Trainee Talk: Continued Performance of EDX Testing After Completing a Pain or Sports Medicine Fellowship: An Expert Panel

Ashmore: My EMG training during residency began with classroom-style education for a few weeks, followed by slow integration into the EMG lab. We had graded autonomy as we went through the rotation, and it culminated in near-complete independence for us by the end. Whenever we were in the lab, we were assigned to a specific attending who would staff the case with us. We received the completed nerve conduction studies (NCS) from a certified nerve conduction technologist, performed the needle examination, and then staffed that case with the supervising attending. We also had allotted time to do NCS with the technologist helping us through that aspect of the study. By the end of the rotation, which was a 6-month total block at the time I went through, we would end up performing about 300 studies. 

 

Colorado: I did my PM&R residency at the Medical College of Wisconsin and had a very strong EMG experience with really great mentors, such as Dr. Wertsch, Dr. Del Toro, Dr. Kotsonis, and Dr. Park. All of our EMGs incorporated both the NCS and the needle exam. In addition to our typical EMG rotations and didactics, I think one of the things that was really helpful for me was the weekly EMG case conferences which we had throughout the year. During our EMG rotations, we also had small group discussion sessions which were often 1-on-1 or 2-on-1 sessions with Dr. Wertsch, where she kind of “put our feet to the fire,” so to speak, and made sure we understood the “why” for a lot of EMG concepts. Very early on in residency, I knew EMG would be a component of my future practice. Having access to incredible EMG mentors only strengthened that. 

 

Colorado: Absolutely! I prioritized Sports Medicine fellowships that would allow me to continue to perform EMGs, especially those that would allow me to get the 200 requirement that would allow me to sit for the ED medicine board exam after my fellowship. The other piece, for me, was the US training, which was also a priority. Even though my US focus when applying to fellowships was on musculoskeletal US, the continued EMG exposure during fellowship and the interesting nerve cases I encountered, served as a springboard to my interest in NMUS. 

Ashmore: Yes, that was very important to me! Especially to have that flexibility. I had not yet signed a contract, or anything of the nature, when I entered my fellowship training. Really, that is the case with most fellows as they enter fellowship training. They may not know what the next step is going to be! I knew I was interested in EMG and was very open to incorporating that as a part of my practice, but I still did not know what I wanted my final practice to look like. Having the ability to go back and train with folks that I really respected, and trusted was a very important aspect of what I wanted in my fellowship. As a bottom line, I wanted to have the ability to shore up some of my skills and really grow in confidence before coming out of training. 

Ashmore: That is a great question. I was in the same EMG lab for my fellowship. I was at Mayo Clinic for my PM&R residency and Pain Medicine fellowship, so I was working, again, with the same attendings that I had worked with before. Compared to my rotation in residency, this was a much more focused and specific time for me. By the time I went back through the EMG lab, I knew what my future practice would look like, and I knew what kind of referrals I would be getting for studies. I was able to tailor the experience a bit more for myself. In some cases, I was able to work through specific problems that I knew would be of particular relevance. There were areas that I felt I was a little less comfortable with and I had more latitude to be able to make decisions of where I was going to spend my time and attention. I also was able to focus on nerve conduction studies (NCS) a little bit more since I knew that was going to be a component of the study I would personally perform when I went into practice. I knew I wanted to go back and have that skillset refined before I was out on my own. 

Colorado: I think, for me, the main difference from residency was there were obviously a lot less EMG-specific lectures and conferences during fellowship, so it was a lot more of the “doing,” so to speak. I also incorporated a lot more US during EMGs in my Sports Medicine fellowship then I did while in residency. This was mostly driven by me and my own interest, but my Sports Medicine fellowship really allowed me to explore this aspect. 

 

Colorado: My current practice, overall, is only 50% clinical due to my administrative responsibilities. Within that clinical component, I practice the full-spectrum of musculoskeletal medicine, including 25% EMG, 25% fluoroscopic- or US-guided procedures, and 50% clinic with a mix of sports, spine, and musculoskeletal patients. I love teaching EMG and NMUS. I direct our EMG didactics and usually have residents with me during my EMG clinic.  

