I mean, I don't think any of us really leading the group here. You know, I'm here with with some friends and colleagues, and I think we're all here to to address questions from the group. I think you're going to, Gina, you're going to you're going to help us with that. I believe that the best way to start this, though, is just for each of us to give our own insights into where we work, why we are, why we have the positions that we have, and elaborate on that. I'm going to defer and deflect always to Lynn. All right. She's my boss and a really good friend of mine. So I think that I should honestly go last, but I think Lynn should go first. She's the president of the APPD right now. But you are the past president, so you came before me. You should go first. Lynn, you go first. I'm Lynn Cohan, the program director at the University of Virginia. I'm not sure, you know, in terms of exactly how I came to be where I am, you know, other than, you know, definitely an interest in education and love. You know, I always tell people I think the best part of my job is actually working with the fellows and our resident trainees. And so just really, you know, happy to be able to be here tonight to really answer any questions or really whatever we can do to support you all. Thanks. So I see another good friend of mine, Rene, online right now. Rene, why don't you go next? Why don't you go next? All right. So for my disclosure, I'm a former IMG. I always have practiced in academic medicine in Europe and in America. And what I like about it is the diversity you have in your clinical practice. So if you were really to integrate research, education, of course, to clinical service, which is the key. You know, if you don't have good clinical service, the other aspects will fail. You know, and of course, the the administrative opportunities and stay involved and shape the field, hopefully for the better future. So for me, it's it's the interest. It's the variability we have, the way we still hopefully can practice academic medicine now and in the future. An RPO, but he can change. I think Eric should. There we go. Kieran texted me earlier this evening and she's she's unable to make it tonight because of some clinical responsibilities, which is which is understandable. Julie, do we have anybody else on this evening? I don't. I don't think so. No, I think Dr. Wright had initially said like maybe to the invitation and then I haven't really heard anything else. So it's just you guys. That's that's fine. I think between Lynn and Renee and I, my our hope is that everyone will have a better understanding, better foundational principles for why we call ourselves pain management, why we believe in a truly integrative pain fellowship. And really, at the end. Of this evening, hoping to to engage all of you. And allow you to make your own decisions about what's best for each each and every one of you. That said, I will, you know, kind of finalize the introduction by saying, you know, I'm Syed Wahizi. I'm the program director of the Pain Fellowship at Montefiore. My background, listen, Lynn's background is different from Renee's. Renee's is different from mine. And mine is mine is as such. I graduated PM&R residency in 2009. I did a spine, sports and MSK fellowship. Out of residency because I couldn't get a pain fellowship. All right. And once I finished my fellowship, I started I started my work as an attending, doing a lot of spine and sports related work at Montefiore. And then there was. A moment of of fortune or a moment of fortune within the institution where there was a call for an integrative pain center. And the the program design was such that anesthesia and PM&R would collaborate to create this program. So from from the get go, we created a fellowship from the ground up. The academic program, the clinical programs were already in effect. They were in place, but the but the institution wanted a a an academic element to it. So I was chosen to be the the academic leader and my my comrade and good friend, Dr. Naomi Chapman, was designated to be the clinical director. And between him and I, we masterminded the program that we have right now. When we created the fellowship. We had a first year enroll and then I enrolled, so I went through the fellowship. I was able to see what was good, what was not good about it, and then kind of understood what kinds of elements I wanted to keep in it. From my previous fellowship and then designed it literally from the inside out. OK, and now every couple of years we have established, reestablished, established, reestablished a baseline and foundations to where we are today. And that's it, you know, to to echo to echo Lynn's comment about enjoying our job. Renee, Lynn and I are all we're all professors. OK, so there's a lot of things that are asked of us to do that are asked of us on a daily basis. All of us belong to national societies and we have a lot on our plate, but we still do this and we still do this. And Lynn and Renee and I have been doing this together for several years now. Right. And I know I understand the passion that Renee has for really redesigning the field. And I know that the love that Lynn has for what she does in her academic prowess. If there's nothing that the people who are listening to this program tonight get from this series, I want them to understand how to how to find impassioned people to work with, because if you can find that, then that will that will elevate you into the next and to the next level of really your life. OK, so now I've said that. Gina, I'm going to let you take over. All right. Thank you so much for starting us off on an awesome foot. Welcome, everyone, to our wonderful AP summer slash early fall series. Technically, summer. We just had so many great sessions that we snuck a little into September here. And today we're obviously are having our pain medicine fellowship Q&A. Friendly reminder that coming up on Monday, September 25th at 8 p.m., we will be having the Q&A fellowship series for spasticity medicine. We are very honored today to have multiple people as they just introduced themselves for our talk today regarding pain medicine. They'll be discussing themselves, their path, as well as