Pain Medicine Fellowship

The Department of Anesthesiology at Vanderbilt University is proud to direct the institution's first and only multidisciplinary pain management fellowship. Accredited by the ACGME in 2008, our fellowship combines extensive experience with advanced interventional techniques in addition to rotations in regional anesthesia, addiction psychiatry, neurology, radiology, neuroradiology, neurosurgery, physical medicine and rehabilitation, cancer pain and palliative care.

Fellowship Program Director: Puneet Mishra, MD

Fellowship Coordinator: Cara Lyle

Fellowship Curriculum
Trainees in the fellowship program will be extensively exposed to strategies of pain management by both anesthesiologists and faculty from other disciplines. The fellows, regardless of their primary specialty, should be competent in pain assessment, formulation and coordination of a multiple modality treatment plan, integration of pain treatment with primary disease management and palliative care and interaction with members of a disciplinary team.

Rotations & Electives
Rotation Information and Schedule
26 weeks - Interventional Pain Center at Vanderbilt at One Hundred Oaks
2 weeks - Neurology & Neuroradiology
10 weeks - Inpatient and Acute Pain Service
2 weeks - Psychiatry
2 weeks - Cancer Pain
1 week - Palliative Care
1 week - PM&R (Physiatry)
2 weeks - Pediatric Pain
3 weeks - Elective time
3 weeks - Vacation

Electives for Pain Management Fellow
Fellows can choose from four (4) electives:
Neurosurgical Pain
Private/Academic Pain Practice (Cool Springs)
Research (Clinical/Basic Science)
Vanderbilt Center for Integrative Health

Interventional Pain Clinic Rotation
(At both Vanderbilt at One Hundred Oaks and Cool Springs locations)
Goals
To develop multidisciplinary management plans involving medications, interventions, therapies, and coping strategies.
To become proficient in interventional techniques for management of pain
To incorporate current scientific literature into routine practice for life-long learning
To empower patients to accept responsibility for their role in the management of pain, and to focus on functional outcomes
To learn the administrative and business aspects of a pain practice
To become an expert consultant in pain management

Goals:
To prescribe narcotics in a safe, appropriate, and legal manner
To demonstrate safe utilization of other medications for the management of chronic pain, including anticonvulsants, antidepressants, local anesthetics, NSAIDs, and topical agents. To take accurate history and conduct comprehensive physical examination and present data in a concise fashion.
To utilize multidisciplinary resources for the management of pain
To demonstrate cooperation with all members of the multidisciplinary team, including clinic staff
To identify a difficult case, perform a literature search of relevance, present the case, and publish the findings
To communicate effectively and professionally with referring providers
To perform adequate numbers of ACGME-required procedures in the advanced interventional track. See ACGME program requirements IV.A.5.a.3.a-h)
To perform all procedures competently, understanding risks, benefits, indications, and contraindications for interventional procedures
To perform relevant literature searches and apply data to daily patient care
To learn how to bill and document appropriately
To treat patients with respect and dignity, provide a comfortable procedural experience inasmuch as possible
To take time to educate patients, regarding contributing factors and treatment options related to pain
To empower patients to participate in medical decision-making and to take responsibility for their role in the treatment plan
To recognize psychological, social, and economic issues which may affect patients and their families, and necessitate adjustment in management plan to accommodate these
To encourage patients to reconsider a “successful” outcome as increased functionality rather than decreased pain score

Addiction/Psych Rotation
Goals:
To appreciate the impact of psychiatric dysfunction in the experience and management of pain
To appreciate the scope and impact of psychological addiction in patients with chronic pain
To appreciate the critical nature of psychiatrists and psychologists in the multidisciplinary management of chronic pain
To foster collaborative institutional treatment of complex patients with pain and psychological comorbidity

