The Ins and Outs of Fellowships From a Fellowship Director

To help residents answer some of their questions about fellowship, RPC President Ai Mukai, MD, recently spoke with Michael Furman, MD, director of an ACGME-accredited pain fellowship in York, Pennsylvania, and member-at-large of the AAPM&R Board of Governors.

How should residents decide which fellowship to go to?

Well, you should ask yourself, “…what is my vision, where do I see myself?” The gut approach would be to do an ACGME-accredited fellowship, but the real question is “Where will I get the best training to do what I want to do?” You should go where you’re going to be best trained. Ideally, it should be ACGME accredited as well. However, if I personally had a choice between the two, I would rather be well trained than well “papered.”

So is ACGME accreditation really important?

Training at an ACGME accredited fellowship implies that your PROGRAM meets a given set of standards. The misinformation out there is that if you don’t get trained at an ACGME-accredited program, you can’t do procedures, and that is not accurate. Individual hospital credentialing committees are the ones who determine whether or not you can perform procedures. A lot of these committee members don’t care about ACGME accreditation. They just want to know that you are well trained.

Another concern some residents have voiced is whether ACGME accreditation matters in a malpractice type situation.

First of all, you hopefully won’t have a bad outcome, because in a fellowship, you’ll get a lot of experience and learn how to avoid the common pitfalls. I think as long as you have the experience to do a procedure, and you trained in a fellowship, the accreditation status of the fellowship doesn’t really matter. Where you will get in trouble is if you don’t do a fellowship or you just go to a weekend course, and the first patient you perform a procedure on has a bad outcome.

There seems to be a lot of emotion and confusion among residents about this topic. Not many residents seem to know all the factors you talked about.

Unfortunately, there are a lot of Web-based forums that put out too many opinions of a few very prolific individuals that may or may not be right. There are things on those forums that are totally based on hearsay. Examples include unsubstantiated listings of the “best” residencies or fellowships. When I’m asked about fellowships, I only know about the one I personally went to and the one I run. You really need to speak to the current and past fellows who trained there and more importantly make sure that they are trained to do what they (or you) want to do. I know people who had to do more than one fellowship, because after their initial fellowship, they realized that they weren’t trained to do what they wanted to do.

Some residents are even confused about the difference between pain, interventional pain, spine, musculoskeletal, and sports.

That’s because the lines are gray. A pain fellowship that is ACGME accredited starting fall of 2007 will need to be multidisciplinary. You’re going to work with all the different aspects of pain including interventional procedures, cancer pain, inpatient pain, potentially be running PCA pumps, seeing chronic pain patients, and managing their medications. Interventional pain is only part of that. A fellowship in interventional pain, which is really interventional spine, is focused on treating mostly spinal disorders. If it is not a multidisciplinary program, it will be unlikely to maintain ACGME accreditation. Prior to the “ACGME rage” physiatrist were satisfied going to (non-accredited) musculoskeletal or sports PM&R fellowships to hone in on their musculoskeletal skills. Now that there has been approval for PM&R-based sports fellowships, I anticipate that a lot of physiatrists are soon going to consider training at ACGME-accredited sports fellowships (once they develop), where they are going to learn more musculoskeletal care, which includes non-operative spine care. I’m not saying that’s going to give them the ACGME pain piece they may be looking for, but that may be the way more physiatrists will ultimately go in the future.

What about the announcement by ABPMR about the three new subspecialty areas of certification (hospice palliative care, sports, and neuromuscular medicine)? How will that affect this whole picture?

The subspecialties are ways to refine your body of knowledge. These should not be misperceived as only a way to get better trained to do particular procedures. If one of these subspecialties “turns you on” and you want to become an expert in that field, you should contemplate the additional training. However, don’t seek the additional training only because you “heard” that it will be easier to do a particular procedure with the associated “piece of paper.” For example, you don’t need to do a neuromuscular medicine fellowship to become an expert in electrodiagnostics.

What do you see in the future for PM&R?

As you know, we are discussing this very issue at this weekend’s strategic planning session (of the board of governors of AAPM&R), and I clearly don’t have a crystal ball. Everything you have asked about is in the back of all of our minds. But I see all of these issues as challenges and opportunities. I see physiatrists being leaders in the management of musculoskeletal and other disabling conditions. You may see less PM&R influences in the pain fellowships temporarily, but we will end up rebounding and adding a lot more PM&R influence in the pain world. I also see the sports fellowships as another avenue through which we can make a bigger impact on musculoskeletal care.

There’s a perception among some of the residents that the leaders of the specialty of PM&R has “missed the boat” on this whole ACGME pain issue and that the leaders are really not in touch with our needs. How do you feel about that?

The subject of ACGME pain fellowships becoming multidisciplinary was discussed at the recent Residency Review Committee (RRC) meeting. The four RRCs (Anesthesiology, PM&R, Neurology, Psychiatry) made the changes in the subspecialty training requirement with the Anesthesia RRC being the driving force. Although this was an ACGME activity, the three boards (ABPMR, ABA, and ABPN) were informed and agreed. I acknowledge that I, personally, was disappointed by the recent move that may potentially make it harder for physiatrists to get pain training. But I would suggest that everyone go out and get the best training they can so they can provide the patients with outstanding care, whatever care the people reading this article want to provide.

Your Academy’s Board consists of many individuals who are much younger and “in touch” than people perceive. There are also many members of our board who at one point were PASSOR Board members. What we are struggling with right now is actually the perception by some Academy members that we are moving too quickly towards more emphasis on musculoskeletal care. We want to represent all Academy members. We’re trying to be a quality organization for all physiatrists and their patients with disabling conditions, and those disabling conditions can be acute, subacute, and/or chronic, musculoskeletal, or neurorehabilitation. We are trying to be proactive and not reactive.

Shifting gears, as a fellowship director, what kind of things do you look for in an applicant?

As physiatrists, we are team players. I’m looking for someone who is a team player, who has the smarts, and is a hard worker. I want someone who is as passionate about what they are doing as I am. A good applicant will have letters of recommendation from not only musculoskeletal people but from everybody saying “…this is one hard working, caring, team player.” If you decide to start being that way when you are applying for fellowship, then it’s too late because those letters of recommendations are really what I look at first. My advice to you PGY1s and PGY2s is work hard in all of your rotations. I want someone who is fun to work with and never makes me feel like I’m asking them to do something that’s below them. We want someone who will help me enjoy my job.

Any other advice for us residents?

Hopefully, during residency or fellowship, you are going to have one or more mentors who are going to teach you, guide you, and inspire you enough to emulate them and follow in their pathway. I know it sounds trite, but a positive attitude transcends everything. If someone enjoys going to work, everybody wants to be with him or her. We have three attendings and four fellows. What’s always comforting to me is when one fellow says to another one, “what can I do to help you?” versus “that’s not my job.” Ideally, this team approach should be present among residents as well.

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