Pain Medicine Fellowship Curriculum
Drs. Honorio Benzon and Jeff Katz, Pain Medicine Attendings
Pain and its management is a very important issue to the patients and their relatives, physicians, nurses and the JCAHO. Pain is considered as the fifth vital sign and its evaluation (and management) is required for hospital accreditation by the JCAHO.
The science of pain and its management has come to the forefront of medicine. Developments in basic and clinical pain research have exploded within the last ten years. The subspecialty has attracted talented basic researchers partly because of increased NIH funding. Clinicians are interested in pain medicine because it is rewarding and because of the opportunities it provides in terms of scholarly productivity for academicians and gainful employment for those interested in private practice.
Pain medicine is challenging because of its multidisciplinary nature. It combines pharmacological, interventional, as well as psychological and physical medicine modalities. As such, it offers respect for the pain practitioner from other specialists once mastery of this subspecialty is obtained
II. Goals and Learning Objectives for Anesthesiology Pain Medicine Center, Inpatient Pain Consultation Service, Perioperative Acute Pain Services, Department of Anesthesiology, Northwestern Memorial Hospital
Gain proficiency in understanding the underlying mechanisms of the different pain syndromes
The fellow will learn the pathways and the neurochemistry involved in pain propagation and transmission. The fellow will learn the mechanisms of the different types of pain and the management thereof. These include such pain syndromes as acute pain, back pain, neuropathic pain, myofascial syndromes, headache, cancer pain, etc.
Gain proficiency in the management of acute pain
The fellow will learn to manage acute postoperative pain, postdural puncture headache and chest trauma (ie complex rib fractures/flail chest). Epidural opioid and local anesthetic infusions, peripheral nerve blocks and catheterization, and intravenous patient-controlled analgesia (PCA) are utilized in postoperative pain management while epidural or intercostal nerve blocks are employed in chest trauma. The fellow will document involvement with at least 50 new patients in this setting.
The fellow will be involved in the assessment and treatment of inpatients with benign and cancer-related pain disorders (other than postoperative pain) while covering inpatient consultation service. Responsibilities to the consultation service are assigned on a rotating basis amongst all fellows. The fellow will document at least 15 new patients assessed in this setting.
Gain proficiency in treating cancer pain and palliative care patients
The fellow will learn the etiologies of cancer pain and gain exposure in the medical and interventional management of patients with cancer pain.
The fellow will have longitudinal clinical exposure to patients with cancer pain and will have longitudinal palliative medicine experiences.
The fellow will be exposed to multidisciplinary and interventional approaches to treating patients with cancer pain and patients with terminal diseases while in outpatient clinics, on inpatient consultation service, and during outside rotations.
The fellow will document experience with a minimum of 20 longitudinal cancer pain patients and 10 palliative care patients during the year.
Gain proficiency in managing chronic noncancer pain
Low back pain, myofascial pain syndrome, headache, pelvic pain and neuropathic pain (postherpetic neuralgia, CRPS, etc) are examples of chronic benign pain. The fellow will be exposed to the pharmacologic, interventional, as well as the nonmedical (psychologic, rehabilitation approaches) treatments of these syndromes.
The fellow will have a longitudinal clinical experience with patients with chronic benign pain syndromes during their outpatient clinic experiences and will document a minimum of 50 different patients over a 2 month observation period.
Interpret and become familiar with basic neuro-imaging, identify significant findings, including MR and CT of the spine and brain and/or MRI studies drawn from the examples within the following areas: brain, cervical, thoracic, and lumbar spine when assessing patients with chronic pain.
