your chest. I'll be helping moderate this session. Please put any questions that you have in the chat. But if anyone is brave and wants to turn on their video and ask a question, I encourage that as well. You can also send me a private message with your question if you want me to say it. But otherwise, I will now turn it over to Dr. Kirschner and Dr. Standart and Dr. Friedrich to tell us about their wonderful fellowships. All right, I guess I'll go first. So I'm Dr. Kirschner. Thanks so much for having me. I'm the Fellowship Director at the Hospital for Special Surgery. I've been the Fellowship Director for I think, seven years now. We have four fellows and we have two separate, sort of two official fellowships on paper, but the fellows more or less have a similar curriculum. So we have an ACPME Sports Fellowship, which I won't talk much about unless people have questions. And then we have a NAS recognized Interventional Spine and Musculoskeletal Medicine Fellowship. So a bunch of accredited spine fellowships joined together under the auspices of NAS to try to have, you know, sort of more weight behind the fellowship. It's not an accreditation, or say a certification, but there's a precedent because NAS recognizes the spine surgery fellowships. And we wanted to make sure that our fellows, you know, would minimize any issues, say getting privileges at hospitals doing procedures, and having sort of the strength of an organization like NAS behind them. So as far as what our fellows do, you know, we do spine and sports medicine, we do a lot of interventional spine, cervical, thoracic, lumbar, epidurals, facets, radiofrequency ablation, you name it. We also do peripheral joint procedures, ultrasound guided procedures, electrodiagnostics. It's a one year fellowship, there's a match through NAS. I could keep talking, but I want to give everyone else a chance to talk. I'll pass the mic. You can go next, Chris, if you want. Sure. I'm Chris Standard. I'm the fellowship director at Pitt. I'm an associate professor and vice chair in the department there. I am an outpatient spine musculoskeletal person. Been in practice for quite a while. We started our fellowship a few years ago, it's a completely different sort of structure. So it is spine and MSK based, it is not interventionally based. If people want to learn interventions, we can teach them, but that is not the focus. We really focus on probably two things. One, really good comprehensive clinical care, how to do that, how to provide that. We rotate the fellow through probably 20 different clinics within UPMC. They learn what other providers do, how they work, what kind of work they do. We go to multidisciplinary conferences. The intent there is that we really want excellent clinicians coming out of this in the musculoskeletal spine realm to take care of patients. And our fellowship is linked to our health plan. UPMC is a huge company. It's a $22 billion a year company. We have 40 hospitals. We're in like seven countries. It's enormous. And we have our own health plan, which ensures about 40% of our patients. And the health plan is in the process of trying to reinvent itself as sort of a giant self-insured entity, which changes our healthcare. So we have a value driven structure at UPMC where we're trying to invest in our patients early on to keep them well and keep them away from expensive things that are either not necessary or don't help them. It's really trying to transform the healthcare system. So our fellowship is funded by the health plan. The fellow spends about 20% of their time in a whole structured curriculum going through the health plan. What they learn is health plan operations and finances, everything from coverage to pharmacy payment to how Medicare Advantage works. We meet with the CMO of the $22 billion a year company once a month and talk about what we're doing. You have direct access to the people who run things at UPMC. You're working at the executive vice president and sort of director level is who you're working with. And in all of it, what we're trying to do are create people who are excellent clinicians, very much interested in evidence and data and how things work and how to provide care and can help us sort of transform the system. We have built several model spine clinics. It's all based out of one. We just have several clinic sites of integrated comprehensive care. We have our own dedicated PTs who only work in those clinics. We have a pain psychologist and a dietician and dedicated nurses and a health coach. And we work together and we track our data and the fellow works with me on data analytics and program development and all the meetings I have with the health plan and all that structure. And we spend a couple hours a week going through original literature and really reading and learning and understanding what we're doing. Joe Shivers was my first fellow who now works with us. So he's on the phone on the phone on the zoom as well. So you probably had something he is a he went through the fellowship. So he has a different perspective than I do. I'll, I'll hold off for right now. But I'm but happy to happy to chime in to the discussion later. And thank you so much, Chris, for the shout out. And thank you, Gina for hosting. Yeah. I have a few slides. So I'm gonna I'll try to share if that works. Yes, yes, please. Is that showing up okay? Yes. Actually had to put some slides together recently because presenting to our own department faculty kind of updates on what the fellowship look like. So I decided to kind of go ahead and use these for this venue too, because it's relatively short and sweet. So my name is Jason Friedrich. I'm at University of Colorado and the current program director for the ACGME accredited multidisciplinary pain fellowship. So this fellowship started back in about 2005. Here's some pictures of our founding fathers. So Dr. Benu Akathoda, who's our current department chair and then Dr. Bill Sullivan, who's now at Vanderbilt got things started. And because it's ACGME, we have a lot of information that we have to furnish to ACGME year after year after year, including program goals and aims, but ultimately the gist of what I wanna to kind of sell to everyone here is that, our primary focus is really on education and leadership. And then clinically the focus is very much on spine and I'll kind of get into kind of how that looks in practice. No, I don't. So in terms of the clinical education, we are a little bit unique and probably even unique relative to other ACGME pain programs, because we have three different clinical tracks. And so typically we have one PM&R fellow and two anesthesiology fellows. The PM&R fellow is primarily housed at our spine center and their core focus is really on spine. And that's really kind of comprehensive, non-operative spine. And then the adult anesthesiology track is a little bit different. They'll do a little bit more, you know, stimulator placements and a little bit more acute inpatient pain service and hospital consults. And then we have a, for the last five or so years, we've had a pediatric focus. And again, that's usually been filled by an anesthesiologist because that's just how the funding works out. There's been a couple of years that a PM&R applicant has filled that spot and they split time between children's and the adult side. And we have a number of different kind of non-core rotations where folks spend time with the neurology, headache clinic and palliative care and addiction medicine, psychiatry, and a little bit of the acute pain service. And then there's some additional elective times. And I talked about that already. In terms of the management structure, you know, it's me as the program director and then in our PM&R department, Dr. Ben Marshall is the associate program director and then Rachel Rosalind from anesthesiology is the other associate program director. And it really does take a village. So we have a lot of different people involved. We have