The Duke Regional Anesthesiology and Acute Pain Medicine (RAAPM) Fellowship is a one-year formal structured PGY-5 fellowship designed to prepare trainees for a role as leaders in academic regional anesthesiology and acute pain medicine. Trainees are expected to demonstrate progressive autonomy in the performance of these skills and competencies throughout the year. Where practical, the goals and objectives are stratified into basic and advanced levels, and trainees are expected to have demonstrated competency and completion of the basic set of these by the 6-month point in the fellowship. Advanced level skills and competencies may be achieved at any point but should be mastered by the completion of the fellowship.

The Chronic Pain/Block/OR rotation is a hybrid rotation that combines a two-week experience in chronic pain management with two-weeks caring for patients in the operating room/block room setting. The goals and objectives for the operating room/block room portion are identical to those listed in the “Block/OR” section below.

The goals and objectives specific to the chronic pain two-week rotation are as follows:

Medical Knowledge
Upon completion of the program, the fellow should be able to: 

1. Explain the IASP definition of pain and be able to define the following commonly utilized terms: allodynia, analgesia, dysesthesia, hyperalgesia, hyperesthesia, paresthesia, pain threshold, and pain tolerance [ADVANCED]
2. Demonstrate a basic knowledge and understanding of anatomy and pathophysiology of pain mechanisms [ADVANCED]
3. Describe the mechanisms and effect of inhibitory modulatory pathways on pain transmission [ADVANCED]
4. Differentiate between somatic, visceral, and neuropathic pain and treatment pathways [ADVANCED]
5. Demonstrate understanding of the W.H.O. step ladder approach to pain management [ADVANCED]
6. Recognize psychological and social effects of chronic pain [ADVANCED]
7. Understand the principles and indications of diagnostic testing for patients with chronic pain [ADVANCED]
8. Describe psychotherapeutic treatment principles, rehabilitation and team management in the setting of the inpatient with chronic pain [ADVANCED]
9. Understand the basic principles of cancer pain management [ADVANCED]
10. Discuss the pathophysiology, presentation and treatment options for a variety of non-cancer pain syndromes including: [ADVANCED]
    1. Low back pain
    2. Myofascial pain
    3. Complex regional pain syndromes I & II
    4. Fibromyalgia
    5. Facet arthropathy
    6. Acute herpes zoster
    7. Post-herpetic neuralgia
    8. Chronic/persistent post-surgical pain including post-thoracotomy pain and post-mastectomy pain [ADVANCED]
11. Discuss the difference between tolerance, physical dependence, and addiction [ADVANCED]
12. Understand the principles of transcutaneous electrical nerve stimulation (TENS) and acupuncture [ADVANCED]
13. Understand the basic principles and perioperative management of the patient who has a spinal cord stimulator or intrathecal drug delivery device. [ADVANCED]
14. Describe the biopsychosocial theory of chronic pain and explain the importance of this in the management of the chronic pain patient [ADVANCED]
15. Describe the rational management of opioid medications including the conversion between agents and the principles of opioid weaning [ADVANCED]
16. Describe the use of screening tools for opioid prescribing [ADVANCED]

Patient Care
Upon completion of the program, the fellow should be able to:

1. Demonstrate management of patients at the level of a consultant whose diagnoses require consultation of the Chronic Pain Management Service. [ADVANCED]
2. Demonstrate skill in the administration and coordination of multimodal analgesic regimens to include such techniques as neuraxial and peripheral nerve catheters, local anesthetic and narcotic infusions, and non-narcotic analgesic adjuvants. [ADVANCED]
3. Conduct appropriate follow-up on his/her chronic pain patients in order to assess the effectiveness of the pain management strategy, and be able to appropriately respond to changes in the pain condition with rational selection of additional adjuvant therapies [ADVANCED]
4. Demonstrate rational selection of regional analgesia for specific clinical situations. [BASIC]
5. Demonstrate skill and knowledge related to the daily management of epidural and perineural catheters including dosing of medications, evaluation of proper dose and rate of infusion medications, and timing of catheter removal.
6. Recognize and intervene to manage inadequate regional analgesic techniques with supplemental blockade or alternate anesthetic approaches. [ADVANCED]
7. Develop administrative skills as they relate to managing a team of trainees, mid-level providers and advanced practice nurses. Fellows will be expected to make triage decisions and allocation of team members as appropriate for consultations, procedures, and follow-up visits. [ADVANCED]

Practice-Based Learning/Scholarship/Teaching
Upon completion of the program, the fellow should be able to:

1. Explain the value of the ASA Guidelines for Acute Pain Management
2. Evaluate and apply evidence from scientific studies, expert guidelines, and practice pathways. [BASIC]
3. Use information technology to obtain and record patient information, access institutional and national policies and guidelines, and participate in self-education. [BASIC]
4. Evaluate own practice with respect to patient outcomes (esp. success and complications from regional block) and compare to available literature. [ADVANCED]
5. Identify strengths, deficiencies, and limits in knowledge and expertise [ADVANCED]
6. Set learning and practice improvement goals [BASIC]
7. Identify and perform appropriate learning activities, including didactic lectures and hands-on demonstrations that promulgate safety [BASIC]
8. Incorporate formative evaluation feedback into daily practice [ADVANCED]
9. Develop teaching techniques by instructing residents and nurse practitioners at the bedside under the supervision of faculty. [ADVANCED]

Interpersonal and Communication Skills
Upon completion of the program, the fellow should be able to:

1. Provide information to the patient and family with respect to the options, alternatives, risks and benefits of the chronic pain management plan in a manner that is clear, understandable, ethical, and appropriate. [BASIC]
2. Employ effective listening skills and answer questions appropriately in the process of obtaining informed consent. [BASIC]
3. Work effectively in a team environment, communicating and cooperating with surgeons, nurses, pharmacists, physical therapists, and other members of the perioperative team. This requires the fellow to:
   1. Appreciate the roles of other members of the team [BASIC]
   2. Communicate clearly in a collegial manner that facilitates the achievement of care goals. [BASIC]
   3. Help other members of the team to enhance the sharing of information. [BASIC]
   4. Formulate care plans that utilize multidisciplinary team skills such as a plan for facilitated recovery (i.e., ERAS, etc.) [ADVANCED]

Professionalism
Upon completion of the program, the fellow should be able to:

1. Respond to pages promptly and professionally; be punctual and reliable; adhere to departmental and university policies and procedures; exhibit integrity in record keeping and medical records [BASIC]
2. Demonstrate respect, compassion, and responsiveness to patients’ needs and concerns [BASIC]
3. Demonstrate independence and initiative befitting a consultant subspecialty physician [ADVANCED]
4. Continuously conduct the practice of medicine with integrity, honesty, and accountability. [BASIC]
5. Demonstrate a commitment to lifelong learning and excellence in clinical practice. [BASIC]
6. Demonstrate a commitment to the fellowship by striving for excellence in clinical and scholarly endeavors [BASIC]
7. Demonstrate consistent subjugation of self-interest to the good of the patient and the health care needs of society. [BASIC]
8. Demonstrate a commitment to ethical principles in providing care, obtaining informed consent, and maintaining patient confidentiality. [BASIC]

Systems-Based Practice
Upon completion of the program, the fellow should be able to:

1. Work effectively in a consultant physician role within the framework of the interprofessional clinical team, including surgeons, nurses, nurse practitioners, physical therapists and other anesthesiology trainees to enhance patient safety and improve quality [BASIC]
2. Participate in identifying system errors and implementing potential systems solutions [ADVANCED]
3. Understand the interaction of the chronic pain medicine consultant team with other elements of the health care system including primary surgical and medical teams, other consultant services, nursing, pharmacy, and physical therapy. [ADVANCED]
4. Demonstrate awareness of health care costs and resource allocation, and the impact of their choices on those costs and resources. [ADVANCED]

The Duke Regional Anesthesiology and Acute Pain Medicine (RAAPM) Fellowship is a one-year formal structured PGY-5 fellowship designed to prepare trainees for a role as leaders in academic regional anesthesiology and acute pain medicine. Trainees are expected to demonstrate progressive autonomy in the performance of these skills and competencies throughout the year. Where practical, the goals and objectives are stratified into basic and advanced levels, and trainees are expected to have demonstrated competency and completion of the basic set of these by the six-month point in the fellowship. Advanced level skills and competencies may be achieved at any point but should be mastered by the completion of the fellowship.

Medical Knowledge
Upon completion of the program, the fellow should be able to:

1. Match specific patient and surgical procedure requirements to an appropriate regional anesthesia selection using sound clinical judgment. Debate the advantages/disadvantages of regional vs. general anesthesia for various procedures and patients regarding patient recovery, patient outcome, operating room efficiency, and cost of care. [BASIC]
2. Perform a preoperative evaluation and optimization of clinical status; perform a detailed neurologic history and physical exam with particular attention to pre-existing neurologic deficits and their impact on the anesthetic plan. [BASIC]
3. Use evidence-based medicine to select local anesthetics and adjuncts for neural blockade. [BASIC]
4. Local Anesthetics:
   1. Understand and explain the pharmacokinetics of local anesthetics: absorption, distribution, metabolism, and excretion. [BASIC]
   2. Understand and explain the mechanism of action of local anesthetics. [BASIC]
   3. Understand and explain structure of amino-amides and amino-esters. [BASIC]
   4. Understand and explain the minimum effective concentration of local anesthetic. [BASIC]
   5. Understand and explain effective concentrations, toxic dosage, influence of site of injection, and vasoconstrictor use regarding clinical practice. [BASIC]
   6. Compare attributes of various local anesthetics: motor vs. sensory blocking discrimination and relative toxicity. [BASIC]
   7. Understand and explain lipid solubility, protein binding, pKa and their influence on onset, potency, and duration of block. [BASIC]
   8. Describe signs, symptoms, and treatment of local anesthetic toxicity. [BASIC]
5. Make sound clinical decisions regarding the administration of systemic and neuraxial opioids, NSAIDs, gabapentinoids, ketamine, and other non-opioid adjuncts for analgesia. [BASIC]
6. Skillfully and efficiently describe and perform a wide variety of modern regional anesthesia techniques including single-shot and continuous peripheral nerve block, spinal and combined spinal- epidural anesthesia, thoracic epidural, and nerve stimulator- and ultrasound-guided approaches (See detailed list below). [ADVANCED]
7. Describe the use of spinal anesthesia, including:
   1. Understand and explain the cardiovascular and pulmonary physiologic effects of spinal anesthesia. [BASIC]
   2. Understand and explain local anesthetics for intrathecal use: agents, dosage, surgical, and total duration of action, as well as adjuvants commonly employed in neuraxial techniques. [BASIC]
   3. Describe baricity of spinal local anesthetic solutions and how to utilize its influence on block level for a variety of surgical procedures. [ADVANCED]
   4. Describe the indications and contraindications for spinal anesthesia. [BASIC]
   5. Understand and explain side effects of agents and complications and management of inadequate anesthesia, hypotension, and ventilatory insufficiency. [BASIC]
   6. Define post-dural puncture headache and describe symptoms, etiology, natural history of the disorder, and risk factors and management strategies. [ADVANCED]
   7. Understand and explain the use of spinal anesthesia in an ambulatory surgery setting. [BASIC]
   8. Explain the relative importance of factors affecting intensity, extent, and duration of block such as dose, volume, and baricity of injectate. [BASIC]
   9. Describe differential blockade during neuraxial blockade. [BASIC]
   10. Describe advantages and disadvantages of continuous spinal anesthesia [ADVANCED]
8. Describe the use of epidural anesthesia, including:
   1. Understand and explain the physiology of epidural anesthesia. [BASIC]
   2. Describe the contents of the epidural space. [BASIC]
   3. Understand and explain the local anesthetics available for epidural use: agents, dosage, adjuncts, and duration of action. [BASIC]
   4. Differentiate between spinal and epidural anesthesia with regard to reliability, latency, duration, and segmental limitations. [ADVANCED]
   5. Describe the indications and contraindications for epidural anesthesia. [BASIC]
   6. Understand and explain side effects, complications and management of inadequate anesthesia, hypotension, total spinal, accidental dural puncture, systemic toxicity, and the use of appropriate test dosing to minimize some of these complications. [BASIC]
   7. Describe the volume-segment relationship and the effect of patient age, pregnancy, position, and site of injection on resultant block. [ADVANCED]
   8. Understand and explain combined spinal-epidural anesthesia as distinguished from lumbar epidural anesthesia, including advantages/disadvantages, dose requirements, complications, indications and contraindications. [ADVANCED]
   9. Understand and explain caudal epidural and thoracic epidural anesthesia as distinguished from lumbar epidural anesthesia, including advantages/disadvantages, dose requirements, complications, indications and contraindications. [ADVANCED]
9. Describe the use of various nerve localization techniques, including:
   1. Understand principles, operation, advantages, and limitations of peripheral nerve stimulation to identify and anesthetize peripheral nerves. [BASIC]
   2. Principles of paresthesia-seeking, perivascular, or transvascular approaches to nerve localization. [BASIC]
   3. Understand principles, operation, advantages, and limitations of ultrasound to identify and anesthetize peripheral nerves. Subcategories of knowledge in ultrasound include:
      1. Applied anatomical principles to nerve block procedures [BASIC]

