? Indications? Spine is spine, any FP or sports doc putting needles in the spine and has a complication and they will not look good in front of a jury.

Education, experience, and training. Standard legal phrase. And a medical board will not look favorably on you either.

You are being trained for spine, and lets hope it is by someone good who has the right credentials like Furman or Falco. But for folks reading this....you might be encouraging untrained people to death and dismemberment of their patients.

So lumbar spine is OK, but mid back and neck no go? Having a comfort level is a good thing. But catastrophic risks are present anywhere along the canal.

 

[The JockDoc]

Wow, you sound like you know nothing about the history of pain/spine. Knee injections ever kill anyone? Paralyze? Stroke? Seizure? Anticoagulants? Indications? Spine is spine, any FP or sports doc putting needles in the spine and has a complication and they will not look good in front of a jury.

Education, experience, and training. Standard legal phrase. And a medical board will not look favorably on you either.

You are being trained for spine, and lets hope it is by someone good who has the right credentials like Furman or Falco. But for folks reading this....you might be encouraging untrained people to death and dismemberment of their patients.

So lumbar spine is OK, but mid back and neck no go? Having a comfort level is a good thing. But catastrophic risks are present anywhere along the canal.

I assumed that there was an understanding amongst us that ALL procedures have risks. Septic knees can definitely happen. Without proper US training, you can easily hit or anesthetize the sciatic nerve with a hamstring conjoint tendon injection causing paralysis.

I'm, incidentally, trained by those who have done their own ACGME pain fellowships. There are at least a few non-accredited spine fellowships teaching spine procedures that produce excellent proceduralists. Windsor, who trained Falco and Furman - since you mentioned them - has an unaccredited fellowship right now. Those programs didn't need the ACGME pain credentialing to determine whether they were safe or not.

As I mentioned in a post earlier, I understand the limitations of my own "particular set of skills". I won't have enough repetition with T- or C- spine injections without even more training than can fit into a year because I recognize the risks that you speak of.

 

[TXPMR]

I think one of the huge elephants in the room is the relative dearth of ACGME accredited PM&R based sports medicine programs. Ever since grandfathering stopped for sitting for the sports boards, physiatrists wanting to do sports medicine have been faced with a terrible situation: non accredited "sports and spine" vs. accredited PM&R sports vs. accredited primary care sports.

As far as accreditation/boarding if someone wants to brand themselves as a "sports medicine doc" and see high level athletes in a competetive or academic market boarding in sports is imperative. There are non-boarded docs who do have high level athletics but all else being equal sports boarding gets you a leg up (especially for physiatrists since some people are still coming around to the fact that we can do sports medicine).

What is unfortunate is that in order to go to an accredited program physiatrists have to enter the match and compete for the few accredited PM&R sports positions or go the primary care route. There are plently of primary care programs that are top notch for physiatrists (especially when partnered with ortho or PM&R departments) but there are also some programs where you're seeing a significant amount of primary care patients. A real argument can be made that a graduate from a top non accredited program (e.g. Furman's as has been mentioned earlier) is better trained then some graduates of primary care sports programs. But the primary care graduate gets the opportunity to get a piece of paper that says they are board certified in sports medicine.

The real tragedy in this in my opinion is the timing of the application processes. A lot of the top sports and spine places (e.g. HSS, Penn, Furman) start locking down candidates in the summer/fall. Meanwhile, the accredited match isn't until the beginning of January. It is impossoble for a candidate to simultaneously weigh accredited and non accredited programs. And the unfortunate scenario could occur in which a candidate forgoes a non-accredited offer to go for the match, doesn't match, and ends up with nothing.

 

[Gauss]

as in all competitive areas, there are never enough residencies/fellowships/jobs etc. It is not "terrible" to have so many fellowship options and not unusual that there are only a few top ones that everybody wants. I find this to be excellent for our field and a necessary quality control. Giving everybody a fellowship and certification makes that cert meaningless. There are a lot more openings if you go with primary care sports fellowships. There are WAY more primary care/ sports jobs out there than anything for PM&R. You can always spend another year doing another fellowship. Shocking but this is more common than you think. 1 year is nothing

 

[Prof Moriarty]

There are at least a few non-accredited spine fellowships teaching spine procedures that produce excellent proceduralists. Windsor, who trained Falco and Furman - since you mentioned them - has an unaccredited fellowship right now.

Pretty sure this is where Lobel trained too.

 

[lobelsteve]

Pretty sure this is where Lobel trained too.

I trained under Winsdor through his ACGME program at Emory. This ended in 2007.

 

[ampaphb]

So they work with the orthopedic group that has the team physician for those two teams. Not at all the same as being the team physician for those teams. I highly doubt that your friends have much say in the management of those athletes. I've worked with several NFL teams as a resident/fellow and I know how it works on the inside.

Could a high level professional athlete make it into your clinic if you didn't do an ACGME sports fellowship fellowship? Sure
Will it happen more than once in a blue moon, unlikely.

