Emerging subspecialties in neurology: Pain medicine.

Traditionally neurologists have been considered masterful diagnosticians. Fellow physicians often rely on neurologists to sort out complex historical and examination data in order to arrive at a diagnosis and plan of action. Our specialty is also known for its expertise in the continuing longitudinal care of patients with serious illnesses that impact social and occupational function. Several neurologic diseases result in chronic pain, e.g., stroke, multiple sclerosis, and radiculopathy. For these reasons, neurologists are well suited to the practice of pain medicine. One of the first US neurologists to contribute to pain medicine was Silas Weir Mitchell. In Injuries of Nerves and Their Consequences, he gave detailed case descriptions of causalgia (complex regional pain syndrome) and phantom limb pain. Subsequently, the concept of multidisciplinary pain management was pioneered by John Bonica, who founded the first interdisciplinary pain clinic in 1947 at Tacoma General Hospital. Currently, the practice of pain medicine involves physicians from multiple specialties including physiatry, psychiatry, anesthesiology, neurosurgery, and neurology. In a survey of practicing US neurologists, 77.4% of respondents reported that they manage patients with chronic headache, whereas 47.6% cared for patients with chronic spine and limb pain.1 Other painful conditions that are seen by neurologists include neuropathy, failed back syndromes, radiculopathy, and postherpetic neuralgia.2,3 Neuropathic pain syndromes affect more than 3 million Americans4 and migraine headaches affect 15% of the US population.5 Despite the large number of patients who neurologists see with pain-related complaints, data suggest that there is considerable room for improvement in pain-related training during residency and beyond. Galer et al. conducted a survey of practicing neurologists and neurology program directors. Thirty percent of respondents reported that they were adequately trained to diagnose pain-related disorders; only 20% felt adequately trained to treat these conditions. A large majority (89%) stated the need for more painrelated training during residency and 91% wanted more pain education for practicing neurologists. Interestingly, neurology program directors rated pain medicine seventh in importance of eight neurology subspecialties. Only 29% of neurology programs had a pain specialist on faculty and 5% had a mandatory pain clinic rotation, reflecting a current paucity of pain education in neurology residency programs.6 As a first step to rectify this situation, the American Academy of Neurology published a pain medicine core curriculum for neurology residents in 2001 (http://www.aan. com/about/sections/residency/pain. pdf). This document clearly documents educational objectives for residents based on their level of training. Pain medicine was recognized in 1998 by the American Board of Medical Specialties (ABMS) as a neurologic subspecialty. The first pain medicine certification examination was given by the American Board of Psychiatry and Neurology (ABPN) in 2000. There are currently four approved pain medicine fellowship programs listed on the Accreditation Council on Graduate Medical Education (ACGME) Web site (www.acgme. org), while 18 neurologists were certified in pain medicine in 2005 (www.abpn.org). Other specialties with accredited pain medicine fellowships include anesthesiology (90 programs), physical medicine and rehabilitation (11 programs), and psychiatry (1 program). The ACGME has uniform accreditation criteria for all pain fellow-