Welcome, everyone. I'm excited to host this session here today. The topic of the session is going to be Choosing the Right Fellowship for Performing Interventional Spine Procedures, Panel Discussion with Fellowship Directors for Educators and Residents. I was really looking forward to giving this in person and answering some questions and having a discussion with the audience, but this is the next best step. And again, I'm really excited to bring this forward and talk about a topic that has definitely been growing more and more and with an increase in residents and trainees asking more questions about fellowships. So I'm at Vanderbilt University Medical Center. I have no relevant financial disclosures. I just want to start off by saying that I did complete an ACGME pain fellowship at the University of Colorado. So this is our outline today. I'm going to do a quick introduction and just talk about the current landscape of available fellowships. Then we're going to have Dr. Nagpal, who is the chief of pain medicine at UTC in Antonio, talk about ACGME accredited pain fellowships. And then Dr. Sam Chu, who is the sports medicine fellowship director at Shirley Ride Ability Lab. And then lastly, Zach McCormick, who is the fellowship director at the University of Utah for the North American Spine Society, or NAS, Recognized Interventional Spine and Musculoskeletal Medicine Fellowship. And after the conclusion of each individual director, we're going to sort of come back and just have a little roundtable discussion with some questions. So we have three main learning objectives. The first is to understand the current landscape of fellowship training and interventional spine procedures. Second will be to learn the similarities and differences between the three different types of fellowships that offer interventional spine training. And the third objective will be to get a clear understanding of what type of fellowship may be best suited for the career objectives for future trainees. So why do I want to talk about this topic at the annual meeting? The first is that there is an increasing trend of residents entering a fellowship with a focus on pain, sports, or spine. There are increasing fellowship options, which leads to often increasing questions and confusion by trainees on what type of fellowship to pursue. So back in 2016, we did a survey of graduating chief residents and we asked them simply, were you planning to do a fellowship? At that time, 72% of graduating chief residents said yes, they were planning to pursue a fellowship. Out of those who were planning to pursue a fellowship, we saw that about 54% of them were planning to pursue a fellowship in either pain, spine, or sports medicine. This was followed up by a more recent survey we did looking at the graduating 2019-2020 graduating residents, so this recent graduates, and 74% of them reported that they had matched into a fellowship. At the time of this survey, they had already matched or accepted a fellowship position. Again, about 129 out of 175 had reported that they were going to do a fellowship. And of those, interestingly, there was an increase in the amount of graduating residents who were doing a fellowship in pain, sports, or spine medicine. Almost made up 80% of those respondents who were planning to do a fellowship. I apologize, the words may be pretty small, but on the right side, I have a red box encapsulating the top four fellowship choices. The first one was ACGME pain medicine fellowship. The second was ACGME sports medicine fellowship. The third was a NAS recognized interventional spine musculoskeletal medicine fellowship. And the fourth choice was unaccredited spine or sports fellowship. So again, 80% of the graduating residents of this most recent graduating class reported doing a fellowship in one of these three disciplines. So we look at available fellowships. There's been an increase in fellowship positions in ACGME accredited spots. There's been an increase in fellowships that accept PM&R residents into their fellowships, in particular, family medicine, sports, and anesthesia pain fellowships. And then also we've had this recent introduction of a NAS recognized ISMM fellowships. I just wanted to point out, there are some other resources out there for trainees and faculty. The first one on the left was, I was notified of it by our residents. And so this is a YouTube that was hosted by Dr. Williams and Dr. Buva. And basically they had a round table discussion with other trainees who had completed a fellowship in either sports medicine, spine, pain, and sports. And then there's been a prior publication in 2013. It was a point counterpoint in the PM&R journal about what is the ideal type of fellowship for training in musculoskeletal medicine. And they discussed ACGME sports, pain, and non-accredited fellowships at that time. So I wanted to bring up a case scenario before we get into our speakers. So Vaso Bagel is a third-year resident who's interested in performing spine injections in her future practice. So she practices musculoskeletal. She likes musculoskeletal medicine and wants to have some further training in axial spine procedures. She's unsure what type of setting she wants to practice in, whether it's academic or private practice. She's also unsure if she wants to work in a rural area or a large metropolitan area. So she wanted to ask a few questions to those around her. And these questions, again, some of these were also shared by other residents. One of the primary questions that's often brought up is, will there be any issues with getting a job or credentialing if I'm not board certified, particularly in pain medicine? How do the fellowships differ in terms of what types of procedures are performed? What are the electrodiagnostic opportunities in each fellowship? And lastly, what are the implications for opioid management? As some states require you to be a quote-unquote pain doctor to manage pain and or addiction. So what qualifies? So without further ado, I wanted to hand it off to our speakers. First will be Dr. Nagpal, followed by Dr. Choo and Dr. McCormick. Here are a summary of my citations, and then we can always circle back if anyone has any questions at the end. All right, Dr. Nagpal. Hello, everybody. So this section of the session, of the panel session, is going to be surrounding ACGME-accredited pain medicine fellowships. Excuse me. I am the division chief of pain medicine at UT Health San Antonio. The Joe R. and Teresa Lazano Long School of Medicine. But for six years, I was the associate program director of the pain medicine fellowship at our institution. And so I do have a pretty extensive knowledge on what a pain fellowship is at our location. There we go. I have no relevant disclosures to this particular talk, other than the fact that I was an APD and I still teach in a pain fellowship. So before I get into my first slide, I just want to bring up a couple of things. Number one is that ACGME-accredited pain medicine fellowships have a little bit of a rigorous, and let me go back to this slide. Here we go. Have a little bit of a rigorous algorithm for what you have to do and what you have to accomplish in order to graduate. But there's a lot of misconceptions about what are called the common program requirements, mainly from program directors and faculty, to be honest with you. These common program requirements are set by the ACGME for all residencies and fellowships. So not just pain medicine fellowships, it's for PM&R residencies, there's a set of common program requirements. But what is misunderstood by many programs and by many faculty and by some residents who know the common program requirements, typically residents don't really know what they are, might not even know they exist, but if they know about them, a lot of people assume them to be rules, and if you don't hit these milestones that are in the common program requirements, then you cannot graduate. But actually what the common program requirements are set up for are to ensure that in general the program is able to offer these things to their trainees. So if a particular trainee does not hit some one of the milestones in the common program requirements, but goes on to be very competent and the faculty of that program feels like that person is fully capable of practicing in their chosen field, then they can graduate. But when the ACGME comes to determine whether or not that program is in compliance with all their rules, they will see that that one trainee did not hit that spot. Now, if you have a PM&R program that's huge and you have 12 people a year or something like this, it doesn't really matter because if one person doesn't hit it, but the other 11 did year after or 12 did year