Welcome, everyone, to the Pain Medicine Fellowship Summer Series. We have a great webinar for you guys tonight. And if the doctors who are participating would like to introduce themselves and get started, that'd be great. Lynn, why don't you go first? I'll go first. I'm Dr. Lynn Cohan. I'm the Program Director and the Division Chief at the University of Virginia in Charlottesville. I'm very happy to be here tonight. Rene, you're next. All right. Thank you, Syed and Lynn. Thank you for the invitation. My name is Rene Eprescora. I'm the Program Director of the University of Florida Multidisciplinary Pain Medicine Fellowship. We are located in Gainesville. And we have six fellows. And I'm happy to be here and to answer any questions you might have. Jason? Hi, everybody. I'm Jason Friedrich. I'm the Program Director at the University of Colorado Pain Medicine Fellowship. And also very delighted to be here. Is there anybody else that I'm missing? Eric? Virgil? No other PDs? All right. So I guess I'm the last one. My name is Syed Wahizi. I'm the Program Director for the Pain Fellowship at Montefiore. We are also a multidisciplinary pain program. And I'm happy to be here. I'm Eric Jones. I'm from the AAPRFC. I'm the Vice Chair. And I'll be helping run the Q&A. So if you guys have any questions, you can put them in the chat. And we'll ask them towards the end. And I'm a PGY2 resident. I'm not in SINA. So, Erika, are you going to kick it off with some questions? No, I think we were just going to, I don't know, we didn't have any questions to start. I think we were going to let you take it away, Dr. Wahizi, unless you. All right. All right. Well, let's do it this way, then. We'll take the same route that we took before. Lynn, what makes your program unique? I think, you know, each of our programs are unique. But, I mean, I think, you know, the main thing is when you're looking for a program is first to kind of really figure out, you know, what it is that you want and really what matches, you know, the educational style that you want. You know, as others have said, you know, we so we also have six fellows. We are multidisciplinary. We know we always take non-anesthesia and anesthesia. But, you know, I think, you know, we try to focus on providing a good foundation in pain management. We do advanced interventional procedures, but it's not just all about procedures. You know, and I think, you know, I've had this conversation with many on this call before, you know, when you're in a fellowship, you really want to learn the basics of pain medicine, comprehensive pain medicine. And so, you know, I think my recommendation would be to try to, you know, find programs that really kind of offer you all those aspects of pain medicine, so you really have numerous tools in your toolbox after you graduate that you can help to provide comprehensive, high-quality care to patients. Rene, can you tell us what some of the most important things are that you look for in candidates? So we look for candidates who are a match, you know, so we go through the match or for most positions, so as the term says, who are a match. And as Lynn says, in the style, you teach or, you know, how you practice in your specific fellowship so that you meet our expectations. But I think also, more importantly, that we meet your expectations, you know, where you want to be, what you want to practice, what you may don't want to really specialize in. So I think that's what we are looking for. So it's pretty broad. We don't have set expectations from geographic locations or applicants or specialties or academic or non-academic. So if you think from the application it's a potential match, we will interview. And my few cents is I think every program is ACGV compliant within the ACGV requirements. You will see certain, let's say, where they are more specialized and sometimes where it's just a compliance or the required number. So we try to represent our program on the interview as it is. So again, that everyone can make a good decision for themselves, for us and for you and for the applicants, you know, if they feel what we can offer matches your desire, you know, where you want to be, the way you want to practice or not, you know. And if not, I think that's fine. I mean, that's part of an interview process. I think as you see tonight, there are many, many more or very well-positioned fellowship programs available. Thanks. Jason, you are from the VINU Akuthata group, correct, in Colorado. Now, moons ago, when I knew about this program, there was a sports component to it. Do you guys still have that sports component? Yeah. Yeah. I want to touch on that. I also, you know, I have like one slide I could share that I think might provide not only just a brief overview of our program, but might trigger some other questions. So is now an okay time to just to share my screen and just bring that up? I'm okay with it, Eric and Jewel. Yeah. All right. Okay. Yeah. Just give me one second here. All right. Can you guys see that? Okay. Yes. Yes. Okay. Yeah. So, I mean, so, I mean, just we'll, we'll cover your question for sure. Cause that's, that's a question I'm commonly getting anyway. Um, but just to let you know, I mean, so we're, we're in Aurora, Colorado. It's just outside of, of, uh, of Denver. Um, and we're a smaller program. It's three fellows per year. It's still multidisciplinary. Um, you know, two of our fellowship spots are typically filled by anesthesiology track and, and, um, and then one, you know, typically by PM&R. Um, one of our tracks is, is a little more pediatric, um, focus. So it was kind of an adult and pediatric, um, uh, experience. And we've got about 15 core faculty, um, who, who are, you know, really kind of intimately involved with kind of fellowship teaching. Um, we're on the typical cycle. Um, I think this is probably like everybody else on the, on the call, um, in terms of like who we're looking for, we're really looking for, you know, people who do well in their core residency. Um, we, as I'll talk about, we have a pretty spine heavy program. And so, you know, we do want to see people who are, you know, have a demonstrated interest in, in truly spine care, you know, in addition to, to more complex pain management. Um, and then, um, at least in the PM&R realm, you know, for our PM&R track candidates, it's such a small specialty overall that to get letter writers who really know you well is, is I think really critical, um, you know, for us as