talking about their individual programs. And this is a very informal session. All of it really, just like I mentioned, is to benefit you, the potential future applicants or current applicants for the pain medicine fellowship. If you have any questions and you feel brave enough to turn on your your your video or your microphone, ask them, go for it. If you want to put it in the chat, I can ask it out loud for you or you can send me a direct message personally on the chat and I can ask it out loud to the group as well. Yeah. Without further ado, welcome to our pain medicine fellowship Q&A series. Thanks. For all of those who will or may be applying tonight, who are somewhat anxious about asking questions, bear in mind that both Lynn, Renee and I will remember the good ones, but we will forget all the bad ones. OK, so this is an opportunity here for everybody to learn. Any questions from the chat? Does anyone want to just know anything in general, the programs? So no questions as of yet in the chat, but just some questions overall, I've seen a lot of people struggle with deciding which programs to go to based on the balance of anesthesiology versus PM&R in regards to the faculty and the history of residents that have been accepted there. Do you have any insight into there or any suggestions for applicants? Lynn, you want to take that? You've had one of the most well-rounded programs in memory. I remember that your program was one that I really wanted to to matriculate to when I was applying. So and I know I don't have the honor, like I said, of having created the program myself. I've been but I did go, you know, actually did go to the fellowship at UVA. So having been through the fellowship myself, you know, you do learn things. I think as I had said, we, you know, so I mean, I can give you some general advice and then kind of a little bit about what we do specifically. But, you know, I think there's been a shift. I mean, I think before in the past, more programs were unfortunately, you know, less non-anesthesia friendly. But I think that's that's changing. I can say at UVA what we've always done is created two match lists. So that way we can purposely have because we value our non-anesthesia fellows so much that we will have two separate match lists. That way we can decide, you know, we can control for specifically having non-anesthesiologists. Everyone learns from each other. You know, everyone is so valuable and important to the field. And it just makes us stronger that way. So that that's how we kind of handle it. We do have a question from our chat. One chat question we have here. Is there a minimum threshold for publications when you're looking that you're looking for when reviewing applications? Maybe all of us should answer that. Rene, why don't you go first? I'll go first. I think when we look at the applications, I call it, it should be well-rounded. And is there a fixed number? The short answer is no. Is there strong advice that you have to have something? I call it on your CV and also how you can show why you're interested in pain medicine. The answer is yes. We do know there are certain programs where the academic resources are less versus other programs who have very established research programs and you just team up and just do a little bit. So we are aware about the differences and just the pure publication doesn't make a good candidate. So we're looking well-rounded. It's also understood that at times we develop our passion. Let's say for a specialty or let's say for pain medicine, maybe during or later in our residency. So it may be also difficult, you know, now to have specific scholarly activities. And I call scholarly activity that can be research, educational reviews, just presentations and that they're limited. But you may have from your previous ideas. So, you know, you have something what I call to show so that you have shown that you understand the value of a scholarly activity, you know, not just to talk about research. The one aspect I cannot answer for you. Of course, you can talk to me about it, but I think where the future is going. But the big question is for you to make the decision. Is pain medicine the right field for you? So that I cannot answer. I can tell you what we think is a good candidate and things like that. But that's the very first question you have to answer yourself. And then once you reach that, again, some are early, some are later in their residence. And I think that's fine because how shall you know what you want to do at the beginning? Right. Maybe you haven't seen everything. And then you see the different subspecialties as you go through your education, your training programs, and then you develop the passion. So so we do understand that. I think the only thing difficult to explain is I call it if your CV is empty. And if you cannot sort of, I guess, convince the programs or the training programs why you want to do pain. You know, those are, I think, the very key aspects. I know there is a debate. How do you decide on which program accepts PM&R, anesthesia or ER medicine? Or do they accept out of state or in state? All those debates. I think the bottom line is you want to pick the programs you like. It is still a competitive field. So my advice is the broader you go and may also accept different location and states, the better are your chances. The fellowship is one year. It goes very fast. It's not like residency where you need to think I'm going to be there three or five years and and so forth. So that's it counts to get in. I would say every training program has pros and cons. Not to hurt my colleagues. Maybe some programs are perfect. A lot of us are not, but we all provide, I call it the ACGME requirements. And also, again, you're all adults. So if there are certain gaps, which every program will have, you'll be able to fill the gaps, you know, because, again, you're an adult learner, you know what to do. If you feel you need to fill the gap or if you say, you know what, that's an area of practice I don't consider worthwhile for me, which is fine. You don't need to do everything. Basically, you can, you cannot do everything. So those are my few cents. When you look at programs, what do