Gain proficiency in interventional fluoroscopy assisted blocks
At the Northwestern Medical Faculty Foundation’s (NMFF) outpatient Anesthesiology Pain Medicine Center, Galter Pavilion, there are two fluoroscopy suites with two dedicated fluoroscopy machines where interventional blocks are performed. There is a four-bed recovery room adjacent to the fluoroscopy rooms where the patients recover after their procedure(s). The fellow will be exposed to interventional procedures such as discography and intradiscal techniques, radiofrequency ablation (pulsed and thermal), intra-articular injections, vertebral augmentation, spinal cord stimulators, and neuraxial opiate trials and long term management. Each fellow will document involvement of a minimum of 25 patients who undergo interventional procedures
Permanent implants (spinal cord stimulators, peripheral nerve stimulators, peripheral nerve and/or field stimulators and intrathecal opiate infusion pumps, battery replacements, epidural ports) are performed in the Feinberg Operating Rooms or the Olson Outpatient Surgicenter Operating Rooms. On occasion, vertebral augmentation procedures will be performed in these locations, but are typically performed in the Anesthesiology Pain Medicine Center. Fellows will actively participate in these surgeries under the direct supervision of pain medicine attendings, and will also participate in the perioperative management of these patients (wound checks, suture removal, pump refills, pump and stimulator reprogramming, management f complications, etc.)
A trend of progressive improvement in manual skills during the conduct of interventional procedures will be maintained by the fellow, with decreasing direct attending “rescue” during injection procedures.
Gain exposure to the multidisciplinary treatments of pain.
The fellow will rotate through the Children’s Memorial Hospital for pediatric pain management, through the Rehabilitation Institute of Chicago (RIC) for rehabilitation rehabilitation, neurology, and psychology exposure. Patients will interact with psychiatry service attending during their fellowship, and fellows will rotate through the Hospice and Palliative Care Service at Northwestern Memorial Hospital for management of cancer pain and palliative medicine experience. In addition, other specialists (psychologists, physical therapists, neurosurgeons, spine surgeons, neuroradiologists, urologists, chiropractors) are invited to give lectures to the service and will participate in multidisciplinary conferences and lectures.
Gain exposure to research design and statistical analyses and exposure to publications.
The Section of Pain Medicine has monthly journal club meetings where research design and statistical analyses are discussed and analysis of classic or pertinent pain medicine papers are evaluated and discussed. These journal club meetings will be lead by a pain medicine attending with active participation by the Multidisciplinary Pain Medicine Fellows.
The Department of Anesthesiology has quarterly journal club meetings where research design and statistical analyses are discussed in the context of anesthesiology practice. All fellows and residents within the department, as well as pain attendings, attend these events.
Research seminar presentations are conducted throughout the year wherein an attending presents his research project(s). Depending on their participation, fellows may be invited as co-authors of case reports, review articles, original articles, or book chapters written by the faculty.
There is a research requirement for all Multidisciplinary. Each fellow will be assigned a faculty mentor to guide and assist the fellow in a research project and assist in submitting an abstract, case report, case series, to a regional or national pain meeting.
Gain exposure to teaching, administrative aspects, and systems-based practices of pain management
The fellow will present formal and informal lectures to the residents and medical students rotating through the service. Depending on his/her expertise and enthusiasm, the fellow will have the opportunity to present cases and lectures to the department, including Department Grand Rounds.
Each fellow will present one Morbidity/Mortality Case discussion to the section of pain medicine during the academic year. A post-conference self-evaluation will be completed by each fellow.
All fellows will gain exposure on the administrative aspects of pain management including setting up a pain practice, billing and coding, compliance, JCAHO standards, etc.
Administrative responsibilities including fellow call schedules, etc, will be rotated amongst all Multidisciplinary Pain Medicine Fellows.
The fellows will be involved with problem solving aspects and process improvement of the Anesthesiology Pain Medicine Center practice and will pursue, develop, plan and execute a project that will improve patient safety and promote “best practice” principles. A timeline for this project will be presented by the Program Director. The project must be fully completed prior to completion of the fellowship. Failure to complete this project will result in probation or suspension.
Gain exposure to the principles of anesthesiology and patient safety
A fellow who has completed an anesthesiology residency or has had significant knowledge and clinical experience in anesthesiology will be exempt from the supplemental OR Anesthesiology rotation during the Multidisciplinary Pain Medicine Fellowship.
