Mission and Vision

To create top leaders, practitioners, and researchers in the field of Pain Medicine through a Pain Medicine Fellowship Program that emphasizes interdisciplinary and collaborative partnerships across all medical disciplines specializing in the management of acute and chronic pain. To provide superior education, training, and mentorship in a clinically and academically challenging environment so that fellows are able to apply their knowledge and skills independently in clinical and hospital settings serving a military population in both a garrison and field environment with a focus on military unique challenges of battlefield and post traumatic pain and comorbid PTSD.

Aims

To foster and maintain the highest standards of training and education in Pain Medicine.

To produce Pain Medicine consultants who relate confidently and appropriately to other specialists and patients, and who are clinically competent in:

• Consultation of patients with acute and chronic pain in both an outpatient and inpatient environment, including the assessment and treatment of pain
• Principal multidisciplinary elements of pain medicine including experience in the fields of anesthesiology, neurology, psychiatry, and physical medicine and rehabilitation
• Leadership, supervision, teaching, and evaluation of those involved in the multidisciplinary treatment of pain
• Clinical and basic science research
• Ethical considerations of Pain Medicine
• Interventional pain treatments

To instruct, observe, and mentor our fellows in the development of essential qualities for certification and to prepare them for optimal performance in the certification process.

To ensure graduates from our program possess sufficient medical knowledge, professionalism, communication skills, and clinical judgment to be competent in providing pain care independently.

To instruct and encourage fellows to participate in academic pursuits including research, publications, presentations, lectures, and case discussions with their colleagues and teachers.

To educate fellows in quality improvement and patient safety and encourage their active participation in these endeavors within the department or sponsoring institution.

To exemplify Navy core values, including responsibility, respect, and integrity as physicians and Naval Officers.

To ensure that our graduates possess personal characteristics essential to the ethical and safe practice of pain medicine.

Academics

Various methods of instruction are utilized by the pain medicine fellowship for education of the fellow and include didactics, simulation, cadaver workshops, journal clubs, critical incident conferences (formerly known as mortality and morbidity conferences), case discussions, attendance of national academic conferences and one-to-one faculty-to-fellow instruction for all clinical activities.  Most academic activities are conducted on Wednesday mornings from 8 a.m. - 12 p.m., although activities such as attendance of the UCSD “Mechanisms of Pain” course (Fall of each year) and national academic conferences (various) occur at different times.  The Pain Medicine Academic Day is mandatory for all fellows (Academic and Non-Academic) unless on a leave or TAD status.

Didactics

Formal presentations on relevant topics in Pain Medicine by faculty, command physicians, providers, and guest speakers are held Wednesdays from 8 a.m. - 9 a.m. In addition to these lectures, each fellow is responsible for creating and presenting two literature-based 1-hour presentations during the fellowship year. The first lecture (done within the first six months) is a general pain medicine topic (e.g., CRPS, failed back surgery syndrome, migraine headaches, etc.), while the second lecture (done in the last half of the year) is a more specific, controversial topic with extensive review of the literature (e.g., transforaminal versus interlaminar epidural steroid injections, intradiscal injection therapy, etc.). 

Journal Club

Journal club presentations are generally done twice per month.  A “local” journal club is conducted during the Pain Medicine Academic Day once per month and is usually presented by a resident, intern, or medical student rotating through the PMC.  It is the responsibility of the Academic fellow to help the rotator choose an appropriate article for the presentation and guide them through the presentation process. A second Video Teleconference (VTC) Joint Department of Defense (DOD)/Veterans Affairs (VA) Pain Medicine journal club presentation occurs on the third Tuesday of every month. Journal club presentations are done by various fellows throughout the DOD and the NMCSD fellows are required to present every 3-4 months.

Critical Incident Conference (CIC)

A critical incident conference is held once per month during a Pain Medicine Academic Day. It is the responsibility of the Academic AND Non-Academic fellow to find cases or patient encounters in which critical incidences occurred (these cases do not necessarily have to result in mortality or morbidity to qualify). This should be a team effort in coordination with relevant faculty members involved in the cases.  Interesting case presentations can also be done during these sessions. At minimum, an organized case presentation, review of the literature, and recommendations on methods or processes to prevent such an incident from re-occurring should be part of the CIC.  