they rank? Again, look at the whole history, not just one year, because you may think they only take X and then the next year it is turned it's Y. For my program, I always say there is a match. That means there are two sides. So there is the program which does something, but there are also applicants who decide pros or cons. So that's, I call it my few cents, and I guess I give it back to my colleagues, Lynn and Sayegh. Lynn, go ahead. You go next, because you've been asking, so you go next. All right. So I just want everybody to understand one thing. Rene is an MD-PhD. He's a highly accomplished person, and he has created a very progressive program at University of Florida. That being said, I'm just going to make sure that everyone understood what he said. And that was, Rene, correct me if I'm wrong, that there is no number that he looks at. There is no number that I look at either. OK, but well-roundedness is important and an interest is important. Now, Lynn and Rene and I have the history of being part of the APPD. And for those of you who don't know actually what the APPD stands for, it's the Association of Pain Program Directors. We are a conglomerate of really enthusiastic pain program directors throughout the country. And we've been on the board of this organization for several years. So, you know, Rene has developed his opinions based upon the interests of all of our colleagues who work with us as well. I don't know of anyone who sets a number or a bar for numbers of publications. OK, I will tell you one thing, though. I do get a little concerned when I see someone who is a PGY2 and has 50 publications. OK, but they're all abstracts or they're all like little inserts. And then I start asking questions about what is this and what is that and what is this during the interviews? And then when people can't explain what they are, it's a bit odd. And that and that disconnect will resonate. And it's something that people will remember. So just bear in mind that if you're going to do something and if you're going to publish something, please be enthusiastic about it. Right. Put your heart into it. Even if you don't get a publication, you may not get an abstract. But if something is in there and you really enjoy doing it, I promise you it's going to come out during an interview. And when you when you have this dialogue, when the question is asked about your research, people will see that and they will remember you for it. OK, that I will tell you, Lynn. Yeah, definitely. So, I mean, a couple of points from what both of you said, and, you know, it's a two way street. So one of the things we what we really want is people who want to come to our program and who want to be in the field of pain because they know what they're getting into. Pain can be very rewarding. It can also be challenging. And so we want to make sure people really understand the field and have had some kind of exposure to the field. Now, it's harder if you get your rotation later, but that doesn't mean, you know, that you can't be committed. We've certainly had, you know, residents who have had the rotations later. But once they did pain, they're like, this is the best thing ever. And, you know, that comes across. It comes across in their letters. It comes across in the interviews. So there's no like numbers or certainly no numbers for publications. I agree with, you know, what I had said in terms of, you know, if you if you have done something, be able to talk about it. Don't just be like, I don't really know, I don't know what I did. Cause that kind of is that disconnect that he's talking about. But really, I mean, the important things are, being around it, like demonstrating that you understand the field and have reasons for really wanting to go into it versus kind of running away from something else. I think I can add, let's say as we all not perfect and you heard from some of our CVs, we started off here and there. We are familiar either with the struggle to get in or a visa and all the requirements. If you have sort of gaps in your CV or perceived gaps or you think it doesn't look good, I think the mature part is to A, be aware about it and be able to address it. And basically that's it. As similar with the abstracts, when you see a lot and you read it and then you get asked and then it comes to a big quiet moment, the aha, right? That's could be irritating. That raises the flag and then they start asking more. If you say, give an answer, okay, it wasn't ideal. I had to repeat this or that or this and that happened or I had to take a break or family reasons, that's fine. I would say most of us are not perfect and our whole CVs will not look like it although they may look like it. So those are the few sense and be prepared and address that. And I think bottom line is that's fine. It's just, if there comes nothing or what I hear sometimes from colleagues, if applicants say they're fluent in certain languages and then they may get excited and oops, first sentence is already, you don't help yourself. So be realistic what you have. What I have done when we started off of our team or let's say nearly 10 years ago, I mean, it was unknown, it was failing and closing. So, and we didn't have a lot of things and what I told the applicants at that point and that's what I expect the same vice versa is and I still do it this way. I think, maybe biased, that I tell the applicants exactly or what I think what we have and what we don't have and if that's something what they're looking forward to experience what we have, then that's fine. If you are looking for something else and we can talk about it, it doesn't jeopardize your position but let's say if there is really some subspecialty in pain you're craving for, then I may also advise you from a collegial aspect there may be other programs where it fits better and in which one it is without burning the bridges with me. I think that's just from a professional aspects. I think what you have to do, I would hate having a graduate walking out, I would say who was misled. So we would anticipate the same. So we say, that's what we have. Then is there a match, what you're looking for and go from there. So that's still my approach. I mean, we're