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Vascular Neurology

Discussion in 'Neurology' started by GrtWhtNrth, Mar 31, 2012.

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  1. GrtWhtNrth

    GrtWhtNrth

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    I am a neurology resident who had a couple questions about stroke fellowship.

    I am trying to figure out what I want to do with my life and was wondering what the benefits are of doing a stroke fellowship. If I went that route I would not do NIR and would likely look for neurohospitalist or stroke job. Although I probably like stroke the best out of everything in neurology, in the long term I am not sure if I want to spend all of my career in the inpatient setting (although I think inpatient would be ideal for at least the beginning of my career).

    Alternatively I could do emg/neurophys (which I am less interested in), work as a neurohospitalist for a while, do some EMG's on the side, and have a skill I could apply in outpatient neurology if I eventually make the transition to outpatient.

    Questions:

    If I did a stroke fellowship would it be practical to transition to an outpatient career eventually ?

    After fellowship, if I were working in a community hospital for example, is stroke call any worse than general neurology call?

    Do you do better financially with a stroke fellowship than without if you were a neurohospitalist? If so, why is that the case? How do non-interventional vascular neurologists command a higher salary?
  2. danielmd06

    danielmd06 Neurosomnologist

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    My opinions...

    1) Politically correct short answer is "maybe, it depends." More pragmatic answer is "no." While you certainly see stroke patients in the outpatient office, stroke medicine is really a different animal from general neurology and all of its idiosyncrasies. Much of stroke is inpatient and emergency consults, in direct contrast to traditional general neurology (which is outpatient heavy). This makes vascular neurology (and it's related cousins) highly useful knowledge for neurohospitalists and inpatient-heavy neuro folks.

    Also, and perhaps more importantly, outpatient neurology and inpatient neurology are really two very different animals. There is an increasing gulf between the two in terms of caseload and spectrum of management. If once you start down the path of practicing exclusively within an inpatient (or outpatient) venue, I think you may find it much harder than you may initially suspect to re-connect to the other half of the coin. Not simply by virtue of having done a stroke fellowship, but rather because you have been practicing inpatient neurology for long enough to completely forget how to manage the old-fashioned neurology office patients. The reverse holds true as well, in my opinion.

    A neurophysiology fellowship would be the best preparation for general outpatient neurology, unless you had a very specific sub-set of patients you wished to work with (neuro-immunology, movement disorders, etc), in which case separate fellowships exist for these entities.

    2) Heh. Yep. People may argue about this but to me it's a no-brainer. Stroke care is virtually the only aspect of neurology that potentially requires STAT consideration, likely personal presence, and meticulous management from a neurologist himself/herself. Something around 99.9% of other neurological issues/emergencies can be managed over the phone and/or the next morning. You just tell the EM or whoever what to do. Status epilepticus? Intubate, load with an AED, and check in the morning. Meningitis? Have the ER tap, get cultures, load with broad antibiotics, and check in the morning. Stroke? You may find yourself driving in at 2AM to do an NIHSS yourself and give clearance for IVtPA. Alot of ER people aren't going to push tPA without you having evaluated the patient or given express clearance for giving the drug. And you have to be arguably more prepared for the potential legal fallout of mismanagement of stroke patients compared to general neurology patients in my opinion, too.

    Stroke call will require a certain amount of maturity and patience on your part. I myself managed this fine for about two years of residency (I originally wanted to do this as a career) before becoming a bit disillusioned. Be prepared for some serious frustration in the form of half-way exams, histories, and physicians who aren't really interested in much beyond "dumping" a patient onto someone else's burden of responsibility.

    3) Not sure because it's highly dependent on a variety of factors but I suspect it's financially equivalent from a neurohospitalist standpoint (though a stroke fellowship would be helpful to you in the capacity of doing your job). You could feasibly pick up some additional dollars as the medical director of a stroke program or stroke center of excellence with the fellowship under your belt. You could also possibly leverage a hospital or group for more money when applying for this type of position with a stroke fellowship if they were specifically in need of a stroke person to augment their existing armamentarium of fellowship training. Otherwise I cannot see what difference it would make.

    I also believe you would be well-served for inpatient neurology with a neurocritical care fellowship, or a neurophysiology fellowship.
    Last edited: Mar 31, 2012
  3. typhoonegator

    typhoonegator Neurointensivist Moderator

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    Agree with above.

    Stroke call is much worse than general neuro call. As someone who carries a teleneurology pager on the speed dial of over 32 community hospitals, I can assure you that in the eyes of a busy ED physician, every transient neurologic deficit that is sudden in onset is a stroke until proven otherwise, and you can't blame them for that because it's a can't-miss diagnosis.

    Tingly hands after an MVA? L arm numbness with chest pain? Left facial burning? Confusion? All r/o strokes, all coming your way, 24h a day. Can you sift through them? Sure, but some you are going to have to see in person to work out, and seeing them in person tomorrow might not be an option.