The majority of the year will be spent in the NMCSD Pain Medicine Center:

Pain Medicine Outpatient Consultations (SPECs) and Follow-Up Visits (FTRs)

The fellow is expected to be actively engaged in new patient consultations and follow-up visits during their time in the Continuity Clinic at NMCSD. It is expected that the fellow will briefly review upcoming new and follow-up patients the day prior as preparation.  In general, the fellow will work with their assigned PMC faculty and are expected (at minimum) to evaluate the patient, devise an appropriate plan of treatment, and coordinate care (as needed) for each patient after discussion with the responsible PMC faculty.  Fellows are also expected to actively pursue unique and challenging chronic pain cases (i.e., cancer pain, complex regional pain syndrome, failed back surgery syndrome, pediatric pain, central pain states, etc.) and should notify their assigned PMC faculty if such cases are scheduled in the clinic.  Documentation for outpatient visits must be done in the outpatient electronic health record (MHS GENESIS). In general, there are three half days of clinic during the work week.

Pain Medicine Outpatient Procedures (PROC)

The fellow is expected to be actively engaged in procedural techniques during their time in the Continuity Clinic.  It is expected that the fellow will briefly review upcoming procedures the day prior as preparation.  In general, the fellow will work with their assigned PMC faculty and are expected (at minimum) to evaluate the patient, review appropriate labs and imaging, determine if the procedure is indicated and appropriate, and perform the procedure with the supervision of the assigned PMC faculty.  Fellows are also expected to actively pursue unique and challenging procedures (i.e., neuromodulation, intrathecal drug delivery, sympathetic blocks, neurodestructive procedures, etc.) and should notify their assigned PMC faculty if such cases are scheduled in the clinic.  Documentation for procedures must be done in the outpatient electronic health record (MHS GENESIS). In general, there are three days per week dedicated to procedures.

Pain Medicine Inpatient Consultation Service

The Academic fellow is expected to be actively engaged in all inpatient consultations during their academic month.  It is expected that the Academic fellow will respond promptly to all inpatient consultations and act as the team leader for the inpatient consultative service.  Responsibilities include, but are not limited to, patient evaluation; development and implementation of a care plan; communication and coordination with the patient, primary consulting team, other members of inpatient pain team (e.g., resident, nursing staff, call coverage team); and daily communication with the responsible SOD.  At minimum, each inpatient should be seen by the fellow twice a day (before clinic and after clinic) and have a daily written note, in addition to the initial chronic pain inpatient evaluation, in the inpatient electronic health record (MHS GENESIS).  The Academic fellow is also responsible for inpatient chronic pain patient consultations on weekends and holidays during the academic fellow month.  Arrangement for one day off in seven (per ACGME guidelines) should be made with the SOD for weekend call coverage.

• Advanced Interventional Pain Consultants of San Diego
• Neurology (NMCSD)
• Neurosurgery (NMCSD)
• Palliative Care (Rady's / UCSD)
• Palliative Care (UCSD)
• Pediatric Pain Management
• PM&R (NMCSD)
• Psychiatry (NMCSD)

The Fellow is expected to respond to all Chronic Pain Inpatient Consults in a professional and timely manner during working hours, after hours during the working week, weekends, and holidays unless on leave or TAD. Part of this duty includes communicating appropriate and updated contact information to the on-call team, SOD, and PMC support personnel and following the Pain Medicine Fellowship Transitions of Care policy.

The program focuses on care of the military service member as well as multidisciplinary and rehabilitative care focused on return of the service member to duty. Further, multidisciplinary conferences and care coordination conferences will focus on return of function, care for the active duty service member and considerations for return of servicemember to full duty and discussion of deployment restrictions. Additional techniques such as Battlefield Ear Acupuncture and Battlefield Acute Pain Management will be taught.

Pain Medicine Fellows are required to maintain Basic Life Support (BLS) certification throughout fellowship.  Pain Medicine Fellows who are anesthesia-trained are required to maintain Advanced Life Support (ALS) or Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) if requesting credentialing as an anesthesia provider.  

Access to monthly biolab and simulation lab for learning and practicing new procedures.

