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Pain Management

Authors

Alexander Arena, MSIV
University of California Riverside School of Medicine Class of 2018

Jonathan Brewer, MSIV
Southwest Regional Representative, Medical Student Council, EMRA
Texas A&M College of Medicine Class of 2019

Author and Editor

Jessica Oswald, MD, MPH
Emergency Medicine Resident, PGY-4
University of California Los Angeles/ Olive-View Emergency Medicine
Pain Medicine Fellow 
University of California San Diego 2018/2019

INTRODUCTION

Description of the specialty
A pain medicine physician treats all pain disorders, ranging from pain as a symptom of a disease to pain as a primary disease. A specialist in this field utilizes various levels of care such as evaluating complex pain problems, prescribing and managing pain relieving medications, acting as an integral component in a multidisciplinary team, and dispatching skills to perform interventional procedures such as nerve blocks and spinal injections. 

According to the first prospective broad based multicenter evaluation of ED patient pain experience by Todd et al in 2007, pain has been designated as the most common reason for seeking healthcare, representing 78% of visits. Despite representing a majority of the patients in the emergency department, 74% of patients were discharged in moderate to severe pain with 60% receiving analgesia. A potential barrier to improving pain outcomes in the emergency department is the shortage of pain medicine specialists.

History of the specialty/fellowship pathway
The history of the specialty spans decades as it was originally part of anesthesiology and, later expanded to all specialties. The origins of the specialty can be derived from the International Association for the Study of Pain (IASP). Founded in 1973, it is the largest multidisciplinary international association in the field of pain founded in 1973. The goals of this body are to foster and encourage research on pain and to improve the management of patients. In 1977, the American Pain Society (APS) was founded due to a need for a national organization of pain professionals. The first credentialing of pain clinics came from the Commission on Accreditation of Rehabilitation Facilities (CARF), though it did not accredit pain clinicians. Thus, the need for a standardization in evaluating the competency of pain physicians was apparent and, in 1983, the American Academy of Algology, later named the American Academy of Pain Medicine, was formed. Emergency medicine’s involvement in pain medicine, however, is a recent trend. On April 24, 2014, the Board of Directors of the American Board of Medical Specialties (ABMS) approved the American Board of Emergency Medicine (ABEM) to join along the various other boards in offering certification in pain medicine.

Why residents choose to follow this career path
There are many reasons why one would choose this career path.  The field allows continuity of care and established relationships with patients, offers training in procedures and medication management, and provides a predictable work schedule with minimal nights or weekends.  

How do I know if this path is right for me?
Knowing whether the path to pain medicine is right for you is both a personal and professional decision. To determine if it is the correct path, one should engage in activities related to pain medicine, such as rotations and research. 

Career options after fellowship?
Being dual board certified in Pain Management and Emergency Medicine is a relatively new pathway that allows for a variety of clinical practice.  Some graduates may practice both Emergency Medicine and Pain Management, while other may choose individual practice in either specialty. 

Academic or community positions are available after fellowship completion. For those in academic settings, research in pain medicine is integral to the specialty. From a previous study on graduates in the specialty, large portions either engage in academic or community practice with a small minority engaging in additional fellowships. In addition to the recent federal government declaration of the opioid epidemic as a public health emergency, pain medicine specialists are especially needed to help set mindful and effective policies that can help direct future government policies.

Splitting time between different departments
Splitting time between two departments is program and funding dependent. One could theoretically work within the same intuition or per-diem in an Emergency Department and part-time in a community pain clinic. 

Academic vs. community positions
Having niche EM training is attractive to both academic institutions as well as community practices and hospitals looking to participate in research and/or develop pain management guidelines. 

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs

As of 2018, there are 100 programs per the ERAS directory, with 91 participating in the match. These programs participate in the December application cycle, accepting anywhere from 1-9 fellows per year.

Differences between programs
Most fellowships provide a mix of training in procedures and medication management, with some heavier on procedures and vice versa. While most fellowships are multidisciplinary, the extent to which they integrate psychiatry, integrative medicine, physical therapy and other teams into their clinical practice significantly varies. In addition, there are variations within the rotations of each program with some including rotations at the VA and others in more community or rural settings. 

Length of time required to complete fellowship 
The current length of time required to complete a fellowship in pain medicine is 12 months. There are optional 24 month long programs that have 12 months of clinical work and 12 months of research.

Skills acquired during fellowship 
Pain medicine fellows gain an understanding of evaluating, diagnosing, and treating pain disorders with various modalities that includes management of medications, coordination with multi-disciplinary teams, and deploying interventional management techniques.