we're kind of going through the, the application review process. And then, uh, and then, so this is just kind of a plug for the field in general. Um, you know, so this is not necessarily just a plug for, you know, for, you know, our program, but, um, you know, I, I still think pain medicine is a good, a good field to go into. Um, I think it's fun. It's challenging. Um, I feel like a lot of other medical specialties and surgical specialties don't, don't do a good job, um, with, with both diagnosis, um, and in some cases, um, with management either. And so, um, you really, there's a lot of opportunity there to, to stand out and, um, and really be an asset in any community. Um, and then I still find the, the science of pain medicine is, is still really fascinating. Um, it's, you know, I think you want to find a field where you're interested in reading the research and, you know, if you're not the one performing the research, you, you know, are, are interested in, in, in kind of learning, learning the nuances, you know, kind of throughout your career. Um, and then this is kind of along the lines of that first bullet point. I mean, I think there's, there's a lot of desperate patients out there getting a whole lot of misinformation, you know, including from, from people with MDs and DOs after their name too, among others. And so, um, you know, I think it's really our role in, in kind of an academic community, make sure that you, you can kind of separate the, the, the noise from the stuff that really has some value. Um, I also really love the field because it's so collaborative. Um, I feel like pain medicine should be, you know, really a team sport. And so, um, there's again, a lot of, a lot of opportunity for program development, um, really regardless of where you work just by, by, by trying to collaborate and then the job descriptions diverse. So you can do a whole lot of different things, um, within pain. And let me see if I can get, there we go. And so now to try to get to the like, why Colorado? So what's a little bit different, you know, so we have, you know, we have a lot of, we have a lot of faculty, you know, and a lot of successful graduates. We have a, you know, a lot more faculty than, than fellows. And then with respect to these tracks, um, you know, everybody has to meet all the ACG me requirements. Um, but kind of like what Lynn was saying, there is going to be some, some variability between what any individual, um, fellow is, is really ultimately going to end up doing for their career. And so the, the, the tracks are really just a means of trying to keep the collaborative relationships we have with the other departments, um, open, um, so that, you know, fellows can kind of take things, you know, a little bit different routes, you know, through kind of elective experiences. Um, and so that's where, you know, we, we try to be as adaptable as we can kind of within the confines of, of ACG me. And so with that, we still do have some sports components. We now have at Colorado, we now have a sport, uh, uh, ACG me accredited sports fellowship. And so our pain fellows no longer do like sports medicine coverage, you know, the way that it was back when I did the fellowship, I did the fellowship in 2010. And back then you could still sit for the pain boards and the, and the sports boards. And so that, that loophole's kind of now been closed. And so it's become much more of a kind of spine and pain, you know, focused, um, experience. Um, however we have had at least PM and R, um, fellows who, who really went into much more of a sports and spine job, you know, after, you know, kind of after fellowship. And so, and, and there in their fellowship year, they might still include, you know, some more of the sports clinics, a little more ultrasound, you know, and maintain some of the EMG training that they had elsewhere. Um, and then probably more similar to conventional, you know, pain experiences, you know, we, we still have everybody work with neurology, headache, and palliative care. We have a family medicine run addiction medicine clinic, which is, you know, still fairly useful experience and, um, and, uh, kind of limited, um, work with, uh, psychiatry and, and we work with the, the, the clinical experiences largely at our spine center. And so we, we kind of share the space with, uh, spine surgery, um, as well. And so it's the last thing I would just say for, for our program is we are, we're very focused on teaching and leadership. You know, we do still have a scholarly activity requirement, you know, a quality improvement requirement, but, um, you know, we're, we, we love people who do research who want to do research, but, but still, you know, kind of teaching, teaching and clinical, you know, training is really still where our, our priority is over, you know, over research, at least for our, for our one fellowship year, despite the plug that I'm always trying to get people more interested in research, but I'm, I'm not a, a major researcher myself. So it's, it's hard for me to, um, to, to really tell people that that's what they need to do for their, for their career. All right. I'll, I'll stop sharing here. Thanks, Jason. All right. So I guess that, that leaves me for the end. Um, as I, as I mentioned earlier, I'm the program director for, uh, the pain fellowship in, in, in the Bronx at Montefiore. Uh, I had been there since the inception of the program. Uh, I am trained in spine MSK as well as pain. And so, uh, the fellowship was birthed with, you know, those two mindsets kind of in, in intertwined, um, within the world that I was trained. I was also trained by a radiologist as well. So we bring to, uh, to the conversation, uh, fairly heavy, uh, radiographic analysis, in addition to physical exam, um, to kind of create, uh, the platform for understanding, create, uh, the platform for understanding, uh, pain patients. We have a, uh, a tight communication with our, with our, uh, psychiatry colleagues as well, uh, as not only psychiatry, not only psychiatry a priori, but also so addiction, uh, our fellows rotate through, uh, the addiction piece. They rotate through headache neurology, as Jason, you had mentioned before as well. Uh, the radiology is kind of built within the program though. Our, our, our group does not, uh, does not rotate with radiologists, not because I don't think that that would be exceptional, but more because we don't have the time to be able to devote to that. Our fellows will rotate