New Application: Pain Medicine
Review Committee for Anesthesiology, Neurology, or
Physical Medicine and Rehabilitation
ACGME
515 North State Street, Suite 2000 Chicago, Illinois 60654  312.755.5000  www.acgme.org
INSTITUTIONS - PARTICIPATING SITES
1. Indicate which of the four sponsoring specialty ACGME-accredited residency programs with
responsibility for the multidisciplinary pain medicine program are in place at the primary institution
and/or its affiliates. These specialties are: Anesthesiology, Neurology, or Physical Medicine and
Rehabilitation: [PR I.B.3.]
ACGME-Accredited Residency Programs
Anesthesiology
Yes or No
☐ YES ☐ NO
Program Name / Number
Name/Number
Neurology
☐ YES ☐ NO
Name/Number
Physical medicine and rehabilitation
☐ YES ☐ NO
Name/Number
a) Explain how each of the participating programs indicated above will contribute to the program.
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2. Is there an institutional policy governing the educational resources committed to multidisciplinary
pain medicine that ensures cooperation of all involved disciplines? [PR I.B.4.] ............ ☐ YES ☐ NO
(A copy of the policy should be available for review by the site visitor).
3. Provide a list of members by specialty of the multidisciplinary pain medicine committee. How
frequently does the committee meet? [PR I.B.4.]
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PROGRAM PERSONNEL AND RESOURCES
Non-Physician Personnel
What additional technical and clerical personnel will be available to support the fellowship? [CPR II.C.]
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Resources
1. Is there a pain center located within a hospital/medical office complex, designed specifically for the
management of pain patients? [PR II.D.1.] ................................................................... ☐ YES ☐ NO
2. Describe the monitoring and life support equipment available where invasive pain management
procedures are performed. [PR II.D.1.]
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3. Describe facilities that will be provided for: [PR II.D.1.]:
Pain Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
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a) Conferences
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b) Research space
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Support Services
1. Appropriate radiologic imaging facilities [PR II.D.2.a)] .................................................. ☐ YES ☐ NO
2. Psychiatric/psychological services, including behavioral modification [PR II.D.2.b)] ..... ☐ YES ☐ NO
3. Physical and/or occupational therapy [PR II.D.2.c)]...................................................... ☐ YES ☐ NO
4. Social services [PR II.D.2.d)]........................................................................................ ☐ YES ☐ NO
5. Appropriate electrodiagnostic facilities [PR II.D.2.e)] .................................................... ☐ YES ☐ NO
Patient Population (Clinical Resources)
1. Indicate the number of patients available for fellows’ clinical educational experience in each
category for the last 12 months. [PR II.D.3.]
TYPE
1. Chronic Pain (benign)
Inpatient
Outpatient
2. Cancer Pain
3. Acute Pain
Inpatient
Outpatient
4. Palliative
5. Pediatric
Under 2 years of age
2-18 years of age
6. Interventional Procedures
# of Patients
#
#
#
#
#
#
#
#
#
#
#
#
EDUCATIONAL PROGRAM
Patient Care
Anesthesiology
1. Indicate the settings and activities in which residents will demonstrate competence in the following.
Also indicate the method(s) used to assess competence.
Competency Area
Settings/Activities
Obtaining intravenous access in Click here to enter text.
Pain Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Assessment Method(s)
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Competency Area
a minimum of 15 patients
[PR IV.A.5.a).(2).(a).(i)-(i).(a)]
Basic airway management
[PR IV.A.5.a).(2).(a).(ii)]
A minimum of Mask ventilation
in 15 patients [PR
IV.A.5.a).(2).(a).(ii).(a)]
Endotracheal intubation on 15
patients
[PR IV.A.5.a).(2).(a).(iii)-(iii).(a)]
Basic life support and advanced
cardiac life support
[PR IV.A.5.a).(2).(a).(iv)]
Management of sedation,
including direct administration of
sedation to a minimum of 15
patients
[PR IV.A.5.a).(2).(a).(v)-(v).(a)]
Administration of neuraxial
analgesia, including placement
of a minimum of 15 thoracic or
lumbar epidural injections using
an inter laminar technique
[PR IV.A.5.a).(2).(a).(vi)-(vi).(a)]
Settings/Activities
Assessment Method(s)
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Neurology
2. Indicate the settings and activities in which residents will demonstrate competence in the following .
Also indicate the method(s) used to assess competence.
