The Multi-disciplinary Pain Medicine Fellowship
Up until about thirty years ago, chronic pain was a diagnosis without a specialist. Patients with disabling pain sought help from primary care physicians and specialists. Once the battery of diagnostic tests was exhausted, or after an exploratory surgical procedure, the pain persisted and the referral to another physician some-times was the only remaining action. Depression, suicide and drug addiction from doctor shopping were an all-to-common sequelae.
Within anesthesiology, a number of physicians with an interest in regional anesthesia and acute pain turned their attention to several serious chronic pain diagnoses. Limited success in a few cases led to other attempts and further investigation by these anesthesiologists demonstrated improvement in the lives of people disabled by headache, reflex sympathetic dystrophy, herpetic neuralgia, and back pain. New diagnostic tools (e.g. thermography) and procedures (differential block, stellate ganglion block) complemented the traditional treatment, and spurred interest in the development of others (celiac plexus block, neurolytic block, epidural steroids).
Three decades later, pain medicine—as a recognized entity and, in part, based on procedural reimbursement—receives a high level of interest by providers. When there were a limited number of providers, the question of credentials was moot. With an ever-increasing array of physicians declaring skill, the questions become: Who gets reimbursed and who gets hospital privileges for invasive procedures? One obvious answer is pain medicine fellowship training. But there is competition from specialties with overlapping expertise (neurology, neurosurgery) and exposure to the patients (psychiatry, addiction, physical medicine). Another increasing category is the physician who has attended a hands-on or cadaver workshop in order to begin to perform invasive pain procedures.
The outcome from the increase in providers is difficult to measure. Indirect measures include increasing litigation for adverse outcomes, and the steady increase in the cost of malpractice insurance for anesthesiologists who practice pain medicine for part or all of their practice. Two decades ago, the malpractice policy cost was substantially lower for pain procedures compared to operating room anesthesia. Now, the policy for the anesthesiologist who practices pain medicine is substantially more expensive, driven by the number and size of claims for adverse outcomes related to invasive pain procedures.
Even the fellowship criterion is complex, with the number of different specialties and organizations that provide various types of certification credential for pain medicine. Although anesthesiology is the oldest, neurology, psychiatry, physical medicine and neurosurgery have all sponsored “pain fellowship.” Based on a variety of experience and training, several organizations offer “certification.” There have been several attempts to create a de novo residency in Pain Medicine directly after medical school, creating a unique specialty without direct parentage by another specialty. So far, the American Board of Medical Specialties has rejected this pathway.
The Accreditation Council for Graduate Medical Education (ACGME) struggled with a simple idea—the creation of a single fellowship for pain medicine that represents all of the stakeholders. The idea is simple but the implementation has been a struggle of nearly a decade. Getting the parent organizations—through their Residency Review Committees—to come together to discuss the project was complex. Creating a clinical and didactic curriculum was a struggle, driven by the specialty-specific fellowship curriculum that already existed. After a long battle, the ACGME took a stand, and dictated that as of July 1, 2008 there could only be one accredited pain fellowship per site, and that it must be multidisciplinary.
The template requires that one discipline be the primary sponsor, but at least three of the four disciplines (anesthesiology, neurology, physical medicine, and psychiatry) must be members of the faculty, with the Education Committee overseeing the fellowship. The fellowship must accept applications from all four disciplines and have a means to ensure fair access to fellowship positions for each specialty. The curriculum must include elements of pain medicine from each specialty and defined case numbers that must be achieved. The result is a truly multidisciplinary fellowship.
In the early phase of implementation, there is already discussion of the length. With more required rotations, there is less time within each specialty. Some would argue that there is two years of curriculum crammed into a one year fellowship. There is already movement toward adding additional time (anywhere from 12 months to18-24 months) to allow additional training in interventional pain management, palliative medicine, EMG and others.
What does the future hold? The next generation of fellowship-trained pain medicine physicians will have a multi-disciplinary background and will be less likely to focus on single procedures or diagnoses. As the parent specialties collaborate within the ACGME-accredited fellowship, they may also break down some of the barriers that keep pain patients isolated within the limits of one specialty. The multidisciplinary pain clinic may become the rule, rather than the exception. It may also be that pain specialists may become concentrated more within tertiary and academic centers where the relevance of these boundaries is less. Ultimately, the future may be driven by reimbursement. If pain credentials become required to achieve full reimbursement for pain procedures, the incentive for physicians to perform a small number of well-reimbursed procedures may disappear. Time will tell!