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What can you tell an MS 1 about Neurology?

Discussion in 'Neurology' started by YoungFaithful, Jan 27, 2004.

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  1. YoungFaithful

    YoungFaithful Senior Member

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    I am starting medical school this august and am interested in neuro stuff. I have my BS in neuro and have a strong interest in neurology. How is the lifestyle of a neurologist?

    Any advice? Recommendations?
  2. doc05

    doc05 2K Member

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    neurology is a great field if you are a total dweeb who isn't bothered by the lack of effective treatment for a large number of neurological diseases.
  3. Fermata

    Fermata kekeke

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    In short:

    Stroke, stroke, stroke, tumor, stroke, stroke, stroke.

    :D :D :D
  4. neurologist

    neurologist Schussing Moderator

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    Actually, it's:

    headache, headache, headache, stroke, stroke, headache, back pain, stroke, headache, psych patient who thinks they have a neurologic problem, stroke, headache, back pain, headache, headache, headache, stroke, headache.
    ;) ;) ;)
  5. YoungFaithful

    YoungFaithful Senior Member

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    You guys have been very helpful.

    Is there no excitement?
    Is it frustrating?
  6. kasimagore1

    kasimagore1 Member

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    depends how you see it. I am personally very excited about stroke, including ischemic and hemorrhagic....partly because I am research-bent. For example, There are so many experimental treatments for SAH...different centers have their own experimental management strategies aside from the usual triple H therapy, nimodipine for vasoconstriction, and possibly use of amicar for untreatable aneurysms. There are lots of translational research on neuronal cell injury and regeneration going on as well. If you work in a large referral center, you will also have the delightment of seeing many deranged, utterly bizzare and unusual neurological problems that await your sherlock holms's investigative intuition to solve them. Also, the availablility of interventional neurology fellowship would sure make procedure-oriented people excited. If you don't like research, are not inquisitve enough to spend time working-up for a complex patient, or simply pessimistic or sarcastic about the current available treatments for neurological problems (yeah, it's another stroke, give aspirin, if it fails, give plavix or aggrnox, next.....) then neurology may not seem an interesting field to you. Try to do a subinternship at many frontier neurological centers (UCSF, Columbia, Partners, JHU, to name a few) and see what neurology is all about. Is it frustrating, well....it also depends how you view neurological problems. If you go into the field and assume all these people are incurable, chronic, and many are morbid-bound, then you would not be so frustrated...a save is a save, right? On the other hand, frustration sometimes is a great dirve for further research, more discoveries, and hopefully better outcomes. The last generation of neurologists/neuroscietists left their legacy in diagnosis and fundamental knowledge in basic neuroscience, it's our time to offer the treatment solutions, as in translational research.
  7. IMGforNeuro

    IMGforNeuro Senior Member

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    hi

    i won't give you the classical definition of neurology because it is well understood.
    Regarding the cases -
    Cerebrovasc dis and stroke , epilepsy , movement disorders , demyelinating disorders , dementia, multiple sclerosis , CNS infections , Brain tumors , COMA and brain death , Spinal cord compression or demyelination , pain syndromes , peripheral neuropathies , etc.
    There are different fellowships too , go to aan.com for info.
    REGARDING Excitement VS Frustration.
    Neurologic cases can be exciting because of the challenge they offer eg. neur emergencies as status epilepticus , acute CVA , conditions with altered sensorium.
    Frustration can arise because of the severity of illness and mortality/morbidity.
    Many new things are on the brink of being approved , including drugs and therapies , plus intervention procedures have also been approved , so this is a transition phase for neurology.
    A fellowship in stroke , critical care , epilepsy can be exciting . You will experience adrenaline rush !!!!
    On the other hand , fellowships in MS , Headache can be sedentary so it depends on what you seek.
    HOWEVER , one must bear in mind , that the CNS is the most complex and critical part of the body , so the personal experiences in neurology practice can be very exciting one day and depressing the other day. There will always be a group of patients with neur deficit and debility so they are also to be managed on long term basis
  8. tofurious

    tofurious Senior Member

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    For more information, go to either American Academy of Neurology (www.aan.com) or the American Neurological Association (www.aneuroa.org) website to get some information for students.
  9. ys

    ys Senior Member

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    IMGforNeuro, could you please elaborate on interventional/procedural outlook for neurologists. Thanks.
  10. IMGforNeuro

