Fellowship for neuro-hospitalist?

[mrbreakfast]

Hey all,

So fellowship decision time isn't too far away (seems way too soon). At this point I'm 90%+ sure I want to be a neuro-hospitalist - I love being busy in the hospital and do not love clinic. However, I'm not certain I'll want to be a full neuro-hospitalist when I'm in my 50s, etc. I've heard varying perspectives on how best to approach this lifestyle, with some people recommending getting a fellowship to "retire" to, while others telling me a fellowship is a waste of time (or even a downside). Wondering what SDN thinks.

A few things:
-I'm definitely not doing stroke. I don't want to run a stroke center and feel confident enough in stroke already that I don't think I'll need a stroke fellowship after an additional two years of residency.
-I thought about NCC but don't think I want to do this for my career
-I'm undecided about academic vs private practice - I enjoy teaching but the difference in lifestyle/pay seems enormous
-One of my mentors is a neuro-hospitalist who did a neurophysiology (EEG and IONM only) and reads EEGs and does IONM cases on off weeks without seeing clinic patients. This appeals to me, but another person told me this kind of fellowship will actually limit private practice opportunities (e.g. hospitals will ask you to manage their EMU, which I don't want to do). Is this (reading a handful of EEG studies and doing a few OR cases a week on off weeks) a viable private practice model, or is it mainly an academic model?
-A little off-topic, but what's the job market like for IONM? I know next to nothing about it other than what the two people at my institution whom I know do (one of whom does IONM and nothing else) but am intrigued.

tl;dr I would like to primarily do neuro-hospitalist work and am wondering if I should do a fellowship as well to increase my overall skill breadth. I'm going to try to do an IONM elective and will do a little more clinic in the specialties I like more, however would appreciate more insight beyond the handful of neuro-hospitalists I know.

Thanks!

---

Members don't see this ad.

 

[Postictal Raiden]

If you’re set on doing inpatient neurology, why bother with fellowship?

Only do a fellowship if you want to gain expertise in a subspecialty or if you want to acquire/hone skills that will help you with your desired career.

Personally I’m doing neurophys because I want to do outpatient general neurology. Being comfortable doing these diagnostic modalities is important for becoming a competent general neurologist.

I know a couple of people who do IOM exclusively. Seems like a lucrative career (300-400k). There are few IOM-focused neurophysiology fellowship programs. UCLA and USC, come to mind.

 

[Telamir]

Don't do NCC if you don't wanna be an intensivist.

If you want to do a fellowship for inpatient I'd say do stroke or do neurophys. I like you came from a very competent stroke center and was quite comfortable with stroke. I did neurophys to read inpatient EEGs which might be required for some jobs and be comfortable with seizure management and complex epilepsy cases which happen quite often.

Unlike above poster I don't know that I'd recommend doing it with no fellowship. Depending on where you want to work you might be "competing" against a bunch of people with fellowships. Neurohospitalist fellowships were a thing in the past, there may be 1-2 left but they're mostly a waste of time IMO.

 

[sharkbaitwhohaha]

Don't do NCC if you don't wanna be an intensivist.

If you want to do a fellowship for inpatient I'd say do stroke or do neurophys. I like you came from a very competent stroke center and was quite comfortable with stroke. I did neurophys to read inpatient EEGs which might be required for some jobs and be comfortable with seizure management and complex epilepsy cases which happen quite often.

Unlike above poster I don't know that I'd recommend doing it with no fellowship. Depending on where you want to work you might be "competing" against a bunch of people with fellowships. Neurohospitalist fellowships were a thing in the past, there may be 1-2 left but they're mostly a waste of time IMO.

I was suprised (and glad) to hear this. I didn't know they were shrinking. Its a complete waste of time and a money grab by institution to suck work hours out of physicians in training (just like pediatric hospitalist movement).

I checked the AAN website, and there are 3 left (Stanford, Colorado, Cleveland clinic).

Why did they shrink?:lack of applicants?

 

[Postictal Raiden]

Entire neuro residency is a neuro-hospitalist fellowship

 

[CargoPants]

I was suprised (and glad) to hear this. I didn't know they were shrinking. Its a complete waste of time and a money grab by institution to suck work hours out of physicians in training (just like pediatric hospitalist movement).

I checked the AAN website, and there are 3 left (Stanford, Colorado, Cleveland clinic).

Why did they shrink?:lack of applicants?

I dont know the history of neurohospitalist fellowships. I would have thought it was liked pediatric hospitalist where it was never a formal entity, but now is becoming required. Were there previously many more programs?

In addition to those listed on the AAN, it looks like UT-Houston, UCSF, and UW also have neurohospitalist fellowships.

 

[xenotype]

Waste of time and just free labor for the programs that still exist. There's only two real choices here- do stroke fellowship so you can get directorship for accreditation, or neurophys/epilepsy so you actually know how to read EEGs. Many neurohospitalist jobs will expect you to read EEGs, many even long term EEG even if you did a stroke fellowship because they have no one else to do it. I do recommend doing a fellowship if you are inpatient bound- there is a lot to know and residency barely covers it. Rarely you can combine some limited EMG time with a hospitalist job, but this is more likely to be in academics of some kind- I'd also say being able to do an inpatient EMG is occasionally very useful especially if you are a referral center for the region but EEG is much, much more important.

 

[mrbreakfast]

Thanks all. Based on what I can tell there doesn't seem to be a necessity for fellowship for neuro-hospitalists, particularly here in the south. Seems academic centers are willing to hire non-fellowship trained neuro-hospitalists simply because it's so much less attractive compared to private practice in terms of hours/salary.

