It seems that neurology is loosing turf war when it comes to interventional neurology. In last decades trend has been towards treating things more minimally invasive and this will likely continue to be the case in the future. But instead of neurologist it seems that neurosurgeons and radiologist are gonna be the ones doing these treatments. Compare that to interventional cardiology where cardiologist have been able to "steal" many patients from CT Surgeons. So why hasn't neurologists been able to do the same?
Interventional neurology?
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They were there first. And people understand the trends much better now than when angioplasty was a new thing. If IR and CT surgery knew then what they know now, they'd have fought harder. Plus there are a lot of cardiologists out there, and tons of coronary procedures that need doing. CT surgery and early IR coudn't have kept up with demand.
Compare that with neuroIR, where the volume just isn't as high, and there are already plenty of surgeons and IR entrenched. Apples to oranges.
Compare that with neuroIR, where the volume just isn't as high, and there are already plenty of surgeons and IR entrenched. Apples to oranges.
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I agree with TN regarding the volume issues and the fact that the radiologists were there first. Although, TECHNICALLY speaking, cerebral angiography was pioneered by a Portuguese neurologist named Egas Moniz in the 1920s... though he won the nobel prize for his work in leucotomy, so some may consider him a neurosurgeon.
I'd say at this point in time, the radiologists are the ones who have "lost" the turf battle. The majority of neurointerventionalists are coming from neurosurgery and neurologists are growing in number. I feel as if the radiologists just didn't push for patient referrals, and surgeons and neurologists control the flow of most of these patients.
Now moving forward, I personally feel (probably have some bias) that the neurologists are the best poised to take over the field, as we are greater in number, and control the stroke patients. Stroke patients going to thrombectomy are arguably rising in number, where as aneurysms (classically the domain of neurosurgery) are tapering off, if not plateaued. There are further trials being conducted w/ intracranial angioplasty for ICAD, but we will see what happens with that in the future.
It's important to keep in mind that the surgeons have political power and can usually get whatever they want from administrators because they bring in $$$ for the hospital system. Neurology departments tend to lose money. As we learn more about other chronic brain disorders, and as more and more treatments become available, this may change, in the future, and we may command a more important role.
I strongly believe that if neurologists continue to be aggressive in this changing atmosphere of health care, we can strengthen our cause, and position ourselves well to follow in the footsteps of cardiology, but likely not in the same degree for the reasons that TN mentioned.
I'd say at this point in time, the radiologists are the ones who have "lost" the turf battle. The majority of neurointerventionalists are coming from neurosurgery and neurologists are growing in number. I feel as if the radiologists just didn't push for patient referrals, and surgeons and neurologists control the flow of most of these patients.
Now moving forward, I personally feel (probably have some bias) that the neurologists are the best poised to take over the field, as we are greater in number, and control the stroke patients. Stroke patients going to thrombectomy are arguably rising in number, where as aneurysms (classically the domain of neurosurgery) are tapering off, if not plateaued. There are further trials being conducted w/ intracranial angioplasty for ICAD, but we will see what happens with that in the future.
It's important to keep in mind that the surgeons have political power and can usually get whatever they want from administrators because they bring in $$$ for the hospital system. Neurology departments tend to lose money. As we learn more about other chronic brain disorders, and as more and more treatments become available, this may change, in the future, and we may command a more important role.
I strongly believe that if neurologists continue to be aggressive in this changing atmosphere of health care, we can strengthen our cause, and position ourselves well to follow in the footsteps of cardiology, but likely not in the same degree for the reasons that TN mentioned.
The field is currently split among 3 disciplines, with radiologists having controlled it in the past and neurosurgeons currently in control (or at least ascension).
But ask a radiologist, and they will tell you they've ceded enormous ground to neurology (and neurosurgery). Go on Aunt Minnie and look for yourself at all the doom and gloom anytime someone whispers NIR. Radiologists aren't falling all over themselves to compete with primary providers (neurosurgeons/neurologists) for referrals, just to bill about the same as they would with DR while taking on a way worse lifestyle. The proof is in the training enrollment---it's fallen off for radiologists given the changing terrain.
The incentives are simply different and there are more neurologists pursuing these fellowship positions.
Neurologists have much more to gain in terms of RVUs and expanded roles in caring for the full spectrum of classic neurologic diseases.
Neurosurgeons on the other hand already take on a way worse lifestyle and lower pay (per unit time) to do cerebrovascular work--as compared to the bulk of neurosurgical practice, spine. Now ask a resident to sign up for a 7 year surgical training program (plus fellowship) to then not do surgery, or worse yet, also do 3-4 years of fellowship to do both skull base surgery and endovascular. All of that to forgo all of the other really cool surgeries they can do (functional, peds, onc, etc), or alternatively, massive paychecks for spine surgeries that are (almost) all scheduled. There are some impressive surgeons that do it, but not enough to cover the field. It's just a tough sell given the competing options--many residents will say that they didn't train in surgery to essentially do IR. The neurosurgical society is already trying to address this problem by changing some of their training standards.