    Now, if you practice somewhere with a fellowship, then someone else might be triaging those calls, but that is a luxury many don't have.
  4. neurologist

    neurologist Schussing Moderator

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    FWIW, there's teleneurology now, where you can do the eval (with assist from the ER doc) and authorize/defer TPA over the phone and computer.
    We've been using this system for a couple years and it seems to work out well.
    It at least (usually) saves you a trip to the ER at 2 am.
  5. bblue

    bblue Member

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    This is an interesting thread, I'd love to hear more opinions about this from both sides.

    I'm interested in stroke, and have heard from recently graduated neurohospitalists it's valuable to have a stroke fellowship, because hospitals who want to be 'designated stroke centers', need people who are fellowship trained.

    If working in a group of neurologists who take call, do you do more 'stroke calls' if you're a stroke-ologist? Where I am, the attendings take an equal amount of overnight call, and noone specifically takes call for strokes.

    I'd also love to hear if there are benefits in doing a 2 year vs 1 year vascular neurology fellowship? Are there outpatient neurologists who complete a stroke fellowship solely to do research in stroke, while working as an outpatient neurologist?
  6. aaddnl

    aaddnl

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    Well this may go against the grain of the typical "more training is always better," but in my opinion you most definitely do not need a stroke fellowship to be a neurohospitalist. A neurohospitalist does what you routinely do at most residency programs--inpatient neurology, and these days most residency programs are very inpatient heavy and you should have had ample training in inpatient neurology at most institutions. Yes, there is a learning curve when you start out and yes you will see a lot of stroke patients, but if you keep up on literature, attend cme particluarly stroke conferences, etc, there is no reason you should not be competent to do clinical inpatient neurology (neurohospitalist work) without a stroke fellowship. Now some big neurology groups in big cities and certainly academic centers will want a fellowship trained vascular neurologist. But that's different than neurohospitalist. As a neurohospitalist doing a stroke fellowship is basically cutting into your income potential and arguably the experience u get in your first year on your own as a neurohospitalist will equal or exceed that of your fellowship. Now if u want to go into academics that's a different story and fellowship is definitely recommended. That's the only scenario I would suggest a two year stroke fellowship--if u want to go into academics and then u need to use that extra fellowship year to develop research projects, papers, get grants etc., not really for extra clinical training. Again, my opinion only.
  7. aaddnl

    aaddnl

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    And to answer the other question---in most places you will share call with your partners and do roughly the same amount of general neurology call regardless of whether you are a stroke trained neurologist, epileptilogist or general neurologist.
  8. bblue

    bblue Member

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    Your input is greatly appreciated! Thank you. Sorry to cut into your thread GrtWhtNrth
  9. GrtWhtNrth

    GrtWhtNrth

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    No problem! I also really appreciate everyone's comments!
  10. neurochica

    neurochica

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    I would like to know how community hospital neurohospitalst work/differ. It seems to me that the the initial 2 posts come from an academic perspective. And while bi value and respect their opinion, here at my Institution, stroke faculty have no idea what's going in the real world. They tell that the avg salary for a stroke doc is $185-225 while I have had 5 offers in the range of $250-325. This info is coming dorm some of thebest stroke faculty in the country....sorry for the spelling etc.. I broke my right hand and it is diff to write with a sling on
  11. typhoonegator

    typhoonegator Neurointensivist Moderator

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    So because you have had 5 offers that are above average for starting income in stroke, your academic stroke attendings "have no idea what's going on in the real world"?

    Sorry, but I'm having a hard time with your logic.
  12. danielmd06

    danielmd06 Neurosomnologist

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    Good morning neurochica,

    To clarify, I'm actually an attending in private practice, and was trying to specifically comment in relation to private practice (not just academics). So I guess I'm confused about your confusion. Perhaps an actual neurohospitalist could chime in and offer some differing specific answers?

    As far as salaries, I've actually commented on this in recent threads. Starting base of $180-350 (with bonus potential to top $400) is exactly what I saw just last year, so it doesn't seem to me that *any* of the numbers you quote are wrong. Better yet, just check the MGMA 2010 threads with updated salary info. Remember also that academic neuro pays different than private practice neuro, and that the salaries vary wildly depending on acuity of need (ie how much work they have for you to do and how desperate they are to get you), geographic location, on-call responsibilities (or lack thereof), size of the group, whether you are employed by a hospital, how well the hiring folks think your personality is going to mesh with the patient base and your colleagues, etc, etc.

    Like TN, I'm not so sure that you can cast away the comments of your attendings just based on a handful of offers (that may even have been supplied to you by headhunters). Take some time and explore around and you'll see what I mean.
  13. Reperfusionist

    Reperfusionist Trainee for Life

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    As as previous vascular neurology fellow, I have seen my colleagues primarily enter into one of three tracks:

    1) Academic Stroke Neurologist

    This position probably allows the most opportunity to soley concentrate on taking care of stroke patients (as opposed to general neurology) and usually involves mixing in clinical/translational research in stroke. This job would most certainly require a vascular neurology fellowship for recent graduates.

