Burnout is increasingly being recognized as affecting physicians and their patients, with over 50% of attending physicians registered through ABPM&R reporting symptoms of burnout . Although definitions of burnout vary, they commonly include 3 things:
Previously, studies were mostly reporting on the prevalence of burnout, but recent studies, including that by Sliwa et al. have shifted to determining factors that contribute to burnout, which include increasing regulatory demands, workload and job demands, and practice inefficiency and lack of resources . Now that some potential contributors to burnout have been identified, the next step is to determine how we can combat them.
Although there has not been a similar study to evaluate burnout in PM&R resident physicians, many residents recognize this as a problem. To help combat burnout and to emphasize resident well-being, the AAP RFC added a new position: the Education/Well-being Representative. This was the most sought-after position on the RFC with the highest number of applicants. Given the great talent and ideas of the applicants, the RFC decided to create a Well-Being Subcommittee.
The AAP RFC Well-Being Subcommittee’s goal is to provide information and resources to support PM&R physician wellness on a national level so that we can encourage and inspire each other to practice physical, mental, emotional, spiritual, and social wellness
Meet the team
I’m Allison Schroeder, a PGY-4 Chief Resident at the University of Pittsburgh Medical Center (UPMC) where I also serve on the UPMC GME Wellness, Environment, Learning, and Living (WELL) committee and am co-chair of the UPMC PM&R resident wellness committee. My interest in well-being started at a young age when my dad would remind her to always “keep a positive, happy attitude” and I continue to value grit, resilience, and positivity. I enjoy running and spending time outdoors to maintain balance and for stress relief.
Mona Ahmed is a PGY-3 resident at the University of Alabama at Birmingham (UAB). She is the social chair of the UAB PM&R resident wellness committee and also serves on the UAB GME Wellness Subcommittee. Mona’s long term goal is to increase resident wellness by identifying and tackling systemic issues contributing to burnout. When she’s feeling down, Mona enjoys a game of racquetball, a good cheeseburger, and some sun.
Tracey Isidro is a PGY-3 at Baylor College of Medicine (BCM) where she is part of the inaugural BCM Wellness Committee. She is very passionate about wellness, and has written and spoken nationally on topics like how to be happy and healthy in medical school, lessons from intern year, wellness tips for busy individuals, how to be your best: tips on how to be successful, and spirituality and compassion in the patient-physician relationship. Outside of residency, she enjoys spending time with her family (Dad, Mom, twin sister Stacey, brother Ace, and three rescue dogs), salsa dancing, and composing piano music.
Olga Komargodski is a PGY-3 at Stony Brook University Hospital where she serves as the Patient Safety Resident. She has become interested in well-being while trying to do her best with both Residency and motherhood. Olga’s favorite hobby is writing fantasy novels, which are published in the Russian language.
Rosa Pasculli is a PGY-3 resident at NYU Rusk and co-chair of the NYU Physician Wellness Committee. Her main wellness interests are fitness and nutrition; she is a certified personal trainer and fitness nutrition specialist through the National Academy of Sports Medicine, and taught group fitness classes prior to starting residency. She loves trying new workout classes around Manhattan (favorites: 305 Fitness and Fhitting Room) and experimenting with paleo recipes.
Jasmine Harris is a PGY-4 at the Icahn SOM at Mount Sinai in New York. She is also a certified Integrative Health and Wellness coach. Her passion for well-being developed when she discovered yoga and meditative practices as a way to readily cope with the rigor and stress of medical training. In her spare time, she enjoys bringing nature indoors by caring for her more than 70 houseplants.
We are planning to provide information and resources to help improve overall well-being which will be available online and published on the AAP website. Please check out the AAP “Words of Wellness”. More content on this website will be coming soon! If your residency program has wellness initiative in place that you would like to have featured on our website and shared with other programs around the country, please contact me at firstname.lastname@example.org.
