Neurology Fellowships for an academic career in neuromodulation?

[Aldertonghen]

I’m interested in this broad field and was wondering which fellowships would be good for it. I know of a person who did pain fellowships and now has a good setup at a large-ish hospital, does a lot of spinal cord stimulation but his patient population seems to be relatively….. umm not my cup of tea. Mostly chronic pain with little improvement.

I would personally like the same setup- a fair bit of procedure, opportunity for research but with more than just chronic pain patients. I’ve heard neuromodulation devices being used for MS (for incontinence, spasticity, pain). I was wondering if I could do an autoimmune neurology fellowship+ interventional pain fellowship and then be able to join the academia where I could do procedures as well as research concerning these two fields. I know MS is immunomodulation heavy- I am currently a research fellow in neuroimmunology (while applying to the match). But in the future I see myself more towards the electrical stimulation side of things rather than immunomodulation (probably since I had a bit of a physics background).

Is this a viable option? Does anyone know anything about this? I’m not putting my eggs on MS only, neuromodulation is an option for virtually every other neurology field and I’m interested to learn if any of them could have what I would like (relatively procedure heavy, academic research).

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[Thama]

By far the most common (and effective) neuromodulatory therapy is DBS, and that's mostly used in movement disorders. TMS is mostly used by psychiatry, not neurology. Spinal stimulators are crap. Epilepsy also has some options along these lines with VNS and recent approval of thalamic DBS, but in general if you want to shock brains for a living you want to find a DBS-heavy movement fellowship.

In general, your area of subspecialization/clinical practice and area of research interest don't have to align, though if you want to recruit subjects for clinical research it helps if they do.

 

[xenotype]

If you want to be placing devices and not just interrogating them/adjusting settings (procedurally) you'll have to do pain, and you won't find enough MS baclofen pump placement patients volume wise and absolutely will have to do chronic pain including the patients that didn't respond to all of the easy stuff. Pump placements and SCS are the high end of pain, and ridden with complications. If you are fine with interrogating devices and reading EEG then epilepsy would offer IOM, RNS/DBS/VNS, sEEG planning and interpretation, cortical stimulation but not actually cutting or sticking needles in people. DBS is a dumb device compared to RNS and there is far more you can do with RNS (but much narrower indications). MS itself is infusions +/- headache procedures, not high level procedures.

 

[Aldertonghen]

If you want to be placing devices and not just interrogating them/adjusting settings (procedurally) you'll have to do pain, and you won't find enough MS baclofen pump placement patients volume wise and absolutely will have to do chronic pain including the patients that didn't respond to all of the easy stuff. Pump placements and SCS are the high end of pain, and ridden with complications. If you are fine with interrogating devices and reading EEG then epilepsy would offer IOM, RNS/DBS/VNS, sEEG planning and interpretation, cortical stimulation but not actually cutting or sticking needles in people. DBS is a dumb device compared to RNS and there is far more you can do with RNS (but much narrower indications). MS itself is infusions +/- headache procedures, not high level procedures.

That’s a very helpful explanation. I’m actually okay with doing multiple fellowships to be able to customise my patient population as I’d like. I do somewhat prefer having to do actual procedures occasionally instead of just adjusting settings and reading them.

Epilepsy seems a good option for research, but the bread and butter of epilepsy is something I’m not sure I’m super excited about. There’s a ton of cases that turn out to not be a seizure, atleast in my med school. MS I actually like, the cases and findings are pretty interesting. Pain is what offers procedures which I want but seems to have lots of complications and the patient population isn’t something I want to get involved.

Is it viable to have a research interest in neuromodulation (DBS/VNS/RNS), while actually having a more MS heavy practice and placing baclofen pumps into those that need it? I’m okay doing 3 fellowships to be comfortable with all 3 of need be. Sorry if it seems like a silly question in any way.

 

[Aldertonghen]

By far the most common (and effective) neuromodulatory therapy is DBS, and that's mostly used in movement disorders. TMS is mostly used by psychiatry, not neurology. Spinal stimulators are crap. Epilepsy also has some options along these lines with VNS and recent approval of thalamic DBS, but in general if you want to shock brains for a living you want to find a DBS-heavy movement fellowship.

In general, your area of subspecialization/clinical practice and area of research interest don't have to align, though if you want to recruit subjects for clinical research it helps if they do.