    IMGforNeuro Senior Member

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    i had posted a similar reply in the radiology forum.
    I will just copy it here. There was some talk about intervention in neuro in that forum too.
    ----------
    Hi ,
    i have been a neurosurg resident .
    Regarding intervention neuro in neurology , HISTORY REPEATS ITSELF.
    Similar stuff used to be said about cardio when they started doing angiograms and intervention. But today they are simply ruling. The reason is that they are ' clinicians' and patients go to clinicians. Not every cardiologist does intervention. Remember that this is a one yr fellowship after three yrs of cardio.
    Similarly every neurologist will never do intervention in future. There are other fellowships in neuro too.
    The core curriculum of intervention neuro , according to the american acad of neuro is a 4 yr neuro residency followed by stroke and cerebrovasc fellowship ( one yr) followed by 2 yrs of intervention. So this is a very long education. This includes three yrs of training exclusively on cerebrovasc dis including imaging and endovasc procedures including detailed knowledge of vasc anatomy and a lot of other clinical things ( as complex relation of cerebral perfusion , ICP , CSF flow) . This pathway is either now board certified or towards board certification. Once this happens , insurance companies will start reimbursing , hospitals will start hiring and the risk of malpractice will be same as for intervention cardio. Regarding pre and post procedure management these clinicians will be/are extremely well trained.
    Regarding competition with a neurosurgeon , nsurg has a vast procedural domain. A nsurgeon with cerebrovasc fellowship still has a lot of craniotomy procedures which include aneurysm clipping , AVMs etc. So depending on indication , a patient with SAH would go to neurosurg or intervention neurologist . This is just like in cardio , a patient with triple vessel or left main cor art dis goes to cardiac surgeon for CABG and the others to cardiologist for PTCA.
    ---------
    Regarding places for intervention neuro
    Let me start with the big names first-
    1. CLEVELAND CLINIC , ohio
    go to website - neurology , under training and education click on other fellowships - you will go to interventional stroke.
    chief is Dr Anthony Furlan - was former chairman of intervention neurology section of american acad of neurology
    2. UCLA
    There prerequisite for intervention includes neurology residency.
    I know of one neuro resident in UCLA who has gone for this 3 yr fellowship.
    3. Wayne State Univ
    go to fellowships - then go to stroke fellowship. They mention as follows
    Opportunities for further training in interventional neuroradiological procedures such as intra-arterial thrombolysis, cerebral arterial angioplasty and stenting are available following completion of the stroke fellowship.
    4. UMDNJ , new jersey
    have a yr of fellowship in stroke followed by 2 yrs of intervention.
    FOR MORE INFO - go to www.aan.com
    Then go to sections and then to intervention neurology section.
    You will get a complete newsletter , core curriculum , members of this section and a lot of info.
    Dr Arani Bose from NYU is also a section member. She is also responsible to deal with the neuro/rad/neurorad pathway. In fact she is a neurologist who is also board certified in INR.
    When i read it last time , the section was about to present a complete proposal of how to develop a career in interventional neurology in 2004.
    ONE THING YOU MAY ASK IS WHY INTERVENTION NEURO?????
    The reason is that this is a way of making neurology more complete with respect to treatment options , make it more lucrative for med students and follow in the lines of cardiology , gastroenterology whuch are now procedure based . Cerebrovasc neurologists feel that if they have to manage a case pre and post procedural then why not do procedures too. So this one yr fellowship is extended to 3 yrs , just like most fellowships in other specialities. Even in radio , there is a 3 yr fellowship in neurorad and then a 1 yr fellowship in intervention so that is 4 yrs after residency.
    Every neurologist will not be an interventionist , just like every radiologist is not a neuroradiologist.
    The mindset is that with a neuro pathway , you become a complete clinician dealing with all aspects of cerebrovasc dis.
    Other centers are also starting these fellowships like i heard long island jewish , U of Alabama .....
    The eventual result will be on same lines as in cardiology that the patient goes to the clinician and careers will evolve as board certification is either in process or already done.
    I hope these links will be helpful.
    I forgot ,
    Dr Anthony Furlan is actually the Chair , endovascular task force of the interventional neurology section of AAN.
  11. Docxter

    Docxter Senior Member

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    Interventional neurology is not a clinical reality as of now. Yes, there are plans to have it and the AAN is working on it. It may or may not be a widespread clinical reality in the future. Only UCLA has a real program, sponsored by interventional neuroradiology, a program which trains radiologists, neurosurgeons and neurologists. The other three mentioned are primarily stroke intervention programs and are not that involved with a lot of procedures that are currently done by interventional neuroradiologists, such as complex aneurysms, AVMs, AV fistulas, and spine procedures. In the future, it may be different but IMGFORNEURO seems too overly optimistic and speaks of it as if it's a done deal. Well, it's not. There is not even yet an established curricululm for it, it has not yet been sent for ACGME approval, not yet even sent for American Board of Medical Specialties review to even be considered a real field, and obviously it's not even close to having a boards for it. If you ask most neurologists about interventional neurology, they'll say "Huh? What's that? It sounds like a good idea."