through, uh, palliative care as well. And so, uh, with all of those other build, build ins, uh, the, the radiographic component is, um, is, you know, part of the, part of the foundation. Uh, and as Lynn had mentioned before, uh, that her program believes in a multidisciplinary, uh, model whereby, you know, the, the thought processes about the patient and very much individualized care. That is, that is the way that we have the discussion with our, with our patients as well, not neglecting, um, you know, spine related procedures and, uh, complex procedures as well. And percutaneous surgeries as the, uh, as that particular term is becoming more and more popular nowadays. So I think that if, if there was one, uh, way that we could describe our program, it is interventional, but also multidisciplinary. The focus being, uh, teaching our fellows, how to teaching all learners that come across that come across our program, uh, to understand who not to do patient, who not to do procedures on. Yeah. I think that that's one of the most important things that can be taught. And I, and I believe that everybody in this conversation tonight believes the same thing. And that's, that's why we're all friends. Um, does anyone have any questions in the group, Eric, do you want to take it from here? Yeah, definitely. Thank you for all those thoughtful answers. Um, so we have one question in the chat to start this from Greg. Um, he said, as someone who hasn't had much exposure to the field, you outline what a year as a pain management fellow looks like and what sort of expectations do you have for your fellows? Anyone who wants to take it? Lynn, you're not on you. Um, so yeah, I mean, I think traditionally what a pain fellowship year looks like is what people have essentially kind of been outlining so far. Um, you know, and I think most of our programs are going to do some, you're going to spend time in clinic. You're going to spend time in procedures. You're going to spend time in the operating room doing, you know, more of the advanced surgical cases. Um, you're going to do your offsite rotations, you know, which are your kind of non-core specialty. So anesthesia, PNR, neurology, um, psychiatry, um, you know, there might be some electives in some cases, you know, some people have mentioned spending time with radiology and our program more similar to say that's kind of built into the everyday practice, but we do kind of have on a quarterly basis, you know, like a conference with the radiologist to go over kind of just more advanced reading of, of imaging, um, you know, in terms of, you know, and so for people, I think it's hard, you know, um, for people who have had less exposure, just to make sure that you really know what you're getting into when you're getting into pain management. Um, I think that's important. And I think, you know, it's not about choosing, like we don't choose fellows who have had a whole bunch of pain experiences because we want, because we, you know, want to come in already trained. Like that, that's not the idea, but we, but we do want is people who understand that pain, the challenges in pain, you know, pain medicine in general, right? There's great patients. There's sometimes challenging patients and you just need to be understanding that you're that, that is fitting with what you really want to do with your life. Um, in terms of what expectations do we have for our fellows? Really? We just want fellows that are going to want to learn. It's one year and one year goes by really quickly, especially in light of the fact that you have your board, you know, written boards, oral boards looking for a job. And so just math, you know, people, the expectation is just people who want, want to learn and really just, um, are choosing this year as a valuable experience to learn as much as they can. Thanks. I, and you know, I'll, I'll add to that and I'll tell you that, um, one of the most important things that I look for in a fellow and, and, and something that I want to produce slash cultivate, uh, as the year goes on is, um, is a, is, is a person, um, and, and an intellectual athlete, uh, that is also extremely conscientious. Jason, you had mentioned earlier that, uh, you know, we deal with a patient population that is vulnerable and I, and I don't know if you use the term vulnerable, but, but, but, you know, use something like that. Um, and that's basically what this field is. We have a lot of patients who, who are desperate for care. And I think that, um, the people who are, you know, these intellectual athletes will be able to understand how to deliver, um, that kind of care, um, carefully and thoughtfully to patients as if they were a family member that they liked. Right. And I think that that's really important. Those are the, those are the physicians who typically don't get themselves into trouble two, three, four, five, 10 years, uh, out of practice. These are patients who typically will all, these are rather physicians who will typically also have a patient following in a group following, um, that embraces them and embraces their philosophy. And in the end, what that means is that those physicians like what they do, right. And they will enjoy, um, their profession and their field because, uh, there's a degree of satisfaction with their patients that may not exist in, um, in a practice with a person with a different, with a, uh, in a, in a, in a physician practice with a different mindset. So I think that's really, really important. All right. Thank you guys. Um, so our next question is from Pablo and he says, in terms of logistics, what is the expected amount of call that was usually have to fulfill? It varies program to program, but anyone has any thoughts? Rene, you want to answer that? I can answer that. I agree with Eric said it varies from program to program. I think, uh, what I can say is that the fellowship year, you're going to get a little more control about your schedule. So usually it's not a Q3 scenario of heavy at night or inpatient load. You know, my background, for example, is anesthesiology. So usually that's not the case in a fellowship in general, maybe, and especially not, uh, pain. One caveat you may want to look if your fellowship has a more ambulatory, so outpatient pain group, or if it is, uh, more focused on inpatient chronic pain that may could determine your call assignment or what you might have to do during the weekends, such as rounding and what will be the patient volume. So