9. 1. 2. Physics and technical aspects of image generation [BASIC]
      3. Machine controls for image optimization [BASIC]
      4. Transducer manipulation for image optimization [BASIC]
      5. Sonoanatomic appearance of nerves and other tissues [ADVANCED]
      6. Needle guidance approaches [ADVANCED]
      7. Injectate appearance and optimization [BASIC]
10. Describe the theory and techniques for upper extremity nerve block, including:
    1. Describe the anatomy of the brachial plexus in relation to sensory and motor innervation. [BASIC]
    2. Understand and explain local anesthetics for brachial plexus block: agents, dosage, duration of action, and adjuvants. [BASIC]
    3. Understand and explain side effects, complications, and management: inadequate anesthesia, systemic toxicity, blockade of adjacent neural structures (phrenic, sympathetic chain and neuraxis), neuropathy, neuropraxia. [ADVANCED]
    4. Describe the various approaches to brachial plexus blockade, along with the indications/contraindications, advantages/disadvantages, and complications specific to each. [ADVANCED]
    5. Describe peripheral nerve block in the upper extremity of the median, ulnar and radial nerves, with indications, contraindications, and complications. [BASIC]
    6. Understand and explain the use and advantages/disadvantages of nerve localizing techniques including transarterial, perivascular, nerve stimulator, and paresthesia-seeking techniques. [ADVANCED]
    7. Understand and explain the use and advantages/disadvantages specific to continuous brachial plexus anesthesia and analgesia. [ADVANCED]
    8. Describe clinical implications of each individual nerve or plexus blockade specific to surgical procedure types, implications for intraoperative care, and postoperative recovery needs and how these differ from the patient undergoing similar procedures without regional techniques. [ADVANCED]
11. Describe the theory and techniques for lower extremity nerve block, including:
    1. Describe anatomy of the lower extremity: sciatic, femoral, lateral femoral cutaneous, obturator nerves in relation to sensory and motor innervation. [BASIC]
    2. Understand and explain local anesthetics for lower extremity block: agents, dosage, duration of action, and adjuvants. [BASIC]
    3. Describe the various approaches to lower extremity blockade, along with the indications/contraindications, advantages/disadvantages, and complications specific to each. [ADVANCED]
    4. Understand and explain side effects, complications, and management of lower extremity blockade: inadequate analgesia, systemic toxicity, blockade of adjacent neural structures, and post-operative neuropathy. [ADVANCED]
    5. Differentiate individual blockade of the femoral, lateral femoral cutaneous, and obturator nerves from the anterior and posterior approaches to the lumbar plexus. [BASIC]
    6. Differentiate individual blockade of the tibial and peroneal nerves from the classic and popliteal approaches to the sciatic nerve. [BASIC]
    7. Describe clinical implications of each individual nerve or plexus blockade specific to surgical procedure types, implications for intraoperative care, and postoperative recovery needs and how these differ from the patient undergoing similar procedures without regional techniques. [ADVANCED]
12. Describe the theory and techniques for truncal blockade, including:
    1. Understand and explain the anatomy of intercostal, paravertebral, rectus sheath, quadratus lumborum, ilioinguinal/iliohypogastric, pectoralis, serratus, erector spinae plane (ESP) and transversus abdominus plane (TAP) blockade. [ADVANCED]
    2. Understand and explain local anesthetics for truncal blockade: agents, dosage, and duration of action. [BASIC]
    3. Understand and explain the indications and contraindications for truncal blockade. [ADVANCED]
    4. Understand and explain the side effects, complications, and management: inadequate anesthesia, systemic toxicity, and pneumothorax. [ADVANCED]
    5. Describe clinical implications of each individual nerve or plexus blockade specific to surgical procedure types, implications for intraoperative care, and postoperative recovery needs and how these differ from the patient undergoing similar procedures without regional techniques. [ADVANCED]
13. Describe the theory and techniques for Intravenous Regional Anesthesia (IVRA), including:
    1. Understand and explain the mechanism of action of IVRA. [BASIC]
    2. Understand and explain agents for IVRA: local anesthetic choice, dosage, and use of adjuvants. [BASIC]
    3. Describe the indications and contraindications, advantages and disadvantages of IVRA. [BASIC]
    4. Understand and explain the complications and management: systemic toxicity, inadequate anesthesia, and phlebitis. [BASIC]
14. Complications of regional anesthesiology and acute pain medicine including the diagnosis and management of:
    1. hemorrhagic complications [BASIC]
    2. infectious complications [BASIC]
    3. neurologic complications
       1. This knowledge must include the interpretation of tests recommended following plexus/nerve injury, including electromyography, nerve conduction studies, somatosensory evoked potentials, and motor evoked potentials [ADVANCED]
    4. complications due to medicines, including local anesthetic systemic toxicity and opioid-induced respiratory depression [BASIC]
    5. other complications including pneumothorax [BASIC]
15. Describe the use of non-opioid adjuncts, including:
    1. Describe the concept of multimodal analgesia and its impact on functional restoration after surgery. [BASIC]
    2. Understand and explain the pharmacology of acetaminophen, NSAIDs, COX-2 inhibitors, NMDA antagonists, alpha-2 agonists, and gabapentinoid agents with respect to optimizing postoperative analgesia. [BASIC]