- Sliwa JA, Clark GS, Chiodo et al. Burnout in diplomates of the american board of physical medicine and rehabilitation-prevalence and potential drivers: a prospective cross-sectional survey. PM R. 2019 Jan;11(1):83–89.
Q&A with the experts on Spinal Cord Stimulation (SCS) — A Summary For Residents & Fellows
by Vinny Francio, MD
Alexios G. Carayannopoulos, DO - Chief, Department of PM&R, Rhode Island Hospital
Jonathan M. Hagedorn, MD - Pain Faculty, Division of Pain Medicine, Mayo Clinic
Richard Kendall, MD - Professor of PM&R, University of Utah
Lynn Kohan, MD - Director of Pain Management Fellowship, University of Virginia
Suzzanne Manzi, MD - PM&R Pain Medicine, Performance Pain & Sports Medicine Houston, TX
Dawood Sayed, MD - Division Chief of Pain Medicine, Program Director of Multidisciplinary Pain Fellowship, Medical Director of The Center of Neuromodulation, The University of Kansas Health System
Byron J Schneider, MD - Assistant Professor, PM&R, Vanderbilt University Medical Center
Last month, I received an invitation from my good friend and Editor of AAP’s Physiatry in Motion, Jim Eubanks, MD, to produce an article on spinal cord stimulation (SCS). He suggested this topic since I’ve been researching SCS for my thesis and have an interest in pursuing a pain fellowship. I started brainstorming ideas on how to approach this paper in a manner that would be valuable to residents and fellows with interest in this intervention. I could think of no way better than “picking the brains” of some of the best neuromodulation experts using questions that residents and fellows emailed to me. Below is a brief summary of the discussion. Due to word count, the full-text is available at https://bit.ly/2YUGlUJ
Neuromodulation includes the application of electricity to the central or peripheral nervous system, and musculoskeletal system. For the purposes of this discussion, we will focus only on SCS, which is classically indicated for chronic neuropathic pain that is otherwise not responsive to more common conservative measures. SCS may no longer be considered a treatment of last resort. Instead, it may be used to reduce persistent opioid use and/or repeat surgical interventions that are unable to show concomitant improvement in long-term pain or function (Carayannopoulos, 2019). Dr. Manzi also provides an interesting insight: “To me, neuromodulation refers to changing the way the brain interprets pain by modulating the nervous system. Any condition that causes nerves to be affected may be a target for neuromodulation.”
Importantly, clinical success with neuromodulation techniques most likely occurs with appropriate patient selection, realistic patient expectations, proper procedural/surgical technique, adequate coverage of a patient’s individual pain pattern, and subsequent improvement of function longitudinally. As such, it is important to schedule regular follow-ups after implant to further educate patients, reprogram as necessary, and ensure adherence with therapy. In terms of successful indications, Failed Back Surgery Syndrome or FBSS with residual leg pain (see North and Kumar’s work) and Complex Regional Pain Syndrome or CRPS (Kemlar’s work) remain traditional research-backed SCS responsive conditions (Hagedorn, 2019).
Pitfalls occur with poor patient selection, unrealistic expectations or understanding of SCS capabilities, poor coverage of individual pain patterns, poor surgical technique, disregard of potential medical issues, which may in turn lead to infection or bleeding, and mechanical failure of the device, including lead fracture or migration (Carayannopoulos, 2019). Numerous medical conditions, including but not limited to bleeding risk, coagulopathy, infection, immune suppression, and/or anticoagulation use could preclude safe trial or implant and increased risk of complications or poor clinical outcomes. Behavioral or cognitive factors may also impede ability to set realistic expectations or understand the appropriate use of devices, including uncontrolled psychiatric illness, lack of social support, and high pain catastrophizing (Hagedorn, 2019; Carayannopoulos, 2019).
Discussion with the Experts
Q: When do you use SCS in your clinical practice?