ramped up a lot of things, we're still nowhere to be perfect and I think in one year we can achieve it. So there's always like be honest and accept the gap in certain aspects but see if the program or what they say they have fits what you're looking for or if there are other ones. And if you're not sure, I would say it's legitimate to ask. Yeah, there's no way in one year that every single program could teach everything there is to learn about pain. And so just like others are saying, I mean, there's gonna be some gaps here and there but it's about finding the program that kind of matches the best with what your interests are and then understanding that it's a lifelong learning. I mean, you're still right there procedures that weren't even around when I was a fellow but having a program that teaches you the basic skill sets so that you can learn new things later on. Yeah, I'm gonna extend both Lynn and Renee's comments to the next question that I saw in the chat and that was, what is your ideal candidate? That's gonna be different for every program that you ask but there is a unity here, there is a commonality, a common denominator. And I can attest to this because Lynn and Renee and some other colleagues of ours from around the country recently did a survey of fellowship PDs. And we asked this kind of question, what's most important to you when you're looking for a fellow? I will tell you that one of the most important things that came up was integrity. And Lynn and Renee and I and others who have been doing this for a really long time and who like doing this, have become somewhat experts in being able to identify the ones who have the passion and the integrity but integrity is important. Insight is really important because of what Lynn and Renee said earlier. If you, hopefully for everybody here, when you are in the fellowship that you want to go into and the fellowship is only one year and there's a lot to learn. I mean, these are career, this is a career transforming year if you wanna do pain medicine. If you're an anesthesiologist, you're learning totally different things. If you're a physiatrist, you're learning completely different things. If you're a neurologist, an ER physician and an internal medicine physician, I mean, this is transformative, career transformative. Life transformative, philosophically transformative. It is an extremely impactful year but you will not maximize your learning if you don't have good insight. If you don't know what you don't know, it becomes extremely difficult for any of us to teach you what you should know. But if you are able to identify the kinds of things that you need to be better at, it makes it a lot easier for Renee and for Lynn and for I. Okay, and those are certain things that we look for in a CV. And Renee pointed to that earlier. Like guys, don't try to pull the wool over our eyes, okay? I mean, serious. Just be who you are, show the enthusiasm, show the passion and then hopefully the cards will land in the way that they were meant to land. All right. Thank you. That was a really great addition. Does anyone else want to add to that? I mean, I think we're all, and we all talk to each other so much, I think we're all very much like-minded. But I think our other colleagues in other programs are as well. I mean, we want people who want to learn, right? And that does come across in your letters, it comes across in your CV. So all those points are very salient. I'm going to ask some questions actually, if it's okay. I'm gonna ask some questions that my residents ask me about fellowships. Lynn, if a resident comes to you and says, you know what, I haven't done a lot of spinal cord stimulators or radiofrequency ablations, would I still be able to do that? Would I still be a strong candidate in your program? What would you say? So I'm just gonna extend that out and say, I didn't do a lot of procedures. Lynn, would you take me in your program? Yes, definitely. We're not expecting people to come in who already know how to do everything, right? We're there to train you for that year and beyond, teach you the skills that you need to be a strong, well-rounded pain physician. And so for us, that's procedures, but then I'll also point out, because some people I think get so worried about procedures, that it's not just doing the procedures, right? It's about learning who to do the procedures on, how to select the right patients, how to optimize your outcomes, what to do when something goes wrong, all those things. And then there's pharmacological treatments as well. And so we are 100% not looking for people who already know exactly what to do and the people who've already just done a ton of procedures. And so that I would tell them not to worry about that, that that's what we are, that's our job. That's our job for the year is to teach, is to teach you how to do those things. Renee, I apply to your program and I'm a physiatrist I'm a physiatrist who doesn't have any letters of recommendation from an anesthesiologist. Does that impact me in your program? No. So the bottom line comes down that I hope, or my colleagues when we review the applications and then conduct the interviews is that you have had enough experience that you now for sure what pain medicine looks like, what the field is and that you want to do it. So if you, whoever you trained it with, if that was community practice, I think there are a lot of training programs. I think let's say from pain medicine, they have to go to a community physician to see it. And this person may isn't be a professor at all. It's just, and sometimes maybe those letters are also be, I don't know, three paragraphs, right? Compared to the highly academic centers where you have, you're going to read a thesis times five. But that doesn't mean anything good or bad. My point is if you are in the process to interview, I always make the joke, probably it's too late to question the field. I mean, if you still do it rather now than later. So I look is if that's where you're coming from, is that something I would say you have seen a good aspect of pain medicine. Again, you can't see everything, but still some are more medication, some more interventional, but that you have an