Patient Care
Upon completion of the program, the fellow should be able to:

1. Demonstrate rational selection of regional anesthesia for specific clinical situations [BASIC]
2. Recognize and intervene to manage inadequate regional anesthetic techniques with supplemental blockade or alternate anesthetic approaches. [ADVANCED]
3. Properly prepare to manage rare but serious complications of regional anesthesia including local anesthetic toxicity and total spinal anesthesia. [ADVANCED]
4. Conduct appropriate follow-up on his/her block patients to assess outcomes of regional anesthesia and analgesia procedures. This includes evaluating patients immediately post-block, post-surgery, and POD #1. [BASIC]
5. Properly perform and teach correct technique for many of the following listed regional blocks to achieve a high success and low complication rate. The demonstration of capabilities in the education of junior trainees is part of what is felt to distinguish a clinician expert.
   1. Basic Techniques and Approaches: [BASIC]
      1. Superficial cervical plexus block
      2. Axillary brachial plexus block
      3. Intercostobrachial nerve block
      4. Wrist Block
      5. Intravenous regional anesthesia (Bier block)
      6. Saphenous/adductor canal nerve block
      7. Ankle block
      8. Spinal anesthesia
      9. Lumbar epidural anesthesia
      10. Thoracic epidural anesthesia
      11. Combined spinal-epidural anesthesia
      12. Femoral nerve block
      13. Interscalene block
      14. Supraclavicular block
      15. Infraclavicular block
      16. Erector spinae plane (ESP) block
      17. Popliteal block
   2. Advanced Techniques and Approaches: [ADVANCED]
      1. Pectoralis 1 and 2 blocks, Serratus plane block
      2. Sciatic nerve block: posterior approaches
      3. Suprascapular nerve block
      4. Intercostal nerve block
      5. Lumbar plexus block
      6. Continuous interscalene block
      7. Continuous infraclavicular block
      8. Continuous axillary block
      9. Thoraco-lumbar paravertebral block: single or continuous
      10. Continuous femoral nerve block
      11. Continuous adductor canal block
      12. Obturator nerve block
      13. Continuous sciatic nerve block
      14. Continuous popliteal block: all approaches
      15. Quadratus lumborum (QL) block

Practice-Based Learning/Scholarship/Teaching
Upon completion of the program, the fellow should be able to:

1. Evaluate and apply evidence from scientific studies, expert guidelines, and practice pathways. [BASIC]
2. Use information technology to obtain and record patient information, access institutional and national policies and guidelines, and participate in self-education. [BASIC]
3. Evaluate own practice with respect to patient outcomes (esp. success and complications from regional block) and compare to available literature. [ADVANCED]
4. Identify strengths, deficiencies, and limits in knowledge and expertise [ADVANCED]
5. Set learning and practice improvement goals [BASIC]
6. Identify and perform appropriate learning activities, including didactic lectures and hands-on demonstrations that promulgate safety [BASIC]
7. Incorporate formative evaluation feedback into daily practice [ADVANCED]
8. Participate actively in clinical research as a major activity of the year-long fellowship. This includes completing the appropriate Deduce training, Redcap training, eIRB training. [ADVANCED]
9. Understand the process of generating a research question, developing a hypothesis, and developing a methodology by which to test that hypothesis. [BASIC]
10. Understand basic statistics and how to generate a sample size calculation as well as powering a study to an appropriate primary outcome measure [BASIC]
11. Be able to successfully navigate the eIRB portal and submit a protocol for approval by the IRB. [BASIC]
12. Have a publication accepted to a journal, or have a manuscript in preparation for submission [ADVANCED]
13. Expect to guest review manuscripts and/or book chapters for the faculty who serve as editors of peer-reviewed journals to gain knowledge of manuscript preparation, when possible. [ADVANCED]
14. Expect to receive mentorship and commitment from the core faculty to help in the production of research, co-author papers as appropriate, and preparation of clinical research proposals with IRB approval prior to the start of the fellowship year. [BASIC]
15. Present a scientific presentation at either Triangle Regional Night or at Anesthesiology Grand Rounds, covering a topic or case relevant to RAAPM. [ADVANCED]
16. Present original, self-generated research/scholarship at the annual Duke Academic Evening in May. [ADVANCED]
17. Review and select articles for monthly journal club and moderate each monthly journal club session [BASIC]
18. Attend every Tuesday afternoon RAAPM fellowship session unless on vacation. Session locations, topics and faculty leads will be published ahead of time. [BASIC]
19. Attend at least 60% of the Thursday afternoon Departmental Fellow lectures [BASIC]
20. Participate in and teach portions of the fresh cadaver anatomy labs organized within the division as external preceptorships. [ADVANCED]
21. Participate in the Annual American Society of Regional Anesthesia and Pain Medicine Meeting (or other similar scientific meeting) with poster, lecture, or problem-based learning presentations where possible. [ADVANCED]
22. Develop teaching techniques by instructing residents at the bedside in the preoperative block area under the supervision of faculty. [ADVANCED]
23. Be responsible for giving a "nuts and bolts" presentation on the first day of each CA-2/ CA-3 resident regional rotation, and ensuring new rotating residents have viewed the lecture and been given the opportunity to ask questions if not available on the day it was given (i.e., post call from another service, etc.) [ADVANCED]