psych directors at children's and, you know, free acute pain service and so on. Number of different faculties. So this is majority of PM&R driven program, but because it's ACGME and it's really required to be multidisciplinary and have kind of some hospital-based components to it, we certainly collaborate pretty closely with the anesthesiologists. So in line with what we're trying to accomplish in terms of kind of education and leadership, we do really are looking for fellows that, you know, have some interest in academics. And, you know, for the most part, you know, that's what our numbers pan out to be. So actually I have a fairly high percentage of folks that end up, you know, ultimately choosing a job in academics. And so these are just some examples of different places where people train. A lot of people that do the fellowship here seem to stay around like myself, but we are starting to kind of spread fellows a little bit more around the country as well. Number of successful fellows out there. These were just folks that were easy to pull pictures off of from the internet. And so, you know, in terms of the recent fellow, relatively recent, Dr. Adele Meron, she's here now and she was a kind of a NAS 40 under 40 member. And then Dr. Scott Laker is the current vice president of AAPMNR. And then Rachel Brackey is, was the program director here for the fellowship and is in leadership positions in AAPMNR. And then Ricky Singh is at Cornell and he's a vice chair there. And that's all I have right now, but I'm certainly happy to discuss more and answer other questions. There was the one other thing I wanted to add just while I have the floor here. The one thing that is a little different, you know, between like an ACGME program and like a NAS fellowship is there are some requirements that does need to be fulfilled for the ACGME programs in terms of types of patients you see and what you log. And historically it used to be a pretty onerous list where you even had to, you know, do 10 intubations and IV starts. And all of that has really gone away since about 2018, 2019. And really the requirements in terms of patient logs that you have to do for an ACGME fellowship now, a pain fellowship now, is really around getting, you know, 50 acute inpatient pain patients that you've seen and evaluated. There's 15 chronic inpatient pain patients that need to be seen and evaluated. And then there's 50 continuity clinic patients. So those requirements are actually pretty low and that does allow us to offer, I would say like a greater degree of flexibility than was historically part of ACGME pain fellowships. Everyone also needs to have some exposure to palliative care and cancer pain, but that's usually pretty easy to accomplish and is not something where you actually have to log numbers. There are not numbers that need to be logged for specific procedures. So we do do a lot of interventional procedures in our fellowship. Yeah, similar to what has been already described through HSS, but it's not like there's a quota that needs to be reached. So we really try to pride ourselves just on kind of comprehensive clinical education, but that does include a lot of interventional training as well. So I'll end there. Thanks for listening. Let me stop sharing. Thank you. That was wonderful. Thank you so much, Dr. Friedrich. At this point in time, I'd just like to open up to everyone. If anybody has any questions, Dr. Kirshner, Dr. Friedrich and Dr. Standart are here to answer all the questions. Sounds like Dr. Shivers, is that how I say your name? Oh, I say it's Shivers, but don't call me late for dinner. Okay, all right. Dr. Shivers, not late for dinner. Has also graciously joined us and sounds like he's open to answering some questions as well, specifically about the fellowship that he did. While we wait for some questions to come into the chat, I'll just kind of like, you know, ask some questions that I feel like the average person who may be interested in your fellowship or applicant may ask. You know, one question that I feel like comes up a lot for this fellowship is how important do you feel research is in your applicant's CV or in your applicants? I think that's, you know, unique to the fellowship. You know, we strive to have an academically rigorous fellowship. We also are trying to train academic leaders who are gonna have leadership positions, but also research positions and people who are gonna hopefully do bigger and better things once they leave our fellowship. So research is a requirement for all of our fellows and we would like to have them ideally have some experience coming in. You know, we're gonna teach our fellows kind of what they need to know, but it's nice to show that track record because past performances somewhat of an indicator of future return on like the stock market. So if you, you know, have a good research track record, you're probably gonna be, you know, ready, willing and able to do it as a fellow versus someone who has no research, maybe won't. Some programs are a lot more clinical and that's not a big deal. You know, we know it's hard to do like a large randomized control trial in one year. So we're looking for people at least, you know, that have written some papers or helped out with other studies, or at least help to devise a study, get an IRB going, even if it's not gonna finish. We always have, you know, I think about a baseball team, they're starting pitchers, middle relievers and closers. So we always have some fellows starting a project, someone closing a project and there's always research going on. So these are very competitive fellowships. You always wanna look for a way to stand out. So people who have a strong CV as far as reachers definitely stand out. I'll go. So our fellowship is fairly flexible, right? It really is designed for the strengths and interests of the person who wants to do the fellowship. Some things are essential, but there's a lot of flexibility in there. I'm really looking for people who are very intellectually curious and really want to be a leader in our field and a leader in healthcare in general and change the world a bit. We are an extremely large organization. We have a lot of people who are very, very, very, we are an extremely large research organization. We have one of the largest sort of research funding programs of human are in the country at Pitt. So there's ample academic and research opportunities in Pitt. Jim Eubanks, our current fellow, our fellow who just finished, just got on the phone too. So Jim was interested in research and did research and carried over a research project from his residency. We certainly support and encourage research, academic curiosity, intellectual curiosity is important. Yeah, but having done it, having, depends if you don't really want to be like, I am not a researcher. I have published well over a hundred papers of various sorts, but I've never written a grant. I'm not that type. We look at, but again, we're an academic institution like everywhere else. We're looking for academic people who are bright and curious and want to lead and take on the world a little bit. Great. Similar, yeah, I mean, similar concepts for the Colorado Fellowship. In terms of applicant pool, we are looking for somebody that's pretty well-rounded. And so, I mean, I guess to be totally honest, I mean, the research is just one component of like demonstrating some of that academic curiosity and demonstrating being able to kind of push a project through the finish line. It's nice when it is really pertinent to the field, but oftentimes in PM&R, you don't have complete access to every type of research project. And you might get involved with one that, maybe more brain injury or spinal cord injury or neuro rehab related. But if you've demonstrated a significant amount of involvement in that, and you have a track record of being able to kind of actually push a paper to completion, then that's just one, kind of that's one added benefit to