neurocritical care-dying field?

[Jimmy B]

I had an attending who is a stroke neurologist mention how she feels that NCC is a dying field and most of the inpatient neurology will be primarily stroke. I also heard from a Neurointensivist that there is a decline in the need for NCC. Contrary to this studies have shown that patients with a NCC issue that were taken care of by a Neurointensivist did better than if the physician was an intensivist. Any NCC fellows/attendings care to chime in on this?

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[AlternateSome1]

I am not a neurointensivist or an NCC fellow, but the idea that NCC is dying is ludicrous. Nearly EVERY academic center that doesn't have a neuro-ICU is trying to make one, and many non-academic centers are doing the same. To have a viable schedule for this, many centers are trying to recruit three NCC docs. Now there is going to be a point where NCC gets saturated, just like everything else, but I would disagree with the idea that it is a dying field. If you do a neuro search you will see many postings attempting to recruit ICU docs. If you are looking for a job, I can put you in touch with someone at my program. (Not meant to be an advertisement, just attempting to emphasize a point)

 

[Elipsis]

Seems like it would be tough for the job market to become saturated quickly with only a handful of new neurointensivists trained each year... Even if you didn't find an academic job I would think all of those skills would make it easy to make a lot of money as a neurohospitalist at a community hospital.

 

[bustbones26]

Seems like it would be tough for the job market to become saturated quickly with only a handful of new neurointensivists trained each year... Even if you didn't find an academic job I would think all of those skills would make it easy to make a lot of money as a neurohospitalist at a community hospital.

The majority of my inpatient consults are Medicare, Medicaid, and self-pays (i.e. why even bother billing them?). I see a huge number of uninsured patients in the hospital setting at the community hospital level.

In my opinion, what makes a neuroICU or even just a plain old neuro ward a better place for a patient to be is not so much the availability of a neurointensivist,stroke-trained neurologist, or neurohospitalist but rather the nursing care. The nurses, respiratory techs, and staff in general on these wards are more aware of neuro protocols than say in a general ICU.

So

 

[typhoonegator]

I had an attending who is a stroke neurologist mention how she feels that NCC is a dying field and most of the inpatient neurology will be primarily stroke. I also heard from a Neurointensivist that there is a decline in the need for NCC. Contrary to this studies have shown that patients with a NCC issue that were taken care of by a Neurointensivist did better than if the physician was an intensivist. Any NCC fellows/attendings care to chime in on this?

The academic market is saturating to some degree, as most NCC groups aren't that large and while there are not a huge number of NCC trainees graduating each year, there are enough to have filled up most of the major academic medical centers. So no, you can't finish fellowship and expect to walk into a job at Duke or something (unless you have a research program to sweeten the deal).

Even if most inpatient neurology care is stroke, as you attending apparently intimates, some of those patients do need ICU level care, and it has been demonstrated that the care delivered in a dedicated neuroICU is superior to a general ICU in the treatment of these conditions. Mortality talks.

Finally, a major role of neurointensivists is the care of neurosurgical patients, both SAH and post-operative. The surgeons like having someone who knows what they're doing managing their patients, and it is a great incentive for even an elective neurosurgical practice to have a skilled neurointensivist managing their complications and expediting recovery/discharge. Endovascular people often don't have a lot of experience managing aSAH medical complications and VSP/DCI issues, and stroke people get essentially no training in management of those conditions, unless they train in a NCC environment.

NCC is not dying. Our fellows have no problems finding jobs, and our staff could move essentially anywhere they want. And if you ever wanted to get out of the ICU, you are ideally positioned for neurohospitalist work as well, especially if you trained in a stroke-heavy environment.

I don't feel the need to convince you that this is the best field in medicine, but I fail to find evidence that this field is dying.

 

[Strokeguy]

Neurocritical care dying is an absurd statement. I don't think there is any basis for this. Yes for academic jobs (as in most neurology subspecialities) you would want to train at a well known research heavy program. There are several jobs available in private practice though. Same for stroke, lots of stroke/hospitalist jobs in practice (for an academic career you need to be trained at a research heavy program).

 

[neglect]

I'm a little surprised to see this as a topic of conversation as well. Many hospitals require neuro ICU beds. There is decent patient population and clinical need. And it isn't just all neurosurgical postops. Don't forget all the neuro consults on normal icu patients. Also there's a need for cardiac cooling. Once some of the monitoring metrics are actually shown to improve patient outcomes, then the field will really come into its own.

But as always one would be wise to never forsake ones training in general neurology. A neuro-icu doctor is much more useful if he can also see floor patients and see clinical outpatient follow ups. I fear the sub sub specialization of neurology.