    On the other hand, the vast majority of neurologists are not very "invasive procedure" type people, something which may be a major hindrance, maybe. They are more cerebral type individuals. The truth of the matter is that interventional neuroradiology (that's what it's called now, maybe in a few years interventional neurology may become a real term) is a very dangerous field with extremely high patient mortality and morbidity. You can easily kill or disable someone in these procedures, if you're not a real "catheter jockey", something very non-cerebral. Not a lot of people would like that level of chronic high stress or have the fine motor skills and manual dexterity for the job if you want to be good at it. NeuroIR people are very liable to malpractice as well, just like neurosurgeons.

    Balloons rupturing the small atherosclerotic vessles, wires puncturing intracranial arteries, the catheter causing thrombosis and stroke, stents throwing too much emboli, glue going too far or backflowing into the undesired vessel are quite common and patients either die, become blind, disabled, or semivegetative. So most people avoid this field with a passion. It sounds "very cool", something medical students and other outsiders find fascinating, but I know of many who were initially awed by this field, but then decided not to do it when they got involved hands-on, including myself. The ruptured basilar artery that I saw wasn't fun when the patient immediately died on the table. Unfoortunately, these complications are much more frequent than you imagine.

    You have to be a catheter jockey to do NeuroIR. If I'm getting my aneurysm coiled, I don't care if the guy know the complex dynamics of CSF, the weird brainstem stroke syndromes, or can recite the PROACT II results by each strata. I just want him to shove enough coils into my aneurysm to occlude it without rupturing it or throwing clots into my brain. As of now, most of the people who are good enough manipulating catheters, wires, and coils are radiologists, not most neurosurgeons, and definitely not neurologists. If they can spend as many years as radiologists (7 years minimum) how to play around with these wires and catheters, then kudos to them. I don't see that happening now in neurology or neurosurgery. Who would you send your loved one to?
  12. IMGforNeuro

    IMGforNeuro Senior Member

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    hi,
    i have personally communicated to all these people concerned regarding the curriculum of their fellowships.
    Secondly , the core curriculum of the stroke fellowship also includes aneurysms and avms (non invasive aspects if 1 yr fellowship).
    Regarding the other 3 programs , i know as a matter of fact that they do intervention procedures for aneurysms , avms , actually cerebrovasc dis. Infact the prog director at UMDNJ is currently chair of interventional neuro section of aan. HE has the credit for performing the first basilar stent in the new york region.
    I do agree that majority of neurologists are not invasive kinds , and honestly even many neurorads are not invasive kinds too.
    If you remember that after three yr neurorad fellowship , there is a 1 yr INR fellowship to train them for intervention procedures.
    I agree that AAN is making an effort in a new direction.
    MAJORITY CURRENT neurologists are not invasive kinds.
    But a large number of future neurologists are very likely to be different from their predecessors. The reason for this deduction is that the Intervention neuro section of AAN currently has over 250 members and a lot of interest and feedback from SIGN ( student interest group in neurology) which is growing each year.
    This is a natural course taken by other nonsurgical specialities.
    The career goal of these fellowships is to prepare these fellows for the post of an instructor in intervention neuro (academic career) which is basically aimed at propagating this field.
    I ADMIT IT is NOT VERY PREVALENT TODAY.
    But the situation will be very different after 10 yrs. So it will be more interesting for current med students or seniors who will be in practice about 10 yrs from now.
    The most ground breaking development in this area will be board certification , as some AAN members say.
  13. Docxter

    Docxter Senior Member

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    That's bullsh*t. Just Alex Berenstein and John Pile-Spillman have been putting intracranial stents, including basilar for 15-20 years now. There are at least ten more who have been doing this for years in the New York area.

    Also, neuroradiology fellowship is two years. NeuroIR is an extra 1-2 years. But, these people have worked with catheters, stents, wires, particles, etc. throughout their residency and their diagnostic neurorads fellowship (5 year training before the start of the NeuroIR fellowship).

    The bottom line is that a lot of people do it, but very few are good at it. If you care for quality, you need to go to the ones with the most adequate training.

    Just one question for you, IMGFORNEURO. God forbid you have a brain or spine AVM brain that needs embolization. Who would you go to and place your life in their hands? One of those alleged 250 members of the interventional neurology section of AAN (self-proclaimed interventionalist without a direct training criteria for membership) or a member of the American Society of Therapeutic and Interventional Neuroradiology (which has very strict documented time and therapeutic caseload criteria for membership)?

    Even the neuroimaging section of the AAN will credential you for reading CTs and MRI after 1.5 to 2 months. The American Society of Neuroradiology, however, requires a minimum of two years. It is obvious that the criteria for neurologists doing something is much more relaxed and easier. Neurologists caring about quality? I have a hard time believing so after seeing these things. The ASITN does not require you to be a radiologist, as some members are neurosurgeons or neurologists. The doors are open to anyone, but it has real criteria for membership and requires that you go through real stringent training requirements. Even Dr. Furlan, the chair of the AAN taskforce has sought ASITN membership, so he could be a legitimate practitioner.