your application compared to somebody that doesn't have that at all. In terms of the, within the fellowship itself, we have a scholarly activity requirement. I would say it's relatively soft. I think we used to be more strict about wanting each fellow to produce some primary data, and then now have kind of evolved into, trying to get involved with a project that produces data. It doesn't necessarily have to come to completion. It could be a review. It could be just a high quality QI project that produces some data and then gets presented, but it's definitely should not be defined in any way, shape or form as a research fellowship. That's just kind of wanting to generate some of the comprehensiveness of the training that we want to include in that. And so most of our research reviews comes by way of, you know, kind of regular journal clubs throughout the year, and then ultimately an eventual either research or quality improvement project presentation at the end, where the hope is that each fellow will have some data to produce. Great, great. Thank you so much for that. We do have a question. A question from our group here says, do the panelists have any insight into whether interviews next year, so this upcoming cycle will be virtual versus in-person? We're, for at Colorado, we're staying pretty much purely virtual at this point. With no plans in the foreseeable future to change that. Would ideally be in person, but because there are people you have to meet and places you have to go within the system. So it helps to have in-person, certainly happy to start virtual if that is the preference, but ideally in-person. Okay, great. Dr. Kershaw, I'm not sure if you heard the question, but do you know if like the upcoming application cycle, with the upcoming application cycle, will interviews be virtual versus in-person? Sorry for my technical difficulty, but we just had our interviews a few weeks ago. We were in-person. It's left up to the individual programs, whether it's in-person or virtual. Because we're not officially accredited, there's a little bit of flexibility with NAS. So some programs like ours do basically a half day in-person, what some people do is they require you to rotate for a day or two. Other places require you to rotate for a week. So yeah, for us, it's just an in-person half day interview, but we encourage people to rotate. You learn about us, we learn about you. I mean, the big thing is really about a match and a fit. There are a lot of great programs out there, but it's important to find what's right for the applicant. So, you know, some are more clinical, some more research, some more interventional, some less. Yeah, yeah, definitely. I always want that right fit. Another question we have from our group tonight is quote, I'm currently inquiring if training in doing minimally invasive spine procedures, e.g. Minuteman endoscopic spider interventions is being introduced to the pain or NAS fellowship training. We don't do that in our fellowship, but some of the programs do. We don't, yeah, we don't do that either through Colorado. Really, none of the tracks really do that. For us, the interventions for PMNR are most of the bread and butter spine stuff, and then actually more of a mix of sports-related procedures and ultrasound-guided procedures and more like traditional sports clamps. I mean, we certainly don't do that. I don't think anybody in our whole institution is doing that necessarily at the moment. Thank you. Another question I have, just, you know, from like the average applicant this year, some of the things you mentioned too was like, you know, with some of the interviews are in person. For some people, they get to do like a rotation with you during the day or work with you, because it's all about finding that good fit. Do any of you or your programs, or do you know of programs that allow residents to come do like an away elective with you or come get exposure or almost like an audition with you? We encourage away electives and we certainly accept people to do away electives. Right now, that's not something that's traditionally been done here. I'm honestly would have to talk with our program director and stuff to even see if that's feasible right now. But yeah, historically that's not been something that's done for the Colorado Fellowship. We haven't done that, but I don't know why we couldn't do that if somebody wanted to come and see what we're doing. Dr. Sandor, Dr. Kirshner, since you guys allow away electives and encourage them, how would like an applicant go about trying to get an away elective? Is your information on your website? How would they do that? For me, they just have to reach out to me. Okay. People can always reach out to me. My email is kirshnerj.hss.edu, but our coordinator, Deja, would be the one to help coordinate the rotation and her email is presleyd.hss.edu, but the information's on our website. Unfortunately, we'll have to fill out paperwork, show proof of immunization, et cetera. There can be a couple months lag time sometimes, so try to do that early. Great. That's awesome. Another question I have just from, once again, through the lens of someone who's thinking about doing this fellowship or possibly applying this year is, many residents come from different backgrounds. Some residents are at different residencies where they may not have the best exposure to spine, spine procedure, sports, or pain medicine. How would you recommend someone who's interested in doing your kind of fellowship, but hasn't gotten that exposure or wants that exposure? What would you encourage them to do? I don't wanna be the first one to always answer, but I also don't like dead silence, sorry, so I'll jump in, but it's a really great point. It's hard because a lot of people, depending on how your rotations are structured as a resident, may be very inpatient heavy first year, and so you're not seeing these things. We don't want anyone to violate work hours, but if you don't have rotations where you're doing some of these things that you may be learning in fellowship, spend vacation day or an elective day. Don't call out sick, but there's always time even to spend a couple hours or pick the brain of some of your attendings because there's nothing like living the day in the life of a patient. I mean, it's a very different practice doing things interventional versus not, seeing chronic pain patients versus not. So it's very hands-on, it can be very procedural, but not always. So yeah, you definitely wanna get hands-on in practice because you may realize it's not quite for you. Yeah, I certainly like and appreciate that answer too. I mean, ultimately, we're really looking for somebody in PM&R first and foremost. Ideally through your PM&R residency, you get your hands on some procedures, ultrasound, or fluoro, or just landmark-based. So you have some comfort level with that, but honestly, it's more the well-roundedness of the program, knowing that you're gonna crush the PM&R boards and do well with that. And then like what Dr. Kirshner said, having a comfort level with seeing difficult patients with chronic pain, sometimes like multiple in a row, to know that you are comfortable or interested in that and interested in the science of spine and interested in the science of pain is I think what's important. So it certainly is useful if you can get into a spine clinic one form or another, it does not have to be an interventional or a pain clinic necessarily. Yeah, I would tend to agree. I mean, it's part of the point of our fellowship is it's a huge system, right? And there are lots of ways, the healthcare system in general, and there are lots of ways of looking at this. And you got to figure out what you like and what you don't like a bit and what you're curious about. And you got to find your why, like why do you want to do this? Why do you want to do things? What is your, I guess, I've seen the Simon Sinek sort of TED Talks, but find your why, like what is it you really