I'm not interested in a neuro-hospitalist fellowship and would be laughed out of my program if I even thought about applying for one...but I'll finish residency with ~85 weeks of inpatient neurology over four years, excluding electives. There are neuro residencies that have a lot less than that, though. I think it's primarily for people in those programs, some of which have just one combined inpatient/consult service.

 

[Postictal Raiden]

Thanks all. Based on what I can tell there doesn't seem to be a necessity for fellowship for neuro-hospitalists, particularly here in the south. Seems academic centers are willing to hire non-fellowship trained neuro-hospitalists simply because it's so much less attractive compared to private practice in terms of hours/salary.

I'm not interested in a neuro-hospitalist fellowship and would be laughed out of my program if I even thought about applying for one...but I'll finish residency with ~85 weeks of inpatient neurology over four years, excluding electives. There are neuro residencies that have a lot less than that, though. I think it's primarily for people in those programs, some of which have just one combined inpatient/consult service.

I agree. My program is very similar. I just calculated that we do 88 weeks over the span of 3 years (no including time spent on inpatient neuro elective during internship). If anything, we lack outpatient subspecialty exposure.

Depending on where you’re looking to practice, you are likely going to be fine without a fellowship. Heck, I’m in one of the large metros on the West, and people from my own program and other neighboring programs have had no issues securing neurohospitalist jobs in the area. Things may change though.

 

[neophyte2008]

I am in the same boat as OP.

As far as my background goes, I am in my PGY-3 year of training. I am an IMG and wanted to go back and hence was interested in stroke and endovascular in the beginning. Now because of life changes, I would love to be a neurohospitalist.

I have already applied for a stroke fellowship and have not yet certified my ROL ( Life changes). I come from a stroke heavy center and am very comfortable with stroke and NCC. However my epilepsy training is limited. I enjoy doing stroke, but EEG not that much. The question that I have is, I am dead set on becoming a hospitalist at this point. My final goal is financial freedom , hence monetary compensation is important.

- Should I do neurophys or stroke to be a neurohospitalist.

Common sense dictates that I should do neurophys, given the heavy stroke training I have. I have interviews from really good places , and most neurophys fellowships are filled. Hence I am thinking that if I train in stroke at a place with 5 months of electives then I can pick up good rEEG skills. So which fellowship should I do for optimization of monetary compensation in between the 2 and would I be trained enough If I just do EEG electives.

 

[Postictal Raiden]

Based on latest MGMA data I looked at, stroke neurologists make the most.

Given the information you provided about your interests/disinterests, I say suck it up and do the stroke fellowship. A good majority of neurology programs are at stroke heavy centers. Nevertheless, people still do stroke fellowship to gain expertise on the subject matter and to improve their employability (ie stroke program director).

 

[mrbreakfast]

If anything, we lack outpatient subspecialty exposure.

Yup, thanks to COVID and the relatively harsh winter in the south I will finish this calendar year (not academic year) with just 20-something half-day subspecialty clinic days combined. Probably couldn't apply to an outpatient fellowship even if I wanted. Oh well, that's neuro residency for you.

Should I do neurophys or stroke to be a neurohospitalist.

If you like stroke and are interested in making money, you should probably do stroke. Most of my program's stroke fellows are of that mind and go off to relatively lucrative inpatient private practice jobs. I'm not considering stroke personally because I don't really care for it and would take a pay cut to minimize the amount I'm called overnight.

I'd rather go into a job where I feel comfortable reading almost any EEG as well as inpatient EMGs. I think I could do this with a one-year fellowship, especially as I'll likely finish residency with 6-7 months total of EEG/EMG rotations. My mentors tell me at many public hospitals the need for inpatient EMG is an indication for transfer to an academic center, so I think this might be a nice skill for a job search.

 

[Postictal Raiden]

Yup, thanks to COVID and the relatively harsh winter in the south I will finish this calendar year (not academic year) with just 20-something half-day subspecialty clinic days combined. Probably couldn't apply to an outpatient fellowship even if I wanted. Oh well, that's neuro residency for you.


If you like stroke and are interested in making money, you should probably do stroke. Most of my program's stroke fellows are of that mind and go off to relatively lucrative inpatient private practice jobs. I'm not considering stroke personally because I don't really care for it and would take a pay cut to minimize the amount I'm called overnight.

I'd rather go into a job where I feel comfortable reading almost any EEG as well as inpatient EMGs. I think I could do this with a one-year fellowship, especially as I'll likely finish residency with 6-7 months total of EEG/EMG rotations. My mentors tell me at many public hospitals the need for inpatient EMG is an indication for transfer to an academic center, so I think this might be a nice skill for a job search.

6-7 months of EMG/EEG exposure is very good. During my residency interview I encountered a program that offered this.

I'll be lucky to finish residency with 2 months of EMG/NM and 2-3 months of EEG/EMU/epilepsy. That's why I decided to do a neurophysiology fellowship.

 

[RainbowYoshi]

Out of curiosity what would you think of pain / headache fellowship into neurohospitalist? I like the idea of having a few extra procedures to offer plus I've seen some place that have inpatient headache units.

 

[Postictal Raiden]

Out of curiosity what would you think of pain / headache fellowship into neurohospitalist? I like the idea of having a few extra procedures to offer plus I've seen some place that have inpatient headache units.

In an acute setting, nerve blocks are the only procedure you do for headache management (well, LPs too for IIH). You don’t need a headache fellowship to learn that. Every PGY2 neurology resident should be comfortable doing nerve blocks.

 

[sloh]

6-7 months of EMG/EEG exposure is very good. During my residency interview I encountered a program that offered this.

I'll be lucky to finish residency with 2 months of EMG/NM and 2-3 months of EEG/EMU/epilepsy. That's why I decided to do a neurophysiology fellowship.

Is it customary for most neurology residencies to only have 2-3 months of EMG training?

