Interested in Neurocritical care

[deleted102545]

Hey,

I'll be starting my first year of neurology this coming July and have been thinking about possible directions of my career. Neurocritical care at the moment is the one field that stands out most for me. Yes, I know it may be way too early to lock any particular field down but I know that NCC fellowships apply earlier than others so I want to be prepared.

I was hoping to ask some practical questions to other fellow residents interested in NCC, those that have been accepted to fellowships, and also current fellows.

1.) I currently have no research but have already contacted the head of our neuro-ICU to discuss possible projects. Will my lack of pre-residency research affect me too much?

2.) How competitive is applying to NCC? Is there a huge applicant pool? What do programs look for in a candidate? I know there aren't too many programs but I'm having a hard time finding hard data and whether spots at certain programs are filled or open.

3.) I've heard the lifestyle for neurointensivists can be rough but I'm curious as to how bad is bad? What is the work schedule like? Is it mostly shift work? I enjoy hard work but I do want to spend quality time with my family.

Any tips or recommendations from your experiences?

Thanks

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[danielmd06]

Hey,

I'll be starting my first year of neurology this coming July and have been thinking about possible directions of my career. Neurocritical care at the moment is the one field that stands out most for me. Yes, I know it may be way too early to lock any particular field down but I know that NCC fellowships apply earlier than others so I want to be prepared.

I was hoping to ask some practical questions to other fellow residents interested in NCC, those that have been accepted to fellowships, and also current fellows.

1.) I currently have no research but have already contacted the head of our neuro-ICU to discuss possible projects. Will my lack of pre-residency research affect me too much?

2.) How competitive is applying to NCC? Is there a huge applicant pool? What do programs look for in a candidate? I know there aren't too many programs but I'm having a hard time finding hard data and whether spots at certain programs are filled or open.

3.) I've heard the lifestyle for neurointensivists can be rough but I'm curious as to how bad is bad? What is the work schedule like? Is it mostly shift work? I enjoy hard work but I do want to spend quality time with my family.

Any tips or recommendations from your experiences?

Thanks

One of the forum moderators is an NCC fellow, so I suspect you'll get detailed answers fairly quickly. As interim answers I would say:

1) No.

2) As of two years ago I was told by a potential NCC applicant that there were actually more positions available than potential applicants. So I would venture to say it's not competitive. I suspect the programs out there are simply interested in bright candidates who are truly interested in NCC and contributing in some way to the furtherance of the field (just like most fellowship programs). Research is always a plus, but not an absolute requirement.

3) I defer this one to people more knowledgeable than myself.

In the meantime you may find this link fairly helpful:

http://www.neurocriticalcare.org/i4a/pages/index.cfm?pageid=1

You can access current UCNS accredited programs under the "Educations and Training" tab on the left. You may also want to check out the "Fellowships and Jobs" tab, too.

For the sake of completeness, here is the UCNS:

http://www.ucns.org/

 

[HarveyCushing]

3.) I've heard the lifestyle for neurointensivists can be rough but I'm curious as to how bad is bad? What is the work schedule like? Is it mostly shift work? I enjoy hard work but I do want to spend quality time with my family.

The PI that I worked under for 2 years is the head of one of the top 3-5 NCC programs in the country. He worked ~8 weeks per year clinically in the NNICU and spent the rest of the year doing research, traveling to give lectures around the world and other administrative duties. However he is very senior. The other junior faculty worked ~ 11-13 weeks per year clinically in the NNICU and then had to do a few weeks of general neurology rounds/stroke coverage. These were faculty that were out of fellowship < 5 years, The rest of the time they put towards research/advancing the program/administrative duties...etc.

So I think it depends on how many other neurointensivists you will be working with. A larger program means less time you need to be on clinical service. The program I worked with, I want to say the attending put in around 10hr days when they were on clinical service. Then they went home and would be available if the fellow who was on at night needed help.

 

[typhoonegator]

I'm a neurointensivist in my PGY7 final year. I'm staying where I trained.

1. No, but start soon. NCC is a research-driven field at the top, and you want to separate yourself and make yourself a unique asset. Also, we're a pretty small group, so getting involved with research gives you a chance to really get to know ICU faculty, which can pay big dividends when it comes time to write letters and make phone calls.

2. There are many NCC fellowship programs, but few you really want to go to. Look around at the faculty of the big name ICUs, and you will find that they all trained at a handful of places. Of course, you can do whatever you want, but you're better off training at the best place you can, and then get a job where you want later. Leaves more doors open.

3. Training in NCC at a good program is hard. Really hard. After that, it isn't really so bad if you're into it. I am going to be working around 10 weeks a year in my first year out of fellowship, and hopefully can dial it back from there. That said, I'm funded for my research, with grants paying a good portion of my salary. There aren't many jobs available for more than 33% clinical anymore, as people have been burning out and leaving, even though the pay is great when RVUs are only shared between 2 people. Depending on the program and if you have fellows, you can be coming back to the hospital every night or almost never, but at the end of the day an intensivist is a 24/7 job when you are on, and it can get pretty messy. And you will often have acute stroke call mixed in as well at many programs. The nice thing is that we are reimbursed better than many of our colleagues, which allows us to cover our salary with fewer weeks on call, freeing us up to do research or admin or teaching work.