Interpersonal and Communication Skills
Upon completion of the program, the fellow should be able to:

1. Provide information to the patient and family with respect to the options, alternatives, risks and benefits of regional anesthesia in a manner that is clear, understandable, ethical, and appropriate. [BASIC]
2. Employ effective listening skills and answer questions appropriately in the process of obtaining informed consent. [BASIC]
3. Work effectively in a team environment, communicating and cooperating with surgeons, nurses, pharmacists, physical therapists, and other members of the perioperative team. This requires the fellow to:
   1. Appreciate the roles of other members of the team [BASIC]
   2. Communicate clearly in a collegial manner that facilitates the achievement of care goals. [BASIC]
   3. Help other members of the team to enhance the sharing of information. [BASIC]
   4. Formulate care plans that utilize multidisciplinary team skills such as a plan for facilitated recovery (i.e., ERAS, etc.) [ADVANCED]

Professionalism
Upon completion of the program, the fellow should be able to:

1. Respond to pages promptly and professionally; be punctual and reliable; adhere to departmental and university policies and procedures; exhibit integrity in record keeping and medical records [BASIC]
2. Demonstrate respect, compassion, and responsiveness to patients’ needs and concerns [BASIC]
3. Demonstrate independence and initiative befitting a consultant subspecialty physician [ADVANCED]
4. Continuously conduct the practice of medicine with integrity, honesty, and accountability [BASIC]
5. Demonstrate a commitment to lifelong learning and excellence in clinical practice [BASIC]
6. Demonstrate a commitment to the fellowship by striving for excellence in clinical and scholarly endeavors [BASIC]
7. Demonstrate consistent subjugation of self-interest to the good of the patient and the health care needs of society. [BASIC]
8. Demonstrate a commitment to ethical principles in providing care, obtaining informed consent, and maintaining patient confidentiality. [BASIC]

Systems-Based Practice
Upon completion of the program, the fellow should be able to:

1. Effectively balance the need for operating room efficiency with a high quality of patient care in the setting of a training program. The fellow will carefully and effectively consider the needs of the surgeons, patients, and be able to employ techniques and approaches to achieve the best balance possible to use regional anesthesia to improve recovery. [ADVANCED]
2. Work effectively in a consultant physician role within the framework of the interprofessional clinical team, including surgeons, nurses, block nurses, CRNAs, other anesthesiology trainees to enhance patient safety and improve quality [BASIC]
3. Participate in identifying system errors and implementing potential systems solutions [ADVANCED]
4. Demonstrate awareness of health care costs and resource allocation, and the impact of their choices on those costs and resources. [ADVANCED]

The Duke Regional Anesthesiology and Acute Pain Medicine (RAAPM) Fellowship is a one-year formal structured PGY-5 fellowship designed to prepare trainees for a role as leaders in academic regional anesthesiology and acute pain medicine. Trainees are expected to demonstrate progressive autonomy in the performance of these skills and competencies throughout the year. Where practical, the goals and objectives are stratified into basic and advanced levels, and trainees are expected to have demonstrated competency and completion of the basic set of these by the six-month point in the fellowship. Advanced level skills and competencies may be achieved at any point but should be mastered by the completion of the fellowship.

