Why Pain Fellowship?
As the ASRA Pain Medicine Fall Meeting approaches in November, the Diversity SIG is excited to share the perspective of some of our trainee members who are planning to apply for chronic pain management fellowships. Pain Management is unique in that its applicants come from various medical specialties including anesthesiology, physiatry, emergency medicine and neurology. The advantages of pursuing a pain fellowship are numerous and include the ability to provide comprehensive care and specialized expertise in pain management. Fellowship trained pain specialists offer a multidisciplinary approach and can tailor treatment to meet specific patients’ needs.
Please register for the ASRA Pain Medicine Fall Meeting from November 21 to 23, 2024. Learn about upcoming and innovative technology and pain management techniques, network with colleagues, and meet the leaders within the field.
The Physiatrist's Toolbox for Pain
By Anthony Kilgore, MD
The link between pain and function must be emphasized. When function declines, increased pain often follows. This quickly becomes a self-feeding loop that can exponentially derail an individual’s desire to manifest a fulfilling lifestyle. Suffering is an innate experience of rehabilitation medicine. We guide patients through the natural arc of healing, embracing suffering as a negative emotion that positively affects their ability to tackle new challenges as their function adapts and evolves. As a PM&R resident physician, I have begun to gain a confident sense of how unchecked pain limits the functional goals of the patients I serve.
I am often challenged with diseases of neurologic or musculoskeletal origin without the ability to stop their progression. It is here where I am faced with the task of formulating a holistic plan to mitigate its overall impacts on the individual’s wellness. I have guided the treatment of many painful conditions, with a keen focus on how this pain affects function. Having functional goals is insurmountable to create a patient-centered plan that emphasizes their agency over their personal goals. The beauty of this lies in how unique these goals can be from one person to another. Taking the time to have an honest inquiry about one’s social history can pay dividends.
My patients demonstrate for me many functional challenges. Painful transfers to perform tasks of daily living such as getting dressed or bathing. Debilitating spasticity impairing restorative sleep. Crippling degeneration of the MSK system that once provided the tools to live life to its fullest and make health social connections. I believe one of the advantages of training in PM&R lies in the evaluation of painful conditions through the lenses of overall function. When we ask a patient “Where do you hurt?” this is often a more complex question that needs to be viewed within a biopsychosocial framework. It does not do my patients justice if I allow them simply to point at the anatomical location; with so many potential pain generators, both superficial and deep, this will likely lead to unnecessary or misguided interventions or medications. It is important to understand the entirety of the kinematic chain. Dysfunction in our body is hardly isolated to a single structure and the domino effect of poor body mechanics is only amplified with age. PM&R training takes a deep look at the developmental pattern of aging and the intricacies of complex movements that both normal humans and high-level athletes rely on. Through a thorough and thoughtful history-taking process and elegant physical exam maneuvers, we aim to untie the knot that pain often represents to our patients. I am often immersed in discussions with my patients about what their unique and personal functional goals are, and these conversations are essential to proper buy-in with the resilience needed to graduate from their therapy programs. The therapist and I remind patients of these functional goals when progress may feel like it is stalling. I recall one patient whose guiding light was the hope of being able to sit on the floor to join her grandchildren and wrap presents for the holidays. After all my interventions were through, I was unable to remove her from pain 100%. We did, however, achieve our functional goal, and thus jointly celebrated a major win.
My toolbox is vast, but I remain prudent and embrace a selective nature. Using evidence-based medicine, I have gained experience choosing the best therapy for the best patient, giving my patient confidence in the outcome. The use of EMG and diagnostic ultrasound have been instrumental in proper diagnosis. Pain medicine as a field was developed by pioneers in anesthesia, and we continue to benefit from their unique expertise. With that said, I am excited to share my diverse perspectives when collaborating with my future pain colleagues, it is with this discourse that we will continue to tackle the most challenging aspects of pain, and I expect to embrace the subsequent functional gains in my patients’ ability, and their ability to spread their version of good in the world.
