Growing up as the son of an engineer, I learned early that you do not fix something by guessing. My dad taught me to break a problem into its parts, test each one, and then rebuild it better. Even our Pinewood Derby car got that treatment. We found the inefficiency, redistributed the weight, and took second place among my school’s group of Cub Scouts.
That same habit of mind is what I bring to the exam room every day. When you walk in with back pain, neck pain, or a shoulder that will not cooperate, you are not one problem. You are a system of nerves, muscles, joints, tendons, and ligaments that all talk to each other. My job is to figure out which part is generating your symptoms and then build a plan that restores what you lost.
That is what fellowship training brings to your care. Not simply a fancier title, but a more refined diagnostic process and advanced training when a procedure is needed.
The path looks like this: Four years of medical school. Then residency, which for physiatry means four more years learning how the body moves, how nerves and muscles work together, what happens when they do not, and how to restore function. During the first year of residency (internship), physiatrists learn fundamental clinical skills, and during the next three years, they cover the full scope of the specialty (UCLA Health, n.d.).
Fellowship comes after all of that. It is an additional year of focused, supervised training in one narrow area, in our case interventional spine and musculoskeletal medicine. A fellow spends that year doing the exact thing you are coming to us for: diagnosing complicated spine and musculoskeletal pain and performing procedures under live imaging with the supervision of an experienced physician.
It is also a year spent learning what can go wrong. Fellowships deliberately expose trainees to the diagnosis and management of procedural complications and medical emergencies that a physician might otherwise never encounter, including through simulation modules (NYU Grossman School of Medicine, n.d.). I would much rather have managed a rare complication in training than meet it for the first time with you on the table.
Here is a piece of research I find genuinely convincing, and it comes from orthopedics rather than pain medicine. Ottesen et al. (2022) looked at more than 73,000 hip fracture patients through the American Board of Orthopaedic Surgery database. The type of fellowship a surgeon completed did not by itself predict complications, but surgeons performing higher case volumes had significantly lower odds of complications. The authors concluded that case volume was associated with lower complication risk and may help explain some of the benefit associated with fellowship training.
I like that finding because it is honest. The certificate is not magic. What matters is repetition under supervision, and fellowship is designed to provide that structure. A fellow performs a high volume of guided injections in twelve months, with a mentor correcting needle angle, contrast flow, and patient selection in real time. That is where the value of fellowship training really lies.
A lot of pain procedures can “technically” be done by feel, using surface landmarks. The literature on whether that works is not flattering. One review comparing needle placement across large joints found that imaging guidance improved accuracy for knee injections from 81.0 percent to 96.7 percent, and for shoulder injections from 65.4 percent to 97.3 percent (Berkoff et al., 2012). For the hip, a meta-analysis found accuracy near 100 percent using ultrasound compared with about 72 percent using landmarks alone (Hoeber et al., 2016). A 2025 systematic review of shoulder injections reported accuracy of 63 to 100 percent with ultrasound guidance versus 40 to 76 percent with landmark-guided injections (Enriquez et al., 2025).
Think about what a miss actually costs you. If medication lands next to the target instead of in it, you do not just lose the relief. You lose the information. A diagnostic block only tells us something when we know exactly where the medication went.
I want to be fair about the evidence, though. An umbrella review published in 2024 found that while guided injections are consistently more accurate than landmark injections, the differences in pain relief and functional outcomes vary across sites and conditions (Shen et al., 2024). Accuracy is necessary; it is not sufficient. Which brings me to the part that matters most.
Musculoskeletal complaints are very common in medicine, and training for them has historically lagged behind the need. In the landmark study by Freedman and Bernstein (1998), 82 percent of clinicians who had just finished medical school failed a basic musculoskeletal competency assessment that had been validated by 124 orthopedic surgery program directors. That was not a one time finding. In a more recent national survey, 77.4 percent of family medicine program directors disagreed that incoming first year residents arrive with the physical exam skills needed to evaluate common musculoskeletal conditions (Wu et al., 2022). That helps explain why there is a specialty built entirely around movement and function.
Physiatrists spend residency developing expertise in exactly this. We are trained to take a detailed functional history, perform a thorough physical exam, and correlate what we find with your imaging rather than let the imaging alone drive the conversation. That distinction matters more than most patients realize. Abnormal findings on lumbar MRI are common, even in people without back pain. The question is not simply what the scan shows. The question is whether what it shows explains your symptoms.
We also have access to a diagnostic tool that most specialties do not perform. Electrodiagnostic testing, meaning EMG and nerve conduction studies, measures how your nerves and muscles are functioning. An MRI shows structure. An electrodiagnostic test shows function. When someone has numbness and weakness in a hand, that test can help distinguish a pinched nerve in the neck from carpal tunnel syndrome, and those two diagnoses lead to completely different treatments.
