Neurohospitalist: vascular vs neurocritical care fellowship

[texasneuro]

Long time reader, first time poster.

I'm currently a PGY-2 resident, and I'm at that stage where I'm trying to figure out what's next after residency. I really enjoy inpatient neurology and think that a career in inpatient neurology is for me. I also enjoy the neuro ICU, but I don't know if I want my career to only be focused on the ICU.

Historically, for a neurohospitalist, it appears that vascular neurology is the fellowship most people pursue. It looks like many of these hospitals with neurohospitalist positions also look for people who could potentially be a stroke director in the future. Would I be limiting my future neurohospitalist career options by choosing a neurocritical care fellowship?

Thanks for your help.

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[neuro critical]

Hi
Let me give my disclosures first: I am finishing a neurocritical care fellowship

My impression is that neuroICU prepares you better to be a neurohospitalist. Although ischemic strokes are frequent, your practice will not be restricted to that. In the ICU you will deal with severe cases of other neuro disesases, such as status epilepticus, MG, GBS, cerebral venous sinus thrombosis, SAH, ICH, etoh/benzo w/d, among others. You will also be extremely proficient with procedures. Although in "theory" ICH and SAH are Strokes, you dont deal with it much in a Stroke fellowship (most places it is taken care by nicu/nsgy). Also, I see many patients "returning" from the step down unit to the nicu due to medical complications not properly addressed by the stroke team (even though we work in a hospital where the nicu and stroke fellowships are considered among the best 3 in the country)
That is my opnion

 

[Strokeguy]

Hi,
My disclosure - Vascular Neurologist.
The best answer to your question lies in what role does the particular 'neurohospitalist job' have for you. If it involves predominantly taking care of pts in the ICU and subsequent step-down to Intermediate care and floor then no doubt NICU is the training that you should pursue. A lot of private practice jobs are in these so called 'neuroscience institutes' where you will also manage pts with neurotrauma, post-neurosurgical pts etc and would be employed primarily by the neurosurgery service.
If the neurohospitalist job predominantly requires you to do inpt neurology and also manage acute stroke remotely through telemedicine as well as in-house ER and also do inpt gen neurology which includes seizures, MS exacerbation, GB, Myasthenia etc then an ACGME accredited vascular neurology fellowship is the best. These fellowships will give you training not just in various aspects of acute stroke care (which has concepts not confined to TPA alone) as well as administrative aspects of managing a stroke unit, managing and developing a telestroke program, GWTG core measures etc. What is a stroke unit? Any pt with ischemic stroke, cerebral venous thrombosis or ICH who doesn't require intubation/vent is taken care of in the stroke unit. This includes care of pts post-endovascular treatment as well (as long as they are not intubated).
How is vasc neuro different from NeuroICU training? Well it goes without saying that we don't manage intubated pts, SAH, TBI. There was more overlap in these 2 subspecialities some yrs ago when stroke neurologists grandfathered into NeuroICU and were also eligible to take the UCNS certification. Now they have moved into different directions with still some overlap. At every institution where there is an ACGME accredited vasc neuro fellowship and a UCNS accredited NICU fellowship, the acute management of neurologic emergencies is predominantly done by the stroke svc. Remember a lot of stroke mimics (which includes sz, migraine, myasthenia ----) present acutely and are all managed by the stroke services. A neuro residency prepares you well for MS exacerbation, etc. Of these pts, those needing intubation/vent are triaged to the ICU, otherwise go to stroke units. So a neurohospitalist job that requires you to manage acute stroke/neuro emergencies and then subsequent care; then vasc neuro is best for you. NeuroICU prepares you to take care of TBI and SAH, but in reality there is a lot of 'interference' from neurosurgery in decision making.
There would be cases of stroke svc perhaps mismanaging medical aspects, but then I have also seen times when recent NICU grads have issue with acute stroke care (no disrespect intended). This is again because the training takes them to a certain population of sick pts who need different care.
Remember - it is by 'doing' things everyday during training that you become proficient in something. Vasc neurology, NICU each have some overlap but also different roles. VN has a greater role in the ER or remotely, NICU more geared towards critical care.
Since there is great variability in neurohospitalist work patterns, the pt population and expectations essentially determine what would be the best training.

