Pain Medicine is an Official Subspecialty of Emergency Medicine

[hopefulgasman]

Without putting too much detail out there how much did they have to hustle to get that spot? Did they have tons of extracurricular stuff and/or research experience with pain?

It seems like the competition for pain out of EM is skyrocketing and I'm trying to get an idea of what a competitive candidate looks like these days out of EM (not necessarily a gasser who is applying out of a strong gas program, who I would assume would have a much easier time matching in pain)

At my current job we now get rotating EM residents and it's interesting to hear how many of them are interested in pain, but can't imagine any of them are competitive for it without an inordinate amount of effort given the new EM-based interest.

EM and its abysmal match rate and complete lack of interest from medical students is not doing its residents or attendings any favors when it comes to matching into a fellowship. Pain PDs are catching wind of this fire sale and so expect to be grilled on why pain if you garner an interview moving forward.

---

Members don't see this ad.

 

[Fox800]

Without putting too much detail out there how much did they have to hustle to get that spot? Did they have tons of extracurricular stuff and/or research experience with pain?

It seems like the competition for pain out of EM is skyrocketing and I'm trying to get an idea of what a competitive candidate looks like these days out of EM (not necessarily a gasser who is applying out of a strong gas program, who I would assume would have a much easier time matching in pain)

At my current job we now get rotating EM residents and it's interesting to hear how many of them are interested in pain, but can't imagine any of them are competitive for it without an inordinate amount of effort given the new EM-based interest.

>25% of pain programs didn't fill this year. Do with that what you will.

 

[painER]

I think the key is to have a coherent story of why you want to go into pain and hopefully have activities that demonstrate that story in action. Getting a letter from a pain physician is also a must. Right now is a good time for EM to apply to pain given the hot anesthesia job market which led to the poor match. It's then up to those who get in to show the ability of EM trained fellows hopefully opening up the door for others. I do think last year was a bit of an anomaly and it will get more competitive in future cycles.

 

[Fox800]

I think the key is to have a coherent story of why you want to go into pain and hopefully have activities that demonstrate that story in action. Getting a letter from a pain physician is also a must. Right now is a good time for EM to apply to pain given the hot anesthesia job market which led to the poor match. It's then up to those who get in to show the ability of EM trained fellows hopefully opening up the door for others. I do think last year was a bit of an anomaly and it will get more competitive in future cycles.

If you haven't matched yet: go anesthesiology->pain.

If you're an EM resident: do a pain rotation, try to do pain research (could make your scholarly project about this), get pain letters. You have to apply the December of PGY-2 year (if you're in a 3-year EM program), so you need to work on this during PGY-1 year and fall PGY-2 year. If you wait too long you'll be filling a gap year with EM work.

If an EM attending: shadow a pain medicine attending, pick their brain, do your research about the field, get a pain letter. Play to your strengths as an EM physician: you know how to work hard, you've seen thousands of patients with different variations of pain over your career, you're good at taking a focused history/physical, you know how to read imaging studies, and you're adept at procedures that would lend well to the world of pain. The application cycle starts in December, match is in September, and you start the following July. It's a long cycle (18 months) so start early.

 

[Goodlife1119]

For Pain attendings/fellows: what are some micro skills you wish you refined as an EM attending/resident that would be useful in the pain world?

 

[Fox800]

For Pain attendings/fellows: what are some micro skills you wish you refined as an EM attending/resident that would be useful in the pain world?

Using a keyboard to type a personal statement for fellowship applications earlier in my EM career.

 

[hopefulgasman]

Using a keyboard to type a personal statement for fellowship applications earlier in my EM caree

For Pain attendings/fellows: what are some micro skills you wish you refined as an EM attending/resident that would be useful in the pain

For Pain attendings/fellows: what are some micro skills you wish you refined as an EM attending/resident that would be useful in the pain world?

Nothing. They’re entirely different fields. If I were a Pain PD and an EM applicant told me they’re doing pain to better take care of their EM patients or try to bridge the two specialties I would DNR on the spot.

 

[BoardingDoc]

Nothing. They’re entirely different fields. If I were a Pain PD and an EM applicant told me they’re doing pain to better take care of their EM patients or try to bridge the two specialties I would DNR on the spot.

I think you've completely misread the question. Nothing about what @Goodlife1119 is asking makes me think they're trying to "bridge the specialties." It makes me think they're in EM, want to go into pain, and want to focus on procedural skills that they think might translate well into pain procedure skills as they eject from EM and become a pain attending.