Competency Area
Eliciting a directed neurological
history
[PR IV.A.5.a).(1).(a).(i)]
Performing a detailed
neurological examination to
include at least mental status,
cranial nerves, motor, sensory,
reflex, cerebellum examinations,
and gait in fifteen patients
[PR IV.A.5.a).(1).(a).(ii)]
Identifying significant findings of
basic neuro-imaging
[PR IV.A.5.a).(1).(a).(iii)]
Neuro-imaging studies in the
following areas: brain, cervical,
thoracic, and lumbar spine
[PR IV.A.5.a).(1).(a).(iii).(b)]
Settings/Activities
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Assessment Method(s)
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©2015 Accreditation Council for Graduate Medical Education (ACGME)
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a) Will faculty members verify fellow experience in detailed neurological examinations in a
minimum of five observed patient examinations? [PR IV.A.5.a).(1).(a).(ii).(a)] ........ ☐ YES ☐ NO
b) Will neuro-imaging studies include at least magnetic resonance imaging (MRI) and
computerized tomography (CT) of the spine and brain on a minimum of 15 CT and/or MRI
studies? [PR IV.A.5.a).(1).(a).(iii).(a)] ..................................................................... ☐ YES ☐ NO
Physical Medicine and Rehabilitation
3. Indicate the settings and activities in which residents will demonstrate competence in the following.
Also indicate the method(s) used to assess competence.
Competency Area
Performing a comprehensive
musculoskeletal and appropriate
neuromuscular history and
examination with emphasis on
both structure and function as it
applies to diagnosing acute and
chronic pain problems
[PR IV.A.5.a).(1).(b).(i)]
Significant hands-on experience
in the musculoskeletal and
neuromuscular assessment of
15 patients [PR
IV.A.5.a).(1).(b).(i).(a)]
Developing rehabilitation
programs to include
assessments of static and
dynamic flexibility, strength,
coordination, and agility for
peripheral joint, spinal, and soft
tissue pain conditions
[PR IV.A.5.a).(1).(b).(ii)]
Clinical evaluation and
rehabilitation plan development
of a minimum of five patients
[PR IV.A.5.a).(1).(b).(ii).(a)]
Integrating therapeutic
modalities and surgical
intervention in the treatment
algorithm
[PR IV.A.5.a).(1).(b).(iii)]
Settings/Activities
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Assessment Method(s)
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Psychiatry
4. Indicate the settings and activities in which residents will demonstrate competence in the following.
Also indicate the method(s) used to assess competence.
Competency Area
Carrying out a complete
psychiatric history with special
Settings/Activities
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Pain Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Assessment Method(s)
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Competency Area
Settings/Activities
attention to psychiatric and pain
comorbidities
[PR IV.A.5.a).(1).(c).(i)]
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status examination on a
minimum of 15 patients
[PR IV.A.5.a).(1).(c).(ii)-(ii).(a)]
Explaining psychosocial therapy Click here to enter text.
to a patient and making a
referral when indicated
[PR IV.A.5.a).(1).(c).(iii)]
Assessment Method(s)
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a) Will each fellow demonstrate, to a faculty observer, the ability to conduct a complete mental
status examination on five patients? [PR IV.A.5.a).(1).(c).(ii).(b)]............................ ☐ YES ☐ NO
Medical Knowledge
Indicate the activities (lectures, conferences, journal clubs, clinical teaching rounds, etc.) in which
residents will demonstrate knowledge of the following areas. Also indicate the method(s) that will be
used to assess resident knowledge in each area.
Area of Knowledge
Settings/Activities
Assessment of Pain [PR IV.A.5.b).(1)]
Anatomy, physiology and
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pharmacology of pain
transmission and modulation
natural history of various
musculoskeletal pain
disorders
[PR IV.A.5.b).(1).(a)]
Natural history of various
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musculoskeletal pain
disorders
[PR IV.A.5.b).(1).(b)]
General principles of pain
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evaluation and management
including neurological exam,
musculoskeletal exam,
psychological assessment
[PR IV.A.5.b).(1).(c)]
Indicators and interpretation Click here to enter text.
of electro-diagnostic studies:
X-Rays, MRI, CT, and clinical
nerve function studies
[PR IV.A.5.b).(1).(d)]
Pain measurement in
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humans, both experimental
and clinical
[PR IV.A.5.b).(1).(e)]
Psychosocial aspects of pain, Click here to enter text.