 

[typhoonegator]

It really depends on the fellowship program and the employment situation. If you want to be a stroke director, then it's a no brainer to do vascular neurology, and the same is true if you want to practice at a hospital that is really caught up in certification titles. Remember, though, that any licensed physician can order tPA if they can find someone to listen to them.

Some NCC programs give a lot of vascular neuro exposure, and others really do not, having farmed it out to "neuro step down" units run by the vascular folks. If you're worried that you won't get enough ischemic stroke training in NCC, then you should make sure you pick a fellowship where you take acute stroke call and where the stroke patients go to the neuroICU.

One thing to keep in mind, however, is that NCC fellowships tend to be much more physically and emotionally challenging than other neuro fellowships. Lots of call, lots of death. If you really want to do mostly neurohospitalist work, you need to decide whether the benefits of being better trained outweigh the time and effort of the training. It's also a question of 1 or 2 years.

I know several neurohospitalists who have no fellowship training, and are doing just fine. On the flip side, I trained in NCC at a program that is very stroke-heavy, and now I attend on both the ICU and acute stroke services. So with the right situation, you can make almost anything work.

N.B. None of this is meant to rip on the vascular folks. I can't run a stroke clinic, or read carotid dopplers, and I am not as up on the literature of secondary prevention as they are. They are really good at that stuff, and I freely admit that I am not. We just focus on different things.

 

[texasneuro]

Thanks to everyone for your help! Very informative responses.

 

[snakesonaplane]

Thanks to everyone for your help! Very informative responses.

All these things considered, can anyone provide information on the UCSF hospitalist fellowship?

Would a stroke fellowship plus a hospitalist fellowship be redundant or is there an advantage of doing this? And if this were to be done, would it just make more sense to do 2 yrs of critical care?

 

[Dvt2000]

Long time reader, first time poster.

I'm currently a PGY-2 resident, and I'm at that stage where I'm trying to figure out what's next after residency. I really enjoy inpatient neurology and think that a career in inpatient neurology is for me. I also enjoy the neuro ICU, but I don't know if I want my career to only be focused on the ICU.

Historically, for a neurohospitalist, it appears that vascular neurology is the fellowship most people pursue. It looks like many of these hospitals with neurohospitalist positions also look for people who could potentially be a stroke director in the future. Would I be limiting my future neurohospitalist career options by choosing a neurocritical care fellowship?

Thanks for your help.

Actually, at the present time, the majority of neurohospitalists nationwide have no fellowship at all. If however, you want to work only at a major center, in academia or quasi-academia, a fellowship would probably be required, unless you've got good connections.

IMO, the NCC route is more difficult, but more sure a thing (the future of stroke as an entity independent of general neurology remains in doubt). I'd also expect it would bring a higher salary.

 

[Strokeguy]

,the future of stroke as an entity independent of general neurology remains in doubt).

Quite contrary to what I have heard and read. A recent article in Stroke by Leira et al highlights the severe shortage of vascular neurologists and the number of jobs available in different settings. The salary in NeuroICU though is more and driven by critical care billing as well as the fact that it is also paid by neurosurgery groups/departments (which also means a lot of interference from them).
In any case, as more trials evolve and get completed there is / will always be more vascular stuff to do. I would think of evolution of neurology as a whole like cardiology (in which EP is another subspecialization, different from interventional cards, but both within the div of cardiology with a clinical overlap). A lot of outpt things (incl MD, MS management with newer agents for example) is likely to be for non-vasc neurologists. All neurology subspecialists can always practice gen neurology (which is a smaller portion of inpt neurology).

 

[Dvt2000]

,the future of stroke as an entity independent of general neurology remains in doubt).

Quite contrary to what I have heard and read. A recent article in Stroke by Leira et al highlights the severe shortage of vascular neurologists and the number of jobs available in different settings. The salary in NeuroICU though is more and driven by critical care billing as well as the fact that it is also paid by neurosurgery groups/departments (which also means a lot of interference from them).
In any case, as more trials evolve and get completed there is / will always be more vascular stuff to do. I would think of evolution of neurology as a whole like cardiology (in which EP is another subspecialization, different from interventional cards, but both within the div of cardiology with a clinical overlap). A lot of outpt things (incl MD, MS management with newer agents for example) is likely to be for non-vasc neurologists. All neurology subspecialists can always practice gen neurology (which is a smaller portion of inpt neurology).

