Pain Fellowship or Just Painful?

I became interested in pain management as a medical student. After looking into the subspecialty, I realized that neurology, anesthesiology, psychiatry and PM&R could all qualify for subspecialty certification. I thought PM&R would be the best fit for me, with its training in musculoskeletal medicine.

It seemed so simple then, but that changed when I began the application process several months ago. Deciding where to apply was the first step. At first, I planned to apply only to ACGME-accredited fellowships, so I could sit for subspecialty pain boards if I wanted to, and as a precautionary measure against some fallout down the road (Read: Will hospitals credential me and will insurers pay?) When I looked into the fellowships, however, I learned that there were only about a dozen PM&R ACGME-accredited pain fellowships, but over 90 anesthesia pain fellowships.

What is the difference? In some cases, not much, but in others the discrepancy was significant. To start, the application process was more extensive for many of the anesthesia programs, requiring a dean’s letter from medical schools, medical school transcripts, United States Medical Licensing Examination (USMLE) transcripts, as well as supplemental applications ($$$). Bear in mind, there is no match, so you have to apply to every program individually. Some PM&R pain programs were very similar to the traditional anesthesia programs in training (acute/postoperative pain, multidisciplinary chronic pain, cancer pain), while others were very interventional. Some incorporated EMG while others did not.

Next, I began looking into PASSOR-accredited fellowships, which seemed to be more in tune with some of my practice aspirations (sports and interventional spine). Most of these, however, did not allow me to sit for the subspecialty pain boards through the American Board of Physical Medicine and Rehabilitation (ABPMR). Further, as I interviewed, I came to realize that some current PM&R pain fellowships would likely no longer be ACGME-accredited in the future due to the recent changes in the ACGME pain fellowship guidelines. Yet some of the PASSOR-accredited programs would qualify one to pursue certification via the American Board of Pain Medicine (ABPM), a non-ABMS subspecialty certification.

In the end, I applied to several ACGME-accredited pain programs in PM&R and anesthesia as well as several PASSOR-accredited, non-ACGME accredited programs. The interview process itself has been great, as I am getting to see a variety of programs. While there does remain some bias against nonanesthesia residents from the anesthesia pain fellowships (even in the midst of the new “multidisciplinary” environment), there are many programs open to nonanesthesia residents. The interviews add up financially (not to mention finding coverage, etc.), and after several months already and several programs left, I am burned out. There is no formal match process, so the programs are on rolling admission basis, with some making offers in the late summer and others in the fall and winter.

Is there a right answer about ACGME fellowships, and does it even matter? There is no consensus. Some say to go where you will get the training you want and don’t worry about the rest while others still push the ACGME-only paradigm. It does seem that the number of applications for pain and musculoskeletal fellowships is up this year, and that this will likely be a continuing trend (one ACGME PM&R pain fellowship reportedly received over 100 applications for one position). The scope of this narrative is too limited to completely address the breadth of this topic, but it will continue to be a controversial subject until we receive further guidance from our leadership.

Greg Moore, MD
University of Virginia
gm4h@virginia.edu