Types of rotations/curriculum
According to the Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Graduate Medical Education in Pain Medicine, the fellowship curriculum is organized as follows: outpatient (continuity clinic), inpatient chronic pain, interventional, acute pain inpatient, cancer pain, palliative care, and pediatric pain management. It is important to note that programs are not required to offer all interventional techniques to their trainees at a minimum through didactics. 60 procedures are to be recorded and include the following: at least 25 image-guided spinal intervention, 10 trigger point injection, 10 neuro-ablative procedures, 5 joint and bursa injections, at least 5 neuromodulation, and at least 5 nerve blocks. 

Board certification afterwards?
Because pain medicine is recognized as an interdisciplinary specialty, the American Board of Physical Medicine and Rehabilitation co-sponsors subspecialty certification in pain medicine along with the American Board of Anesthesiology and the American Board of Psychiatry and Neurology. As of 2014, the American Board of Emergency Medicine can also confer subspecialty certification in pain medicine. 

Average salary during fellowship
Salary varies depending on the program and would be considered either PGY4 or PGY5 status depending on whether a 3 or 4-year program was completed for residency. Some programs may allow moonlighting.

PREPARING TO APPLY

How competitive is the fellowship application process?
Although pain medicine is officially a subspecialty of anesthesiology, PM&R, neurology, and psychiatry, it is important to note that no specialty is barred from applying and participating in an ACGME accredited pain medicine fellowship. Pain medicine is quite competitive, as evident by match data for the previous few years. In the most recent match, 98.8% of positions were filled with 331 applicants from a pool of 438. In 2018, approximately 75% of the applicants matched. 

Requirements to apply
According to the ACGME, entry into an ACGME accredited fellowship program requires completion of a residency program accredited by the ACGME, The Royal College of Physicians and Surgeons of Canada (RCPSC), or The College of Family Physicians Canada (CFPC). After this, one applies through the Electronic Residency Application Service (ERAS).Most programs require the following: Curriculum Vitae (CV), personal statement, photo, medical school transcript, United States Medical Licensing Examination (USMLE) scores, In-service Training Exam (ITE) score, and letter of recommendation. It is important to note that some programs do not participate in ERAS. Lastly, there are some program specific requirements that will be listed on their websites. 

Research requirements
This is dependent on the type of applicant you want to portray yourself as and the type of program you are applying to. Research is always a positive addition to one’s CV, especially when it is related to pain medicine. In addition, applying with research to programs that have more focus on research or that offer a 2-year fellowship tract can be an additional bonus to the application. 

Suggested elective rotations to take during residency
It is absolutely recommended to undertake pain medicine elective rotations during residency, more preferably with programs that can produce a letter of recommendation by someone affiliated with a fellowship program. It is recommended to complete rotations before applications are submitted (mid PGY2 for 3 year programs and mid PGY3 for 4 year programs). These elective rotations help bridge the gap between emergency medicine residents and other specialties in terms of interventional skill and pain medicine exposure. 

Suggestions on how to excel during these rotations
Absolutely acquire material on the field to have adequate knowledge and preparation. Reference the “Textbooks to consider” section for which texts books are effective at this. As with all rotations, be prompt, courteous, and an effective team member. Ask for evaluations to assess your own progress in order to make adjustments. 

Should I complete an away rotation?
This is dependent on your personal preferences and the capacity of your residency program. If your program has a pain medicine fellowship in house, you could either do a rotation there or conduct an away. If your program does not have the capabilities of providing a pain medicine rotation, it would be beneficial to complete an away rotation. 

What can I do to stand out from the crowd?
Your background in EM already sets you apart. Having applied work in pain medicine related research, policy, or clinical exposure would strengthen an application. In addition, attending the fellowship director/resident meet-and-greet hosted by the American Society of Regional Anesthesia (ASRA) allows residents and program directors to informally meet ahead of the application deadline. 

Should I join a hospital committee?
Committee work to help set policy related to pain medicine is a great indication of one’s commitment to the field. Thus, joining a hospital committee can be highly beneficial. 

Publications other than research
Publications can be outside of traditional clinical medicine journals that relate to pain medicine. These include publications in textbooks, policy journals, etc. 

How many recommendations should I get? Who should write these recommendations?
An assessment of programs reveals that a minimum of 3 letters of recommendation is needed with many of these programs asking for at least 1 of the letters to be from a pain specialist. 

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship? 
This is a personal preference. The difficulty with a 3-year emergency medicine residency is completion of adequate pain medicine rotations in time for applications. Many 3-year programs have at least 2 elective rotation months throughout the 3 years, often one in PGY2 and one in PGY3. If this is the case and modifications cannot be made, it might be helpful to complete these rotations and then apply, allowing time to work as an attending. 

What if I am a DO applicant?
DO applicants are eligible for board certification after the completion of an ACGME accredited residency. The most recent match does not break down the number of osteopathic applicants that matched. 