after year after year, then it's okay. So it is not a set of graduation requirements. The requirements are for the program to maintain offering these things to each individual resident or fellow. And that's so important, especially right now during COVID, because there were a lot of programs that were not able to get their trainees to the numbers that might be on any document from the ACGME, whether it's the 200 EMGs in a PM&R program or so on and so forth. And none of the programs are going to be held responsible for that because in general, and none of the, by the way, none of the trainees will be held responsible if you understand these rules for not having done that and therefore not being able to graduate. Because in general, the programs are able to offer these things. Okay. So that's a caveat to this. So we'll talk about pain medicine, pain medicines, ACGME accredited common program requirement document is 58 pages, which is kind of small for these. A lot of them are in the hundreds. The, you could see from the ACGME's website, the program requirements for graduate medical education in pain medicine, parentheses subspecialty of anesthesiology, child neurology, neurology, or physical medicine and rehabilitation. So PM&R is listed on the ACGME's website as one of the specialties of which pain medicine is a subspecialty. There's been a false misconception for a long time that it's only anesthesiology and PM&R is sort of happens to get into some of these spots, but in general, anesthesia owns the field. Having worked in an anesthesia department for more than seven years, including eight years, if you count my fellowship and spent a lot of time networking and coordinating doc manuscripts and panel presentations and so on with a lot of anesthesiologists who practice pain. It is the exception rather than the rule that there are anesthesia based fellowships that are against allowing physiatrists into their programs. It is much more likely, much, much, much more likely that they embrace physiatrists as part of their programs. And what I believe has happened over the years is that it's like a cultural thing that residents have passed on from year to year to think, oh, anesthesia programs don't like physiatrists. There are probably two or three like that in the country, but the vast majority appreciate having physiatrists in their programs. Here's the link to that program requirement, by the way, so if anybody wants to see it. So I'm not going to go down the road of showing you 58 common program requirements, 58 pages of program requirements, but what I'm going to show you here is the program requirements associated with what is necessary for a program to offer in terms of historical information, so what history a physiatrist as a fellow has to obtain, and then here what they have to obtain from procedurally, from procedural competence, or what they should be offered. And so I bolded all the various things, and then we'll just go to the next slide here, and I kind of pulled them out of that document, but I wanted you guys to see those paragraphs are like viciously onerous. When you're spending time trying to figure out what a fellow has to get out of something, we spend a lot of time with that document, and it gets updated every two to three years. So these are the things that a fellow has to be offered as part of their training and should demonstrate competence in from a historical perspective, so a neurologic history and exam identifying significant findings of basic neuroimaging. Now that training must be verified by a faculty member in either neurology, neurosurgery, radiology, or someone else qualification acceptable to the ACGME review committee. A comprehensive musculoskeletal and neuromuscular exam in history, they have to be able to identify and prescribe rehab interventions, so if you came from a PM&R residency, you still have to demonstrate competence in this. You have to develop patient rehab programs, proficiency in clinical evaluation, and development of rehab plans, so a lot of this is rehab, right? Identifying patients who should be in a multidisciplinary team pain management, again, something that most physiatrists come in with the ability to do, therapeutic modalities as well as surgical modalities, carrying out complete and detailed psych history, a complete mental status exam, and explaining psychosocial therapy to a patient. So those are the history and physical elements that you need to be able to accomplish at the end of a fellowship in pain, ACGME accredited pain fellowship. Here are the procedural skills, obtaining IV access and basic airway management, as well as advanced airway management. A lot of the procedures we do have the potential for a deleterious outcome, and you need to be able to do basic BLS and ACLS and then manage an airway while you're waiting for help. Management of sedation is a critical part of our fellowship. Recognizing and managing perturbations of the physiologic system of a human associated with neuraxial anesthesia and analgesia, and intravascular injection of local anesthetic, because we use high volume local anesthetics quite frequently in some of our procedures. Now, there used to be numbers associated with these procedures that are classically described as being done by any one of the speakers on this panel, not just from a pain fellowship. Epidurals, trigger points, facet and medial branch blocks, neuroablative procedures, and sympathetic blocks. But those numbers have been removed. I think two years ago, it used to be they had to do 10 of these and 50 of these and 30 of these and so on and so forth. Now, it's just that you have to demonstrate competence in these, because there are fellows who do five sympathetic blocks, and you could feel comfortable and say, that person really gets it. And they understand everything about it, not just how to do the procedure, but what the consequences are if you have a bad outcome. What if you inject into the iliac vessels or the aorta, and what would you do? And some fellows just get that right away. So those numbers have been removed, and now it's just demonstrating competence. You have to understand the psychosocial risk factors that contraindicate interventional procedures, and you have to have a range of hands-on interventional treatment exposure to neuromodulation and intervertebral disc procedures. So that includes things like SCS, spinal cord stimulation, peripheral nerve stem, targeted drug delivery, which is intrathecal pumps, and so on. So the only numbers, let's say, that are left on the document of numbers you have to hit is that fellows have to have a primary response, and I didn't put this on a slide, I apologize, but it's on pages 28 and 29 of the program requirements. So fellows have to have primary responsibility for 50 different patients followed over at least two months. There must be an inpatient chronic pain experience, which includes assessment and management of inpatients with chronic pain, and either through a consultation team or an inpatient pain medicine service or something like this, and you have to have at least 15 patient experiences with exposure to an inpatient consult. And then you must have a minimum of 50 patients who are new to the fellow in an acute pain inpatient experience with supervised assessment and management of those inpatients with acute pain. So the only numbers left are 50 patients that you follow longitudinally over at least two months, 15 inpatient chronic pain, 1-5 inpatient chronic pain consults, and 50 5-0 acute pain consults in the inpatient setting. So in terms of programs, there are 106 programs right now. The link is here to ERAS in my slides where you could see all the 106 programs. Almost all the programs participate in the match. I would say like 90 probably of the 106 participating in the match. It's not required out of just full transparency. Our program pulled out of the match this year due to COVID, and we accepted internal applicants who were stellar because when COVID started, we didn't know what was going to happen. We didn't know virtual interviewing was going to come to this huge process, and we had a lot of excellent internal applicants. That will not happen in the future. We're going to go back to being in the match. That was the only year we've come out, but I want to be transparent about that. But in general, and several other programs did the same thing this year. In general, almost all the programs are in the match. Some programs are like in the match, but also keep a spot for themselves, like from an internal candidate. So it's not as, there's a little bit of a handshaky thing that some programs do. We tend not to do that. We don't do that. We don't do that. But there are