UNIVERSITY OF FLORIDA PAIN

 MANAGEMENT FELLOWSHIP PROGRAM

The Anesthesiology department’s ACGME approved Pain Medicine Fellowship Program is sponsored through the University of Florida and is based at the Malcolm Randall VA Medical Center (MR-VAMC), specifically in association with the Pain Management Clinic.   Rotations for Fellows at Florida Pain Clinic, Ocala, Florida and North Florida Hospice, Inc., @ E.T. York Hospice Care Center, Gainesville, FLorida providing Fellows with additional opportunities in their comprehensive education and training program.

Pain Management Fellowship Contact Information:

For Fellowship Information:

Box 100254

Department of Anesthesiology

University of Florida College of Medicine

Gainesville, FL  32610-0254

Contact Phone #:  352.265-0077 (Debbie Brown or Ricky McHugh)

Contact E-mail:  Contact E-mail: dbrown@anest.ufl.edu or RMcHugh@anest.ufl.edu

Application for Pain Management Fellowship Training - Microsoft Word version,

Mail your completed application (with recent photo and applicable enclosures) to:

Andrea Trescot, MD, Director

c/o Debbie Brown and Ricky McHugh, Coordinators
UF Pain Management Fellowship Program

University of Florida College of Medicine
Department of Anesthesiology
1600 SW Archer Road
Gainesville, FL 32610

________________________________________________________________________________________

FACULTY and ADMINISTRATION

Malcolm Randall VA Medical Center:

Andrea Trescot, M.D., Pain Clinic Medical Director and Pain Medicine Fellowship Program Director

Emilio B. Lobato, M.D., Acting Chief of Anesthesiology Service

University of Florida:

Jerry J Berger, MD

F Kayser Enneking, MD

William Paul MD

Florida Pain Clinic, Ocala Florida:

Stephen T. Pyles, MD

North Central Florida Hospice Inc., @ E.T. York Hospice Care Center

Neel Karnani, MD

FELLOWSHIP ROTATION SCHEDULE TEMPLATE

Responsibilities of Physicians

The Pain Physician is responsible for the care of the patient as it relates to pain management therapy and/or assessed pain related  medical problems. The pain Fellow’s clinical assignment and duties will be based on the following grid, which will lead to a well balanced clinical and basic science exposure.

 Assigned Fellow Rotations

Legend

VAMC[C]-   MR-VAMC anesthesiology chronic pain clinic

VAMC[R]-   MR-VAMC based rotating assignments

              -  Four-month clinic based rotation

I. MR-VAMC Pain Management Rotation

PAIN MEDICINE FELLOWSHIP

GOALS & OBJECTIVES

CORE ROTATION INFORMATION

The Anesthesiology Department’s ACGME Pain Medicine Fellowship Program is sponsored through the University of Florida and is primarily based at the Malcom Randall VA Medical Center (MR-VAMC) Pain Management Clinic.

The fellows gain experience in chronic pain management experience at the free standing Outpatient VA Pain Clinic. Working together with the faculty members, a pain management plan is developed and treatment initiated.  The clinic sees approximately 850 new patients per year, and performs more than 4000 procedures. Common pain problems treated are:  upper and lower back pain, neck pain, cancer pain, complex regional pain syndrome, post-herpetic neuralgia, pancreatic pain, phantom limb pain, diabetic neuropathies, degenerative joint disease, chronic headaches, and central and neuropathic pain of all origins.  Fellows will be trained in multiple procedures including:  stellate ganglion blocks; thoracic and lumbar sympathetic blocks; celiac plexus blocks; cervical, thoracic, and lumbar facet blocks; cryoneuroablation and radiofrequency lesioning, cervical, thoracic, lumbar, and caudal epidurals, adhesiololysis and spinal endoscopy, as well as spinal cord stimulators, intrathecal pumps, vertebroplasty, discograms and intradiscal procedures.  Fellows will also become proficient in the use of pharmacologic pain control methods including opioid analgesics, non-steroidal analgesics, antidepressants, anticonvulsants, hypnotics, and other relevant pain medications. On-site massage/neuromuscular therapy, acupuncture, and psychology allow a multidisciplinary approach to pain patients.