The fellow will rotate through the Anesthesiology OR Service to gain clinical exposure to pre-anesthetic assessment, patient monitoring, principles of intravenous sedation, airway assessment and management (including mask ventilation and intubation). The fellow will gain practical experience in placing intravenous catheters, as well as performing spinal anesthetics and epidural catheterizations, and will gain experience in the management of perianesthetic complications of these modalities.
All fellows will be involved in the conscious sedation of patients undergoing interventional procedures in the Anesthesiology Pain Medicine Clinic and during the conduct of Acute Pain Service duties. They will provide safe and efficient care of these patients intra-procedurally and post procedurally.
All fellows will participate in formal and informal lectures regarding radiation safety, addiction/dependence issues in pain practice, and will identify issues of physician impairment and fatigue.
Fellows will be directly involved in monthly morbidity and mortality discussions of the section of Pain Medicine under the direction of an attending.
Optional exposure to psychiatry
Fellows may spend clinical time with other specialists including addictionologists and psychiatrists at Northwestern Memorial Hospital. This will involve evaluation of patients with psychiatric or addiction disorders. Fellows will perform 15 mental status examinations during this experience, 5 of these examinations will be directly supervised by a psychiatry attending physician.
III. Goals & Learning Objectives for Outside Rotation
Operative Services (for PM & R based fellows), Department of Anesthesiology, Northwestern Memorial Hospital. During the consecutive 4 week rotation, the fellow will demonstrate competency in:
1. Obtaining IV access in a minimum of 15 patients
2. Basic airway evaluation and management including mask ventilation in a minimum of 15 patients and endotracheal intubation in 15 patients
3. Management of sedation, including direct administration of sedation to a minimum of 15 patients
4. Administration of neuraxial analgesia, including placement of a minimum of 15 thoracic or lumbar epidural injections via interlaminar technique.
5. The fellow will obtain a medical history pertinent to the delivery of anesthesia services and relay this information in an appropriate manner to the supervising Anesthesiology Attending.
6. The fellow will describe the anesthesia plan and/or anesthetic treatment options to patients and family prior to surgery/procedure.
7. The fellow will communicate patient’s history and perioperative course to PACU staff in the postoperative period during “sign out” exercise.
8. The fellow will communicate appropriately with ancillary staff and attending staff in the OR, will participate in Pre-Operative Team Briefing and “Time-Out” exercises in addition to any other pertinent patient safety procedures.
9. The fellow will accept guidance and instructions from Anesthesiology Attendings.
Cancer Pain Program, NMH Palliative Care Unit, Northwestern Memorial Hospital
During the intensive consecutive 2 week rotation, the fellow will:
1. Assess and manage pain and non-pain symptoms experienced by patients with terminal disease(s).
2. Maintain longitudinal clinical involvement in the management of cancer patients and hospice patients.
3. Understand the clinical approach to the treatments that comprise multidisciplinary cancer pain care.
4. Understand strategies to integrate pain management into this multi-dimensional treatment model, which may be integrated with continuity experience or inpatient experience.
5. Identify issues associated with the prognosis and terminal care of patients with cancer and non-cancer diseases.
6. Know the current literature related to pain management in the terminally ill patient.
7. Learn the cultural factors involved in palliative care and various communication techniques used to overcome these boundaries.
8. Examine the legal and ethical concerns related to pain control at the end of life care as well as the administrative and logistic issues that may affect treatment(s).
Rehabilitation Institute of Chicago, Multidisciplinary Rehabilitation Rotation, 4 week rotation, 2 days/week. During these rotations the fellow will:
1. Conduct a complete psychiatric/psychological history with special attention to psychiatric and pain co-morbidities
2. Conduct complete mental status examinations and demonstrate this ability to a faculty observer
3. Understand how to perform a full musculoskeletal history and the appropriate components of a neuro-musculoskeletal examination as they related to pain problems.
