Program Contact: Katelin.Benton@childrens.harvard.edu
Alternate Program Contact: Benjamin.Paret@childrens.harvard.edu
Program Director: Anjali Koka, MD

Background: The Boston Children’s Hospital Pain Medicine Fellowship was developed in July 2008 and was the first ACGME accredited graduate medical training program in pain medicine with a focus in pediatric pain medicine in the United States. It is the premier pediatric pain medicine fellowship training program with extensive training in the management of patients with diverse pain conditions and procedures necessary for the treatment of pain. This is an American Board of Anesthesiology approved and ACGME accredited Combined Pediatric and Adult Pain Medicine Fellowship that offers in-depth training in Pediatric Pain Medicine. On average, we have accepted 2 ACGME-accredited fellows per year. The fellowship meets the ACGME Program Requirements for GME in Pain Medicine.

In addition, we offer non-ACGME accredited training opportunities for in-depth training in Pediatric Pain Medicine. On average, we have accepted 1 to 2 non-ACGME-accredited fellows per year. This is an unfunded fellowship. The non-ACGME fellowship fills a deficit for international medical graduates who are not pursuing fellowship for board certification or for medical graduates from specialties that are not eligible for pain medicine board certification (emergency medicine, pediatrics, etc.). This fellowship pathway combines clinical, research and administrative training and experience. There is a training deficit for these candidates who wish to return to underserved areas to lead programs in Pediatric Pain Medicine and are not pursuing fellowship for board certification.

Duration: The ACGME-accredited Pediatric Pain Medicine Fellowship training is 12 months. At the end of the fellowship, trainees will be prepared to become leaders in Pediatric Pain Medicine. The non-ACGME fellowship is tailored to the trainees needs and varies from 3 to 12 months.

Prerequisite Training/Selection Criteria: Applicants to the ACGME-accredited Pediatric Pain Medicine Fellowship must have medical doctorate degrees and complete a residency in neurology, PMR, psychiatry or anesthesiology. Participants must obtain ECFMG certification; possess a valid Massachusetts State medical license and valid visa sponsorship (if applicable). The application process is through the Electronic Residency Application Service (ERAS, a program of the Association of American Medical Colleges), but the fellowship program does not participate in the match. The application cycle is December 1 through May 31.

Applicants to the non-ACGME fellowship are usually from specialties that are not eligible for pain medicine board certification throuagh the American Board of Anesthesiology® (ABA). Often the applicants are from board eligible specialties and do not wish to pursue 12 months of training or pain medicine board certification.

Goals and Objectives for Training: The Boston Children’s Hospital Pain Medicine Fellowship meets the ACGME Program Requirements for GME in Pain Medicine. Fellows spend six months of the fellowship training at Boston Children’s Hospital learning the care of acute, chronic and cancer pain in infants and children. During the six months at Boston Children’s Hospital, fellows will gain inpatient experience on the Acute Pain Service and Regional Anesthesia Service and outpatient experience in Pediatric Chronic Pain Clinic, Pediatric Headache Clinic, Acupuncture Clinic and Mayo Family Pediatric Pain Rehabilitation Center. Depending on their background, fellows rotate for 2 weeks in the following pediatric services – Palliative Care, Psychiatry, Physical Medicine and Rehabilitation, Anesthesia and Regional anesthesia. Fellows spend six months of the fellowship training in the adult pain medicine centers of Beth Israel Deaconess Medical Center (BIDMC) and Brigham and Women’s Hospital (BWH). BIDMC and BWH have renowned training programs in adult pain medicine and provide diverse and complementary training for fellows. Fellows work as adult pain medicine fellows when at these locations, and they participate in didactics, give lectures and journal club and take inpatient call.

Educational Program (Basic Curriculum)

Clinical and Research Components: The pain medicine fellowship provides in depth training in the care of infants, children and adults with various acute and chronic pain conditions. Through the rotations outlined above, fellows gain expertise in the comprehensive management of pain including pain assessment, the pharmacologic management of pain, interventional techniques, psychological modalities, and rehabilitative approaches. Fellows learn to work with referring providers, psychologists, occupation and physical therapists, and nurses to provide multidisciplinary care in the treatment of pain. Although there is no research requirement, fellows are encouraged to participate in a research project. To facilitate this involvement, fellows are given academic time during the fellowship and mentorship from a faculty member.