The Fellows are rotated in one-month blocks to related specialties requiring a knowledge of pain. This allows the Fellows to become better consultants by understanding the needs of physicians in other specialties.  This also allows the Fellow to have an understanding of patient dynamics in relation to medications and the reasonable expectations of other therapeutic modalities.  The rotations include: (1) Psychiatry/Psychology/Addiction Medicine; (2) PhysicalMedicine and Rehabilitation; (3) Oncology and Palliative Care; and (5) Acute Pain. Additional advanced level elective rotations in pain management are available at a variety of locations.

General Goals

This program will help the Fellows develop the skills needed to ameliorate suffering caused by chronic pain problems.  The Fellow will learn to use many indicated pain treatment modalities, by learning to perform an initial assessment of the patient with chronic pain, deciding on appropriate diagnostic testing, developing skills in performing diagnostic and therapeutic procedures, and learning the appropriate use of pharmacotherapy.  In addition, the Fellow will develop communication skills helpful in developing a professional, therapeutic relationship with chronic pain patients and their families.  Using a multidisciplinary approach, the Fellow will learn to develop management strategies, tailoring pain management and treatment modalities to the patient's individual needs. 

SPECIFIC COMPETENCIES:  (General Competencies also apply)

Patient Care Skills

• Assessment skills:
• Performance of a thorough, goal-directed patient history with emphasis on historical information relevant to the patient's chronic pain problem.  Because the etiology of a chronic pain problem is often complex, the Fellow must be able to perform a complete, thorough history of the pain problem as well as a comprehensive review of all systems.
• Performance of a thorough, goal-directed physical examination with emphasis on the neurologic system.  Because the etiology of a chronic pain problem is often complex, the Fellow must be able to perform a complete, comprehensive physical examination of all systems.
• Appropriately order laboratory tests, radiologic studies, and psychological testing in order to assist in determining the nature / etiology of the patient's chronic pain problems.
• Based on information obtained from the history, physical examination, and testing, develop a complete differential diagnosis of the patient's chronic pain problem.
• Be able to differentiate among the different common chronic disease states including, but not limited to, neuropathic pain, sympathetically mediated pain and myofascial pain syndromes

• Management skills
• Be aware of the various available modalities for treatment of the patient with chronic pain and appropriately utilize a multidisciplinary approach to designing a treatment plan
• Pharmacotherapy
• Appropriately use the different classes of drugs available for the treatment of chronic pain syndromes (including opiates, nonsteroidal antiinflammatory drugs, anxiolytics, anti-convulsants, antidepressants, local anesthetics, and others)
• Diagnostic and Therapeutic blocks
• Perform appropriate pre-procedure evaluation
• Obtain informed consent
• Be able to perform common blocks.
• Know when it is appropriate to refer patients to different specialists for definitive or adjunctive therapy, for example, neurosurgery, orthopedic surgery, neurology
• Provide appropriate post-procedural follow up and continuing care
• Provide appropriate continuing care for patients receiving non-procedural treatment
• Be able to independently evaluate and develop a treatment plan for patients with common pain syndromes including:
• Trigeminal neuralgia
• Post-herpetic neuralgia
• Phantom limb pain
• Diabetic neuropathy
• Sympathetically mediated pain
• Low back pain
• Neck pain and headaches
• Myofascial pain
• Inflammatory mediated pain such as bursitis, carpal tunnel syndrome, arthritis related pain
• Visceral pain
• Evaluate for and participate in the more invasive pain management modalities including
• Facet injections
• Adhesiolysis
• Radiofrequency lesions
• Selective nerve root/ transforaminal injections
• Sympathetic blocks
• Spinal cord stimulation
• Intrathecal pump implantation
• Celiac plexus and splanchnic nerve blocks
• Vertebroplasty
• Intradiscal Electrothermal Therapy (IDET) and other intradiscal therapies
• Know indications, efficacy, contraindications, and complications of the above pain procedures.
• Know supportive neuroanatomy to facilitate performance of these more invasive blocks
• Develop an understanding of the organization and administration of a Pain Clinic

Medical Knowledge

• Know current theories regarding the pathophysiology of chronic pain syndromes
• Based on an understanding of the pathophysiology of each syndrome, know which syndromes are best handled by pharmacotherapy, physical or occupational therapy, therapeutic interventional procedures, or alternative pain management methods such as massage therapy or acupuncture.  Know which pain syndromes are best treated with more invasive modalities such as spinal cord stimulation, implantable intrathecal pumps, or ablative procedures such as radiofrequency lesions or cryoneuroablation.