 

[DocMom1]

I had an attending who is a stroke neurologist mention how she feels that NCC is a dying field and most of the inpatient neurology will be primarily stroke. I also heard from a Neurointensivist that there is a decline in the need for NCC. Contrary to this studies have shown that patients with a NCC issue that were taken care of by a Neurointensivist did better than if the physician was an intensivist. Any NCC fellows/attendings care to chime in on this?

Sorry to revive this old thread. But one of my attending said the same thing today as i am interested in the field. His opinion was partially based on the mid levels involvement in the NeuroICU , he stated it will be a “midlevel service” and limited jobs availability in the future. Any input on this topic as I am thinking of this field for fellowship.

Certainly not in decline, but gIven how relatively new the field is, it is nearly fully saturated at most academic departments with few hiring opportunities, but wide open and in high demand in most non-academic hospitals. Not sure what is meant by "midlevel service" and why this uniquely applies to NCC

 

[CCM-MD]

Certainly not in decline, but gIven how relatively new the field is, it is nearly fully saturated at most academic departments with few hiring opportunities, but wide open and in high demand in most non-academic hospitals. Not sure what is meant by "midlevel service" and why this uniquely applies to NCC

This is not true. Most community hospitals do not have dedicated neuro ICUs, those large enough to have one often don't have the neurological pathology to warrant a neurointensivist - often a post-op parking lot for neurosurgical patients.

 

[stevresidentp]

This is not true. Most community hospitals do not have dedicated neuro ICUs, those large enough to have one often don't have the neurological pathology to warrant a neurointensivist - often a post-op parking lot for neurosurgical patients.

What about strokes, status, NM crises and encephalitis ?

 

[CCM-MD]

What about strokes, status, NM crises and encephalitis ?

Much of that can be managed well by an intensivist and a neurological consultant. I guess it’s a matter of opinion where you draw the line.

 

[xenotype]

What about strokes, status, NM crises and encephalitis ?

If you can't competently read continuous EEG you'll be relying on another neurologist for treatment decisions in these cases anyways even if you are NCC trained. One of my main issues with NCC training is that most of the questions involving it require continuous EEG and a lot of comfort with epilepsy, unless one is simply going to do whatever an epileptologist tells them to do. At that point, why have two different consultants following a patient if one them adds little value. You can get around these issues by adding a year of CNP or epilepsy fellowship, but NCC training is also of no help to some of the occasional tough NM cases that are very treatment refractory or not straightforward in diagnosis. A general neurologist who treats a decent amount of MG/myopathy is simply going to be more useful and more comfortable treating these patients in the ICU. It's hard to be good at everything, and trading experience in SAH and other neurosurgical problems may mean losing bits of general neurology that were really more useful to begin with. In a big center it doesn't matter because you can have 5 or 6 super subspecialized consultants following the patient.

 

[Tuloste]

What about strokes, status, NM crises and encephalitis ?

Out of interest, why would a stroke patient need ICU level care, at least from the point of view of a neurologist? Hemorrhagic stroke is completely a neurosurgical problem if ICU even springs to mind. Malignant MCA infarctions are few and far between, and sometimes it's almost questionable whether treatment is in the patient's best interest. Same with BAO, if you need to tide the patient over in the ICU that is. Expansile cerebellar infarctions are also, in my opinion, a neurosurgical problem.

I could see this only being beneficial in a few extreme cases mostly involving acute comorbidities, say a concurrent aortic dissection/ myocardial infarction/ bowel ischemia/ AHF. But most of these patients are SOL as well no matter what wizardry is used to treat them.

 

[xenotype]

Out of interest, why would a stroke patient need ICU level care, at least from the point of view of a neurologist?

If you have a dedicated stroke unit with stroke/neuroscience nurses and low nurse to patient ratios then sure stroke patients don't need ICUs. In residency I had numerous patients have acute decompensation with severe deficits after admission from the ER with very mild deficits that were amenable to immediate thrombectomy/angioplasty/carotid stent placement, and better nursing care either would have caught the clinical change or did catch it. In a general hospital without specialized RNs at least the ICU has low nurse to patient ratios so the nurse has time to do a cursory exam to catch badness. Many ICU nurses have a passing familiarity with post tPA care which is a significant edge over a floor nurse. You appear to be from EM- ED nurses are far better than floor hospital nurses at neurologic problems on average. If the new but quite severe aphasia isn't noticed until I'm rounding the next morning, the patient admitted with mild deficits is going to be permanent nursing home bound rather than going home without PT/OT required.

It's about level of attention paid to the patient, and skill of the nurse involved. I do the same thing with lethargic patients on the floor- they are better off in the ICU with neurochecks where they can get tubed for their impending renal/hepatic failure than coding on the floor after a neuro consult for 'AMS'.

