Ability to do Bread and butter procedures coming out of fellowship

[PMRorBUST]

Current fellow here. 9 months in and starting to doubt myself on whether or not I know how to perform bread and butter procedures proficiently. Will struggle with the occasional LESI and even some lumbar medial branch blocks. Attendings don’t really give me a chance to correct myself and I continue to lose confidence daily. Haven’t done a cervical procedure in a while and I’ve only had the ability to see two cervical rfas in all of fellowship.

can anyone else relate coming out of fellowship?

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[bedrock]

Current fellow here. 9 months in and starting to doubt myself on whether or not I know how to perform bread and butter procedures proficiently. Will struggle with the occasional LESI and even some lumbar medial branch blocks. Attendings don’t really give me a chance to correct myself and I continue to lose confidence daily. Haven’t done a cervical procedure in a while and I’ve only had the ability to see two cervical rfas in all of fellowship.

can anyone else relate coming out of fellowship?

That is a bit scary and frankly it sounds like your fellowship is.......not good.

It is normal to feel apprehensive about bigger more rare procedures like SCS implants and kyphoplasty, but cervical/lumbar MBB/RFA/ESI should be routine at this point.

I would speak with your program director. Hopefully they can can get you more procedure time.
Given what you told us I also highly advise you take the IPSIS (SIS) procedure course (all of them.) They have fellow discounts. Good clear instruction and cadaver time definitely helps.

 

[deadhead2]

Current fellow here. 9 months in and starting to doubt myself on whether or not I know how to perform bread and butter procedures proficiently. Will struggle with the occasional LESI and even some lumbar medial branch blocks. Attendings don’t really give me a chance to correct myself and I continue to lose confidence daily. Haven’t done a cervical procedure in a while and I’ve only had the ability to see two cervical rfas in all of fellowship.

can anyone else relate coming out of fellowship?

I finished fellowship in 2022. This is definitely not normal. Sure, some patients might have more difficult anatomy, but you should be pretty confident with joint injections, MBB, ESIs, and RFA by this point. When I started at my job, I was ready to do all these procedures (and SCS trials) solo with the usual new job jitters but no real apprehensions.

Why are you struggling with procedures? Trouble getting fluoro views, finding landmarks, steering the needle? Something else?

Are your co-fellows having the same problems?

Would definitely discuss this with your PD as well as the attendings that you work with. If they don’t know your concerns, they can’t help you.

 

[NJPAIN]

Current fellow here. 9 months in and starting to doubt myself on whether or not I know how to perform bread and butter procedures proficiently. Will struggle with the occasional LESI and even some lumbar medial branch blocks. Attendings don’t really give me a chance to correct myself and I continue to lose confidence daily. Haven’t done a cervical procedure in a while and I’ve only had the ability to see two cervical rfas in all of fellowship.

can anyone else relate coming out of fellowship?

Definitely worth taking to your PD. While it is great to be exposed to lots and lots of procedures and feel confident with most of them, it doesn’t always work out that way and it’s not the end of the world. There are lots of resources to fill in the blanks as long as you have the basic skills. IPSIS courses, great atlases, online videos, visiting experienced pain docs willing to share their wisdom. Also, feel free to tell company reps that you would use more of their products if you were more comfortable with the procedure. They all have the ability to hook you up with docs outside of your area who won’t mind showing you how it’s done as long as you are not the competition.

 

[PMRorBUST]

Thank you all for the advice.

I’ve brought up my concerns with the PD and he feels that I’m doing fine but I’ve been corrected multiple times on procedures recently. At this point I thought I’d be doing the bread and butter procedures without attendings coming in to help me but I guess I was wrong. With that said, only 2 cervical rfas all year really bugs me - thought I’d get way more.

Regarding courses, I don’t know how beneficial those would be for me. If I don’t feel confident after a year of doing procedures, I definitely won’t feel confident after a weekend course.

Pretty bummed at the training I’ve received thus far. I will have about 200 procedures for this month coming up so maybe that’ll boost up my skills and morale

 

[RoloTomassi]

will have about 200 procedures for this month coming up so maybe that’ll boost up my skills and morale

Just to clarify, are you at 200 total or doing 200 per month?

 

[PMRorBUST]

Just to clarify, are you at 200 total or doing 200 per month?

I’m expecting to do 200 this month alone. We have different rotation sites and this one is more volume with bread and butter - about 8-10 procedures a day

 

[bedrock]

I’m expecting to do 200 this month alone. We have different rotation sites and this one is more volume with bread and butter - about 8-10 procedures a day

What percentage of those 200 case per month are fluoro guided spine procecures?

 

[RoloTomassi]

I’m expecting to do 200 this month alone. We have different rotation sites and this one is more volume with bread and butter - about 8-10 procedures a day

If your other months have been anywhere near this one, that's a ton of reps.