• Know the neuroanatomy relevant to the performance of diagnostic and therapeutic blocks
• Learn the anatomy of the sympathetic and somatic nervous systems, specifically, the anatomy of the epidural and subarachnoid spaces and the location of sympathetic and parasympathetic ganglia
• Know the cutaneous dermatomal mappings 
• Know medical conditions that may cause chronic pain (e.g. herpes zoster)
• Know the types of drugs that relieve pain and their efficacy, indications, doses, side effects, interactions, and contraindications - specifically:
• opiates
• non-steroidal antiinflammatory drugs
• anticonvulsants
• local anesthetics
• antidepressant medications
• sedatives
• anxiolytics
• How doses and dosing intervals may have to be adjusted in patients with chronic pain
• Know the different modalities of physical therapy that may relieve both acute and chronic pain and learn how to obtain such therapy 
• Know the indications and efficacy of each of the above described blocks for common chronic pain syndromes.
• Know the complications associated with each of the above described blocks

INTERPERSONAL AND COMMUNICATION SKILLS, PROFESSIONALISM

• Learn interpersonal skills that enable the pain physician to communicate effectively with the difficult, hostile or needy chronic pain patient
• Gain skills to be able to avoid being manipulated by patients with chronic pain and to maintain control of the therapeutic relationship
• Learn to accept the slow pace of improvement often seen in this patient population
• Learn to effectively communicate with other professionals who have skills helpful to the patient with chronic pain
• Learn to communicate effectively with the patient's primary care physician to gain information needed for your evaluation of the patient and to provide ideal continuing longer term care for the patient.

PRACTICE-BASED LEARNING AND IMPROVEMENT

• Learn to efficiently manage a pain clinic that must (and often simultaneously):
• Evaluate new patients
• See return / follow-up patients
• Perform invasive procedures
• Deal with multiple phone calls from patients

SYSTEMS-BASED PRACTICE

• Appropriately utilize consultants and laboratory testing to correctly diagnose and develop treatment plans for patients with chronic pain
• Anticipate the impact of each patient's pain pathology and planned procedure(s) on the level of subsequent care and follow-up required.
• Integrate the care of the pain management specialist with the patient's primary care physician to best manage the overall patient.
• Practice cost-effective, safe pain management

Evaluation to Determine Goal Achievement:

• At the end of the rotation, the Fellows will take a short oral examination designed to specifically test ability to diagnose common pain syndromes and knowledge of commonly applied treatments for these syndromes. The answers will be reviewed at the time of the examination. 
• Knowledge and skills in the management of acute pain will be tested by an oral examination in which fellows discuss a case scenario and your approach to the case.
• Fellows are evaluated online weekly by all attendings with whom they have contact.  The attending physicians complete a Departmental Fellow Evaluation Form, which are reviewed quarterly by the Clinical Competence Committee and continuously by the program director.  The Program Director informs the Fellows of any problems identified, and serious problems will be discussed immediately after they occur. 
• Fellows will complete a Departmental Rotation Evaluation Form.

Teaching Resources to Accomplish the Objectives

In fiscal year 2007, the Veterans Administration Pain Center saw 8040 patients, which included:

• New patients: 830
• Return patients: 3360

• Procedures: 4060
• Facets/MBB: 1200
• SI injections: 600
• Epidurals
• Cervical: 70
• Thoracic: 10
• Lumbar: 240
• Caudal: 140
• Adhesiolysis: 60
• Facet RF: 660
• Cryoneuroablation: 30
• Fluoroscopic joint injections: 80

The clinic has since added discography, spinal cord stimulation, and IDET, with the anticipation of vertebroplasty/kyphoplasty and spinal endoscopy.

