International Pain Fellowship

Pain Medicine Fellowship Training Program Description

The Pain Medicine Program at the University of Puerto Rico – School of Medicine provides an academic environment for the acquisition of knowledge, skills, clinical judgment and attitudes, which are essential to the practice of pain management. The program director, faculty, supporting are accomplished in a friendly supportive atmosphere of mutual respect. The one-year continuum of education provides fellows with graduated responsibility and a broad range of pain management experiences with emphasis of interventional techniques. Fellows spend most of their time at the Interventional Pain Clinic located at the main building of the School of Medicine. OR staff, and administrative staff are fully committed to meet these educational needs. Pain medicine fellow training and education cases such as neuromodulation, intrathecal drug delivery systems, and vertebroplasty are done on a weekly basis. Fellows are allowed elective rotations with in PMR and Neurosurgery-Spine services. Acute Post-Operative Pain Management is covered at the Trauma and University Hospitals nearby.

Objectives:

At the end of one year the pain medicine fellow should be able to demonstrate the following:
Knowledge

1. The anatomy and physiology of pain perception
2. Epidemiology, economic impact and sociology of pain
3. Pharmacology of opiates, non-narcotic analgesics and non-steroidal anti-inflammatory medications
4. Pharmacology of centrally-acting drugs used in pain management
5. Measurement and assessment of pain and function
6. Principles of neurostimulation
7. Principles for diagnostic testing
8. Regional nerve blocks and pain management
9. Neurolytic techniques
10. Cognitive, behavioral, and supportive psychotherapeutic treatment principles, including rehabilitation and the role of team management
11. Quality pain management – This requires of the trainee a certain foundation of knowledge, pool of technicall skills, and bedside manner.
12. To recognize the need for a multidisciplinary approach for pain management
13. To gain knowledge of the role of a Pain Management physician
14. To distinguish clinical characteristics of acute, chronic and cancer pain
15. To recognize and appreciate the role as a pain Consultant
16. Understand the principles of neural stimulation (TENS, PNS AND DCS)
17. Understand the principle and rationale for intrathecal catheters and infusions
18. Understand and become familiar with alternative pain therapies
19. Evaluation and treatment of all genders, adults and children and to become familiar with the diagnostic methods and treatment modalities of male and female pain patients. To include the differences in pain presentations and techniques based on gender
20. Evaluation and treatment of pain patients utilizing the various interventional and invasive management techniques, indications, contraindications and follow-up. These include intradiscal electrothermal therapy {IDETT}, spinal cord stimulators, intrathecal pumps, vertebroplasty and kyphoplasty
21. Principles, evaluation and treatment of workman’s compensation, disability claims and impairment ratings
22. Learning the appropriate billing and coding for evaluation and medical treatment and interventional therapies

Exposure to and/or knowledge of:

1. Acupuncture
2. Botox Injections for pain
3. Brachial Plexus Block
4. Clinic visits for prescription refills
5. Clinic visits for continuity of care
6. Morphine pump refills
7. Caudal Steroid Injection
8. Celiac Plexus Block & Denervation
9. Cervical Epidural Steroid Injection
10. Percutaneous Discectomy
11. Discography
12. Epidural Lysis of Adhesions
13. Facet Joint Injections and Medial Branch Block (Cervical/Thoracic/Lumbar)
14. Ganglion of Impar Block
15. Intercostal Nerve Block
16. Intradiscal Electrothermal Therapy (IDET)
17. Lumbar Epidural Steroid Injection
18. Lumbar Radiofrequency Neurotomy
19. Lumbar Sympathetic Block
20. Lumbar Transforaminal Epidural Steroid Injection
21. Occipital (Greater & Lesser) Nerve Block
22. Piriformis Injection
23. Psoas & Quadratus Lumborum Muscle Injection
24. Radio Frequency Denervation
25. Sacroiliac Joint Steroid Injection
26. Selective Nerve Root & Dorsal Root Ganglion Block
27. Spinal Canal Endoscopy
28. Stellate Ganglion Block
29. Sphenopalatine Ganglion Block & Neurolysis
30. Splanchnic Nerve Block & Denervation
31. Superior Hypogastric Plexus Block
32. Suprascapular Nerve Block
33. Thoracic Epidural Steroid Injection
34. Trigeminal Ganglion Block & Neurolysis
35. Trigger Point Injections
36. Removal of trial stimulating catheters
37. Follow-up visits for post surgical or IPM procedures
38. Removal of sutures or staples
39. Interrogation of Spinal Cord Stimulators and peripheral nerve stimulators
40. Examination and re-evaluation of an acute pain flare
41. Consultations/Letters/Conferences
42. Occasional minimally invasive procedures
43. Telephone call backs
44. Cervical, thoracic, lumbar and caudal epidural catheter placements
45. Trial and Permanent Spinal Cord Stimulators
46. Permanent morphine pump placement
47. Peripheral Nerve Stimulator Placement
48. Replacement of Malfunctioning SCS and Morphine Pumps
49. Repositioning of SCS electrode leads
50. Sacral Stimulating Catheter Placement
51. Subcutaneous Cervical Stimulator
52. Nucleoplasty
53. Dekompressor
54. Vertebroplasty