programs, absolutely, that will put a couple of their spots in the match and leave a couple not in the match. It's not like PM&R residency. It's not like applying for residency where everybody's in the match, and there's a rule that you can't come out of the match and so on. It's not like that. Here's a rough timeline of the application process. And so the application opens in December and most programs accept applications through March. And also most programs don't really look at their applications until March. I mean, you're talking about a year and a half before that person's going to show up. So in December, geez, our fellows, it's a one-year fellowship. They've only been there for five months. You're still trying to know them. You're trying to learn their habits and what kind of people they are and make sure that they're comfortable and they have good wellbeing in the fellowship. And so really most people don't look at it before March. So as opposed to residency where there's this push as a medical student to really get your application in on the first day it opens, I don't think that's at all necessary for pain fellowships. If you want to wait a little bit because you're waiting on something to be published and you want it to be in your application, it's perfectly okay to wait until January, early February to get your application in. Interviews are over a huge timeframe. Every fellowship does it at a different way, spanning May through August. I mean, really like a huge timeframe. Early August is when the rank website opens. So you can put in your rank order and soak in the programs. In mid-September is the rank order deadline. And this year, October 14th, which was three days ago on the day that this is being recorded was match day. And every year it's in mid-October, the match day for pain fellowship. So some of the things we look for at UT Health San Antonio, and I can't speak to necessarily what other programs look for, but we look for strong letters of recommendation. We look for people who really have shown an interest in the field, which means that they've maybe joined some pain medicine organizations like SIS or ASRA or AAPM or ASIP. There's so many at this point, but those are the big ones, I think. I don't think I missed any of the big ones. And your local state society. Texas Pain Society is a big one here. Every state has its own pain society. We look for that people have demonstrated their interest by having posters or abstracts at national meetings. We look to see if somebody is a chief resident. It means that your program has already vetted you and decided that you're a really good candidate for our fellowship because they've given you some extra things to do in your own program. We look at your USMLE status. Okay. So we don't look at your scores, but we want to make sure that you have passed all your exams. And we do look to see if you've ever failed a USMLE exam, because that's an indicator of potentially having that trouble in the future with standardized tests. And then we do look and make sure nobody has had a history of criminal behavior, which is a part of the ERAS application. Things we don't look for include SAE scores. We don't look at that at all. We know that the SAE is made by the AAPMNR and your boards are made by the AAPMNR. And while there might be a correlation between the two, it's not predictive at all of what kind of fellow you're going to be. And in fact, we are not allowed to ask for those scores, nor are we allowed to ask for the in-training exam scores from anesthesiologists, or psychiatrists, or ER docs, or family practice docs, or anybody who applies to our fellowship based upon rules set around ERAS by the Association of Pain Program Directors who have decided that because of poor validity of deciding whether or not an SAE really matters or an in-training exam at all really matters to your career or what type of fellow you'll be, we just don't ask for in-training exam scores. So we don't care. If you did really well, it might behoove you to send that to some of the programs that you're really interested in so that they know about it, but we're not going to ever ask for them ourselves. We don't look for publications. We know how hard it is to get publications. Depending on the program you're in for residency, it might be easier for you than in another program where maybe it's more clinical, and so we don't think it's fair to compare people that way. If you have publications, it's great. It shows that you have demonstrated interest in the field, and it might put you a little bit of a leg up, but we won't disqualify somebody because they don't have publications. And then like I said, we don't look at you as somebody's scores. We do look at your status, but not your scores. The last thing I want to bring up is this is something that was created by the Association of Pain Program Directors. It's a Pain Fellowship Standardized Letter of Recommendation for Pain Program Directors, and we are seeing these more and more every year. It's basically checkboxes of just to make it easier for the program directors, I think, because they were getting hammered with the letter of recommendation requests, and everybody is very benevolent and really wants to write letters for as many people as they can, but it was getting to be a lot of work. There's only so few. There's 106 program directors in the country, right? And also, they wanted to add some objective nature across the board for each candidate, and so there are questions about work ethic and attitude and interaction with patients and interaction with healthcare team and academic potential, professionalism, history and physical exam, interpretation of radiologic imaging, use of image guidance for procedures, critical thinking and judgment, technical and procedural skills, and note writing and communication, and then there's a written concise area for a written summary for one of these references, so we see these a lot as the letter of recommendation that we get from not just program directors now, but also pain faculty inside of programs that aren't necessarily even program directors, so I'm just giving you guys a look under the hood as how, like, these letter of recommendations have drifted and shifted over the last couple of years. Okay, so I'm going to stop here, and then we'll do questions, of course, at the end with Dr. Yang, so I will sign off at this time. Thank you. I'll see you in a few minutes for questions. All right. Hi, everybody. Thanks so much for having me, and I just wanted to thank all the other panelists as well as Dr. Yang for the invitation. My name's Sam Chu. I'm one of the sports medicine attendings and MSK attendings at Shirley Ryan Ability Lab. I'm also the program director for the Sports Medicine Fellowship, and I'm here today to talk to you about some of the specifics of ACGME-accredited sports fellowships, and specifically some of the procedural and interventional spine training that you can get through these fellowships. So I have no relevant disclosures to report. Similar to Dr. Yang, though, I will tell you that I did do the sports fellowship myself at Shirley Ryan, formerly RIC, and at Northwestern. So my role here is, as program director, we do have two fellowship positions per year. It is a one-year fellowship, and we are housed under the Northwestern McGaugh Medical Center as well as primary training center at the Shirley Ryan Ability Lab. Just as an overview, I know many of you are familiar with this already, but when it comes to sports medicine and fellowships, generally the terminology we hear about is primary care sports medicine. And underneath that, there are fellowships that are housed under various different departments. So PM&R, as you can see, there has currently 20 programs. There are certain programs that have one spot. Some have more than one spot, like ours has two. Family medicine is probably the specialty that has the most sports medicine programs, with currently 151 listed through the ACGME site, and that's as of October 1st, if you look at the link there. You can also find fellowships that are through the departments of pediatrics or emergency medicine. So this is not to say that PM&R applicants or residents can only apply for and go into PM&R sports fellowships. There are a number of residents who will apply for programs in other specialties, specifically family medicine, pediatrics, and we'll talk a little bit more about that as well. So as Dr. Nagpal had mentioned, there is this whole booklet and PDF of common program requirements, and I'm not going to belabor you guys with all of that, but I wanted to point out a couple things regarding specific responsibilities for sports medicine fellowships, especially