All that to say, the current incentive structure simply does not point to neurologists being squeezed out of the field. Neurosurgeons remain in the driver's seat for sure, but that's not a given moving forward.
But ask a radiologist, and they will tell you they've ceded enormous ground to neurology (and neurosurgery). Go on Aunt Minnie and look for yourself at all the doom and gloom anytime someone whispers NIR. Radiologists aren't falling all over themselves to compete with primary providers (neurosurgeons/neurologists) for referrals, just to bill about the same as they would with DR while taking on a way worse lifestyle. The proof is in the training enrollment---it's fallen off for radiologists given the changing terrain.
The incentives are simply different and there are more neurologists pursuing these fellowship positions.
Neurologists have much more to gain in terms of RVUs and expanded roles in caring for the full spectrum of classic neurologic diseases.
Neurosurgeons on the other hand already take on a way worse lifestyle and lower pay (per unit time) to do cerebrovascular work--as compared to the bulk of neurosurgical practice, spine. Now ask a resident to sign up for a 7 year surgical training program (plus fellowship) to then not do surgery, or worse yet, also do 3-4 years of fellowship to do both skull base surgery and endovascular. All of that to forgo all of the other really cool surgeries they can do (functional, peds, onc, etc), or alternatively, massive paychecks for spine surgeries that are (almost) all scheduled. There are some impressive surgeons that do it, but not enough to cover the field. It's just a tough sell given the competing options--many residents will say that they didn't train in surgery to essentially do IR. The neurosurgical society is already trying to address this problem by changing some of their training standards.
All that to say, the current incentive structure simply does not point to neurologists being squeezed out of the field. Neurosurgeons remain in the driver's seat for sure, but that's not a given moving forward.
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"The neurosurgical society is already trying to address this problem by changing some of their training standards" - those effin in-folded fellowships are such a bad idea... some programs have PGY3s and PGY4s as junior and senior fellows, then don't practice endovascular at all as they finish the rest of their training... then all of a sudden are out in practice not having handled a tower of power in over 3 years.
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For someone whose goal it is to pursue interventional neuroradiology, what is it a better idea to get there via neurology residency or radiology? In terms of years it's the same
Radiology (4) + IR (1) + Neuro IR (1)
Neuro (4) + Neuro IR (2)
Would you agree? Which one better prepares you and has higher match rate for fellowship?
Matching into a good-name residency program (Cornell, Columbia, Yale) seems to be easier in Neuro than Radio based on Step 1 score.
Radiology (4) + IR (1) + Neuro IR (1)
Neuro (4) + Neuro IR (2)
Would you agree? Which one better prepares you and has higher match rate for fellowship?
Matching into a good-name residency program (Cornell, Columbia, Yale) seems to be easier in Neuro than Radio based on Step 1 score.
NeuroIR is longer than what you listed.
For neurology: 4 years + 2 or 1 year (either NeuroICU or Stroke) + 2 years NeuroIR = 7-8 years postgraduate training
For radiology: 5 years + 1-2 year Neuroradiology + 2 years NeuroIR = 8-9 years postgraduate training
For neurology: 4 years + 2 or 1 year (either NeuroICU or Stroke) + 2 years NeuroIR = 7-8 years postgraduate training
For radiology: 5 years + 1-2 year Neuroradiology + 2 years NeuroIR = 8-9 years postgraduate training
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Just one point about radiology time path. Typically it is 7-8 years as well for radiology. 6 years is possible as well, but more rare.
Most people who will be doing neuroIR will do a 1 year neuroradiology fellowship (2 years is reserved for those who want to take academic appointment in diagnostic neuroradiology). So one year of neuroradiology fellowship is more than adequate prior to NeuroIR for a radiologist.
A few places allow for NeuroIR training to be done in 1 year following neuroradiology fellowship depending on prior experience ie. if radiologist has done numerous endovascular procedures / angiography in residency. For instance I have done >20 3-vessel cerebral angiograms already as primary operator as a resident, in addition to either being primary operator or secondary operator for peripheral arterial angiography/intervention. Therefore, if one finds a program that allows 1 year with experience this cuts downt ime.
One program I know for sure, Brown, has a VIR (body IR to neuro-centric people) fellowship that incorporates high volume NIR into the fellowship and would therfore take 6 years total to become a Neurointerventionalist from radiology.
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While I agree that neurosurgery, and to a much lesser extent neurology, have made inroads into neuroIR, which I have no problems with since this is a multidisciplinary field, many IR minded radiologists like myself are excited. This is exciting times in NIR. New trials are showing benefit in appropriately selected candidates for endovascular thrombectomy in acute stroke. I know of a few guys that are doing Vascular and Interventional Radiology (VIR or body IR to the neuro-centric crowd) who want to do stroke therapy. This is different than doing elective aneurysms or AVM embo's, this is an acute therapy. Potentially a VIR guy can be trained in stroke alone (leaving out anuerysm and AVM) and be able to provide both acute stroke care and all the rest of VIR care to a hospital. One stop shop.