Is the lack of cervical RFA due to them feeling like you're not ready or has everyone else also only done a couple?

I feel like something isn't clicking for you, just need to figure out what it is, and actively try to make each rep better.

It's good that you have a good sense of self awareness and want to improve though. Better than being overconfident while lacking skills.

 

[SSdoc33]

There’s not 1 ‘right’ way to do a shot.There are some basics you should know, but most of us fine tune it on our own. My guess is you are better than you think

 

[MD87]

Cervical RF is a challenging procedure. There are lots of threads on here from experienced docs asking for new tips and tricks.

Even a lumbar TFESI can be challenging in some cases. Anyone on here who says they were as good at a lumbar TFESI on day 1 as an attending compared to day 2000 is either a liar or bad at TFESI.

Don’t be too hard on yourself.

 

[Espn123]

You will continue to improve for several years after fellowship, no worries

 

[Dr. Ice]

It’s almost midnight where I am, and I’m awake and feel like starting something so here it is…

To the OP, are you in an acgme accredited fellowship? Just curious to see how you respond and then how others respond on here, cause let’s bring it up for the millionth time. If I don’t, someone else will

 

[PMRorBUST]

at this one rotation site, 95% of the procedures are Fluoro guided.

Im at an acgme pain program so we do non pain rotations like anesthesia, psych and radiology so I’ve had a good amount of reps - I just feel that the quality of reps weren’t amazing (ie the attending is involved in the basic procedures or they take over immediately)

Unfortunately I don’t have great attendings. One one who is fresh out of training, one who isn’t board certified and one who is scared of doing any RFA and will talk you thru every procedure until the end of fellowship. Then there are two who I try to learn from the most but they are the ones that take over or join in the procedure, even for ESI, MBB and RFA. Only rotate with one attending who does ultrasound guided nerve blocks and that was only for 4 weeks.

Don’t even care about advanced procedures at this point given the situation I am in.

just speaking to some of my colleagues, they have felt way more comfortable at this point in their training than I have which scares me. I am somewhat neurotic and that is probably contributing as well.

Appreciate the tips and words of encouragement in prior posts

 

[pastafan]

Regarding courses, I don’t know how beneficial those would be for me. If I don’t feel confident after a year of doing procedures, I definitely won’t feel confident after a weekend course.

IPSIS courses are worthwhile. Take the basic courses and learn the correct way to perform procedures. After that, take the comprehensive course where you will be taught by some of the best physicians in the world. Perhaps your confidence will not soar but you will learn what should have been taught in your fellowship.

 

[Espn123]

Fellowship is about learning anatomy and guiding a needle or instrument under fluoroscopy. These skills can be advanced with courses, observerships at other practices after fellowships

If you still feel you need something extra, consider doing extra. ACGME programs often are far worse in procedural experience. You can overcome this with some hard work.

 

[Agast]

at this one rotation site, 95% of the procedures are Fluoro guided.


Unfortunately I don’t have great attendings. One one who is fresh out of training, one who isn’t board certified and one who is scared of doing any RFA and will talk you thru every procedure until the end of fellowship. Then there are two who I try to learn from the most but they are the ones that take over or join in the procedure, even for ESI, MBB and RFA. Only rotate with one attending who does ultrasound guided nerve blocks and that was only for 4 weeks.

Ack. One of the greatest downsides to academia is that it tends to be populated by people who go directly from training to teaching. It would be nice if everyone had a few years of independent practice under their belt.

I’ve run into some tricky interlaminar epidurals from patients with significant degenerative changes. Change your fluoro angles, try entering on the opposite side. Sometimes when I’m in the contralateral oblique I will advance under pulsed fluoro while I’m trying to push the tip past whatever schmutz is in the way. Had to do that this week. It’s always awkward when the patient is awake and wondering why you’re pushing so hard on their back. I’ve had to completely abort a procedure twice in the last 10 years. Threw away 5 bent needles before giving up. It makes you wish you had the bone rongeur from the MILD kit lol.

If the patient is awake you can always consent them for the level below or a transforaminal approach.

 

[callmeanesthesia]

It sounds like what you are lacking is a systematic way to approach the procedure. That’s what the SIS courses will give you. The most fundamental basics that your faculty may not think to walk you through - you rotate with many different staff so each assumes the other taught you the basics, or when you’re first learning it gets all jumbled because they’re all trying to teach you their own way and they’re all different.

I’m talking basics like “which one is C7?” Where on the Scotty dog is my target for a lumbar TFESI?”

I won’t even add “where should my needle entry be for RFA?” Because if you’re a frequent user of this forum you know that’s a matter of significant debate. However, for now learn the SIS approach and try to do that.