when it comes to procedures. As you can see on this one here, this slide talks about performing procedures considered essential for the area of practice, and this slide specifically talks about ultrasound-guided procedures. So we know that ultrasound is a big portion of what our residents are learning and what a lot of people want to learn in fellowship, and that's outside of the scope of this talk, but there is a discussion specifically on ultrasound-guided procedures. Similar to the prior talk, there are no specific requirements for ultrasound-guided procedures, similar to the prior talk, there are no specific numbers that are listed here. The second slide talks about additional procedures that are relevant to the practice of sports medicine, and this includes non-operative interventional procedures that are clinically relevant to sports medicine. And as you can see, there is no specific mention of interventional spine procedures or requirements that are listed in the Common Program Requirements. And I think this is probably not super surprising. If you think about all the different fellowships that are out there, including all the family medicine-based programs, EM-based programs, most of those programs will not necessarily include a lot of interventional spine training, although many of them will. And so I think in the context of today's discussion and thinking about how much interventional spine exposure there will be through a sports medicine fellowship, I think it's very variable based on the specific program and the specific requirements that each fellowship and opportunities that they have available. What I will say is that other requirements for sports medicine, just to kind of touch on a couple other things, include, of course, sports medicine coverage, sideline coverage, and participation in organization of mass participation events. So I have listed here just a couple of different opportunities that our fellows do undergo in terms of Northwestern and Shirley Ryan Ability Lab coverage. And just to touch upon a few, our fellows are involved with performing arts medicine throughout the Chicagoland area. They work with collegiate division one varsity teams and club sports at Northwestern University and covering Big Ten sports. They cover the Chicago Marathon and the Chicago area running association, various races. And then they also work with Paralympic sports and adaptive sports, adaptive athletes through various opportunities that come up throughout the years. So they have a bunch of other opportunities that come up throughout their training, in addition to some of the procedural training that we'll further talk about. So specifically at our fellowship, I will say that we do offer a fluoroscopic and interventional spine training for our fellows. Generally, it's about one to two half days a week that our fellows will spend with a number of our faculty members. These are, we have about six current sports boarded faculty who do spine procedures. And really our fellowship specifically is very customizable. We have people who are interested in maybe doing a half day a week, and we have others who are interested in doing more time with the fluorosuite. And so they'll spend a little bit more time with us as well. Generally, we have procedures that our fellows train in and perform include lumbar injections, specifically epidurals, facet injections, medial branch blocks, as well as sacroiliac joint injections, peripheral joint injections. We have had some fellows who are interested in more cervical based procedures, and that is a possibility. But given some of the other responsibilities, it's not something that our fellows typically spend that much time doing. In terms of other fellowships and other opportunities for training, our fellows will have a one day spine intervention course that our fellowship runs for also for residents where we practice with a mannequin. And a majority of our fellows will participate in a national course generally during their fellowship training, whether that's a NAS course or an SIS course, just to further get exposure and work with cadavers. All right. So I would say out of more of an anecdotal experience myself, kind of going through the process number of years ago, that a majority of our PM&R based sports programs will offer at least some sort of interventional spine training. And I will kind of put a little bit of a preface that not every applicant that we see coming through the sports medicine application process are interested in spine procedures. Many of them are interested in team coverage and ultrasound experience. But for those who are interested, I would say most but not all PM&R based sports fellowships will offer this training. And then a number of family based sports programs that have accepted PM&R residents in the past will also offer spine training or fluoro training through their fellowships. However, it's not a universal, you know, I guess a reality that every program will offer this or have the opportunities or elective times to do that. So really it comes down to having that discussion and doing some of the research, talking to prior graduates and understanding about that. So I did put on a slide here that it is important to ask questions when applying. This is typically asking about the availability of training and what is really part of the program and what has been done in the past. I think it's important to find out about what types of procedures are being performed in the fellowship as well as who you would work with just to get a sense of, you know, what the general curriculum is like, what are available electives or required rotations that happen throughout that fellowship. And, you know, I think really the number of programs hopefully will continue to expand in the future, but there are a limit for sports medicine applications. ERS generally opens for submissions around July 1st and this is as most residents start their final year of training. At least this year, programs were available to review the applications starting mid-August. Generally it's actually mid-July. So you can see there's a little bit of a tight turnaround between when programs can review applications and when interviews will happen, usually between September to December or the fall. Rank lists are due in mid-December and then match day is generally the first week of January. So this is a little bit more of a process that starts in your PGY4 or last year of training and I do think it is important to get your application in as close to the date when programs can review applications because of that tight turnaround for offering interviews. So there's a couple resources here I put, you know, certainly looking for fellowships and understanding, you know, what programs can offer and what programs are available. I think certainly looking through the ACGME site is important to keep up to date because we have some new programs that have been becoming accredited over the past couple of years throughout for sports medicine specifically. I think APM&R and both AMSSM have good fellowship guides and sort of different documents that can help a resident through that process. So those are some links I would definitely look into going forward. And so happy to answer some questions later on during the roundtable, but thanks for your attention and thanks for having me for this panel. Hello, everyone. Zach McCormick. I'm at the University of Utah. I'm our Chief of Spine and Musculoskeletal Rehabilitation, and I do direct our NASS ISMM Fellowship. And I'll echo Dr. Yang that I think we all were hoping to do this in person, and hopefully maybe next year, but certainly a pleasure to be on the panel with the other faculty members. So thanks for having me. These are my disclosures, nothing specifically relevant, but I should mention as the other speakers did, I completed a pain fellowship, an ACGP pain fellowship at Northwestern. And I'm also, I do chair the NASS committee on the ISMM fellowships. So perhaps I'm a little bit biased, but should be transparent about that. So everything I'm going to mention is also easily accessible on the NASS website. That link is listed at the top of this slide. And I, of course, can't really go into the level of detail that would be ideal in the time that we have, but I just encourage any that are interested to peruse the website when you have time. So what are these fellowships? Dave O'Brien, Dr. O'Brien, who's on the NASS board and runs, he's a fellowship director for one of these ISMM fellowships in South Carolina. He just wrote an article actually for SpineLine, which probably many are familiar with, NASS's newsletter publication. So I think he actually did a great job of summarizing it quickly