Anthony Kilgore, MD, is a resident physician specializing in PM&R at Mayo Clinic-MN. Originally, Dr. Kilgore is from the Central Coast of California and a first-generation college graduate who achieved his degree from Cal Poly. He received a medical degree at Mayo Clinic in Arizona and completed his medicine internship at Mayo. He has a love for German Shepherds and sports. His personal life has been guided by the tenants of caring for Mind, Body, and Spirit, and he has begun to integrate Lifestyle Medicine into his training. His career goals include a fellowship in interventional pain medicine to serve those with pain related to chronic conditions and sports.
The Emergency Medicine Resident's Path to Chronic Pain Fellowship
by Abdoul Kone, MD, and David Nguyen, MD
It is common to see surprised expressions, even on fellow physicians faces, when telling them that as an emergency medicine (EM) physician, you are subspecializing in interventional pain medicine. Although traditionally uncommon, more and more EM physicians are pursuing chronic pain fellowships. Notably, pain has been designated as the most common reason for seeking health care, representing 78% of emergency department (ED) visits. Recognizing this, on April 24, 2014, the Board of Directors of the American Board of Medical Specialties approved the American Board of Emergency Medicine to join various other boards (namely anesthesiology, PM&R, psychiatry, neurology, family medicine, and radiology) in offering certification in pain medicine. As of 2022, only 25 board-certified pain physicians were EM-trained.
One might ask what special skill sets EM-trained physicians (EPs) bring to the field of chronic pain management, particularly in comparison to their peers from other eligible specialties. Depending on who is asked, the answer might be variable. This is my perspective as an EM resident at the end of my pain medicine fellowship application cycle. The nature of the EM specialty, with its blend of procedures and clinical encounters, makes EPs well-suited for the alternating structure of pain medicine between clinic and procedures. Here are a few traits of EPs that make them an asset to the field of pain medicine.
Diagnostic Acumen and Clinical Expertise
The variety of complaints and presentations, along with the constant diagnostic exercises and critical thinking in the ED, enable EPs to develop strong diagnostic acumen and robust differential diagnoses. EPs are skilled at identifying missed diagnoses and ensuring comprehensive workups. Their ability to conduct thorough but focused assessments and apply critical thinking skills aids in identifying underlying causes of pain, distinguishing between acute exacerbations and chronic pain syndromes, and ruling out emergent conditions that may mimic chronic pain presentations. In that same vein, EPs are also proficient at managing acute exacerbations of chronic pain, interventional procedure complications, and identifying and treating infections. This diagnostic acumen allows EPs to formulate precise treatment plans addressing the root causes of pain while managing acute exacerbations effectively.
Comprehensive Understanding of Pain
EPs have a broader perspective on pain, having encountered it at various stages—acute or triggering events, acute on chronic, and chronic or refractory stages. They see patients at their lowest: when they run out of their medications, when they are non-compliant for various reasons, when they misuse or divert pain medications, and during overdoses and withdrawals. They are acutely aware of the numerous psychosocial and financial barriers that may hinder appropriate pain management.
Procedural Skills, Versatility, and Efficiency
EPs are accustomed to seeing a lot of patients in a short time period and tend to stay pertinent during patient encounters, making them efficient. They are also versatile, comfortable with procedures, and adept at quickly acquiring new procedural skills. From airway management and moderate sedation to complex laceration suturing, arthrocentesis, and a wide range of ultrasound use including nerve blocks, EPs possess skills that translate seamlessly into the procedural aspect of chronic pain medicine.
Multidisciplinary Approach
EPs adopt a multidisciplinary approach in patient management, collaborating closely with specialists from various fields to optimize patient care. In chronic pain management, this skill is particularly advantageous as it often requires a holistic approach involving physical therapy, psychological support, pharmacotherapy, and interventional procedures. Their experience in coordinating care among different specialties ensures that chronic pain patients receive comprehensive assessments and tailored treatment plans that address not just the pain but also its underlying causes and associated comorbidities.