Medical Knowledge
Upon completion of the program, the fellow will be able to:

1. Perform a perioperative evaluation of the patient with acute pain; perform a detailed acute pain history and physical exam. [BASIC]
2. Describe the different etiologies of common acute pain syndromes and identify these in the inpatient hospital setting. [BASIC]
3. Differentiate between somatic, visceral, and neuropathic pain and treatment pathway [BASIC]
4. Describe various tools for the assessment of acute pain and evaluate the advantages and disadvantages of each. [ADVANCED]
5. Describe different routes for providing analgesia. [BASIC]
6. Explain the principles of patient-controlled analgesia, including patient evaluation, initiation, contraindications, troubleshooting and side-effects. [BASIC]
7. Outline an approach to caring for the patient with acute-on-chronic pain, including the use of pharmacologic and non-pharmacologic therapies [ADVANCED]
8. Understand and explain the pharmacokinetics, pharmacodynamics, indications, contraindications, side-effects, and interactions of the following medications or classes of medications:
   1. Local anesthetics [BASIC]
   2. Gabapentinoids [BASIC]
   3. NMDA antagonists [BASIC]
   4. Non-steroidal anti-inflammatory drugs (NSAIDs) [BASIC]
   5. COX-2 inhibitors [BASIC]
   6. Acetaminophen [BASIC]
   7. Alpha-2 agonists [BASIC]
9. Skillfully and efficiently describe and perform a wide variety of modern regional analgesic techniques including single-shot and continuous peripheral nerve block, spinal and combined spinal-epidural anesthesia, thoracic epidural, and nerve stimulator- and ultrasound-guided approaches [ADVANCED]
10. Describe the use of epidural anesthesia, including:
    1. Understand and explain the physiology of epidural anesthesia. [BASIC]
    2. Describe the contents of the epidural space. [BASIC]
    3. Understand and explain the local anesthetics available for epidural use: agents, dosage, adjuncts, and duration of action. [BASIC]
    4. Differentiate between spinal and epidural anesthesia regarding reliability, latency, duration, and segmental limitations. [ADVANCED]
    5. Describe the indications and contraindications for epidural anesthesia. [BASIC]
    6. Understand and explain side effects, complications and management of inadequate anesthesia, hypotension, total spinal, accidental dural puncture, systemic toxicity, and the use of appropriate test dosing to minimize some of these complications. [BASIC]
    7. Describe the volume-segment relationship and the effect of patient age, pregnancy, position, and site of injection on resultant block. [ADVANCED]
    8. Understand and explain combined spinal-epidural anesthesia as distinguished from lumbar epidural anesthesia, including advantages/disadvantages, dose requirements, complications, indications and contraindications. [ADVANCED]
    9. Understand and explain caudal epidural and thoracic epidural anesthesia as distinguished from lumbar epidural anesthesia, including advantages/disadvantages, dose requirements, complications, indications and contraindications. [ADVANCED]
11. Discuss complications of regional anesthesiology and acute pain medicine including the diagnosis and management of:
    1. hemorrhagic complications [BASIC]
    2. infectious complications [BASIC]
    3. neurologic complications
    4. This knowledge must include the interpretation of tests recommended following plexus/nerve injury, including electromyography, nerve conduction studies, somatosensory evoked potentials, and motor evoked potentials
    5. complications due to medicines, including local anesthetic systemic toxicity and opioid-induced respiratory depression [BASIC]
    6. other complications including pneumothorax [BASIC]
12. Describe the use of neuraxial opioids, including:
    1. Understand and explain available drugs, effective dose, and duration of action. [BASIC]
    2. Understand and explain the incidence of complications and side effects, monitoring, prevention, and therapy. [BASIC]
    3. Describe the indications/contraindications for the use of neuraxial narcotics for acute pain management. [BASIC]
    4. Describe the mechanism of action of neuraxial narcotics. [BASIC]
    5. Differentiate intrathecal vs. epidural administration relative to dose, effect and side effects and how hydrophilic and hydrophobic drug pharmacokinetics differ. [ADVANCED]
13. Describe the use of systemic opioids, including:
    1. Understand and explain the pharmacokinetics of opioid analgesics: bioavailability, absorption, distribution, metabolism, and excretion. [BASIC]
    2. Understand and explain the site and mechanism of action of opioids [BASIC]
    3. Understand and explain the differences of chemical structure of the various opioids. [ADVANCED]
    4. Describe challenges of post-procedure analgesic management in the patient with chronic pain and/or opioid tolerance [ADVANCED]
    5. Describe the concept of multimodal analgesia and its impact on functional restoration after surgery. [BASIC]

Patient Care
Upon completion of the program, the fellow should be able to:

1. Demonstrate management of patients at the level of a consultant whose diagnoses require consultation of the Acute Pain Management Service. [ADVANCED]
2. Demonstrate skill in the administration and coordination of multi-modal analgesic regimens to include such techniques as neuraxial and peripheral nerve catheters, local anesthetic and narcotic infusions, and non-narcotic analgesic adjuvants. [BASIC]
3. Conduct appropriate follow-up on his/her patients to assess the effectiveness of the pain management strategy, and be able to appropriately respond to changes in the acute pain condition with rational selection of additional adjuvant therapies [BASIC]
4. Demonstrate rational selection of regional analgesia for specific clinical situations [BASIC]
5. Demonstrate skill and knowledge related to the daily management of epidural and perineural catheters including dosing of medications, evaluation of proper dose and rate of infusion medications, and timing of catheter removal. [ADVANCED]
6. Recognize and intervene to manage inadequate regional analgesic techniques with supplemental blockade or alternate anesthetic approaches. [ADVANCED]
7. Properly prepare to manage rare but serious complications of regional analgesia including local anesthetic systemic toxicity and total spinal anesthesia. [ADVANCED]
8. Develop administrative skills as they relate to managing a team of trainees, mid-level providers and advanced practice nurses. Fellows will be expected to make triage decisions and allocation of team members as appropriate for consultations, procedures, and follow-up visits. [ADVANCED]
9. Understand how the acute pain medicine service (IPS) addresses the provision of acute pain management to select non-surgical patients, such as those with sickle cell disease or other conditions known to cause acute pain [ADVANCED]

Practice-Based Learning/Scholarship/Teaching
Upon completion of the program, the fellow should be able to:

1. Explain the value of the ASA Guidelines for Acute Pain Management [BASIC]
2. Evaluate and apply evidence from scientific studies, expert guidelines, and practice pathways. [BASIC]
3. Use information technology to obtain and record patient information, access institutional and national policies and guidelines, and participate in self-education. [BASIC]
4. Evaluate own practice with respect to patient outcomes (esp. success and complications from regional block) and compare to available literature. [ADVANCED]
5. Identify strengths, deficiencies, and limits in knowledge and expertise [ADVANCED]
6. Set learning and practice improvement goals [BASIC]
7. Identify and perform appropriate learning activities, including didactic lectures and hands-on demonstrations that promulgate safety [BASIC]
8. Incorporate formative evaluation feedback into daily practice [ADVANCED]
9. Participate actively in clinical research as a major activity of the year-long fellowship. This includes completing the appropriate Deduce training, Redcap training, eIRB training. [ADVANCED]
10. Develop teaching techniques by instructing residents and nurse practitioners at the bedside under the supervision of faculty. [ADVANCED]

Interpersonal and Communication Skills
Upon completion of the program, the fellow should be able to:

1. Provide information to the patient and family with respect to the options, alternatives, risks and benefits of the acute pain management plan in a manner that is clear, understandable, ethical, and appropriate. [BASIC]
2. Employ effective listening skills and answer questions appropriately in the process of obtaining informed consent. [BASIC]
3. Work effectively in a team environment, communicating and cooperating with surgeons, nurses, pharmacists, physical therapists, and other members of the perioperative team. This requires the fellow to:
   1. Appreciate the roles of other members of the team [BASIC]
   2. Communicate clearly in a collegial manner that facilitates the achievement of care goals. [BASIC]
   3. Help other members of the team to enhance the sharing of information. [BASIC]
   4. Formulate care plans that utilize multidisciplinary team skills such as a plan for facilitated recovery (i.e., ERAS, etc.) [ADVANCED]

Professionalism
Upon completion of the program, the fellow should be able to:

1. Respond to pages promptly and professionally; be punctual and reliable; adhere to departmental and university policies and procedures; exhibit integrity in record keeping and medical records [BASIC]
2. Demonstrate respect, compassion, and responsiveness to patients’ needs and concerns [BASIC]
3. Demonstrate independence and initiative befitting a consultant subspecialty physician [ADVANCED]
4. Continuously conduct the practice of medicine with integrity, honesty, and accountability. [BASIC]
5. Demonstrate a commitment to lifelong learning and excellence in clinical practice. [BASIC]
6. Demonstrate a commitment to the fellowship by striving for excellence in clinical and scholarly endeavors. [BASIC]
7. Demonstrate consistent subjugation of self-interest to the good of the patient and the health care needs of society. [BASIC]
8. Demonstrate a commitment to ethical principles in providing care, obtaining informed consent, and maintaining patient confidentiality. [BASIC]

Systems-Based Practice
Upon completion of the program, the fellow should be able to:

1. Work effectively in a consultant physician role within the framework of the interprofessional clinical team, including surgeons, nurses, nurse practitioners, physical therapists and other anesthesiology trainees to enhance patient safety and improve quality [BASIC]
2. Participate in identifying system errors and implementing potential systems solutions [ADVANCED]
3. Understand the interaction of the Acute Pain Management Service (IPS) with other elements of the health care system including primary surgical and medical teams, other consultant services, nursing, pharmacy, and physical therapy. [ADVANCED]
4. Demonstrate awareness of health care costs and resource allocation, and the impact of their choices on those costs and resources. [ADVANCED]