Interview by Austin Marcolina, DO
Since PM&R is a relatively small field, how did you first learn about the specialty and were there any specific characteristics that drew you to PM&R and then interventional spine?
In third year of medical school, like many students, I was constantly changing my mind about what field to pursue. I was initially interested in sports medicine and pain medicine. I first rotated through various specialties including family medicine, ER, and internal medicine, as well as anesthesia-based pain medicine. When weighing the pros and cons of each specialty, I was speaking with a family medicine-trained, sports medicine physician at U Penn who suggested that I look into PM&R. This physician knew I was interested in the musculoskeletal system, but was wavering on whether or not I wanted to undergo the broad-based training of family medicine residency. I then rotated with Dr. Chris Plastaras, who at the time was running the U Penn Spine program, and that really clicked with me. From there, I did more rotations that covered the true breadth of the field. The fact that the field focuses on functionality and the whole person really drew me to pursue further training in PM&R.
While in residency at RIC/Northwestern, I continued to explore the options between sports medicine and interventional spine/pain medicine. I ultimately felt most engaged by the complexities of diagnosis and patient management, as well as the more prominent procedural focus, in the spine/pain medicine niche.
What are some of the common conditions you treat in an interventional spine practice? What does a day in the life of an academic interventional spine physician look like?
This varies significantly between physicians, but for my practice specifically, I see everything along the acute to chronic spectrum, from acute back/neck pain due to disc herniation to chronic pain after remote spinal fusion with adjacent segment degeneration and multiple failed treatments. While we have great spine surgeons here at the University of Utah, inevitably some patients will fail surgery and require other modalities for their spine-based pain. Outside of our institution, in the Salt Lake City region, a large number of spine surgeries are performed, so I probably see more of the chronic, so called "failed back surgery" patients than most interventional spine physicians.
As an academic physician, I actually have wonderful balance. In regards to my practice, I spend approximately 70% of my time on clinical care and 30% of my time is split between research, administrative duties, and teaching. For the research component of my practice, we have a great team composed of attending physicians, clinical research coordinators, a biostatistician, fellows, residents, and students who assist in projects, including clinical trials and large data mining studies. At the end of the day, you can carve out any split of duties you desire within academics. There are positions that are significantly more research-based than mine, and there are others that include minimal research. It is a common misconception that academic positions require consistent procurement of significant grant funding and a robust research component; this is simply not the case. The key is finding your niche and exploring opportunities that are consistent with your career goals.
As you completed your training in an ACGME-accredited pain medicine fellowship and now are the director of an interventional spine and musculoskeletal medicine fellowship, you seem to have unique insight in regards to the similarities and differences between the two. For those that may be considering both types of fellowships, how would you differentiate the knowledge and skills learned between the two fellowships? Are there specific instances or patient populations that may be better served by one over the other?
There is clearly going to be a significant amount of overlap between the two fellowships and eventual practices, as the diagnosis and treatment of spinal pathology is common to both fields. Of course, within pain management, you will see a wider variety of pain conditions, including: headache, facial pain, peripheral/neuropathic pain, and the like. During the pain medicine fellowship itself, you will spend more time with other services, such as palliative care, psychiatry, neurology, pediatrics, etc., as the goal is to develop as a broad-based multidisciplinary pain specialist. For patients that have a significant behavioral component to their experience of pain, they are best served multidisciplinary pain programs, sometimes also known his functional restoration programs. This is a necessary part of training in any strong Pain Medicine fellowship where the goal is to finish training as a well-rounded provider. A great example of this is RIC/Shirley Ryan AbilityLab multidisciplinary pain program. It is rare for behavioral pain management to be integrated into an interventional spine fellowship or into an interventional spine practice.
Every interventional spine fellowship is going to be a bit different, primarily due to the fact that, historically, there was not as much structure associated with these fellowships. For example, when considering ACGME pain fellowship programs, the are specific guidelines in place that dictate what each fellow needs to accomplish by the end of their year (ex.: psychiatry, acute pain, pediatric pain, etc.). However, this discrepancy in structure between Pain Medicine and Interventional Spine Fellowships is changing. The North American Spine Society (NASS) has begun to recognize spine fellowships, and the tentative plan is that these fellowships will be accredited by an organization other than the ACGME, similar to many orthopedic surgery subspecialties. The plan is that NASS will recognize a fellowship if it meets specific standards set by NASS leadership. Through this process, high quality Interventional Spine Fellowships will be recognized for both their curriculum and commitment to academics. Currently there are approximately 15 fellowships that are recognized by NASS, including our program at the University of Utah.