A robust curriculum for developing leaders in pain medicine and in the military. Opportunities start from day one and the fellow is expected to be the leader of the NMCSD Pain Medicine Service and Clinic and representative on all things pain in the MTF:

• Leadership and team building exercises
• Peer mentorship
• Quarterly program leadership and mentoring sessions
• Resident leadership roles, including educational, clerkship, research, wellness, etc.

Research is an important component of the relatively new specialty of Pain Medicine and, as such, is required for all fellows. During the fellowship year, each fellow will be required to complete a scholarly activity.  Examples of scholarly activities include but are not limited to: authorship on a publication in a peer-reviewed journal (e.g., IRB-approved study, case report, technical description, review paper) or book chapter; creation and implementation of an IRB-approved protocol; and poster presentations at a local, national, or international academic conference. Research meetings are conducted Wednesday mornings (once per month) and fellows should attend and actively participate in the Pain Medicine research activities.  

As a component of its next accreditation system, the ACGME has established the Clinical Learning Environment Review (CLER) program to assess the graduate medical education (GME) learning environment of each sponsoring institution and its participating sites. CLER emphasizes the responsibility of the sponsoring institution for the quality and safety of the environment for learning and patient care, a key dimension of the 2011 ACGME Common Program Requirements. The intent of CLER is “to generate national data on program and institutional attributes that have a salutary effect on quality and safety in settings where residents learn and on the quality of care rendered after graduation.” CLER provides frequent on-site sampling of the learning environment that will: increase the educational emphasis on patient safety demanded by the public; and, provide opportunity for sponsoring institutions to demonstrate leadership in patient safety, quality improvement, and reduction in health care disparities.

As such, each fellow is required to develop or participate in a patient safety or quality improvement activity that is part of the Pain Medicine clinic or part of the command (NMCSD).  The Pain Medicine Fellowship follows guidelines set forth by the NMCSD GME for resident and fellow education in patient safety and quality improvement and it is expected that the fellow will complete this educational checklist in conjunction with the PD and/or APD.

While developing excellent pain medicine skills, the NMCSD Pain Medicine Fellowship also focuses on developing future military leaders through mentoring and modeling.

Funding for fellows to attend at least one professional conference during training when presenting a scholarly activity may be available. Our fellows have given national lectures, research podium presentations, have held national leadership board positions, and taught procedural courses.

• Advanced Interventional Pain Consultants of San Diego
• Rady's Children Hospital
• University of California San Diego (UCSD)

• Partial or full month rotations are available through the Pain Medicine Clinic for medical students.
• Please visit our Medical Student Rotation informational page to see a listing of available medical student rotations offered at NMCSD.

If you would like to request an interview with the Pain Medicine Fellowship Program, please email us at: dha.san-diego.San-Diego-NMC.list.nmcsd-pain@health.mil. Interviews can be in person or via audio or video conference.

Program graduates take the American Board of Anesthesiology (ABA) Pain Medicine board exam. This exam is offered annually. To become fully board certified, applicants are eligible to take board certification exam three months following graduation. To be eligible to take specialty board exams, applicants must be board certified in their primary specialty. All applicants should discuss board eligibility with their Program Director to determine individual board eligibility for the respective certifying board.  Board eligibility is described on the following sites depending on the primary specialty:  Subspecialty Exams Archive - The American Board of Anesthesiology (theaba.org) -and- ABPMR - Pain Medicine.

The fellow is the primary contact and instructor for rotating medical students and residents.

Expectation is to provide grand rounds lecture to the Anesthesia residents as well as presentation of a poster or podium lecture at a national conference.

All faculty are double board certified in Anesthesia and Pain Medicine. There are at least six full-time faculty assigned to the fellowship and pain medicine center at any time.

The Fellow is assigned a primary mentor at start of fellowship; however, all faculty have mentorship expectations and at least 50% of the faculty have prior or current military experience.

• The fellowship program and its curriculum have been restructured to ensure maximal opportunities for fellow growth and wellness. We have worked to consolidate all official activities in such a manner as to maximize off time without reducing the maximal opportunities for training.
• Fellows can participate in an optional Wellness Committee geared at optimizing program wellness and involvement with hospital-wide peer wellness and support groups.