it depends. Um, I think it's fair to ask that, uh, what are the expectations? Another aspect is how your fellowship practices and what type of procedures. So procedures do play a role. Many applicants are asking for them. Um, do they fix everything? I'm straight for the answer is no. So it is a tool in the toolbox and there are many other tools which are sometimes feel we sometimes applicants are actually neglecting or the fellows anyway. So let's say if you are heavy interventional, there will be problems, not necessarily complications, but pain or questions you have to address. So that's the bind. If you are, let's say in a more surgical pain medicine fellowship or the schedule, the daily schedule is more unpredictable because you may do advanced procedures or surgeries, which may will take longer. So that's again, another debate you want to consider. Or if you're in a fellowship, again, I mentioned inpatient volume or which is very specialized or expertise that's saying cancer pain. Those are, I'll be fair scenarios in my opinion, that cannot wait till Monday, come back in the clinic. So if there's at night, uh, weekends, um, those patients, uh, again, you know, especially if their, uh, life is shortened, you know, those are things we have to address. So that's a way to look at your fellowship and ask again, I may be misguiding you by my advice. So, um, ask what's the, the fellow expectation. I think what sometimes helps is to talk to fellows who are there, hopefully fellows who are finishing up. So if you have an interview, let's say May or June, there may be a, uh, they may be leaving in case there's fear of retaliation, but more importantly is I think they have two advantages if you get those fellows, because a, they have done the fellowship. They're not guessing that they have done it. And B, they can also tell you a little bit about how does the job market look like. Now it's a little late when you're in the applicant interview cycle for pain medicine fellowship, but I think those are legitimate points to ask. So as a program director, I'm not holding it against you. If you ask me, what's the call volume, because I have to be fair. I respect the time you spent with us as an additional fellowship year, and current job market opportunities and certain specialties, you know, they speak against doing any additional training here. They're just going to practice. So I think it's more fair to, to tell you that. Our call is home call to be fair on that. There's a very low or lower inpatient visit or consultation volume. Thanks Rene. So I'll, I'll use this as a teaching moment and I'll also probably self-select myself out from some of the, some of the callers here by saying this, there was an interviewee who about seven or eight years ago asked me the question, how many days of vacation do I get? I don't remember who that person is. Okay. I will tell you this one year of pain fellowship goes by really quick, like really, really, really quick. My fellows who every single class that I've had has said to me, man, I wish this could have been longer. Right. And, and, and, and, and I agree with them. And we are now at a point where almost everybody on this call almost every senior on this call is, is, is performing percutaneous surgeries or surgeries. And this is, these are things that, that did not exist six, seven, eight years ago. All right. So the load of education has increased without the load of without time, without time. So there's, there's a potential deficit here. When I was a fellow, and I'll say this like an old man, when I was a fellow my choice was to take more call because I knew that that would be the only way that I would get extra education. It sounds kind of nerdy. All right. But like in all the sports I ever played, I was the one who wanted to practice more. Right. And cause I wanted to be prepared for a game day. My suggestion to the intellectual athletes on this call and any other intellectual athlete that I speak to is you got to practice and you got to practice and you got to practice and you got to practice and call is one form of practice that said, and in our fellowship, our, our fellows don't do a lot of call, but we try to plug in education in as much as possible. Right. If it's not clinic, it's going to be an, an, an ultrasound not course, but, but, but an ultrasound demo or a radiographic discussion, or it's going to be a psychiatric discussion, or it's going to be a legal discussion or a complications discussion or lecture. We've got to do it somehow because otherwise, you know, I don't believe that we're, we would be doing our, our, our children justice. So that said, I'm glad that you asked that question. I think it's a really important question. My hope is that that question was asked because you want to know how much more education you can get and I'll leave it there. Yeah. No, when you think about call, right. It's not like you're on call a night, you know, like a general surgeon where like the spinal cord stem is going to come in, in the middle of the night. Right. I mean, it's not that type of thing. Right. I think like Sayed and Renee were hinting, you know, getting to this point too, but it's just using that time to just learn as much as you can. But traditional call where you're like getting called in, I mean, luckily in pain, right. You're not really going to be there often in the middle of the night, unless there's like a true emergency. Baclofen pumps, like, you know, we do Baclofen pumps. We've had luckily in many years, you know, very few, but once or twice they've stalled. Right. And there's been a manufacturing issue and that obviously can be an emergency. In general, call in terms of you think about emergencies are pretty rare, but that doesn't mean, you know, that you're not, you know, learning and using all your time to try to learn. Yeah. Thank you guys all for the kind of different perspectives. I was going to ask about some more emergent things in pain medicine. So that was a helpful answer, Dr. Cohen. Thank you. Okay. So our next question, kind of a transition to future job prospects. So this is from Cleaver. So he says, based on your experience, can you describe any nuances between the career paths for prospective attendings who have completed an ACG, me accredited NASA accredited or non-accredited pain, MSK, MSK spine fellowship. So kind of the three categories there. Are there any differences based on, you know, once you're outside of fellowship. I