    I don't care who does these procedures (radiologists, cardiologists, neurosurgeons, neurologists) as long as they are adequately trained. Unfortunately, most of those claiming the so-called "interventional neurology" status to doing these procedures are not, at this point in time. I hope that would change in the future.
  14. IMGforNeuro

    IMGforNeuro Senior Member

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    regarding curriculum,
    Go to AAN website and click on fellowship core curriculum, you will get the entire core curriculum of this fellowship.
    Regarding malpractice,
    every intervention field has greater malpractice and high stress levels. Stress levels of course will be very high in this field , simply because intervention procedures are dangerous.
    Every field has its pros and cons.
    Intervention cardiologists also have high stress levels and malpractice liability , this is something which is a part of the deal.
    There are other fellowships in neurology too. So it also depends on what kind of subspecialization , people want to do.
    Current neurologists never had these options and conversely the field attracted people who were not the intervention types.
    Regarding the question ,( who would you send your loved one too ?) , this depends on what direction clinical medicine takes .
    Intervention procedures in cards has followed the same path .
    There are many people who are initially interested in a particular speciality and then change their opinion. This is true for all specialities. But the development of pathways to do invasive procedures attracts some people to that field and dissuades others. So the net result remains the same. To be honest , all specialities and subspecialities which are invasive have become more competitive despite malpractice and stress issues.
    The most stressful residencies of neurosurg , OBG , ortho are still very competitive. Same is true for intervention cards .
    Anesthesia has now become competitive because of the ' pain procedures ' they are doing.
  15. Docxter

    Docxter Senior Member

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    Don't dodge my question. Who would go to for the AVM embolization?
  16. IMGforNeuro

    IMGforNeuro Senior Member

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    you mentioned Alex Bernstein,
    so let me tell you that i have communicated to him as well at the Beth Israel Med CTR.
    I have myself asked him the same question regarding the pathway of intervention in neuro after a 'neurology residency' .
    I also verified every info i have posted on this forum.
    He initially thought i have already completed a neuro residency and directed his secretary Lillian Medina for a fellowship application. Then i said that i am yet to do the residency.
    Finally i wish to add that i am not posting any bluff on this forum , just adding genuine info.
    And yes i have also been a neurosurg resident and know what neur critical care is.
    The person at UMDNJ i mentioned is Dr Adnan Qureshi . He was initially at SUNY buffalo before shifting to umdnj.
    If anyone has any doubts regarding all this , then you can communicate to these people directly.
    I know i have brushed some people's egos by posting this info.
  17. Docxter

    Docxter Senior Member

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    Good. As long as you are willing to train adequately (e.g. with Alex Berenstein), you're good. Adnan Qureshi has had good training with L. Nelson Hopkins in Buffalo as well (still he did not put in the first stent). I'm complaining about the ones who want to bypass stringent training requirements and proclaim themselves to the public as experts, i.e. all too many of these self-proclaimed interventional neurologists.
  18. IMGforNeuro

    IMGforNeuro Senior Member

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    The answer to the AVM question is self explanatory .
    I will have symptoms first , will go to a clinician (neurologist or neurosurg), who will send me for the investigation.

    If an AVM presents as an SAH then a CT and MRA or ANGIO are imminent.
    If an AVM presents as SOL (space occupying lesion , which is another common presentation of avm) then MRI.
    Depending on indication surg or intervention procedure.
    WHO WILL DO INTERVENTION PROCEDURE - will depend on what direction medicine has taken?
    Intervention Rads used to do Coronary angioplasties in eighties untill the cardiologists took over.
    The most difficult part - is pre and post procedural management (which is one of the most important determinants of prognosis) which is done by neurologists or neurosurgeons.
    Cardiologists always did this even in eighties.
  19. IMGforNeuro

    IMGforNeuro Senior Member

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    All the initial intervention cardiologists picked up things fron INT RADS and took of from there.
    Now we know who does vasc intervention. It is all about what direction medicine takes.
  20. Docxter

    Docxter Senior Member

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    You're still dodging the question. That's fine. You sort of indirectly answered me by trying to dodge it.
  21. IMGforNeuro

    IMGforNeuro Senior Member

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    you are still thinking about it in terms of ego.
    I respect INR rads for their skill and expertise , but the question is about what direction modern med takes?
    If something were happening today , i would be referred to a INR , but after 10 yrs is a different question.
    It all depends on the expetise available at that point of time.
  22. neurologist

    neurologist Schussing Moderator

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    Interesting debate.

    I agree with Docxter that, at least for now, I'd much rather go to an interventional radiologist than a neurologist for a cath procedure.

    This may change in the long run, but it's not going to be widespread change any time soon. Rads and Neuro will be fighting "turf wars" over this for years to come.