Fellow Responsibilities:

Fellows are expected to participate actively at the Pain Clinic Monday thru Friday. Each week a fellow is assigned to cover the acute pain service. This fellow is in charge of carrying the pager and making rounds with the attending each morning (usually fewer than 5 patients) prior to the Pain Clinic. This fellow is also assigned for interventional cases at the OR on Thursdays.

Fellows are expected to attend educational program activities, which consist of Pain Medicine lectures and Journal Club on Monday and Tuesdays at 7:00am and Anesthesiology Lectures, Journal Club, and Morbidity and Mortality on Tuesdays at 3:00 pm. Fellows will be asked to prepare lectures on a monthly basis to be presented to attending physicians, residents, and medical students. Every other month a case presentation is assigned to a fellow to be presented to the Pain Management specialists.

Qualifications:

In order to fill an application for the Pain Medicine fellowship Program, the physician must meet the following requirements:

1. Graduation from an Anesthesiology Residency Program.
2. Fluent in Spanish (written and spoken). English is not required, but highly recommended.
3. Able to demonstrate interest in Pain Medicine and Interventional Techniques, and have a plan to follow after graduating from the Pain Medicine Program.
4. Three letters of recommendation.

Faculty:

Carlos Buxó Tirado, MD
Director
Interventional Pain Management

Francisco Lebrón Arzón, MD
Interventional Pain Management

Vilma T. McCarthy Nazario, MD
Psychiatry

José Santos, MD
Acupuncture

Luis Baerga, MD
Pain Medicine

Taking Call:

Each week a fellow is assigned to cover the acute pain service. This fellow is in charge of carrying the pager and making rounds with the attending each morning (usually fewer than 5 patients) prior to the Pain Clinic. Rounds will also take place during the weekend if necessary. The service consists mostly of acute postoperative pain management with PCA machines and epidurals, but include chronic pain consults as well. Acute pain consults should be taken care of ASAP. Consults for flail chest patients also have priority and need to be attended to ASAP. Consults regarding chronic pain patients can wait up to 24 hours to be answered.

All patients need to be presented to the attending physician by the fellow. When a resident is carrying the pager, the resident will call the fellow, and then the fellow will present the case to the attending physician.

Usually, the fellow taking call will be assigned to the procedure room during the same week, and will be in charge of the OR cases during the week. The same fellow will be in charged of calling back patients in the afternoon, to attend to any questions or concerns.

Pain Clinic:

Fellows should be present at the Clinic at 7:00am. The Clinic usually runs until one hour past noon on Monday, Wednesday, and Friday. Clinic runs until 3:00pm on Tuesdays. Thursdays are unpredictable, but usually duty is over early in the afternoon.

Dress code for the Clinic is business casual, unless the fellow is assigned to the procedure room, in which case scrubs may be worn.

Fellows are expected to evaluate new patients and present them to the attending physician. A complete history, physical exam and evaluation of imaging is expected. The fellow should be able to design a plan of treatment and discuss it with the attending physician.

Residents and medical students will be directly supervised by the fellows. A lecture will be given to the residents and medical students by a fellow on Wednesdays at 1:00 pm. These lectures should cover basic acute pain management topics, as well as chronic pain management.

Rotations:

The fellows will spend most of their time at the Pain Clinic during the year. At some occasions, rotations will take place at other facilities with close relationships with our Pain Clinic. These rotations will include one month at the Spine Center and one or two months doing a 2 day per week rotation at the Veteran's Administration Hospital (VAH) Physical Medicine and Rehab Pain Clinic.

Contact Information:

Pain Clinic
787-758-7910 x225 236 787-758-2525 x1528

Department of Anesthesiology
787-758-0640 787-758-2525 x1920 fax 787-758-1327

Dr. Carlos Buxó
cabuxo@rcm.upr.edu

Dr. Francisco Lebrón
franciscocisco@yahoo.com