4. Gain significant hands-on experience in the neuromusculoskeletal history and physical examinations and demonstrate proficiency in the clinical evaluation of these patients.
5. Observe and perform a comprehensive musculoskeletal and appropriate neurologic history and examination with emphasis on both structure and function as it applies to diagnosing acute and chronic pain problems and developing rehabilitation programs for them, including assessments of static and dynamic flexibility, strength, coordination and agility for peripheral joint, spinal, and soft tissue pain conditions.
6. Gain an understanding of the natural history of various musculoskeletal and neurologic pain disorders and be able to appropriately integrate therapeutic modalities and surgical intervention in the treatment algorithm
7. Understand the indicators and interpretation of electro-diagnostic studies. Fellows will gain significant hands-on experience in the musculoskeletal and neuromuscular assessment and demonstrate proficiency in the clinical evaluation and rehabilitation plan development.
8. Discuss with a physiatrist/neurologist the issues associated with pharmacologic management of pain
9. Understand the role of psychological testing as part of assessment of patient’s suitability for interventional procedures. Observe with a licensed psychologist some of the psychological treatments of pain including biofeedback therapy, psychosocial therapies, behavioral and cognitive therapies and relaxation techniques.
10. Observe psychological evaluations as performed by a psychologist with expertise in pain management.
11. Observe physical therapy treatments of patients with back pain and other chronic pain syndromes and understand how therapeutic modalities integrate into treatment plans
12. Become familiar with basic neuroimaging; identify significant findings on MR, CT, radiographs.
13. Participate in multidisciplinary patient care conferences and develop a rehabilitation plan for chronic pain patients.
14. Document longitudinal patient care experiences and new patient evaluations in case logs.
Chronic Pain Service, Department of Anesthesiology, Children’s Memorial Hospital
During the consecutive 4 week rotation (1/2 day, weekly) the fellow will:
1. Describe the approach to evaluation and treatment of pediatric patients with pain complaints.
2. Understand the reasons why pain is viewed as difficult to evaluate in children, is often not recognized by the health care personnel, and consequently, is poorly treated.
3. Identify the difficulties in the evaluation of the pediatric patient with pain and learn how to utilize the available tools for the assessment of pain in this age group.
4. Discuss the need for a multidisciplinary team approach to meet the needs of children and adolescents with chronic pain syndromes.
5. Recognize the importance of treating pain in infants, children and adolescents to enhance their quality of life and to reduce the adverse impact of chronic pain and stress on the course of their illness.
6. Identify how complimentary medicine techniques like acupuncture, massage, and counseling are integrated into the care plan of the pediatric pain patient.
IV. Clinical Responsibilities
The fellow is expected to participate in the clinical activities of the section.
These include making rounds on the postoperative pain patients, seeing inpatient consults, performing neuraxial and peripheral nerve blocks, seeing patients in the outpatient pain clinic and performing interventional procedures therein.
The fellow is expected to demonstrate improvement in manual skills with less need for attending procedure “rescue” as training progresses.
The fellow is expected to demonstrate improved accuracy in assessing history and physical examination findings as training progresses, as validated by supervising attendings who directly observes the fellow’s history taking and examination skills.
The fellow is expected to be involved in the research activities of the division.
The fellow is expected to supervise residents and medical students rotating through the service.
The fellows have no operating room call responsibilities.
The fellows will rotate in taking out-of-hospital calls to answer questions, pages, etc. related to the management of inpatient consults, patients on epidural opioid infusions and continuous peripheral nerve blocks, as well as pain clinic patients. The fellows will cooperatively create and manage a pain call schedule amongst themselves, in conjunction with the APNs on the Acute Pain Service.
The fellows will see emergency consults such as postdural puncture headache in the emergency room, acute vasospasm conducive to sympathetic blockade or patients with impending ventilatory failure secondary to fractured ribs. These emergency consults are rare. The fellow will communicate with the covering pain attending and discuss/plan management of these patients.