Somehow I'm not surprised to see that Stroke is beating the drums about a perceived shortage of vascular neurologists. Every field needs to generate "scarcity" by whatever means are available. A perceived need in 5-10 years isn't much to hang your hat on today.

With the cost control measures coming, one needs to consider that Medicare might one day take a more cost-benefit approach to reimbursement, and if IV-TPA is the only one that Medicare chooses to pay for, because other interventions haven't panned out, then vascular neurology will dry up significantly.

 

[Strokeguy]

EMG already has a 50% cut. No speciality/subspeciality is spared. I am purely referring to patient populations and the need of employers. I don't even have to say that with >800k strokes a year and the single largest neurologic disease entity and the fact that JCAHO is moving towards core measures (GWTG) and stroke center certification, these are the jobs employers are looking to hire for.
The cost-cutting measures will create problems for every physician. Neurology in general or particularly vasc neuro is no different. There are huge patient populations to take care of. The 'other' interventions that haven't panned out were never billed for by vascular neurologists !!

 

[Dvt2000]

EMG already has a 50% cut. No speciality/subspeciality is spared. I am purely referring to patient populations and the need of employers. I don't even have to say that with >800k strokes a year and the single largest neurologic disease entity and the fact that JCAHO is moving towards core measures (GWTG) and stroke center certification, these are the jobs employers are looking to hire for.
The cost-cutting measures will create problems for every physician. Neurology in general or particularly vasc neuro is no different. There are huge patient populations to take care of. The 'other' interventions that haven't panned out were never billed for by vascular neurologists !!

No, but the salaries of those neurologists was partly or near-fully paid by those procedures. We are, after all, talking about neuro-hospitalists, the vast majority of whom are hospital-employed.

Also, any neurologist should be able to treat stroke. The whole impetus for a vascular branch in neurology was because, supposedly, a whole new world of intervention was coming, that was going to take special expertise. That doesn't appear to be going anywhere fast, as far ahead as can be seen.

The original poster asked about a vascular fellowship vs. NCC. I stand behind my original statement, that a NCC felllowship has a much more certain future. Again though, it limits the number of places one can work, to a small percentage.

 

[RAD345]

Vascular neurology is now the common trend for nerurohospitalist positions. The NCC is well desired for ICU related care not a Neurohospitaliat.

Lots of small community hospitals get a load of stroke pt and transfer almost all of their sick pt like SAH to larger/tertiary hospital with NCC/Neurosurgry back up.

There is need for both specialities. It's your choice to spend more time in the ICU or on the floor.

 

[Iliopsoas]

My bias is towards NCC

I agree with Dvt2000 and Rad345, but will add this point. NCC trained doctors can do everything a vascular neurologist can do. Conversely, a vascular neurologist cannot do everything a NCC trained doc can. I absolutely agree with Dvt2000 that the need to specialize in vascular neurology to manage stroke is vanishing. Most PGY4 residents can manage even the most complicated strokes. Many of the private neurologists in my area that are hiring, indicate that stroke fellowship is really not needed. Many of my peers are being hired without vascular neurology fellowship for positions as neurohospitalists. The transition to being the Director of a department is one more of seniority in some hospitals than training. But, it certainly depends on what city you are in.

While I have the highest admiration for my colleagues and mentors in vascular neurology, I simply feel that their job prospects outside of academics would be more limited than a NCC trained person. This is a very interesting discussion & one I have had with some of my attendings in residency. I am curious to hear what other vascular neurologist's think.

 

[Vader]

Long time reader, first time poster.

I'm currently a PGY-2 resident, and I'm at that stage where I'm trying to figure out what's next after residency. I really enjoy inpatient neurology and think that a career in inpatient neurology is for me. I also enjoy the neuro ICU, but I don't know if I want my career to only be focused on the ICU.

Historically, for a neurohospitalist, it appears that vascular neurology is the fellowship most people pursue. It looks like many of these hospitals with neurohospitalist positions also look for people who could potentially be a stroke director in the future. Would I be limiting my future neurohospitalist career options by choosing a neurocritical care fellowship?

Thanks for your help.

These are two of several paths people are taking to a neurohospitalist career.

I would also add that:
1) It is NOT necessary to do a fellowship to be a neurohospitalist.