want, right? And then you kind of go chase that and get some information and find people who work in it and find people who love what they do and figure out why they love what they do. I'm a very rehabby spine pain person, right? I really focus on rehab. My practice is very more akin to, oh, I don't know, sort of overall wellness. So yeah, you got to find sort of where you want to be in that space and understand the space. And again, even in our fellowship that we, again, we send people all, the fellows go all over the place. They go over a whole system. They work with a whole variety of providers to really understand the system and the ecosphere and figure out where they fit in that and how they work in that and how they optimize their care in that. So the curiosity and that desire, the desire to be exposed and learn and really sort of be good at what you do is important, more important sort of where you were, frankly, for me. I just want to jump in on that real quick and kind of echo some of what Dr. Sander said. This is Joe Shivers, one of the fellows from Dr. Sander's program in Pittsburgh. I also trained as a resident with Dr. Friedrich in Colorado. And so the residency program at Colorado is certainly top-notch, but in terms of the spine and musculoskeletal thing, but I would say that some of the most valuable experiences for me now seeing patients with really difficult, painful, complex spine problems were the rotations in spinal cord injury and traumatic brain injury and amputation where it's trying to make the best of a bad and unfixable situation that people didn't want. And maybe it's their fault and maybe it's somebody else's fault and all of the complex medical and spiritual and emotional and cognitive factors that go into that and really trying to understand how to help people in that setting, I think was probably the best training I got in residency for the work that I did in the fellowship that I'm doing now. Yeah, I just want to say those are really phenomenal points. And we're a quote, interventional fellowship, but we're physiatrists first and foremost. What Dr. Shriver said is just so on point. I mean, we're treating complex people with complex problems and having that team in our background is really key. So we're, we're looking at that whole biopsychosocial model. We're making sure that you did well in your spinal cord rotation, your TBI rotations. We're not just, you know, a block fellowship. You're learning how to do procedures. The people who fail in our fellowship are people who just think they're going to do procedures. And that's what this, this field is. So even if you're only interested in procedures, you're going to be treating people and dealing with their families and the whole biopsychosocial emotional spirit, all that with the patient. So understand that, you know, there's no way to hide and just do procedures. That's interventional radiology. So, you know, we're, we're whole body doctors and there's a different flavor and style to how each of us are doing it, but that's really, I think the thread that binds us all. So great. Yeah. Second, that, you know, in rehab, you know, PM&R connections are so important. We're very lucky to have AAP hosting this, but in the spine world, are there any national like national organizations you would recommend that a resident join or someone who's interested in applying to your fellowship, join maybe to get exposure, more exposure, or make those connections or possibly find someone near them that they could rotate with or kind of take on as like a mentor. I mean, I recommend the North American Spine Society or NASC because they do recognize our fellowships and they're great organization interdisciplinary. So involving surgeons, radiologists, internists, chiropractors, and then the Spine Intervention Society or SIS is another good organization. Trainees can join for free and there's a lot of great educational materials, full disclosure. I'm one of the instructors for SIS. Risks in rehab is that we become sort of the other, right? That the spine community is really surgically driven when you go, who is the ultimate expert in spine? Almost every institution that defaults to the surgeons, be it orthopedic or neurosurgical, depending where you are. And they control hospital systems because they make so much money for hospitals. They control the systems much more than we do. And so I think it's important to really work with them and understand them and essentially be their intellectual and equal in terms of care. So I think NASC is helpful for that because it is multidisciplinary, but it's 85% surgeons, right? It's a very surgical organization. I mean, I was in NASC for many, many years and I was their health policy chair for a while, but a very surgical organization, but it helps you learn sort of what they do. And even if you, but then that's really where, you know, so much of care in spine is really driven by the surgeons because that really is where the money is. Like we only operate on two or 3% of people with spine problems. Most spine programs, if you go around the hospitals are run by surgeons, right? Cause they make it, that's where the money is. And you have to understand them and what they do and how they think and what they work and be able to talk to them and understand their language and know what they know. So that's how you get to be sort of an equal in the room, which I think is really important for you. Yeah, for me, that's why I personally in like, in you know, kind of post-fellowship career ended up gravitating towards NASC for that, you know, for that reason. And because there is just a small percentage of non-surgeons that are there, you can actually have a relatively loud voice through committees and through curriculum development there. I can speak for like recent fellows though. They've gotten a ton out of SIS. They've gotten a ton out of the educational offerings through SIS, at least once you're a fellow. I can't speak for how necessarily effective it is, you know, for the, you know, for the PM&R resident, but past few fellows have really taken advantage of SIS as kind of augmenting the education that's provided in the fellowship too. But I would just promote for when you are getting through this process and getting out there, if you are in the spying world, I would just try to get involved with a organization, you know, to get a seat at the table. Great. I have a question from the chat. This one's particularly for Dr. Friedrich. It's they, I think they started a little late. So I just wanted to clarify a question from your presentation. Do the anesthesia and the PM&R fellows that you accept go through different curriculums or different trainings in your fellowship? Yeah, there's, they're slightly different. It's, it's mostly about where your, where your home base is. And so the PM&R track is really their home base is the, you know, PM&R spying clinics, and then, you know, they'll spend more additional time, you know, in a kind of a PM&R musculoskeletal or sports clinic, and then just a limited amount of time, somewhat dependent on the interests of the fellow in terms of how much time they spend with an anesthesiologist. The so then the flip side of that is, is the anesthesiologist really stay with their home base anesthesiology pain, you know, clinic for the majority of the time. And then they cross over and join us for, you know, some PM&R clinics, almost, you know, kind of as a, I want to say, maybe 20% of their time with the PM&R folks. And then usually kind of once you get to six months in the year, it starts coming down to where do people's interests lie? You know, are there certain things that they're planning on doing for their career or job search, that they need to get more exposure for? And if there needs to be more crossover and stuff more after than they do, the curriculum is identical in terms of didactics and journal clubs. And the curriculum is identical in terms of, you know, taking