The fellows will rotate in making Acute Pain Service rounds on weekends with the attending on call. In most cases, the attending makes rounds by himself on Sundays when the number of inpatients on the service is small.
The fellow is expected to regularly tabulate his experience logs as required by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Anesthesiology (ABA). These logs should be kept on electronic data base. They will be checked regularly by the program director to ensure that program requirements are appropriately met. Failure to complete these logs in a timely manner may result in probation or suspension.
V. Scheduled Teaching Sessions- Educational Responsibilities
Lectures are given to the fellows and residents rotating through the Anesthesiology Pain Medicine Clinic four days a week, Monday - Thursday. The schedule of lectures is made monthly. The lectures are given either by an attending covering the clinic for the day, by one of the fellows, by one of the residents rotating on the service, or by an invited visiting lecturer. There will be monthly Radiology Rounds for the pain fellows whereupon a pain attending reviews interesting, unique or exceptional radiographic images of the spine or appendicular joints in the context of pain management.
The lectures given by the pain fellows are expected to be in-depth and sophisticated than that given by the residents rotating on the service. These lectures should be based on the latest original studies or reviews that have been recently published.
Lectures and presentations will be submitted by the fellow in PowerPoint format to the Program Director or his designee. These will be uploaded onto New Innovations after the presentation is made and will be integrated into each fellow’s Educational Portfolio. The presentations will be reviewed by a pain clinic attending to prevent plagiarism with regard to prior archived presentations. Failure to transmit this information in a timely manner may result in probation or suspension.
There are multidisciplinary lectures and conferences offered throughout the academic year, including monthly Interdisciplinary Spine Conferences and bimonthly Neurosurgery/Pain Conferences. There may be case conferences at the Rehabilitation Institute of Chicago and lectures given to fellows by RIC attendings during the RIC rotations.
Fellows will be relieved of clinic duties to attend lectures and participate in multidisciplinary conferences unless there are extenuating circumstances.
Pain fellows will participate in monthly Anesthesiology Fellow Forum meetings. These meetings are open to all anesthesiology fellows and are directed at improving teaching skills for fellows, and to promote academic activity/career development. A syllabus and schedule of meeting topics will be distributed at the beginning of the academic year.
Fellows are mandated to participate in on-site cadaver workshops developed by the Program Director whereupon interventional procedures including spinal cord stimulators, intrathecal pumps and catheters, upper cervical nerve root injections, intradiscal procedures, and vertebral augmentation procedures. Fellows will be relieved of clinical duties to participate in this activity when possible.
The fellows will participate in 3 mandatory surgical training workshops on site at the Northwestern Center for Advanced Surgical Training in the Olson Pavilion. These are 3-4 hour sessions proctored by general surgeons and pain attending early in the academic year. Fellows will be relieved of clinical duties to attend these workshops. The subjects of suturing, tissue handling, and wound management are covered. Fellows will be given written study materials prior to the workshop and are expected to review these materials before attending the workshops.
The fellows are expected to review assigned reading material pertinent to the care of clinic patients on any given day, including away rotations.
The fellows will present classic and contemporary articles during journal club meetings; the specific journal article to be presented is selected by the fellow and pain attending faculty.
