39: Academic Pain Medicine From an Anesthesiology Background

Session 39

Dr. Bunty Shah is an academic Pain Medicine Physician at Penn State. He completed his residency training in Anesthesiology. He shares the specialty with us.

Back in Episode 17, we interviewed a community-based pain medicine doc who came from a radiology background. So you get to hear some differences between these two episodes.

Bunty has been out of fellowship training now for two years. He now serves as the Associate Program Director for the Fellowship at Penn State.

If you haven’t yet, please check out all our other episodes on MedEd Media Network.

[01:33] An Interest in Pain Medicine

When he was in his surgery rotation in medical school in his third year, there was no actual anesthesiology rotation. But it was built into the surgery rotation. It was by chance that he actually encountered anesthesia during his surgery rotation. He met an anesthesiologist during third year rotation in medical school. He learned that anesthesiology was all about an interplay between physiology and basic sciences. It was very procedure-oriented and he enjoyed it. That was his first experience with anesthesia. And so he decided to pursue that.

He also wanted to do emergency medicine initially being formerly an EMT. He thought emergency medicine was very exciting. He still thinks it is but the finds anesthesia to have combined all the different specialties he was interested in. He could be a cardiologist, a nephrologist, an ICU doctor, and all these things at once in the operating room.

As far as pain medicine goes, he didn't know anything about it back in medical school. It was a subspecialty so he didn't have much exposure to it as a medical student. It wasn't until his CA two year being his third year of anesthesiology as a resident. He rotated through the pain management clinic and he saw all the different procedures done for pain of different causes. It married what he likes about anesthesia which is procedures. A lot of the procedures they do in anesthesia are carried over to pain medicine such as skills when doing epidural injections. So this gravitated him towards the pain medicine.

Another thing he liked about pain medicine that was missing when he was doing anesthesia was having more face-to-face time with patients while they're awake and talking with him. The other thing about anesthesia was he would do a case and take of a patient for one surgical procedure and not see them again. He considers this as a good thing in the grand scheme of things. Because it means they improved or did well.

"I like the continuity of care I get with some of my patients in pain medicine and establish relationships that is more long-lasting."

Again, it's the patient interaction along with the procedures that led him to pursuing a career in pain medicine.

[04:54] Learning Hand Dexterity and Other Skills

Bunty says you have inherent coordination skills to be able to do these procedures but you do learn by practicing. So the things that to some degree, it can be taught. But the most important thing to be masterful with procedures is understanding your limitations. You have to develop an overall sense of safety, knowing when you can advance a needle, and when you have to be a little bit more cautious. You have to understand the relevant anatomy. He recommends to medical students and residents that knowing your functional anatomy is very important to doing procedures.

"Knowing your functional anatomy is very important to doing procedures."

Bunty adds that your knowledge of the anatomy is your road map for doing a procedure. Aside from having dexterity and manual skills, your knowledge of the anatomy is a major factor in making sure you can do a safe procedure for a patient.

[06:13] Community vs. Academics

Bunty chose to stay in Academics because he likes to teach. He believes that if you can teach something, you can do something. He chose to stay at a program where he trained both in anesthesiology residency and in his pain medicine fellowship. Currently, he's the Associate Program Director for the Pain Medicine Fellowship. He is tasked with training fellows going to go out in practice within one year.

So he has the opportunity to shape these fellows to some degree. He also has a hand in the patients they treat since he's responsible for teaching them. For him, this is a tremendous responsibility and it's one he doesn't take lightly.

He feels humbled to know that they are shaping fellows who are going to go out and practice pain medicine on their own. They're touching other patients through them. And this is the major motivating factor for him.

Another reason he stayed in academics is he's able to get exposure to educational resources he wouldn't have gotten elsewhere. Because they're a training program, they have educational conferences. They have journal clubs where they review relevant articles. They're always learning. Not to say that you're not always learning in private practice, but he feels as an educator, the impetus is on them to do as much learning as they can.

"It's my responsibility to teach others so I need to stay abreast of developments in my specialty."

[08:15] Traits that Lead to Becoming a Good Pain Medicine Doctor

Bunty cites some traits that lead to becoming a good pain medicine physician. One is patience. As an educator, you're working with fellows and residents who may have limited exposure to some of the procedures and conditions they see at the center. You can't do everything yourself so you need to be able to teach the fellow. Allow them some autonomy at times but within a safe window. Other traits include inquisitiveness and curiosity.

[09:20] Types of Patients and A Typical Day

Being a major referral center at central Pennsylvania, they see a wide variety of cases and conditions. But being a large part of what they see is back pain, especially low back pain but also pain from the cervical spine and thoracic spine. They see a good deal of neuropathic pain related to conditions of the nerves and nervous system. They deal with things like neuropathy related to diabetes. They also treat pinched nerves of the spine which is considered neuropathic pain. They treat them with injections and medications.