some time with neurology and palliative care and, and psychiatry. And those are all, you know, fairly limited, just mostly like exposure based rotations, you know, where you just do, you know, a week or something like that. And then with the option of doing more, if again, if that's something that's of particular, really particular or strong interest for you. Great. Oh, yes. Thank you. And then another question from our chat is kind of a two-part question for, so for the non-HGMA accredited programs, do graduates, are graduates able to get privileges to perform epidurals, RFAs, etc. And then for the accredited program, do you offer any, well, you kind of answered this, offer strong ultrasound opportunities for those interested. So feel free to answer or not answer it since you kind of just said Dr. Friedrich, but I'll let the non-HGMA accredited programs go first. The privileging issue always comes up and it's a real potential issue as far as how often it actually happens. I'm not sure. We haven't had that issue for any of our fellows recently, although I will say I personally had that issue with myself getting accredited for certain procedures or privilege, I should say. So, you know, if you know you want to be in a highly competitive urban environment with a lot of academic centers, like a New York, Philadelphia, Los Angeles type metro area, then it's probably more important to be accredited. If you're going to be in a private practice or depending on the setting you're going to be, if you're in an underserved area, then I don't think that's as much of an issue. So if you know, if you have an idea of where you're going to practice, ask them locally, you know, what their preferences are. Everybody would love accredited folks, but I would argue you don't have to be accredited to be a good physician. That's a very complicated question and answer, but you don't have to be accredited. Some people are sort of intimidated into thinking they need to be, but again, it doesn't hurt to be accredited. It's probably an advantage, but it's not necessary. Yeah, my experience has been that hospitals, I mean, it's frankly, it's a political and economic decision whether you get privileges, right? If you are qualified and you were trained and you can demonstrate adequate numbers for whatever they require for numbers, and you are sponsored by your department or somebody else, and they need you to do this, they will accredit you. If there are competitors who don't want you in that space, it doesn't really matter how well trained you are, they won't let you in. So it's much more of a political sort of thing. And again, our fellowship is not intended to sort of make people into highly prolific interventionalists. That's sort of what we talk about a lot. How do we actually care for patients and what do we do? And what is, you know, we don't inject the vast majority of our patients. We track this in our clinics, in the spine clinic we run, I think 9% of our patients get some sort of injection. And I think that even includes peripheral injections. We just don't do it a lot. We really manage people comprehensively. And so that is the focus. Again, you could learn interventions if that was part of what you want to do, but that's not the focus that we do. But I think for your own sake, there's probably too much pressure to sort of get into a accredited program because there are lots of people out there doing injections who did not do that. They go train some other way. They go learn from NASA, they go learn from SIS, they go learn, then they talk to their hospital and they do them, right? I mean, these people, post-graduates will go learn. You don't need to have that for the most part, but you do need to think through like your setting and who your sponsor is and what the political environment is like when you're going somewhere. And is there room for you to do these procedures? Because some places are oversaturated and it doesn't matter, you won't get in. I would say for, you know, for our department, I mean, we have proof of not needing, you know, like, you know, faculty hires to have come from accredited programs. You know, oftentimes it comes from knowing who they trained with and what kind of skill set are they bringing? You know, are they bringing something that's new or unique or a niche, you know, to add to the department that we don't, you know, that we don't already have. And so certainly the department here, you know, the PM&R here doesn't need that. And once our department chair kind of ouches for you, there's not really been any issue from the, you know, from the hospital side in terms of performing these procedures. My first job at a fellowship back in 2011 was at Kaiser Permanente in Denver. And historically there, it was only anesthesiologists that did any floral-based spine procedures. And so I was the first one to come in and do those. And that did cause some friction. And because the PM&R hadn't been in that space before. And I think having the accredited fellowship for that location at that time mattered, but subsequent hires to the spine department there came from sports programs, from non-accredited programs. Like, you know, once you have that person who's already doing it and then can then vouch, then my guess is that in most places, it probably doesn't matter. It's just, if you're going to be the first one in an anesthesiology-dominated group, that might be a little bit challenging without a pain accreditation. Yeah. Great insight. Another question we have from the group, how do you advise applicants that are deciding between applying for NASP or ACGME pain fellowships? A question that comes up every year. You have to ask yourself, you know, what do you want to do day-to-day? What sort of patients do you want to see? What sort of pathologies do you want to deal with? Some of the NASP programs are more, you know, very spine heavy. Ours is a mix of both spine and peripheral MSKs slash sports. We do a lot of ultrasound, a lot of peripheral joint pathology. We do a lot of radiology interpretation. We do electrodiagnostics. So there's definitely a gamut. I don't want to stereotype and say pain fellowships don't do that because I know Dr. Friedrich's program does. So I'll let him speak to that. But, you know, historically, they're sort of, do you want to do spine only versus other peripheral stuff? But now even those lines are getting blurred. Yeah. I think this is a really hard question and it's really hard to advise even our own residents who are applying to this. You know, I think in most cases, our fellowship at Colorado probably looks more like a NASP sports and spine fellowship for the PM&R person, honestly, overall. But you're not necessarily going to get that across the board with pain fellowships. A lot of pain fellowships I'm aware of are going to be more structured rotations, like X number of months on acute pain service versus a cancer pain rotation. Depending on the size of the fellowship, everybody just kind of rotates through that process. Whereas here, it's again, it's a lot more spine specific and then some sports. I mean, historically until I wouldn't say maybe in 2013, there was a change. We did enough sports medicine that you'd actually could sit for both the sports and the pain boards. When sports became an official subspecialty of PM&R and had its own fellowship tracks and stuff, then that ability to do that went away. And once we established more of a true accredited sports fellow here, a lot of our sports coverage opportunities for the pain fellow kind of naturally went away because it's kind of all gone to the sports fellow. But the culture is still embedded in there where you do some general, more general MSK in sports as part of the pain fellowship. But I don't think you could count on that at most ACGME accredited programs. And who knows, it may for us, may get increasingly hard to maintain that flexibility over time as there's potentially more accreditation changes