    An interesting comment that one of you made was about neurologists being "more cerebral" types rather than "cath jockeys." This is a good point. While some neurologists may think they want to include cath in their repetoire, that is a bit disingenous; I suspect they really mean they would rather be doing caths than general management. What I am saying is that for the most part, you will be either an interventionalist or a noninterventionalist. Most docs who do caths want absolutely nothing to do with long term management, and as soon as the patient is off the table, they sign off and it's someone else's problem. Now, I'm not saying this is good or bad (after all, if you are going to be a good "cath jockey," you need to be doing caths, not killing time sitting in a clinic listening to patients complain about all their chronic symptoms), but my point is that in the real world, once you start doing procedures, your point of view narrows considerably, and I don't think you will be seeing too many cath-trained neurologists managing the patient from diagnosis, through the procedure, and for long term follow up. They will get the consult, wash their hands, throw on the lead apron, and say adios when the procedure is over. Docs go into procedural specialties precisely because they like dealing with discreet procedures and not long-term patient care issues. Even cardiology, which has pretty much taken over the cardiac cath stuff, has a pretty clear dividing line between interventional and noninterventional practitioners. I suspect that ultimately neuro will be the same way.
  23. Docxter

    Docxter Senior Member

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    Good point. Out of the nine neurosurgeons I know who have trained in interventional neurorads, seven of them either do NeuroIR exclusively with no craniotomies, or don't utilize their neuroIR training at all and only do neurosurgery. Only two of them do both in their day-to-day practice. Rumor is that neither of them is really technically excellent at both.
  24. IMGforNeuro

    IMGforNeuro Senior Member

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    This is true . It is simply not possible for one person to do everything. Even some of my seniors in neurosurg who went on to specialise in Cerebrovasc , do not do anything else.
    If this pathway evolves then the neurologist will be confined to that area , so no gen neurology , emg etc for him.
    It does take time and effort to achieve perfection or expertise in a given field since modern med is vast.
    All i wanted to say was that there is an evolving pathway for neurologist to train in these procedures, But yes no one can claim to be a master of the complete spectrum of neur dis or even a fraction of it for that matter .
  25. eddieberetta

    eddieberetta

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    I would like to add one point to this discussion. The AAN is a political organization, and not a recognized specialty board. AAN "certificates" in neuroimaging are as worthless as any they may or may not have in INR. The short training periods are meaningless (however they do call the AAN into disrepute).

    (On a related note, if anyone would like the eddieberetta certificate in radiology, email me -- keep your checkbook handy).

    The only certificates that matter are those issued by the ABR and ABPN. The official pathways for INR ("endovascular surgical neuroradiology") are still being finalized, and the specialty will likely be performed by a mix of neuroradiologists, neurosurgeons and some neurologists. Notice the stringent training pathway all three specialists will go through.

    Nevertheless, I doubt that neurologists will be the major players. In reality, INR training for neurologists has been available for years, but not many are interested. And the NRad and NSX who enter do tend to become mainly INR guys.

    Anyway, the real bottom line is that the person doing the procedure should be an expert in the technical aspects of the catheterization and the interpretation of the imaging. Whether you start as an imager or a surgeon (or neither), you should rigorously learn the missing skills.
  26. Docxter

    Docxter Senior Member

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    Good point. Programs are going towards more formalization of the training requirements and seeking ACGME approval in addition to the traditional ASITN membership requirements. This is has formalized into an ACGME approved route for doing neurointerventional procedures and is called "endovascular surgical neuroradiology". Actually, EddieBeretta, the process finished two years ago and is already approved by the American Board of Medical Specialties and ACGME. A few institutions have already gotten ACGME approval for training and WashU already has trainees as well. Many others are in the approval process. In this new specialty designation, the door is open to radiologists, neurosurgeons, and neurologists to be trained. This assures adequate preparation and training for the future and is ACGME recognized. It's not like some of the scam certificate programs the AAN is trying to push, with minimal and inadequate training. The neuroimaging certificate of the AAN for example requires 150 CTs and 250 MRIs to certify you. This is a joke and pure scam. In that case, I should have been a "AAN certified neuroimager" after my first two neuro rotations when I was a first year resident.

    I just don't understand why some of these neurologists don't want to get adequate training. Are they "ethically challenged" or something? The real training programs are out there and available to them, and many of them go unfilled. Why don't they go and get real training?
  27. IMGforNeuro

    IMGforNeuro Senior Member

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    there are only 2 acgme accredited INR programs till now , one at Washington univ and the other at Cleveland Clinic , ohio.
    NO OTHER PROGRAM HAS ACGME CERTIFICATION AS OF NOW.
    Do you want to say that all the other ' endovascular surgical neuroradiologists' from other programs are scams as well.
    And yes , the intervention neuro program at cleveland clinic is actually leading the AAN section at of int neuro as well.
    The biggest misconception you have is that neurologists are trying to bypass the stringent training procedure. Well , they are not.
  28. Docxter

    Docxter Senior Member

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    If they're not trying to bypass the training requirements, why don't they join the "endovascular surgical neuroradiology" movement (a move to formalize neuroIR training for radiologists, neurosurgeons, and neurologists and designed by specialists in all three fields) like all the other programs who have applied for ACGME approval? Why does the AAN want to provide it's own certificate? If the ridiculously lame AAN neuroimaging certificate requirements are any example, I see no other reason other than them trying to bypass stringent training criteria.
  29. tofurious

    tofurious Senior Member

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    For any MS1s actually interested in Neuro, this is not how neurologists behave among themselves. This is just a fight between two individuals that needs to happen elsewhere instead of a thread designed to address what a MS1 needs to know.

