Pain Management Fellowship Curriculum

The pain management trainee in the Pain Management Program at St. Elizabeth's Medical Centerwill gain a rich experience in the evaluation and management of acute, chronic, cancer, and non-cancer pain in the adult patient in both inpatient and outpatient settings.

The population served is diverse, including the Boston inner-city communities (Black, Hispanic, Asian, etc.) referred from Tufts-New England Medical Center (T-NEMC), the suburban communities in Massachusetts who seek care within the Steward Health Care System to which St. Elizabeth's Medical Center serves as a tertiary care center, as well as the communities in proximity to St. Elizabeth's Medical Center (Russian, Irish, etc.). Appropriate translators are available as needed. Thus, the pain management trainee will gain the benefit of caring for those who may experience and express their pain differently and have different expectations regarding treatment.

The pain management staff brings together a wealth of experience and academic accomplishment, which will provide excellence in didactic teaching, as well as the teaching that occurs so often when "teaching moments" are recognized and seized throughout the day during the usual course of patient care. All staff members are fellowship trained in pain management, interestingly, at different sites. Specifically, a pain management fellowship was completed by Dr. Frederic Gerges (fellowship director and medical director) at Brigham and Women's Hospital. Dr. Gerges is an American Board of Anesthesiology certified in anesthesiology and pain management. Furthermore, the physician staff will provide a healthy variation in practice style for trainees to observe.

The clinical outpatient training in interventional pain will be solely at the Pain Management Center at St. Elizabeth's Medical Center. Trainees will be assigned to a particular attending who will supervise that trainee for the day on a one-to-one basis. The trainee will see the scheduled new patients, follow-up patients, and patients requiring procedures in conjunction with the attending physician. Other rotations are established with Boston Medical Center for physical medicine and rehabilitation training, and at St. Elizabeth’s neurology and psychiatry departments for additional training.

For new patient evaluations, the trainee will be expected to take a careful history. including but not limited to, the description of the pain onset, location, intensity, time of occurrence, modifying factors, as well as the functional status and a quality of lifestyle assessment. The trainee will perform a physical exam appropriate for the pain complaint. The trainee will present this information to the attending physician who will help the trainee develop an assessment and therapeutic plan. The attending physician will confirm physical exam findings and, together, the trainee and the attending physician discuss expectations and the plan of treatment with the patient. The trainee will provide additional instructions and teaching to the patient to clarify the plan as needed. Evaluations are reviewed with the staff member prior to the dictation into the electronic Medial record of a full note for the electronic chart.

Similarly, for follow-up visits, the trainee will obtain updated information from the patient as to changes in general health, new social stressors and response to the prescribed therapy. Directed physical exam is done with subsequent confirmation by the attending. Again, this information will be presented to the attending staff and an assessment and plan will be developed. Together, the trainee and the attending physician present the plan to the patient. The trainee will provide additional instructions and teaching to the patient to clarify the plan as needed.

All invasive procedures for pain management are provided under the direct supervision of staff pain physicians. Trainees are expected to have reviewed the procedure in advance. They will obtain informed consent from the patient. Trainees will help prepare the patient and equipment (needles, medications, etc.) with the assistance of a nurse specialist. The trainees, according to their level and stage of training, either assist or independently (with close supervision) carry out the procedure. The trainee takes report from the recovery nurse, assesses the patient during the recovery period and discharges the patient to home under the direction of the attending physician.

Trainees will actively participate in the monthly multidisciplinary pain management conferences. The Pain Management Center physician and nursing staff, psychologist, consulting physical therapist, administrator, and secretary are in attendance. Patients' cases are discussed, evaluations are compared and a multidisciplinary treatment plan is developed.

At the start of the training program, trainees will be required to watch a pre-recorded (video taped) lecture and complete a written test on radiation safety and correct operation of the fluoroscopy unit. Safe and proper use of the fluoroscopy unit will be reinforced during interventional procedures using fluoroscopy. Trainees will learn not only how to read fluoroscopy images, but also how to direct the beam to obtain the best images with the least amount of radiation to themselves and the patient. Lead aprons and radiation badges will be provided to trainees for use with fluoroscopy.

Trainees are assigned on a rotating on call basis to the Pain Management Consult Service. As such, they will see, evaluate, and manage patients with intractable pain on the medical and surgical wards. Consultations are approached in a similar manner to new outpatients described above. Plans for treatment are discussed with the patient and with the physician or physician team member who requested the consult. The consult service provides opportunities to interact and discuss patient care with other referring departments such as oncology, neurology, orthopedics, internal medicine and surgery.

The pain management trainee is expected to become familiar with the program's policies and procedures during the first three months of the academic year. The trainee is responsible for administrative follow-up (dictations, forms, reports, etc.) related to consultations and procedures in which they have been involved. Documentation of returned phone calls and communication with the attending physician is also expected.

The trainee attends physician meetings with the contracted billing company representative for updates on appropriate pain management coding, documentation, etc.

Pain management trainees organize the clinical coverage schedule for themselves with the assistance of the director and/or administrator.

Administration and management principles, including scheduling, reimbursement, referral requests and front office management are studied as part of the didactic curriculum.