that unfold. We are really at the mercy of people in the ACGME who set the rules and the standards to make sure we meet those requirements. Good points, good points. Another question we have from the group chat is this one's particularly for Dr. Stannert and Dr. Kirschner. Have any of the fellows that have graduated from your programs obtained an academic job or gone into academics? Yeah, both of mine are on the phone and both did. Dr. Eubanks is on the phone also. He could describe his job, Joe can describe his job. Yeah, we are an academic space and we want academic, curious, intellectual people. And by academic job, there are lots of ways to look at that. I consider myself in an academic job. I do not apply for grants and I do not get grant-funded research. I just don't. But anybody who's met me, who's talked to me, who knows me, Jason's known me for a very long time, I am a very academic person. And I work in an academic department, but there are 10-year track academics who are trying to get grants and spending the vast majority of their time researching and trying to get tenure in your organization. And they're non-tenure track academic people at most places. Where you're in an academic environment, which is just, I was private practice for 10 years too. It's distinct from private practice, right? In academic setting because there are other things about it. But yeah, like I said, both of our fellows are in academic setting. Every one of our fellows that wanted to have an academic position has obtained it. So we're very proud of that. And you can be in private practice and do academics. You could be in an academic setting and be pretty non-academic. You can do an ACGME Payne Fellowship and not be academic afterwards. So it's really about the person and what they want to do and not the piece of paper behind them. And think about the skills you want to learn that are going to be helpful for your future practice. And those are the kind of skills you want to acquire during your fellowship. Do you at your fellowship, or do you know of any other fellowships that sponsor visas? Yeah. Are your fellowship for others? We do. Our institution does as well. Yes. I want to say I've mixed reports on that because we have run into certain types of visas where I guess the university doesn't sponsor it. But I think it's really case by case. But unfortunately, I can't answer in like as strong of an affirmative that the other two have answered out of my control. But yeah. Yes. OK. Another question from the group chat. Do you heavily put weight on SAE and USMLE while selecting applicants? We use it as a factor to screen our applicants. And we've found some correlation with certain aspects of being a successful fellow. But there are certainly many other aspects. So we look at the whole application in its entirety, that being one aspect. I would just say it's probably a flag if somebody does really, really poorly or fails. So it is a rough screen. We have a small enough specialty that usually a little more weight is put towards where are people training, and who are they training with, and who knows them. And then they're kind of more global performance. But I'm not going to lie. You do want to do well on your exam. OK. Another question from the group. The question is this. Could you speak about the balance of clinic versus procedural time during the year, and then the balance of spine versus peripheral joint pathology that fellows typically see during the year? I'm just thinking about the breakdown really. I would say my rough estimate would probably be about 60% clinic time, you know, like clinical evals and then maybe 40% on interventions and then within that 40%, I would say probably 80% spine, 20% peripheral and then a mixture of EMG nerve conduction studies. So it's not a requirement that people do EMG nerve conductions, but generally it just kind of naturally happens in the clinics that they're rotating through that they'll do some of those. The way our clinical structure works is we, the fellows usually do a half day to a whole day of procedures per rotation. So that would put them at 10 to 20% of their time is doing procedures. That's for our special procedures unit where we do the spine procedures. Then we do peripheral joints within our regular clinics. So we probably do 60% or maybe yes, 50 to 60% spine and then 40 to 50% peripheral joint. So our fellowship is, it's very flexible. It depends a lot what the person wants to do. They probably average about half their time in the clinic seeing comprehensive spine, MSK care, more spine than sports, but then they rotate everywhere because they want to go to hip surgeons or knee surgeons or foot ankle people or whatever they go there. And so they can do joints and other pieces and parts of what they do. Both of them have done sort of almost like a mini EMG fellowship in the midst of it. They go to radiology almost a half a day a week on average about maybe five or 10% of their time is with radiology throughout the whole year, learning how to read films. I think you really have to be good at radiology to be competent. So we have our fellows spend a fair amount of time with our radiologists over the course of the year, really learning how to read. Personally, for your own thing, I spent the first 20 years of my practice going to radiology every week, having them reread every single MRI I ordered every week for 20 years. That's how I learned how to read films. And so I think it's critically important, but that's part of it too. And then there are other things that they can do. I think Joe did some work on spasticity stuff. Jim did do some injections of, Jim did some research stuff. And then again, there's a 20% or so where you're really working with the health plan, which is all non-clinical, no patients, obviously. You're in the health plan and understanding operations and finances and where things are going. And I would add back to some of the other questions, like that issue of the why, of what you wanna do, what you wanna be, what really drives you is what you should be thinking. For people thinking purely economically, I don't think any of us know what the hell healthcare looks like in 10 years. I don't think it's gonna look like it looks right now. I think value will be far more important is why we built our fellowship. I think there's a lot of pressure on the interventional community to do less because the data is not robust and the payers don't like it and they don't like paying for it. And so there are all these driving forces around things, but somewhere in there is you really gotta love what you do every day. If you love what you do and you can do a decent amount in your work, you will be happy doing what you do for your whole career. If you just chase something but you don't really care for it and you just sort of think that's what you have to do, you risk being in that 40% that are not very happy with their jobs. I am not one of those. I like what I do. Good, that's great. Another question from the chat, two part, two sort of three part question we have here. So what are the major things that NAS programs look for in your application? So what bears the most weight, research, volunteer, letters of rec, et cetera. Then how many letters of rec do you need for the application and who should they come from? Do they have to be all pain slash spine people? So again, we're looking for the whole application, just like Dr. Friedrich said, where the patient, where the patient, sorry, where the applicant trained, how they did on their other rotations. I look at your spinal cord rotation or TBI. If you didn't do well there, but you have all A's and all-star interventional stuff or spine stuff, to me that's a red flag that you're not focusing correctly. So we want well-rounded people. Same thing with research. We want people, the purpose of research is to show that you can get a job done. I care less about, is it actually spine or MSK related? Obviously