Objectives:
To perform complete psychiatric history with special attention to psychiatric and pain comorbidities, including completion of a mental status exam on a minimum of 15 patients, five of which must be in the presence of a faculty observer, ACGME IV.A.5.1.d
To interview and examine patients with common psychiatric and pain co-morbidities, including substance-related, mood, anxiety, somatoform, factitious, and personality disorders, ACGME IV.A.5.1.d.
To demonstrate understanding of the principles and techniques of the psychosocial therapies, with special attention to supportive and cognitive behavioral therapies, sufficient to explain to a patient and make a referral when indicated, ACGME IV.A.5.1.d
To communicate effectively and professionally with referring providers
To formulate pain treatment plans which include, as appropriate: Medications, interventions, therapies, and appropriate cognitive behavioral therapy and coping skills training
To learn techniques for inpatient detoxification from opioids and benzodiazepines, including associated risks and benefits of each technique
To recognize signs of primary psychiatric disorder (including personality disorders), and methods used to distinguish these from a primary pain disorder
To gain understanding of institutional and community resources available for treatment of chronic pain patients with psychological impairment, addiction, and primary psychiatric disorder
To treat patients with respect and dignity
To take time to educate patients, regarding contributing factors and treatment options related to pain
To empower patients to participate in medical decision-making and to take responsibility for their role in the treatment plan
To recognize psychological, social, and economic issues which may affect patients and their families, and necessitate adjustment in management plan to accommodate these
To encourage patients to reconsider a “successful” outcome as increased functionality rather than decreased pain score

Cancer Pain Rotation
Goals:
To appreciate the differences in managing cancer pain and chronic non-malignant pain
Objectives:
To demonstrate knowledge of the epidemiology of pain in the cancer population (ex: peripheral neuropathy – chemo; mucositis – radiation therapy)
To recognize and initiate treatment for emergent causes of pain in the cancer population (ex: HA-brain met; back pain-cord compression)
To recognize treatable causes of pain in the cancer population (ex: bone met – radiation therapy)
To learn to titrate opioids (via all available routes of administration, including subcutaneous pumps, as an inpatient and an outpatient), and to treat associated toxicities of opioids in the cancer pain population
To gain experience in pharmacologic management in pain in patients with end-stage organ disease which affects absorption, metabolism, excretion of medications; to effectively anticipate and/or treat adverse side effects of medications in this setting
To treat patients and families with respect and dignity
To empower patients to participate in medical decision-making at the end of life
To recognize psychological, social, spiritual, and economic issues which may affect patients and their families, and necessitate adjustment in management plan to accommodate these
To explore the multidisciplinary resources necessary in order to effectively treat cancer patients with pain, with an without evidence of ongoing disease, and to work well within the team providing them
To maintain continuity with inpatients with chronic cancer pain, and to adjust plans accordingly based on daily assessment

Inpatient Pain Service/Chronic Pain Service
Goals:
To become facile in the use of medications and regional techniques in the management of acute pain
To ensure that those fellows untrained in anesthesiology gain competency in basic principles of airway management, resuscitation, and sedation
To appreciate differences in inpatient and outpatient management of acute on chronic pain in an inpatient setting
Objectives:
To become certified in BLS/ACLS (if not already done) (Certification card)
To learn/review techniques in basic airway management, including a minimum of mask ventilation in 15 patients and endotracheal intubation in 15 patients*
To directly administer sedation in 15 patients*
To administer neuraxial analgesia, including a minimum of 15 thoracic or lumbar interlaminar epidural injections or catheters*
To document involvement with the assessment and management of 50 patients with acute pain
To demonstrate judgment regarding the appropriate indications and contraindications for the spectrum of regional techniques for analgesia and/or anesthesia
To review the ASRA consensus statement for anticoagulation and regional techniques
To safely perform a range of regional techniques, including peripheral nerve blocks and catheters, for analgesia and/or anesthesia
To manage adverse events related to peripheral and neuraxial catheters, maintained longitudinally in inpatients with acute pain
To demonstrate understanding of the pharmacology of local anesthetics and opioids, including relative potencies, expected duration of effect, side effects, and dose-limiting toxicities
To create management plans for inpatients consults who have chronic pain or acute on chronic pain
To facilitate the transition from inpatient to outpatient pain management

*If not previously trained in anesthesiology, ACGME IV.A.5.a.1.i-v.