Thank you for the explanation. I’m interested in neuromodulation research and would be interested in both epilepsy and movement disorders from that perspective. However from a clinical perspective I would like some procedural component. Movement does provide that with Botox to some extent but I was hoping for more, hence I mentioned pain fellowship for stuff like SCS or pump placement.

Sort of unrelated to the above, but would you happen to have any input on the recent research on connectomics in the field of neuro critical care, or medical devices such as the Stentrode that are inserted through endovascular means (on ALS patients)? These two certainly piqued my interest.

 

[flapjack3d]

By far the most common (and effective) neuromodulatory therapy is DBS, and that's mostly used in movement disorders. TMS is mostly used by psychiatry, not neurology. Spinal stimulators are crap. Epilepsy also has some options along these lines with VNS and recent approval of thalamic DBS, but in general if you want to shock brains for a living you want to find a DBS-heavy movement fellowship.

In general, your area of subspecialization/clinical practice and area of research interest don't have to align, though if you want to recruit subjects for clinical research it helps if they do.

Spinal cord stimulators are not crap. they used to be for sure but the technology has advanced. just did a pain rotation and about 40-50% of patients who had a trial of SCS said that it was "life changing" (going from 1 hr of sleep a night to 4 or 5 hrs, able to actually walk around during the day, drop in opioid requirements). i was skeptical too before this rotation.

 

[xenotype]

That’s a very helpful explanation. I’m actually okay with doing multiple fellowships to be able to customise my patient population as I’d like. I do somewhat prefer having to do actual procedures occasionally instead of just adjusting settings and reading them.

Epilepsy seems a good option for research, but the bread and butter of epilepsy is something I’m not sure I’m super excited about. There’s a ton of cases that turn out to not be a seizure, atleast in my med school. MS I actually like, the cases and findings are pretty interesting. Pain is what offers procedures which I want but seems to have lots of complications and the patient population isn’t something I want to get involved.

Is it viable to have a research interest in neuromodulation (DBS/VNS/RNS), while actually having a more MS heavy practice and placing baclofen pumps into those that need it? I’m okay doing 3 fellowships to be comfortable with all 3 of need be. Sorry if it seems like a silly question in any way.

Don't want to give you the wrong impression- you can really help people in interventional pain and as the above post references SCS and pumps can really, really help the right patients. But you'll get called about every problem with them, and occasionally the problems are fairly disastrous like baclofen withdrawal with a malfunctioning pump, infections etc. Most patients get better after pain procedures- there really is a precise, logical approach to it. Do a pain rotation before you decide one way or another. Most people who are skeptical of pain haven't worked with a pain physician in years and try to avoid chronic pain patients.

As for epilepsy- pseudoseizure patients are easy. Sure, they are a solid 20-30% of the referral base but the diagnosis is usually straightforward and you are done with them once you have 'the talk' in the EMU. The hard cases are actual, treatment resistant epilepsy. As for doing multiple subspecialties- you simply cannot be good at everything at once. You have to pick. RNS for example requires an epileptologist to really understand it and to interpret the data to gauge how to use the data- example that the standard in many cases of the quite common temporal lobe epilepsy in adults is shifting to placing RNS first for accurate, non-sampling biased data collection plus treatment, then definitive resection later if there is any question about bilateral disease (and there usually is). You can't really handle RNS and do mostly MS or pain- it is far too complex.

I wouldn't try to combine two vastly different highly technical subspecialties to suit niche interests of yours and then try to find a small patient population where they overlap to practice. You won't get enough of that volume, and you won't be very good at either one of the two areas. Pain is very procedurally complex, and at most you can be a decent general neurologist and do pain, or do MS, general neurology, headache etc, or do epilepsy/general neurology etc. Doing two fellowships is fine if there is some overlap or the field like headache has not a lot of risk for complications in every day practice. Hard to combine MS at a high level and pain- two entirely different areas that are always expanding in complexity quickly. It is already to the point that if one has no special expertise in MS or sees a substantial number of MS patients starting them on anything beyond basic copaxone/tecfidera requires referring out, and mismanaged natalizumab patients can result in a fatality from IRIS/infection/PML etc.

 

[Thama]

Spinal cord stimulators are not crap. they used to be for sure but the technology has advanced. just did a pain rotation and about 40-50% of patients who had a trial of SCS said that it was "life changing" (going from 1 hr of sleep a night to 4 or 5 hrs, able to actually walk around during the day, drop in opioid requirements). i was skeptical too before this rotation.