2) A fellowship should give some particularly additional expertise and ideally a skill set that the non-fellow does not have.

3) Clinical neurophysiology, particularly those fellowships focused on EEG/EMU or IOM should be strongly considered.

4) Using the term "historically" for a career pathway that is really only 5-6 years old makes me feel VERY old.

 

[Strokeguy]

"No, but the salaries of those neurologists was partly or near-fully paid by those procedures. We are, after all, talking about neuro-hospitalists, the vast majority of whom are hospital-employed.

Also, any neurologist should be able to treat stroke. The whole impetus for a vascular branch in neurology was because, supposedly, a whole new world of intervention was coming, that was going to take special expertise. That doesn't appear to be going anywhere fast, as far ahead as can be seen."

Again, the salaries of vasc neurologists are never partially or completely paid for by 'procedures'. The failure of IAT trials again opens the field more for vasc neurologists (quite contrary to above). WHY? At least in the US people have for whatever reason been more aware of IAT procedures for stroke. Now we know it will likely have a relatively limited role - this by itself opens the game significantly for medical therapies. These are NOT 10-15 yrs away. We have these in phase 1,2,3 trials and in the next couple of yrs or so you will start hearing about these. Of course this is beyond the scope of this forum, but suffice it to say we will have a more algorithm based approach in ischemic stroke treatment.
On a different note - I may not have liked the attitude of neurologists from the EU - but certainly they have ensured that gathering evidence with other multiple med therapies has continued to progress. All these will require training to practice.
Another complex issue - arrival of new antithrombotics as alternatives to coumadin (how would you pick and choose); how will you treat pts taking newer agents who present with a stroke....
'Stroke med getting phased out is a completely ridiculous statement'.
WHY do we have so many neurohospitalist jobs? Because many neurologists are retiring and others don't find it cost effective or want a better lifestyle with outpt work; creating severe shortage of physicians for inhouse work. The senior neurologists who are hiring want to get rid of their calls so almost everyone has several hospitalist jobs to choose from. Again, at more desirable locations. a stroke fellowship remains advantageous if there are more people applying.
HCA and Merritt Hawkins associates who I have spoken to certainly have conveyed this.
What do you bring to the table as a Vasc Neurologist (for neuro hosp in private practice)- TCD/CUS- portable dopplers are not expensive and reimbursement for the entire billing goes to the 'neurology division'. Theoretically any neurologist can be certified in neurosonology - but it would take them a long time to get 100 TCDs and 100 carotid US to be eligible for certification. Apart from other skills a stroke fellowship gets you these as well.
This forum is visited by med students and residents who have at least 4-5 yrs before they start practicing. It is also important for them to realize the politics of working with neurosurgeons in an ICU setting. It is too simplistic and even naive to say that 'NCC trained doctors can do everything a vascular neurologist can do. Conversely, a vascular neurologist cannot do everything a NCC trained doc can.'
I strongly believe that the best outcomes for neuro pts in an ICU setting is when there are 'neurointensivists' to take care of them.
Before I go further - I have some disclosures - I have trained and working at tier1 institution (whatever it is); have been involved in several multicenter trials; double boarded in VN and NICU; and have friends in other institutions as well who are stroke neurologists and intensivists. The unfortunate part is that there is significant 'control' of neurosurgeons on most decision making of pts in the NICU. Even procedures that are specific to NICU - placement of EVD, ICP monitors, microdialysis (if you are into research) are all done by them. Even things like EVD management (when to raise it, clamp it and remove it, or using TPA offlabelled for IVH) is completely controlled by them. They even throw weight on issues like BP goals for many pts with trauma or SAH. There is so much interference in vasospasm management incl when to take the pt for angioplasty, BP goals etc. I know of a few friends who also trained to place EVDs during NICU fellowship (there is just one program in the nation where you can learn this skillas well). But they couldn't get credentialled anywhere after training since the neurosurgeons didn't let them. Again no offence intended to neurointensivists, they are some of the most hard working neurologists.
In private practice - a lot of these procedures are done by nsurg PAs. This helps to pay their salaries and the consultant neurosurgeons are able to maintain a relatively decent lifestyle without making a dent on their billing. It also ensures that they maintain 'control' over neurosurgical pts.
The idea of neuroICU as an extension of VN (and these being a single subspeciality) didn't survive for this very reason. This also leads to a significant conflict of interest when you work.
Again, I didn't want to offend any NICU folks. I share excellent professional terms with them. Apologies if anyone is offended. There were some statements made in this forum which were too farfetched more so when neurohosp track is barely few yrs old. It was in my opinion necessary for the those who visit this forum to be aware of all realities mentioned above to make informed decisions.
I do not want to cite specific examples for sake of privacy (pm me for any details). While everyone is free to believe anything, VN as an independent subspeciality is going to stay. In many ways, it is a better time to be a stroke neurologist now than ever before.