can try to tackle that. Cause I mean, this came up recently in a discussion we had, you know, I think it depends a little bit on where you, what part of the country you practice in. So I can kind of only really speak for, you know, kind of Colorado in this regard. In Colorado at this point in time, I think if you wanted to enter a spine practice, you know, either academic or in a PM&R group or a ortho spine practice or a neurosurgery spine practice, it actually probably does not matter. If you go to a reputable, you know, NAS accredited fellowship, you'll, you know, reach the same kind of career path that you would with a ACGME accredited, you know, pain fellowship. However, if you want to actually run a pain program, you want to, you know, be a program director for a pain program. If you want to join a hospital system where it's, where pain interventions have been historically provided by, you know, the anesthesiology department or anesthesiology pain physicians, and, you know, you are needing to kind of introduce PM&R, you know, to that hospital system, then, you know, having a board subspecialization in pain medicine can be helpful. So, you know, I finished my fellowship in 2011 and my first job out of fellowship was with Kaiser Permanente in Denver. And the only PM&R person there was kind of a non-operative, you know, generalist, you know, PM&R provider. And so when I came in and joined the neurosurgery department there, you know, with the expectation of doing pluroscopic guided procedures, having the board certification in pain medicine kind of got my foot in the door to collaborate and have conversations, you know, with the anesthesiologist who had already been there. And it just kind of worked. It kind of meshed well in that regard. I think they would have been, I think that group would have been fairly skeptical, you know, if I hadn't had, you know, the fellowship that I did. But outside of, kind of outside of that circumstance, you know, I think you're seeing more acceptance of the NASH fellowships. And so, you know, if your interest is primarily spine and MSK, I think you really just try to find a fellowship that fits your needs and goals. But, you know, if you wanted to really be doing complex cancer pain, CRPS, you know, stims, pumps, you know, to be honest with you, like even some of the percutaneous surgeries that you all are talking about, you know, a pain fellowship is probably the way to go. And, you know, not to over-talk, but I also just want, just since I have the floor for a second, just to be clear as you're kind of looking at different programs, you know, one differentiator is, you know, in our program, you know, we really don't do, within our own like primary pain department, we don't do percutaneous surgeries. And so, you know, that does vary, you know, quite a bit. So if we have somebody that is, you know, absolutely interested in, you know, learning how to do inner spinous, you know, spacer, you know, placements, or, you know, even, you know, for that matter, you know, in our primary pain department, we don't do vertebroplasty, kyphoplasty, sacroplasty, that goes to IR. So we have graduated fellows who are doing that type of stuff in their practice now, but that was, you know, as a result of their job opportunity, job expectations, and then helping set up some additional time with interventional radiology. But we have, you know, many of our fellows have no interest in doing that stuff. And so, you know, we don't necessarily, you know, seek that out, but I think that just brings up how there is, you know, a fair amount of variability, you know, between various programs. And because it's such a short year, there's always gonna be trade-offs, you know, one way or the other. And so I think that's where the interview process is tricky. You gotta ask a lot of questions. And I do, I like the suggestion of really trying to get, you know, a conversation with a prior or current fellow, I think would be helpful. So. And I would just say, I mean, you know, for us, you know, I'm probably gonna be biased towards ACGME fellowships, so the ACGME accredited program and a program director. You know, I would look at it from the point of, you know, I think maybe it was Renee, I think, whether you or Sayed who said earlier, you're not gonna fix everyone with just interventional treatment. And so when you're thinking about how to really treat patients, you know, you're gonna just need other tools. And I think, you know, that ACGME fellowships, because there's a curriculum that's, you know, that you're supposed to be teaching all these different things, it's gonna provide perhaps a broader spectrum of how to treat patients. So you're gonna have different tools in your toolbox to be able to provide that. Now, I kind of always say like each thing, or I kind of tell patients might help patients this much, and you need to kind of add them together to make a bigger difference in people's quality of life. And that's why I'd be kind of more partial to the ACGME. Not so much, can you get a job? Yes, but what kind of physician do you want to be? You know, what kind of care do you want to provide to your patients? Thank you. All right, I'll keep an eye on the chat, but for now, I can keep asking some questions. So I think, you know, kind of like Dr. Ortizia had mentioned, so this, you know, our field is really moving quickly, and now, you know, we're doing things like percutaneous surgeries. And so my kind of question is, based on all of your experience in the field, how do you kind of see the field changing in the future, you know, with things like, you know, neuromodulation, or even the awareness of pain medicine, and how, you know, even fields like emergency medicine neurology are involved in pain medicine? What excites you guys about the field? And, you know, why should we as trainees be excited to enter pain medicine? I know it's kind of a large 360 view question. I've spoken, talked, yelled, cried, written a lot about this in the last couple of years. The things that excite me are also the things that sadden me. There's a duality here, and I mentioned it earlier, and that is that the pace of education, the pace of information in our field is outpacing our ability to teach that information, okay? And to teach the people who are coming into our field. So, you know, I'm not saying that I'm not excited about it, but I'm not saying that I'm not excited about it. But to teach the people who are coming into our field. So the EM team that is now taken up probably, Lynn, what, 10% of the applicant pool at least, right? 