    For the two individuals involved in this fight: good arguments from both sides, but let me ask you this: how are either one of you going to change either what the AAN is going to do or how INR is going to be certified otherwise? In order for people to take you seriously, especially when you are making such drastic attacks on one field or another, it's about time to step out behind the veil of anonymity and share your name and credentials. Otherwise, I think most of us are tired of the fight.
  30. Blake

    Blake

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    Wow, I'm speechless. Very interesting thread ! I'm amazed by how much stuff you guys know, but I guess that comes with time. I'm starting my first year of medicine in 2 months and I'm really interested in neurology and neurosurgery. I can't wait :D
  31. Bugpie

    Bugpie OC-Learner

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    Blake....I agree. You found a nice tennis match with this one. I too have been following the neurology scene but I'm probably in the wrong neighborhood. If I decide to go with neuro....it will be pediatric neuro....and not much is heard around here along those lines. If not, then I'm also considering FP. I have personal reasons for both choices......only time will tell.

    The AAN encourages students interested in neurology to participate in their S.I.G.N. program. Here's a link for you to check out when you can:
    Student Interest Group in Neurology Program
  32. INR

    INR Junior Member

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    Adnan is good, but he was not the first to place basilar/intracranial stents
  33. charcot

    charcot Member

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    Yes, there are neurologists doing interventional but did you know...
    Both adnan qureshi (UMDNJ) and dileep yavagal (UCLA) did neurology then neurocritical care fellowships (Suny-buffulo and Columbia respectively)before neurointerventional. Moreover, other programs (there is a new program at Michigan state) also require some NeuroICU training prior to neurointerventional for neurology residents.
    Check out the brigham's diagnostic neuroradiology website as well as UCSF's. They both offer interventional neuro (Randy Higashida is the bomb), but they require significant neurocritical care training beforehand.
    Cleveland clinic's Jay Yadav, is both a neurologist and cardiologist. Do you think he gets angio suite time because he can run through the cranial nerves or illicit hoover's sign?? He's also working with tony furlan, the guy who ran proact II.
    Check out NYU and you might think it accepts neurology residents, butalmost all fellows have been nsurge.
    It's a great gig, but 1-2 years of ICU training prior to the 3 years of learning cath techniques and serious on-call schedules will likely turn off more neurologists and leave the door wide open for nsurge, cards, and of course rads.
    I think in the future neurologists will have to get certified in neuro-ICU/Vascular neurology (1-2yrs), then neurointerventional (3 yrs) which is on top of 3 years of neurology. Either way, people will need solid training to get privilages at hospital based angio suites. Currently most hospitals have 2 sets of angio suites, cardiac cath labs, and Interventional Radiology. Do you think there is enough demand for coils and stents to devote an angio suite for neurointerventional? How many hospitals will have a neuroICU for post-cath monitoring? Or how about neurosurgery back up? If they do, it is likely a large hospital (academic) with strong radiology and cards presence.

    It's gonna be a long, tough fight for neurology.
  34. IMGforNeuro

    IMGforNeuro Senior Member

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    Just to clear this misconception, these programs include neurocritical care.
    All neurocritical care programs are run and managed by neurologists.
    Even the MSU program includes first yr of stroke and neurocritical care followed by 2 yrs of intervention.
    All the people you spoke about did stroke/neurocritical care fellowships which are of 1 yr duration. It is very similar to people doing cardio fellowships ( they need intervention cards after 3 yrs of card to do interventional procedures).
    All hospitals do not do intervention. Just like all all cardiac centers do not do cardiac intervention.
    It goes without saying that neuro intervention is also a sub-subspeciality (just like any other interventional field) and this expertise will be available only in select hospitals.
    Regarding candidates for neuro intervention, the current standard is IV TPA within three hours, BUT Intraarterial TPA is 6 hrs ( also MCA strokes class 2B recommendation) provided a center has the expertise. Things are changing fast. With the kind of work done in neuroprotective agents, this window period will increase, so the candidates for neurointervention will also increase. Managing these cases needs real knowledge of neurosciences.
    Regarding angiosuites, there were hardly any cardio cath labs before cardio became aggressive and went interventional.
    There is absolutely no possibility of cardio going intracranial, this suggestion is kind of similar to GI doing endoscopies in KUBU (done by urology) or vice-versa.
    Regarding demand for coils and stents- a recent clinical trial (involvin thousands of patients , conducted at several centers throughout the world - probably called SAPPHIRE trial) established the superiority of endovasc management over clipping.
  35. charcot