I've seen a fair number of people with SCS over the years and not once has someone reported that it did much more than a minor improvement if that. If there's been a recent change in technology in this area and they are vastly more effective than they have been historically, then that's awesome, but I've yet to see it trickle through to my practice.

Proceduralists routinely overestimate the effectiveness of their procedures. Surgeons often think their treatments work because they might see a patient once post-op but not follow through to see the long-term trajectory (see: neurosurgeons and NPH). Proceduralists like us who manage devices over time are subject to bias in who keeps coming back and who doesn't - after a while, some people just give up on the device working, and so you just keep seeing the good outcomes over time.

 

[Thama]

Thank you for the explanation. I’m interested in neuromodulation research and would be interested in both epilepsy and movement disorders from that perspective. However from a clinical perspective I would like some procedural component. Movement does provide that with Botox to some extent but I was hoping for more, hence I mentioned pain fellowship for stuff like SCS or pump placement.

Sort of unrelated to the above, but would you happen to have any input on the recent research on connectomics in the field of neuro critical care, or medical devices such as the Stentrode that are inserted through endovascular means (on ALS patients)? These two certainly piqued my interest.

Movement has both BTX and DBS for procedures. While DBS in the community is often done as a solo NSGY procedure, at any decent DBS center with a movement fellowship this is joint OR time with neurologist and neurosurgeon. Meanwhile, neurology-trained pain management docs generally refer to NSGY for SCS and intrathecal baclofen pump placement as well - just like movement, the procedural component is injections and device management. Just with a... different... patient population.

Re: connectomics in NCC - not really my field, though I do know some people doing this in coma research. Real connectomics (e.g. resting state fcMRI, high-directional multi-shell DTI) are pretty difficult in the critically ill, but there is some EEG-based and optical tomography-based work going on that may be promising.

Re: stentrode and similar devices - I'm extremely skeptical of this line of research for any brain-machine application. What these people are doing is equivalent to inventing the USB-C cable before anyone has figured out how to make a microprocessor work properly, and just Elon Musking the **** out of the marketing strategy to drum up funding and press.

 

[elanmorin]

I wouldn't try to combine two vastly different highly technical subspecialties to suit niche interests of yours and then try to find a small patient population where they overlap to practice. You won't get enough of that volume, and you won't be very good at either one of the two areas. Pain is very procedurally complex, and at most you can be a decent general neurologist and do pain, or do MS, general neurology, headache etc, or do epilepsy/general neurology etc. Doing two fellowships is fine if there is some overlap or the field like headache has not a lot of risk for complications in every day practice. Hard to combine MS at a high level and pain- two entirely different areas that are always expanding in complexity quickly. It is already to the point that if one has no special expertise in MS or sees a substantial number of MS patients starting them on anything beyond basic copaxone/tecfidera requires referring out, and mismanaged natalizumab patients can result in a fatality from IRIS/infection/PML etc.

This. With the rate the body of knowledge is expanding, by the time OP finishes residency and 3 fellowships, this will be even more true, and probably the only field they could consider themselves truly expert in would be their last fellowship.

I would say stick with one fellowship if you're interested in neuromodulation, and right now pain, movement disorders, and epilepsy would be your best bets (in that order). If you haven't already, do some rotations in PM&R and neurosurgery (especially with functional/stereotactic specialist) as well to get an idea of how other disciplines fit neuromodulation into their practices as well.

 

[Aldertonghen]

Spinal cord stimulators are not crap. they used to be for sure but the technology has advanced. just did a pain rotation and about 40-50% of patients who had a trial of SCS said that it was "life changing" (going from 1 hr of sleep a night to 4 or 5 hrs, able to actually walk around during the day, drop in opioid requirements). i was skeptical too before this rotation.

That was my experience too, although I onlyshadowed someone instead of an actual rotation.

 

[Aldertonghen]

This. With the rate the body of knowledge is expanding, by the time OP finishes residency and 3 fellowships, this will be even more true, and probably the only field they could consider themselves truly expert in would be their last fellowship.

I would say stick with one fellowship if you're interested in neuromodulation, and right now pain, movement disorders, and epilepsy would be your best bets (in that order). If you haven't already, do some rotations in PM&R and neurosurgery (especially with functional/stereotactic specialist) as well to get an idea of how other disciplines fit neuromodulation into their practices as well.

Thank you! You’re right about not trying to spread oneself too thin and instead focusing on just 1 subspecialty. I will do a pain rotation soon to find out more.