 

[Postictal Raiden]

Is it customary for most neurology residencies to only have 2-3 months of EMG training?

It varies. At my program, unless you actively seek it out and request electives in NM, you won’t get any hands on exposure. We get plenty of didactics tho. Other programs, Harbor UCLA and UTSA come to mind, have built in EMG blocks in their curriculum.

Vast majority of neurology residents don’t have adequate exposure to EMG by time they graduate. This in contrary to EEG which is a modality that is often used on the inpatient side.

How about PMR residencies, do you guys get enough EMG exposure to feel comfortable performing the test independently?

 

[mrbreakfast]

Is it customary for most neurology residencies to only have 2-3 months of EMG training?

No, in the sense that 2-3 months would be the upper end. I would say the average is 1 month, but probably a third of programs have 2 months and a third (or more) have zero.

Of course, as mentioned above inpatient EMGs are rare, so more inpatient-focused residencies will just let interested residents take it as elective time. This is contrary to EEGs for which (at my program anyway) we are expected to be able to provide at least a preliminary read by the latter half of PGY2.

At my program we do 2 months each of EEG and EMG. Doing an extra month of one or the other (or both) from electives isn't uncommon. Factoring in required epilepsy/NM clinic time, you could theoretically complete the coursework of an entire neurophys fellowship as a resident, though that would take all of your elective time. One of our recent grads did something like 6 months of EEG alone.

 

[sloh]

It varies. At my program, unless you actively seek it out and request electives in NM, you won’t get any hands on exposure. We get plenty of didactics tho. Other programs, Harbor UCLA and UTSA come to mind, have built in EMG blocks in their curriculum.

Vast majority of neurology residents don’t have adequate exposure to EMG by time they graduate. This in contrary to EEG which is a modality that is often used on the inpatient side.

How about PMR residencies, do you guys get enough EMG exposure to feel comfortable performing the test independently?

Thanks for the responses. I would say EMG blocks range from 4-6 months for PM&R residencies. I had 6 months at mine but my program was considered EMG heavy. Coming out of residency, most of us are really only comfortable and honestly should only be doing straightforward carpal tunnel, cubital tunnel, cervical radic, lumbar radic cases. Anything more involved and complex than that, the general consensus is you should complete a fellowship. I always thought Neurology had equal to or more EMG exposure because we tend to refer to you guys for more complex cases and zebras.

 

[xenotype]

Based on latest MGMA data I looked at, stroke neurologists make the most.

Given the information you provided about your interests/disinterests, I say suck it up and do the stroke fellowship. A good majority of neurology programs are at stroke heavy centers. Nevertheless, people still do stroke fellowship to gain expertise on the subject matter and to improve their employability (ie stroke program director).

Based on OPs first post they should not do stroke as they feel comfortable. You don't need to be a fellowship trained stroke neurologist to do acute stroke. Every neurologist is really expected to cover acute stroke at many non-academic jobs and is credentialed for it. The only thing you gain with stroke fellowship in practical terms is an easy route into being stroke center director as you reference, which can add maybe 25-50k on your salary in exchange for a lot of meetings and paperwork. See a bit more volume and you'll make way more. Do a stroke fellowship out of intellectual interest in stroke, but a halfway decent neurology residency should make one comfortable with acute treatment decisions and work up for 95% of stroke patients. The 5% left will need an angiogram and a lot of work up you can't do at a community center.

No, in the sense that 2-3 months would be the upper end. I would say the average is 1 month, but probably a third of programs have 2 months and a third (or more) have zero.

Of course, as mentioned above inpatient EMGs are rare, so more inpatient-focused residencies will just let interested residents take it as elective time. This is contrary to EEGs for which (at my program anyway) we are expected to be able to provide at least a preliminary read by the latter half of PGY2.

At my program we do 2 months each of EEG and EMG. Doing an extra month of one or the other (or both) from electives isn't uncommon. Factoring in required epilepsy/NM clinic time, you could theoretically complete the coursework of an entire neurophys fellowship as a resident, though that would take all of your elective time. One of our recent grads did something like 6 months of EEG alone.

Two months of EEG or EMG isn't enough to interpret even basic studies properly. Most programs in my opinion should strongly focus on EEG and ensure their residents have 4-6 months of EEG experience with a lot of volume so one can at least understand normal correctly rather than writing about phase reversals on every report and putting people on silly medications for incompetence. EMG is beyond the timeframe of a neurology residency, unless one is going to be deficient in a lot of the inpatient aspects of neurology.

Thanks for the responses. I would say EMG blocks range from 4-6 months for PM&R residencies. I had 6 months at mine but my program was considered EMG heavy. Coming out of residency, most of us are really only comfortable and honestly should only be doing straightforward carpal tunnel, cubital tunnel, cervical radic, lumbar radic cases. Anything more involved and complex than that, the general consensus is you should complete a fellowship. I always thought Neurology had equal to or more EMG exposure because we tend to refer to you guys for more complex cases and zebras.

Depends entirely on the individual neurologist. No one gets this training in residency alone. The most I have seen is 3-4 months of EMG training in neurology residencies, and this was heavily at the expense of EEG to the point that graduates hadn't read a single EEG from said program- dangerous when you consider the average neurologist in many places is expected to manage an ICU EEG with status with only intermittent epileptologist input. To be truly excellent at EMG you need a 1-2 year fellowship in it, but the average patient really does just need a CTS, neuropathy, or radiculopathy screen. Immunosuppression is more widely taught in neurology residencies and neurologists would be much more comfortable with IVIG, cellcept, plasma exchange, steroids etc for management of CIDP, MG, MMN as we use these for many other diseases and every neurologist needs to be able to comfortably manage AIDP and myasthenic crisis.

