Publications
APS Bulletin • Volume 17, Number 3, 2007
Training Issues and Advancement
Robert P. Yezierski, PhD, Department Editor
New ACGME Requirements for Fellowship Training in Pain Medicine
Honorio T. Benzon, MD, James P. Rathmell, MD, Marc A. Huntoon, MD
Department editor’s note: Training programs in pain medicine represent the pipeline for healthcare professionals who will meet the needs of the next generation of pain patients. In recent years, the requirements for these training programs have undergone significant changes in an effort to produce better pain medicine physicians who appreciate the role of other specialists in meeting the challenges of pain management. In the following article, the new guidelines adopted by the American Council for Graduate Medical Education (ACGME; 2007) are reviewed.
Until the advent of formal training programs in pain medicine 15 years ago, training in pain medicine was carried out through informal fellowships under the tutelage of self-trained experts, such as John J. Bonica, who developed the field (Rathmell & Brown, 2002). The ACGME established formal accreditation of pain fellowship training programs in 1992, and the first trainees to complete the new qualifying examination received the Certificate of Added Qualifications in Pain Management from the American Board of Anesthesiology in 1993 (this has since been renamed Subspecialty Certification in Pain Medicine). The ACGME establishes guidelines that spell out specific required components for all postgraduate physician-training programs. The original Program Requirements for Training in Pain Management (later renamed Pain Medicine) were accepted in June 1998 and became effective July 1, 1999. These requirements were intended solely to establish a means for subspecialty training of anesthesiologists. The Program Requirements underwent minimal revision in 2000 and 2003, but remained largely unchanged since their original conception 20 years ago, failing to keep pace with a rapidly evolving field. The ACGME recently adopted new and completely revised Program Requirements for Fellowship Training in Pain Medicine, which officially went into effect July 1, 2007 (ACGME, 2007). In this article, we will describe the process that led to the development of the new Program Requirements and discuss how they are aimed at broadening the training of all pain medicine specialists to include multidisciplinary care.
The original Program Requirements mandated that each training program be directly associated with a core residency program in anesthesiology accredited by the ACGME. The duration of training lasted 12 months with a minimum of 9 months in clinical pain medicine. The Program Requirements called for trainees to see a minimum of 200 new patients with 30 new patients each in acute, chronic, and cancer pain. Experience with both inpatients and outpatients was required, but no specific numbers were noted. The didactic curriculum was required to cover a broad range of topics, including the anatomy and physiology of pain pathways and the ethics of pain research. Although these original requirements were meant to promote the training of pain subspecialists with a broad range of experience crossing numerous disciplines, they rapidly became outdated as the field of pain medicine underwent rapid growth and change. The primary limitation of the original Program Requirements was its excessive focus on neural blockade and its lack of clear instruction on training nonanesthesiologists. Program directors were also faced with an increasing number of qualified nonanesthesiologsists who wished to enter the discipline. How could program directors, who were largely anesthesiologists running busy acute postoperative epidural analgesia services, train a neurologist or psychiatrist in the technical aspects of neural blockade? With these obstacles in place, how could nonanesthesiologists gain equal access to subspecialty training in pain medicine? For the ACGME Residency Review Committee (RRC) for Anesthesiology the question became, “How could the Program Requirements be made stringent enough to prevent the continual reaccreditation of programs that offer nothing more than technical training in acute postoperative pain management without exposing trainees to the broad scope of the multidisciplinary management of chronic pain?” From the patient’s point of view, the question to consider was, “How could training pain medicine specialists be improved to eliminate the tremendous lack of consistency in what is offered from one pain subspecialty clinic to another?”