What if I am an international applicant?
International applicants are allowed to complete ACGME accredited fellowships with program discretion and approval. Referring to the requirements to apply, there are additional criteria allowing eligibility exceptions. Per the ACGME Program requirements guideline, a program may accept an exceptionally qualified applicant who does not satisfy the requirements in terms of eligibility but meets additional conditions. Exceptionally qualified is defined as someone who completed a non-ACGME accredited residency program in the core specialty and demonstrates clinical excellence. Additional evidence of exceptional qualifications include satisfaction in at least one of the following areas: participation in research in the specialty or subspecialty, demonstrated scholarship in the specialty or subspecialty, demonstrated leadership during or after residency training, and/or completion of an ACGME-international accredited residency program. Accepted exceptionally qualified candidates must demonstrate satisfactory completion of the USMLE Steps 1, 2, and (if the applicant is eligible) Step 3, and have complete fellowship milestones evaluation conducted by the program within 6 weeks of matriculation. Again, check with programs individually to see if they accept international applicants.

APPLICATION PROCESS

How many applications should I submit?
Applying broadly will yield a higher chance of matching. We recommend reaching out to a local mentor who is familiar with the application process. Avoid applying to programs which you do not plan to attend. 

How do I pick the right program for me?
The decision is personal and is dependent on whether you prefer to join an academic or private practice. Look for fellowships that will not only provide exceptional training but also create opportunities that support your long-term goals.

Common mistakes during the application process
The application process is similar to the process that you underwent during residency applications. Make sure to apply on time and contact program directors early to determine whether or not you are eligible for their program. Do not forget about the programs that do not participate in the match; they typically require a separate application.

Application deadlines
Typically, applications are accepted from December 1st through varying dates in the spring (usually between March – May) with Interviews beginning as early as February. Deadlines vary from program to program. 

Tips for writing your personal statement
Ensure that your personal statement tells the story of why you are interested in pain medicine and what you can bring to the specialty. Make your application flow and relate the personal statement to your application. 

Is this a match process?
Yes, the majority of the ACGME accredited fellowship programs participate in the NRMP Match. The programs that do not participate in the match will usually offer positions ahead of match day. 

What happens if I don’t obtain a fellowship position?
You can repeat the application process the following year. In the meantime, there are many ways to get involved. Reach out to mentors, program directors, and physicians in the pain medicine field to find potential opportunities. There are also non-ACGME accredited pain fellowships to consider. 

INTERVIEW PROCESS

How do I stand out from the crowd?
Always be unique. Your background in EM already sets you apart, but be ready to defend why this is a benefit to the field of pain medicine. What makes you the best candidate for the program? 

What types of questions are typically asked?
Why do you want to do a pain management fellowship? What makes you unique? Why this program? Why this location? What are you going to do after fellowship/Where do you see yourself in ten years? 

How many interviews should I accept?
Pain management fellowships are competitive. It is hard to predict how emergency medicine applicants will fare when compared to anesthesia and PM&R. We recommend meeting with an advisor who can help gauge how many interviews you should attend.  

PREPARING FOR FELLOWSHIP

Textbooks to consider reading
There are a considerable amount of textbooks available to Pain Medicine physicians, but some of the more recommended ones include the following:

  • Clinical Text:
    • Benzon H, Rathmell J, Wu C et al. Raj’s Practical Management of Pain, 4e. Chicago, IL: Mosby; 2008.
  • Procedural Texts:
    • Waldman S and Winnie A. Interventional Pain Management, 1e. W B Saunders Co; 1996.
    • Rathmell J. Atlas of Image-guided Intervention in Regional Anesthesia and Pain Medicine, 2e. LWW; 2011.

Important skills to practice while in residency to prepare for fellowship
Practice injections with ultrasound guidance (lumbar punctures, nerve blocks, joint injections, IVs, etc) to develop tactile feedback and spatial awareness.

Tips on how to succeed as a fellow
Learn to empathize and understand your patients. Pain is frequently multifactorial, and procedures, as well as medications, are just one avenue to treat pain. 

Be receptive and seek feedback from your attendings and mentors. If your opinions differ, try to understand why.

Read and be proactive with your learning. Stay up-to-date with the literature and new interventions.

CONCLUSION

Additional resources
There are numerous resources available for residents interested in pain medicine. ACEP recently added a pain medicine section. There are journals with pain medicine related research such as the Pain Medicine Journal and Regional Anesthesia and Pain Medicine. The pain national organizations also have an abundance of educational resources

National Organizations
The following are organizations that relate to pain medicine: American Society of Regional Anesthesia and Pain Medicine (ASRA), American Academy of Pain Medicine (AAPM), and American Pain Society (APM).

Conferences
Most of these organizations/societies hold annual meetings that consist of lectures, workshops, and networking opportunities.

How to find a mentor
Due to the nature of emergency medicine physicians being relatively new to pain medicine, it may be difficult to find a mentor with a background in emergency medicine. However, attending conferences or joining pain medicine societies can help foster mentor-mentee relationships.