Essentially the average academic neurologist doing EMG is going to be way ahead than PMR. The average community neurologist on par with PMR or maybe even worse in many cases especially if mostly 'self taught' or taught by partners.

 

[sloh]

Essentially the average academic neurologist doing EMG is going to be way ahead than PMR. The average community neurologist on par with PMR or maybe even worse in many cases especially if mostly 'self taught' or taught by partners.

That's a good way of putting it. During my residency (academic), the Neurologists who shared the EMG lab with us were definitely ahead. Once I finished residency, what you said in your latter statement is on point.

 

[Telamir]

I agree. I don't think anyone is remotely prepared for interpreting EMGs or EEGs independently after 4 years of neurology. I did an extra year for neurophys-EEG and while I had some EMG overlap I wouldn't dream of doing them myself, I just know enough to interpret the verbiage and kinda figure out if the study or the operator sucks. Being able to interpret EEG has been invaluable mostly because I've had asshats with poor training interpret EEGs and I can reverse their incorrect reads.

A fellowship is 1 year. Yes, it sucks to do 1 more year but I think it will pay off in job security and extra expertise later on.

 

[bigamygdala]

just curious if i want to do botox etc do I need a neuromuscular fellowship or can I do that after just residency?

 

[Postictal Raiden]

just curious if i want to do botox etc do I need a neuromuscular fellowship or can I do that after just residency?

Botox for headache or for dystonia/spasticity?

 

[bigamygdala]

Botox for headache or for dystonia/spasticity?

mostly dystonia/spasticity

 

[xenotype]

just curious if i want to do botox etc do I need a neuromuscular fellowship or can I do that after just residency?

Ideally residency should train you for headache, but there are some ridiculous programs that don't. Spasticity/dystonia will require a movement or a neuromuscular/clinical neurophysiology fellowship (CNP with at least 40% EMG). You won't know the surface anatomy well enough from residency. Some movement and some CNP/NM fellowships do not teach you any botox, and these should be avoided in my opinion as 1) patients need these procedures and 2) they bill well currently.

 

[Telamir]

Headache is easy peasy. Residency should train you (although I had to go out of my way to learn it on mine) and worst comes to worst read the package insert, it's all there.

For dystonia or spasticity like the above poster mentions...you might be able to do it for the more superficial muscles but for the deeper anatomy and EMG guided injections you will definitely need a CNP fellowship. You might not need to do movement or neuromuscular. If you're doing CNP at an institution where they do these sort of injections (especially if EMG guided) you might get enough exposure that way.

 

[t2hyperintensity]

Along these lines, what does everyone think about doing outpatient general neurology without a fellowship?

Most of the faculty at my program have been in academics their whole career and there is the general attitude that (aside from chronic pain management) all neurology should be practiced at large academic centers by sub-specialists who only see one or two diseases. Not doing a fellowship is pretty unthinkable to many of them. Some of them look down on CNP fellowships and believe that even a CNP boarded neurologist isn't really qualified to interpret EMG or EEG. I have trouble separating their ivory tower pretension from actual concerns about having enough training to practice competently in the community. I am very tired of being a trainee and would love to move on with my life without spending an extra year in indentured servitude. I don't want to make a colossal career mistake though and end up unemployed or replaced by a midlevel in 5 years though by not doing a fellowship.

 

[90sportsfan]

Along these lines, what does everyone think about doing outpatient general neurology without a fellowship?

Most of the faculty at my program have been in academics their whole career and there is the general attitude that (aside from chronic pain management) all neurology should be practiced at large academic centers by sub-specialists who only see one or two diseases. Not doing a fellowship is pretty unthinkable to many of them. Some of them look down on CNP fellowships and believe that even a CNP boarded neurologist isn't really qualified to interpret EMG or EEG. I have trouble separating their ivory tower pretension from actual concerns about having enough training to practice competently in the community. I am very tired of being a trainee and would love to move on with my life without spending an extra year in indentured servitude. I don't want to make a colossal career mistake though and end up unemployed or replaced by a midlevel in 5 years though by not doing a fellowship.

I'm only a med student, but am very interested in Neurology so have been actively looking into the specialty. It looks like almost everyone (95+%) of resident graduates do fellowships. I will wait for the experts here to weigh in, so take my advice with a grain of salt, but it seems like the safe thing (from a career standpoint) would be to do one. If you ever end up changing your mind and want to go back into academics or if you want to move to a popular geographic location (and jobs happen to be tight years from now), it seems like it can only help and it's not too long. Plus even in the community, having some additional expertise in an area could be a nice niche to have.

 

[Thama]

Headache is easy peasy. Residency should train you (although I had to go out of my way to learn it on mine) and worst comes to worst read the package insert, it's all there.

For dystonia or spasticity like the above poster mentions...you might be able to do it for the more superficial muscles but for the deeper anatomy and EMG guided injections you will definitely need a CNP fellowship. You might not need to do movement or neuromuscular. If you're doing CNP at an institution where they do these sort of injections (especially if EMG guided) you might get enough exposure that way.

You don't need CNP to do EMG-guided injections for dystonia. You do need movement or other similar training. The hard part is not hitting the right muscle, it's knowing which muscles to target in the first place, the dose range for the muscle depending on severity, and how to fit BTX into a complex treatment regimen. Taking a weekend course and considering yourself competent in this area is irresponsible.

 

[xenotype]

Along these lines, what does everyone think about doing outpatient general neurology without a fellowship?

