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.

A Transition to Practice Curriculum for Anesthesiology Fellows.

Graduate medical education trainees must be well-versed in practice management principles and how the application of this knowledge affects their patient care. The lack of exposure of anesthesiology trainees to practice management topics remains an ongoing concern nationally. Given similar feedback regarding education on practice management and financial literacy topics across all of our department's fellowship specialties, a novel pilot curriculum comprising a virtual lecture and workshop series was delivered to anesthesiology fellows throughout the academic years 2020 to 2023. Lecture topics included (1) personal finance and contract negotiation, (2) interview preparation and well-being, (3) conflict management, and (4) diversity and inclusion lectures.

Perioperative Considerations for Patients Exposed to Psychostimulants.

Concerns regarding the perioperative management of acute psychostimulant intoxication have been recognized for decades, but novel and diverse substances in this class continue to be developed. Despite the similarities in mechanisms of action among psychostimulants, each subclass within this broad category has unique receptor specificity and different mechanisms that play a role in patient clinical presentation. These issues present challenges to anesthesia providers when caring for patients with either acute or chronic exposure to psychostimulants during the perioperative period. Challenges result from both physiological and psychological effects that influence the action of the primary anesthetic agent, adjuvant anesthetics, and analgesics used for perioperative management of pain. The epidemiology, pharmacology, and perioperative implications of psychostimulant use are presented for amphetamines and similar acting nonamphetamines, cocaine, and, finally, the mixed-action drugs known as entactogens that share stimulant and psychedelic properties. This information is then used as the foundation for safe and effective perioperative management of patients exposed to psychostimulants.

Preoperative Pelvic Floor Injections With Bupivacaine and Dexamethasone for Pain Control After Vaginal Prolapse Repair: A Randomized Controlled Trial.

OBJECTIVE: To test the hypothesis that preoperative pelvic floor muscle injections and pudendal nerve blocks with bupivacaine and dexamethasone would decrease postoperative pain after vaginal native tissue prolapse repairs, compared with saline and bupivacaine. METHODS: We conducted a three-arm, double-blind, randomized trial of bilateral transobturator levator ani muscle injections and transvaginal pudendal nerve blocks before vaginal reconstructive and obliterative prolapse procedures (uterosacral ligament suspension, sacrospinous ligament fixation, levator myorrhaphy, or colpocleisis). Women were randomized to one of three study medication groups: 0.9% saline, 0.25% bupivacaine, or combination 0.25% bupivacaine with 4 mg dexamethasone. Our primary outcome was a numeric rating scale pain score on postoperative day 1. Using an analysis of variance evaluated at the two-sided 0.05 significance level, an assumed variance of the means of 0.67, and SD of 1.75, we calculated 21 women per arm to detect a 2-point change on the numeric rating scale (90% power), which we increased to 25 per arm to account for 20% attrition and the use of nonparametric statistical methods. RESULTS: From June 2017 through April 2019, 281 women were screened and 75 (26.7%) were randomized with no differences in baseline demographics among study arms. There was no significant difference in median pain scores on postoperative day 1 among study groups (median [interquartile range] pain score 4.0 [2.0-7.0] for placebo vs 4.0 [2.0-5.5] for bupivacaine vs 4.0 [1.5-5.0] for bupivacaine with dexamethasone, P=.92). CONCLUSION: Preoperative pelvic floor muscle injections and pudendal nerve blocks with bupivacaine and dexamethasone did not improve postoperative pain after vaginal native tissue prolapse procedures. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03040011.

Near-resolution of persistent idiopathic facial pain with low-dose lumbar intrathecal ziconotide: a case report.