Start by reviewing all the procedure guides on The Pain Source (Procedures Archives - The Pain Source). It’s a great site written by one of our own forum members. I would suggest getting the SIS procedure manual and reading the whole damn thing. Maybe get another fluoro procedure guide and read that too. Do as much of that as you can before you start your procedure-heavy rotation. You will get a lot more of the nuance of the procedure if you know what you’re trying to accomplish before you start. Your attendings may also be less likely to take over.

Do the SIS courses if your fellowship will allow. Great excuse for a little travel.

Overall, relax a little. You don’t stop learning when you exit fellowship.

 

[RoloTomassi]

You should have a talk with each of your attendings about giving you more time before they take over. Learning when and how to make adjustments with the needle and the c-arm is crucial to improvement, and they seem to be robbing you of that when they should be coaching you through it.

 

[agolden1]

There's a lot of good advice on this thread. OP, I felt somewhat uncomfortable with certain procedures coming out of fellowship two years ago as many of my attendings were biased against certain kinds of work. Similar to yours, they were uncomfortable with cervical RFA and relied heavily on facets (both lumbar and cervical). They did a fairly lousy job of teaching RFA in general.

That being, said, they did teach me how to drive a needle and that opened up a world of possibilities.

In the 18 months since I've been out, I've read extensively, talked with a huge number of people, spent some quality time with the Furman atlas and gone to one of the SIS courses. The learning really doesn't stop when you finish fellowship. Keep pushing every day, and things will continue to fall into place. The change during this time period has been drastic and has been noticed by those around me. I think there are more fellowships where your experience may actually be not so uncommon from talking with some fellows from other programs.

While I think the IPSIS courses are well intentioned, they aren't quite as effective as you may be hoping for. You'll be five-six people to a cadaver and may not have the amount of hands on time you are expecting. Still, if you go to one and try and watch the mistakes and successes of others, you may pick up some details even if you aren't entirely hands on.

Don't get discouraged, and good luck! Feel free to PM if you'd like to chat more.

 

[PMRorBUST]

Thank you all for the great advice and feedback.

Will definitely speak to my attendings about my concerns. Still have 3 months left so hopefully things will come together.

 

[bedrock]

IPSIS courses are worthwhile. Take the basic courses and learn the correct way to perform procedures. After that, take the comprehensive course where you will be taught by some of the best physicians in the world. Perhaps your confidence will not soar but you will learn what should have been taught in your fellowship.

agree with this but I disagree about the IPSIS book. It is very very low yield unless you are already at a high level.

1- Definitely buy Furmans pain atlas. It is by far the most user friendly of any of the pain atlases for bread and butter procedures, and gives helpful hints for advanced procedures.
2- Definitely go to IPSIS courses. You need a regimented approach to how you do each procedure because your attendings are all over the map.
The IPSIS course are just that. The are by far the best way to approach each procedure, but particularly RFA. If want to tweak those techniques in a year or two down the road that is fine. But master the essentials first with IPSIS courses and Furman atlas.

 

[Agast]

So, I finally joined SIS. Is this the only course that teaches RFA skills?

 

[BobBarker]

Stryker had a nice RF course. I’m sure Medtronic does now as well. I would just go to one of those for free.

 

[agolden1]

So, I finally joined SIS. Is this the only course that teaches RFA skills? View attachment 384772

There are also lumbar and cervical specific courses where they have lectures then have cadaver sessions.

This session is just sort of a free for all where they touch on anything you want to at each station.

 

[bedrock]

So, I finally joined SIS. Is this the only course that teaches RFA skills? View attachment 384772

I expect that you just barely missed it and so they haven't scheduled the next RFA course. IPSIS will do a dedicated RF course at least once a year. Usually covers both cervical and lumbar. Sometimes they do a combo lumbar disc and lumbar RFA course.

Check back to the IPSIS website in two months and you will see a dedicated IPSIS RFA course scheduled sometime during the next year.

 

[NJPAIN]

The IPSIS RF course is excellent. Only validated techniques are taught. They won’t teach you shortcuts that may make you faster but also may degrade the quality of your work.

Again, concentrate on basic skills for now; needle driving and even more important is X-ray image interpretation. Once you have that down, you will have the confidence to go to a weekend course or read an atlas and then perform a procedure or use a technique for the first time.

For now, don’t let your RT set up the view for you. YOU need to understand and recognize the anatomy. Knowing that will further boost your confidence. Too many pain docs don’t know how to acquire the desired view and just stand there saying “ I can’t see!”.

 

[IHawkDO]

The IPSIS RF course is excellent. Only validated techniques are taught. They won’t teach you shortcuts that may make you faster but also may degrade the quality of your work.