that's helpful, that's a bonus, but someone just who has the experience of going through the research so we know what they're doing. I can't speak for the other NAS programs. Some are just purely clinical. They want someone who's already done procedures and they can just hit the ball, hit the ground running. We don't expect anyone to have done any spine procedures before they joined our program. So we want the basic tools so that someone's teachable. They don't need to come in already knowing that stuff, but some programs want that. And as far as letters, we want people that can attest to your quality as a physician, as an individual, your character, your eagerness, willingness to learn. So again, that could be a TBI attending, a spinal cord attending, doesn't have to be a MSK spine attending. That being said, you should have at least one, ideally two letters from someone in the field just because it's a small field and a lot of us know each other. And so if you have a recommendation from a certain doctor that we know that carries more weight. I just want letters from people who believe in you and can attest to you as a person and a learner and a leader change agent type. The field doesn't matter. So the space doesn't matter so much. Like I said, it's not that big a field. A lot of us know each other. And so it's, if you're coming from most institutions, we'll find somebody who knows the person who wrote your letter. So it's not too hard. But somebody who believes in you and understands you and can speak to your qualities as a person and clinician. I would agree that, you know, you look at hundreds, hundreds of letters, recommendations in this process and you get really tired of the generic ones. And so I get it. I agree. I think it's really good to have one letter from a spine or pain provider, but it's much more important that you have somebody who can speak to your kind of unique characteristics because those are the ones that are kind of easier to keep reading. Yeah, very, very good points. Question from the chat, for the application process, do most programs use a rolling system so early applicants are favored or do most work like towards their deadline to review and it's better to maximize, you know, experience, exposure before applying? In the old days, there was rolling admissions and there was competition sort of for the higher quality applicants or the more desirable applicants, I should say. And so for that reason, NAST decided to go to a match program. So I highly, highly encourage people to make sure your application is complete before submitting it. You can add addenda to it, but a lot of us kind of go through the applications once and that's it. So put your best foot forward, gather all your required information, know when your deadlines are. Different programs have different policies, but, you know, we have an application deadline. After the deadline, I review all the documentation and then we offer interviews based on that. Some places have limited interviews and yes, once those slots are gone, there are no more. That's not us. We're like that. We wait until probably March 1st to start reviewing applications. So no interviews are offered until, you know, all the applications are reviewed. So we just do it in one massive bunch. So, you know, you're gonna get the same look whether or not you submitted in December versus, you know, February 25th. Ours is a very personal process. You spend a decent amount of time working with a small, you know, you see a lot of people and Joe and Jim each worked with 50 or 80 people through their residency, but you spent a lot of it with a few of us. And so when we find the right person, we find the right person. That's the way it works, right? And so we have one. And so it's a unique thing. We're the only one in the world that's the way we find the right person. We found the right person, we're done. So that's the way it sort of works. It's not a, we're not part of it. We're not part of the match of NAS because we're not so interventionally focused that if somebody really wanted interventions and got matched to us, they wouldn't, if that's what they wanted to do with 90% of their day, they would not be happy. So we can't be in that match because we're not gonna balance out very well. Yeah, so it's about the right person. And so the sooner, the better. Yeah, a question from the group. Are fellowships looking for geographical ties? I imagine this question is like geographical ties, like in the applicant applying to your program. I can say, I've heard this from the interview trail. And when I was applying and interviewing, some programs actually don't want people who are local because they were afraid you're gonna compete with their job. We work in New York City where it's already pretty saturated competitive. So we have no geographic preferences whatsoever. We wanna know that if you're gonna match, you're gonna come to us, but we don't care about geography. We would ideally like people who wanna stay with us because you really build an incredible structure around you of people to work with. So, but that's, it depends what people wanna do. Depends on the person. Change the world a bit. We're very much case by case where we've had so many, so many graduates either from our residency or fellowship that have stayed on as faculty. I would say like overall, it's probably ideal to actually have somebody come here from somewhere else to train here and then go back to an institution somewhere else just to kind of help spread the kind of name for University of Colorado around the country. But that being said, if it's the proof's in the pudding, if somebody is a good candidate and they wanna stay in Denver, most of the time that works out and kind of they find a faculty position here. But we don't look at geography as a means of deciding who we interview or who we select. Great. And then is a program director letter required for the application? I believe it is for NAS, but I don't have the exact requirements in front of me. I mean, it's nice to have a program director's letter because hopefully they would know you well. And I suppose it could be a red flag if you don't have one, but I would defer to the NAS website for the exact requirements. I don't wanna tell anybody the wrong thing. I think for ACGME, it is required. I mean, I can't think of somebody that didn't have a program director letter. I don't know if that's in our requirements or not. That's from the program director. I don't think so. Again, very personal process. Okay. And then this question's kind of for the recent, maybe the recent fellows, maybe more than the recent program, or the current program directors, my apologies. Is there a Reddit spreadsheet like there was for residency for these fellowships? Or maybe the program directors do know of it as well. I can speak for ACGME. My fellow from this most recent year alerted me to it and showed it to me. And so there is something for ACGME paying fellowships. I mean, the information on there is not always 100% accurate or trustworthy, but I mean, it's reasonable, as a way of starting to try to differentiate programs. I think the challenge is for like a program like ours that has a few different tracks, what may be true of one track may not be completely true of another one. So you have to take it with a little bit of a grain of salt, but you can get a sense of like, if you are a PM&R applicant and you are dead set on doing a massive number of stimulators, or you wanna learn intrathecal pump placements, University of Colorado is probably not the best place to come. Like you probably wanna go to more of an anesthesia based pain fellowship, where you know they're gonna have a high volume of stimulators and pump placements and other advanced pain procedures, such as those other implants. Just to answer the question as one of the recent graduates, Jim Eubanks is extremely good at being aware of the field and sort of the people in it. And I think