Additionally, they also see pain from other causes like cancer pain, arthritis of the spine and knees. They treat pain of all sorts and kinds. If there's a condition that's painful, they see it.

A typical day for Bunty starts at 8 am when he arrives in the clinic. He has half a day of procedures that would include ultrasound-guided procedures, fluoroscopic-guided procedures, which would be x-ray-guided procedures. The second half of his day is seeing new and return patients. He works them up for different conditions and making recommendations about medications or possible procedures to help alleviate their pain.

In cases when there are case conferences or journal clubs, he stays a little bit later until 6 or 7PM. But a typical work day for him is anywhere from 8am to 4:30pm or 5pm.

[11:35] The Academic Side

In terms of the academic side of things, they have medical students and residents and fellows. They are with them for a year at a time. They have several different rotations, most of which, are in the pain clinic. But for about a half a year, they rotate out of their pain clinic and onto other services such as spine surgery, palliative care, psychiatry, neuroradiology. So they get exposure in these other areas that are also relevant to their specialty.

Their residents are part of the anesthesiology department and they rotate one month at a time. They come initially in their clinical base year, which is the first year of anesthesiology residency. And they return during their CA two year, which is their third year residency.

The occasionally have a resident from neurology coming to their clinic and they also have fellows who rotate with them from rheumatology and orthopedics. They also have medical students rotating with them about every month or so.

"A lot of different people coming in from different backgrounds but it's an educational experience for everyone."

[13:25] Percentage of Patients that Go to the O.R. and Taking Calls

Bunty estimates that 60% of their patients or maybe even 70% are patients who may benefit from a procedure and who are offered a procedure. The remainder of these patients are managed more conservatively with medications, physical therapy, sometimes pain psychology. It's a very multi-faceted approach. Especially in light of the opioid epidemic, they try to really approach issues from all different angles to really maximize benefit and minimize any harm they can cause to the patient.

In terms of taking calls, Bunty takes a minimal amount of calls. He has a group of five physicians. So he takes call one in every five weeks. His call consists of seeing in-patient consults on days when he's on call. So gets a call one week at a time from Monday thru Friday. If he's seeing patients in the morning, after lunch break, he sees inpatient consults in the afternoon. This allows him to actually get out by 4 or 4:30 PM. The rounds on patients who have nerve catheters or epidurals on the weekends. It takes anywhere from 1-2 hours and he's free for the rest of the day when he's taking home call for that entire week (Monday-Sunday).

If there are issues, they are first fielded by their fellow and if they have questions they can call him. Then they address these issues. Typically, they do this over the phone and it's only rare when he has to come to the hospital to take care of an issue. So he gets to have a good work-life balance and this is another motivator as to why he chose this specialty.

"For the most part, the call is not very bad. It does allow a good work-life balance in my opinion."

[16:05] The Path to Pain Medicine

Pain medicine is a subspecialty, initially created within anesthesiology. However, it is a specialty which can be entered via several different routes.

The traditional one is anesthesiology which is a four-year residency. Then that is followed by one year pain medicine fellowship. So pain medicine fellowships are all one-year long.

Neurology is another route as well as Psychiatry, Emergency Medicine, and Physical Medicine & Rehabilitation (PM&R). These are specialties through which one can enter pain medicine. By and large, most candidates are coming from anesthesiology and neurology. Currently, they have three fellows in their program. Two of them are PM&R and one is Anesthesiology. So the fellowship doesn't differentiate between what residency they came from. There aren't separate pain medicine fellowships for different specialty backgrounds. It's all one and the same.

In terms of treating patients, having one specific background doesn't necessarily give them an advantage over another.

"Depending on the specialty you come from, you bring a different skill set."

Bunty thinks PM&R residents and fellows have excellent examination skills of the musculoskeletal system. They come with good skills as far as procedures and ultrasound. They have a good understanding of the musculoskeletal system as far as dynamics and conditions that affect the system.

On the other hand, Neurology residents and fellows come with a very good understanding of the neurologic bases for pain and neuropathic pain states. They're very well-versed in conditions like headaches.

Anesthesiology residents come with very good understanding of analgesic pharmacology, basic physiology, as well as procedural skills as far as ultrasound goes. In anesthesia, they do a lot of peripheral nerve blocks and epidural injections. So Bunty thinks everyone brings something different to the table. That said, he wouldn't say one particular specialty is better than any other. In the end, he believes all of their fellows regardless of the specialty they originate in become excellent fellows. They're all on par with each other as far as becoming good pain physicians.

[19:37] Competitiveness in Matching

Bunty describes the Pain Medicine Fellowship as being quite competitive to match into. There are a number of pain medicine spots but it does happen to be one in high demand. One reason is particularly because the work-life balance is good in the specialty. You have an applicant pool that consists of candidates from multiple different specialties that may also contribute to the competitiveness of matching into the specialty.

Being an associate program director, what he looks for in competitive applicants are strong academic record including good examination scores, and in-service examination scores, as well as board exam scores. He looks at the character, particularly assessed by interviewing the candidate but also reflected in the letters of recommendation. He looks for personality that will be compatible with working in a team.