Again, concentrate on basic skills for now; needle driving and even more important is X-ray image interpretation. Once you have that down, you will have the confidence to go to a weekend course or read an atlas and then perform a procedure or use a technique for the first time.

For now, don’t let your RT set up the view for you. YOU need to understand and recognize the anatomy. Knowing that will further boost your confidence. Too many pain docs don’t know how to acquire the desired view and just stand there saying “ I can’t see!”.

The last part of this comment is absolutely key. I ended up at a fellowship where we didn’t have RTs and had to run our own C arm. While I thought it was annoying at the time, it has definitely made my transition into practice easier, as I’ve been able to more confidently direct the RTs I currently work with.

At the end of the day, I don’t want you to stress too much, OP. Talk to your PD, lean on your co fellows, and put in the extra studying/work necessary to feel more comfortable before you leave. Having some additional concern about procedures isn’t always a bad thing. It’s infinitely better to ask for assistance if you’re unsure rather than being overconfident and getting yourself into sticky situations. Luckily, the last 3 months of fellowship can be an excellent time to work out some of those kinks before you leave. Best of luck!

 

[Dr. Ice]

At the end of the day what I’ve learned is that since you’re gonna have the piece of paper, you can get a nice cushy hospital job and ride the rvu gravy train into the ground.

I was trained well, was extremely comfortable doing everything the day I left fellowship by Furman. I remember teaching some senior docs at my first job certain techniques.

Alas, 15 years ago I was 6 months shy of the piece of paper and for that I’ll never ride the hopd gravy train, but to the OP you can..and apparently the hopd will be willing to take a risk on someone like you who is posting that despite your piece of paper you feel unsure of your training.

What a world we live in…

 

[bedrock]

At the end of the day what I’ve learned is that since you’re gonna have the piece of paper, you can get a nice cushy hospital job and ride the rvu gravy train into the ground.

I was trained well, was extremely comfortable doing everything the day I left fellowship by Furman. I remember teaching some senior docs at my first job certain techniques.

Alas, 15 years ago I was 6 months shy of the piece of paper and for that I’ll never ride the hopd gravy train, but to the OP you can..and apparently the hopd will be willing to take a risk on someone like you who is posting that despite your piece of paper you feel unsure of your training.

What a world we live in…

Agree. Furman fellows are better trained than half of the ACGME programs. (Not necessarily the other half).

Hospital bureaucrats are oblivious to this. If you have the piece of paper you are in for the cushy HOPD job, if not, you might be Paul Dreyfuss/Ray Baker/Tim Mauss combined, but they will hire the guy from the worst ACGME pain fellowhip in the country instead because the paper is all they see or can understand.

 

[Dr. Ice]

Agree. Furman fellows are better trained than half of the ACGME programs. (Not necessarily the other half).

Hospital bureaucrats are oblivious to this. If you have the piece of paper you are in for the cushy HOPD job, if not, you might be Paul Dreyfuss/Ray Baker/Tim Mauss combined, but they will hire the guy from the worst ACGME pain fellowhip in the country instead because the paper is all they see or can understand.

Yup, at 15 years in now, all I can hope for is a PE payout and cut my losses..

Pretty damn sure I can train anyone to drive a needle anywhere, and could do it day #1 post fellowship. I remember my first day as an attending, helping a guy figure out the c arm on a difficult tfesi, if I remember correctly, the c arm tech was also new and I asked if I could position the c arm for the doc as that was part of my training before I even touched a needle

 

[Dr. Ice]

OP, if you’re PMR trained, you know of the Elkins award I’m sure. My junior fellow was the Elkins award winner and now holds a prestigious academic title, but he also doesn’t have the piece of paper so you are still in a better position than even him. Don’t worry be happy

 

[Doctodd]

My MA does my facet injections(hypothetically of course)…..the only reason I can think of that you can’t is because the attendings hog all the procedures. Take a course, watch videos, read, and then be more assertive for the next procedure….you’ll be fine.

 

[PinchandBurn]

Thank you all for the great advice and feedback.

Will definitely speak to my attendings about my concerns. Still have 3 months left so hopefully things will come together.

Dont fret

get together with all the SCS reps. I know you dont care about SCS right now. But have them send you to their cadaver courses etc FREE. THen when you are there ask the docs how they do things like ESI, mbb,etc.

Same thing with your RFA generator rep...have them get you to a course.

Dont be down on yourself. Plenty of learning options to tune things up. THe main thing with fellowship is learning what NOT to do and avoiding "the badness" . You will pick everything else up.

 

[AlvinKamara]

Do you work with rad techs?

If so, ask them to let you line up your own images for each procedure. Don’t let them help you. Count your levels. See what works best for each procedure. Get comfortable interpreting CLO. Line up your own cervial mbbs.

This will help you understand the anatomy which in turn will help you understand where your needle is in space.