 

[Aldertonghen]

Movement has both BTX and DBS for procedures. While DBS in the community is often done as a solo NSGY procedure, at any decent DBS center with a movement fellowship this is joint OR time with neurologist and neurosurgeon. Meanwhile, neurology-trained pain management docs generally refer to NSGY for SCS and intrathecal baclofen pump placement as well - just like movement, the procedural component is injections and device management. Just with a... different... patient population.

Re: connectomics in NCC - not really my field, though I do know some people doing this in coma research. Real connectomics (e.g. resting state fcMRI, high-directional multi-shell DTI) are pretty difficult in the critically ill, but there is some EEG-based and optical tomography-based work going on that may be promising.

Re: stentrode and similar devices - I'm extremely skeptical of this line of research for any brain-machine application. What these people are doing is equivalent to inventing the USB-C cable before anyone has figured out how to make a microprocessor work properly, and just Elon Musking the **** out of the marketing strategy to drum up funding and press.

Could you tell me more about what a DBS neurologist does in the OR? You’ve mentioned before that they do the programming, but I’m not fully familiar with the process. Similarly, epilepsy also seems to be growing in this direction with VNS, opportunities for IOM and so on. Just wondering about the procedural component in these two semi-niche academic fields.

 

[Aldertonghen]

Don't want to give you the wrong impression- you can really help people in interventional pain and as the above post references SCS and pumps can really, really help the right patients. But you'll get called about every problem with them, and occasionally the problems are fairly disastrous like baclofen withdrawal with a malfunctioning pump, infections etc. Most patients get better after pain procedures- there really is a precise, logical approach to it. Do a pain rotation before you decide one way or another. Most people who are skeptical of pain haven't worked with a pain physician in years and try to avoid chronic pain patients.

As for epilepsy- pseudoseizure patients are easy. Sure, they are a solid 20-30% of the referral base but the diagnosis is usually straightforward and you are done with them once you have 'the talk' in the EMU. The hard cases are actual, treatment resistant epilepsy. As for doing multiple subspecialties- you simply cannot be good at everything at once. You have to pick. RNS for example requires an epileptologist to really understand it and to interpret the data to gauge how to use the data- example that the standard in many cases of the quite common temporal lobe epilepsy in adults is shifting to placing RNS first for accurate, non-sampling biased data collection plus treatment, then definitive resection later if there is any question about bilateral disease (and there usually is). You can't really handle RNS and do mostly MS or pain- it is far too complex.

I wouldn't try to combine two vastly different highly technical subspecialties to suit niche interests of yours and then try to find a small patient population where they overlap to practice. You won't get enough of that volume, and you won't be very good at either one of the two areas. Pain is very procedurally complex, and at most you can be a decent general neurologist and do pain, or do MS, general neurology, headache etc, or do epilepsy/general neurology etc. Doing two fellowships is fine if there is some overlap or the field like headache has not a lot of risk for complications in every day practice. Hard to combine MS at a high level and pain- two entirely different areas that are always expanding in complexity quickly. It is already to the point that if one has no special expertise in MS or sees a substantial number of MS patients starting them on anything beyond basic copaxone/tecfidera requires referring out, and mismanaged natalizumab patients can result in a fatality from IRIS/infection/PML etc.

That’s a great point, thank you! Regarding fellowships that overlap with each other, what are some fellowships that people can add onto/combine with epilepsy or pain, respectively? I’ve heard someone who did in pain and EMG/neuromuscular both as there’s some overlap (neuropathic pain). Headache+pain is another that seems doable.

 

[xenotype]

That’s a great point, thank you! Regarding fellowships that overlap with each other, what are some fellowships that people can add onto/combine with epilepsy or pain, respectively? I’ve heard someone who did in pain and EMG/neuromuscular both as there’s some overlap (neuropathic pain). Headache+pain is another that seems doable.

EMG and pain can overlap- at least the common stuff for EMG, but PM&R residency is honestly a better integrated route if you want to go that direction. The overlap is radiculopathies, and it can occasionally help you better target injections but not nearly as much as an MRI.

Headache and pain are doable, but honestly a neurology residency and a pain fellowship should be plenty of background in headache to skip the second fellowship in most cases.

 

[Thama]

Could you tell me more about what a DBS neurologist does in the OR? You’ve mentioned before that they do the programming, but I’m not fully familiar with the process. Similarly, epilepsy also seems to be growing in this direction with VNS, opportunities for IOM and so on. Just wondering about the procedural component in these two semi-niche academic fields.

