The Growing Divide.
Pain Management has undergone many reinventions since inception. From the focus on opioids to interventions to neuromodulation and now to minimally invasive spine (MIS). These areas of focus, and treatment delivery, have grown from industry innovation and partnership, capitalizing on the skill sets of well-trained individuals to execute new therapies, either through the forms of studies, either investigational device exemption (IDE) studies or single arm prospective studies or through 510K approval pathways to commercial use.
The training, historically, was grounded under the banner of continued medical education (CME). In this phase of specialty treatment advancement, although necessary, the heavy lifting of procedure candidacy and training is performed by industry, which offers complexities of potential bias and the unavoidable conflict with sales, with branding, and messaging that promotes use. However, this is the necessary beginning. With the expectation that more formal training will be integrated into unbiased programs, namely through the vehicle of the ACGME.
But there, unfortunately, is a problem.
To follow the maturation of a specialty, integrating a skillset and training of the therapy to integration into formal training as a requirement, let’s use the case example of Spinal Cord Stimulation (SCS). We all know the story. Developed in 1967, significant data was generated to demonstrate treatment success, in IDE prospective, multicenter studies, and countless others, highlighting the importance of its use to manage severe refractory pain of the trunk and limb.
At the beginning, due to the paucity of trained physicians able to perform the procedure, industry sought out physicians with the foundational training to perform the procedure, and they were trained by industry with Medtronic leading the charge. As commercial use grew, the acceptance grew, and additional companies came to the market, including Advanced Neuromodulation Systems and Advanced Bionics.
Spinal Cord Stimulation then became commercially used in 1968 but was not first commercially available as an implantable system in the United States until 1981 and was formally integrated into ACGME training on July 1, 2014.
The predicate training program for medical specialty and practice, within the United States, is the American Counsel of Graduate Medical Education (ACGME). As stated by the ACGME, it has a simple mantra: train folks to do the things that are representative of the specialty in the real world.
Recently, the confidence of graduating ACGME fellows from Pain Management Fellowship Programs was surveyed. The results are alarming to many but not surprising to those exposed to this group. Approximately 1/3 of fellows were uncomfortable with interventional therapies like sympathetic nerve blocks and SCS implants, while 70% were uncomfortable with intrathecal pump implants vertebral body augmentations. Even more so, 80% were uncomfortable with basivertebral nerve ablations. We can argue that competence and confidence are different.
That said, the identifying reason was exposure in the fellowship program. More cautionary is that ACGME recently removed, as of September 2025, procedure volume requirements for Spinal Cord Stimulation, and although, clearly, tissue management intraoperative surgical training is required to avoid both intraoperative and post-operative complications, offered no more formal surgical training. The oncoming potential problems of complications leading to explant may further jeopardize the system. Further, even the basic skill sets are lacking in many settings with many fellows not being trained on even common practice techniques.
A few strategies (or schemes) can be gleaned from this training approach. Either the members creating the guidelines for training within ACGME programs don’t believe in these treatment modalities, blaming industry-driven studies as not being scientifically valid (despite following the rigor of the scientific method and with FDA and IRB oversight) and working within their ivory towers, not actually doing the critical work to identify data or knowledge gaps and creating scientific inquires to fill it (as academic institutions should do), but instead shifting our specialty focus to medication management. Or we have a challenge with the competency of the trainer. Or we have an execution problem with patient access due to inter-specialty politics. Or maybe it is a combination of this stew of complex issues. Nevertheless, the impact puts the specialty at risk and puts a spotlight on deficiencies of current ACGME fellowship programs.
For certain, as was the evolution of interventional cardiology to cardiothoracic surgery, these minimally invasive spine techniques, including percutaneous decompression, interspinous process fusion and indirect decompression, facet fusion, sacroiliac joint fusion, basivertebral nerve ablation, vertebral body augmentation, peripheral nerve stimulation, dorsal root ganglion stimulation, and spinal cord stimulation are here to stay.
The growing divide is real. Unaccredited programs are becoming more popular, as they are outpacing the training development and are more representative for preparing clinicians to practice within the real-world scope of pain management. Even more, training programs have been created specifically for “filling the gap” from ACGME programs, commonly executed at the societal level. However, exposure and competence are vastly different.
Society training programs, based on volunteerism, are filling the divide, along with CME quality programs, to not only offer exposure but also training to the level of competence. These programs are under development and some are already being executed. The question remains: Will ACGME answer the call?
Perhaps the only path forward is an interventional pain residency since two years in fellowship that many have suggested will not fill the gaps that exist unless we see a major overhaul of the programs as a whole. For now, we are seeing the divide between the academic center and the “real world” widen and that can only be remedied by a meeting of the minds to bring the field forward.
References:
- ACGME Common Program Requirements, Section VI; CLER Pathways v2.0; Milestones Guidebook).
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Timothy R. Deer, MD Chairman, The American Society of Pain and Neuroscience Chairman, The International Society of Pain and Neuroscience
Jason E. Pope, MD, DABPM, FIPP Senior Advisor Executive Board Past President The American Society of Pain and Neuroscience