Dr. Sayed: The most ideal indication is chronic intractable neuropathic pain, secondary to post-laminectomy syndrome and/or FBSS. Other indications included CRPS, peripheral neuropathy, diabetic neuropathy, post-herpetic neuralgia and chronic radiculopathy that failed conservative care. The strongest body of evidence with SCS treatment is with the first two.
Dr. Hagedorn: While I’m excited about neuromodulation and recognize its effectiveness, I still try more conservative measures first. If these are not effective or results are not long lasting, I offer neuromodulation to my patients.
Dr. Kendall: I am very conservative with my referrals for SCS. CRPS and chronic radiculopathy are the only two indications, I have seen it useful in. I am not convinced with the data on SCS for back pain, even in the post-surgery group. The fact that it is better than repeat surgery does not mean it is better than other conservative methods with lower risks.
Dr. Schneider: I most often refer for an SCS evaluation patients with recalcitrant axial spine and/or radicular pain despite a technically successful surgery, in the absence of any new pathology, and in whom there are limited other treatment options.
Q: Briefly, what are the different technique interventions for SCS?
Dr. Sayed: SCS is a two-stage procedure, first a trial, and if successful, followed by a permanent implant. Trial is most commonly performed percutaneously using fluoroscopy guidance. Permanent placement may be performed percutaneously (by interventional pain PM&R/Anesthesia physicians or surgeons), as well as surgically via a laminectomy (usually if paddle placement, performed by a spine surgeon).
Dr. Hagedorn: Non-surgically trained (Anesthesiologists, PM&R, Neurology, Psychiatry, etc.) physicians will almost exclusively perform percutaneous trials with cylindrical leads. On the other hand, neurosurgeons have the training to safely perform paddle lead (versus cylindrical lead) implantation. This is typically performed with an incision and a laminotomy to implant the device, including the trial. Paddle and cylindrical leads have different energy delivery, which has not been shown to affect outcomes.
Q: What is the difference in training between SCS trials vs. SCS permanent placements?
Dr. Sayed: As mentioned, placement may be performed by pain physicians or surgeons. There are surgical skills required for percutaneous placements, therefore it is imperative to have proper training to manage pre-op and post-op care. It is my opinion that anyone doing SCS should have trained at an ACGME accredited Pain Fellowship at a minimum.
Dr. Manzi: Training depends on the trainee. One can be very hands on and learn all of the techniques, from trial through implant. Others may not feel comfortable performing and managing surgical complications that may occur. Only physicians confident in being able to manage their own complications should be performing these procedures. It will take a trainee to seek out higher level training to become proficient at these skills. A neurosurgeon or orthopedic surgeon should be utilized if that is the setup in the community, if there is a level of discomfort in doing these procedures, or if the patient has altered anatomy and may be high risk. PM&R physicians and anesthesiologists with the appropriate training can perform trials and surgical implants confidently.
Dr. Hagedorn: I would hope that during a chronic pain fellowship training, one would get adequate training in both trials and permanents. This involves training at your fellowship program, but also industry sponsored training events and conference opportunities. A percutaneous trial is performed through the skin, but in addition to placing the lead in the epidural space and steering it to the appropriate level, you must securely fasten the lead to the skin to reduce migration and cover the device with a sterile dressing to avoid infection. The work is not done when you get loss of resistance in the epidural space. An implant involves making two incisions in the skin and really is a surgical procedure. Thus, appropriate surgical training is necessary. This involves the whole surgical experience, including pre-operative, intra-operative, and post-operative preparations, in addition to a responsibility to handle complications when they arise. All chronic pain fellowship trained physicians should be able to handle both SCS trials and implants. If anatomy or prior surgery precludes safe placement of a cylindrical lead, a surgical referral should be placed for paddle lead placement under direct visualization.