and would just encourage you guys, if you're interested, again, to take a look at this article. But essentially there have been physiatry-based so-called sports and spine, interventional spine, MSK, what have you type fellowships since the 1980s. So these types of fellowships within physiatry predate any ACGP sports or pain programs. And then over the years, of course, we've seen the evolution and the formalization of the ACGP pain and sports programs. And the whole reason for this panel and ongoing conversation and questions by trainees, of course, is what's sort of the right fit and what's going to match the nature of the practice that they want to eventually develop? Well, I think you're aware and you've got to get the sense that pain fellowships are broader, certainly, than spine and MSK fellowships. So Dr. Nagpal outlined some of the program requirements, and certainly these include pediatric pain, acute pain, palliative care, so on. Sports fellowships, as Dr. Chu mentioned, there's always going to be some emphasis on sports coverage, care of the athlete and related conditions, some of which may or may not be the musculoskeletal system. So, you know, ultimately, there are, you know, interventional spine and musculoskeletal medicine fellowships, or what maybe used to be called more sports and spine fellowships, that many were more focused specifically on spine and MSK and intervention. But historically, there hadn't really been a way for applicants or potential employers to judge the quality of those fellowships. There was a time when Password Fellowships existed, and those were actually sponsored by the Academy. That went away, and there was a long gap where, again, we had pain fellowships, sports fellowships, both ACG accredited, and then non-accredited other fellowships. Again, leaving some question to applicants and employers, how good are they? There's certainly going to be a spectrum and a range of quality. So, that essentially led to the formation more recently of the NASS ISMM fellowships. And this is a bit of a timeline. So, these fellowships were formalized just about three years ago. So, at that time, the NASS board did approve the formation of the ISMM fellowship committee in NASS, and with the primary focus being to standardize the quality and the focus of these fellowship training programs. Two years ago, the first cohort of programs applied and qualified. Others did not. But the applications were open, and that solidified the first group of NASS-recognized fellowship programs. And then we just had the inaugural match in just this past August. So, there were 69 applicants, 24 total programs, I'll show those to you, and 41 total positions available for match. So, 100% of fellowship positions filled in this match. So, what does it take, essentially? Where is the bar? What does a program need to do to qualify as a NASS-recognized fellowship? Well, there are a few areas, but one is that there is a points qualification system that has to be met by the program director. And if there is an associate program director, those points can essentially be added, half the points of the associate program director. But the purpose here is that there aren't programs that simply have a program director in place to perform administrative work, but isn't truly an excellent researcher, educator, leader in the field. The purpose is that who's truly providing the majority of the education and the hands-on experience for the trainees is someone who really, truly is committed and a leader within our field. You'll notice, and I'll show you in a moment, the points system, it's reflective of basically systems for academic promotion at university centers. So, peer-reviewed publications, national lectures that are CME-qualified lectures, research grants, and I'll show those to you. The other bit, like other fellowship programs, the ACGME-based programs, there are minimum curriculum standards, and I'll show that to you as well. And then the last is that the programs do have to sign a legally binding contract in which they agree to adhere to the match. So, programs can't elect to take people outside of the match. If they do, it's a violation. And this is really meant to level the playing field and meant to really benefit the applicants, to kind of take the power out of the hands of the programs and make sure that the applicants are favored. So, this is that point system, and I'm afraid actually it's a bit cut off. So, there are some additional categories, but as I alluded to, these are the high points. So, various publications with an emphasis on original research, full peer-reviewed publications, clinical trials that are not sponsored by industry, but rather federal funding or foundation grants, and also a formal commitment to education of trainees, and again, national CME-qualified lectures. There's also another category that is not shown here, but essentially national leadership. So, whether it's healthcare policy advocacy or positions, committees, board roles in national societies, these are ways that program directors or associate program directors can gain more points and qualify potentially for NAS recognition status. So, these are the current programs. You can see in the first two columns, these are the recognized programs, NAS recognized fellowships. And then in the far right column, those are provisional programs. So, they haven't yet met the full point total necessary to qualify for recognized, but they meet a bit of a lower threshold, and they just need to increase their points within two years to fully qualify. So, you'll notice there's essentially a mix, about 50-50, a little bit heavier towards academic centers, but otherwise, you know, very well-known private practices with program directors that are extremely active nationally, board roles, leadership, and so on. And these are the minimum curriculum themes. So, and these are the minimum curriculum standards. Again, like the other speakers said, I'm not going to go through these line by line. I just encourage those interested to go to the website, and you can take a look at these. But you'll notice that these requirements are much more focused than a sports medicine program or a pain program, for example. You know, truly, much heavier focus on spine, and that's the intention. So, I'll just scroll through these, but ultimately, again, check out the website when you have a moment. Okay, and this is the timeline. So, for the next match class, which ultimately is the class of 2022-2023, these would be current PGY3s that would be applying. Registration through NASS opens on January 1st of 21 coming up. There's an interview period, and then rank lists have to be submitted by July 24th, and the match happens on Wednesday, July 28th of 21 next summer. So, briefly, our own fellowship. So, you know, we have a NASS ISMM fellowship here at the University of Utah. We have two positions at this time, and, you know, ultimately, we are, we certainly, at bare minimum, are looking to develop, you know, budding specialists who are going to be excellent clinically, both clinically and procedurally. But we ultimately do want to do more than that, and so we really do want to develop the next generation of leaders in spine care. And leadership takes many different forms. So, it could be scholarly pursuits, research, educational program development, clinical program development, society work, and so on. We don't necessarily favor sort of one career path versus the next, but we do want to see a history of commitment to scholarly achievement or other leadership. And, you know, I think the rec letters we do pay careful attention to. A lot can be clean from a good rec letter or one that's skimpy. So, we do pay attention to, you know, the work ethic that's communicated through these letters amongst other intangibles that can't really be clean from a CV or otherwise. We also have a somewhat unique program. There are other programs that do this, not so many, not quite the way we do it, but we have our fellows actually run their own continuity clinic solo. So, you know, they have attending backup. We're always available for questions and so on. But our fellows are, they do have visiting instructor faculty status. So, they are able to have their own patients, follow their own patients over the course of the year, and essentially have the experience of growing their own practice or founding their own practice, which is, you know, we feel incredibly valuable so that you're not super green when you start your first job. You've already had the experience of building a clinic, following patients, learning the logistics of, you know, practicing independently. And for that reason, we really do favor applicants who have very