At the end of the day, I doubt there is much you can focus on in EM that's going to make a huge difference in pain though I would imagine that when it comes to procedural skills in general, you likely have a large leg up on applicants from any field other than gas in that I'm sure you're going to be more facile with a needle than folks from say PM&R.

 

[hopefulgasman]

I think you've completely misread the question. Nothing about what @Goodlife1119 is asking makes me think they're trying to "bridge the specialties." It makes me think they're in EM, want to go into pain, and want to focus on procedural skills that they think might translate well into pain procedure skills as they eject from EM and become a pain attending.

At the end of the day, I doubt there is much you can focus on in EM that's going to make a huge difference in pain though I would imagine that when it comes to procedural skills in general, you likely have a large leg up on applicants from any field other than gas in that I'm sure you're going to be more facile with a needle than folks from say PM&R.

🙄 Im saying in the instance they were to say such things that is how it would be perceived.

 

[hopefulgasman]

For Pain attendings/fellows: what are some micro skills you wish you refined as an EM attending/resident that would be useful in the pain world?

Can’t send you PMs…

 

[Apollyon]

Can’t send you PMs…

Person doesn't have enough posts.

 

[HemorrhagicShock]

🙄 Im saying in the instance they were to say such things that is how it would be perceived.

I'm wondering why "bridging the two specialties" would be a big roll-eyes to you? Over 80% of ED visits include some sort of pain complaint, and an experienced ER doc has plenty of experience treating acute/chronic pain and has plenty of experience doing regional anesthetic techniques (blocks etc.) This, along with relevant shadowing/observership experience within a full spectrum pain practice would seem like somebody who is a great candidate for pain medicine.

We've had plenty of people here in the SDN forums talk about how that's what they mentioned in their personal statements and within their interviews and they've matched pain medicine.

So I'm curious about your comment and if it holds any weight beyond rolling your eyes at EM going into a subspecialty that has traditionally been intentionally gate-kept by gassers who want to keep it to themselves.

 

[hopefulgasman]

I'm wondering why "bridging the two specialties" would be a big roll-eyes to you? Over 80% of ED visits include some sort of pain complaint, and an experienced ER doc has plenty of experience treating acute/chronic pain and has plenty of experience doing regional anesthetic techniques (blocks etc.) This, along with relevant shadowing/observership experience within a full spectrum pain practice would seem like somebody who is a great candidate for pain medicine.

We've had plenty of people here in the SDN forums talk about how that's what they mentioned in their personal statements and within their interviews and they've matched pain medicine.

So I'm curious about your comment and if it holds any weight beyond rolling your eyes at EM going into a subspecialty that has traditionally been intentionally gate-kept by gassers who want to keep it to themselves.

You’ve completely misunderstood what is being said and if you think this has anything to do with stifling EM from going into Pain. EM should go into pain. The reason needs to make sense.

 

[BoardingDoc]

You’ve completely misunderstood what is being said and if you think this has anything to do with stifling EM from going into Pain. EM should go into pain. The reason needs to make sense.

Then please clarify?

 

[HemorrhagicShock]

You’ve completely misunderstood what is being said and if you think this has anything to do with stifling EM from going into Pain. EM should go into pain. The reason needs to make sense.

I'd appreciate clarification if I've completely misunderstood, and it seems like others would as well.

I don't care to go through your post history but I assume you have some experience here and since this is a place where people come looking for tips/education on pain applications from EM, this is a great opportunity for you to educate everybody

 

[namethatsmell]

For Pain attendings/fellows: what are some micro skills you wish you refined as an EM attending/resident that would be useful in the pain world?

If you want to work on anything, consider this: on every patient you see with neck/back/major joint/extremity pain, force yourself to briefly consider 2-3 non-emergent causes for their pain beyond just "musculoskeletal." No need to necessarily change what you do in the ED, but starting to regularly think about a differential of things that won't kill people will help more quickly free your mind during fellowship.

 

[Goodlife1119]

^ Love it. Some of the things I have already started working on is learning basic fluro anatomy, identifying what level I am at, perfecting my two hand tie(saw it come to use during intrathecal pain pump placement), refreshing myself on how to sterile gowning/gloving in a OR setting. I also got my hands on a epidural kit that I am going to familiarize myself with. I am also open to any other ideas any of you have. Thanks in advance.

 

[sevo00]

it's weird seeing how excited you all to go into pain when in reality I see anesthesia pain docs leaving the field in masses to return back to anesthesia because of how ****ty pain is

 

[GatorCHOMPions]

it's weird seeing how excited you all to go into pain when in reality I see anesthesia pain docs leaving the field in masses to return back to anesthesia because of how ****ty pain is

Clearly it speaks to the state of the primary specialties. EM is a dumpster fire and general anesthesia is having a Renaissance. I still work 2-3 EM shifts per month and they always end up being the 2-3 worst days of my month. Make no mistake, I agree Pain can be a pain, but it's all relative.