Dr. Kohan: Training for both is similar in regards to identification of appropriate radiographic interlaminar entry points and “driving” of the leads. Fellowship trained pain management physicians (regardless of primary specialty) are generally well suited to perform both percutaneous trials and implants, assuming they received sufficient training in both methods during their training. Sometimes it may be necessary to refer a patient to a spine surgeon to perform an implant. Because percutaneous leads emit energy circumferentially, more energy is “wasted” since it is not directed towards the spinal cord. Depending on the needs of the patient and his/her pain pattern, a paddle lead may be more appropriate at times to “capture” the painful area, hence a surgeon involvement. Yet, technology has advanced, and percutaneous leads are now better able to “capture” the back, therefore it seems less likely that a patient would need to be referred for a “paddle lead”.
Q: What are the advantages of performing trials only vs. trials and permanent SCS procedures?
Dr. Sayed: The biggest advantage for me is the continuity of care with patients by performing the trials and permanents. Most patients like the idea to have a physician that participates in all phases of care, that helps to develop the trust factor and a comfort level that is important in chronic pain care.
Dr. Manzi: Trials can take only a few minutes to perform, where as a permanent implant can take usually at least a half an hour. Trials are like doing an epidural injection, and usually very straightforward. Permanent implants are a surgical procedure and may take some time to become proficient. If in a practice that utilizes a specific team of surgeons for implants, then the pain physician should wisely perform the trials.
Dr. Hagedorn: I strongly believe that all chronic pain physicians should perform both SCS trials and implants, if they are comfortable and have sufficient training. As a former surgeon, this is the aspect of chronic pain management that I enjoy the most. Advanced interventional therapies to improve quality of life and provide pain relief.
Dr. Kohan: In the community setting, there may be advantages to only performing SCS trials. Many physicians decide to only perform SCS trials and to routinely refer patients to a surgeon for a laminectomy implant. There are various reasons behind this decision, including maintaining a referral base and not have access to a surgical suite. Studies have shown a higher risk of lead movement and infection with cylindrical leads, which may lead a private practice physician to prefer referring to a spine surgeon for implantation. In the academic setting, advantages of performing both the trial and the implantation includes ensuring fellows are appropriate trained in both techniques.
Dr. Kendall: For the patient it is nice to get everything done with one physician and in a timely manner. Not waiting for trial approval, then getting trial, then having explanted, then seeing surgeon, then scheduled for OR, then having it done.
Dr. Schneider: Doing permanent SCS implants requires the infrastructure to take care of these patients on an emergent basis, necessitating a call pool that can physically assess and treat patients if needed and be available to the ED if needed. While surgical practices often have this in place already, many outpatient pain or PM&R spine practices do not necessarily have this in place.
Dr. Carayannopoulos: Advantages of performing both trials and implants include clinical continuity of care with the patient, as the same physician will be performing both procedures. Additionally, there is more assurance that if the same physician is performing both the trial and implant, the placement of electrodes will be most consistent. Advantages of performing trials only include clinical practice efficiency and reduction of surgical risk.
Q: How do you foresee the future of SCS?
Dr. Sayed: We are very lucky. There is a renaissance in the field. When I was doing my fellowship, the innovation was fairly flat. What we have seen in the last five years are actual innovations that improve outcomes and new targets, such as dorsal root ganglion (DRG), high frequency stimulation, microglial stimulation, closed loop stimulation, etc. This is really a fascinating time to be in the field. There is no shortage of patients and chronic pain has been improperly managed, so the timing is great that we have this explosive advance in technology to match with a great need, given the opioid epidemic.
Dr. Manzi: The opportunities are endless. I believe that the field of neuromodulation has only begun. Although it has been around for 40 years, this field will likely have widespread applications for years to come.
Dr. Hagedorn: I think the momentum will continue and the future is very bright. I believe we will see smaller devices, better technology and energy delivery, and improved safety. All of these improvements will allow us to provide better pain care to our patients.