Most of the faculty at my program have been in academics their whole career and there is the general attitude that (aside from chronic pain management) all neurology should be practiced at large academic centers by sub-specialists who only see one or two diseases. Not doing a fellowship is pretty unthinkable to many of them. Some of them look down on CNP fellowships and believe that even a CNP boarded neurologist isn't really qualified to interpret EMG or EEG. I have trouble separating their ivory tower pretension from actual concerns about having enough training to practice competently in the community. I am very tired of being a trainee and would love to move on with my life without spending an extra year in indentured servitude. I don't want to make a colossal career mistake though and end up unemployed or replaced by a midlevel in 5 years though by not doing a fellowship.

These people do exist, but their opinions don't matter in the real world. You can get hired at many academic centers to be a general neurologist with no fellowship. CNP is the only way to get combined EMG and EEG training in one year, and many outpatient jobs expect you to do both. Plenty of CNP fellowships are really just 10 months EEG and vice versa anyways. The need for neurologists is desperate in many areas of the country. Ask the ivory tower people how long their waiting list for EMGs is and what they are doing to fix that. My center used to be >6 months. As for what will happen when the sky falls 20 years from now, I have no idea.

I recommend doing fellowship if at all possible though. Most people in outpatient neurology unless very specialized end up needing at least a basic understanding of EMG (beyond what you get in most residencies) due to how much general neurology is neuromuscular (CIDP, MG etc are not uncommon diseases). Most neurologists that provide hospital coverage wind up needing to read EEGs, or at least have a good understanding of epilepsy and EEG terminology. CNP allows you to be the swiss army knife patients need, especially in far flung regions that barely have any neurologists or have demand that way outstrips supply. Doing fellowship in something else like MS, movement, stroke will always be beneficial and expand your knowledge base/experience considerably. So I recommend doing fellowship in something, but it can be skipped. Some FMGs are forced to skip fellowship due to unexpected visa issues.

You don't need CNP to do EMG-guided injections for dystonia. You do need movement or other similar training. The hard part is not hitting the right muscle, it's knowing which muscles to target in the first place, the dose range for the muscle depending on severity, and how to fit BTX into a complex treatment regimen. Taking a weekend course and considering yourself competent in this area is irresponsible.

In my institution the movement people don't do EMG guided botox- the CNP/NM trained EMGers do it. My medical school was 50/50 between the two. I totally agree a weekend course is not sufficient and patients that have a bad experience or inefficacy with botox often don't come back. There are also movement fellowships that do not teach any botox.

 

[Thama]

In my institution the movement people don't do EMG guided botox- the CNP/NM trained EMGers do it. My medical school was 50/50 between the two. I totally agree a weekend course is not sufficient and patients that have a bad experience or inefficacy with botox often don't come back. There are also movement fellowships that do not teach any botox.

You are correct that there's a lot of institutional variation on who "owns" botox for various conditions. However, I would be very surprised if any reputable movement fellowship does not teach *any* botox. Botox for dystonia is about as core a part of a movement fellowship as learning to manage Parkinson's, and I've never met a movement-trained neurologist that wasn't trained to do at least necks and faces.

 

[t2hyperintensity]

I recommend doing fellowship if at all possible though. Most people in outpatient neurology unless very specialized end up needing at least a basic understanding of EMG (beyond what you get in most residencies) due to how much general neurology is neuromuscular (CIDP, MG etc are not uncommon diseases). Most neurologists that provide hospital coverage wind up needing to read EEGs, or at least have a good understanding of epilepsy and EEG terminology. CNP allows you to be the swiss army knife patients need, especially in far flung regions that barely have any neurologists or have demand that way outstrips supply.

Thanks! This was a very helpful answer. It sounds almost like the situation in the community almost requires a neurologist to interpret EMG/EEG regardless of their comfort level. So even if a neurologist didn't want to do a CNP fellowship, they would still be doing these diagnostic tests and just interpreting them poorly. Is this the correct take away? Or is it economically feasible for a neurologist to just not do these procedures, make a living off E/M, and then and kick them all to bigger center?

 

[Postictal Raiden]

Thanks! This was a very helpful answer. It sounds almost like the situation in the community almost requires a neurologist to interpret EMG/EEG regardless of their comfort level. So even if a neurologist didn't want to do a CNP fellowship, they would still be doing these diagnostic tests and just interpreting them poorly. Is this the correct take away? Or is it economically feasible for a neurologist to just not do these procedures, make a living off E/M, and then and kick them all to bigger center?

If you want to live in a big city, you’d be limiting yourself severely if you are not fellowship trained in something. Groups like to have different flavors of neurologists so they can capture as many patients as possible and minimize referring out. CNP (mixed) makes most sense in an outpatient private practice setting. It is also very helpful if you want to do straight up neurohospitalist since you almost always are expected to be very comfortable with EEGs, including ICU ones. However, because EMG is seldom done inpatient, a training in epilepsy or even EEG-heavy CNP is perfect for this setting. Stroke is another sought after subspecialty for inpatient neurology jobs since it allows the hospital to become a stroke center.

You may chose to not do a fellowship and still thrive. However you need to be geographically flexible. Every year, one person graduate from my program and goes straight into the workforce. None had difficulty finding employment so far, even in n a competitive market on a non-coastal Western metro. However, I think things are slowly changing. Jobs are become less abundant each year in desirable areas.

 

[xenotype]

You are correct that there's a lot of institutional variation on who "owns" botox for various conditions. However, I would be very surprised if any reputable movement fellowship does not teach *any* botox. Botox for dystonia is about as core a part of a movement fellowship as learning to manage Parkinson's, and I've never met a movement-trained neurologist that wasn't trained to do at least necks and faces.

Colleague recent graduate from high powered name brand program (overall- not necessarily specific to movement) learned zero botox in fellowship, and had to learn it with our NM faculty. Otherwise a very strong and smart movement doc. Personally I would never choose or recommend a movement fellowship that doesn't teach the skill (or DBS for that matter).