 

[neurochica]

I accepted a neurohospitalist position with a Neurosurgery private practice group last year with no fellowship training. I am also training in a program that is extremely stroke heavy with world class stroke faculty and hence, feel comfortable in an inpatient setting.

In my opinion, in the real world, not academic, when looking for a neurohospitalist job it is more important how you "fit" in with a group/hospital than if you have a vascular/NCC fellowship. I know for a fact that there was 2 fellowship trained vascular neurologist who competed with me for my position and obviously I was offered the position.

I interview in numerous private practice, academic, and employed positions and not having a fellowship was never an issue. I was in an interesting position because I was offered a vascular fellowship position in my program and when interviewing I always told them that I was willing to complete a vascular position if it was for the best interest of the group/hospital.
I agree with strokeguy in regards with neurosurgery turf wars in most institution. That's why I joined them!!!
My 2 cents.

 

[Hockeyfan23]

Bump. Reviving an old thread. Like the original poster I am a current PGY-2 in Neurology. I am also looking to go into the neurohospitalist field but am not so much interested in obtaining a fellowship. I am at a program that is very “inpatient and stroke” centered so I definitely feel I will be able to handle inpatient neurology and stroke following completion of residency. I have no interest in research or academics and would be looking into the private sector. Would like to hear opinions from my peers regarding fellowship importance as it has been a few years since this thread was last approached. Also any guidance from people who have recently gone through the job hunting process would be appreciated. I realize I’m still a PGY-2 but I’m trying to figure life out... Thank you in advance!

 

[typhoonegator]

I don't see any good reason to do NCC fellowship if you're certain all you want to do is neurohospitalist work these days. Why put yourself through the ravages of a two year intensive care fellowship if your goal isn't going to be to optimize CC billing in the ICU or teach or do research or whatever?

Plenty of people on these boards are successful in neurohospitalist practice from different (or no) fellowship backgrounds. There are a few predominantly optical advantages to VN fellowship since everyone these days wants to be a PSC or PSC+ in the near future, and having "dual use" neurohospitalists has some appeal in those situations -- but it is by no means mandatory, and tons of neurologists give tPA and manage post-stroke workups every day without VN fellowship experience. Plenty of VN fellowships are pretty clinically light anyway (more research focused) and so some so-called VN specialists know more about stroke epidemiology than they do about inpatient stroke care.

The key is understanding how confident you are in what you want. Deciding later on that you'd rather specialize (in whatever) has a larger opportunity-cost associated with it than just doing fellowship post-residency. But if you never end up using it, it's just wasted time no matter how you slice it.

 

[Hockeyfan23]

Thank you for the reply. That is all I am thinking. I do not want to waste a year of fellowship if it is just to say that I have one. I am originally from the southwest suburbs of Chicago and am looking to return when I finish residency. I would be willing to work in suburbs or even northwest Indiana. Will there still be opportunities in that area without fellowship? Is there a lot of opportunity for partnership in the neurohospitalist field? Thanks again.

 

[Hank Rearden]

I'm an academic neurologist with VN fellowship training. Did some moonlighting in the past as a neurohospitalist. Based on the limited neurohospitalist groups I'm familiar with, typically you would be an employee of the hospital. I know of one group where they have a partnership and are contracted by the hospital, but I think those are few and far between. I'm not familiar with the lay of the land for neurohospitalist jobs in Chi-town, but would guess there are some opportunities. VN fellowship training would definitely make you more competitive for these spots and could be the difference between working in the city vs. NW Indiana. If you had any interest in being stroke director somewhere that would probably also come with a bump in salary. For what it's worth I think doing a neurohospitalist fellowship is a complete waste of time.