Pain Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Assessment Method(s)
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Area of Knowledge
including cultural and crosscultural considerations
[PR IV.A.5.b).(1).(f)]
Taxonomy of pain syndromes
[PR IV.A.5.b).(1).(g)]
Pain of spinal origin, including
radicular pain, zygapophysial
joint disease, and discogenic
pain
[PR IV.A.5.b).(1).(h)]
Myofascial pain
[PR IV.A.5.b).(1).(i)]
Neuropathic pain
[PR IV.A.5.b).(1).(j)]
Headache and orofacial pain
[PR IV.A.5.b).(1).(k)]
Rheumatological aspects of
pain
[PR IV.A.5.b).(1).(l)]
Complex regional pain
syndromes
[PR IV.A.5.b).(1).(m)]
Visceral pain
[PR IV.A.5.b).(1).(n)]
Urogenital pain
[PR IV.A.5.b).(1).(o)]
Cancer pain, including
palliative and hospice care
[PR IV.A.5.b).(1).(p)]
Acute pain
[PR IV.A.5.b).(1).(q)]
Frequent psychiatric and pain
co-morbidities, which include
substance-related mood,
anxiety, somatoform,
factitious, and personality
disorders
[PR IV.A.5.b).(1).(r)]
The effects of pain
medications on mental status
[PR IV.A.5.b).(1).(s)]
Assessment of pain in special
populations, including
patients with ongoing
substance abuse, the elderly,
pediatric patients, pregnant
women, the physically
disabled, and the cognitively
impaired
[PR IV.A.5.b).(1).(t)]
Settings/Activities
Assessment Method(s)
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Pain Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
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Area of Knowledge
Settings/Activities
Functional and disability
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assessment
[PR IV.A.5.b).(1).(u)]
Treatment of pain [PR IV.A.5.b).(2)]
Drug Treatment I: opioids
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[PR IV.A.5.b).(2).(a)]
Drug Treatment II: antipyretic Click here to enter text.
analgesics
[PR IV.A.5.b).(2).(b)
Drug Treatment III:
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antidepressants,
anticonvulsants, and
miscellaneous drugs
[PR IV.A.5.b).(2).(c)
Psychological and psychiatric Click here to enter text.
approaches to treatment,
including cognitive-behavioral
therapy, psychosocial
therapies and treatment of
psychiatric illness
[PR IV.A.5.b).(2).(d)
Prescription drug
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detoxification concepts
[PR IV.A.5.b).(2).(e)
Functional and vocational
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rehabilitation
[PR IV.A.5.b).(2).(f)
Surgical approaches
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[PR IV.A.5.b).(2).(g)
Complementary and
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alternative treatments in pain
management
[PR IV.A.5.b).(2).(h)
Treatments that comprise
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multidisciplinary cancer pain
care
[PR IV.A.5.b).(2).(i)
Strategies to integrate pain
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management into the
treatment model
[PR IV.A.5.b).(2).(j)
Hospice and
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multidimensional treatments
that comprise palliative care
[PR IV.A.5.b).(2).(k)
Treatment of pain in pediatric Click here to enter text.
patients
[PR IV.A.5.b).(2).(l)
General topics, research, and ethics, including: [PR IV.A.5.b).(3)]
Epidemiology of pain
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Pain Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Assessment Method(s)
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Area of Knowledge
Settings/Activities
[PR IV.A.5.b).(3).(a)]
Gender issues in pain
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[PR IV.A.5.b).(3).(b)]
Placebo response
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[PR IV.A.5.b).(3).(c)]
Multidisciplinary pain
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medicine
[PR IV.A.5.b).(3).(d)]
Organization and
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management of a pain center
[PR IV.A.5.b).(3).(e)]
Continuing quality
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improvement, utilization
review, and program
evaluation
[PR IV.A.5.b).(3).(f)]
Patient and provider safety
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[PR IV.A.5.b).(3).(g)]
Designing, reporting, and
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interpreting clinical trials of
treatment for pain
[PR IV.A.5.b).(3).(h)]
Ethical standards in pain
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management and research
[PR IV.A.5.b).(3).(i)]
Animal models of pain, ethics Click here to enter text.
of animal experimentation
[PR IV.A.5.b).(3).(j)]
Interventional pain treatment, including: [PR IV.A.5.b).(4)]
Selection criteria for a broad Click here to enter text.