There is one more reason this topic is worth writing about now. The mix of clinicians performing spine procedures is shifting. In a recent analysis of Medicare claims, nurse anesthetists performed 17,834 interventional pain procedures in 2024, up from 15,868 in 2017 (Hyman et al., 2026). The same analysis found that in 2024, 10.4 percent of epidural steroid injections performed without imaging guidance were done by nurse anesthetists, compared with 0.6 percent of those performed with imaging guidance.
The numbers are still small. I raise this only because most patients never think to ask, and it is a completely reasonable question. You are always entitled to know who is performing your procedure, what their professional training is, and how much experience they have performing that specific procedure.
Bring these questions. A good physician should welcome them.
That last one is my favorite. A procedure should never be a standalone treatment. It should be one step in a plan that may include therapy and movement, with a clear idea of what comes next.
Here is the part I care about most. In my experience, many patients living with pain do not fully understand the process happening inside their body, and that gap can become a real barrier to recovery. If you do not know why your back hurts, every flare can feel like a catastrophe.
So I try to explain it plainly. I want you to leave understanding the likely source of your pain, what we are doing about it, and what your part of the work looks like. Patients are not just seeking a better number on a pain scale. They are seeking the ability to move, work, travel, lift a grandchild, and live fully again. This is what I mean by restoring movement, independence, and dignity, and it is the whole reason I chose this field.
At Desert Spine and Sports Physicians, that is the model. Careful evaluation first, precise diagnosis second, and treatment matched to the problem we identify. If you have been living with pain here in the Valley and have not had a thorough spine or musculoskeletal evaluation, that is where I would start.
The information in this article is for educational purposes and is not a substitute for professional medical advice, diagnosis, or treatment. Always speak with your physician about your specific condition.
Berkoff, D. J., Miller, L. E., & Block, J. E. (2012). Clinical utility of ultrasound guidance for intra-articular knee injections: A review. Clinical Interventions in Aging, 7, 89–95. https://doi.org/10.2147/CIA.S29265
Enriquez, R., Jones, E., Özçakar, L., & Jain, N. B. (2025). Accuracy and efficacy of ultrasound-guided glenohumeral joint injections: A systematic review. American Journal of Physical Medicine & Rehabilitation, 104(12), 1071–1085. https://doi.org/10.1097/PHM.0000000000002786
Freedman, K. B., & Bernstein, J. (1998). The adequacy of medical school education in musculoskeletal medicine. The Journal of Bone and Joint Surgery, 80(10), 1421–1427.
Hoeber, S., Aly, A.-R., Ashworth, N., & Rajasekaran, S. (2016). Ultrasound-guided hip joint injections are more accurate than landmark-guided injections: A systematic review and meta-analysis. British Journal of Sports Medicine, 50(7), 392–396. https://doi.org/10.1136/bjsports-2014-094570
Hyman, M. J., Modi, P. K., Kremer, M. J., & Sun, E. C. (2026). Trends in interventional pain management procedures performed by nurse anesthetists: A retrospective cross-sectional study. Anesthesiology, 144(5), 1254–1257. https://doi.org/10.1097/ALN.0000000000005965
NYU Grossman School of Medicine. (n.d.). Pain medicine fellowship. Retrieved September 19, 2026, from https://med.nyu.edu/departments-institutes/anesthesiology-perioperative-care-pain-medicine/education/fellowships/pain-medicine
Ottesen, T. D., Mercier, M. R., Brand, J., Amick, M., Grauer, J. N., & Rubin, L. E. (2022). The case for decreased surgeon-reported complications due to surgical volume and fellowship status in the treatment of geriatric hip fracture: An analysis of the ABOS database. PLOS ONE, 17(2), Article e0263475. https://doi.org/10.1371/journal.pone.0263475
Shen, P.-C., Lin, T.-Y., Wu, W.-T., Özçakar, L., & Chang, K.-V. (2024). Comparison of ultrasound- vs. landmark-guided injections for musculoskeletal pain: An umbrella review. Journal of Rehabilitation Medicine, 56, Article jrm40769. https://doi.org/10.2340/jrm.v56.40769
UCLA Health. (n.d.). Physiatrists. Retrieved September 19, 2026, from https://www.uclahealth.org/medical-services/spine/patient-resources/physiatrists
Wu, V., Goto, K., Carek, S., Petrizzi, M., Deck, J. W., Sulapas, I., DeStefano, S., DeCastro, A. O., Rooks, B. J., Mainous, A. G., III, & Kulshreshtha, A. (2022). Family medicine musculoskeletal medicine education: A CERA study. Family Medicine, 54(5), 369–375. https://doi.org/10.22454/FamMed.2022.975755