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PASSOR vs ISIS vs others. Any experiences and/or thoughts re: quality, hands-on work, and philosophy.
algosdoc said:ISIS workshops are a graduated series of increasingly technical and risk laden techniques that are taught using standardized protocols. The groups are small (usually 4-6 per cadaver), the quality is excellent of the physician instructors, and the experience is very concentrated in techniques of one type or regional area of anatomy (eg. Level I is lumbar injections). The physician must be proficient in one level in order to advance to the next. In all, there are approximately 7 levels and ISIS does teach a workshop on pumps and stim implants. If you do things the ISIS way (Practice Guidelines) you will have the most optimal chance of having a procedure actually work. ISIS courses fill up quickly and one may have to wait for up to 6-9 months to get into the course of choice (upper level).
PASSOR has techniques divided into 3 levels and offers similar experience relative to ISIS minus the intensity of techniques. (for example, ISIS offers a single cadaver course on RF of the spine that includes SI, medial branch, thoracic, splanchnic, etc. while PASSOR offers the more bread and butter cervical and lumbar medial branch. The PASSOR RF is included in Phase III which includes other injection techniques. PASSOR has some of the finest instructors I have ever met. PASSOR is the physiatry equivalent of ISIS and their injection techniques and stratification levels were initially based on many of the ISIS techniques.
ASIPP offers a series of cadaver courses that are rather packed with many physicians per cadaver. They have developed their own practice guidelines independent of other organizations. The techniques they teach range from basic to intermediately advanced and they also have loosely defined the workshops into stratifications. Part of the emphasis in the ASIPP organization is politically motivated.
SPPM offers 3 cadaver workshops each year with some of the workshops being 4 day cadaver workshops. The SPPM experience is comprehensive with a billing/coding/legal/lecture session either preceding or following the cadaver course. The non-cadaver sessions run from 7a to nearly 10p at night with injection workshops and RF workshops being provided outside the cadaver sessions. This year for the first time, selective endoscopic discectomy is being taught with a combination cadaver sessions and didactic sessions for only the most advanced practitioners. The cadaver courses are constantly being updated with non-reimbursed techniques being dropped.
ASRA offers a small cadaver course and I believe the American Academy of Pain Medicine also offers cadaver courses. There are a few commercial cadaver courses (for profit), such as IPI, but I do not know the quality of such.
For a listing of courses coming up, see the conference listings on this website
drrinoo said:algos,
point well taken...the neophyte injectionist should have some introductory didactic structure...and anatomy/physiology/imaging with guidelines based on these concepts is important...
...but when practitioners become dogmatic in their views and believe they understand spinal pain based on their selective readings of the literature and conversations with colleagues...it is hard to stomach...especially if they demand all practitioners practice their way
I have had a number of epiphanies at times (having been faculty only for 3 years) with the realization that the plethora of pain practitioners have only helped a minority of patients, that pain and pain management are vastly complex-we will never understand it within our lifetimes, and that oversimplification of a complex entity should only be used for instructional purposes....injections in my view, if they are safe, play a complementary role to any other intervention....what I call...'Reducing the afferent nociceptive burden...RANB'...whether RANB occurs secondary to placebo or not...doesn't matter, as long as your intervention is safe.
pain is a subjective experience and assessment depends on the patient's report (barring any miraculous advancement in functional neuroimaging or identification of a CSF/ serum biomarker)....the use of EBM to study pain interventions is too premature and the use of VAS/outcomes not sensitive enough to determine if a patient has done well....
as a digression, apply Evidence Based 'Medicine' to other sociological problems where the outcomes are completely subjective:
evidence based real estate....how do you prove that house A is better than house B...and how do you present this information to a potential house buyer to make an informed decision
evidence based politics....how do you prove that law A is better than law B or that allocation of monies for project A is better than project B....
evidence based plumbing...how do you prove that the use of a jackhammer is needed to investigate every case of a slab leak...isn't this intervention too expensive?
evidence based beer drinking....a randomized placebo controlled double blind trial demonstrates that St. Pauli Girl beer is more satisfactory than Rolling Rock....it was a tough study to perform, because the ethics committee had to ensure that minors were not allowed to drink beer, that participants would not drive a vehicle, that enrollees were adequately informed about the consequences of drinking such as cirrhosis...in a letter to the editor, one researcher commented that the trial investigators did not control for patients being drunk and not being able to communicate their preferences...in fact, there were several dropouts from the study because they were passed out and could not finish the exit interview
evidence based techniques, when applied to a complicated sociological problem (pain), are not informative....unless you simplify the model you are using....ie., spine pain is an anatomic entity...in this scenario, it is hard for me to accept, in an unselected sample of patients with back pain, to have exclusively SI pain, facet pain, disc pain, epidural pain...and if they don't fall into these categories...then there are non-specific factors..
let us be honest with ourselves...patients are not dumb...we as pain/spine physicians are....
it is fortunate that ISIS is now using the term guidelines...but historically (correct me if I am wrong) they used the term standards....the use of the term standards implies that physicians know it all...this is not a rhetorical semantic debate...because deviation from guidelines versus deviation from standards are mean two completely different things..
for instance, if the consensus conference on IT granulomas came out and said that the standard practice for managing this condition is surgery...then any deviation from this practice would constitute malpractice...but they didn't...rather they presented a balanced review of the literature and provided guidelines for managing this condition, surgically and non-surgically...
remember malpractice lawyers are always on fact finding missions and any signs of impropriety can build a case that the practitioner is incompetent on many levels...so if you perform a lumbar transforaminal with a low posterolateral approach (akin to the discogram approach) which is not the method ISIS advocates (they advocate the 'safe triangle' approach)
if a group of physicians mandates that we have figured out a certain pathological condition (e.g., spine pain), the rest of society will believe us...it is better to admit that we don't know, rather than saving face and pretending that we have it all figured out.