Your pain fellowship rotation schedule?

[Ligament]

Hi All,

We are in the midst of possibly reorganizing our pain fellowship rotation schedule. Wanted to get some input as to how other programs run. How many months of electives do you get, what other departments do you rotate through and for how long, how long do you spend doing inpatient, clinic, procedures? How many lectures do you get/give per month? I've asked so many fellows these questions in the past few weeks that I just can't remember specifics.

thanks.

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[lobelsteve]

We are dedicated to 12 months of interventional spine with a heavy focus of SCS and peripheral stimulation. No hospital responsibility. Procedures are done everyday in both the office and in our ASC's. All spinal axis procedures are fluoroscopically guided and contrast enhanced (neuraxial).
There are no electives. Call is from home and refill requests are not put through to the on call physician. Lectures are currently on Thursdays and follow the ABA-PM exams table of contents. There are 40 prepared lectures, mostly given by attendings, but the fellows will each present 2-3 topics. Research is encouraged but not mandatory.

The best features of the program are having Robert Windsor available to answer questions and watch him perform a procedure when a fellow (or myself) cannot get the needle in the optimal position.

I feel the program is similar to an apprenticeship in the Renaissance Period sort of way. You learn everything from a master in the field.

Because we are a for profit facility and were sharing a title with Anes at Emory- we have decided to turn in our ACGME accreditation after this graduating class even though we were accredited through 2009. The changes in the PIF made our program non-viable from an ACGME and Emory standpoint. We may seek PASSOR status and I have contacted the AAPM for advice.

We are training people who want to do what we already do. THere is no desire to reduce the interventional training for training we consider useless for the type of practice our applicants want to be a part of. Peds, geriatrics, cancer, pregnancy, PCA's, regional blocks, and intrapleural catheters are not on our radar and we discuss in lecture only. At the risk of offending the academic lurkers: cancer pain hurts like other pain and it responds well to opioids. We work with the patients oncologist to assist in improving their regimen when MSIR/MSContin fails. We do little to no intervention for cancer related pain but will on occasion treat spinal pain in patients with CA and without spinal mets. My point being- you can't learn adequate stim in a weekend course or 5 months of interventional rotations sharing with a few other fellows. Many complicatins may not be experienced with reduced time in the procedure suite- handling something inprivate practice when you haven't seen it before is harrowing and can be career ending.

We have not seen a reduction in applicants to our fellowship program with the announcement that we are giving up on the ACGME. We have increased the size of the program from 4 to 6 fellows and this incoming class starting in July is the most academically accomplished the program has ever seen.

THis post brought to you at 5AM by Buddy the barking dog.

 

[gecko]

The UCLA PMR program is comprised of four 3 month long rotations, which I believe gives you the most comprehensive pain exposure in a 1 year fellowship. One may argue if it is necessary to have exposure to the inpatient side of pain management, cancer pain, chronic pain clinics, etc, but I believe that if you want to come out of fellowship and be prepared for any type of setting, this is the program to come to. You will have enough experience doing stims/pumps if this is what you wish to pursue.

1) 3 months with Dr. Fish: 3 days of interventional procedures/week. You'll have exposure to a huge variety of cases (pumps/stims, vertebroplasties, cervical and lumbar discograms, stellate ganglion, sympathetic blocks, as well as the bread an butter facet/mbb, ESIs, RFs, etc). Not as many SCS implants as Windsor's program, but I've had 5 implant cases in the last month, and Dr. Fish lets you do most of it....he just guides you. Mondays are EMG days (you do about 8, and every other Friday, you do another 4). You have 1/2 day clinics on Wed, Thurs, and full day on Fri...all in the UCLA orthopedic spine dept. You learn much of the private practice model of an interventional spine practice collaborated with ortho/neuro spine surgeons.