PURPOSE: Persistent idiopathic facial pain (PIFP) is a poorly defined and debilitating chronic pain state with a challenging and often inadequate treatment course. This is the first case report identifying the novel use of low-dose lumbar intrathecal ziconotide to successfully treat PIFP with nearly complete resolution of pain and minimal to no side effects. METHODS: The patient was a 37 year-old female whose PIFP was refractory to multimodal medication management and multiple neurovascular surgical interventions. A single-shot lumbar intrathecal trial of ziconotide (2.5 mL, equivalent 2.5 µg) was injected when she was at her baseline pain level - VAS 7/10. She received complete resolution of her pain for about 9 hours, concordant with ziconotide's half-life. She was subsequently implanted with a lumbar intrathecal delivery system. RESULTS: The patient experienced complete resolution of her facial pain with a single-shot intrathecal trial of ziconotide. The intrathecal pump system has provided nearly complete (VAS 1/10) pain relief. Two flares of pain occurred 10 and 18 months after pump placement, which subsequently resolved after increasing the ziconotide dose by 0.5 µg/day on each occasion. The patient is currently maintained on a dose of 2.0 µg/day and is pain-free. CONCLUSION: This is the first case report describing the use of a single-shot lumbar intrathecal trial of ziconotide and subsequent placement of lumbar (as opposed to thoracic) intrathecal ziconotide pump for PIFP. A single-injection intrathecal trial is a low-risk, viable option for patients with this debilitating and frustrating pain condition. Successful trials and subsequent intrathecal pump placement with ziconotide may supplant multimodal medication management and/or invasive orofacial surgical intervention for PIFP.

Chronic pain clinic efficiency analysis: optimization through use of the Gantt diagram and visit diagnoses.

OBJECTIVE: The aim of this study is to identify scheduling inefficiencies and to develop a personalized schedule based on diagnosis, service time (face-to-face time between the patient and the provider), and patient wait time using a Gantt diagram in a chronic pain clinic. DESIGN: This is an observational prospective cohort quality improvement (QI) study. SETTING: This study was carried out at a single outpatient multidisciplinary pain management clinic in a university teaching hospital. SUBJECTS: New and established chronic pain patients at the University of Pittsburgh Medical Center (UPMC) Montefiore Chronic Pain Clinic were recruited for this study. METHODS: Time tracking data for each phase of clinic visit and pain-related diagnoses were collected from 81 patients on 5 clinic days in March 2016 for patient flow analysis. RESULTS: A Gantt diagram was created using Microsoft Excel® software. Areas of overbooking and underbooking were identified. Median service times (minutes) differed dramatically based on the diagnosis and were highest for facial pain (23 [IQR, 15-31]) and chronic abdominal and/or pelvic pain (21.5 [IQR, 16-27]) and lowest for myalgia. Abdominal and/or pelvic pain and facial pain median service times consistently exceeded the 15-minute allocation for return visits. CONCLUSION: Schedule efficiency analysis using the Gantt diagram identified trends of overbooking and underbooking and inefficiencies in examination room utilization. A 15-minute appointment for all return patients is unrealistic due to variation of service times for some diagnoses. Scheduling appointments based on the diagnosis is an innovative approach that may reduce scheduling inefficiencies and improve patient satisfaction and the overall quality of care. To the best of our knowledge, this type of scheduling diagram has not been used in a chronic pain clinic.

A retrospective review of required projects in systems-based practice in a single anesthesiology residency: a 10-year experience.

STUDY OBJECTIVE: The Accreditation Council for Graduate Medical Education has emphasized in its core competencies and more recently, in its Milestones Project, that residents understand the importance of systems-based practice (SBP). The objectives of the study are to evaluate the quality of residents' SBP projects and to determine the degrees that were subsequently implemented. DESIGN: A retrospective educational observational study. SETTING: A university-based anesthesiology training institution. SUBJECTS: One hundred forty-nine anesthesiology residents in their final (postgraduate year 4) year of training who completed SBP projects for the last 10 years (2004-2013). INTERVENTIONS: A structured SBP course was provided for postgraduate year 4 anesthesiology residents with deadlines set such as project identification, data collection, and proposal draft. Each resident's written SBP proposal received inputs by 2 members of the department executive steering committee. The SBP projects concluded with oral presentations by each resident to the department executive steering committee, who provided overall scores. MEASUREMENTS: All SBP projects were categorized into 7 categories: safety initiatives, economic analysis, process analysis, policy change recommendations, education initiatives, teamwork/communication, and operating room efficiency. Evaluation scores using a Likert scale (1-9, where 9 is the best) were analyzed. The rate of implementation of project ideas within the department based on the presentations to the executive committee was examined. MAIN RESULTS: Of 149 projects, policy change recommendations was the most frequently chosen category (46 projects; 30.9%), followed by process analysis (36 projects; 24.2%). The overall evaluation score was 7.6 ± 0.6 (mean ± SD). A total of 53 projects (35.6%) were implemented in the department. There was no statistical difference between SBPs with implementation vs SBPs without implementation in terms of evaluation scores, year of the presentation, or categories. CONCLUSIONS: This SBP project has given residents the opportunity to participate in a hospital system change aiming to improve efficiency and safety.