he dropped his email in the chat. He was the one who just graduated from Dr. Standard's chat. I am not very online and did not apply to ACGME or NASS fellowships. And so can't speak to that as well, but would also echo Jim and say that I'm extremely happy to speak about our unique opportunity at Pittsburgh. And I will drop my email in the chat as well. Thanks everybody. Thank you, that was super generous of you. Thank you so much. Any other last questions from our group? Feel free to turn on your microphone, turn on your video. Great opportunity to get some face time with some amazing program directors. If anybody's interested in asking any other last minute questions, I'll give you about 23 seconds. Hey, can you hear me? Yes, yes, Brian. Yeah, feel free to ask a question. Yeah, not brave. My keyboard's not working. But I'm just starting out in PGY2 at Burke and I'm kind of like navigating this all throughout these years, figuring everything out about medicine and now physiatry. Really interested in like sports and sports and spine, learning about that now. But for a question for all y'all, since you guys have already done a lot of it and you kind of like excelled in your fields, what would you recommend for someone like me being in PGY2, what I should focus on and what I should start looking towards and how I should start building myself appropriately so that not just to look competitive for whatever fellowship if I decide, but also as a physiatrist for my patients. If you guys were back in, I had a time travel machine to come back. I personally think very strongly, you have to learn how to be a physiatrist and what that is and what that means. That's what differentiates you from an anesthesia pain person, from frankly a surgical PA, right? Like we're non-surgical sports and spine people, right? Why are we different? What is it different about you? It really is being a physiatrist, that rehab component, that understanding adaptation to injury, reconfiguration of lives, functional biomechanics, how people move, how they do things, how they function, right? And gait and biomechanics through your amputee rotations and understanding neuroanatomy and adaptation to your spinal cord rotations and really understanding the passion for being rehabbed. Be a good, well-rounded doctor in your field so you know, and then when you go do something, you'll be good at it and you will differentiate yourself from the people who are not physiatrists. But you can't, I don't think you can do a good job with spine MSK care if you blow off your spinal cord and TBI and you think it's irrelevant, right? If you can sit in a room with somebody who injured their spinal cord two weeks ago and you can go through their life and over the course of four weeks, you can reconstruct it so they actually want to go home, build their lives back and get better, you can take care of back pain. If you can't do that, you really can't take care of really complex back and sports and musculoskeletal injuries that are life-altering, right? Because you have to be able to do that. But if you can do that conversation, you can do what I do, right? But you gotta be able to do that. So I take it seriously is what I would take every piece of what you do seriously so that you can really learn what you need to learn from it, right? Whether it's what you love or not, understand the passion of people who are doing it and take that from it so you become, you know, I think so from my standpoint, part of what we want is people who want to change the system and change the world. And what I told Joe and Jim and everybody else who talks to me about is you cannot do that if you're an excellent, if you're not an excellent clinician. If you're a really good clinician, people will listen to you and you can change the world around you. If people don't think you are and think you're more of sort of a, you know, just trying to make the money and go home and do whatever, you can't change anything. You can get your job, but you can't, nobody's listening to you, right? You gotta be a good clinician. So absorb it all, that's what I would say. Take it seriously and absorb it all. Amen. I want to do Dr. Standard's fellowship after that. I mean, that was a phenomenal answer. I mean, absolutely. You gotta be a good physiatrist. It's about how to handle problems and spine problems, MSK problems, it's the same problems as spinal cord injury, TBI. So you have to be able to take care of people with complex issues, with a family, with spouses, you know, who had a bad day and still have to go to work. So, you know, immerse yourself in whatever you're doing, but at the same time, get the experience so that you are exposing yourself to different aspects of PM&R, if you're only say inpatient-based or only seeing a few, you know, a narrower slice of it, just so you can get exposed to more things and, you know, find a mentor, a local mentor, someone, you know, through the AP program, maybe outside of your institution. They don't necessarily have to be in the same subspecialty, you know, find senior residents as mentors as well, because really getting the advice from others is going to help you out, help me out a lot. I, yeah, again, I mean, I had the opportunity to work with Chris Standard in residency, and so I can't speak to it as eloquently, but I certainly still agree with what I learned from him then and now. And I guess I, you know, I think you don't necessarily recognize how important all of your rehab rotations are, like, until you're actually in practice. You might not even realize it in fellowship, but then once you're in practice and, you know, sometimes a little bit on an island, then you often will reach back to, you know, non-spine rotations to figure out how to manage somebody. And so I really, we really look hard for that, honestly, in even the application process. I know it's not always easy to tease out, but we're really looking for somebody that has, you know, demonstrated high performance or maybe, you know, a letter from, you know, a non-spine or non, you know, pain person that really showed that you, you know, really cared and performed well. And the concept of differentiating yourself in practice, I think is really important. You don't, you want to show your worth to the patients and to the hospital system. How do you differentiate yourself from an anesthesiologist? How do you differentiate yourself from a, you know, even from a primary care doctor for that matter, or an interventional radiologist? There are so many different people doing different kinds of spine treatments, and you want to really know, you know, what your value is and be able to talk kind of confidently about it, even if you're with a group of surgeons. Really appreciate the answer, guys. Now I'm gonna take all that in and bring it forward for the future. Okay. Great answers, very inspiring. Thank you so much. If there aren't any other questions, then I just want to take a moment to, you know, begin the close for our session here. I just want to, like I mentioned, take a moment to just sincerely thank Dr. Friedrich, Dr. Standart, Dr. Kirshner for joining us, and also so cool that Dr. Shivers and Dr. Eubanks could join us too as recent grads of these amazing programs. Thank you, everyone, for joining. Thank you, everyone, for all you do, and thank you, Jewel, for helping get this wonderful opportunity organized and set together. Friendly reminder that we do have our spinal cord injury session coming right up, so be on the lookout for that email coming in the future, and let's give a virtual round of applause to our speakers, and have a good night, everyone. Thanks. Thank you. Thanks, everyone.

pain fellowship programs

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interventional spine

musculoskeletal medicine

clinical rotations

residency training

ACGME accredited Multidisciplinary Pain Fellowship

curriculum of pain fellowship programs

HGMA accreditation

application process