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Rotations

Internal Rotations

Clinic

Fellows are required to be at MD Anderson during regular duty hours (7:30 a.m. to 5:00 p.m., Monday through Friday). Fellows are expected to "sign out" with the attending physician and the on-call physician. Signing out consists of the provision of a brief problem list and a report on the clinical status of patients. Staff members involved in workups, procedures, voice mail or urgent medical/psychosocial situations should remain until these activities are completed.

Inpatient Rotation (see Mobile Team Information)

The primary goals for the Fellow on the Inpatient rotation is to learn to assess and manage acute and chronic pain problems in the hospitalized patient. This includes, but is not limited to, the following specific learning objectives:

  • Perform an appropriate assessment of hospitalized patients with acute pain including perioperative and cancer pain
  • Perform an appropriate assessment of hospitalized patients with chronic pain including cancer pain
  • Accurately integrate history, physical examination and diagnostic testing data to generate a working diagnosis and additional diagnostic evaluation as indicated
  • Develop an appropriate management plan for hospitalized patients with acute and chronic pain utilizing a range of therapeutic options including medical, interventional and psychosocial
  • Apply didactic information from lecture, grand rounds, journal club, independent study and other sources to the care of individual patients
  • Provide continuity of care by monitoring patients throughout the hospitalization and appropriately adjusting the pain management plan for changing patient needs
  • Effectively communicate and coordinate the pain treatment plan with the patient's primary service
  • Develop interpersonal skills needed to manage and treat complex pain problems throughout the course of the patient's illness

Under faculty supervision, to establish adequate experience to fullfill these objectives, the fellow must document involvement with a minimum of 15 new chronic pain patients and a minimum of 50 new acute pain patients on the inpatient service.

The inpatient fellow will be responsible for triage duties for consult requests for pain management. For routine postoperative consults, the inpatient fellow will assess the patient and perform the initial history and physical examination. An advanced practice nurse or physician assistant will then follow the patient and discuss the patient's daily progress with the inpatient fellow or the staff physician. For other (non-postoperative) consults, the inpatient fellow will be responsible for the patient's care on a daily basis, beginning with the history and physical examination on the first day. The inpatient fellow will also be required to "round" on their patients on a daily basis and formulate a thoughtful care plan. After discussion with the staff physician, the inpatient fellow will be responsible for the implementation of the plan. Four months (in one-month blocks) are allocated for this rotation.

Outpatient Rotation

The primary goal for the fellow on the outpatient rotation is to learn to assess and manage acute and chronic pain problems in the outpatient setting. This includes, but is not limited to, the following specific learning objectives:

  • Perform an appropriate assessment of outpatients with chronic pain including cancer pain
  • Perform an appropriate assessment of new and acute pain in patients with existing chronic pain
  • Accurately integrate history, physical examination and diagnostic testing data to generate a working diagnosis and additional diagnostic evaluation as indicated
  • Develop an appropriate management plan for outpatients with acute and chronic pain utilizing a range of therapeutic options including medical, interventional and psychosocial
  • Understand the clinical approach to the treatments that comprise multidisciplinary cancer pain care and strategies to integrate pain management into the treatment model
  • Apply didactic information from lecture, grand rounds, journal club, independent study and other sources to the care of individual patients
  • Improve patient presentation skills for both comprehensive consultation visits and problem-focused visits
  • Develop and/or improve administrative and record-keeping skills including progress note and procedure dictations, medical record documentation, practice management and proper prescribing guidelines
  • Establish good decision-making skills in treating pain problems including chronic pain management, telephone management and triage
  • Effectively communicate and coordinate with referring physicians and other caregivers
  • Perform psychiatric evaluation of patients with special attention to psychiatric and pain co-occurring conditions including substance-related, mood, anxiety, somatoform, factitious, personality disorders and environment stressor
  • Understand the principles and techniques of psychosocial therapies, be able to explain these therapies to a patient and make appropriate referrals for psychiatric services
  • Develop interpersonal skills needed to evaluate and treat complex pain problems throughout the course of the patient's illness
  • Function effectively as part of a multidisciplinary team in the management of chronic pain patients

Under faculty supervision, to establish adequate experience to fulfill these objectives, the fellow must document primary responsibility for a minimum of 50 different outpatients followed over at least two months each, and a longitudinal involvement with a minimum of 20 cancer pain patients. Fellows must also document a complete mental status examination in a minimum of 15 patients, and with a faculty observer in five patients.