2) Inpatient VA with Dr. Pangarkar and Dr. Zirovich: Mon and Fri are Block Clinic days (from 8 am to 2-3pm). Block clinics are run by any of 4 attendings (2 of them are anesthesia based, fellowship trained by Dr. Ferrante's UCLA anesthesia pain program...and the other 2 are PMR pain attendings). Daily rounds on inpatient acute post op patients, and PCA patients. See inpatient pain consults, and also perform interventional procedures on the cancer patients (pumps, stims, epidural PCA caths, celiac plexus, stellate ganglion, impar ganglion, sympathetic blocks). Every 3rd weds of each month is reserved for OR time to do more invasive procedures...but we schedule patients for the OR on an as-needed basis. Interventional spine clinic on Wed mornings. Chronic pain clinic on Thurs and Fri afternoons...with a complete multidisciplinary team of a psychiatrist, psychologist, 3 PMR pain attendings, 1-2 anesthesia pain attendings, a neurology pain attending...you present to one or more of these attendings depending on the complexity of the patient.

3) Dr. Prager's rotation: a big name anesthesiologist who's specialty is in CRPS. Work at his UCLA Medical Ctr office. Performs plenty of SCS implants, sympathetic blocks, amongst other procedures. Haven't done this rotation yet, but on Fri, you also come to the VA to share the block clinic with the VA fellow, and have the chronic pain clinic in the afternoon.

4) Palliative Care rotation: a misnomer, as you only do 2 weeks rotating with the palliative care team. It's actually a rotation that spreads you out and you see a ton of different things. 2 wks of anesthesia, 2 wks palliative care, and the other 2 months are split in private practice offices at 3 locations. Also spend Mon, Wed, Fri at the VA doing block clinics, interventional pain, and chronic pain clinics. Usually spend Tues/Thurs afternoons with Dr. Fish doing "special procedures" if there are any interesting cases scheduled.

All rotations, you come to the VA on Wed Am for Pain Lecture that is broadcast live over the UCLA network. Mostly done by attendings and guest speakers. Fellows do 3 journal clubs, 1 M&M case, and 1 pain lecture each over the course of the year.

You'll also get a ton of casual lectures given by Dr. Pangarkar when the consults are light. He LOVES to teach...and is a huge asset to the program.

The VA fellow carries the on call pager during the week, and the fellows split up weekend calls (1 weekend/month). All from home...and you hardly ever get paged...if you do, it is usually medication management that can be handled over the phone.

Research has just recently become mandatory...fellows are assigned to ongoing research projects, and mostly oversee them (residents and medical students are assigned to help out). The fellow is responsible for presenting the study later in the year, and writing it up for publication at the end of the year.

All of the fellows are extremely happy with the program. The program really caters to the fellows to make sure they have the most comprehensive exposure possible in 1 year. All the attendings are easy to get along with. And best yet...you will have a LIFE in West LA!

Another plus: you can get UCLA housing which is at a huge bargain...and moonlighting opportunities via connections through Dr. Fish and Dr. Pham are available.

 

[gecko]

One other thing:

Because the UCLA PMR program is based in the VA hospital, there is no requirement by ACGME to merge with the UCLA anesthesia pain program.

We are accredited, I believe, through 2009.

 

[JackPB]

There are nine fellows on any given weekday: One is on-call in the hospital. One is post-call at home. Seven are in the clinic. Usually, one or two senior anesthesiology residents are in the mix as well. When a resident is on call, he is backed up by a fellow from home.

The on-call and post-call guys are in the pre-op area in the morning to put in epidurals for the day's first cases. The post-call guy then goes home. The on-call guy rounds wth the PA's and residents on the acute pain service (we handle all post-op epidurals and the difficult IV PCA's) as well as the chronic pain service (this is the primary admitting service for pain patients as well as the consult service). The on-call guy covers all inpatients, consults, ER visits, and phone calls from the afternoon until the next morning.

The seven in the clinic are split between office visits and procedures. About two out of three days are procedure days. Most procedures, including simple stuff as well as SCS's, IDET's, and intrathecal pumps are done in the clinic procedure rooms. Kyphoplasties and procedures involving laminotomies are done in the main hospital operating rooms.

Every week during the year is the same. There are opportunities to take electives for up to four weeks in the headache clinic, psych clinic, radiology, and a few other places. I don't think anyone ever takes electives.

From September on, there is a meeting or lecture or inservice in the clinic at 7:00am four mornings per week. There are assorted sponsored lunch and dinner meetings throughout the month. All fellows are working on research projects, book chapters, and presentations in our free time, such as it is.

Good times.