Fellowship education in a new era of pain medicine: concerns and commentary for change

We are concerned about the current state of pain medicine education in our country and the future of our field. The current 1-year fellowship program might not adequately meet the needs of our learners and patients. Although there have been significant improvements in pain care since the inception of pain fellowships more than 3 decades ago, fellowships have struggled to keep up with the exponential increase in educational content due to the availability of new percutaneous surgical techniques and novel pharmacological options for pain treatment. However, more patients have access to pain care than ever before, and the volume of data from patient interactions over several decades has exposed the need for emerging pharmaceutical and procedural technologies. Whereas the diagnosis of chronic pain pathology has improved over time, comprehensive treatment is still lacking, secondary to insufficient resources. This unmet need places pain medicine in an unsustainable position for the future. Educational time in pain fellowships is not adequate to cover the breadth of content needed to develop the scope of knowledge necessary to offer the high-quality pain care that is needed to support our society. Although much progress has been made in the past 3 decades in identifying shortcomings in pain care and innovative treatments, there is still much to be done. It is time that our current leaders apply what was learned to create a system to support the burgeoning field our predecessors created.1,2 The field of pain medicine plays a vital role within the health care system and encompasses a core of thought leaders within pain societies and academic centers who are eager to carry the field into the next era of development. The main participants have been anesthesiology, physical medicine and rehabilitation (PMR), neurology, and psychiatry,3 each of which has made important contributions to our field. Most pain fellowship programs focus primarily on anesthesiology and PMR, with limited integration of other core fields, such as neurology and psychiatry. It is time for a more hybridized approach to education that embraces each of these fields’ expertise in a more comprehensive manner. Unfortunately, the current 12-month pain fellowship does not allow sufficient time for most programs to provide a truly multidisciplinary balanced curriculum. Additionally, there is a growing need to integrate surgery and radiology into pain medicine training to ensure that practitioners possess the necessary skills to successfully perform more novel and advanced percutaneous procedures. This integration would also require a research arm within fellowships to support the use of these new technologies. I argue that pain medicine requires more formal education to adequately instruct learners if it is to survive in the new era. The post–COVID-19 era has acutely changed the landscape of pain medicine fellowship applicants. Although the number of physiatry (PMR) and neurology applicants, who have historically applied with consistency, continues to grow,3–5 there has been a modest decline in the number of anesthesiology residents because of the increasing demand for general anesthesiologists and the subsequent strong job market. On the other hand, the number of applicants from other specialties, such as emergency medicine, internal medicine, and family medicine, has significantly increased. This presents a fundamental issue with education as it currently exists within pain fellowships. Most programs have designed their training to cater to the knowledge base of anesthesiology and PMR, as these are the specialties that have the greatest representation of Accreditation Council for Graduate Medical Education (ACGME) pain medicine graduates. However, the influx of new trainees from other specialties will require time to build mutual understanding and bridge knowledge gaps between trainees and faculty. This compatibility assessment could take several generations to stabilize, similar to when pain medicine became a popular postgraduation destination for PMR physicians. There is a pressing need to integrate specialties, as multispecialty collaboration is the accepted model for chronic pain treatment. However, until the field has educators with diverse clinical backgrounds, pain medicine fellowships will face steep learning curves that require time and patience to overcome, and unfortunately, most academic centers lack the necessary resources for this. There might be several ways to address the issue of additional education. The options we suggest are listed in descending order of their potential impact on our field and the challenges they pose: Pain medicine has the internal talent and society representation to become its own specialty. This has the disadvantage of breaking away from sponsoring programs, which support the financial structure of the current fellowships. In addition, medical schools must also recognize pain medicine as a specialty, and this requires a significant build within academic institutions for which capital, space, and organizational structure must be developed for each program. Although this might be the most grandiose way of growing the field, the potential for losing support from sponsoring specialties makes it an inherently risky proposition. Fellowship length could be extended to support extra surgical, radiology, and multidisciplinary education, as well as research to help provide a truly comprehensive curriculum and produce highly skilled pain physicians. However, extending the pain fellowship beyond 1 year might dissuade some residents from applying, as they are eager to start their careers. Programs would need to demonstrate the benefits of increased training for professional success, but budgetary limitations from the ACGME could hinder this proposition. Sponsoring residencies could create advanced pain tracks within their programs, offering additional rotation time for applicants interested in pain medicine. However, many residency programs might be unwilling to divert residents to pain medicine if they are already overwhelmed with other clinical services. This option also poses risks for applicants in terms of missed opportunities to work closely with other subspecialties in their primary program if they ultimately decide not to pursue pain medicine. Furthermore, larger residency programs with established fellowships could experience a greater education bias because they will have the ability to offer additional pain rotations, whereas smaller programs without pain fellowships cannot provide this opportunity. Medical schools could offer pain medicine as a mandated course structure. This could cultivate young learners to begin their intellectual pursuit of pain medicine early in their careers and begin self-education through social involvement. Unfortunately, much of their learning would not be directly clinical. This option could be implemented alongside any of the aforementioned options. Pain societies could have even greater involvement in fellow education, creating structured educational plans and workshops to supplement training. Ideally, there would need to be an inter-society collaborative effort to produce different learning sessions in each society meeting to increase the number of educational offerings during the year. Ideally, all programs would provide an opportunity to attend all these meetings; however, ubiquitous trainee attendance is very unlikely, as many programs would not allow all fellows to attend, creating an educational gap for those who cannot attend. Web-based educational sessions with an organized and standardized curriculum, mandated by the ACGME, could supplement the clinical experience. However, creating interest in Web-based platforms is challenging, as there is significant content available now, and Web “burnout” is a concern. Implementing major changes in fellowship education is undoubtedly a significant challenge. The answer is not a simple one, but the success or failure of pain medicine hinges on medical leaders throughout the country collaborating to find a solution to our problem. There is no funding to disclose. Conflicts of interest: S.E.W. receives research funding from Boston Scientific, Abbott, and Vertos. He is also a consultant for Boston Scientific.