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What Can We Learn From Nonaccredited Pain Medicine Fellowships?

Aug 1, 2021, 09:00 AM by Reda Tolba, MD, Cleveland Clinic Abu Dhabi, and Janus Patel, MD, Wake Forest Baptist Medical Center


Cite as: Tolba R, Patel J. Is there something to learn from non-accredited pain medicine fellowships?. ASRA News. 2021;46.  

The status quo for training a pain physician involves a one-year, Accreditation Council for Graduate Medical Education (ACGME)-accredited fellowship, usually following a residency in anesthesiology, physiatry, neurology, or psychiatry. The fellowship develops clinical and procedural skills, and its rotations in several disciplines provide a comprehensive, multispecialty experience. The goal is to produce comprehensive pain physicians with sufficient clinical and procedural acumen as well as multidisciplinary knowledge to confront the complexity of chronic pain. In a one-year time frame, it strikes a balance among didactic educational training, exposure to interventions, and clinic management.

Very few non–ACGME-accredited fellowships allow participants to gain such a focused set of skills. Instead, non-ACGME accredited fellowships for pain management are usually embedded in pain private practices, which may not allow for participation in academic endeavors, advanced interventions, or formal lectures, conferences, didactics, or multidisciplinary rotations.

Nonaccredited Fellowship: Does It Have Merit?

The question then becomes, what are the advantages and disadvantages of completing a non-ACGME accredited pain fellowship? Perhaps the utility is as an avenue to gain specialized experience in pain medicine, business, and practice management from successful faculty. However, ineligibility for board examination and certification, prioritization of fellow labor over education, and potential future ineligibility for hospital credentialing, reimbursement, and academic or private career options are inherent disadvantages.

Because the quality of education in non-accredited programs is not regulated through a crediting body, trainees should thoroughly research and understand a program’s risks and benefits. The authors believe that formal ACGME-accredited fellowship training should be required for any practicing pain physician to ensure quality of care.

Is Longer Training the Solution?

Whether a pain medicine fellowship should be lengthened to more than one year instead of progressing to a pain residency has been debated. Given the ACGME requirement to provide multidisciplinary education, the argument was made to extend the time to two years or more. Some educators and learners believe that a one-year fellowship has insufficient time for a fellow to become proficient in a plethora of interventions and complex clinical management. Because most graduates obtain employment at private practice–based settings, proficiency in the arenas of practice management, insurance, and billing is paramount.

A 2018 survey showed that 25% of pain fellows reported receiving no formal business training.1 Of those who received practice management training, 64% reported that they spent only one to four hours on it throughout the training year.1

Given all of the skills a graduating fellow is expected to have mastered, is one year of training enough? Would more training lead to fewer complications, better clinical and procedural decisions, and more appropriate healthcare use? Although a two-year fellowship is not necessary, some suggest it as an option for those who desire a well-rounded education and, ultimately, more efficient and competent practice. However, a two-year curriculum must be formalized and allow a fellow to focus on their own interests so they may innovate and advance the field if they desire.

On the other hand, ending an apprenticeship after one year and moving toward independent practice is rooted in the assumption that pain physicians will use continued medical education as their career progresses. There is a lot to learn in the first year of practice, and no measurable evidence supports extending training requirements for longer than one year. In addition, obtaining funding for a two-year fellowship program represents a challenge for academic institutions, especially with limited resources. The role of program directors and teaching faculty is crucial in establishing a robust learning experience that applies assessment tools to ensure fellows receive quality training that prepares them for independent practice.



Dr. Reda Tolba
Reda Tolba, MD, is department chair and clinical professor of the pain management department at the Anesthesiology Institute of Cleveland Clinic, Abu Dhabi, UAE.

Dr. Janus Patel

Janus Patel, MD, is a clinical adjunct faculty in the anesthesiology department at Wake Forest Baptist Medical Center in Winston-Salem, NC.





  1. Przkora R, Antony A, McNeil A, et al. Do pain medicine fellowship programs provide education in practice management? A survey of pain medicine fellowship programs. Pain Physician. 2018;21(1):E43–E48.



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