idea what the field looks like. And you're going to say, yeah, that's it. Get me, set me up for success in that area. So that's what I'll be looking at. Thanks. Then I have another very popular question that comes through my channels. I'm a rehab doctor and I know that applications begin, what is it? Is it December 1st? It opens December 1st, yeah. It's December 1st. It's December 1st. Lynn, do I have to get in my application by December 1st? Yeah, that's a good one. My people ask that all the time. We do not look at any applications in December. We do not look at, probably we start end of February. I tell people maybe to get their applications in by January. We do not look at any. And I think when this has come up in our discussions for the APPD, can't remember anyone who said that they looked at them in December. I might be wrong, but I think most of us say, you know, there's too much going on in December, right? We're not looking at them in December. So don't be too late. I mean, we do get ones that are too late. But January, I think aiming for your application to be in by early January, mid-January is probably a good target. I don't know if you can say it, Rene, you guys. I think we look at it February, March. Yes. We do interview May, June. The reason May, June is so that you can still talk to maybe one or two of our graduating fellows who have done the program. So they can talk about how that specific program at UF is because they have lived it. And also, I hope there's no more fear of retaliation because they're nearly done, no matter what I would come up with. And they hopefully can also tell you now how is the outlook, not necessarily come from our program, but let's say, how does it look when you are a pain physician? You know, how do the job looks like? Is it employed? Do you do it yourself? You go academic, what's there? Again, what's there in the Southeastern part of the United States? So they can tell you, or hopefully can tell you that whole spiel that you may also want to consider. That's great. Thank you so much. I do have another question from the group. Would you mind talking about if you factor into any ties to your program like, or geographically like that city or region when you're selecting applicants? And also, is there anything that residents who don't have ties to your program area can do to show a particular interest into said program? That's a good question. Why don't you take that one? That's a good question. I think that's what Lynn and Renee and I have been waiting for, things like that. And my hope is that we continue to open up the channels. I have had medical students, residents email me and ask me if there's any active research projects going on. I have had residents message me and not text message, email me and ask me if there would be a time that they could come by and observe our practice. Pre-COVID, it was much simpler to have non-Montefiore learners come to our institution just to visit the site. Post-COVID, it's been very, very challenging. And even now it remains challenging. But if you want to be remembered by the program directors, I believe that it's important to be part of some society events. So the APPD has presentations in ASRA, in AAPM. We are hoping to do something in AAPMNR and AAP as well. But if we're there and there's groups of us there and we hold a face-to-face session similar to what we're doing tonight, when someone comes and they shake your hand, or if it's COVID and they don't want to shake your hand, that's fine too, but having FaceTime is important. Okay, so being part of those events is important. Being part of the SIGs in the aforementioned societies is good as well because Lynn and Renee and I and many of the board members or members of the APPD are within SIGs, special interest groups, for those of you who don't know what that is. And so that would be important. Again, face-to-face time, that demonstrates interest and also just a quick email asking about research opportunities. And if someone turns around and said, there's nothing now, it's not a bad idea to write another short email, four or five months later to see if there's anything active. You just, you remain active, you remain memorable, okay? Yeah, and in terms of like, geographic, you know, we're in essentially rural Virginia. And so it does, you know, we need, we do want to make sure people are willing to come to a rural area, but that doesn't mean you have to be from Virginia. I'm not from Virginia. You know, here I am still in Virginia. And so just that you understand the area and that it suits your needs, you know? So, and that doesn't mean, so if you're not from there, you can still demonstrate that, you know, hey, I, you know, you can ask about the area. I mean, there's many ways to express interest, you know? I think, you know, one of our colleagues at Mayo, you know, they got to find people. So, you know, who want to come to a really cold, rural area too. So, you know, as long as you're showing that you need to be excited or okay with living in that area, that's good enough. We're not just only taking people from Virginia for sure. Great, great. Another question we have from the chat is, if an applicant is interested in finding a program that teaches a specific procedure, what is the best way to figure out which program do these procedures versus those programs that don't? Renee, you want to take that? I would say, I mean, there are, I call it their social media outlets where you make and find some ideas, but that's, take it with a grain of salt what you read there, the pros and cons. I think worse comes to worse, as you do, you need to ask, you know, and of course that makes you uncomfortable because you don't want to cross, coming across, but I think if this is something you're interested in or where you see a future or where you want to practice over the group, then I think in the end, you have to ask. And I hope, you know, from our side, from the programs that you get a, call it an honest answer, you know, there are, what we do, we, like I said, we tell the applicants where are we strong at and where are we not, or where there is just a requirement. So that again, if there's something what you envision for