Establishing a Multidisciplinary Fellowship in Pain Medicine and Preparing Graduates to Depart: Contemporary Challenges in Post-Graduate Medical Education
A NEW BEGINNING
Reda Tolba, MD
Currently, there are 100 Accreditation Council for Graduate Medical Education (ACGME) accredited pain fellowship programs with approximately 376 new graduates each year. Despite these numbers, large areas of the country remain without fellowship-trained pain physicians. In the absence of specialty expertise, comprehensive management strategies often remain unexplored. This is especially true when nonspecialists are tasked with addressing chronic pain on top of a multitude of other comorbid conditions. Even with the expansion of our specialty, it remains a rarity to have comprehensive interdisciplinary pain management available to patients outside of metropolitan areas.
Establishing a pain fellowship at Ochsner proved to be an exciting experience. The initial step was to obtain internal institutional approval from the graduate medical education (GME) department by proving that fellowship training will add value to the core anesthesiology residency and align with the educational mission of the institution. Financial feasibility analysis was done to assure that starting such a training program parallels the institution’s vision. Securing stakeholders—from anesthesiology, neurology, physical medicine and rehabilitation, psychiatry, palliative care, and acute pain—is pivotal to ensuring a comprehensive fellowship education with the broad range of specialties that treat pain. Beyond the intellectual commitment, real estate including call rooms, office space, and research areas warranted physical consideration.
Striking the balance between service and education is a fine line. Core faculty should have dedicated time for educational activities. Quantifying educational effort is not usually as transparent as quantifying clinical workflow. After obtaining institution approval, the next step on the agenda is to apply to the ACGME to get approval for an accredited fellowship. It is a lengthy process that requires a collaborative effort between the assigned program director, the GME department, hospital administrators, and core faculty. I consider this experience to be a marathon rather than a sprint. You need a slow steady pace to achieve your goal and be able to complete the race successfully.
CONSIDERING THE END
Robert Bolash, MD
Postgraduate fellows accomplish a multitude of clinical tasks during their fellowships as they move from novice interventionalists to safe and competent independent practitioners. They are challenged to apply the basic fundamentals of multidisciplinary pain medicine while progressively privileged with increasing independence in a supervised clinical practice.
Besides a reference letter, the task of securing employment had historically been overlooked by teaching faculty. Nonetheless post-fellowship disposition remains in the forefront of the mind of the postgraduate throughout their tenure. Although new pain physicians have decades of education, many trainees have never sought formal employment. Fellows go through undergraduate, graduate, and postgraduate education with their destiny determined by a computerized matching algorithm. Despite their chronological age, graduating fellows have comparatively little experience in evaluating prospective employers when considered against agematched peers outside of medicine.
As a result, the likelihood for physician turnover is highest around the time of joining a new practice. Overall aggregate physician turnover totals 25% within the first three years of signing an employment agreement.1 It is unknown if these rates are higher amongst graduating regional anesthesiology or chronic pain trainees. The specialty indiscriminate cost of a physician vacancy totals $4,000 to $6,000 per day.1 Not surprisingly, an unfavorable employer–employee pairing is the predominant reason contributing to a physician’s decision to depart.
It is not entirely clear who is responsible for addressing job satisfaction and retention of graduating trainees. Indeed, “practice issues” and “broken promises” were the predominant contributors to the mismatch between physician and employer expectations.1 Often, a more open appraisal of the employer and the candidate could have identified these issues early on and saved both parties the challenges associated with separation. Whereas Baby Boomers value compensation, members of the present generation remain with their employers because they have opportunity to grow.2 Learning and advancement deserve considerable attention since engagement, rather than compensation, fosters retention. When compared to previous generations, millennials (born between 1980s and 2000) ranked as the least engaged generation.2,3 Only 27% of doctors reported having a formal retention plan with their present employers, a potential opportunity for practices to retain new hires.1
While many stakeholders have opportunities to ensure the success of newly minted regional anesthesiologists and chronic pain physicians, we recognized the opportunity and began a curriculum to formally address challenges surrounding the transition to practice, improved satisfaction of graduating trainees, and decrease turnover. These monthly discussions surrounded commencing a job search and included roundtables with physicians from various practice models. Trainees engage speakers transparently in a setting where no topic is considered taboo. We openly discuss business planning, negotiation, and interview strategies. Contracts are reviewed alongside employment attorneys and critiqued by the whole group.
What we observed was an open discussion wherein fellows presented their own challenges with a heightened degree of introspection. It remains too early to determine the long-term results on retention or satisfaction these discussions have made, but they certainly have led to trainees asking more sophisticated questions than I’ve seen in the past.
Whether starting a new pain fellowship or seeing trainees graduate and move into independent practice, investing in our specialty warrants fostering future pain physicians’ success as they are entering postgraduate training or transitioning to their next stage of practice.
- Gramer J. Physician recruitment trends that can help shape a successful strategy. Recruiting Physicians Today. 2015;23:1–3. Available at: http://www. nejmcareercenter.org/minisites/rpt/physician-recruitment-trends-that-can-helpshape-a/. Accessed April 2017.
- Rigoni B, Adkins A. What millennials want from a new job. Harvard Business Review. May 2016. Available at: https://hbr.org/2016/05/what-millennials-wantfrom-a-new-job. Accessed April 2017.
- Adkins A. Majority of U.S. employees not engaged despite gains in 2014.Gallup: Employee Engagement. 2015. Available at: http://www.gallup.com/poll/181289/ majority-employees-not-engaged-despite-gains-2014.aspx. Accessed April 2017.
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