 

[carefulamoeba1]

How is the job market for people who did the fellowship now? I heard it’s not as robust as other neurology specialists?

 

[Neurologo]

I see medicine track critical care docs certifying as "neuro," either by passing the exam after few months of study or some extra training for a year or less. They seems to have more value to hospitals at least in appearance than neurologists trained in neurocrit fellowship simply because they can manage all ICU cases instead of needing to have both critical care and neurocritical docs managing same patients. Thus at least in non-academic neuroICUs, I see a lot more crit care docs w/ additional certification in neuro-crit care consulting neurohospitalists comfortable in managing ICU cases along with neurosurg. This set up seems to run decently although it is heavily dependent on how good they actually are. In short, crit care docs seems to be defending their ICUs pretty well for now from neurology track crit care guys, who may have better selling point to business managers if they can show they can handle all other ICU cases on their own without any support from crit care docs or additional neurologist involved.

 

[oopsy]

NCC job opportunities are very robust. Starting salary is comparably high (>300 at vast majority of places academic centers, add another 100-150 for most private centers [outside of most top 10 metros]), expectation is 26 weeks on, 26 weeks to do whatever you want. NCC is not going away for several reasons:

1) Surgeons arent going to let random pulm doctors take care of their crani patients. It affects their post-op outcomes. Hospitals cannot attract surgeons and setup a neurosurgical capable center without them, and cranial surgeons are reluctant to go somewhere that wont commit to NCC support. This has been a huge draw for mid sized hospitals trying to get NCC on staff to help attract/retain surgeons. It's more like a package deal.

2) CSC status requires a NIR, stroke doc, and NCC physician on staff. There's huge $ for the hospital in going from PSC-->CSC. Stroke is comparably much easier, there are many NIR folks trying to setup centers and willing to go solo at a lower volume place, the hardest piece of the puzzle is finding an intensivist to come (because it's hard to just hire one to be on forever, you usually need at least two to maintain the service line).

3) NCC keeps a lot of revenue generating patients in house (ie-strokes, aneurysms, etc) and at most centers is a revenue generating ICU, and at big centers, allows NSGY to stay in the OR more and generate more RVUs for the hospital. It's often profitable for the hospital in ways most other ICUs are not.

4) NCC can easily cover neurohospitalist duties, vice versa is not doable. I can intubate, prone, manage all varieties of shock, consult in the other units, etc, and cover the hospitalist floor. They can't. NCC hires are much more versatile.

Most NCC programs around the country have shifted towards a general crit training + NCC expertise, and most new hires are expected to care for general CC as well as NCC patients to be more flexible/adaptable. You will always have the possibility of non-neuro, overflow patients landing in your bed, and theyre youre patient. Whoever is suggesting that NCC is on the way out has been huffing too much glue. We are consistently the highest paid neurologists in any department, outside of IR.

 

[CCM-MD]

NCC job opportunities are very robust. Starting salary is comparably high (>300 at vast majority of places academic centers, add another 100-150 for most private centers [outside of most top 10 metros]), expectation is 26 weeks on, 26 weeks to do whatever you want. NCC is not going away for several reasons:

1) Surgeons arent going to let random pulm doctors take care of their crani patients. It affects their post-op outcomes. Hospitals cannot attract surgeons and setup a neurosurgical capable center without them, and cranial surgeons are reluctant to go somewhere that wont commit to NCC support. This has been a huge draw for mid sized hospitals trying to get NCC on staff to help attract/retain surgeons. It's more like a package deal.

2) CSC status requires a NIR, stroke doc, and NCC physician on staff. There's huge $ for the hospital in going from PSC-->CSC. Stroke is comparably much easier, there are many NIR folks trying to setup centers and willing to go solo at a lower volume place, the hardest piece of the puzzle is finding an intensivist to come (because it's hard to just hire one to be on forever, you usually need at least two to maintain the service line).

3) NCC keeps a lot of revenue generating patients in house (ie-strokes, aneurysms, etc) and at most centers is a revenue generating ICU, and at big centers, allows NSGY to stay in the OR more and generate more RVUs for the hospital. It's often profitable for the hospital in ways most other ICUs are not.

4) NCC can easily cover neurohospitalist duties, vice versa is not doable. I can intubate, prone, manage all varieties of shock, consult in the other units, etc, and cover the hospitalist floor. They can't. NCC hires are much more versatile.

