Cite as: Bautista A. Reframing the value of pain fellowship. ASRA Pain Medicine News 2026;51. https://doi.org/10.52211/asra050126.007.

There has been a change in the last 5-10 years in the environment of anesthesiology practice and subspecialty fellowships. Pain medicine fellowship training has historically been viewed as a viable option and a natural progression for residents pursuing an anesthesiology career who are interested in pain medicine, longitudinal care, and multidisciplinary care. However, recent evidence suggests that fewer trainees, especially those in anesthesiology programs, are seeking fellowship pain training. In an era when general anesthesiology practice is both financially lucrative and professionally flexible, the question is how the value of pain medicine fellowship training is being framed, communicated, and understood by trainees.

The 2025 Pain Medicine Match

The results from the 2025 Pain Medicine Fellowship Match reveal an evolving training environment today. There were 112 accredited programs involved in the matching process—75% of programs filled all the slots, while 25% had openings. A total of 333 positions were filled out of 390, amounting to 85.4%. Compared to historical averages, where pain medicine has always dominated in filling most posts due to strong talent, these figures look different. There was a 45% decrease in the number of anesthesiology residents applying for pain medicine fellowships between 2019 and 2023 (from 351 to 193), despite a stable number of fellowships available.

These trends did not emerge abruptly in 2025 but represent a continuation of shifts observed over several prior match cycles. Program director surveys conducted prior to the 2025 match had already identified declining applications from anesthesia residents, alongside increasing concern about workforce signaling.

Interpreting the Trends: More Than Just Numbers

An alternative to labeling the outcome of the matches as a “crisis” is to examine the ecosystem in which multiple forces shape the training participants’ choices.

1. Strong job market in anesthesia
   • Residents today have ample opportunities for general anesthesia and locum work with good pay. This makes it less enticing to pursue another year of training. Educational debt further amplifies this calculus, particularly for residents carrying six-figure loan burdens, who may prioritize immediate earning potential and financial stability.
2. Shifting applicant profiles
   • Survey data from the directors of fellowship programs indicate a decline in anesthesia-based applications across all respondents’ programs. Conversely, there has been an increase in applications from other specialties, including physical medicine & rehabilitation, neurology, and emergency medicine.
   • However, such diversification indicates changing perceptions of pain care, revealing the pain medicine specialist community’s increasingly diverse composition. Nevertheless, such trends complicate trainees’ perception of pain medicine, who might have viewed the discipline entirely through the prism of anesthesiology.
3. Reimbursement and administrative burdens
   • The factors that current program directors commonly cite as turning people away from the field include declining payment for interventional procedures in pain management, patient authorization requirements, and the increasing complexity of these aforementioned processes.
     
   

Why Pain Fellowship Still Matters

Although it is neither possible nor practical to make a case for every fellowship candidate needing a pain medicine fellowship, there are several clear, evidence-based justifications for the importance of Pain Medicine fellowship training.

Clinical Preparedness for Complexity

Pain Medicine fellowships offer focused training opportunities in advanced diagnostic and interventional procedures, complex pharmacotherapy, longitudinal care, and coordination. These are a step above and beyond core anesthesiology training and reflect the current complexity levels, which indeed reflect a changing practice scenario.

Value-Based Care

The problem of chronic pain in the United States remains enormous. Patients with complicated and difficult-to-manage pain conditions can especially use professionals well-versed in evidence-based multimodal care. More importantly, fellowship-trained professionals are increasingly involved in developing pain-related programs.

Professional Leadership and Flexibility

Typical fellowship programs may include training in leadership, engagement, and excellence. Many of them advance fellows into roles in learning and leadership that enhance the field of pain management.

Fellowship training also supports career flexibility, enabling graduates to pursue academic careers, hybrid interventional consultative models, value-based chronic disease management programs, and integrated specialty clinics. Many fellowship-trained physicians assume leadership roles in education, quality improvement, and program development—contributions that extend beyond individual clinical productivity.

The Association of Pain Program Directors has taken steps to address these changing dynamics by:

• Developing curriculum and toolkits for the support of standardized and high-quality fellowship experiences and early exposure experiences in residency.
• Initiating cooperative ventures with ASRA Pain Medicine and other organizations to advance awareness of the breadth of pain medicine.
• Initiating data-driven recruitment tools, such as sharing trend data with residency programs.
• Continuing to provide support for early career transitions because the skills gained during the first years of practice are as valuable as the credentials brought by a fellowship.

These experiences highlight an investment in improving education and meeting workforce needs, without diminishing the case for fellowship in the first place.

Facilitating Honest Conversations with Trainees

Faculty and program leaders have a responsibility to engage trainees in transparent, individualized discussions about career pathways. This includes acknowledging market realities while emphasizing the distinctive skill sets, professional identity, and leadership opportunities that fellowship training affords. Early exposure to meaningful pain care experiences during medical school and residency with thoughtful mentorship will enable informed decision-making. Fellowship training should be framed as one of several legitimate pathways rather than an obligatory credential. At a systems level, pain medicine educators also serve as stewards of workforce planning, helping ensure appropriate alignment between training capacity, population needs, and long-term access to high-quality pain care.

It is vital to discuss the realities of the workforce truthfully, including the marketplace dynamics and the variety of paths. It is also important to emphasize the skill sets and training that fellowships provide and the extent to which they go beyond mere procedural numbers. Early, meaningful pain care experiences should be fostered during residency training to support informed decision-making. Personalized coaching should be offered, recognizing that fellowships represent only one route to meaningful involvement.

Conclusion

The trends in pain fellowships reflect not only changes in the healthcare industry but also in education and trainees’ choices. In contrast to viewing the data as a reflection of a failure of the recruitment process, the data invites nuanced interpretation and adaptive educational strategies. To the degree that such discourse is grounded in evidence, open to the trajectory of evolution across multiple disciplines, and supportive of strategic efforts in education, the pain medicine community can continue to improve training programs and the ensuing workforce responsible for caring for patients with complex pain.

References

1. Pritzlaff SG, Singh N, Sanghvi C, et al. Declining pain medicine fellowship applications from 2019 to 2024: a concerning trend among anesthesia residents and a growing gender disparity. Pain Pract 2025;25(1):e13441. https://doi.org/10.1111/papr.13441
2. Jueng J, Pritzlaff SG, Mehta N, et al. Analyzing trends in the pain fellowship match: a survey of program directors. J Pain Res 2025;18:2335-41. https://doi.org/10.2147/JPR.S496104
3. Christiansen S, Pritzlaff S, Escobar A, et al. A sudden shift for pain medicine fellowships: a recount of the 2024 match. Interv Pain Med 2024;3(2):100404. https://doi.org/10.1016/j.inpm.2024.100404
4. Pain medicine match results 2025: programs filled, unfilled, and certified positions. Washington, DC: National Resident Matching Program. Available at: https://www.nrmp.org/match-data. Accessed January 24, 2026.