Facilitation of resident scholarly activity: strategy and outcome analyses using historical resident cohorts and a rank-to-match population.

BACKGROUND: Facilitation of residents' scholarly activities is indispensable to the future of medical specialties. Research education initiatives and their outcomes, however, have rarely been reported. METHODS: Since academic year 2006, research education initiatives, including research lectures, research problem-based learning discussions, and an elective research rotation under a new research director's supervision, have been used. The effectiveness of the initiatives was evaluated by comparing the number of residents and faculty mentors involved in residents' research activity (Preinitiative [2003-2006] vs. Postinitiative [2007-2011]). The residents' current postgraduation practices were also compared. To minimize potential historical confounding factors, peer-reviewed publications based on work performed during residency, which were written by residents who graduated from the program in academic year 2009 to academic year 2011, were further compared with those of rank-to-match residents, who were on the residency ranking list during the same academic years, and could have been matched with the program of the authors had the residents ranked it high enough on their list. RESULTS: The Postinitiative group showed greater resident research involvement compared with the Preinitiative group (89.2% [58 in 65 residents] vs. 64.8% [35 in 54]; P = 0.0013) and greater faculty involvement (23.9% [161 in 673 faculty per year] vs. 9.2% [55 in 595]; P < 0.0001). Choice of academic practice did not increase (50.8% [Post] vs. 40.7% [Pre]; P = 0.36). Graduated residents (n = 38) published more often than the rank-to-match residents (n = 220) (55.3% [21 residents] vs. 13.2% [29]; P < 0.0001, odds ratio 8.1 with 95% CI of 3.9 to 17.2). CONCLUSION: Research education initiatives increased residents' research involvement.

The cost of resident scholarly activity and its effect on resident clinical experience.

BACKGROUND: Scholarly activity is an important aspect of the academic training of future anesthesiologists. However, residents' scholarly activity may reduce training caseloads and increase departmental costs. METHODS: We conducted this study within a large academic anesthesiology residency program with data from the 4 graduating classes of 2009 through 2012. Scholarly activity included peer-reviewed manuscripts, case reports, poster presentations at conferences, book chapters, or any other publications. It was not distinguished whether a resident was the principal investigator or a coinvestigator on a project. The following data were collected on each resident: months spent on a resident research rotation, number of scholarly projects completed, number of research conferences attended, and Accreditation Council for Graduate Medical Education case entries. Comparison was made between residents electing a resident research rotation with those who did not for (1) scholarly projects, (2) research conference attendance, and (3) Accreditation Council for Graduate Medical Education case numbers. Cost to the department for extra clinical coverage during residents' time spent on research activities was calculated using an estimated average cost of $675 ± $176 (mean ± SD) per day with local certified registered nurse anesthetist pay scales. RESULTS: Sixty-eight residents were included in the analyses. Twenty-four residents (35.3%) completed resident research rotations with an average duration of 3.7 months. Residents who elected resident research rotations completed more scholarly projects (5 projects [4-6]: median [25%-75% interquartile range] vs 2 [0-3]; P < 0.0001), attended more research conferences (2 conferences [2-4] vs 1 [0-2]; P < 0.0001), but experienced fewer cases (980 cases [886-1333] vs 1182 [930-1420]; P ≤ 0.002) compared with those who did not elect resident research rotations. The estimated average cost to the department per resident who elected a resident research rotation was $13,500 ± $9724 per month. The average resident time length away from duty for conference attendance was 3.2 ± 0.2 days, with an average cost to the department of $2160 ± $565. The average annual departmental expense for resident conference travel was an additional $1424 ± $133 per resident, as calculated from reimbursement data. Together, the estimated departmental cost for resident scholarly activity during the residency training period was $27,467 ± $20,153 per resident. CONCLUSIONS: Residents' scholarly activities require significant departmental financial support. Residents who elected to spend months conducting research completed significantly more scholarly projects but experienced fewer clinical cases.