yourself and we are not the strongest program in, you may find alternatives. So I think in the end, you have to ask. You have to ask. When you look at the ACGV requirements, especially regarding procedures itself and their experience and the numbers, I think it's very vague if it is even still in there. So again, feel free to look at it. So you need to do some background check or you can talk to graduating fellows. And again, as Dr. Syed said, you know, Syed you said, go to meetings. Hopefully you communicate there, you get some information. Again, I encourage you, if you need that information, whatever it is, whatever burns under your nails or there's something with your CV, you know, I would say, bring it up. You know, you want that answer, it is on your mind. So then also try to get that answer. Yeah. Lynn and Renee, permission to go on a soapbox run here because there is a question about procedures. I'm gonna point out that Lynn's program does a lot of procedures. Renee's program does a lot of procedures. My program does a lot of procedures. Cautionary, if a patient comes to me because they wanna do pain for the procedures, that's a red flag. Renee and Lynn and I are doing what we're doing because we love what we do. We wanna preserve our field. And you can't preserve a field when there's people who wanna do so many procedures and so many complicated procedures without understanding why you do them. And that's a point that Lynn brought up before. So bringing up procedures is an excellent point. Wanting to do them is a good thing. But there has to be a way that you demonstrate that enthusiasm without turning off the person who you're talking to. You just have to be careful and there's an art to it. And my suggestion is that you refine the art within yourself, meaning you start to really want to learn when to do the procedures. Let me restate this. You start to learn how to select the patients to do the procedures on. I think that's verbatim from what Lynn said earlier. Then you can start to begin the conversation about why you want to do the procedures. That I think is much more palatable to the ears of program directors. It sounds better. It's like music because otherwise it's just like noise and banging. That's very important. I wanna make that point. I have told residents not to apply to pain because they could not get the pain equals procedures formula out of their mind. I actually thought those people would be dangerous to our field. Just is what it is. And I echo that in your personal statements as well. Don't only say procedure, procedure, procedures. We all like doing procedures, right? That's why we are all here, but you're never gonna get anyone better just sticking needles in them, right? There's more to pain management than just that. And so that's the point you need to get across that you enjoy procedures, you enjoy using many different modalities to improve the lives of patients. And yes, it's cool to do high-end interventional procedures, but you're gonna use all the tools for the right patients and know when to apply them. Yeah, I echo my colleagues. When you write in your statement, I wanna do pain, I had pain, I did an injection and it was fixed. Yeah, right. So you see on my gray hair, that may not be the case. So it's not just procedures to be very clear. And sometimes, maybe it's judgmental, but when you have a idea that the applicant basically just wanna know, just tell me how many stimulator trials you do so I can move on, you have lost it. And it's not really a good colleague in our field when you have that scenario, because if you look at pain medicine and look at the books, it's such a broad field, what you all can do. And those are all your toolboxes. So if you're gonna start tossing them out, devalue them, doing a lot of procedures, trust me, they're getting reimbursed less and less because that's just a statistic. So the payers do know how to do it and how to get it back in balance. And again, you get devalued. You put yourself maybe at risk to no longer practicing independent, because if you do procedures or you rely on certain third parties to provide things or medications or devices, again, your independent practice as a physician, that's what you strive for, that's what you studied 10 years for, might be at risk. So think about it twice. So procedures can help. A lot of times in pain medicine, we treat wear and tear. So there's a rate of changes. Again, as of now, no one can give you back your 20-year-old spine when you're 90 years old. So we can help them, or sometimes there's also a scenario, you do no harm with the tools you have available, but they wouldn't be appropriate. So as my colleague said, it's that decision, who you're gonna treat, by what type of intervention and when I say intervention, I mean, everything in a toolbox. That can be from, I'll be honest, doing nothing PT to do a procedure or medication management or expected management. So those are all the options you have. And then I think, what is the champion? You know, when you do something, no matter what it was, I'll call it the injection, and it didn't work. I think that's when, in my opinion, you really get the expert on A, who can handle that, because your patient may not be happy or disappointed, or he still trusts you, but now, you know, I call it the pressure is on, you're in the light, right? And now, you know, can you distinguish yourself and make a difference for the patient? And even if it means, like I said, do no harm, and say, right now, the options are limited, and not just, for example, jump on a procedure because there is something on the MRI, but the patient's comorbidities are not making it survivable what you're just planning on doing. So I think that's, in my opinion, that's a physician, right? That's by a few cents. And I think the other thing too is, you know, it's really usually not the technical part that's the challenge, right, in terms of learning. I would also maybe ask questions about like, because it's something I think fellows don't think about till later, is like the system-based practice that's involved with creating a pathway to do the more advanced surgical procedures. But like, that's what you need to