• Other Specialty Rotations
• Palliative Care (VA Palliative Care Service)/ Haven Hospice
• Medical management
• End of life care
• Oncology (VA Oncology Service)
• Advance pain management procedures
• Intrathecal drug system maintenance
• Epidural drug system maintenance
• Radiotherapy palliation
• Chemotherapy management
• Physical Medicine and Rehabilitation (UF Orthopedic Clinic)
• Physical diagnosis
• Physical therapy
• Orders and expectations
• Electrodiagnostics
• Psychiatry/Psychology/Addiction Medicine (Shands Pain Clinic)
• Patient dynamics
• Addictive behavior
• Physician-patient interaction
• Medication management
• Identification and treatment of depression in pain patients
• Acute pain/ Regional Anesthesia (Shands Anesthesia Department)
• Ultrasound directed injections
• Catheter techniques
• Inpatient pain management
• Implantables (North Florida Hospice, Inc., E.T. York Hospice Care Center in Ocala)
• Focus on major invasive procedures in private practice setting

• Text Books:
• Waldman SD.  Interventional Pain Management, 2nd Edition.  W.B. Saunders Co, New York, 2001
• Raj PP.  Practical Management of Pain, 3rd Edition.  Mosby, 2000.
• Benzon et al.  Essentials of Pain Medicine and Regional Anesthesia, Churchill Livingstone, 1999.
• Abram SE, Haddox JD.  The Pain Clinic Manual., 2nd Edition.  Williams and Wilkins, Philadelphia, 2000.
• Netter FH. Atlas of Human Anatomy., 2nd Edition.  ICON Learning Systems, New Jersey, 1997
• Cousins MJ, Bridenbaugh PO.  Neural Blockade in Clinical Anesthesia and the Management of Pain, 3rd Edition.  Lippincott-Raven, Philadelphia, 1998.
• Manchikanti, L. Interventional Techniques in Chronic Spinal Pain. ASIPP Press 2007

• Faculty: 
• Andrea Trescot, M.D., Program Director
• Vance Elshire, M.D.
• Mark Larkins, MD

ACGME Requirements

Neurology

 1. Elicit a directed neurological history         

       Perform a detailed neurologic exam

                      Mental status

                      Cranial nerves

                      Motor, sensory, reflex exam

                      Cerebellar examination

        15 patients (5 faculty observed pt examinations)

2. Interpret basic neuro-imaging (CT and MRI of the spine)

        15 CT and/or MRIs (brain, cervical, thoracic, and lumbar spine)

              (can be done via neurology, neurosurgery, or radiology)

3. Understand the indications and interpretation of electro-diagnostic studies

              (can be done via PM&R)

Psychiatry

1. Elicit a complete psychiatric history and mental status exam

         15 patients (5 faculty observed pt examinations)

2.  Understand the principles and techniques of the psychosocial therapies

3. Appreciate the psychiatric and pain co-morbidities

(mood, anxiety, somatoform, factitious, and personality disorders)

Anesthesia (for non anesthesia trained fellows)

1. Obtain IV access in a minimum of 15 patients
2. Confirm basic airway management

Mask ventilation and endotracheal intubation in a minimum of 15 patients

Obtain BCLS and ACLS certification

1. Deliver direct administration of sedation to a minimum of 15 patients
2. Administer neuroaxial anesthesia

Thoracic or lumbar epidural anesthesia w/out fluoro in a minimum of 15 patients

Physical Medicine and Rehabilitation

1. Elicit a full musculoskeletal history and the appropriate components of a neuro-musculosketal exam

H&P in 15 patients, clinical evaluation in a minimum of 5 patients

Outpatient Pain Experience

1. Provide continuum of care to patients in an approximately weekly supervised program throughout the year.

Primary patient responsibility for at least 50 different patients, each over at least 2 months; full time equivalent of at least 60 half-days

1. Interact with other specialists in a multidisciplinary model

Acute Pain Experience

1. Supervision on a team involved in the assessment and management of inpatients with acute pain.

Document a minimum of 50 new patients

Inpatient Pain Experience

1. Supervision on a team involved in the assessment and management of inpatients with chronic pain, including cancer pain.

Document a minimum of 15 new patients

Cancer pain Experience

1. Supervision of a longitudinal experience in an ambulatory or inpatient cancer pain population
1. Understand the clinical approach to multidisciplinary pain care
2. Understand the strategies to integrate pain management into the treatment model

Document a minimum of 10 patients who need palliative care

Revised:  5/8/08 (dsb)