10 to 20% ish in some fellowships, probably even more than that. This is a group that comes in with a different knowledge base, right? And so what that means is that the teachers who now are bringing on this new 20% of learners has to now understand how to teach EM residents, right? Which is very different from teaching a physiatrist or an anesthesiologist that makes up a primary pool. So, I mean, that's one challenge as educators. I think it is great to have a pool of applicants and an array within your pool of applicants. I think it beautifies the field because we need a lot of different thinkers in our field. Because as Lynn mentioned before, you got to think differently and you have to be able to understand how different specialties think and behave because pain patients think and behave differently. And they come with problems from where in each of the specialties have a knowledge base, right? So that's what I'll say about that. For now, there's even more to it. I'll leave the rest up to Renee. Renee, you have anything to chime in on this? Why pain? No, what excites you? What excites you about the future? Like what are the things that you foresee in the next five or 10 years that are good or bad? I think we have a lot more to do to understand pain and what goes on in the black box. We need to be organized because there are many outsiders who may will determine the fate of our specialty. So not to discourage anyone. Yeah, I mean, I think that's so right in terms of so much more to discover. There's so much we don't know, right? Why do one medicine work for one person great and does nothing for somebody else? Why does STEM work so well for someone and not for somebody else? I mean, there's just so much we don't know. So I hope we continue to discover and learn these things. There are challenges coming in our field, payers, authorizations, over-utilization of procedures that they're curtailing some of these things that we're doing. And so making sure that the more science we understand about what we're doing and kind of as Sayed alluded to the beginning, making sure you're choosing the right people and not just offering a certain interventional treatment to every person who walks through the door, that's only gonna hurt us. It's gonna hurt our patients. It's gonna hurt all of us in the field. Jason, do you have anything to add? Anything that excites you about the next five or 10 years or maybe brings you to tears as I mentioned before? I mean, I think some of both. I mean, I will admit I'm like, I think probably other people would probably describe me as cynical, not so much about pain medicine, but just in terms of like our healthcare system in general. But in terms of the pain specialty itself and I kind of wrapped spine into that too, there's such a need. I mean, again, I'm assuming it's similar in other communities too. I mean, it's just a fire hose of patients that need help. And so it's kind of a blessing and a curse. It's a blessing in the sense of, if you're a good spine doctor, a good pain doctor, you don't need to do a whole lot of advertising. Like the patients will come, the referring doctors are just as desperate as the patients to find somebody who they can trust and work with. And so I think that part is really exciting. I think I can even see some excitement in if I took a really positive spin on it in terms of some of the payers asking for more accountability from the specialty in terms of why are we providing an intervention in this circumstance? Because unfortunately procedures have been utilized as a, hey, we can do this procedure. So we're gonna try every procedure on every patient that comes through the door as opposed to really forcing ourselves to really subgroup well and have some predictive modeling of who should get what. And so I think we're still just scratching the surface on actually kind of providing tiered care or providing some care based on some predictive modeling of who's likely to respond and not. And so I think that part's still more exciting to me than scary. Of course, if you are spending more and more of your time breaking down kind of insurance red tape, then yeah, that's of course a frustrating aspect of any field. And I share an office with a neurosurgeon and it's no different in his specialty. So he's kind of doing the same thing and they're asking for the same kind of accountability. So I don't think that's unique to pain medicine at all. And I think that's where we really do have to lean on research and do what we can, even if you're not a primary researcher, really support research through writing, through reviews, peer reviewing, getting involved with journals, getting involved with national societies and trying to help support your colleagues who are doing this research because it's needed now more than ever. I think you said several really important things. You know, one about the predictive modeling, right? I think that is becoming more and more important and where AI might be able to help assist with that. You know, people are afraid of AIs can take over doctor's jobs. I don't really see that happening, but we can use it to our advantage in gathering more information for predictive modeling. And then as Jason just said, you know, societies getting involved, even if, you know, you're in private practice, sometimes people think of societies as just really academic people. You got to support those societies because they're the ones that are helping to make these guidelines that are then, you know, helping, you know, determine the science that's, you know, sound enough to allow us to do what we do. Yeah. Look, I think that, you know, it omits my, in spite of, rather, my cynicism. I think that we're in a really great place for growth, meaning pain is. I think that if the leaders of our organizations and our community banded together and worked together and did all the things that, you know, Jason and Renee and Lynn have mentioned, we could really push this field to probably be one of the strongest, if not the strongest in all of medicine. And this is not an understatement. What's the main reason why patients go in and see their physicians, right? If we could figure out a way to understand that and harness that, and then, you know, improve upon patient satisfaction within our community, we would have a very strong voice. We have more