learn, because you can, you know, if you do enough pumps, you can put in a stem. If you do enough stems, you can put in a pump, right? It's not the technical aspects. Yes, you need exposure to that. You need basic skills to do that. But it's like, how, when you go and graduate, do you know what to do to, if your practice doesn't have that, how to create the nursing structure, everything that goes along with creating that type of a program. That's actually harder to learn than the actual technical aspects. I really appreciate- And I think if you- Oh, sorry, sorry, my apologies. No, it's the, what is it, if the foundation, right? So if you know how to handle tissue, how to work in the ore, how to make incisions, hemostasis, that's a big point, you know, when you have a cadaver where you come from the weekend, the first thing you do on a real patient is gonna bleed. That's just the first break and you get stunned to know how to close an incision and things like that. So that's the base. And then it comes to the point, is it now a stimulator or a pump? Yes, they are different. Yes, they have different indication, but the technical aspects are the same. Or if you do a fluoroscopically guided, you know, you're gonna look what the anatomy looks like, cervical procedures, you have seen your cervical spine. Now, if you now do just epidurals or never an ablation or vice versa, but you are sort of familiar, you know how you can get safely to the target and how you talk your patient through it. So those are quality key aspect. Does it always mean 150 of everything? The answer is no, and that's not achievable and that's not something you would look for. Now you can get those programs, but if you think about it's just one year, that also means they're gonna be certain gaps in other areas because you can only do that much in 24 hours. That's the way to look at it. So look, if you get a broad foundation from call it non-procedural, what all there is, to the procedural aspects, so that if you feel you haven't learned it in your fellowship, like I said, there's a good chance, but you have, you know, the basics. So you can integrate, you're an adult learner. It's not such a big deal. There's a certain comfort level, but you can do it. Or you have seen a broad variety so that actually you have that, I call it hopefully comfort level that you want to integrate something. Or you also can make a conscious decision, not because of weakness and fear, but just, you know, I have seen it. I do not do implants. You still be a perfect physician. So not the decision-making because you haven't seen it and it's also mysterious and who knows what, and the one you did, let's be fair, didn't turn out to be so well. So then you have that problem, right? That trust issue, that confident level, but that you have the confident level to just say, okay, I'll do it. Well, I'm confident, I know there's a gap, but I know how to close it. Or the way we practice or how many colleagues we have in our infrastructure, we are not doing certain interventions. And there's still so many other options you have how you can help your patients. You're not an incomplete or incompetent physician if you don't offer the whole spectrum, to be very fair. And that hopefully helps a little bit with the stress when you go to the applications, who you can swear to and who has the most. Like I said earlier, when I was a fellow, there was no intercept, there was no reactivate, right? I mean, there wasn't even DRG. So you can't, there's gonna be new things, you're gonna learn them. So as long as you have a foundation, like others have said, that's really what's important. You'll learn to do the other procedures. The one aspect I think I may say I brought in is when we started off, I started off in Florida in 2014, where we had, again, we really didn't have advanced procedures. We may had trials and implants, and besides that, it was what we call bread and butter. So it wasn't very sophisticated at that time, but I do have some experiences, let's say in surgery in Europe. Again, I'm not a surgeon to be very clear for the disclosure but what my philosophy was and what I tried to do with the fellows is that what I have, that what is available, that you have your hands-on experience. So it's not the job, you're watching me and telling me how great I am. No, it's hand-on experience from day one. And if you get the feeling in June or maybe already in February, hey, you can do that 10 times faster than when Prince Cora does it, or you wonder, has he ever done it? Then it may sound arrogant in my mind on making the checkbox. I say for myself, job well done because that's where I need to get you, not to watch me. You need to be able to do it. Again, with the pros and cons, the mistakes, the failures, the errors, the great outcomes too, don't get me wrong. But that again, what I have, that is for you. That's the reason you do the fellowship, not like maybe previous years in Europe, surgery very hierarchical. So you were watching basically five out of six years other people doing things. Now, if that's a manual part of your profession, there is a gap. And that was my approach when I said, I'll do pain medicine. And now we don't have a lot of things, but that what is there, what is available is a needle to drive, you're gonna drive. So that's, I think, what was my, and it's still my philosophy. I hope my colleagues are able to keep it up. It varies between personalities, but again, that's also the interesting part of a fellowship. Hopefully you have several different faculty. So you see pros and cons and you make the conscious decision. Okay, I like this. I like how he does it. I like how he talks to patient. I like his overall approach. And you pick the pieces and make a big picture for you what works out. That is amazing insight. Thank you so much for that very, very valuable information. Out of another question, we sort of talked about earlier today, but you could hit on again. How many letters of recommendations are you looking for? And should all of them be from pain physicians? I think you're right. Iris is like two or three, I think three letters. Yeah, three. I think five is too much, unless there's a circumstance. Yeah. Some