range of interventions and an
understanding of the risks
and potential advantages of
these interventions
[PR IV.A.5.a).(4).(a)]
Airway management skills
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[PR IV.A.5.a).(4).(b)]
Sedation/analgesia
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[PR IV.A.5.a).(4).(c)]
Fluoroscopic imaging and
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radiation safety
[PR IV.A.5.a).(4).(d)]
Pharmacology of local
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anesthetics and other
injectable medications,
including radiographic
contrast agents and steroid
preparations
[PR IV.A.5.a).(4).(e)]
Pain Medicine
©2015 Accreditation Council for Graduate Medical Education (ACGME)
Assessment Method(s)
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Area of Knowledge
Treatment of local
anesthetic systemic
toxicity
[PR IV.A.5.a).(4).(e).(i)]
Trigger point injections
[PR IV.A.5.a).(4).(f)]
Peripheral and cranial nerve
blocks and ablation
[PR IV.A.5.a).(4).(g)]
Spinal injections including
epidural injections:
interlaminar, transforaminal,
nerve root sheath injections,
and zygapophysial joint
injections
[PR IV.A.5.a).(4).(h)]
Discography and
intradiscal/percutaneous disc
treatments
[PR IV.A.5.a).(4).(i)]
Joint and bursal injections,
including sacroiliac, hip,
knee, and shoulder joint
injections
[PR IV.A.5.a).(4).(j)]
Sympathetic ganglion blocks
[PR IV.A.5.a).(4).(k)]
Epidural and intrathecal
medication management
[PR IV.A.5.a).(4).(l)]
Spinal cord stimulation
[PR IV.A.5.a).(4).(m)]
Intrathecal drug
administration systems
[PR IV.A.5.a).(4).(n)]
Settings/Activities
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Assessment Method(s)
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Practice-based Learning and Improvement
1. Briefly describe one learning activity in which fellows demonstrate the ability to investigate and
evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously
improve patient care based on constant self-evaluation and life-long learning. [PR IV.A.5.c)] (Limit
response to 400 words)
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2. Briefly describe one planned learning activity in which fellows engage to identify strengths,
deficiencies, and limits in their knowledge and expertise (self-reflection and self-assessment); set
learning and improvement goals; and identify and perform appropriate learning activities to achieve
self-identified goals (life-long learning). [PR IV.A.5.c).(1)-(3)] (Limit response to 400 words)
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©2015 Accreditation Council for Graduate Medical Education (ACGME)
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3. Briefly describe one planned quality improvement activity or project that will allow fellows to
demonstrate the ability to analyze, improve, and change practice or patient care. Describe planning,
implementation, evaluation, and provisions of faculty member support and supervision that will
guide this process. [PR IV.A.5.c).(4)] (Limit response to 400 words)
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4. Briefly describe how fellows will receive and incorporate formative evaluation feedback into daily
practice. (If a specific tool is used to evaluate these skills have it available for review by the site
visitor.) [PR IV.A.5.c).(5)] (Limit response to 400 words)
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5. Briefly describe one example of a learning activity in which fellows engage to develop the skills
needed to use information technology to locate, appraise, and assimilate evidence from scientific
studies and apply it to their patients' health problems. [PR IV.A.5.c).(6)-(7)] (Limit response to 400
words)
The description should include:
 Locating information
 Using information technology
 Appraising information
 Assimilating evidence information (from scientific studies)
 Applying information to patient care
 Conducting a comprehensive literature search
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6. Briefly describe how fellows will participate in the education of patients, families, students,
residents, and other health professionals. [PR IV.A.5.c).(8)] (Limit response to 400 words)
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Interpersonal and Communication Skills
1. Briefly describe one learning activity in which fellows develop competence in communicating
effectively with patients and families across a broad range of socioeconomic and cultural
backgrounds, and with physicians, other health professionals, and health-related agencies. [PR
IV.A.5.d).(1)-(2)] (Limit response to 400 words)
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2. Briefly describe one learning activity in which fellows develop their skills and habits to work
effectively as members or leaders of a health care team or other professional group. In the
example, identify the members of the team, responsibilities of the team members, and how team
members communicate to accomplish responsibilities. [PR IV.A.5.d).(3)] (Limit response to 400
words)