Most NCC programs around the country have shifted towards a general crit training + NCC expertise, and most new hires are expected to care for general CC as well as NCC patients to be more flexible/adaptable. You will always have the possibility of non-neuro, overflow patients landing in your bed, and theyre youre patient. Whoever is suggesting that NCC is on the way out has been huffing too much glue. We are consistently the highest paid neurologists in any department, outside of IR.

As a "random" intensivist that takes care of "crani patients" according to you, I'm going to provide a different perspective here. Real neuro ICUs that warrant a neurointensivist exist in university hospitals and very large community hospitals. These hospitals are limited in number in comparison to the enormous number of small, medium and large community hospitals. Also keep in mind that there are plenty of CCM docs that have/will be grandfathered into NCC in the coming years. Most intensivists will not look at a neurologist with a NCC fellowship as having equivalent training to manage medical, surgical and cardiovascular ICU patient populations. As much as you might want to tell yourself that, don't expect to practice non-neurological critical care you will be disappointed. NCC is not a backdoor to practicing CCM, they are far from the same thing.

A quick look on practice-link reveals there are 27 NCC jobs advertised. Compare that to the 1300+ jobs advertised for neurology. Its not as easy to get a job as one might think, especially if geographically limited due to family/other reasons. Willing to move anywhere? Sure you will find a job easily and make a boatload of money - but thats the case for most specialties.

 

[oopsy]

To be clear, I have no interest in being a general intensivist, nor do I pretend to be one. I love being a neurologist and neurointensivist and have no interest in competing for your pancreatitis, flail leaflet, etc pathologies. You can have them all. There are large academic centers with NCC jobs that are asking their NCC staff to rotate through their community (general) ICUs to manage less complex general CCM to support their salary, I'm not interested in those jobs, but they are certainly out there. Personally, I have to take care random overflow patients into our unit, and happy to do so on a limited basis, but despite my best efforts, I certainly do not deliver the same standard of care to general MICU patients as I do to my NCC patients. No illusions of grandeur here.

The same, however, applies to you. While you are certainly capable of neuro-informed vent management, I doubt that our community CCM colleagues are can handle complicated operative misadventures or complex neurologic issues. I know this because they turf them to us all the time. So as you assume that the neurologist cant possible manage that straight forward pancreatitis patient boarding in their unit, do consider the converse. Regardless, I agree that most intensivists can manage an ischemic stroke patient riding the vent with a consulting neurologist. But with all due respect to your critical care expertise, there's a reason why that practice pattern is the exception, not the rule, at large centers with significant volume of cranial neurosurgery and referral neurology. And it's not because neurologists are good at defending our practice or monetizing our services... Quite frankly, the polemics about neurologists not having a role a role in CCM are simply lost and over. NCC is here to stay, and is the standard of care moving forward.

Further, we have trained fellows from an IM/pulm/CCM background, and happy to do so, but you can't just become a neurologist (and neurointensivist) in 1-2 years, no matter how much smarter you are than me. Different skill sets are brought to bear, and it is absolutely a value add to community practice where there isn't enough NCC volume to support a neuro-trained NCC (ie- 4-6 overflow beds, mostly ischemic stroke and a few post-ops). And thank you for it, it needs to get done in the community, and that's a perfect skill set to add to a community setting without significant complexity/volume. That person is even more flexible in their healthcare system and can cover their overflow neuro.

But when the hospital is trying to expand a dedicated neuro service line with stroke, neurosurgery, inpatient neuro, and CSC status, with all due respect, a neurointensivist who can also flex to cover the floor/consults is far more attractive. Colleagues who have gone out to establish practices have found this to be a consistent pattern, where neurosurgery simply doesnt want to turn their patients over to non-neuro specialists (or folks they dont know, in the absence of those specialists), for fear of post-op complications that ultimately come down on their reputation. There are plenty of these kinds of opportunities out there, and plenty of grief from neurosurgeons who all trained at institutions with dedicated NCC support and expect that moving forward. My surgeon friends all have the same complaint about setting shop at a new center, lack of NCC support. Similarly, you can bank on every large community hospital chasing that CSC status and therefore revenue by establishing their own dedicated NCC.

In terms of job availability, there's always drama getting a job in the specific neighborhood of the specific city you want. While the game of musical chairs is always a foot, arguing that finding NCC job postings is hard is because you dont know who or how to ask. I live in a top 10 metro city, there are currently 4 open NCC jobs, all of which are at nice setups (spanning academic and private), none of which are on practice link. Next year maybe it's zero or 1, who knows. But it's always in flux, and yes, it's a smaller field, so no question not as easy to find a job as gen neuro. But people with realistic expectations between salary/responsibilities and good credentials will have many opportunities to select a nice job.