Effective Communication
EPs are trained to communicate effectively and compassionately with patients and their families under stressful circumstances. This communication skill is crucial in chronic pain management, where patient education, counseling, and shared decision-making play significant roles in achieving treatment goals. They excel in providing patient-centered care by understanding the impact of chronic pain on patients’ quality of life and functioning. EPs are adept at discussing treatment options, managing expectations, and fostering therapeutic relationships with patients over time, which is essential in chronic pain management, where continuity of care and trust are vital components of successful outcomes.
Navigating the Path to a Pain Medicine Fellowship
Despite these attributes and strengths, many pain medicine fellowship programs have not been exposed to EM-trained fellows. Therefore, additional efforts must be made by EM-trained applicants to demonstrate their competitiveness and genuine interest, as they are sometimes perceived as escaping from EM rather than being genuinely interested in pain medicine. In my experience, several strategies helped me on my journey to a pain medicine fellowship:
- Showing Interest Early: This can start with finding a mentor, expressing your interest, and asking for guidance and collaboration on projects. Reach out to mentors or faculty from programs you are interested in and offer to help with any ongoing projects.
- Engaging in Scholarly Activities: This includes writing articles, contributing to book chapters, and presenting posters or oral presentations at conferences. It can be challenging without mentors or faculty in pain medicine, but many people are willing to help. I contacted several pain doctors on LinkedIn and other social media platforms; a few responded and collaborated on projects I later presented at conferences. My program director connected me with an EM-trained pain physician and facilitated a program letter of agreement with an institution that has a pain fellowship, allowing me to do a pain medicine elective there. Becoming an active member of pain medicine organizations such as ASRA, AAPM, and ASIPP and participating in special interest groups helps you network with leaders in the field who share similar interests. This involvement can lead to further scholarly work and publications.
- Completing an Elective Clinical Rotation in Pain Medicine: Gaining hands-on exposure and understanding the daily activities of a pain medicine physician solidifies your interest. During interviews, a recurring question was about my exposure to pain medicine. My elective rotations provided the knowledge and experience needed to answer these questions confidently. Excelling on this rotation by coming to work prepared and being enthusiastic will likely translate into a strong letter of recommendation, which has a heavy weight on the selection criteria from programs.
- Excelling as an EM Resident: Your unique strengths come from the specific traits of your specialty, which naturally show in your performance on shifts, on USMLE and in-training exams. Your excellence will also earn you a strong letter of recommendation from your program director. Given the limited time in residency, it is wise to design your required scholarly activities, didactics, and lectures/journal clubs around pain management in and outside of the ED.
- ERAS Specific Tips: Indicating your preferred region helps program directors know you are genuinely interested in their area. Tailoring your personal statements to specific programs of interest is also beneficial. Reaching out to programs, expressing your interest, and visiting if possible, can further demonstrate your commitment.
In summary, EM-trained physicians bring a unique skill set to the field of chronic pain management, characterized by their aptitude in acute management, multidisciplinary approach, differential diagnosis, critical thinking, patient-centered communication, versatility, efficiency, and procedural skills. Their extensive exposure to pain at its different stages enables them to offer a special perspective to pain management. This combination of skills equips them to effectively manage the complexities of chronic pain, optimize patient outcomes, and improve the overall quality of life for patients suffering from chronic pain disorders. Being relatively new to the field and having limited access to mentors, EM-trained physicians must proactively demonstrate their commitment and genuine interest in pain medicine.