tools now than we've ever had. We've at least tripled the number of tools for pain management in the last five years, okay? And there's more tools coming. And so I think that, you know, responsible use of these tools is paramount. I think that working together as professionals, the community of leaders that we have in pain medicine, coming together and working together with humility and with enthusiasm is going to push our field in a really great place. And I know some of the leaders in our field, and I know where their hearts are. And I do believe that we will get there. It's going to take us a little bit of time, but I think that the future is very, very bright. Thank you all. I appreciate all those perspectives. I think one thing that I found interesting I've seen recently is, you know, even discussions of like increasing the amount of time within the pain medicine fellowship. Obviously now it's only one year, but like Dr. Rahizy said, all these different tools that are coming out to interesting thoughts now. Okay. Feel free to also unmute if you have any questions, but I can keep going. All right. So considering this is an AAP event and, you know, we have PM and R backgrounds here, what do you guys feel like uniquely suits us to go into pain medicine? And what kind of, you know, patient encounters or certain diagnoses can we be focusing on throughout our rehab residency to best prepare for fellowship? I think you guys are perfect. Oh, sorry. I'm punting this to Jason. Yeah. I'm happy to, I mean, I'm happy to answer this one, but there might be some other perspectives on this too. I mean, you know, I mean, this is, obviously I'm biased. I love PM and R, you know, as a specialty and stuff. And again, I think what we spend a lot of our fellowship year trying to emphasize and what I try to pride myself, you know, as a physician in is really being an excellent diagnostician because I think if you can get the diagnosis right, then very often, you know, one of our treatments is going to be effective, you know, for somebody. And so, you know, very often we're seeing our third, fourth, fifth, sixth opinion type patients, you know, it's still pretty frequent that we identify something that wasn't thought about before. And so the, I think the PM and R residency prepares you for that. And even your second year of inpatient, you know, is still preparation for your pain medicine fellowship and beyond. And I think sometimes folks who are in their PM and R residency don't, are unable to appreciate how important that inpatient rehab year is until you're actually, you know, out in practice on your own. And then you are gonna quickly recall conversations that you had with families or patients in various challenging situations and say, oh, boy, I'm actually glad, I'm really glad I had that experience. I'm really glad I was forced to lead that team meeting, you know, or, you know, discuss with this patient, you know, how, you know, there's really not a, you know, not a cure, not a fix, you know, for this condition. And so I think that second year is preparedness. And then, you know, and then in your more outpatient years, I mean, that's really what you're doing. You're learning, you know, imaging interpretation, you're learning, you know, kind of honing your diagnostic physical exam skillset. And so when you come into pain fellowship, my expectation is that, you know, as the PM and R, my expectation is that for the clinic, like you are hitting the ground running. Like, so we are getting into the nuances of pain interventions, you know, primarily. And I kind of don't care how procedurally oriented you are at that point. Obviously when we're training the anesthesiologist, it's a little different. So their learning curve's a little steeper for the physical exam side, but they tend to be pretty good with their procedural skillset and kind of pharmacology background. And so we kind of tailor it both ways, but, you know, again, for a PM and R trainee, I'm expecting when they come, I would be disappointed if they can't like run a clinic really independently, you know, when they first come in and then we just help with some of the nuance and complexity and kind of long-term management stuff. And I was just going to say, you guys care about function, right? Like that's a key component of pain medicine. It's not just about pain. You know, I'm an anesthesiologist by background, but, you know, in most of your training, we're taking care of anesthetized patients. So we see pain, we see objective things in their heart rate and we just kind of try to fix those things. But that's not really what pain medicine is. It's about improving function. And that's a really core component of your basic philosophy of your residency. And so I also think that's important. Yeah. You know, I mean, function is a term that almost every physiatrist will tell me is important to them when they're doing pain and I agree with them. But I add to that by stating that, you know, function is found in many different ways. Function is not just mechanical function. Function is psychological function, right? Function is a social function, which kind of feeds into the same. But when you guys and gals are in your PM&R residency, you're dealing with SCI patients and you're dealing with TBI patients. You know, this is a patient population that cognitively mirrors chronic pain patients. Now there's evidence to suggest that, that there is cerebral atrophy. There are cognitive deficits, but even beyond that, these are patients who are struggling, right? And there's a certain type of conversation that you have to have with these kinds of patients. And it just becomes, it's natural for the physiatrist to have those kinds of conversations and understand that when there's a patient in front of them who's struggling with something, and we'll call it pain, right? That thing that we call pain may be something else. It may be a social discord. It may be a cognitive discord. It could be a mechanical discord, right? So all of these things kind of play into the physiatrist being pretty good at understanding and I believe excelling in pain medicine, right? Doing procedures is cool and it's fun. I'll tell you after a while, it kind of gets boring, but it's important. But the most important thing to understand is an ability to read your patients, understand your patients and figure out what it is that this patient is actually conveying to you when they're in your office. And if you