Thanks! This was a very helpful answer. It sounds almost like the situation in the community almost requires a neurologist to interpret EMG/EEG regardless of their comfort level. So even if a neurologist didn't want to do a CNP fellowship, they would still be doing these diagnostic tests and just interpreting them poorly. Is this the correct take away? Or is it economically feasible for a neurologist to just not do these procedures, make a living off E/M, and then and kick them all to bigger center?

Yes this is exactly what happens. Community neurologist takes job, learns they have to do EMGs and read EEGs because there is no one else to do them and huge demand, does them poorly after taking a weekend EMG course and they end up having to be repeated by someone who does know how to do them. Every EEG has a 'phase reversal' or 'generalized/temporal sharp waves' and most of the patients wind up on AEDs, being told they can't drive. Or worse- frontal lobe epilepsy deemed 'psychogenic'. Bad medicine, and not terribly uncommon in community neurology.

If you want to live in a big city, you’d be limiting yourself severely if you are not fellowship trained in something. Groups like to have different flavors of neurologists so they can capture as many patients as possible and minimize referring out. CNP (mixed) makes most sense in an outpatient private practice setting. It is also very helpful if you want to do straight up neurohospitalist since you almost always are expected to be very comfortable with EEGs, including ICU ones. However, because EMG is seldom done inpatient, a training in epilepsy or even EEG-heavy CNP is perfect for this setting. Stroke is another sought after subspecialty for inpatient neurology jobs since it allows the hospital to become a stroke center.

You may chose to not do a fellowship and still thrive. However you need to be geographically flexible. Every year, one person graduate from my program and goes straight into the workforce. None had difficulty finding employment so far, even in n a competitive market on a non-coastal Western metro. However, I think things are slowly changing. Jobs are become less abundant each year in desirable areas.

EMG is occasionally useful inpatient, but the knowledge you gain from having some neuromuscular training is extremely useful inpatient. Even if you don't do EMGs, many neurologists aren't as well rounded at PNS problems as they should be which do come into the ER, and occasionally there are serious problems needing intervention.

 

[deathmerchant]

Thanks! This was a very helpful answer. It sounds almost like the situation in the community almost requires a neurologist to interpret EMG/EEG regardless of their comfort level. So even if a neurologist didn't want to do a CNP fellowship, they would still be doing these diagnostic tests and just interpreting them poorly. Is this the correct take away? Or is it economically feasible for a neurologist to just not do these procedures, make a living off E/M, and then and kick them all to bigger center?

I wouldn't say required, but certainly very helpful and makes your marketable. Esp if you want to go solo or work in a very small community. Procedures add to your billing. You can't bill much by seeing a lot of followups. CNP is best suited for this type of setting. You could even learn to read sleep studies in CNP.

Colleague recent graduate from high powered name brand program (overall- not necessarily specific to movement) learned zero botox in fellowship, and had to learn it with our NM faculty. Otherwise a very strong and smart movement doc. Personally I would never choose or recommend a movement fellowship that doesn't teach the skill (or DBS for that matter).

I think its more unusual to have NM people do Botox regularly than Movement fellows Not learn Botox.
And like mentioned above, anyone can inject. The key is diagnosing Dystonias and its phenomenology (which, if you have been in a movement clinic is very hard) and then deciding the appropriate muscles and dosing. You can't argue that NM people are as good as Movement people at that. May be rare experts who have been doing it a lot.
Thats like saying a movement person can also do EMGs as good as NM

 

[BoneWizard]

Stroke is another sought after subspecialty for inpatient neurology jobs since it allows the hospital to become a stroke center.

I hear this a lot and I'm still confused by it. Does the hospital just instantly become eligible to be a stroke center once they hire a vascular neurologist?

 

[xenotype]

I think its more unusual to have NM people do Botox regularly than Movement fellows Not learn Botox.
And like mentioned above, anyone can inject. The key is diagnosing Dystonias and its phenomenology (which, if you have been in a movement clinic is very hard) and then deciding the appropriate muscles and dosing. You can't argue that NM people are as good as Movement people at that. May be rare experts who have been doing it a lot.
Thats like saying a movement person can also do EMGs as good as NM

From both of my institutions it is not unusual at all for NM/CNP people to do botox for spasticity and dystonia and do a high volume regularly. I do agree that movement not learning botox is rare. I disagree that movement has special secret knowledge when it comes to what muscles to inject and how much for common dystonias like cervical, assuming one does a reasonable volume. Rare dystonias (and unusual myoclonus, tremors etc) can certainly be very challenging and there are many, but these are a small percentage of the patients needing injections in most clinics. I don't think anyone straight out of fellowship will be super great at botox even with consistent dedicated time as you haven't had enough time to learn from experience as the delayed results from botox requires- definitely an art but this applies to a lot of neurology. Whether the injections work or not is highly visible to the patients who will decide whether someone is 'good' or not.

 

[deathmerchant]

From both of my institutions it is not unusual at all for NM/CNP people to do botox for spasticity and dystonia and do a high volume regularly. I do agree that movement not learning botox is rare. I disagree that movement has special secret knowledge when it comes to what muscles to inject and how much for common dystonias like cervical, assuming one does a reasonable volume. Rare dystonias (and unusual myoclonus, tremors etc) can certainly be very challenging and there are many, but these are a small percentage of the patients needing injections in most clinics. I don't think anyone straight out of fellowship will be super great at botox even with consistent dedicated time as you haven't had enough time to learn from experience as the delayed results from botox requires- definitely an art but this applies to a lot of neurology. Whether the injections work or not is highly visible to the patients who will decide whether someone is 'good' or not.