With these difficulties before them, the leaders of the ACGME RRC for Anesthesiology set out to radically modify pain medicine training, aiming to improve the quality of all training programs and ensure access to a broad range of medical specialties and subspecialty training in pain medicine. Leaders from the ACGME RRC for Anesthesiology (i.e., Drs. Butch Thomas and James Arens) first met with the Association of Pain Program Directors (APPD) in 2001. The APPD comprises program directors of ACGME-accredited pain medicine fellowships. The ACGME outlined their goals and asked that we join a group of representatives from numerous disciplines to craft revisions to the Program Requirements for Training in Pain Medicine. The result was the formation of the ACGME ad hoc Task Force on Pain Medicine. The group came together approximately twice a year between 2002 and 2004, and was composed of representatives from the RRCs for Anesthesiology, Physical Medicine & Rehabilitation (PM&R), Psychiatry, and Neurology, as well as a member from the American Board of Pain Medicine (a group that has promoted the creation of primary residency programs in pain medicine). This ad hoc committee wrestled with how to create optimal training that would expose trainees to the expertise of each primary field during the course of fellowship training. It was clear from the outset that trying to accomplish such broad exposure during a 12-month training period would be difficult, if not impossible. Extending the fellowship to 2 years was also deemed unfeasible; a survey clearly suggested that the majority of current trainees would not be willing to bear an additional 2 years of training nor would there be funding for an extension in the training period. What evolved was the concept of a 6- month period of prerequisites, during which trainees would spend 2-month rotations on each of the three specialty services other than their own parent discipline. The RRC for Anesthesiology set out to incorporate this prerequisite period into the PGY-4 (CA-3) year, to be completed before the commencement of the formal 12-month fellowship. This would prevent extending the overall length of training. However, support for the 18-month fellowship from the other RRC members of the ad hoc committee gradually eroded. Finally, the RRC for Anesthesiology asked our group (APPD) to take the final draft of the 18-month fellowship produced by the ad hoc committee and craft the best possible training program within the constraints of a 12-month period. The current requirements are largely the product of the ad hoc committee’s original document, but revised by our group to fit a 12-month training program. Key elements of the revised requirements are highlighted in Table 1.
Several changes are evident between the old and new Program Requirements. Although the original requirements for a fellowship in pain medicine included that the program had to be related to a core residency program in anesthesiology, the new Program Requirements pave the way for core residency programs in other disciplines to establish pain medicine training programs (the only caveat being that only a single training program will be accredited at each institution). Cognizant of the multidisciplinary nature of pain medicine, the ACGME revised the requirements to integrate neurology, PM&R, and psychiatry and standardized the training program and requirements regardless of the sponsoring specialty. As in the previous requirements, the training program is to last 12 months, although it can be extended if there is a clear educational rationale for the additional experience.
Common to both the old and new requirements is the description of the qualifications and responsibilities of the program director. The program director and the faculty must be certified in their primary specialty and subspecialty certified in pain medicine (or hold “equivalent qualifications acceptable to the [ACGME] RRC”). The responsibilities of the program director are unchanged: to organize and oversee the educational activities of the program, prepare an accurate narrative and statistical description of the program, and implement fair policies, grievance procedures, and due process. However, the new requirements incorporate the ACGME Core Competencies and Requirements, including limitations to duty hours, on-call activities, and moonlighting. Duty hours must be limited to 80 hours a week averaged over a 4-week period. In-house call must occur no more frequently than every third night, and continuous on-site duty must not exceed 24 hours. At-home or pager call must not be more frequent than every third night averaged over a 4-week period. Fellows must have 1 day in 7 free from all educational and clinical responsibilities averaged over a 4-week period. Evaluations of the trainee must be timely, in writing, and accessible to the trainee, and final evaluation of the trainee must be included in the trainee’s permanent record. The trainees must also evaluate the faculty. Finally, a group consisting of the program director, one fellow, and one additional faculty member must evaluate the effectiveness of the program each year, identify deficiencies, and recommend changes to improve the program.
Perhaps the most important addition to the new requirements is the mandate that all programs must be multidisciplinary. Indeed, the institution where the program is basedmust have ACGME-accredited residencies in at least two of the following specialties: anesthesiology, neurology, PM&R, and psychiatry, along with an institutional policy that ensures cooperation among the involved disciplines.
The didactic curriculum in the new Program Requirements has been expanded and is now more detailed. The ACGME requested and was given approval from the International Association of Pain (IASP) to use their Core Curriculum for Professional Education in Pain (Charlton, 2005) as the template for the required didactic program, which allowed the ACGME to take advantage of the extensive work conducted by IASP to formulate this up-to-date curriculum.