can do that, and I think the physiatrists are built for that. If you can do that, you'll generally have a pretty successful practice and I think pretty successful life. All right. Kind of a similar question. So considering our background with managing patients with spinal cord injuries, brain injuries, I think a lot of us advocate for our patients and like Dr. Arrizia had mentioned, patient advocacy and pain medicine is something you've touched on throughout the fellowship. So how do you kind of recommend as we go throughout our training, how to be the patient advocates to the patients we see with chronic pain or just any pain in general? You know, does anyone want to take that patient advocacy and how to project that? I guess, you know, when I think about where I feel like a patient advocate, like on a daily basis in the clinic is honestly, I mean, this is going to sound, you know, a little bit, maybe a little contrived, it's what I feel like is missing in many patient visits in our field is honestly time. So in terms of being a patient advocate, you know, if I'm seeing, you know, as a patient who's a third opinion and they're kind of frustrated with the system, they've bounced through different providers, you know, honestly, where I feel like I'm an asset is taking the time to listen, you know, not rushing through the exam, not rushing through the discussion. And that is hard, right? Because you will get behind, you know, at times, you know, it will feel like a struggle in the moment, but it'll pay off in the long run, you know, through the longer term care relationship, things will be easier, you'll have the diagnosis right, you'll understand the patient goals, you have a trusting relationship. So pretty much anything you throw at them works better because you've got a good relationship and rapport. And so I feel like that's, some might not call that patient advocacy, some might call that just being a doctor, but in our current healthcare system, right, like to me, that is still a differentiator, you know, from the norm, right? The norm is unfortunately rushing and jumping to conclusions. And so that's kind of where I would take it initially is really just be that person who's kind of different than the average physician that your patients are seeing. Thank you, I appreciate the thoughtful answer. All right, so we have about one minute left unless there's any other questions. There's gotta be something in these 17 or so learners here that they really wanna know. And I promise that none of us will remember your names unless you want us to remember your names. But if there's something burning, ask it now. I mean, you have four program directors who've been doing this for a while, who kind of understand, you know, how things turn or should turn, anybody. All right, I'll ask this question. Rene, what do you not want in a fellow? It's the one trait. Short answer is a someone who decides on the field for the wrong reasons. Yeah. So it's a very satisfying field. There is a big need. I hope we're gonna get more and more in the patients coming up. If you do it for the wrong reason, you will own the field for us. And more importantly, you will own it for the patients. The budget is tight, so it's gonna get looked at what you're doing, why you're doing it, and what are the outcomes. And I'll bring it up. As I mentioned, you hear it probably in my sentence when I say procedures don't fix everything. So the Pain Medicine Fellowship, although some of them are called procedure-heavy, that the training which gets provided there, but again, to be conscious that this is not all about it. So I hope that I don't call anyone off, have to call a future colleague who went into the field for the wrong reasons. So do it for the right reasons. You'll be happy in it. And maybe even your social life will be happy when you have a good professional life. Do it for the wrong reason, as if any other job decisions and you know that's not you, you will have a failure. So try to avoid it. Thanks. How about this? I'm gonna ask one more question because I don't want to leave it on a negative, on a negatory note. So Lynn, finish this sentence. The perfect fellow is one who? There's no perfect fellow, right? None of us are perfect, not even attending. So no, there's no perfect attending. There's no perfect fellow. I think, you know, I kind of had mentioned this earlier. We just want people who are willing to learn, right? Willing to learn and have a good time, right? Like these are people you work closely with. They become just, you know, you become friends with them for life. And so just good people who are willing to learn, who are willing to work, who are willing to take ownership of their patients. Like that's another big one, right? It's not just kind of passive, like, oh, well, I'll just kind of do the attending says, but really these are your patients too. And we work as a team. And so just learning and taking ownership of your patients. I agree. Fun and humility. Those are the two things that I think are really important. Jason, you have anything to add before we go? I was actually just going to mention that I was going to say the same thing. I was again, kind of picture the old Volkswagen ad, right? So you kind of want a driver and not a passenger. So along the lines of, you know, just like you don't love taking care of the patient with chronic pain that's so passive and just kind of waiting for you to do something. Like you don't really want a fellow that's the same way. Like you want the fellow who wants to actually like, you know, make the clinic run better, you know, you know, teach, you know, teach the residents, teach their attendings, you know, ask a lot of questions and really like actively manage their year is such a better year than somebody that's just kind of waiting, kind of waiting for things to happen. I agree completely with Lynn. Awesome. All right. All right. Well, thank you all so much for joining us tonight for our first edition of AAP Summer Fellowship Series. And thank you to all of our pain program faculty here for joining on a Monday night. We really appreciate all of your time and your honestly very thoughtful answers. So thank you so much. Yeah. Thank you everyone. Thank you. Good luck. Bye. Bye-bye.

Pain Medicine Fellowship

Program Directors

faculty members

educational goals

comprehensive pain management

individualized care

patient advocacy

percutaneous surgeries

neuromodulation

physiatrists