strong interpersonal skills. Someone who is, you know, incredibly bright, great clinical thinker, but perhaps just lacking some of the soft skills, they're going to have a hard time in our fellowship, again, because they do need to be practicing independently one day a week. And then otherwise, certainly we pay attention to personal statements, and it's our chance to get to know you beyond what's evident from your CV. And then finally, board scores. So, we, this is not a number one priority. We do pay attention to them. It's not something that's, you know, going to exclude you from consideration, but it's still somewhat of an indicator of achievement. That's what I have, and thanks very much for your attention. I'll pass it back over to Dr. Yang. Thanks, Zach, for, and everyone else on this panel for sharing all some great insight regarding your fellowships. In terms of timing-wise, I really had five questions initially listed, but I think we're going to try to focus mostly on two of the questions here, as I think it will cover some of the other questions by residents. And so, the first question I wanted to ask for you, Amit, to start off is, what kind of setting do you ideally see your fellows practicing in after completing fellowship? And in terms of prior fellows, what types of jobs have they pursued? Sure. Thank you, Aaron, and thank you, everybody. I wish we could have done this in person, but it's, you know, if any of the residents see any of us in Nashville next year, please come up and say hi and ask any questions you have. So, we have had traditionally six fellows a year. Starting next year, we're decreasing our complement to four through no, not because we have an educational problem, but because it's a financial problem based upon, around the way that the fellows are funded. So, I've had a lot of fellows over the time. I mean, you know, 40, more than 40 fellows I've seen go out. The vast majority of our fellows have gone into private practice. I think the most people who do ACGME-accredited fellowships wind up going into private practice. There's just not that many faculty positions available around the country. Most places have fellows who have been there for a long time who are pretty good and don't want to leave those jobs. Secondarily, in private practice, they make a lot more money. It's always sad when I see my fellows graduate and they come to me and say, hey, can you look at my contract? Because they know I've looked at contracts over the years, and I look at their salary, and I'm like, man, you're going to make double what I make, just like everybody. So, it's always been frustrating to see that for me, and I'm excited for them. I've had a handful go into academics, one of whom is Dr. Yang's partner now, Dr. Joe William, who was my fellow last year. And I think our fellows are well-equipped to go into academics if they chose to and there were positions available. You know, correct me if I'm wrong, Aaron, if Joe's not doing well over there, but I'd like to think that most of our fellows knew academics if they chose to, but I think I don't really care what they do. I want them to be happy and successful. So, a lot of people come into our fellowship, they don't want to do academics. They don't feel the need to teach. They don't feel the need to do research, and that's fine. There's nothing wrong with that. And so, we want to set them up for success. And if that success means getting into a good private practice in their old hometown that they want to move back to, or if that means trying to get them into an academic center, I'm okay either way. But in general, it's much harder to find an academic position, I think. Great. Thanks, Amit. That's very helpful to hear that. What about for you, Sam? Yeah. You know, for our fellowship, we have two per year. And I think, you know, similar to what Amit was saying, it's important to kind of talk to your fellows and understand what their career goals are, and kind of get that from the outstart just to help prepare them for that year. I will say the majority of our graduates from fellowship do end up pursuing an academic position, at least from our fellowship. You know, I think one of our missions is to try to help train the future leaders as we can, you know, to get involved both at a local level, but also at a national level, and hopefully potentially start or run programs going forward. As you guys saw, you know, the sports programs from a PM&R standpoint, they're in the 20s or, you know, at 20 right now. So we're hoping at some point that can continue to expand. And, you know, a lot of the responsibilities that we ask our fellows to do, not just from a spine standpoint, but just in terms of their day to day includes a lot of teaching and education, you know, scholarly activity. We certainly have had a number go into private practice as well in the past, and that's absolutely fine. We just want to kind of equip them for what they're trying to do next. So we just, it's about understanding their goals and trying to help them pursue that. Great. And Zach, what about your thoughts? Yeah, I would, I would echo Dr. Nagpal and Dr. Chu in that we ultimately want our fellows to pursue the career path that is going to make them happy and for which they're going to feel fulfilled. You know, the nature of our fellowship, like I mentioned, we do tend to just maybe attract people that are more interested in academics or other sort of leadership endeavors. So remember that our spine fellowship is also relatively new. So this is our second class, and we'll have the third class starting, you know, this coming summer. So our first fellow, Aaron Conger, Dr. Conger, we hired onto our faculty. He's phenomenal. We were very excited to retain him. Our current fellows, we expanded to one finalizing a contract to accept a faculty position. Another is deciding between a faculty position at another institution and private practice jobs. Ultimately, I'm sure that we will have fellows who go into private practice. As Dr. Nagpal alluded to, there just aren't that many positions out there. It's competitive. And that'll be just fine. You know, we train our fellows. You know, it's a busy program. We run busy clinics and busy procedure schedules. Our fellows, you know, don't have trouble with volume and certainly can thrive in private practice. But, you know, ultimately, we do want to set people up for success, but they do choose an academic career path. Great, great. I had another question about electrodiagnostic studies, but I do get that every program varies. You know, some programs do EMGs. Some programs don't. I think the bigger question that I get from a lot of residents, and particularly to you, Sam and Zach, are what about credentialing-wise? You know, there's a stigma out there that if you're not quote-unquote ACGME accredited in pain, you may have difficulty getting credential to do procedures. But has any of your prior fellows or just heard of in general from your guys' experience, including you and me, of places where they may say, hey, you need to be ACGME pain accredited to do spine fellowship or spine procedures? Yeah, I mean, yes, I've heard of that. I know this is a state-to-state issue, for sure. And it's not so much that you did the ACGME accredited pain fellowship, it's that you're board certified in pain medicine in these states, in these states, very few states like this. But if you have a need to practice in a certain state, for family reasons, you want to spend the rest of your life in whatever state it is, you should learn those guidelines of that state before you make this decision. I wish that we can say it's all sunshine and donuts, but there are states where you won't be able to get your sunshine or your donuts if you don't have... By the way, you might go to Zach or Sam's fellowship and be better trained than my fellowship. That's definitely a possibility. Not only a possibility, I know there are fellowships that are either sports or ISME that are superior at training their fellows than ours. They're just like resource issues, things like this. But if you don't get that ability to say you have pain fellowship and get board certified in pain medicine, there are a few states, just a few, where you may not be able to get credentialed by insurance companies. Nevada is one that comes to mind for me. We had a resident here in PM&R who is now practicing in Nevada. He did a non-accredited spine fellowship back before there were NASA-accredited fellowships. He's reapplied to our pain fellowship now, and he can do all these. He's better at it than I am probably, but he can't get on any insurances except for Medicare in Nevada. Now, those regulations may change next year. They might change in five