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.
Explore This IssueACEP News: Vol 32 – No 04 – April 2013
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.