n our rapidly changing world of modern health care, new technologies appear at a dizzying rate. Many of these new treatments require physicians to acquire detailed new knowledge and technical skills. The example that comes to mind immediately is the introduction of laparoscopic surgical techniques such as laparoscopic cholecystectomy. While the clinical presentation and diagnosis of gall bladder disease had remained fairly unchanged, the technical skills required of a general surgeon to perform laparoscopic surgery were suddenly dramatically different. As anesthesiologists many of us stood at the bedside and painfully witnessed some of those first laparoscopic procedures being performed in new hands.

And so, as with other specialties, the question of how practitioners should be trained before using new techniques in daily practice is before us, and in no area of the field of anesthesiology is this more of a concern than in pain medicine.

Genesis of New Techniques
The introduction of new techniques typically extends from centers in the public or private sector, where the ideas are conceived and tested in a limited realm among innovators. From there anecdote can often take over, and many techniques in pain medicine have blossomed into widespread use with nothing more than word of mouth to propagate their use. The use of pulsed radiofrequency treatment for pain is one such example where clinical application has preceded detailed clinical testing.¹

In the United States and Europe, industry often leads innovation by testing and leading the introduction of new devices. When the innovation appears to have merit in limited trials, many devices are introduced to the market with approval through the Food and Drug Administration’s 510K “substantially similar device” process with little or no data regarding efficacy. Once on the market, the means by which practitioners decide to adopt new technologies, the speed of progression of these new techniques, and — of great importance — the means by which practitioners gain enough expertise to introduce new techniques into their own practices are all highly variable and seemingly without any rational or consistent approach.

Training
Let us focus first on formal subspecialty training. Laparoscopic cholecystectomy was introduced largely by the academic general surgical field, with a number of manufacturers marketing equipment for the technique. General surgeons already in practice attended workshops and gleaned hints about technique from the literature, national meetings and limited training workshops. All too often, they returned to their own operating rooms to struggle through their first cases without guidance. Over the past decade, laparoscopic techniques have become usual and customary treatment and are now a core part of the technical training required during residency for all general surgeons.²

Another example that comes to mind is the recent advent of endovascular repair of abdominal aortic aneurysms, a groundbreaking development that has moved the perioperative management of these cases from among the most challenging to a mundane procedure often conducted under regional anesthesia. In this case, the device manufacturers recognized that the success of their new technique was critically dependent on detailed preoperative planning in which the endovascular prosthesis must be custom-designed and on vascular surgeons recognizing success from their very first procedures. The manufacturers wisely designed a system by which practitioners wishing to begin endovascular repairs using these new devices could consult with a practitioner with expertise. The consultations were open-ended and detailed and culminated in the “mentor” attending the actual surgical procedure to guide the new practitioner in operative technique, with successful mentoring applied using new approaches such as telemedicine.³ This approach is exemplary — training done correctly to ensure safety and success in the introduction of a new treatment.

A Discipline Evolves
Interventional pain medicine is evolving as a distinct discipline that requires detailed new knowledge and expertise. Familiarity with radiographic anatomy for the conduct of image-guided injections and the minor surgical skills needed to place implanted devices such as spinal cord stimulators and implanted drug delivery systems are just a few of the techniques that many of us have had to master after entering practice. As we set out to introduce new interventional techniques to our own pain practices, how can we ensure credentialing committees (and, more importantly, our patients) that we have been properly trained to conduct these techniques to assure safety and success?

Adequate exposure during the fellowship training period to these newer treatment alternatives is necessary to ensure appropriate application and optimize patient outcomes. While we do not have scientific data that define the average minimum level of experience that will be necessary to achieve competence, especially for complex procedures that are associated with significant risks, logic dictates that there is a minimum number of these procedures that trainees should be exposed to during a fellowship.

The Accreditation Council for Graduate Medical Education (ACGME) has established requirements for average minimum numbers of epidural, spinal and peripheral nerve blocks necessary for accreditation of anesthesiology residency programs. Other medical subspecialties also require a minimum number of specified procedures to achieve and maintain competence, e.g., subspecialty training in gastroenterology has a requirement of performing a minimum of 100 esophagogastroduodenoscopies and 100 colonoscopies with polyp removal4; and cardiovascular subspecialty training requires 100 cardiac catheterizations to demonstrate minimum proficiency.⁵

Indeed the ACGME Residency Review Committee for Anesthesiology (RRC) has tentatively accepted revised program requirements for pain medicine training programs that specify minimum exposure of trainees for various techniques. These include image-guided spinal injection techniques of the cervical and lumbar spine; sympathetic blockade; neurolytic block, including radiofrequency treatment for pain; intradiscal procedures, including discography; spinal cord stimulation; and placement of permanent spinal drug delivery systems (personal written communication from David L. Brown, M.D., Chair, ACGME RRC for Anesthesiology). For those techniques that are now widely accepted as a core part of pain practice, we must ensure that our trainees gain enough experience to conduct these procedures independently.