Neurology and Neuroradiology
Goals:
To appreciate the unique perspective and skill of neurologists in the multidisciplinary management of pain
To understand the necessity of multidisciplinary effort in treatment and rehabilitation of complex neurological disease
To gain familiarity with common diagnostic tools employed in pain assessment
Objectives:
To perform a detailed neurological history and examination to include mental status, cranial nerves, motor, sensory, reflex, cerebellar, and gait examinations. At least fifteen examinations should be performed, with direct attending verification of experience in five.
To understand the indicators and interpretation of electrodiagnostic studies.
To become familiar with basic neuro-imaging and identify significant findings, to include at least MR and CT of the spine and brain on a minimum of 15 CT and MRI studies drawn from the examples within the following areas: Brain, cervical, thoracic, and lumbar spine.

Physical Rehabilitation
Goals:
To appreciate the unique perspective and skill of physiatrists in the multidisciplinary management of pain
To appreciate the unique perspective and skill of physical therapists in the multidisciplinary management of pain
To understand the necessity of multidisciplinary effort in treatment and rehabilitation of complex musculoskeletal disease
Objectives:
To perform a comprehensive musculoskeletal and neuromuscular history and examination with an emphasis on both structure and function as it applies to diagnosing acute and chronic pain problems. This is to include assessments of static and dynamic flexibility, strength, coordination and agility for peripheral joint, spinal, and soft tissue pain conditions. At least fifteen patients must be assessed in this way, with demonstrated proficiency in the development of rehabilitation plans in five.
To understand the various musculoskeletal pain disorders and be able to appropriately integrate therapeutic modalities and surgical intervention in the treatment algorithm.
To explore the multidisciplinary resources necessary in order to effectively rehabilitate patients with pain, and to work well within the team providing them
To understand the role of a physiatrist in a private pain practice setting

Pediatric Pain Rotation
Goals:
To appreciate the differences in pain management in children and adults
To understand the multidisciplinary resources which are necessary for developing a pain management plan which involves pediatric patients AND their families
Objectives:

To learn to interview and examine children, using age-appropriate tools and techniques, to assess pain
To safely perform regional techniques for pain control in a sedated patient, demonstrating understanding of risks, benefits, and challenges involved
To incorporate families into treatment algorithms, recognizing the potential of family dynamics to aggravate or alleviate stress and pain in children
To prescribe medications appropriately in a pediatric population, considering weight, immaturity of organ function, etc.
To work effectively within the multidisciplinary team, and incorporate families into this team
To educate children, with age-appropriate tools and techniques, regarding pain and the plan for its management
To foster healthy behavioral coping strategies in children and families dealing with chronic pain

Pallative Care
Goals:
To understand the multidisciplinary clinical approach and treatment strategies necessary for palliating patients at the end of life
Objectives:
To learn to titrate opioids (via all available routes of administration, including subcutaneous pumps), and to treat associated toxicities of opioids in the cancer pain population
To gain experience in pharmacologic management in pain in patients with end-stage organ disease which affects absorption, metabolism, excretion of medications; to effectively anticipate and/or treat adverse side effects of medications in this setting
To treat patients and families with respect and dignity
To empower patients to participate in medical decision-making at the end of life
To recognize psychological, social, spiritual, and economic issues which may affect patients and their families, and necessitate adjustment in management plan to accommodate these
To explore the multidisciplinary resources necessary in order to effectively treat terminal patients with pain, and to work well within the team providing them
To maintain continuity with inpatients with palliative conditions pain, and to adjust plans accordingly based on daily assessment
To work within a hospice environment and assess resources necessary to provide care in this setting

How to Apply

All applications for our Pain Anesthesiology fellowship are accepted each year January 1^st through March 14th in ERAS (ACGME Program ID # 5304704001), the online application service of the AAMC. Letters of recommendation should be addressed to the program director, Dr. Christopher Sobey.
Visit the NRMP Match website at http://www.nrmp.org and click on the "Fellowship Timeline" button and follow the prompts to register for a match. There will be a nominal fee charged by the NRMP Match organization for registering your application. Be sure to read, complete, and send all of your application materials using ERAS.

If you have any questions, contact:
Cara Lyle
Associate Program Manager
615-936-7616
cara.lyle@vumc.org
Pain Medicine Fellowship Coordinator
Vanderbilt Interventional Pain Clinic
One Hundred Oaks
719 Thompson Lane, Suite 22209
Nashville, TN 37204
Applications accepted January 1st - March 14th.

Rotation Information and Schedule

Electives for Pain Management Fellow