argue the program director should write one. They don't all have to be pain physicians though. Right. I actually think it's odd if it's only pain physicians that write it. Because what I wanna know, I think is similar to what Lynn and Renee wanna know. Lynn and Renee wanna know how their applicants did on their general anesthesia rotations, how they did in PEDS, how they did in cardio. Okay. And I wanna know how the residents did in their TBI rotations, on their SCI rotations, or in their general MSK rotations on EMG. Like that stuff is important because what I wanna establish is what we talked about very early on, right? I'm bringing this now full circle. And that is the well-roundedness. You have to be able to demonstrate that you value other elements of patient care other than just the pain aspect. If one can demonstrate that, and then they become special. Very true. That's great. That's great. And then a message that I got is, do you know if interviews are going to be staying virtual for the majority of programs in this application season? Yes. Nods of yes. Okay, great, great. And then another question from our group chat, as this is only one year that transforms your career, as fellowship directors, how do you try to support your fellows once they graduate? More generally, is this something I should hope for for a program when I'm evaluating programs? Yeah, I think we're limited time. So I've definitely asked that of programs. When you're looking into programs, you want a program with, I think, well, I shouldn't say that. You can choose what you want, but if that's something that interests you, you should be looking for programs that potentially have a strong alumni network. Yeah. You know, for me, it depends upon how much contact they actually want to have with me afterwards. I'm available to them. They all have my cell phone number. You know, my former fellows and I are still texting back and forth on football Sundays about individual plays that happen, right? And what happens to a team. So, and then, you know, between the football and baseball jargon, there is communication about, you know, what should I do with this patient? This person has a history of blah. And, you know, it seems like they may have something else. What do I order? How do I, how do I order it? You know, I think both Renee and Lynn and I, again, we do this because we value what we, there's a lot of value in this element of our work. And we do it because we enjoy it. It is the responsibility of the applicants to be able to see that. Which I think, yeah. And I think that's when I say this may be a bit harder with Zoom, unfortunately, but I still think, I still think it shows through. When you, you know, when you get to talk to the fellows of the programs, they know because they talked to the past fellows and they talked to the past fellows and, you know, they say how much they still communicate with all of us. So. Yeah. Establishing a communication line amongst fellows that have graduated from a particular region or a particular fellowship is important. Because there's a lot of, there's a lot of insight that one can gain just by talking to, you know, former applicants, former graduates. It goes, it goes a long way. There's a lot of, there's a lot of learning there. So that's, that's one thing that I would advise most of you here to do. That's really great. I know we only have like one more minute before we need to close. So I don't know if you want to take maybe a 30 second stab, but we have time for maybe one more question. ACGME pain programs have similar curriculum components, but is there any key difference between PM&R versus anesthesiology based program in terms of training perspective? I'm gonna, I don't think it's because it's PM&R versus anesthesia. I think there might be differences between programs, but that might be the philosophy of the program versus the core specialty. Right. It may also affect the, I call it the institution the program is housed in, you know, what is available there, how many are competing with potential pain patients. You know, that's, that's, that's, I think it's the bigger aspect, not necessarily where, who is the primary specialty. It's more like how is the institution set up and what are the competing interests, which could diminish your experience, you know? So that's, those are my few cents. Yeah. I mean, it really comes down to resources. And, you know, there's intellectual resources, there are material resources, there are personnel administrative resources as well. Every program, every program is different. And that's, you know, it also a reason why there should be communication. There should be, there should be self-learning on the part of the applicants to understand the programs and how they may be different. Now there are anesthesiologists who apply to our program because they want to learn, you know, elements of physiatric medicine, okay? Which, you know, we implement within the framework of our education. We have physiatrists who don't want to come to our program because they already know that and they want to learn from anesthesiologists and they want something new, right? It just depends upon the learner and what they're comfortable with also. There's not a bad, there's not a good. Lynn, Renee and I have been working to break down barriers since almost the inception of our PD reigns, so to speak. That's amazing. Awesome. As it is nine, I just would love to hear any closing remarks that you guys have as we end our session and I'd like to send a friendly reminder that we do have our next Best of the City Q&A Fellowship Series next Monday, 8 p.m. And it was very, a big pleasure having you all here at the Q&A Fellowship Series session for pain medicine. Thank you for having us. Thank you and good luck. Thank you so much. Thank you all. Thank you so much for coming. Bye. Good night, everybody.

pain medicine fellowships

well-rounded applicants

application process

letters of recommendation

selecting patients for procedures

submitting applications in January

comprehensive approach to patient care

strong alumni networks

PM&R and anesthesia-based programs

selecting the right pain medicine fellowship program