As an emergency physician 8 years post residency, I resigned my position as emergency medicine attending to become “house-staff” again and do a fellowship. I did not do an emergency medicine fellowship, but instead an ACGME-accredited pain medicine fellowship, at Albert Einstein College of Medicine/Beth Israel Medical Center Program in New York City. Yes, the same type of fellowship that anesthesiology and physical medicine and rehabilitation (PM&R) residents apply for. Unlike traditional emergency medicine fellowships, a pain medicine fellowship gives one the chance to expand one’s skill set outside of traditional emergency medicine and practice options out of hospital-based medicine and into the outpatient setting as a subspecialist.

Most emergency physicians are not aware they are potential candidates for such fellowships. Though pain medicine is officially a subspecialty of only anesthesiology, PM&R, neurology, and psychiatry, no specialty is excluded from applying for and completing a 1-year ACGME-accredited pain medicine fellowship. Upon completing the fellowship, one is eligible to take the same pain medicine subspecialty American Board of Anesthesiology exam that fellows from other specialties take. For emergency physicians, one typically registers for the exam through the American Board of Physical Medicine and Rehabilitation. This allows one to be dual board-certified in emergency medicine and pain medicine by the American Board of Medical Specialties, as I now am.

While working in the emergency department, I saw many patients who suffered needlessly, not having access to proper outpatient pain care. Also, I learned that with a wider array of skills applied in the outpatient setting, I would be better able to treat chronic pain patients effectively, beyond just acute pain treatments in the emergency department. As I read more about the specialty of pain medicine, I learned that there is much, much more to the specialty than just pain “medicine.” There are many modalities and disciplines pain physicians use to treat pain, including a wide variety of procedures such as epidural steroid injections, radiofrequency nerve ablations, fluoroscopic-guided joint injections, sympathetic nerve blocks for conditions like RSD, botox injections for migraines, kyphoplasty, and surgically implanted spinal cord stimulators, to name a few. Also, modalities such as physical therapy, psychotherapy, NSAIDS, topical analgesics, and other non-opiate adjuvant medications can be effective.

For someone who enjoys helping patients in pain who are truly suffering, the field can be very rewarding. I am reminded of a patient I treated with severe and debilitating chronic radiating buttock and leg pain. He was referred to me, having had intense and disabling pain for almost a year, even after spine surgery, analgesics, and spine injections had failed. With one fluoroscopic guided pyriformis muscle injection, his disabling and life-altering pain was nearly gone. Three months and a second injection later, he still feels dramatically improved and is requiring little, if any opiate analgesics. I am also reminded of another patient who cried tears of joy after she felt her disabling foot and ankle pain from RSD/CRPS melt away for the first time in a year, after a lumbar sympathetic nerve block.

Chronic pain can be very challenging to treat at times, especially in a busy emergency department. However, such treatment is much more effective when one is able to focus on it full-time in the outpatient setting.

One stark difference between emergency medicine and pain medicine is the difference between hospital-based rotating shift work, versus an outpatient setting with a set schedule. Furthermore, one may choose from such varied practice settings as solo private practice, single-specialty group practice, multi-specialty practice or hospital-based employed practice. With such training, one option is to work full-time as a pain physician. Another option is to work a mixture of clinical pain medicine and emergency medicine. Yet another option is to continue primarily as an emergency physician, bringing techniques learned in fellowship back to the specialty, possibly in an academic setting. Doing such a fellowship doesn’t require trading one specialty for another. It gives one two specialties, and makes one dual board-certified, increasing one’s options.

I feel that emergency physicians are very qualified to pursue such training. More than 70% of the patients that one sees in the emergency department have a chief complaint of some type of pain, with at least 40% of them having underlying chronic pain conditions.¹ The portions of anesthesiology that are relevant to the subspecialty of pain medicine overlap greatly with emergency medicine. Consider the anesthesiology-based skills that the ACGME requires non-anesthesia applicants to pain medicine fellowships to learn. They include placing 15 peripheral IVs, intubating and BVM ventilating 15 patients, performing IV sedation on 15 patients, BLS and ACLS certifications, and learning how to perform at least 15 epidural injections. The first four are second nature for emergency physicians. The fifth is a technique that can be easily learned by someone with the procedural skills the typical emergency physician has in abundance, especially in a proper fellowship where he or she will have the opportunity to perform hundreds of epidural injections. A sample of other requirements are to be able to perform a neurologic history and exam, musculoskeletal history and exam, psychiatric assessment and mental status exam, and read 15 spine CTs or MRIs.²

Considering the current epidemic of prescription opioid drug abuse, emergency physicians have a unique perspective on the adverse effects of abused and inappropriately prescribed pain medicines. They are on the front lines of treating and resuscitating patients who have overdosed on prescription pain medicines. For this reason among others, having more emergency physicians pursuing pain fellowship training would be an asset to the subspecialty of pain medicine. Emergency physicians have other skills to bring to the field, including skills in ultrasound, with many pain injections now being done with ultrasound guidance, and airway and resuscitation skills, which are important particularly when doing invasive procedures and those that require sedation. Also, focused orthopedic, neurologic, psychiatric and mental status exams are part of an EPs repertoire, which is an invaluable base to build upon for someone learning to specialize as a pain physician.

Since such fellowships are very competitive, it would be wise for an applicant from an emergency medicine background to cast as wide a net as possible. Beginning this year there is an application match, but some programs may not participate and may continue to require separate applications, which can make the process laborious. The odds of obtaining a fellowship position are long, especially for non-anesthesiologists, let alone one from none of the four official parent specialties of pain medicine. Despite this, several emergency physicians have attended fellowships and passed the pain subspecialty board exam. I know of at least one on faculty of the Pain Department at a very prestigious institution with a pain medicine fellowship program.

Something to consider before applying for a fellowship would be to attend a procedure course where introductory pain procedures can be learned (www.asipp.org/meetings.htm). Valuable introductory skills can be learned, such as guiding a needle under fluoroscopy, epidural steroid injections, facet nerve blocks and other basic procedures that can accelerate the learning curve once fellowship is started. Pain society meetings may be worthwhile, such as the American Society for Interventional Pain Physicians (ASIPP), American Pain Society (APS), and International Spine Intervention Society (ISIS) among others, to learn more about the field from the “inside.” This also helps to meet people in the small community of pain medicine, including fellowship directors. Any research related to “Pain in the Emergency Department” can be highlighted on one’s application, including ultrasound guided regional techniques, disparities of pain treatment in the emergency department, procedural sedation or IV pain treatments in the emergency department, only to name a few. Also, if available, taking a pain medicine elective as a resident would be invaluable, as would shadowing a pain physician.

I encourage any interested emergency physician to consider applying to pain medicine fellowships. Pain specialists will be in great demand by our aging population. I view this as not giving up one specialty for another, but as furthering one’s education and adding to one’s skill set. Also, I believe emergency physicians have a tremendous amount to offer the field of pain medicine and their patients by pursuing ACGME-accredited pain medicine fellowship training.

Dr. Mayhew is at Carolina Health Specialists, Pain Medicine, Emergency Medicine, Myrtle Beach, SC: PainMedicine.EmergencyMedicine@gmail.com

(A list of accredited Pain Medicine fellowships is at www.acgme.org/ads/Public/Reports/Report/1 )

References

1. Knox H. Todd. Annals of Emergency Medicine 2010; 56 (1):24-26.
2. http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/sh_multiPainPR707.pdf pages 10-11