Fellowship Training:

The Ann Arbor VAMC

The VA Multidisciplinary Chronic Pain Clinic

The Chronic Pain Clinic at the Ann Arbor VA has been functioning since 1995 as a multidisciplinary clinic within the Physical Medicine and Rehabilitation Service. The clinic consists of physiatrists, anesthesiologists, psychologists, pharmacists, nursing and physical therapy. The clinic serves all of the VAs in Michigan and northern Ohio (VISN 11) and meets 2 days a week with spinal procedures done on 5 half days. The clinic sees approximately 1,750 patients each year with approximately 1,500 spinal and other injections. The procedure rooms are new and have state of the art C arms. The Pain Clinic uses 7 rooms that are in the new clinical addition (opened Feb. 2000). Each clinic is staffed by a physiatrist, an anesthesiologist and a Pain Psychologist with a Spine/Musculoskeletal fellow and a PM&R resident.

The program is multidisciplinary involving 3 medical specialties and several allied health services. The pain management services provide acute, chronic and consultative services as noted below. The pain program has been in existence for over 12 years and has trained 28 Spine/Musculoskeletal Fellows, 25 post doctoral psychologists, 1 Rheumatology fellow, 2 fellows in Addiction Psychiatry, over 50 PM&R residents, over 25 general medicine residents, and several pharmacy doctoral trainees.

The PM&R service also provides a consult service for acute management of inpatients with pain problems and post-operative pain management.

EMG Laboratory

EMG laboratory at the VA is run exclusively by PM&R and approximately 700 studies are performed each year. There are 2 staff physiatrists, both are AAEM Boarded, a resident and a fellow doing EMG cases. One third are lower extremity cases for radiculopathy or compression neuropathy, another third are upper extremity (primarily rule out carpal tunnel syndrome and the final third are for peripheral neuropathy with a small number of studies to evaluate weakness. The same EMG database is used as at the University laboratory. The clinic is both a diagnostic and treatment clinic. The staff act as consultants and the patients diagnosed with a neuromuscular disorder are actively managed in coordination with the referring physician.

Physical Medicine/Orthopedic Triage Clinic

All musculoskeletal consultations are reviewed by PM&R and initially screened in our Physical Medicine clinic. This is primarily patients with hip, knee, shoulder and back pain and patients are evaluated and given optimum conservative treatment including physical therapy, orthotics and injections as necessary. These patients are seen in the new clinical addition and staffed by Dr. Cavender. Those patients meeting criteria for surgical consideration are then referred to Orthopedics for further care. Approximately 2,000 patients are seen yearly in this clinic. These patients are seen in Ann Arbor as well as the Toledo outreach clinic.

Orthotic and Prosthetics Clinic

This clinic evaluates patients with foot, ankle and knee pain and provides shoe inserts and braces for management of mechanical alignment and instability. Amputees are also evaluated and many have pain management issues.

Palliative Care Clinic/Consult Service

The program is an initiative of Dr. Daniel Hinshaw. Dr. Hinshaw is a surgeon (the immediate past chief of staff) who recently completed a fellowship in Palliative Care. He has a weekly clinic to follow terminal patients with end of life issues. Approximately 50% have pain as their major problem area and are managed in this clinic. The clinic sees approximately 100 new patients a year. The clinic has been in operation only since the fall of 2001 but is increasingly busy. The Pain fellow will start participating in this clinic I July, 2002 under the supervision of Dr. Hinshaw. The majority of patients are oncology patients but there are also pulmonary and cardiac patients. The clinic also interfaces with the Arbor Hospice which is affiliated with the University of Michigan.

There is an interdisciplinary team meeting which meets regularly and includes representation from social work, pastoral care, psychiatry, as well as nursing and Dr. Hinshaw. The purpose of the meeting is to review the plan of care for patients receiving ongoing palliative services which often include discussion of pain management.

Another major component of the program is an inpatient consultation service which at present accounts for approximately 2/3 of the new palliative care consults. The remainders of patients are initially evaluated as outpatients. The vast majority of our patients have advanced cancer. The Pain fellow will have a rich exposure to management of cancer pain.

The inpatient palliative care unit located on site at the VA has been operating for over a year. The primary function of the unit is aggressive symptoms management in patients with advanced illness. The pain fellow has the opportunity to learn how to address acute pain crises in a setting in which the nursing staff are also highly skilled in pain and symptom management.

Dept. of Anesthesiology, Univ. of Michigan Medical School

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