 

[xenotype]

you can't just become a neurologist (and neurointensivist) in 1-2 years

Yes. 'Grandfathered neurocritical care' general CCM guys can't even do a reliable, reproducible complete neuro exam on an obtunded patient.

An honest concern I have with NCC on the whole is that many even with the modern two year fellowship training are not neurology background(EM, surgery, IM, anesthesia), and I have seen this play out as very limited competence when it comes to dealing with status, myasthenic crisis, GBS and variants, encephalitis etc and still needing the input (or curbside) of a consulting neurologist. These patients are never easy when it comes to 1) being as sure as you can about the diagnosis and 2) immunosuppression and other high level areas of treatment like when to back off on AEDs. Not being a neurologist means you don't have a clue with them. They aren't rare either- every neurology resident is used to getting train wreck transfers with these with a completely inappropriate work up, wrong diagnosis, and inadequate treatment from St. Elsewhere. Often these patients don't fully recover and some die.

 

[CCM-MD]

At the end of the day, it honestly does not matter how concerned you or I might feel about non-neurology intensivists being certified in NCC, the boards think it’s fine and grandfathered certificates are being handed out left and right, and it’s going to go on until at least 2028. Hospital administrators and employers will look for the cheapest and logistically easiest option to insert into their assembly line, which may not be a neurologist. As inpatient fields become more saturated, employability is an important factor to keep in mind for those considering this for a long term career. Every specialty has jobs that aren’t advertised and fill through word of mouth but job boards are an indicator of demand.

As disinterested as you might be in caring for other critically ill patients, majority of other intensivists are probably just as equally or more disinsterested in caring for neurological patients. I did my best to avoid turning this into a pissing contest but since you're not going to hold back, I won't either: you can have your numerous brain injured vegetables for whom futile care is continued because families think are going to come back to life. Like you said, and I agree, there is probably no real competition here in either direction.

Bottom line is most hospitals in this country are not large volume referral centers for neurological patients and aren't hurting for neurointensivists. As someone who has had colleagues that have had difficulty securing initial jobs and changing jobs, choosing a specialty with limited practice settings is something applicants should keep in mind in today's world - and it seems like they are considering the number of empty NCC fellowship positions every year.

 

[oopsy]

you can have your numerous brain injured vegetables

Maybe we'll just have to agree to disagree on how competitive neurologists will be in competing for NCC coverage. Happy to let the job market continue to do the talking.

 

[CCM-MD]

View attachment 337726


Maybe we'll just have to agree to disagree on how competitive neurologists will be in competing for NCC coverage. Happy to let the job market continue to do the talking.

That's not where the disagreement is. It is natural to defend the field you are in but there is no reason to, you are obviously doing very well financially from your other posts. This is more for those still trying to choose a career path.The disagreement is about the available opportunities for neurointensivists, which are: in academics and in some large community hospitals, where real neuro ICUs exist. The amount of care provided to non-neurological patients by neurology-neurointensivists has also been overstated in this thread. But sure, lets let the 27 advertised jobs do the talking and lets also let the 3 pages worth of empty NCC fellowship programs on the San Francisco match website do the talking.

 

[xenotype]

That's not where the disagreement is. It is natural to defend the field you are in but there is no reason to, you are obviously doing very well financially from your other posts. This is more for those still trying to choose a career path.The disagreement is about the available opportunities for neurointensivists, which are: in academics and in some large community hospitals, where real neuro ICUs exist. The amount of care provided to non-neurological patients by neurology-neurointensivists has also been overstated in this thread. But sure, lets let the 27 advertised jobs do the talking and lets also let the 3 pages worth of empty NCC fellowship programs on the San Francisco match website do the talking.

As a non-CCM/NCC outsider I think you both have great points and it is nice to get a realistic perspective from a non-neurologist. There are not a lot of 'real' neuroICU jobs. NCC should not be used to do much 'general' critical care. There are a lot of grandfathered NCC docs from non-neurology backgrounds. However, these docs are not neurologists and hospitals really, really need neurologists. NCC easily flexes into covering any area of hospital neurology well (stroke, ED, general inpatient consults) so if a small 'not real, or sorta real' neuroICU isn't enough work there is plenty of other stuff to do. Small neuroICUs will be growing as CSC accreditation requires it and is a big chunk of hospital cash to go after in building 'neuroscience centers' to keep profitable neuro patients rather than just transferring them to the academic center the moment they hit the ED or a couple days later out of the general ICU.

Also the best jobs aren't advertised as everyone knows. To me it seems like the majority of neurohospitalist jobs are not advertised and the ones that are well advertised may have hidden red flags. Additionally- empty fellowship spots are the best hidden part about neurology and are common across most subspecialties in neurology. To a neurologist NCC is more a big set of extra skills rather than a whole job in many cases- the same for an EEG fellowship or movement fellowship etc. I didn't have to do any extra work or butt kissing to get my fellowship spot, and it was a blessing after years of hard work.