Which Skills Are Necessary?
We may argue what the core techniques should be for a pain practitioner, but it does seem that detailed knowledge of radiographic anatomy of the spine and the minor surgical skills required to implant spinal cord stimulators and place permanent spinal drug delivery systems are among those skills most practicing pain physicians would expect from a new pain fellowship graduate. More importantly the program directors must clearly state what their trainees can and cannot do at the conclusion of their training. One of us (Dr. Rathmell) has adopted a detailed listing of all techniques that each trainee has learned in the course of fellowship. Each trainee is given this final letter and asked to sign a copy for his/her file. This letter will be provided to all organizations requesting information about their training and will make it clear and simple to understand a practitioner’s expertise.

It is one author’s opinion (Dr. Lubenow) that fellows should be exposed to a minimum of 10 spinal cord stimulation procedures or 10 intrathecal drug delivery procedures in their fellowship period. In this era, it really is inappropriate for a new graduate to request hospital privileges to perform any technique to which they have not yet been exposed. We both have witnessed more than one practitioner who has requested privileges to perform a technique with which they have had no experience during fellowship. We have sat perplexed as more than one credentialing committee has assumed that any new graduate would have specific skills, and the requested privileges were granted based on faith in their training alone.

Keeping Up With New Techniques
New techniques are appearing at a staggering rate, and we cannot rely on pain fellowship programs to provide all of the technical training that is needed. Stronger standards for minimal training following fellowship also are urgently needed. Some pain practitioners feel that all too many of their colleagues find it perfectly acceptable to attend a brief weekend course and then introduce a highly technical new treatment into practice without additional study, training or oversight.6 Intradiscal electrothermal therapy, nucleoplasty and radiofrequency treatment are among the many techniques that show promise, and each requires unique knowledge and skills to be used safely and effectively. Practitioners themselves must take the lead in obtaining adequate training before proceeding with any new and unfamiliar technique. The weekend workshop is just a start, often a good start — the best will give practitioners a detailed understanding of anatomy, pathophysiology of disease related to the use of the new technique, patient selection, conduct of the procedure, outcomes and avoidance, management and recognition of complications. Here we would like to suggest a method for practitioners:

Study the new technique, the published literature and gain a detailed knowledge of all aspects of the technique;

Attend a workshop, preferably a hands-on cadaver-based workshop, that allows introduction to the technique in as realistic a setting that can be assembled;

Plan adequate time for your initial procedures;

Get help at the bedside during initial conduct of new procedures — perhaps another experienced practitioner at your institution, an invited expert to assist, or team up with a colleague in a related discipline;

Inform your patients that you are introducing a new technique and include this discussion as part of the informed consent process; and

Examine your outcomes carefully in the initial stages of using any new technique and compare them with those of your colleagues and the published literature.

While we as practitioners should take the lead, those sitting on hospital credentialing committees also should be more demanding and require practitioners to provide evidence for just such a logical introduction, or they should prevent practitioners from performing new techniques.

References:
1. Richebe P, Rathmell JP, Brennan TJ. Immediate early genes after pulsed radiofrequency treatment: Neurobiology in need of clinical trials. Anesthesiology. 2005; 102:1-3.
2. Chung R, Pham Q, Wojtasik L, et al. The laparoscopic experience of surgical graduates in the United States. Surg Endosc. 2003; 17:1792-1795.
3. Di Valentino M, Alerci M, Bogen M, et al. Telementoring during endovascular treatment of abdominal aortic aneurysms: A prospective study. J Endovasc Ther. 2005; 12:200-205.
4. Available at <www.acgme.org/acWebsite/downloads/RRC_progReq/141pr799.pdf>. Accessed on June 14, 2005.
5. Available at <www.acgme.org/acWebsite/downloads/RRC_progReq/141pr799.pdf>. Accessed on June 14, 2005.
6. Rathmell JP. The injectionists. Reg Anesth Pain Med. 2004; 29:305-306.

Timothy R. Lubenow, M.D., is Professor of Anesthesiology, Rush Medical College, and Director, Section of Pain Management, Rush University Medical Center, Chicago, Illinois.

James P. Rathmell, M.D., is Professor of Anesthesiology, University of Vermont College of Medicine, and Director, Center for Pain Medicine, Fletcher Allen Health Care, Burlington, Vermont.