Ashmore: I work in a hospital-based neurosurgery and pain management practice in Lexington, South Carolina. My practice incorporates some general musculoskeletal medicine, a little bit of spasticity treatment, and primarily, spine-related care. My time is split about 50% clinical and 50% procedural. Within the procedural portion, I perform EMGs on one half day per week. A lot of the EMGs are referrals from my neurosurgical and primary care colleagues, but I also perform EMGs on a good number of my own patients I see in my clinic. What is nice about that part of my pain management practice is that I can see a patient and perform a study in a short order of time – the next day if needed. This is a much shorter timeframe than referring out elsewhere and the patient needing to wait until we can move forward to the next step clinically.  

Meiling: Transitioning from fellowship into your current practices, did you feel comfortable making that jump independently right away, or was there anything you had to do to personally brush up on skills in the in-between? 

 

Colorado: It was easy for me because I ended up staying in the same place that I did my fellowship, so it was pretty seamless. I was able to use the same EMG machine, same US machine, and same EMR. I also had a referral base already in place.  

Ashmore: I did feel comfortable moving forward, but it was a stretching time for me too. I did not end up practicing where I trained and, like any skill in medicine, I think there was a lot of refining over time that needed to take place. What I was most thankful for, coming out of training, was being able to recognize what I felt comfortable with and identifying the areas I knew needed to continue to focus on and grow. One of the biggest pieces was setting up my own EMG lab. The EMG machine equipment was the same, but there were a lot of different settings I needed to learn, compared to what I was used to during my training. Being able to navigate the backend of these machines, thinking about things like filter settings, or even just why I was performing each NCS and what data I wanted each study to output for me was really important. I did not foresee this at all when I was in training and first anticipating going out into practice. You show up and you realize what you need to accomplish to make your own practice run. Doing more NCS on my own and not having my own dedicated technologist to work with ended up being a helpful thing for me, as a new attending as well. And if you do have technologists when you enter into practice, you need to able to work with them effectively and at times be able to do on the job training. After having done all aspects of the study for a year now, I have the skillset to work with other members of the team much more effectively. 

Meiling: Thank you. I know that a lot of PM&R residents, when they are in residency, are considering either pursuing a Sports Medicine or Pain Medicine fellowship. What kind of advice, that you have not shared already, might you give to these individuals who are considering either of these routes but want to continue to perform EMGs in the future? 

Colorado: I would just advise residents to continue to perform EMGs no matter what area of PM&R you go into. In my opinion, continuing to perform EMGs will only enhance your sports or musculoskeletal practice. Many times, a patient who is referred to me for an EMG becomes my patient for another musculoskeletal issue. I might have a spine surgeon refer a patient for an EMG, maybe to assess for a cervical radiculopathy, and then the EMG ends up being normal. After further assessment, I may identify a rotator cuff disorder, maybe even a partial tear with US. Now I am managing the patient’s rotator cuff issue, and then that might lead to an injection. The EMG may become a built-in referral source. A lot of times, surgeons refer patients to you and if it is not surgical or ends up being a different diagnosis, now you are kind of the next step and have already established that rapport with the patient. Referring providers like that “one-stop shop,” so embrace that additional skillset that you learned in residency, and it will really distinguish you from other physicians in your specialty that do not perform EMGs. 

Meiling: Thanks Dr. Colorado. What about you, Dr. Ashmore? 

Ashmore: I would really encourage residents who are interested in incorporating EMGs into a pain management practice. There are a lot of opportunities out there for that! There are regional variations in terms of demand and need for a physician who can perform these studies, but in general, it is a very needed skillset. Certainly, I have seen this regionally for myself that sometimes there can be really long wait times for patients to get EMGs. Being able to incorporate them into your practice, as Dr. Colorado said, can be helpful from a referral standpoint. EMGs are a practical way that we can be very useful and helpful to our patients by being able to move their care forward in a timely manner. I think it is also a great way to diversify your skillset and schedule. Most commonly, this skillset fits with a practice in collaboration with neurosurgery or orthopedic surgery but can also fit well into a lot of other settings. Many practices ask candidates with a PM&R or neurology background whether they have the skillset to perform EMGs. I think that, again, it comes back to encouraging trainees that there are a lot of opportunities and benefits to incorporating EMGs into a pain management practice. 

 

Meiling: Fantastic! Well, thank you both very much for your time tonight and for your answers and advice that I can pass on to trainees who are wondering these questions.