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3. Briefly describe how fellows will be provided with opportunities to act in a consultative role to other
physicians and health professionals related to clinical information systems. [PR IV.A.5.d).(4)] (Limit
response to 400 words)
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4. Briefly describe how fellows will be provided with opportunities to maintain comprehensive, timely,
and legible medical records, if applicable. [PR IV.A.5.d).(5)] (Limit response to 400 words)
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Professionalism
Briefly describe the learning activity(ies), other than lecture, by which fellows demonstrate a
commitment to carrying out professional responsibilities and an adherence to ethical principles,
including: compassion, integrity, and respect for others; responsiveness to patient needs that
supersedes self-interest; respect for patient privacy and autonomy; accountability to patients, society,
and the profession; and sensitivity and responsiveness to a diverse patient population, including to
diversity in gender, age, culture, race, religion, disabilities, and sexual orientation. [PR IV.A.5.e).(1)-(5)]
(Limit response to 400 words)
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Systems-based Practice
1. Briefly describe the learning activity(ies) through which fellows demonstrate an awareness of and
responsiveness to the larger context and system of health care, as well as the ability to call
effectively on other resources in the system to provide optimal health care. [PR IV.A.5.f)] (Limit
response to 400 words)
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2. Briefly describe the learning activity(ies) through which fellows achieve competence in the elements
of systems-based practice: working effectively in various health care delivery settings and systems,
coordinating patient care within the health care system; incorporating considerations of costcontainment and risk-benefit analysis in patient care; advocating for quality patient care and optimal
patient care systems; and working in interprofessional teams to enhance patient safety and care
quality. [PR IV.A.5.f).(1)-(5)] (Limit response to 400 words)
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3. Briefly describe an activity that fulfills the requirement for experiential learning in identifying system
errors and implementing potential systems solutions. [PR IV.A.5.f).(6)] (Limit response to 400
words)
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Curriculum Organization and Fellow Experiences
Clinical Experience: Indicate whether clinical experiences will be provided in each of the specified
areas:
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List all sites that apply
Outpatient (Continuity Clinic)
Site #
#
Y
☐
N
☐
Will fellows attend a supervised outpatient clinic, approximately weekly, for a
minimum of eight months (60 days FTE)? (50 different patients per fellow,
followed over at least two months, for whom the fellow has primary
responsibility) [PR IV.A.6.b).(1).(a)-(b)]
Inpatient (Chronic Pain)
#
☐
☐
Will fellows be provided supervised experience on a pain team responsible for
assessment and management of inpatients with chronic pain, including cancer
pain? (15 new patients assessed in this setting) [PR IV.A.6.b).(2).(a)-(b)]
Acute Pain (Inpatient)
#
☐
☐
Will fellows be provided a supervised experience in the assessment and
management of a minimum of 50 new patients with acute pain? [PR
IV.A.6.b).(3).(a)-(b)]
Interventional
#
☐
☐
Will the program provide a supervised experience with a minimum of 60
patients who undergo interventional procedures? [PR IV.A.6.b).(4).(b)]
Cancer
#
☐
☐
Will the program provide a supervised longitudinal experience for an
ambulatory or inpatient population who require care for cancer pain?
(20 patients) [PR IV.A.6.b).(5).(a)-(a).(i)]
Palliative Care
#
☐
☐
Will the program provide a supervised longitudinal experience in an
ambulatory or inpatient population that requires palliative care?
(10 patients) [PR IV.A.6.b).(6).(a)-(b)]
Pediatric
#
☐
☐
Will the fellows be provided experience with the assessment and treatment of
pain in children? [PR IV.A.6.b).(7).(a)]
If the program elects to offer a track in advanced interventional pain medicine, briefly describe both
didactic and clinical experiences that will be offered. (Limit response to 400 words)
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FELLOW FORMATIVE EVALUATION
Describe the CQI program that will be provided during the 12-month program. Will fellows regularly
participate in quality assurance activities? [PR V.A.2.d)]
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FELLOW DUTY HOURS IN THE LEARNING AND WORKING ENVIRONMENT - MAXIMUM DUTY PERIOD LENGTH
Explain how the program will ensure continuity of care experiences for fellows during 24-hour call
assignments. Include information as to the level of responsibility expected of fellows on call. [PR
VI.G.4.b).(4)]
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©2015 Accreditation Council for Graduate Medical Education (ACGME)
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