"Pain medicine is a team specialty that requires compatibility with working with members of other specialties, nurses, ancillary staff."

Other traits include being inquisitive and having a good work ethic. He also adds that it's very hard to judge someone on procedural skills. You haven't seen them do procedures but instead, he looks into their experience in pain medicine. He sees if they've done rotations in pain medicine and what sort of procedural exposure they've had. And they also look at the letters of recommendation. Bunty uses the interview to see what the candidate's personality is like. He also tries to understand the candidate's motivation for pursuing a career in pain medicine.

[22:55] Subspecialty Opportunities and Working with Primary Care and Other Specialties

When you finish an interventional pain medicine fellowship, Bunty explains it's pretty much as specialized as you can get. One can also do another fellowship but Bunty explains this is pretty much where you end your training. Nevertheless, learning being a lifelong endeavor, you'd be required by the specialty to do CME (Continuing Medical Education). He thinks it's a good idea to go to conferences and meetings to continue your learning. But as far as fellowship training goes, there's typically no further subspecialization for pain medicine.

In their pain clinic, Bunty describes a good relationship with their primary care colleagues. They have a good mutual understanding of what they can offer as pain medicine specialists for patients. He thinks it's important for primary care doctors to understand that they really strive to provide multidisciplinary care for their patients. Understand the indications for procedures like epidural injections. Understand that opioids are really the last resort and not proven in many studies to confer long term benefit in chronic pain. This is a major thing he'd like most primary care providers to understand.

He also stresses that in terms of the use of adjuvant medications in the treatment of pain, it's important to think outside the box as far as pain medicine treatments go. Lastly, understand the benefits of physical therapy and pain psychology such as cognitive behavioral therapy and biofeedback techniques. The interplay of all these things in the treatment of pain and the holistic approach they give to patients is very important.

Other specialties they work the closest with include primary care, neurosurgery, and orthopedic spine services since back pain plays a large part in why patients come to see them.

[27:01] Special Opportunities Outside of Clinical Medicine

If you're interested in research and has a PhD, there's a large need for research in pain medicine. Especially in the midst of opioid epidemic, research into the mechanisms of pain regulation and treatments are large areas that need a lot of research focus.

What he wished he knew about pain medicine going into his training is how daunting it is to understand how low our success rate can really be.

"For a lot of patients, even a small amount of relief can translate into a larger change in the quality of life."

Now he appreciates it when he sees patients with a small increase in functionality or decrease in pain levels and how impactful this is in a patient's life. This is something he didn't appreciate early on which he does now.

What he likes about being a pain physician is the ability to make a difference in patients' lives. Many patients come to them after having tried multiple different medications and even procedures. He starts from the beginning and he starts to understand why the patient is there. Sometimes they only want to be listened and to be validated in their thinking about their pain. Many patients are inappropriately labeled as medication seekers and so it's important to understand what the patient is saying. He takes the opportunity to really listen to the patient and get on the same page with them and what he can do for them.

On the flip side, his least favorite part is getting coverage in certain procedures, doing peer-to-peer, and working with insurance companies which can be frustrating. He does his best to reach out to them and get procedures approved but there are times when he's not able to do so. Nevertheless, this does not diminish his enthusiasm for the specialty.

"In any specialty, there's going to be some degree of dissatisfaction with working with insurance companies."

Bunty clarifies that there are times when you can all insurance company for a peer-to-peer. You call someone from a completely different specialty. They often have policy guidelines to which they're obligated to adhere to. For instance, he has a colleague who did a peer-to-peer for a spinal cord stimulator. The physician he spoke with in the insurance company was a pediatrician. So you may not always speak to a pain physician although you will very often. It just depends on any given day that you may speak to someone from a different specialty. Then you argue your case to have it covered.

[33:06] Major Changes in the Future

Bunty illustrates a larger emphasis on procedures to treat pain and a move away from the prescription of opioids. Again, he stresses the importance of this since many people are dying from opioid abuse or misuse and overdoses related to this. It doesn't take a lot to appreciate the enormity of the situation. Many times, prescriptions are filled especially after surgical procedures or even dental procedures or oral surgical procedures. These pills don't fall into the right hands. Patients with multiple co-morbidities which may include cardiovascular or respiratory issues on opioids are at risk for overdose as well. He adds the general lack of study supporting the long term benefit of opioids in the treatment of chronic pain. Then you realize now there might be more harm from these medications. This is mostly for the treatment of non-cancer pain. This said, opioids have a long standing track record for being helpful in pain related to cancer. Still, you have to think out of the box and think about adjuvant medications and use the the World Health Organization ladder that emphasizes the use of weaker opioids and adjuvant medications (NSAIDS) before escalating to stronger opioids.

"Many people are dying from opioid abuse or misuse and overdoses related to this."

So what Bunty sees in the future is a...