Abdoul Kone, MD, is a PGY-3 emergency medicine resident at Baylor College of Medicine. He attended medical school in an international military medical school (ESSAL) in Togo on the single scholarship from Ivory coast for that school. He later emigrated to the United States where he restarted from English as a Second Language to college and then medical school at Howard University. Throughout his medical school and residency, Dr. Kone has been heavily involved in acute and chronic pain research and activities, publishing with the Center for Sickle Cell Disease, at Howard University, and the National Institute of Health (NIH) in Maryland. Recently, Dr. Kone has worked and published with several interventional pain physicians from Baylor College of Medicine, MD Anderson and Baylor Scott and White. He is on track to start a fellowship in chronic pain medicine in the fall of 2025. During his free time, he enjoys playing soccer and stand-up comedy.
David Nguyen, MD, is triple board certified in pain management, anesthesiology, and emergency medicine. He completed his emergency medicine residency at the University of Texas at Houston Health Science Center. He pursued further training with a second residency in Anesthesiology at the University of Texas Medical Branch and expanded his skill set with an interventional pain management fellowship at Texas A&M Health Sciences Center at Scott & White Hospital in Temple, Texas. He is currently in private practice at Minivasive Pain and Orthopedics in Houston.
Neurology Training Improves the Quality of Care in the Pain Medicine Subspecialty
by Mahsa (Melika) Eskian, MD
The American Board of Neurology is one of the six boards that cosponsor pain medicine board certification. However, as of December 2023, only 442 physicians in the United States were board-certified in neurology and pain medicine.1 Per a CDC report in 2021, an estimated 20.9% of United States adults (51.6 million persons) experienced chronic pain, and 6.9% (17.1 million persons) experienced high-impact chronic pain.2
During my training, I have had several encounters with patients in their end-stage disease in the neuro ICU, and I had to have serious yet bitter conversations about the goals of care with the family. There was always a unique sentence that the peaceful family would say while saying goodbye, “He or she had a good life.” Later, I began thinking about the “good life” and how to achieve it for my patients as their physician. I spoke to patients, and their lives’ simplest and most beautiful moments were the definition of a “good life.” Dancing at their children’s weddings, picking up their toddler grandchildren, and going for a long walk with their partners. I thought about my patients who were simply asking to have these moments, but pain was the major barrier holding them back from enjoying a great quality of life. I always wanted to save lives and realized that bringing these moments back “saves” their lives. It might not prolong the time, but it will bring back the joyful life they deserve in the time they already have.
I chose neurology residency because I have always wanted to be by my patients’ sides on their worst days and to hold their hands on the rollercoaster of overwhelming disease. One particular story has always stood out to me about the role that physicians play in patients’ lives. We had a patient sadly suffering from Capgras syndrome. He had the delusion of his wife being replaced with a stranger who looked like her. During the visit, he asked us where his wife was, and his wife looked at us, worried about our answer. My attending replied, “I assure you she is fine, and she loves you.” That was when the patient and his wife both had joyful tears and big smiles on their faces and when I decided to become a neurologist—having the knowledge, connection, and bravery that can impact lives, just like this story: something simple but meaningful and profound.
Neurologists have a lot to offer to the pain management sub-specialty, particularly continuity of care. Studies have shown that patients recovering from chronic or injury-induced pain will achieve better outcomes and recovery if they have continuity of care.3 This continuity of care can be provided by a pain interventionalist physician with a neurology background who obtains the history, performs a physical exam, reviews imaging, makes the final diagnosis, and prescribes oral agents and/or interventional procedures.
I have appreciated the importance of continuity of care in both neurology and pain management. One of my clinic patients was admitted to the emergency room for a myasthenia gravis crisis, and I was on the consulting team. When I entered her room, she smiled and said seeing a familiar face was what she needed the most in that scary moment. Another patient was admitted for her refractory trigeminal neuralgia and wanted to see me before her stereotactic radiosurgery simply because she wanted to hear from me again about the risks and benefits of the surgery. After the discussion, she could finally sleep on the night of the procedure.
