The current state of training in pain medicine fellowships: An Association of Pain Program Directors (APPD) survey of program directors.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) approved the first pain medicine fellowship programs over three decades ago, designed around a pharmacological philosophy. Following that, there has been a rise in the transition of pain medicine education toward a multidisciplinary interventional model based on a tremendous surge of contemporaneous literature in these areas. This trend has created variability in clinical experience and education amongst accredited pain medicine programs with minimal literature evaluating the differences and commonalities in education and experience of different pain medicine fellowships through Program Director (PD) experiences. This study aims to gather insight from pain medicine fellowship program directors across the country to assess clinical and interventional training, providing valuable perspectives on the future of pain medicine education. METHODS: This study involved 56 PDs of ACGME-accredited pain fellowship programs in the United States. The recruitment process included three phases: advanced notification, invitation, and follow-up to maximize response rate. Participants completed a standard online questionnaire, covering various topics such as subcategory fields, online platforms for supplemental education, clinical experience, postgraduate practice success, and training adequacy. RESULTS: Surveys were completed by 39/56 (69%) standing members of the Association of Pain Program Directors (APPD). All PDs allowed fellows to participate in industry-related and professional society-related procedural workshops, with 59% encouraging these workshops. PDs emphasized the importance of integrity, professionalism, and diligence for long-term success. Fifty-four percent of PDs expressed the need for extension of fellowship training to avoid supplemental education by industry or pain/spine societies. CONCLUSION: This study highlights the challenge of providing adequate training in all Pain Medicine subtopics within a 12-month pain medicine fellowship. PDs suggest the need for additional training for fellows and discuss the importance of curriculum standardization.

Percutaneous Coracohumeral Release for Patients with Adhesive Capsulitis: Two-Year Results from a Randomized Control Crossover Study.

BACKGROUND: Adhesive capsulitis (AC) causes a variety of symptoms, including but not limited to pain, stiffness, and a gradual restriction of active and passive range of motion (ROM). The coracohumeral ligament (CHL) plays an important role in this disease process, and percutaneous CHL release (PCHLR) has demonstrated efficacy in treating manifestations of this disorder that are refractory to pain medication, physical therapy, and local injections. Our previous study demonstrated one-year efficacy and durability, and this study examines 2-year data from our original randomized control crossover cohort. OBJECTIVE: To highlight the importance of extended follow-ups evaluating PCHLR's efficacy in AC management. STUDY DESIGN: A prospective, randomized, controlled, cross-over trial. SETTING: An academic medical center. METHODS: Patients with AC refractory to oral medication, physiotherapy, and at least one local injection were included in our original study. In all, there were initially 40 patients (46 shoulders), including 6 patients who underwent bilateral PCHLR using the Tenex® system. In this prospective study, 2 groups, the experiment group (scheduled to receive PCHLR) and the control group (scheduled to receive a local anesthetic in the coracohumeral ligament [LACHL]) were determined through 2-to-1 block randomization. Of these 46 shoulders initially treated, 39 remained in the study at one year. Twenty-six of the 39 shoulders were assigned to the PCHLR group whereas 13 were assigned to the LACHL group. Nine out of 13 shoulders in the LACHL group crossed over to the PCHLR group. Ultimately, 31 shoulders remained in the PCHLR group for 2-year analysis. The effectiveness of these interventions was assessed using a variety of parameters. Pain scores, ROM, and the Oxford Shoulder Score (OSS) were evaluated before the procedure and at one-year and 2-year follow-up visits. RESULTS: In this 2-year follow-up study, a total of 31 shoulders were sampled, comprising 22 women and 5 men, with 4 patients undergoing bilateral procedures. The mean age of the patients was 65 years (± 11.48). Patients' mean body mass index (BMI) was 36.33 (± 6.55), and the mean CHL thickness was 38.5 (± 3.45). Osteoarthritis was present in 11 cases. The mean follow-up period for the study was 29.7 months (± 6.39). The baseline mean external rotation was 30° (± 8), which increased to 62° (± 18) at one year and 53° (± 18) at 2 years. The baseline mean abduction was 60° (± 16), which improved to 77° (± 21) at one year and 68° (± 20) at 2 years. The median NRS decreased from 8 (IQR: 8, 9) at baseline to 3 (IQR: 2, 7) at one year and 5 (IQR: 2, 7) at 2 years. The baseline median OSS was 7 (IQR: 3, 10), which increased to 32 at one year and 22 (IQR: 15, 35) at 2 years. LIMITATIONS: The present investigation has a limited sample size of patients who have ROM impairment caused by CHL thickening. CONCLUSIONS: While the algorithm for AC care has seen little change for several decades, the authors suggest that PCHLR is a safe, durable, and effective option for cases of AC that are refractory to traditional management.

Trainee Insight into Pain Fellowship Programs: A Critical Evaluation of the Current Educational System by the APPD.

BACKGROUND: Since 1992, when the Accreditation Council of Graduate Medical Education (ACGME) acknowledged pain medicine as a subspecialty, the field has experienced significant growth in its number of programs, diversity of sponsoring specialties, treatment algorithms, and popularity among applicants. These shifts prompted changes to the educational model, overseen by program directors (PDs) and the ACGME. The pool of pain fellowship applicants also changed during that period. OBJECTIVES: This study aims to investigate trainees' reasons for applying to pain medicine fellowship programs as well as the applicants' specific expectations, interests, and motivations, thereby contributing to the remodeling and universal improvement of programs across the country. STUDY DESIGN: Online survey via SurveyMonkey. The online questionnaire targeted pain fellowship applicants in 2023 and current fellows in the US. METHODS: Our study was designed by board members of the Association of Pain Program Directors (APPD). The board disseminated a survey to those who applied to ACGME Pain Medicine fellowships in 2023 as well as to existing fellows. The survey was emailed to residency and fellowship PDs for dissemination to their trainees. The participants answered a 12-question survey on their reasons for pursuing pain medicine fellowships, expectations of and beyond those fellowships, and educational adjustments. RESULTS: There were 283 survey participants (80% applicants in residency training and 20% fellows). Participants ranked basic interventional procedures and a strong desire to learn advanced procedures as the most significant factors in pursuing a pain fellowship. Most trainees (70%) did not wish to pursue a 2-year fellowship, and 50% desired to go into private practice. LIMITATIONS: The relatively small number of respondents is a limitation that could introduce sampling error. Since most of the respondents were from the fields of physical medicine and rehabilitation (PM&R) and anesthesia, the use of convenience sampling reduced our ability to generalize the results to the wider community. Furthermore, approximately 80% of the trainees were residents, who might have had less experience in or knowledge of the survey's particulars than did the fellows. CONCLUSION: This survey demonstrated that procedural volume and diversity were important factors in trainees' decisions to apply to the field of pain medicine; however, extending the duration of a pain fellowship was not an option survey participants favored. Therefore, PDs and educational stakeholders in pain fellowship training need to develop creative strategies to maintain competitive applicants' interest while they adapt to our evolving field.