Department of Anesthesiology
Interventional Pain Management Clinic
University of Puerto Rico – School of Medicine
Interventional Pain Management Training Program for International Physicians
The Pain Medicine Program at the University of Puerto Rico – School of Medicine provides an academic environment for the acquisition of knowledge, skills, clinical judgment and attitudes, which are essential to the practice of pain management. The program director, faculty, supporting are accomplished in a friendly supportive atmosphere of mutual respect. The one-year continuum of education provides physicians with graduated responsibility and a broad range of pain management experiences with emphasis of interventional techniques. Trainees spend most of their time at the Interventional Pain Clinic located at the main building of the School of Medicine. OR staff, and administrative staff are fully committed to meet these educational needs. Pain medicine training and education cases such as neuromodulation, intrathecal drug delivery systems, and vertebroplasty are done on a weekly basis. Physicians are allowed elective rotations with in PMR and Neurosurgery-Spine services. Acute Post-Operative Pain Management is covered at the Trauma and University Hospitals nearby.
Objectives:
At the end of one year, trainees should be able to demonstrate the following:
Knowledge
- The anatomy and physiology of pain perception
- Epidemiology, economic impact and sociology of pain
- Pharmacology of opiates, non-narcotic analgesics and non-steroidal anti-inflammatory medications
- Pharmacology of centrally-acting drugs used in pain management
- Measurement and assessment of pin and function
- Principles of neurostimulation
- Principles for diagnostic testing
- Regional nerve blocks and pain management
- Neurolytic techniques
- Cognitive, behavioral, and supportive psychotherapeutic treatment principles, including rehabilitation and the role of team management
- Quality pain management – This requires of the trainee a certain foundation of knowledge, pool of technicall skills, and bedside manner.
- To recognize the need for a multidisciplinary approach for pain management
- To gain knowledge of the role of a Pain Management physician
- To distinguish clinical characteristics of acute, chronic and cancer pain
- To recognize and appreciate the role as a pain Consultant
- Understand the principles of neural stimulation (TENS, PNS AND DCS)
- Understand the principle and rationale for intrathecal catheters and infusions
- Understand and become familiar with alternative pain therapies
- Evaluation and treatment of all genders, adults and children and to become familiar with the diagnostic methods and treatment modalities of male and female pain patients. To include the differences in pain presentations and techniques based on gender
- Evaluation and treatment of pain patients utilizing the various interventional and invasive management techniques, indications, contraindications and follow-up. These include intradiscal electrothermal therapy {IDETT}, spinal cord stimulators, intrathecal pumps, vertebroplasty and kyphoplasty
- Principles, evaluation and treatment of workman’s compensation, disability claims and impairment ratings
- Learning the appropriate billing and coding for evaluation and medical treatment and interventional therapies
Exposure to and/or knowledge of:
- Acupuncture
- Botox Injections for pain
- Brachial Plexus Block
- Clinic visits for prescription refills
- Clinic visits for continuity of care
- Morphine pump refills
- Caudal Steroid Injection
- Celiac Plexus Block & Denervation
- Cervical Epidural Steroid Injection
- Percutaneous Discectomy
- Discography
- Epidural Lysis of Adhesions
- Facet Joint Injections and Medial Branch Block (Cervical/Thoracic/Lumbar)
- Ganglion of Impar Block
- Intercostal Nerve Block
- Intradiscal Electrothermal Therapy (IDET)
- Lumbar Epidural Steroid Injection
- Lumbar Radiofrequency Neurotomy
- Lumbar Sympathetic Block
- Lumbar Transforaminal Epidural Steroid Injection
- Occipital (Greater & Lesser) Nerve Block
- Piriformis Injection
- Psoas & Quadratus Lumborum Muscle Injection
- Radio Frequency Denervation
- Sacroiliac Joint Steroid Injection
- Selective Nerve Root & Dorsal Root Ganglion Block
- Spinal Canal Endoscopy
- Stellate Ganglion Block
- Sphenopalatine Ganglion Block & Neurolysis
- Splanchnic Nerve Block & Denervation
- Superior Hypogastric Plexus Block
- Suprascapular Nerve Block
- Thoracic Epidural Steroid Injection
- Trigeminal Ganglion Block & Neurolysis
- Trigger Point Injections
- Removal of trial stimulating catheters
- Follow-up visits for post surgical or IPM procedures
- Removal of sutures or staples
- Interrogation of Spinal Cord Stimulators and peripheral nerve stimulators
- Examination and re-evaluation of an acute pain flare
- Consultations/Letters/Conferences
- Occasional minimally invasive procedures
- Telephone call backs
- Cervical, thoracic, lumbar and caudal epidural catheter placements
- Trial and Permanent Spinal Cord Stimulators
- Permanent morphine pump placement
- Peripheral Nerve Stimulator Placement
- Replacement of Malfunctioning SCS and Morphine Pumps
- Repositioning of SCS electrode leads
- Sacral Stimulating Catheter Placement
- Subcutaneous Cervical Stimulator
- Nucleoplasty
- Dekompressor
- Vertebroplasty
Responsibilities:
Physicians are expected to participate actively at the Pain Clinic Monday thru Friday. Each week a physician is assigned to cover the acute pain service. This physician is in charge of carrying the pager and making rounds with the attending each morning (usually fewer than 5 patients) prior to the Pain Clinic. This physician is also assigned for interventional cases at the OR on Thursdays.