The outpatient fellow will be responsible for daily activities in the clinic. Clinic assignments will rotate between the various staff physicians assigned to that day's clinic. The outpatient fellow will assess patients, perform a complete history and physical examination and present the patient to the staff physician. The presentation should also include a carefully formulated plan of treatment. Fellows will develop the skills above during the time spent on this rotation. After the patient is seen by the staff physician and is discharged from the clinic, the outpatient fellow will be responsible for dictating the record of the patient's visit. Four months (in one-month blocks) are allocated for this rotation.

Interventional Procedures

The primary goal of this educational activity is to prepare fellows to perform interventional procedures for pain management. This includes, but is not limited to, the following specific learning objectives:

  • Understand the selection criteria for a broad range of interventions used in pain management
  • Understand the risks and potential advantages of interventional procedures used in pain management
  • Perform an appropriate patient assessment and accurately identify appropriate interventional procedures in specific patients in the inpatient and outpatient setting
  • Provide appropriate explanations to patients and obtain proper informed consent for procedures including radiologic imaging
  • Demonstrate adequate technical knowledge and skill for common pain procedures including equipment and set-up for procedures
  • Formulate and dictate accurate and appropriately detailed history and physical, and procedure or operative notes
  • Demonstrate understanding of appropriate post-procedure follow-up care pain procedures

In addition to faculty assessments, to establish adequate experience to fulfill these objectives, the fellow must document involvement with a minimum of 25 patients who undergo interventional procedures.

Additional Internal Rotations

To assure fellows are familiar with elements of all four disciplines of pain medicine, fellows will participate in clinical experiences in the disciplines beyond their own specialty training. Pain management faculty with expertise in neurology and psychiatry will work directly with fellows to provide this clinical experience. Separate internal clinical rotations in anesthesiology and physical medicine and rehabilitation are provided for fellows who need these specific clinical experiences. All fellows complete and additional internal rotation on the Supportive Care and Palliative Medicine Service. Each of these internal rotations is two weeks in length. If fellows have not met set rotation objectives at the end of the rotation, the rotation will be extended until the clinical and learning objectives are met. Specific learning objectives for each of the four disciplines and for palliative care are listed below.

Anesthesiology

After completing the rotation with the Anesthesiology Service, the fellow will demonstrate competency in each of the following as documented with appropriate faculty:

  • Obtaining intravenous access in a minimum of 15 patients
  • Basic airway management, including a minimum of mask ventilation in 15 patients and endotracheal intubation in 15 patients
  • Provider course in basic life support and advanced cardiac life support
  • Management of sedation, including direct administration of sedation to a minimum of 15 patients
  • Administration of neuraxial analgesia, including placement of a minimum of 15 thoracic or lumbar epideral injections using an interlaminar technique

Neurology

After completing clinical experiences with pain management faculty with expertise in neurology, fellows will:

  • Be able to elicit a directed neurological history
  • Perform a detailed neurological examination to include at least mental status, cranial nerves, motor, sensory, reflex, cerebellar and gait examinations in 15 patients
  • Become familiar with basic neuroimaging and be able to identify significant finding
  • Understand the indicators for and interpretation of electro-diagnostic studies
  • Faculty shall verify this experience in a minimum of five observed patient examinations
  • Additionally, faculty will verify that fellows can identify significant findings, at least MR and CT of the spine and brain, on a minimum of 15 CT and/or MRI studies drawn from examples within brain, cervical, thoracic and lumbar spine

Physical Medicine and Rehabilitation

After completing the rotation with the Physical Medicine and Rehabilitation Service, the fellow will be able to:

  • Perform a comprehensive musculoskeletal and appropriate neuromuscular history and examination with emphasis on sstructure and function as it applies to diagnosing acute and chronic pain problems including assessment of static and dynamic flexibility, strength, coordination and agility for peripheral joint, spinal and soft tissue pain conditions
  • Demonstrate understanding of rehabilitation programs for treatment of various acute and chronic pain problems
  • Understand the natural history of various musculoskeletal pain disorders
  • Appropriately integrate therapeutic modalities and surgical interventions into the treatment algorithm
  • Understand the indicators and interpretation of electro-diagnostic studies related to pain disorders
  • In addition to general faculty assessment, to establish adequate experience to fulfill these objectives, the fellow must document hands-on experience in the musculoskeletal and neuromuscular assessment of 15 patients and demonstrate proficiency in the clinical evaluation and rehabilitation plan development of a minimum of five patients

Psychiatry

After completing clinical experiences with pain management faculty with expertise in psychiatry, fellows will be able to:

  • Carry out a complete psychiatric history with special attention to psychiatric and pain comorbidities
  • Assess patients for potential psychiatric and pain co-morbidities including substance-related, mood, anxiety, somatoform, factitious and personality disorders
  • Recognize the impact of pain medications on mental status and be able to assess, evaluate and treat a patient for mental status changes
  • Understand the principles and techniques of the psychosocial therapies, with special attention to supportive and cognitive behavioral therapies
  • Understand the indications for and appropriately refer patients with psychiatric symptoms
  • In addition to general faculty assessment, to establish adequate experience to fulfill these objectives, the fellow must conduct a complete mental status examination on a minimum of 15 patients, and must demonstrate this ability in five patients to a faculty observer

Palliative Care

After completing the inpatient rotation with the Supportive Care and Palliative Care service, the fellow will be able to:

  • Understand the clinical approach to the multi-dimensional treatments comprising palliative care
  • Understand strategies to integrate pain management into this multi-dimensional treatment model
  • In addition to general faculty assessment, to establish adequate experience to fulfill these objectives, the fellow must document longitudinal involvement with a minimum of 10 patients who require palliative care

External Rotations

Fellows will learn about pain management not offered at MD Anderson Cancer Center. Specifically, these include rotations in the private practice setting and in predominantly nonmalignant pain clinics. External rotations are designed to provide intensive training in diagnostic and therapeutic treatment related to the management of acute and chronic nonmalignant pain syndromes.

Fellows will learn to:

  • Follow appropriate care and treatment guidelines
  • Reassess individuals that do not respond to the most common pain therapies
  • Provide a time-governed (e.g., short or long-term) treatment of pain

While on external rotations, fellows will not take call. All fellows are required to complete the mandatory staff evaluations for their rotations. A maximum of two months may be taken on external rotations and only one fellow may be gone at a time to allow for adequate coverage.

External rotations are available at the following:

The Pain Management Clinic (Private Practice Rotation)

Stephen Sims, M.D.
Huntsville, Texas

In the private practice rotation, fellows will be responsible for learning to efficiently perform interventional procedures and to learn about the private practice office-based setting. Fellows are exposed to patients that receive treatments based largely on interventional pain management. Fellows must follow the guidance of Dr. Sims, who is affiliated with our program, and should adhere to his instruction while performing “hands-on” procedures. Dr. Sims supervises all fellows during patient visits and while doing procedures, and he will also evaluate the performance of the rotating fellow.

The Pain Management Center at The University of Texas Medical Branch at Galveston

Gulshan Doulatram, MD
Program Director
Galveston, Texas

This rotation is designed to provide intensive training in diagnostic and therapeutic injections related to the management of acute and chronic pain patients. These include, but are not limited to peripheral nerves and muscles, spinal column and sympathetic nerves. Neuromodulation and intrathecal therapy is utilized when needed. Also, fellows will have the opportunity to work closely with pain management psychologists and physical therapists in a multidisciplinary setting to help patients to deal with chronic pain. Fellows will work under the supervision of faculty to see patients and to do procedures. Dr. Doulatram will evaluate the performance of the rotating fellow.


© 2014 The University of Texas MD Anderson Cancer Center