 

[CCM-MD]

As a non-CCM/NCC outsider I think you both have great points and it is nice to get a realistic perspective from a non-neurologist. There are not a lot of 'real' neuroICU jobs. NCC should not be used to do much 'general' critical care. There are a lot of grandfathered NCC docs from non-neurology backgrounds. However, these docs are not neurologists and hospitals really, really need neurologists. NCC easily flexes into covering any area of hospital neurology well (stroke, ED, general inpatient consults) so if a small 'not real, or sorta real' neuroICU isn't enough work there is plenty of other stuff to do. Small neuroICUs will be growing as CSC accreditation requires it and is a big chunk of hospital cash to go after in building 'neuroscience centers' to keep profitable neuro patients rather than just transferring them to the academic center the moment they hit the ED or a couple days later out of the general ICU.

Also the best jobs aren't advertised as everyone knows. To me it seems like the majority of neurohospitalist jobs are not advertised and the ones that are well advertised may have hidden red flags. Additionally- empty fellowship spots are the best hidden part about neurology and are common across most subspecialties in neurology. To a neurologist NCC is more a big set of extra skills rather than a whole job in many cases- the same for an EEG fellowship or movement fellowship etc. I didn't have to do any extra work or butt kissing to get my fellowship spot, and it was a blessing after years of hard work.

I think the number of hospitals chasing CSC status is being overstated as well as the economics behind it. In addition to the investment in infrastructure and even more in staffing, these patients have long length of stays which is a direct counter to hospital financial health in todays world of DRG. Thus profitability probably requires volume so I personally doubt we are going to start seeing multiple CSC popping up all over the place in one geographic area. In addition, I work at a hospital that is a CSC accredited by DNV - which does not require neurointensivists, so keep in mind that CSC accreditation is attainable without having anyone boarded in NCC.

But let’s keep the above aside for a moment. You’re still making my point for me here. How can one say the opportunities for NCC are really that robust if after completing 2 years of additional training (66% of a neurology residency), the only opportunities outside academia and large community hospitals are those that require one to spend a majority of their time practicing general neurology and not NCC. At that point you are attesting to the strength of the neurology job market not NCC.

 

[Neurologo]

Both CCM-MD and Oopsy are making great points. It would be interesting to see the actual profitability of CSC status; a neighboring hospital corp is planning to set up one to compete against the sole CSC in town. Also neurosurgeons wanting neurology-trained NCC is interesting to note and makes a good argument for hiring neuro-NCC. This must be a new trend, however, among recent neurosurg grads who are more used to having such set up during their training.

CCM-MD is pointing out relatively small job opportunity for neuro-trained NCC in comparison to other neurology jobs, while acknowledging the skills and knowledge between neuro-NCC and pulmo-NCC are not interchangeable and to be mutually respected as such. Oopsy agrees with the latter point while pointing out still adequate job opportunities for neuro-NCC and projects more growth in the future. Can this be explained by the fact that although there are small number of jobs openings there are equally small number of graduates each year as evidenced by unfilled fellowships?

 

[Thama]

You’re still making my point for me here. How can one say the opportunities for NCC are really that robust if after completing 2 years of additional training (66% of a neurology residency), the only opportunities outside academia and large community hospitals are those that require one to spend a majority of their time practicing general neurology and not NCC. At that point you are attesting to the strength of the neurology job market not NCC.

This is a function of neurology being a much smaller specialty than IM, not a function of the NCC job market. Outside of academics, being able to practice exclusively your fellowship-trained subspecialty is pretty rare throughout neurology, simply because that level of hyperspecialization only really exists at the largest centers. Your average epilepsy/movement/neuromuscle job in a single specialty private practice tends to be ~50% your subspecialty and 50% general neurology, or even more general neurology. It's not anything like IM subspecialties that 100% do cards/pulm/etc with no PCP work.

 

[CCM-MD]

I think the goalpost is being shifted. My primary disagreement is with the overstating of the robustness of NCC jobs. NCC job = where one practices as a neurointensivist in a neuro ICU for a majority of their time. These will remain limited to university hospitals, and some large community hospitals that choose to staff their neuro ICUs with neurologist-neurointensivists. The market for neurologists and neurohospitalists is obviously strong and working at a community hospital while dabbling in NCC or another subspecialty isn't really the same thing as working as a neurointensivist. I have worked with neurology residents that enter NCC fellowship training with the expectation of practicing full time as a neurointensivist upon completion. These jobs obviously exist but can be a challenge to find if one is geographically limited or does not want to work in academia, and goes against the stated robustness of this specialty's job market. Prospective applicants reading this forum should be aware of what they are getting into.