Physicians are expected to attend educational program activities, which consist of Pain Medicine lectures and Journal Club on Monday and Tuesdays at 7:00am and Anesthesiology Lectures, Journal Club, and Morbidity and Mortality on Tuesdays at 3:00 pm. Physicians will be asked to prepare lectures on a monthly basis to be presented to attending physicians, residents, and medical students. Every other month a case presentation is assigned to a physician to be presented to the Pain Management specialists.
Qualifications:
In order to fill an application for the Pain Medicine Training Program, the physician must meet the following requirements:
Graduation from an Anesthesiology Residency Program.
Fluent in Spanish (written and spoken). English is not required, but highly recommended.
Able to demonstrate interest in Pain Medicine and Interventional Techniques, and have a plan to follow after graduating from the Pain Medicine Program.
Three letters of recommendation.
Faculty:
Francisco Lebrón-Arzón, MD
Director
Interventional Pain Management
Daniel Fernández, MD
Interventional Pain Management
Taking Call:
Each week a physician is assigned to cover the acute pain service. This physician is in charge of carrying the pager and making rounds with the attending each morning (usually fewer than 5 patients) prior to the Pain Clinic. Rounds will also take place during the weekend if necessary. The service consists mostly of acute postoperative pain management with PCA machines and epidurals, but include chronic pain consults as well. Acute pain consults should be taken care of ASAP. Consults for flail chest patients also have priority and need to be attended to ASAP. Consults regarding chronic pain patients can wait up to 24 hours to be answered.
All patients need to be presented to the attending physician. When a resident is carrying the pager, the resident will call the pain physician, and then he/she will present the case to the attending physician.
Usually, the physician taking call will be assigned to the procedure room during the same week, and will be in charge of the OR cases during the week. The same physician will be in charge of calling back patients in the afternoon, to attend to any questions or concerns.
Pain Clinic:
Physicians should be present at the Clinic at 7:00am. The Clinic usually runs until one hour past noon on Monday, Wednesday, and Friday. Clinic runs until 3:00pm on Tuesdays. Thursdays are unpredictable, but usually duty is over early in the afternoon.
Dress code for the Clinic is business casual, unless the physician is assigned to the procedure room, in which case scrubs may be worn.
Physicians are expected to evaluate new patients and present them to the attending physician. A complete history, physical exam and evaluation of imaging is expected. The physician should be able to design a plan of treatment and discuss it with the attending physician.
Residents and medical students will be directly supervised by the physicians. A lecture will be given to the residents and medical students by a physician on Wednesdays at 1:00 pm. These lectures should cover basic acute pain management topics, as well as chronic pain management.
Rotations:
The physicians will spend most of their time at the Pain Clinic during the year. At some occasions, rotations will take place at other facilities with close relationships with our Pain Clinic. These rotations will include one month at the Spine Center and one or two months doing a 2 day per week rotation at the Veteran’s Administration Hospital (VAH) Physical Medicine and Rehab Pain Clinic.
Contact Information:
Pain Clinic (Clínicas de la Escuela de Medicina-UPR Reparto Metropolitano)
787-620-2247/2248, 787-758-7910 X 236
Department of Anesthesiology
787-758-0640 787-758-2525 x1920 fax 787-758-1327
Dr. Francisco Lebrón-Arzón
franciscocisco@yahoo.com