The requirements for clinical experience within the new Program Requirements recognize that trainees may come from many differing parent specialties and they mandate that all trainees attain significant exposure to anesthesiology, neurology, PM&R, and psychiatry. The specific minimum clinical experience required for each discipline is shown in Table 2.
In addition to the required exposure to specific disciplines, the trainee must see a minimum number of new patients: inpatient chronic pain experience = 15; acute pain inpatient experience = 50; interventional experience = 25; cancer pain = 20; and palliative care = 10. A rotation through pediatric pain is encouraged but not mandated.
For those programs that choose to offer the “advanced interventional track,” the fellow must demonstrate competence in a number of specific interventional techniques. The ACGME has given guidance on minimum numbers for each technique, but clearly indicates that the numbers are only to be used as a general guideline. Indeed, the ACGME states that the specific procedures used in interventional pain medicine are likely to change rapidly over time. New techniques are being introduced continually and interventionalists have been eager to embrace these techniques, even without randomized controlled trials to support implementation of the technique (Rathmell, 2004). Adequate training of fellows should provide enough background to determine whether the new technique should be adopted and how a competent practitioner should introduce these emerging therapies into clinical use. In fact, the new Program Requirements stipulate that program directors write a final summary letter detailing the specific techniques for which each trainee has demonstrated competence. This new requirement should serve as an invaluable aid to hospital credentialing committees as they grapple with credentialing new physicians (Lubenow & Rathmell, 2005) and understanding the amount of experience new physicians have with new and emerging techniques.
The new ACGME Program Requirements now mandate exposing all trainees to the core specialties relevant to pain medicine and ensure that each trainee demonstrates a minimum of clinical experience. The involvement of many specialties is welcome and much needed. Familiarizing trainees with the different subspecialties will make them more aware of the breadth of approaches to treating patients with chronic pain and will undoubtedly make them better pain medicine physicians. The subspecialty of pain medicine continues to develop and is now attracting extremely qualified applicants from many parent medical disciplines. With improved and standardized training, future graduates will bring the subspecialty to greater heights, performing translational research and much-needed clinical research that will allow us to practice evidence-based medicine (Merrill, 2003). The new ACGME Program Requirements are a first step in the right direction toward establishing pain medicine as a well-recognized subspecialty with a consistent and broad approach to treating patients suffering with chronic pain (Rathmell & Brown, in press).
References
American Council for Graduate Medical Education. (2007). ACGME Program Requirements for Fellowship Education in Pain Medicine. Retrieved August 19, 2007 from www.acgme.org/acWebsite/ downloads/RRC_progReq/sh_multiPainPR707.pdf.
Charlton, J.E. (2005). Core Curriculum for Professional Education in Pain (3rd. ed.). Seattle, WA: IASP Press.
Lubenow, T. R, & Rathmell, J. P. (2005, August). Let’s take a rational approach to technical training in pain medicine. American Society of Anesthesiologists Newsletter,69(8), 6–8.
Merrill, D. G. (2003). Hoffman’s glasses: Evidence-based medicine and the search for quality in the literature of interventional pain medicine. Regional Anesthesia and Pain Medicine, 28, 547–560.
Rathmell, J. P. (2004). The injectionists. Regional Anesthesia and Pain Medicine, 29, 305–306.
Rathmell, J. P., & Brown, D. L. (2002, October). Evolution of pain medicine training in the United States. American Society of Anesthesiologists Newsletter, 66(10). Retrieved November 6, 2007 from asahq.org/Newsletters/2002/10_02/feature1.htm.
Rathmell, J. P, & Brown, D. L. (in press). Education, training, and certification in pain medicine. In: H. T. Benzon, J. P. Rathmell, C. Wu, D. C. Turk, & C. E. Argoff (Eds.), Practical Management of Pain (4th ed.). New York: Elsevier.
Honorio T. Benzon, MD, is professor of anesthesiology in the division of pain medicine at Northwestern University Feinberg Medical School, Chicago, IL.
James P. Rathmell, MD, is associate professor of anesthesia at Massachusetts General Hospital and Harvard Medical School, Boston, MA.
Marc A. Huntoon, MD, is associate professor of anesthesiology at the Mayo Clinic College of Medicine, Rochester, MN.
The authors are present or past presidents of the Association of Pain Program Directors (APPD).