Generally, the neurosurgeon is on one side of the curtain and the neurologist is on the other facing the (usually) awake patient. Neurologist and neurosurgeon generally jointly plan target and trajectory, neurosurgeon preps, drills and inserts recording electrode, neurologist performs and interprets MER recordings and decides target depth, neurosurgeon drops stimulating electrode, neurologist tests and programs stimulating electrode while examining patient, and neurosurgeon closes once electrode confirmed in good position. There are variations on this theme, but this is the idea you'll find at most well-known DBS centers.

 

[Aldertonghen]

Generally, the neurosurgeon is on one side of the curtain and the neurologist is on the other facing the (usually) awake patient. Neurologist and neurosurgeon generally jointly plan target and trajectory, neurosurgeon preps, drills and inserts recording electrode, neurologist performs and interprets MER recordings and decides target depth, neurosurgeon drops stimulating electrode, neurologist tests and programs stimulating electrode while examining patient, and neurosurgeon closes once electrode confirmed in good position. There are variations on this theme, but this is the idea you'll find at most well-known DBS centers.

That sounds really interesting! I hadn’t really considered movement disorders before but it sounds like a really cool field for the type of work and research I’m interested in. The movement docs in my med school all have outpatient exclusive practices so I don’t have much exposure.

I would like to ask if movement disorders can potentially have inpatient/hospitalist-like work as well. I’m really considering epilepsy too because it has some cool applications but also has an inpatient component that I’m really starting to like on my current rotation. The attending here does inpatient hospitalist(+EEGs) for two weeks, the other two weeks he’s mostly free for epilepsy research (other than two half days of clinic). In an ideal world, I’d very much like to have a similar setup to the above where I do clinical duties for two weeks and research the other.

 

[Aldertonghen]

EMG and pain can overlap- at least the common stuff for EMG, but PM&R residency is honestly a better integrated route if you want to go that direction. The overlap is radiculopathies, and it can occasionally help you better target injections but not nearly as much as an MRI.

Headache and pain are doable, but honestly a neurology residency and a pain fellowship should be plenty of background in headache to skip the second fellowship in most cases.

My reason for neuromuscular/EMG was that it would be complementary in some way to pain, yet would also greatly help in an outpatient setting in general neurology in case I want to go down that line later on. General neurology+pain with the ability to interpret EMGs looked like a decent clinical practice to go alongwith research, although I’m not sure if that’s even possible in a big academic place.

It seems hard to decide right now. I guess I’ll need more exposure. I know what sort of research I’d like to be involved in but have less of an idea about the clinical setting. I thought I always wanted outpatient but I actually like my current inpatient rotation with an EEG specialist/hospitalist.

Apart from pain, movement and epilepsy, are there other promising fields? I read a couple of articles of transcranial direct current stimulation in stroke and was wondering if you might know more about it. What about NCC (considering that it is very procedure heavy too)?

 

[Thama]

That sounds really interesting! I hadn’t really considered movement disorders before but it sounds like a really cool field for the type of work and research I’m interested in. The movement docs in my med school all have outpatient exclusive practices so I don’t have much exposure.

Movement disorders is mostly outpatient by nature, with the occasional inpatient procedure mixed in if you do DBS.

I would like to ask if movement disorders can potentially have inpatient/hospitalist-like work as well. I’m really considering epilepsy too because it has some cool applications but also has an inpatient component that I’m really starting to like on my current rotation. The attending here does inpatient hospitalist(+EEGs) for two weeks, the other two weeks he’s mostly free for epilepsy research (other than two half days of clinic). In an ideal world, I’d very much like to have a similar setup to the above where I do clinical duties for two weeks and research the other.

It depends on what you mean by "neuro-hospitalist". In large and academic centers, it doesn't really matter what fellowship you do to work on the inpatient service - I know people that do substantial inpatient time who are trained in dementia, MS, neuromuscle, movement, headache, etc. But that's unlikely to be in any way 7 on / 7 off, it's typically a handful of 1-2 week blocks per year (depending on clinical effort %), and you're still doing your own outpatient clinic the rest of the time. If you want to do an inpatient only gig then you aren't going to see all that much movement, and you also probably aren't going to do this at a center where you'll be able to fund research for over half your effort. If you're doing something like the epilepsy attending you describe then research is your hobby not your career.