No knowledge is secret. Its all in the open.
I do my own EMGs and EEGs without any fellowship and I think I'm pretty good at it. I also have a PMR guy who does a lot of EMGs. But for the rare cases, I prefer sending them to a NM specialist. Similarly NM guys can do Botox pretty good, but you need movement trained person for Diagnosing and Treating rare dystonias and phenomenologies as you mentioned. Botox training is a big part of 2-3 year fellowships.

In my fellowship at a top program we had EMG guys who also did a pretty good job at Botox and had many patients and I know many people who do Botox injections without any fellowship training. Just like everything else.

 

[xenotype]

No knowledge is secret. Its all in the open.
I do my own EMGs and EEGs without any fellowship and I think I'm pretty good at it. I also have a PMR guy who does a lot of EMGs. But for the rare cases, I prefer sending them to a NM specialist. Similarly NM guys can do Botox pretty good, but you need movement trained person for Diagnosing and Treating rare dystonias and phenomenologies as you mentioned. Botox training is a big part of 2-3 year fellowships.

In my fellowship at a top program we had EMG guys who also did a pretty good job at Botox and had many patients and I know many people who do Botox injections without any fellowship training. Just like everything else.

This is rich. EMGs and EEGs are easy- no fellowship required and you are great at them! Except botox.. that is too hard without a movement fellowship...

 

[Thama]

This is rich. EMGs and EEGs are easy- no fellowship required and you are great at them! Except botox.. that is too hard without a movement fellowship...

Yeah... I would say that most neurology residents get pretty good at interpreting routine EEGs, though the full spectrum of EEG monitoring is well beyond general neurology training. I use a portable EMG in just about every clinic day but would never consider myself competent to perform a diagnostic EMG/NCS. Even doing CTS studies I don't think would be appropriate, as there's always the chance that its something unusual rather than CTS and I've seen far too many reports of "normal" EMGs in patients with rather obvious motor neuron disease once they're performed by someone appropriately trained to do the study.

 

[xenotype]

Yeah... I would say that most neurology residents get pretty good at interpreting routine EEGs, though the full spectrum of EEG monitoring is well beyond general neurology training. I use a portable EMG in just about every clinic day but would never consider myself competent to perform a diagnostic EMG/NCS. Even doing CTS studies I don't think would be appropriate, as there's always the chance that its something unusual rather than CTS and I've seen far too many reports of "normal" EMGs in patients with rather obvious motor neuron disease once they're performed by someone appropriately trained to do the study.

My program had pretty good resident training for routine EEGs (200-500 read by conclusion of residency) but this is still not enough to really be competent, especially with patients that are in the ICU or actually have epilepsy. That full spectrum you refer to can unfortunately come to bear occasionally on 'routine' EEGs especially in hospitalized patients. You can screen and probably be correct most of the time on whether it is abnormal or not, but you'll miss a lot in ICU patients, and be fairly clueless with patients that actually have seizures on the EEG. Less common stuff like unusual tonic seizures, EEG negative frontal seizures on video, or subtle temporal seizures will be missed entirely if inexperienced. That said, everyone in the community reads EEGs with or without a fellowship with widely varying degrees of competence, and I also believe every neurologist needs a basic familiarity with EEG at a minimum which most residents do accomplish.

EMG is a whole different animal, and very easy to miss even common diagnoses if one is inexperienced. Much more difficult to learn and do well in my opinion. Again, plenty of people do them without fellowship with varying degrees of competence (including family medicine, physical therapists, chiropractors...). Often patients are given no diagnosis or the wrong diagnosis and it later has to be repeated by someone who does know what they are doing.

 

[deathmerchant]

This is rich. EMGs and EEGs are easy- no fellowship required and you are great at them! Except botox.. that is too hard without a movement fellowship...

You are just making my point. Many neurologists do EEG, EMG and Botox with varying degree of competency with or without fellowship. I think we can all agree on that.

Fellowship in each of the above, (TYPICALLY, but not always) makes you better at that skill. (IMO! that's what additional training is for). I don't claim to know EEG or EMG better than an average fellowship trained person. I do claim to be better at Dystonia diagnosis and treatment than your average non fellowship trained person. Although I will admit there are few NM people or others who have more experience and expertise than me. Similar to my initial premise that on an average movement trained neurologists are better than NM trained for Dystonia, with exceptions.

 

[xenotype]

You are just making my point. Many neurologists do EEG, EMG and Botox with varying degree of competency with or without fellowship. I think we can all agree on that.

Fellowship in each of the above, (TYPICALLY, but not always) makes you better at that skill. (IMO! that's what additional training is for). I don't claim to know EEG or EMG better than an average fellowship trained person. I do claim to be better at Dystonia diagnosis and treatment than your average non fellowship trained person. Although I will admit there are few NM people or others who have more experience and expertise than me. Similar to my initial premise that on an average movement trained neurologists are better than NM trained for Dystonia, with exceptions.

Well, then we don't really disagree about anything.

 

[noxiushade]

I am a practicing neurohospitalist for 5 years and I have fellowship training in stroke. Most hospitals wanting to hire a NH will want you to cover stroke and will have a preference that you're stroke trained. And no, as a resident you don't know how to manage strokes as if you had fellowship training. Some hospitals also would want you to reed EEG. If you can bite two years of extra training, I'd do stroke and clinical neurophys EEG. If you don't do any extra training you will be less hirable, and maybe will find a job only in a smaller city community hospital. I also think NH fellowship is a waste of time, if you look at their curriculum / rotation is pretty much another year of neurology residency.

 

[Postictal Raiden]

I am a practicing neurohospitalist for 5 years and I have fellowship training in stroke. Most hospitals wanting to hire a NH will want you to cover stroke and will have a preference that you're stroke trained. And no, as a resident you don't know how to manage strokes as if you had fellowship training. Some hospitals also would want you to reed EEG. If you can bite two years of extra training, I'd do stroke and clinical neurophys EEG. If you don't do any extra training you will be less hirable, and maybe will find a job only in a smaller city community hospital. I also think NH fellowship is a waste of time, if you look at their curriculum / rotation is pretty much another year of neurology residency.