VI. Required Reading List
Required Reading List/Materials Provided
A. A schedule of lectures for the fellows and residents is made every month and is distributed to the fellows. The schedule is given to the fellow at the end of the previous month. All topics required by the ACGME will be covered. The topics that are covered throughout the year include, but are not limited to, the following topics of pain assessment and treatment:
1. Pathways of pain
2. Postoperative pain
3. Physical/neurological examination of the pain patient
4. Electromyography and Nerve Conduction Studies
5. Radiology of the spine
6. Low back pain: Nerve root irritation and radiculopathies, Facet arthropathies, Discogenic pain, Sacroiliac joint arthropathy, Piriformis syndrome
7. Cancer pain
8. Hospice/end of life care issues
9. Myofascial pain syndromes
10. Complex regional pain syndrome (CRPS)
11. Herpes zoster and postherpetic neuralgia
12. Neuropathic Pain
13. Pelvic Pain/Urogenital Pain
14. Obstetric Pain/Pain Syndromes during Pregnancy
15. Pain in Special Populations: Elderly, Addicted & Impaired
17. Major opioids
18. Minor opioids
19. Addiction, pseudoaddiction, dependence, tolerance
20. Nonsteroidal antiinflammatory drugs/COX-2 inhibitors
22. Membrane stabilizers/anticonvulsants
23. Local anesthetics
24. Pharmacology for the interventional physician (steroids, radioopaque dyes)
25. Neuraxial opioid & local anesthetic infusions
26. Patient-controlled analgesia: intravenous & epidural
27. Neuraxial Drug Delivery Systems for Chronic Pain Syndromes
28. Epidural steroid injections
29. Facet joint injections
30. Facet nerve blocks/rhizotomy (RF)
31. Thermal and pulsed RF
33. Intradiscal procedures (eg annuloplasty, biacuplasty)
34. Percutaneous disc decompression procedures
35. Vertebral augmentations (eg Vertebroplasty, Kyphoplasty)
36. Spinal cord stimulator trials, permanent implantations
37. Modalities for Multidisciplinary Pain Management
38. Functional and Disability Assessment
39. Billing Issues in Pain Management
40. Pain Practice Management
B. The fellows are expected to read the following books:
Benzon HT, Raja S, Molloy RE, Liu SS, Fishman SM. Essentials of Pain Medicine and Regional Anesthesia, 3rd ed. Philadelphia: Elsevier-Churchill Livingstone, 2011.
Benzon HT, Rathmell J, Wu et al. Raj’s Practical Management of Pain, 4th ed. Philadelphia: Elsevier-Churchill Livingstone, 2008
Rathmell, J. Atlas of Image Guided Intervention in Regional Anesthesia and Pain Medicine. Philadelphia: Lippincott, Wilkins, and Williams, 2011
Fenton DS, Czervionke LF. Image-Guided Spine Intervention. Philadelphia: Elsevier-Churchill Livingstone, 2002.
A book on spine imaging e.g., Renfrew DL. Atlas of Spine Imaging. Philadelphia: Elsevier-Churchill Livingstone, 2002.
A book on physiatry e.g., Braddom, Physical Medicine and Rehabilitation, 2010
All fellows have access to the Eckenhoff Anesthesiology Library at any time. In addition, an extensive collection of recommended pain medicine textbooks is kept in the Anesthesiology Pain Medicine Center, which fellows have access to at any time. Computer access for journals, reference articles, and other texts are available to fellows at any time on site or from a remote location. All fellows have access to the RIC virtual library in the Learning Center at the Superior Street location
VII. Proposed Examination Process-Written and/or Oral Examination
There is no written examination for the fellows. The fellow is encouraged to have a mock oral examination, near the end of their training, to help in their preparation for the oral examination portion of the American Board of Anesthesiology (ABA) if applicable.
VIII. Evaluations of the Fellows
The fellows are evaluated by attending staff quarterly. In addition, the fellows will be evaluated by supervising faculty during away rotations at the completion of an individual rotation experience. The fellows will be able to access their evaluations through New Innovations. Fellows will electronically sign all four Quarterly Performance Summary Evaluations. The program director will meet with each fellow at least twice during the fellowship to review goals and objectives, assess and communicate areas for fellow improvement, and to identify any issues or problems with the curriculum, clinical experience, or supervising faculty.
IX. Performance Evaluations and Feedback
The fellows are asked to provide evaluations of the faculty every 6 months and the program at the end of their training. In addition, the fellows should complete evaluations of the residents rotating through the outpatient pain center monthly. All evaluations are in New Innovations.