In regards to Interventional Spine fellowships in particular, these will generally be more focused and provide more in-depth training related to diagnosis and management of spinal pathologies. For example, in our program, there is an expectation that fellows exit fellowship as experts in spinal imaging. While not to the same degree as a diagnostic radiologist per se, the fellows should be comfortable in interpreting everything from plain films to CT scans and MRIs, due to the amount of time that is allotted with neuroradiologists and attending physicians interpreting imaging both in clinic and during procedures. This is generally the case with high-quality Interventional Spine fellowships as opposed to most Pain Medicine fellowships. There is also more allotted time to be spent with spine surgeons, in order to obtain a better understanding of the nuances of surgical indications and how to properly manage post-spine surgery patients over time. From personal experience, interventional spine physicians typically see a larger percentage of these postsurgical patients than I did in pain fellowship. Neuromodulation (i.e.: spinal cord stimulators) is also something that most interventional spine fellows should be comfortable with, as one of the primary indications for this modality is failed back surgery syndrome. Neuromodulation is used widely in Pain Medicine as well, so this is not necessarily a differentiating factor between the two types of fellowships. However, this is where the differentiation of individual fellowships of the same type becomes more noticeable, as there are some pain fellowships that have a large amount of exposure to neuromodulation, while there are others that are a bit lighter on exposure. Finally, a key part of an interventional spine fellowship, and this is especially notable with the University of Utah fellowship, is the amount of time spent with physical therapists. As opposed to a Pain Medicine fellowship, where time with physical therapists is limited, this is an essential component of a good spine fellowship, as understanding how appropriate physical therapy works is a great “tool in the toolbox” for interventional spine attendings.
One aspect that is readily evident when speaking with you is your drive for research. As someone with over 100 publications and current Director of Clinical Spine Research at the University of Utah Division of PM&R, how did you first become involved with research? How do you manage the schedule of a busy clinical practice in addition to ongoing research projects? Do you have any advice for residents/medical students in regards to becoming an efficient and effective researcher?
I actually started out as more of a basic scientist. I completed a thesis in developmental T-cell immunology during undergrad, and I continued rat/mouse model research through medical school. It was not until the end of medical school that I started learning more about clinical research, and this is when I began to transition my focus. What I have found is that if you enjoy being a clinician, there is great synergy between clinical practice and clinical outcomes research.
Research is a team sport. It is much more enjoyable and effective when working with collaborators that have curious minds and also want to advance science. These days, I spend much more time organizing and leading teams than I did in the past. While I still spend quite a bit of time with research design, grant writing, and editing manuscripts, it takes a team to move all of our projects forward. In my opinion, it’s more fun and rewarding to share in the successes together (as a group).
For medical students and residents, the most important thing to do is to find strong mentorship. This does not have to be one person. Over the course of my career, I have had numerous mentors. It is important to remember that every mentor can contribute something different to your education and development. The goal is to find people that are truly interested and invested in helping you to grow. Another key component is to read the primary literature. While textbooks are fine for basic or foundational knowledge, they will not keep you up-to-date on new advancements or the most current knowledge gaps. Reading primary literature will also expose you to elements of study design and science writing, both good and bad. Make sure to ask your mentors what to read - the classic papers and recent meaningful papers that are changing practice.
Do you have any advice or resources for residents that may be considering a career as an interventional spine physician or medical students interested in PM&R?
The AAPM&R has a ton of great resources for those interested in physiatry as a whole and all of the specific sub-specialties. For those already interested in interventional spine, pain medicine, or both, I would recommend becoming a member of the sub-specialty societies (NASS, SIS, AAPM), as membership is typically free or low cost for trainees. Another way to truly immerse yourself within a field is to attend conferences and workshops. During these meetings and labs, you will be able to hear from and speak to the thought-leaders within each field. These interactions can be invaluable in obtaining a better understanding of how each field is moving forward and what types of opportunities are available.