Not entirely true.

No one argues that doing a fellowship gives you a leg up. However, not doing doesn’t prevent you from getting a job in the most desirable job market.

I speak from a very recent hands-on experience. Also two other colleagues were able to secure NH jobs in very desirable metros.

I’m not going to be as well-versed on all of the stroke trials as someone who recently did a fellowship (having done a fellowship a decade ago doesn’t count because of the dramatic changes in stroke guidelines). However, I consider myself very competent in managing every type of stroke having done 10 dedicated months on the stroke service, not including night float coverage, during my residency training.

To a mildly lesser degree, the above applies to EEG skills. I won’t be able to work in an EMU or engage in epilepsy surgery planning, but being able to recognize seizures or frank focalities on EEG shouldn’t be a problem coming out of a rigorous residency program.

 

[xenotype]

I am a practicing neurohospitalist for 5 years and I have fellowship training in stroke. Most hospitals wanting to hire a NH will want you to cover stroke and will have a preference that you're stroke trained. And no, as a resident you don't know how to manage strokes as if you had fellowship training. Some hospitals also would want you to reed EEG. If you can bite two years of extra training, I'd do stroke and clinical neurophys EEG. If you don't do any extra training you will be less hirable, and maybe will find a job only in a smaller city community hospital. I also think NH fellowship is a waste of time, if you look at their curriculum / rotation is pretty much another year of neurology residency.

I don't agree. Stroke fellowship is essentially another year of neurology residency too with most residencies heavily weighted towards stroke. Most medium sized community hospitals hiring neurohospitalists have already shifted to telestroke and entirely cut acute stroke out of the equation for the neurohospitalist, and several of the biggest telestroke companies only care that you have recent high volume stroke experience. Large hospitals that can afford both epilepsy and stroke subspecialty coverage will of course prefer fellowship in those areas, but these are not the majority of the jobs out there.

A stroke fellowship trained neurologist just out of training is inferior compared to a non-stroke trained neurologist with 5-10 years of experience covering a high volume hospital(s) provided that person is reasonably up to date on the latest standard of care. The bar for competence is set when residency training ends. Fellowship certainly helps, but it does not make you an expert or a master in the field compared to someone with many years of experience. Nor is it (or can it reasonably considered to be) a prerequisite for providing acute stroke care given the shortage of neurologists and great need amongst patients. The vast majority of stroke care is quite formulaic compared to other areas like neuromuscular with much deeper complexity.

I harp on this because as a young resident I was specifically advised away from doing a stroke fellowship by wise attendings who said I'd need to be more comfortable with MG, GBS, drug resistant epilepsies etc as stroke was straightforward. No one who decided to defer income for an extra year of stroke training is going to hear that and believe it.

 

[mrbreakfast]

Thanks for all the comments. Just for the benefit of any future residents in a similar situation reading this: I have decided not to apply for a fellowship this cycle. I still haven't completely ruled out applying for something next cycle (as a PGY4), partially because I'm not set on 100% inpatient work, and would probably think pretty hard about it if my home neurophysiology program would be willing to add me on as a fellow for my PGY5 year. I haven't started the job search yet, but part of my thinking involves my already getting two informal job offers, including one at a large community hospital that would take me as a neurohospitalist without a fellowship (turns out connections are worth something).

I feel pretty confident both with acute stroke care and post-stroke care, but ultimately if I end up at an institution that has stroke specialty care and would want me to take a pay cut to not see acute strokes, so be it. I'd be willing to stay on as an academic neurohospitalist at my home institution, for example, where neurohospitalists don't staff stroke alerts (the stroke fellows do).

Most of my co-residents on similar inpatient career trajectories feel differently, but there's a lot of things I'd rather do than take stroke call overnight. I like teaching and am good at it, and I have interest in an extremely niche field of outpatient neurology that I might be able to practice in without a fellowship. Overall we'll see whether not sucking it up and doing a stroke fellowship was a mistake, but I'll let SDN know either way.

 

[Postictal Raiden]

Thanks for all the comments. Just for the benefit of any future residents in a similar situation reading this: I have decided not to apply for a fellowship this cycle. I still haven't completely ruled out applying for something next cycle (as a PGY4), partially because I'm not set on 100% inpatient work, and would probably think pretty hard about it if my home neurophysiology program would be willing to add me on as a fellow for my PGY5 year. I haven't started the job search yet, but part of my thinking involves my already getting two informal job offers, including one at a large community hospital that would take me as a neurohospitalist without a fellowship (turns out connections are worth something).

I feel pretty confident both with acute stroke care and post-stroke care, but ultimately if I end up at an institution that has stroke specialty care and would want me to take a pay cut to not see acute strokes, so be it. I'd be willing to stay on as an academic neurohospitalist at my home institution, for example, where neurohospitalists don't staff stroke alerts (the stroke fellows do).

Most of my co-residents on similar inpatient career trajectories feel differently, but there's a lot of things I'd rather do than take stroke call overnight. I like teaching and am good at it, and I have interest in an extremely niche field of outpatient neurology that I might be able to practice in without a fellowship. Overall we'll see whether not sucking it up and doing a stroke fellowship was a mistake, but I'll let SDN know either way.

Congratulations on the offers.

Remember, the decision is not final. You can always come back and do a fellowship. You won't be the first or the last to do so. People decide on changing careers and doing medicine in their late 30s and 40s. Doing a stroke fellowship after spending a couple years working as an attending should be much easier.