As I said, you can definitely see a smattering of sports med patients without an ACGME fellowship, mainly weekend athletes, and some high school team members. Plenty of general outpatient physiatrists do this and those sports patients are a nice change of pace from the usual spine and general chronic msk patients found in PMR clinics.

But it is extremely rare nowadays to regularly treat high-level athletes or have a clinic filled primarily with sports med patients, if you haven't done an ACGME sports fellowship. Those are the harsh realities.

That's just not so anymore. (Of course, Bedrock said it originally 4 years ago, so his thoughts may have changed). The vast majority of teams these days have cashed in such positions. The job is simply sold to the highest bidder. Credentials are irrelevant, at this point.

 

[ampaphb]

You are being trained for spine, and lets hope it is by someone good who has the right credentials like Furman or Falco.

These fellowships are very different. Dr. Furman runs a highly regarded academic high volume practice, where you learn a ton. Dr. Falco, on the other hand, writes a lot of papers with Lax.

 

[ampaphb]

I think one of the huge elephants in the room is the relative dearth of ACGME accredited PM&R based sports medicine programs. Ever since grandfathering stopped for sitting for the sports boards, physiatrists wanting to do sports medicine have been faced with a terrible situation: non accredited "sports and spine" vs. accredited PM&R sports vs. accredited primary care sports.

As far as accreditation/boarding if someone wants to brand themselves as a "sports medicine doc" and see high level athletes in a competetive or academic market boarding in sports is imperative. There are non-boarded docs who do have high level athletics but all else being equal sports boarding gets you a leg up (especially for physiatrists since some people are still coming around to the fact that we can do sports medicine).

What is unfortunate is that in order to go to an accredited program physiatrists have to enter the match and compete for the few accredited PM&R sports positions or go the primary care route. There are plently of primary care programs that are top notch for physiatrists (especially when partnered with ortho or PM&R departments) but there are also some programs where you're seeing a significant amount of primary care patients. A real argument can be made that a graduate from a top non accredited program (e.g. Furman's as has been mentioned earlier) is better trained then some graduates of primary care sports programs. But the primary care graduate gets the opportunity to get a piece of paper that says they are board certified in sports medicine.

The real tragedy in this in my opinion is the timing of the application processes. A lot of the top sports and spine places (e.g. HSS, Penn, Furman) start locking down candidates in the summer/fall. Meanwhile, the accredited match isn't until the beginning of January. It is impossoble for a candidate to simultaneously weigh accredited and non accredited programs. And the unfortunate scenario could occur in which a candidate forgoes a non-accredited offer to go for the match, doesn't match, and ends up with nothing.

I have often wondered why candidates willingly cede programs all he power. Clearly, Furman, HSS, and Penn did this to force candidates to make this kind of Herculean choice. Candidates have been told they will ruin their careers, piss off important people, and forever have a bad name in their field if they take a position, and then still go through the match. In the real world? You need to do what's best for you.

Furman, Penn, HSS, etc. will have no trouble finding another candidate. Will they be mad for a minute? sure. Trust me, they will get over it. These programs want to lock down candidates early in the process. They are doing what's best for the program. If it screws candidates in the meanwhile? Not their problem. Their approach is at best Machiavelian. So when they tell you what you are doing is unethical? Ask them about those folks didn't match, and now have no options.

 

[ampaphb]

I trained under Winsdor through his ACGME program at Emory. This ended in 2007.

Me too. Steve was the assistant PD at the time. However, please understand this was (and still is) very much a fellowship where you are taught by the fellows. Dr. Windsor actively teaches for the first month. Very good people have been trained here, but this is not a program where you are spoon-fed. If you are self motivated, and want to get a lot of hands-on experience, however, it is a terrific opportunity.

 

[Prof Moriarty]

Clearly, Furman, HSS, and Penn did this to force candidates to make this kind of Herculean choice.

Also consider they may want candidates who want the interventional spine/sports model that they're teaching ("good fit"), which is definitively different from the current ACGME anesthesia-based pain medicine model. I actually wish they made offers sooner - it would allow you to skip unneeded pain interviews, saving time and $. If this is what you want to do, it is not a Herculean choice, it's pretty straightforward.

That said, the ACGME pain programs only recently joined the match, and not all programs participate. Assoc PD at UCLA told me that since they joined he felt they had lost out on some top candidates who were poached by good interventional spine progs pre-match as you said.

 

[oreosandsake]

curious, how do the spine fellowships teach airway management, or emergency protocols for iatrogenic oopsies related to spine procedures?

 

[Baritonebass]

Do all Pain programs teach those things in a universal manner? Or is it based on the institution's interpretation of learning objectives?

 

[DOctorJay]

all ACGME pain programs MUST teach you those things to remain accredited

 

[Baritonebass]

I guess my point is that they don't all teach it the same way even if checking a box saying they taught complications is required...And they are regulated so asking how independent non-accredited programs teach would require a response from every program... So good others scary I imagine.... Which is why applying to those programs require a few more than your standard soft ball questions... Some places have structure other spend a month showing where to put needles and turn you loose