    charcot Member

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    I respect IMGforeuro's comments. But I think calrification is needed. Not "all" neurocritical care progrmas are run by neurology. In fact columbia, Hopkins and UCSF are run by neuroanesthesia/critical care and neurosurgery in conjuction w/neurologists. The depts are divisions either within anesthesia (Hopkins and partners) or nsurge (columbia and UCSF).

    In terms of things changing fast w/neuroprotection, look at the literature for the last 8 years from NMDA antagonists to cryprotection, there is little there that is FDA approved. In fact the new thrombectomy devices are where it's at, using no lytics at all. more over, there is a trial for PFO closure, to reduce stroke risk done by guess who....cardiology.

    Finally you should look at the CREST trial....Comparing stent vs. CEA. guess who will be doing procedures: rads, cards and nsurge. No neurologists are doing procedures, only evaluating the efficacy with Rankin scores and NIHSS.

    The neurologist will be dealing with patient selection, triage into appropriate study and long-term follow up. The neurointensivist will monitor the pts during the peri-procedural time period. The interventional neuroradiologists/cardiologists/nsurge's will likely get to play with the toys.

    Still, a few neurologists will get involved w/intervention, but they will be few and far in between.
  36. IMGforNeuro

    IMGforNeuro Senior Member

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    I do agree with you to an extent that is is not a rapid change that will happen in a couple of yrs time. But eventually it will.
    Secondly , the role of cardiology in neurointervention will be confined to extracranial , not beyond the extracranial carotids. The reason they can do PFO closure is because the lesion lies in the heart. Patent foramen ovale is a very uncommon cause of strokes.
    Even if we consider ischemic stroke, one third of these are in vertebrobasilar circulation which are more or less inoperable and unapproachable. Neurointervention is the way to go. These lesions can be treated by neuro/nsurg/intervention neurorad.
    All carotid strokes do not originate extracranially. Many have intracranial origin esp atheromatous plaques which again will be approached by someone who specializes in these treatments. Many stroke patients have multiple levels of occlusion in intra as well as extracranial vasculature.
    Secondly new tools as transcranial doppler are being investigated in ischemia and these are predominantly used by stroke neurologists is ischemic strokes. Further refinement and improvement in TCD technology will also add a new dimension and could probably save time during the 3 hr window period.
    Why neurology in intervention, honestly speaking is because almost every medical field is going interventional. For any subspecialist to be an interventionist will need a long education. Majority nsurgeons will probably not go interventional , firstly because of the even longer training and secondly because nsurg has a vast procedural domain (individual preferences may be different). Neurologists never ventured into intervention because no pathway existed earlier. It is only now that some aggressive neurologists have opened this new chapter. And the acgme has only recently opened the doors for neurology to go interventional. The new recruits in neurology would also be more aggressive as this change proceeds. In this day and age, who doesn't want to do interventional stuff.
    But it is very clear that any field with intervention needs long residency education , be it cardio, GI , pulm/critical care or even neuro intervention and is a fulltime committment.
  37. DawnOnBrain

    DawnOnBrain

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    Hey Docxter.
    What are you babbling about the rads guys working for 7 years to become interventionalists? And these so called godly cath-joks? They do 5 years of diagnostic rads (i.e. sitting in the basement using their hands to stroke a mouse or a microphone), and then they do 2 years of pushing catheters.
    I have seen a cath-god in action and any guy with above average IQ could do those after 2 years of training, you don't even need medical school and the residency...
  38. DawnOnBrain

    DawnOnBrain

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    Never before have neurologists tried to get into the procedure/catheter business. Now they are trying. And they will succeed to certain degree, if not comletely, b/c: 1) surgeons do not push catheters, they cut. 2) radiologists are not clinicians (please, they are not) 3) Neurologists can now create comprehensive departments with neuro and interventenial neuro together and will not rely on basement rats for interventions.
    You need cardio training to learn how to push catheters into hearts, and not cardiothoracis surgery training. Now draw a parallel to neurology and you will see the future.
  39. sluox

    sluox Copier

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    I find it really interesting that some sort of turf war happens on SDN every time even with a tangential question like this.

    Fact: you can be trained as a interventional neuroradiologist certified by the ACGME even if you started out as a neurologist. The competitiveness/length is variable. It is however possible, and many programs exist to do that.

    Fact: patients don't give a damn what you started with once you are certified, for insurance purposes. seems like the only people who actually care are the radiologists. A wee bit insecure are we? there's no evidence that radiologist does a better job doing cath in general anyway. such study was just not done.