years, but there are going to be states like that. There are other states where they say you have to be board certified, but there are workarounds where you get board certification through the ABPM, which is the American Board of Pain Medicine, which is a non-ABMS board certifying organization. Essentially, they're taking your money in exchange for you being able to practice in that state. A lot of this is almost racketeering in nature, frankly. We should support our residents who do the type of training that they can that makes them competent. That's all that really matters, but these are the realities of the situation as far as I know them. Hopefully, Sam and Zach have less examples of that because it shouldn't be that way. What about you, Sam? What is your experience? Yeah. I took a look back maybe the last four or five years of our alums from our fellows. Actually, in reality, about half of them are still doing spine procedures in their current practice. About half have chosen positions that don't include that, but I haven't had any issues or heard of issues with our fellows getting the ability or credential to do that at their local institution. Majority of those who are still doing spine procedures are at major academic institutions, but I agree with Amit that it definitely is a state-by-state issue. Just to briefly mention, our fellows do complete the fellowship and are able to sit for the sports medicine board, which certainly plays maybe a little bit of a role, but I think from a spine standpoint, maybe less so. Zach, what are your thoughts? Yeah. I've yet to see it happen. Amit, that information about Nevada is news to me. I guess we've never had anyone go to Nevada. We have a longstanding sports fellowship. Dr. Willick runs at Utah, 15, 20 years of fellows out practicing. They certainly did more spine back before there was this evolution where sports became more heavy on coverage and care of athletes. Yet to hear about it. I think a couple of things, probably one reason for that is what you alluded to, that one can sit for pain boards that are not, I guess it's the, you'll have to remind me which is which, but there are other boards aside where you don't have to have done an ACGP pain fellowship to sit for them and have board certification status in pain. But more specifically for the NAS program, so clearly people come out of these programs extremely well-trained in spinal intervention. And so what it really comes down to is there's a legal issue of restriction of trade. And so at a state level, that's probably something that takes a bit more pushing, kind of higher level policy. But when it comes down to institutions, ASCs, hospital systems that theoretically say we need someone to be pain boarded to do spinal intervention. Well, ultimately, especially with these NAS programs, there's a very high bar, clearly, and a stamp of approval from the largest spine society in the world. So it's pretty hard to argue that someone coming out of these programs isn't equally equipped, if not in some cases, better equipped to perform spinal interventions. And so there becomes a legal issue with restriction of trade if someone were to try to deny privileges to a graduate of one of the NAS programs. So let's, I want to circle back a little bit to what Zach just said. So there's a, underneath the hood of this is that if you do a pain fellowship or a sports fellowship, you're going to get your ACGME accredited, sit for the board exam, and you're going to be board certified by the ABPMNR. The test for pain is made by the ABA, the American Board of Anesthesiology. They then sell the test, same test, but they sell it to the ABPMNR and the American Board of Psychiatry and Neurology and the American Board of Family Medicine and the American Board of Emergency Medicine, or no, Emergency Medicine takes it through Family Medicine, I take it back. But those organizations, ABPMNR, ABA, they administer the test, and then they also give you your board certification in spite of the fact that everybody took the same exam. So in some states, the insurance laws are such that you must be board certified by, there's very few states like this, by your ABMS, the American Board of Medical Specialty, board certifying organization, which for us is the ABPMNR, in pain medicine, in order for you to be on the insurance docket so that you could bill and collect. Because of the restriction of trade that Zach mentioned, Medicare can never do that. It's federal, it's a federal, so you could always bill and collect Medicare. I'm not aware of anybody, any fellow who's gone, anybody, any trainee fellow who's gone out and had difficulty getting privileges at a hospital or an ASC because of some of the workarounds that are available to them. But if you can't bill an insurance company, then you really have trouble like, you know, seeing patients in that ASC or hospital or what have you. Now, in some states, they say you must be board certified, but you could go through the American Board of Pain Medicine, like I said, or the ABIP, the American Board of Interventional Pain Physicians, and they both have a board certifying exam that you could take and then you could claim board certification. And then in some states will then say that's fine, that's acceptable. And then therefore, you move on and go ahead and do what, you know, you could do your procedures and bill the insurances and so on and so forth. So there's a lot of nuance to it in those situations. But ultimately, the value in, many people don't know where they're going to go live. Like I had a fellow who lived in Texas his whole life and he took a job in Sandpoint, Idaho, and he's lived there and been fishing and skiing for the last five years and he's happy in a little tourist trap destination. He never knew he was going to go to Idaho. But if you know that you're going to live in a particular state, you should familiarize yourself with those rules before you make this choice. Yeah. So, Amit, I'm curious what, because my understanding and what I've seen around the country is that I've yet to see problems with those trained in non-ECGME pain programs being able to normalize insurance contracts. Now, Nevada might be an example. What other states actually do this? Because I've yet to hear of any other. I don't know of any other that are that restrictive, like Nevada. I don't know of any, but I also don't know the laws and restrictions of every state because I've, you know, I haven't had any fellows move to Kansas or Nebraska or there's so many, the Dakotas, like I don't know what the rules are in those particular places. But I'll tell you in Texas and California and Tennessee and some other places where my fellows have gone, there are no issues in those places. Even if it was an issue, it was as simple. If we have, let's say we had residents in our program who did interventional spine fellowships like yours, they've had no problems going out into those places. And I still keep up with several of those residents who have gone out and done that. And sometimes they do have to take that ABPM exam to, so that, and maybe if they challenged it at a state level from a legislature level, maybe that could be removed, but it's probably easier for those people, frankly, to just say, fine, I'll just take this one test that's pretty straightforward and then go on. But even, I would say most of the time, they don't even have to do that. And so, yeah, Nevada. I think that there may be stories from years ago that I think sort of get propagated and it kind of becomes this urban legend. And there may be, maybe Nevada is an example, some where it's a state level regulatory issue, but that is the exception to the rule because ultimately there are many people out there practicing, doing procedures, and they did not do an ACGB Payne fellowship and they are getting paid. So I don't think this is a, should sway anybody. There are other good reasons to do one fellowship versus the next. Concerns about credentialing are not there unless perhaps you want to be in Nevada. And as Amit alluded to, it's probably wise just to look into state specific law and so on. But this is not an issue for 99% of people that are going to practice. I wanted to just chime in there too, in that, you know, even from my days at training at Shirley Ryan, former RIC, I mean, I have not heard prior fellows having issues, even my own chair, DJ Kennedy, who did the fellowship there, which was a sports fellowship, but there's been no issues. And I think really what it comes down to ultimately, especially in academic jobs, and especially just asking Dr. Kennedy, who's our chair, who knows a teeny amount about spine, all joking aside, but he says, look, the big things I look for