The differential diagnosis of chronic pain complaints is broad, and, in many cases, crucial. Chronic pain chief complaints require a detailed history, examination, and imaging review to form the most accurate differential diagnosis. Patients with polyneuropathic pain could be suffering from toxic, metabolic, infective, or autoimmune neuropathic pain. Patients with back pain can be suffering from radiculopathies, diabetic plexopathies, bursitis, impingements, disc degeneration, or epidural abscess. The broad and crucial differential diagnosis warrants an extensive and detailed history taking and physical exam. Neurology physicians get extensive training in obtaining goal-directed history and thorough physical exams. Neurology residents obtain significant experience in outpatient practice treating headaches, back pain, polyneuropathies, and tendinopathies during residency, making it feasible to encounter challenging aspects of chronic pain management in subspecialty clinics.
I recall a patient who was visiting with a complaint of headache. The headache was unusual and had orthostatic features, which warranted an investigation into intracranial hypotension and subsequent bilateral subdural hematoma. In a case of non-thorough examination, she could have been misdiagnosed as having a migraine headache and been at risk of catastrophic brain herniation.
In another case, a pain complaint took an unpredictable turn when a multiple sclerosis patient visited with worsening leg pain. On examination, the level of sensory loss was worrisome. He underwent further imaging and was found to have a spinal cord infarction, which could have been misdiagnosed without a thorough physical exam, particularly considering his underlying MS.
Chronic pain management is a fast-growing specialty. The opioid epidemic has increased the urgency of better understanding chronic pain syndromes and advancing new nonopioid pain treatments. Functional neuroimaging, headache and facial pain, central pain syndromes, and neuromodulation are several lines of clinical research that may be especially well-suited to neurologists given their knowledge of neuroanatomy and neurophysiology, comfort level in diagnosing and treating neurologic disorders, and experience reviewing and interpreting neuroimaging studies.4
One of the most fascinating aspects of medicine for me is research. I have joyfully worked on research projects since I was a medical student, later as a postdoctoral student, and now as a neurology resident. The joy of looking for the answers to what we don’t know is a unique experience. Pain is one of the most incredible, complex, crucial, and complicated nervous system functions. I find that pain is one of the few points where mental, physical, and physiological aspects of the nervous system meet, and its function is not fully understood. Answering our fundamental questions about pain can translate to life-changing interventions and expand our patients’ lives even more.
References
- American Board of Psychiatry and Neurology Facts and Statistics. https://abpn.org/about/facts-and-statistics/. Accessed July 1, 2024.
- Rikard SM, Strahan AE, Schmit KM, et al. Chronic Pain Among Adults - United States, 2019-2021. MMWR Morb Mortal Wkly Rep. 2023 Apr 14;72(15):379-385. doi: 10.15585/mmwr.mm7215a1.
- Cabana MD, Jee SH. Does continuity of care improve patient outcomes? J Fam Pract. 2004 Dec;53(12):974-80. PMID: 15581440.
- Schuster NM, Hascalovici JR. Emerging Subspecialties in Neurology: Pain medicine. Neurology. 2018 Nov 27;91(22):1025-1028. https://www.neurology.org/doi/full/10.1212/WNL.0000000000006580.
Mahsa (Melika) Eskian, MD, is a neurology resident at the State University of New York. After graduating from NODET (National Organization for Development of Exceptional Talents), she received her MD as an Honored Student from Tehran University of Medical Science, the first-ranked medical school in her country of origin. She has also completed three years of post-doctoral research fellowship at Harvard Medical School, focusing on the application of artificial intelligence and evidence-based algorithms in clinical decision-making. Dr. Eskian has collaborated with over twenty distinguished scientists worldwide, authored over thirty peer-reviewed publications and book chapters, and was honored with over ten scholarships, grants, and awards. The US Citizenship and Immigration Service distinguished her with the National Interest Waiver Permanent Residency as a researcher with extraordinary abilities. Her clinical and research interests include the neuropathology of pain perception and the application of artificial intelligence in objective pain assessment.