Dr. Kohan: The future of neuromodulation is bright. New modalities with increasing efficacy are emerging at an astounding rate. Different frequencies and types of waveforms are allowing for better efficacy of the therapy. These new techniques have allowed for paresthesia free stimulation, which many patients prefer. Closed-loop technology is also being utilized. This technology allows the SCS device to communicate with the spinal cord and adjust the degree of stimulation accordingly. It is likely that the future will continue to see evolving technology allowing patients to see increased efficacy from their devices, thereby allowing for improved pain control and better function.
Dr. Kendall: Neuromodulation has come a long way since I trained. I think there is hope that there will be continued success for some of the chronic pain and neurogenic pain (central and peripheral). However there is still a lot of difficulty with longevity of relief, due to loss of efficacy of stimulators (scar tissue, lead migration, central adaptation). There is still difficulty with more than 2 year outcome data, which is problematic if it is a permanent implant that limits MRI for future.
Dr. Schneider: There is certainly momentum with neuromodulation, and almost certainly a role for this in the future. SCS is still riding an upward slope towards a peak of inflated expectations. There is very little literature on SCS that is not influenced by industry, and collectively many of the studies are in conflict with each other.
Dr. Carayannopoulos: The future of neuromodulation will grow exponentially as electrical paradigms evolve, indications expand, and as the technology improves. The introduction of closed-loop technology, which offers a more individualized treatment approach may revolutionize the future.
Q: What recommendations and words of wisdom do you have to share with residents/fellows looking to practice this intervention in their careers?
Dr. Sayed: It is a competitive climate now, the quality of people continues to rise and it is so competitive. My biggest advice is to get involved and work to advance the field of pain management. Get involved in academic endeavors, research, abstracts, associations. We are really looking for people with a dedication to the field, more than board scores and good grades in training exams. Show a genuine interest and motivation to stand out.
Dr. Manzi: Be a sponge and learn what you can while you have the opportunity in residency and fellowship. This time is going to prepare you for the rest of your life. Utilize it wisely. Do not hesitate to ask questions and be involved as much as possible. What you learn in residency and fellowship may not be exactly what you are doing in the future; however, it will prepare you to be well versed and know what to do and when to refer out.
Dr. Hagedorn: Always remember the patient. The sole reason we should be discussing this technology is to decrease the suffering and increase the quality of life of a patient in pain. If this remains your focus, you will do great things.
Dr. Kohan: While technical skills are of course important in SCS training, I would encourage all trainees to pay attention to pre-operative planning, as well as post-operative care. These are essential to the proper management of patients with neuromodulation devices. It is not simply the act of placing the stimulator. Patient selection, the ability to clearly communicate the procedure and obtain proper consent, as well as the ability to recognize and manage post-operative and long term complications is essential.
Dr. Kendall: My opinion is all providers entering the field at this time should be aware of the mechanisms of action, appropriate indications for use, contraindications for use, and methods of placement. Even if not performing them they should be able to explain to a patient if they may benefit, and also understand the risks of placement before referral. If residents/fellows intend to practice this procedure they should probably do (not watch) about 10 trials and 10 implants to expect to receive credentials upon starting a job after training.
Dr. Schneider: Learn the proper indications, and limitations of the technology. Learn it as one tool to be leveraged in the management of these conditions, but realize there is still plenty to be determined about how it will ultimately be utilized long term.
Dr. Carayannopoulos: My recommendations for trainees are to find an appropriate mentor to provide guidance along their journey. Additionally, it is helpful to volunteer your time to help with committees and other educational opportunities, such as academic writing and contributing to research, Furthermore, and most importantly, it’s imperative to study and learn not only the anatomy and pathophysiology, which compose the biomedical side of pain, but also to learn and understand the biopsychosocial aspects, which need to be addressed and treated in order for a patient in pain to improve in the long term.
Full-text available at: https://bit.ly/2YUGlUJ
Vinny Francio is a PGY1 TY Resident at SSM Health St. Anthony Hospital in Oklahoma City, OK, and incoming Resident in the Department of Physical Medicine and Rehabilitation at The University Of Kansas Medical Center (KUMC). Follow him on Twitter @VinnyFrancioMD.