is who was training them? You know, what, do I know that person? Are they, you know, an educator? Are they at a good place where they're learning some things? And so I think, you know, the training environment makes a big difference, not necessarily the label that comes attached to it, per se. And again, that's more the exception than the rule. Sorry, my light just went out. But I wanted to ask one more question in the dark. Can I say one last thing about that? And I don't want to sound like this person. I'm coming across like I'm saying, okay, because like, I didn't mean to come across like this is something that is something that everybody has to worry about. I agree 100% with what Zach said. This is an exception, not the rule. And boy, the thing, the thing I'm about to say is going to make it sound like I'm pushing this, but I'm not. Those people like DJ Kennedy, and so on, who did those sports medicine or sports in spine or spine fellowships back in the day, were grandfathered into the ability to sit for the pain boards through the ABPM&R and are now most of them, who have been doing this for decades, are board certified in pain through the ABPM&R in spite of not doing a pain fellowship. And that's and so that arbitrary rule in some states, and let's say it's just Nevada, that's the only one I'm aware of about insurance or in some other states where they say you have to be board certified is quite arbitrary. And I think the training is the most important thing. And nobody will ever stop you from hanging a shingle and opening a private practice anywhere and having a CRM in your office short of if you can't build the insurances, which again, I only know to be in one state. And this is recent, so it's not a historical cultural thing. This is in the last two years, this has happened in Nevada. But I don't want to make it seem like I'm deterring people. You should choose based on what's important to you. But also there is always going to be things around that information that needs clarification. That's it. But I agree with Zach. That's just like sports boards. People could grandfather in without doing an accredited sports fellowship. Even up to when I graduated in 2013, people could do a private practice and take the sports boards. But again, that changed a couple of years after. The last question I wanted to ask is, I'm sure a lot of residents come to you guys and ask about advice. And so in general, what advice do you give to residents? What kind of questions are you asking back to these trainees of what type of fellowship to help sort of guide them, what type of fellowship they should pursue? What are some things that you make them think about before they're going to come to you and say, these are the fellowship I'm interested in. How can you help guide me? What are some of those questions? We'll start back with you, Amit. Okay. So the first thing I say to them is you're a physiatrist, you've treated chronic pain for years at this point when you're coming to talk to me about this, or at least a year. Do you want to treat patients with chronic pain? Because that if you're going to do a pain fellowship, then there are going to be chronic pain patients who do not require interventions. In fact, it would behoove you to not do interventions to some of these people because of the need for patients catastrophize and they generally are trying to seek extra healthcare and so on. Then if they say, no, I really don't like treating patients with chronic pain, then I immediately say, okay, so now you're down to sports and sports fellowships or interventional spine fellowships. And then I say, do you like doing a heavy procedural volume? Do you like treating athletes? And then it sort of starts dichotomizing from that point. But if, and then, and then really, if they really want to be heavy procedural, it depends what kind, do you like doing things under fluoro? Do you like doing things under ultrasound? More and more, we do everything with either fluoro. We don't do any blind procedures anymore. But, you know, certainly if somebody really appreciates ultrasound, wants to do diagnostic ultrasound, and in addition to, in addition to procedures, I'll, and they like taking care of athletes, I'll suggest go to a sports fellowship. But it all comes down to what type of patients you want to treat and how you see your practice in the future. Yeah. Thanks to me. That's very helpful. What about you, Sam? Yeah, I would echo that and I completely agree. You know, the things I talk about with residents who are asking questions are, you know, really thinking about their career goals and kind of their priorities for what that fellowship year, you know, kind of what they want to get out of that year. You know, you know, sometimes, you know, it's a single year, maybe a two-year fellowship at the most, but one year is not a lot of time to fit in a lot of additional training. You know, certainly if you want to split it between ultrasound, fluoro, sports coverage, clinic, you know, research. So there's a lot of things that, you know, residents are interested in doing and trying to figure out the priorities of where they, you know, where that falls. You know, if they're really interested in ultimately becoming, you know, a team doc and they want to work with, you know, covering the marathon and they want to do fluoro, maybe sports is the way for them to go. If they have no interest in that, then they're probably not going to be very happy doing a lot of sports coverage during their fellowship year. So I think it's, for me, I tried to have them understand or talk a little bit more about their career goals. And that's something that they'll get asked on in the interviews as well, to be able to delineate maybe their plans a couple of years out of practice, where do they see themselves working, and what kind of setting and what kind of patients that they want to be seeing as well. So. Yeah, great. What about you, Zach? Yeah, obviously fairly similar conversations to Sam and Amit. But, you know, ultimately, I do try to get a sense of what they want their career and their practice to look like. And really, a lot of it does come down to that patient population question. You know, do what sort of patient do you want to be taken care of? And, you know, do you have any aspirations for certain roles? And so again, like Sam said, if you want to be a team doc, you want to do Olympic coverage, you want to do more, you know, high level event coverage, medical directorship, so on, you know, then if that those are your goals in a sports fellowship is the right way to go. And if you, if you wanted to do much broader pain medicine, you know, potentially not necessarily what we kind of think of as sort of the bread and butter spine and MSK, but, you know, perhaps be involved with, with palliative care with cancer pain management, especially, or if you want to be a fellowship director in a pain and ACGP pain program, certainly you need to do an ACGP pain fellowship to be able to, you know, sort of qualify for those positions or set yourself up for those positions. You know, otherwise, you know, I think, as I've already talked about at length, the sort of population that maybe one takes care of, if they have more of an interventional spine MSK type clinical practice, it's not going to be quite the same. It's not quite sort of the functional restoration type clinical practice that might be ideal for especially more chronic pain patients with more psychological overlay, psychosocial issues, etc. And certainly, it's, you know, one can can do a bit of sports medicine, if trained in these fellowships, but probably not the higher level type of sports medicine, medical directorships or program directorships. Medicine, you know, an ACGP accredited sports medicine fellowship. Awesome, I feel like we could probably go on for another at least an hour and a half going over all these questions. But I think this is a great start for residents to learn about this other faculty members who I'm sure get inundated with these questions. And so I really appreciate all your guys's time and effort you put into this and to share your information. And so again, I know everyone here is very receptive to questions. So if anyone who is watching this, sees us at a conference or wants to reach out, and we'd be more than happy to help guide you. So again, appreciate your time. And for those who are watching, thank you for watching this.

panel discussion

selecting the right fellowship

interventional spine procedures

ACGME accredited pain fellowships

ACGME accredited sports medicine fellowships

NASS recognized fellowships

training opportunities

requirements

credentialing

career goals

patient population interests