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