 

[HemorrhagicShock]

it's weird seeing how excited you all to go into pain when in reality I see anesthesia pain docs leaving the field in masses to return back to anesthesia because of how ****ty pain is

Consider how bad EM is for this to be the case. EM is not sustainable as a career long term.

 

[Fox800]

it's weird seeing how excited you all to go into pain when in reality I see anesthesia pain docs leaving the field in masses to return back to anesthesia because of how ****ty pain is

Is it that, or is that tons of anesthesiologists quit/retired/went part-time after COVID and now anesthesiology pay is $$$?

Pain docs I've talked to lately are all very happy and salaries are higher than EM with infinitely better hours/working conditions.

 

[namethatsmell]

^ Love it. Some of the things I have already started working on is learning basic fluro anatomy, identifying what level I am at, perfecting my two hand tie(saw it come to use during intrathecal pain pump placement), refreshing myself on how to sterile gowning/gloving in a OR setting. I also got my hands on a epidural kit that I am going to familiarize myself with. I am also open to any other ideas any of you have. Thanks in advance.

In terms of the potential work:benefit yield of stuff you could work on before fellowship, there's probably no better option in your position than starting to tinker with honing a focused yet thorough Hx/PE to generate a reasonable ddx.

If you really want to put some time in, check out this book:
Amazon product

After that, looking at some fluoro pics to at least give you an idea of what to look for could be helpful...but no matter how many images you look at, things likely won't start to meaningfully click until at least a few months into your fellowship and your interpretation skills will continue to level-up probably at least into your first year of practice. It's kind of like reading EKGs...you really can't become proficient by just reading a book, you need tons of reps in training to build a useful foundation. IMHO, the time to binge on looking at fluoro anatomy is the evening before/after your procedures in fellowship. That said, if you really want/have time to spend on fluoro before fellowship, grab the Furman procedure book.

The other stuff you mentioned is likely to be low yield at this point.

Only other thing I would caution you against...and not saying you're intending to do this...but...don't get too focused on the "advanced" pain procedures until you can competently/reliably do the bread/butter pain procedures (ie ESIs, MBBs, RFAs etc). Fellows/new attendings who are preoccupied on SCS, pumps, every stupid new SIJ fusion device, etc come off as well as the EM intern who brings up the possibility of placing a TV pacer on anybody with a whiff of weakness/dizziness/etc and happens to have a HR < 60...

But, overall, it's just tough to prepare for pain fellowship before you actually start. And that's OK. You'll have periods of feeling lost/confused like everybody who came before you, and then you'll make it though a-ok....just like you did with EM.

 

[305_JAFERD]

I am set to start pain fellowship this July and am pretty anxious about going back into a training environment after several years on my own as an attending. For anyone who has completed fellowship, did you notice any discrimination based upon specialty when applying to jobs? My concern is that hospitals and private groups would prefer an applicant that is residency-trained in anesthesia or PM&R over an EM doc who later completed a pain fellowship. I am terribly worried about completing the fellowship and having limited job prospects after all of that work. I do not have a desire to go into private practice.

 

[GatorCHOMPions]

I am set to start pain fellowship this July and am pretty anxious about going back into a training environment after several years on my own as an attending. For anyone who has completed fellowship, did you notice any discrimination based upon specialty when applying to jobs? My concern is that hospitals and private groups would prefer an applicant that is residency-trained in anesthesia or PM&R over an EM doc who later completed a pain fellowship. I am terribly worried about completing the fellowship and having limited job prospects after all of that work. I do not have a desire to go into private practice.

First, don't be anxious, I found it kind of cool to go back into training after some time off.

It's true that there are a few specific jobs that want anesthesia and/or PMR. Those tend to be academics where the Department only wants their own, private practice where they want docs to split between anesthesia and pain, and certain ortho groups that like to have people who can do EMGs. This probably represents like 10-20% of jobs if I had to guess. Additionally, the job market overall is pretty tight in competitive areas. With that said, just as you worked hard through residency and had the gumption to go back into training after time off, you'll use those skills again to land a decent job in a decent location.

When you say private practice I assume you meant on your own, right?

 

[Agast]

I am set to start pain fellowship this July and am pretty anxious about going back into a training environment after several years on my own as an attending. For anyone who has completed fellowship, did you notice any discrimination based upon specialty when applying to jobs? My concern is that hospitals and private groups would prefer an applicant that is residency-trained in anesthesia or PM&R over an EM doc who later completed a pain fellowship. I am terribly worried about completing the fellowship and having limited job prospects after all of that work. I do not have a desire to go into private practice.

