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November 2000
Volume 64 |
Number 11
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| Are
We Training Too Many Pain Specialists? |
James P. Rathmell,
M.D
Committee on Pain Medicine
The Association of Pain Fellowship Directors
invites representatives from all pain management training programs
that are accredited by the Accreditation Council for Graduate
Medical Education (ACGME) to meet biannually and discuss issues
of interest and importance with those who lead pain management
training. During last year's meeting, the group asked that I make
an attempt at analyzing the current supply/demand relationship
in the marketplace for physicians with subspecialty training in
pain medicine. The following text is a summary of that analysis
as compiled and presented at the meeting of the Association of
Pain Fellowship Directors meeting held last fall in Dallas, Texas.
In the specialty of anesthesiology, we
have witnessed a drastic swing in the number of young physicians
entering training during the past five years. The ebb occurred
just four years ago when the smallest number of senior medical
students in more than a decade entered training in anesthesiology.
There seemed to be no positions available for graduating anesthesiologists,
and salaries for new attending physicians declined rapidly. Now,
just four years later, the demand for newly trained anesthesiologists
has returned and many would suggest that there are now far too
few new anesthesiologists. Are we facing a similar trend in pain
medicine? Are we training too many pain specialists?
Let us start by examining the supply side
of the equation – just how many new pain physicians are we
training? Last year, ASA surveyed all 132 ACGME-accredited anesthesiology
residencies and questioned them about the number and type of resident
physicians seeking additional training in various subspecialties.
There are currently 97 ACGME-accredited pain management training
programs in the United States; each program offers between one
and eight training positions. The number of physicians seeking
fellowship training in pain management has steadily grown over
the past decade with more than 200 in training during the 1998-99
academic year Figure 1.
For those physicians who gain expertise in pain medicine, there are two primary routes for certification: the American Board of Anesthesiology (ABA) Certificate of Added Qualifications in Pain Management and the certification examination offered by the American Board of Pain Medicine (ABPM). Since ABA first offered the pain management examination in 1993, 2,243 diplomates have passed the examination. The number of candidates sitting for the examination and the overall pass rate are shown in Figure 2. During the most recent exam given in September 2000, candidates holding primary board certification from the American Board of Psychiatry and Neurology (ABPN) as well as the American Board of Physical Medicine and Rehabilitation (ABPMR) were allowed to sit for the exam offered by ABA. Of the 631 candidates taking the most recent examination, 435 registered with ABA, 146 with ABPMR and 50 with ABPN. Training reports received by ABA indicate that there were 260 fellows training in ACGME-accredited pain management training programs during the 1998-99 academic year.
An alternate means of certification, albeit
a certification not currently recognized by the American Board
of Medical Specialties, is that offered by ABPM. According to
ABPM, there are currently 1,179 diplomates who have passed their
exam. A survey of the list of diplomates reveals that approximately
75 percent hold primary board certification from ABA, with the
second most frequent specialty being neurology. Since many physicians
have taken both tests, the total number of physicians who have
passed either the ABA or ABPM exam is unclear.
Assessing the demand side of the workforce
equation is more difficult. While market analysis data are available
from the Medical Group Management Association (MGMA) for many
subspecialties, there are no such data available for pain management
specialists. MGMA and other groups have amassed data from a variety
of practice settings, including heavily health maintenance organization-penetrated
areas and other regions that remain largely fee-for-service. These
data provide some estimates of the population base needed to support
the full-time practice of a single physician based on his or her
specialty. Many institutions have turned to analyses of this type
of data to guide their physician hiring. Similar data for subspecialists
in pain medicine are certainly in the making, but none are yet
available.
Experience at my own institution suggests
that demand for the services of pain physicians continues to grow.
We have seen a rapid escalation in the demand for our services,
including psychological services, cancer pain management and end-of-life
care and management of chronic noncancer pain.
This analysis can take us only so far.
We are producing 200-250 new physicians with pain management training
each year, the majority still being anesthesiologists. How many
physicians in other specialties who are currently training or
in practice and will seek board certification in pain medicine
will become more clear in coming years now that ABA offers certification
to other specialists. Be assured that fellowship directors will
be watching the trends closely in an attempt to make some sense
of the supply/demand relationship for pain medicine specialists
in the United States.
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James
P. Rathmell, M.D., is Director, Pain Management Center, Fletcher
Allen Health Care, and Associate Professor, Department of
Anesthesiology, University of Vermont College of Medicine,
Burlington, Vermont |
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