There is obvious bias in a neurologist stating that neurosurgeons prefer neurology trained neurointensivists, but I'll accept that some probably really do. Whether or not that translates to how a non-university hospital chooses to staff is not clear because there are things that an internist/anesthesiologist/EM physician trained in both CCM and NCC brings to the table including having the training to provide the standard of care to other ICU populations. There are plenty of employment opportunities specifically looking for physicians with both CCM and NCC certifications, and with grandfathering there are many of these dual certified physicians out there.

The general sentiment that CSC certification brings in a boatload of cash for a hospital is not universally true. In the right circumstances and catchment area, probably yes, but definitely not universally true. The statement that neurointensivists are required for CSC certification is also not true in the case of the DNV GL.

 

[blue.jay]

There are also plenty of midlevels covering surgical, neruo,cardiac ICUs than medical ICU. That should also put some pressure on job market for fresh grads.

 

[Spinothalamic]

...The general sentiment that CSC certification brings in a boatload of cash for a hospital is not universally true. In the right circumstances and catchment area, probably yes, but definitely not universally true...

View attachment 337794

This statement is perhaps true but data collected from 2005-2010 published in a 2013 study are not relevant to the current market given advances in stroke care and ubiquity of mechanical thrombectomy.

I am in total agreement with the statement that NCC will “remain limited to university hospitals, and some large community hospitals that choose to staff their neuro ICUs with neurologist-neurointensivists” and am unclear of the nature of disagreement.

I feel that much of this back and forth is not actually related to that premise but rather the utility of neurologists practicing NCC, which clearly has advantages for patients with neurologic issues and is preferred by various parties in some situations.

 

[callosum]

I think the goalpost is being shifted. My primary disagreement is with the overstating of the robustness of NCC jobs. NCC job = where one practices as a neurointensivist in a neuro ICU for a majority of their time. These will remain limited to university hospitals, and some large community hospitals that choose to staff their neuro ICUs with neurologist-neurointensivists. The market for neurologists and neurohospitalists is obviously strong and working at a community hospital while dabbling in NCC or another subspecialty isn't really the same thing as working as a neurointensivist. I have worked with neurology residents that enter NCC fellowship training with the expectation of practicing full time as a neurointensivist upon completion. These jobs obviously exist but can be a challenge to find if one is geographically limited or does not want to work in academia, and goes against the stated robustness of this specialty's job market. Prospective applicants reading this forum should be aware of what they are getting into.

There is obvious bias in a neurologist stating that neurosurgeons prefer neurology trained neurointensivists, but I'll accept that some probably really do. Whether or not that translates to how a non-university hospital chooses to staff is not clear because there are things that an internist/anesthesiologist/EM physician trained in both CCM and NCC brings to the table including having the training to provide the standard of care to other ICU populations. There are plenty of employment opportunities specifically looking for physicians with both CCM and NCC certifications, and with grandfathering there are many of these dual certified physicians out there.

The general sentiment that CSC certification brings in a boatload of cash for a hospital is not universally true. In the right circumstances and catchment area, probably yes, but definitely not universally true. The statement that neurointensivists are required for CSC certification is also not true in the case of the DNV GL.

View attachment 337794

Neurocritical Care Outcomes, Research, and Technology: A Review - PubMed

Neurocritical care has become an important part of health systems and an established subspecialty of neurology. Understanding its structure, scope of practice, consequences for care, and research are important.

pubmed.ncbi.nlm.nih.gov

Implementation of Neurocritical Care Is Associated With Improved Outcomes in Traumatic Brain Injury - PubMed

Implementation of a NCC program is associated with improved 6 month GOS in severe TBI patients.

pubmed.ncbi.nlm.nih.gov

Effect of implementation of a paediatric neurocritical care programme on outcomes after severe traumatic brain injury: a retrospective cohort study - PubMed

St Louis Children's Hospital and the Sean Glanvill Foundations.

pubmed.ncbi.nlm.nih.gov

Thank you for this discussion. I have been intent on neurology and am now exploring the idea of neurocritical care, so it is nice to see the arguments on either side.

When discussing opportunities as relates to financial incentivse for facilities and smaller community adoption of NCC units, does the evidence for improved outcomes and decreased healthcare burden not suggest that this will be adopted more by hospital systems (even in smaller communities) with the push for quality/outcome-based reimbursement as well?