    2) Neurohospitalist/Stroke Director

    This position is most common in private hospital settings and usually involves performing some general neurology consultations in addition to taking care of stroke patients. Outpatient work may be incorporated as well depending on the inpatient volume. The Stroke Director responsibility involves building up and maintaining stroke center certification for hospitals which is highly sought after by most places. This job does not "require" a vascular neurology fellowship but having formal training certainly puts you at the top of the candidate list.

    3) Neurointerventional Fellowship

    This is the track that I chose and allows a vascular neurologist to pursue additional training in endovascular techniques. A vascular neurology and/or neurocritical care fellowship is required for neurologists entering this track. Graduates can then go on to to academic or private settings performing a various mixture of stroke care and neurointerventional work.
  14. Neurology22

    Neurology22

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    As I am nearing the completion of my residency, I am debating between going out into private practice vs a stroke/vascular fellowship.

    I feel very comfortable managing stroke from my experience in residency, however is there any additional benefit to pursuing a fellowship? I have already secured a job as a neuro-hospitalist which I prefer at this time. Is there any benefit to the added year of training? I have no plans on pursuing an academic career or doing neuro-interventional training if I were to choose the fellowship route.

    Has anyone had a similar experience? Any advice would be appreciated. Thanks!
  15. Hank Rearden

    Hank Rearden

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    To Neurology22, there are only a couple of reasons to do stroke fellowship from your standpoint:
    1) You desire to be director of stroke at your hospital, which sometimes comes with a small bump in salary.
    2) You live / wish to live in a highly competitive city for physicians like LA, SF, NYC where your fellowship training would give you an edge up on your competition. In my experience this isn't so much an issue. Most groups are much more interested in how well you will mesh with other members of their team than they are your accolades. No one wants a bad egg in their small neurohospitalist team. This, added to the fact that the neurohospitalist field is still fairly new and all hospitals are trying desperately to acquire them make the need for a stroke fellowship less important for you.
  16. neurochica

    neurochica

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    Neurology, I am in the same position. I been offered a stroke fellowship at my home institution and I am been debating whether to accept a neurohospitalist job with a base pay of $315k plus incentatives working 7 on 7 off 10 hr shift. I have no intention of going academics and I am really struggling with this decision.
  17. HarveyCushing

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    That sounds like a very sweet gig IMO. How large/busy of a hospital is that at?
  18. neurochica

    neurochica

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    Harvey, not very busy compared to what I am doing right now in residency...infact, the work load here at my institution is three times as much so not really a big deal....I am getting similar offers here in the Midwest.....
  19. Domerr

    Domerr

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    315K starting salary? Daaaamn. But I'm assuming that job offer is from the middle of nowhere? But that schedule sounds more like a EM type of lifestyle, which can be good or bad.
  20. neurochica

    neurochica

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    It all depends of what YOU are looking for. My criteria was simple:

    Small-medium size community—less than 150,000 within driving distance to a big city.
    Low crime (very important)
    Residency stipend
    Starting at least 75% MGMA Base+ production.

    7on-7off work schedule

    All of this criteria is met on this practice. However, just like Daniel said, what is also important is how well you gel with the group. I won’t know until I get there (If I accept the position of course).
  21. Neurology22

    Neurology22

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    Would there be any benefit to doing a non-accredited Stroke/Vascular Neurology fellowship?
  22. RAD345

    RAD345

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    Sitting for Vascular Neurology would be very difficult then.

    There are about 44 accredited vascular neurology fellowship programs, that accepts fellows each year.
  23. Neurology22

    Neurology22

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    how important is it to be board certified? I am an off-cycle resident and can go straight into fellowship at an non-accredited program. is it worth it or would it be better to wait for an on-cycle accredited fellowship?
  24. typhoonegator

    typhoonegator Neurointensivist Moderator

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    A tough question to answer. Your training would probably be adequate, but credentialling for the rest of your career could be painful. If you plan on practicing at the same hospital or in the same vicinity of where you did your non-accredited stroke training, then you may not have any ill effects. But things could certainly get painful for you down the road, as you may be denied hospital privileges or denied reimbursement as a sub-specialist from some insurance companies.

    These accreditation systems exist for a reason. In the long run, you'll probably sleep better if you play ball. But no one here can say for sure that you couldn't get by with a non-accredited program.
  25. RAD345

    RAD345

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    Some times there are unexpected vacant spots available...ask around!

    Hospitals and insurance comapnies, have started paying more attention to BC stuff than before...,but it is still at the level of general neurology board.

    However, for stroke directors, vascular board holder will be more competitive than their non-certified colleagues.
  26. danielmd06

    danielmd06 Neurosomnologist

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    There seems to be increasing importance on being board certified for credentialing (as others are saying). I vote you just go with the flow and do an ACGME-accredited fellowship. There are many vascular neurology spots open (including one at UF in Gainesville starting in 2012 according to the most recent set of job classifieds I've gotten). It's assuredly not the only one that's open.

    In other words, I think you'll find open ACGME stroke fellowships around the country. You just need to look. And I think it'd be worth your while in the long run to complete an official, ACGME accredited stroke fellowship, too.

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