Trainee’s Supervisory and Patient Care Responsibilities: The Fellows patient care responsibilities are split between time in the chronic clinics and acute pain service. The acute pain service responsibilities include managing children of all ages with a variety of pain conditions such as acute postoperative pain, cancer pain, and chronic pain. The fellow may supervise nurse practitioners or other affiliating trainees.  The fellow’s patient care responsibilities while in the chronic clinic vary depending on their assignment. As a multidisciplinary clinic, fellows can be assigned with a psychologist, pain medicine physician, neurologist or physical therapist.  Fellows are responsible for obtaining a complete pain history and completing the appropriate physical exams and presenting their treatment plan to the attending physicians.

Clinical Procedural Experience: The Pain Medicine Fellows will have exposure to ultrasound, fluoroscopy-guided and surgical pain procedures. At Boston Children’s Hospital the fellows perform procedures under the direct supervision of attending pain physicians. It is not a goal for the non-ACGME fellow to become proficient in pain procedures. Common procedures done at Boston Children’s Hospital include Didactic Session and Teaching Methods: The Pain Medicine Fellows participate in didactics Monday through Thursday given by the Department of Anesthesiology, Critical Care and Pain Medicine. There are also recorded lectures available online at OpenPediatrics. Fellows also attend didactic pain sessions by pain faculty members of Beth Israel Deaconess Medical Center and Brigham and Women’s Hospital while on rotation at these facilities.  Additionally, the Boston Children’s Hospital Department of Anesthesiology offers a full didactic program including lectures, case discussions, and journal club. There is a curriculum on Wellness education, as well as a serialized curriculum on fundamentals of research methodology. During the year the fellow will have the opportunity to present a thirty­ minute in-depth presentation on some aspect of pediatric pain medicine to all clinical staff within the department.

Educational Program (Detailed Curriculum)

Educational Goals for the Acute Pain Service: Learn how to manage acute postoperative pain, regional anesthesia catheters (epidural, paravertebral, lumbar plexus, and peripheral nerve catheters), inpatients with chronic pain, opioid and sedation weaning and sedation consults.

Educational Goals for Pediatric Chronic Pain Clinics: Learn how to diagnose and manage common pain conditions in pediatrics including axial back pain, myofascial pain, neuropathic pain, visceral pain, head and face pain, abdominal pain, complex regional pain syndrome, pelvic pain, urogenital pain, rheumatologic and cancer pain.

Educational Goals for the Regional Pain Service: Gain experience in ultrasound-guided peripheral nerve blocks (brachial plexus, femoral nerve, adductor canal, proximal to distal sciatic nerve), truncal blocks (paravertebral, erector spinae, epidural, caudal) and plexus or field blocks (lumbar plexus, fascia iliaca).<

Educational Goals for Pediatric Interventional Pain: Learn fluoroscopic, ultrasound and landmark based procedures and how to manage complications. Fluoroscopic procedures include epidural steroid injections, medial branch blocks, sacroiliac joint injections, epidural blood patches, ganglion impar blocks, intrathecal administration of baclofen / oligonucleotides, intrathecal pump placement, and epidural catheter placements. Ultrasound-guided blocks include intercostal nerve blocks, rectus sheath / transversus abdominis plane blocks, lumbar plexus catheters, peripheral nerve catheters, paravertebral catheters, trigger point injections (including quadratus lumborum and psoas muscles. Additionally, fellows learn greater occipital nerve blocks and BoTox for head and neck pain.

Educational Goals for Adult Pain Medicine: Learn how to diagnose and manage common pain conditions in adults including axial back pain, myofascial pain, neuropathic pain, visceral pain, head and face pain, complex regional pain syndrome, abdominal pain, pelvic pain, urogenital pain, rheumatologic and cancer pain. Learn interventions, surgical procedures and how to manage the complications. Interventions include sympathetic blocks (ganglion impar, lumbar sympathetic, stellate ganglion, celiac plexus block/ablation), spinal cord and peripheral nerve stimulators, intrathecal pain and baclofen pump placement, DRG, epidural steroid injections, medial branch blocks and ablations, sacroiliac joint injections, epidural blood patches, ganglion impar blocks, caudal blocks, greater occipital nerve blocks, trigger point injections and BoTox for head and neck pain. Proficiency in all of these procedures (i.e. spinal cord and peripheral nerve stimulators, DRG, nerve ablations) is not imperative for practicing pediatric pain, but the goal is to understand the concepts, step of the procedure and be able to manage complications.