Hospitals typically have to hire you within a department so if it’s under anesthesiology they probably prefer an anesthesiologist. If it’s the neurosurgery department hiring I don’t think they really care and they probably don’t realize there are other specialties getting trained in pain.

 

[Fox800]

My last ED shift was yesterday (starting pain fellowship this summer). Feels...weird, but good. Like you're leaving behind a toxic relationship.

I'm sure I'll miss some of the fun things (had a STEMI and an intubation). However, the stress of overflowing waiting rooms, demented septic nursing home dumps, having to assuage psychosomatic complaints/anxiety issues (chest pain/dizziness/numbness combos), and family packs with COVID that are still to the ED in 2024 because ???..I will NOT miss that stuff.

 

[BoardingDoc]

My last ED shift was yesterday (starting pain fellowship this summer). Feels...weird, but good. Like you're leaving behind a toxic relationship.

I'm sure I'll miss some of the fun things (had a STEMI and an intubation). However, the stress of overflowing waiting rooms, demented septic nursing home dumps, and having to assuage psychosomatic complaints/anxiety issues (chest pain/dizziness/numbness combos), family packs with COVID that come to the ED in 2024 because ???..I will NOT miss.

What did the fellows you talked to when interviewing say the job market was like? Obviously getting into fellowship is getting easier with how good the anesthesia market is right now, but I've heard that finding a decent pain job has been nigh impossible lately.

 

[Fox800]

What did the fellows you talked to when interviewing say the job market was like? Obviously getting into fellowship is getting easier with how good the anesthesia market is right now, but I've heard that finding a decent pain job has been nigh impossible lately.

I didn't ask nitty gritty details, but from the handful of folks I talked to that got jobs in the past 1-2 years, they had no problems getting jobs that they were happy with and interviewed in multiple metro areas. From what I'm seeing salaries in pain are still consistently higher than median salaries in EM.

 

[Birdstrike]

Started doing a new procedure today: LinQ SI joint stabilization (some of you probably already do it if OR-based).

Implanting a cadaver-bone allograft into the SI joint. I like this one and hope the results are as good as the data. If so, I'll likely do a bunch.

VIDEO

 

[namethatsmell]

Started doing a new procedure today: LinQ SI joint stabilization (some of you probably already do it if OR-based).

Implanting a cadaver-bone allograft into the SI joint. I like this one and hope the results are as good as the data. If so, I'll likely do a bunch.

VIDEO

I hope your patients do better than mine did in fellowship. Albeit that was several years ago and a different system. Keep us posted on how things go!

 

[swamprat]

Started doing a new procedure today: LinQ SI joint stabilization (some of you probably already do it if OR-based).

Implanting a cadaver-bone allograft into the SI joint. I like this one and hope the results are as good as the data. If so, I'll likely do a bunch.

VIDEO

I do lateral screws when they changed the code. I think linq works but I suspect you do not get sufficient fusion so essentially over time the ligaments start to loosen and the pain returns. Lateral screws have been a home run although more invasive - SI bone, orthofundamentals mostly.

 

[Birdstrike]

Started doing a new procedure today: LinQ SI joint stabilization (some of you probably already do it if OR-based).

Implanting a cadaver-bone allograft into the SI joint. I like this one and hope the results are as good as the data. If so, I'll likely do a bunch.

VIDEO

It’s still very early and an n of 1, but at 8 days follow up this patient already has >80% pain relief. I’m surprised it can work this quickly, but it does match up with the data that’s been reported. We’ll see how she does long term, and how future patients do.

@swamprat @namethatsmell

 

[Birdstrike]

I just got another private message from an EM-Pain applicant who was accepted to fellowship at a highly desired program:

"...We spoke a couple years ago about transitioning to pain med....recently got an interview at one of my top choices...I'll be starting this July...Very excited about the entire thing..."

 

[Agast]

Started doing a new procedure today: LinQ SI joint stabilization (some of you probably already do it if OR-based).

Implanting a cadaver-bone allograft into the SI joint. I like this one and hope the results are as good as the data. If so, I'll likely do a bunch.

VIDEO

There’s a local doc who did a ton of these and now he’s re-doing them with the lateral screws due to “SI joint fusion failure” fyi

 

[Birdstrike]

There’s a local doc who did a ton of these and now he’s re-doing them with the lateral screws due to “SI joint fusion failure” fyi

Will keep it in mind.