    Now you can have various interpretation of this. Is neurology then an easy way into INR? Neurology residency at top programs are, realistically, as competitive as ~ average rads programs.
  40. hqt331

    hqt331

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    Is it okay to bump this years-old thread? I'm an MS-1 whose main interests as of right now lie in neurology, although I realize that could change. The problem is, I do like to do hands-on stuff, and general neurology, as far as I can tell, doesn't offer that. Can anyone tell me about the current state of INR? Is it easy for a neurologist to get into these fellowships? Does it look like more neurologists will do so in the future?
  41. CSnowFoxD

    CSnowFoxD

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    Sorry for bumping again, but I'm very interested to know what hqt asked also, if anyone knows...
  42. danielmd06

    danielmd06 Neurosomnologist

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    Let me guess. You're a general surgeon?
  43. danielmd06

    danielmd06 Neurosomnologist

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    The current state of INR? Neurologists can pursue this course if they want. Additional procedural specialties available for neurologists include pain medicine.

    The pain aspect is beyond my knowledge base...but the availability and usefulness of NIR fellowship has been discussed in numerous threads on this and the radiology forum. It's a fun sub-specialty.
  44. Raggaman

    Raggaman Member

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    The most handsy you will get with gen neuro is with LPs and EMG. Most of us like to be handsfree anyway. Our strength lies in the neuro exam and management of some very disabling diseases. If you are interested, dont let people tell you that neuro "doesnt cure anything". Find me one internist who can "cure" CHF.
  45. Mattchiavelli

    Mattchiavelli

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    I consider a neuro exam to be hands-on... It just doesn't bill like a procedure. A whole lot of tickling and tapping and Dix-Hallpike action involved with it.
  46. startoverat40

    startoverat40 MS2

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    any opinions about neurodevelopmental disorders path? I guess you do 2 yrs pediatrics, then 4 years of neuro and NDD. can get board certified in peds and neuro. working with autistic kids can be challenging, rewarding, frustrating. anybody know about this field? thanks.

    http://www.abpn.com/cert_ndd.html
  47. PETRAN

    PETRAN

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    Interesting. Can you work with ADHD and stuff or this is more child psych's turf? (Edit: I just had a loot at it and it says that you can together with ODD, OCD, Tics etc.)


    How many specialties deal with this sort of thing? "Behavioral-Developmental Peds", "Child Neuro-NDD", "Child-Adol. Psych"...wow. I guess there is a sortage? It looks interesting though. Too bad that you need 2 years of pediatrics. They should do it 1-year jut like the IM-intership for the adult Neuro path.
  48. typhoonegator

    typhoonegator Neurointensivist Moderator

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    The old LADDERS program (now the Lurie Center) at MGH takes care of patients with ADHD as well as OCD, TS, Retts, CP, and the autism spectrum, and is staffed by a multidisciplinary team of psychologists, psychiatrists, and behavioral neurologists, along with social workers and SLP/OT/PT folks. Some of the neurologists (if I recall correctly) have been peds trained, but some have even been entirely adult trained. If you look at the staff listing for the Lurie Center, you will see all of these disciplines represented.
  49. drCNS

    drCNS

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    To answer the question of how hard or easy it is for neurologists to get into INR, in short, it's not.
    As you have probably witnessed from this jarring discussion in this thread, the paths are multiple and confusing. The most direct paths are, indeed, though radiology or neurosurgery That is not to say that it's not impossible, but it is harder to do if you are a neurologist. One of the residents in my program thought about doing INR and is now thinking of applying to neurosurgery advanced placement in order to do so. Part of the problem is that unless you go to a neuro-run interventional suite, neither rads nor NSGY have any interest in hiring you. There are exceptions such as the NSGY group that is looking for a guy to just do these endovascular procedures and will pay well - but this serves as an example of how a neuro-trained INR peeps also can have more trouble finding a job afterwards.
    But if you like neuro, and like hands on, enjoy neuro for what it's most enjoyable for: localizing the lesion, thinking on your feet. It is an ability that most other clinicians just don't have.
    And then if you like hands on, you can consider doing EMGs and billing for them, or interventional pain, or neurocritical care (some programs have you putting in EVDs, BOLTs, and trachs, but for certain are things like lines, chest tubes, intubating, bronchs, etc.)! So there are still other 'hand-on' options for neurologists, so don't get dissuaded just because of INR.
  50. Mattchiavelli

    Mattchiavelli

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    There are also programs that will get you triple board eligible in adult and child psych in addition to pediatrics if you want to work with that patient population. The school that houses my residency program has both these and NDD and I can tell you the triple board has a lot more training in unrelated psych areas (think adult forensic psych) and NDD has a lot of unrelated training in general neurology (think neuromuscular). As far as scope of practice after that I'm not too sure.

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