 

[oopsy]

Neurocritical Care is the standard of care for any hospital with a dedicated critical care population with neurological or surgical volume, etc . In smaller community hospitals that may keep a handful of stroke / post op spine cases, there will continue to be not enough volume to justify a neurointensivist and CCM physicians with NCC credential/comfort will continue to care for those patients in those settings. Most of us would not consider that as competition for a dedicated neuroICU—those hospitals don’t have the volume and surgeries to justify dedicated NCC in the first place. I think of this is more of a complementary role than competition, but not everyone agrees. Regardless, NCC credentialing and dedicated support are clearly the standard moving forward at centers with notable neuro volume. Clearly, most hospitals don’t need NCC. But then again, most hospitals have a hard enough time getting any neurologist to come.

 

[CCM-MD]

Neurocritical Care is the standard of care for any hospital with a dedicated critical care population with neurological or surgical volume, etc . In smaller community hospitals that may keep a handful of stroke / post op spine cases, there will continue to be not enough volume to justify a neurointensivist and CCM physicians with NCC credential/comfort will continue to care for those patients in those settings. Most of us would not consider that as competition for a dedicated neuroICU—those hospitals don’t have the volume and surgeries to justify dedicated NCC in the first place. I think of this is more of a complementary role than competition, but not everyone agrees. Regardless, NCC credentialing and dedicated support are clearly the standard moving forward at centers with notable neuro volume. Clearly, most hospitals don’t need NCC. But then again, most hospitals have a hard enough time getting any neurologist to come.

Close to 50% of the hospitals in this country don't have any intensivist coverage, forget about NCC. Lets put 27 advertised NCC jobs into the perspective of over 6000 hospitals and 65000 ICU beds in this country. Calling it the standard of care shows how out of touch you are with reality. Perhaps you have never worked a day outside of academics, or you don't actually know what the term standard of care means.

PS "CCM physicians with NCC credential" are neurointensivists, distinction in bold not necessary.

 

[barzan]

As a Neurointensivist I can tell you, no its not dying. in fact with the new ABPN acknowledgement I see this field expanding further.

I had an attending who is a stroke neurologist mention how she feels that NCC is a dying field and most of the inpatient neurology will be primarily stroke. I also heard from a Neurointensivist that there is a decline in the need for NCC. Contrary to this studies have shown that patients with a NCC issue that were taken care of by a Neurointensivist did better than if the physician was an intensivist. Any NCC fellows/attendings care to chime in on this?

 

[Staphylococcus Aureus]

How competitive is the fellowship for neurology applicants? How common is it for them to oscillate between NCC and non-icu consultant work?

 

[oopsy]

NCC fellowship is a buyer's market, there are more spots than applicants. ICU is not what most neurologists want to do. NCC is not as attractive for PCCM/ED/anesthesia folks for a variety of reasons, so that together makes it more a buyer's market.

Regarding non-ICU consultant work, see above in the thread, but I think that's going to be an emerging model where NCC physicians will be very attractive to medium sized hospitals trying to setup a CSC (you need an NCC physician) and more neurology FTE coverage to cover consults (not a standard model now, but that's a way to sell yourself and I know several junior attendings who have successfully done this). At larger centers, NCC physicians dont leave the ICU context very often. I work at a large academic center and cover some non-ICU consult time, but vast minority of my time. For what it's worth, our group is shifting so that some of the NCC physicians are going to contribute to the consult service time, but only those who were willing to (...AMS consults). Similarly, this was the case at the large academic center where I trained. But for financial reasons, you may find medium hospitals particularly more receptive to that model if you've got an interest in covering both floor and ICU services (it's not the only way of doing it, and is in fact atypical), but there you're more likely to run into politics re: who is going to provide ICU care for neuro/neurosurgical patients, etc. Largely a moot point at large centers.

 

[neurocritmd]

Thought these may be pertinent to this thread:
Survey of Neuro-intensivists on salaries and further stratified by geographical area and type of practice: 2019 Neurocritical Care Society Compensation Survey

I also found this recently published post on what new neurocritical care grads can expect from different models of practice that I think does a nice job of breaking it down:

The Business of Neurocritical Care: Practice Models and Models of Documentation

I am a neuro-intensivist that finished training last July and I really enjoy my job. Contrary to some of the provocative and inflammatory statements by some in this thread, I think delivering compassionate humanistic care to patients with either neurological injuries or risk of developing neurological injury in the ICU is a meaningful job. Contrary to the idea of "vegetable farming", so eloquently said by some, I find that having someone able to understand and communicate what a certain injury to the brain means for a patient usually results in better and quicker transitions to palliative care for those patients with poor prognoses, and less inappropriate withdrawals of care because someone doesn't understand prognosis or recovery for certain illnesses.