Pain Management Fellowship

Clinical Rotations

The clinical outpatient training in interventional pain is solely at the Center for Pain Management at BMC Brighton.

Trainees are assigned to a particular attending who supervises them for the day on a one-to-one basis. In conjunction with the attending physician, the trainee sees the scheduled new patients, follow-up patients, and patients requiring procedures.

Other rotations are established with BMC Brighton neurology and psychiatry, as well as at Boston Medical Center (the main campus in Boston’s South End neighborhood) for physical medicine and rehabilitation training.

Patient Evaluations & Consults

The trainee plays a major role as a consultant to other specialties. Primary care physicians and specialties such as neurology, neurosurgery, orthopedics, and oncology provide the majority of requests for consultations.

While some of these consultations are done on an inpatient basis, most are outpatients.

For inpatient consultations, trainees are assigned on a rotating on-call basis to the Pain Management Consult Service. They see, evaluate, and manage patients with intractable pain on the medical and surgical wards.

Evaluation of New Patients

For new patients, the trainee takes a careful history and performs a physical exam appropriate for the pain complaint. The trainee presents this information to the attending physician, who sees the patient and confirms the important aspects of the history and physical exam findings.

The attending physician helps the trainee develop an assessment and therapeutic plan and, together, the trainee and the attending physician discuss the plan of treatment with the patient.

Follow-up Visits

For follow-up visits, the trainee obtains updated information from the patient regarding changes in general health, new social stressors, and their response to the previously prescribed therapy. The trainee performs a directed physical exam, subsequently confirmed by the attending.

This information is presented to the attending staff and they work together to develop an assessment and plan.

Together, the trainee and the attending physician present the plan to the patient. As needed, the trainee provides additional clarifying instructions and teaching to the patient.

Fluoroscopy

At the start of the training program, trainees are required to watch a prerecorded lecture and complete a written test on radiation safety and correct operation of the fluoroscopy unit. Lead aprons and radiation badges are provided to trainees for use with fluoroscopy.

Safe and proper use of the fluoroscopy unit are reinforced during interventional procedures using fluoroscopy. Trainees learn not only how to read fluoroscopy images, but also how to direct the beam to obtain the best images using the least amount of radiation exposure to themselves and the patient.

Invasive Procedures

All invasive procedures for pain management are performed under the direct supervision of staff pain physicians.

Trainees are expected to have reviewed the procedure in advance. They obtain informed consent from the patient.

Trainees help prepare the patient and equipment (needles, medications, etc.) with the assistance of a nurse specialist.

According to their level and stage of training, trainees either assist or independently (with close supervision) carry out the procedure.

The trainee takes report from the recovery nurse, assesses the patient during the recovery period, and discharges the patient to home under the direction of the attending physician.

Didactics

A weekly lecture series is organized for staff, fellows, residents, and other allied healthcare personnel to present topics and case studies.

Conferences

Fellows actively participate in monthly multidisciplinary pain management conferences. The Center for Pain Management physician and nursing staff, psychologist, consulting physical therapist, administrator, and secretary are in attendance. Patient cases are discussed, evaluations are compared, and a multidisciplinary treatment plan is developed.

Teaching Opportunities

Fellows give brief morning teaching sessions to one another (in the presence of attending staff) related to topics that arise as a result of patients seen in clinic or on rounds.

Each fellow gives one in-depth, comprehensive presentation on the pain management–related topic of their choice at the Grand Rounds of the BMC Brighton Department of Anesthesiology and Pain Medicine.

Fellows present cases discussed at the monthly multidisciplinary conference when the fellow has seen that patient for an initial evaluation.

Biweekly journal clubs and case presentations are organized and conducted by both pain fellows and anesthesia residents.

Fellows help orient and advise anesthesia residents from the core program at BMC Brighton and serve as a resource to them regarding the policies and procedures of the Pain Management Center. One or two residents rotate through the Pain Management Center each month.

Fellows research and present an assigned core lecture in pain management under the supervision of an attending physician.

Faculty Appointment

Interventional pain medicine fellows are accorded a faculty appointment with the Boston University Chobanian & Avedisian School of Medicine. Included in the appointment is the expectation that fellows will teach the residents rotating through the department. Fellows confer didactic medical knowledge and introduce residents to basic interventional procedures in the fluoroscopy suite.

Boston University provides resources for faculty development, and our interventional fellows are encouraged to take advantage of these resources for teaching and personal publication.

Research

The Pain Management Center space and facilities are used for clinical studies done in collaboration with BMC Brighton’s Department of Anesthesiology.

Research opportunities may include those focused on:

• Cancer pain
• Complementary therapies
• Joint clinical studies with other BMC Brighton departments, such as orthopedics, oncology, and radiology, as well as other multidisciplinary pain management centers
• Outcomes research and evidence-based medicine
• Palliative care
• Pharmaceuticals
• Radiology

Evaluation of Pain Management Trainees

Formal written evaluations of trainee progress will be conducted at six-month intervals. Evaluations may be done more frequently at the direction of the Program Director.

A scoring evaluation is completed by appropriate staff every six months, and constructive comments are encouraged from the attending staff. These evaluations are reviewed by the Program Director.

The Program Director will meet with each resident on at least a biyearly basis to review their evaluations. Each resident is given a summarized copy of the evaluation and a copy is retained by the department.

Evaluation of Faculty by Trainees

Faculty members will be evaluated yearly by the trainees. They will be evaluated in five different areas (availability, personal attributes, case-related teaching ability, didactic teaching, and overall contribution to learning) on a 1 to 5 Likert scale.

These evaluations are completely confidential and anonymous. The results are tallied by the departmental manager and a percentile score is developed for each faculty member, for each question, as well as a total percentile of the faculty member’s teaching evaluation. These evaluations are reviewed annually with each faculty member.

Policies and Procedures

Pain management trainees are expected to become familiar with the program’s policies and procedures during the first three months of the academic year.

Documentation and Follow-up

Trainees are responsible for administrative follow-up (dictations, forms, reports, etc.) related to consultations and procedures in which they have been involved. Also expected are documentation of returned phone calls and communication with the attending physician.

Medical Billing and Coding

Trainees attend physician meetings with the contracted billing company representative for updates on appropriate pain management coding, documentation, etc.

Scheduling and Clinic Management

Pain management trainees organize the clinical coverage schedule for themselves with the assistance of the program director and/or administrator. Administration and management principles, including scheduling, reimbursement, referral requests, and front office management are studied as part of the didactic curriculum.

Progam Quality Assurance

The quality assurance process, led by the Center for Pain Management administrator, includes study and documentation of:

• Patient access for cancer patients
• Use of psychological services within the clinic
• Patient follow-up
• Wait times for invasive procedures and other institution-wide CQI studies.

Some of the above quality assurance studies will continue, and others will be developed.

The Pain Management Fellowship Program will have an ongoing daily process of tracking outcomes. Any procedural problems, standard-of-care issues, and systemic shortcomings can be identified and dealt with in a prompt and appropriate manner. These quality assurance procedures will be flexible and closely intertwined with the trainees’ education, and with the Center for Pain Management’s clinical practice.