 

[danielmd06]

I'm a neurointensivist in my PGY7 final year. I'm staying where I trained.

1. No, but start soon. NCC is a research-driven field at the top, and you want to separate yourself and make yourself a unique asset. Also, we're a pretty small group, so getting involved with research gives you a chance to really get to know ICU faculty, which can pay big dividends when it comes time to write letters and make phone calls.

TN,

How much does it matter where you train if you're interested in private practice (as opposed to academics like yourself)?

 

[HarveyCushing]

^ I don't see where you trained mattering at all if going to go into private practice. Just like other fields of neurology. For academics you go to maybe 3-5 programs because that is where the research is taking place, where the research programs/grants are, where the big PI's are...etc. If you know you don't like research/academics and want to go straight to a non-academic hospital, not sure a research heavy program is the best fit except for the clinical training.

 

[typhoonegator]

TN,

How much does it matter where you train if you're interested in private practice (as opposed to academics like yourself)?

Well, it doesn't, except that it still does

The trick is that the best clinical training in NCC still happens in the research-heavy places, because that is where the catchment is best. And since people still haven't realized that not everyone can land a job out of fellowship at Penn/MGH/Columbia/JHU/Duke/UCSF/yada-yada, the better private jobs out there still have a pretty good shot at landing a really well-trained intensivist from a big name program. This is a good thing if you trained at a top program and want to go into private practice. But if you trained at a less well-known program, you need to be aware that while you've still got a great shot at a primo private-practice NCC job, you're still going to get usurped by a Columbia grad (as an example) if they're looking at the same position.

The disclaimer here is that the landscape might look a lot different in 5 years. NCC is a rapidly maturing specialty.

 

[rockydoc]

3. Training in NCC at a good program is hard. Really hard. After that, it isn't really so bad if you're into it. I am going to be working around 10 weeks a year in my first year out of fellowship, and hopefully can dial it back from there. That said, I'm funded for my research, with grants paying a good portion of my salary. There aren't many jobs available for more than 33% clinical anymore, as people have been burning out and leaving, even though the pay is great when RVUs are only shared between 2 people. Depending on the program and if you have fellows, you can be coming back to the hospital every night or almost never, but at the end of the day an intensivist is a 24/7 job when you are on, and it can get pretty messy. And you will often have acute stroke call mixed in as well at many programs. The nice thing is that we are reimbursed better than many of our colleagues, which allows us to cover our salary with fewer weeks on call, freeing us up to do research or admin or teaching work.

Typhoonegator,

I was wondering if you could clarify some things for me. Do you mean that in NCC most people can't find jobs that are more than 1/3 clinical and the rest teaching/research?? And that this clinical time amounts to only 10weeks out of the year? Because 2 and a half months of hospital time doesn't seem like much.

I am curious, because NCC is something that I would seriously consider in the future (I am starting M4 year in a month), but I am not sure yet if I could handle a job where I always work 60-65+ hours per week (which is what I heard intensivists often do).

Thanks for your time

 

[HarveyCushing]

Typhoonegator,

I was wondering if you could clarify some things for me. Do you mean that in NCC most people can't find jobs that are more than 1/3 clinical and the rest teaching/research?? And that this clinical time amounts to only 10weeks out of the year? Because 2 and a half months of hospital time doesn't seem like much.

If you want to work at a non-academic center, better hope there are a few other physicians to share clinical duties. If it is just you for 52 weeks each year, God bless your soul. The minimal increase in salary over an academic position just isn't worth it.

I am curious, because NCC is something that I would seriously consider in the future (I am starting M4 year in a month), but I am not sure yet if I could handle a job where I always work 60-65+ hours per week (which is what I heard intensivists often do).

Thanks for your time

There are jobs out there that are not at an academic/research center where you can do just about only clinical. If you are in an academic center and expect to only work 10 weeks per year, you better bring something else to the table like research money. Otherwise will need to spend more time on the NCC service or take a few stroke calls.

If you go to a non-academic center better hope there are other physicians to help cover the 52 weeks each year. If it is just you, God bless your soul. The slight increase in salary over an academic position just isn't worth IMHO.

Here you can see the variety of job opportunities by location and practice type. http://www.neurocriticalcare.org/i4a/pages/index.cfm?pageid=3307

 

[typhoonegator]

The last 10 years or so has seen an explosion in the number of NCCU in the US. Early on, these were heavily understaffed with only 1-2 physicians, who were essentially "always on". And by always on, I don't mean available for prescription refills, but rather, coming back to the hospital every night at least once. Burnout was very high, but so was pay since you were constantly billing.

People increasingly recognize that essentially no one can sustain a two person 50% model of neurocritical care, and so small units have added staff or contracted with other intensivists to cover the time better. So while a few years ago you'd see a bunch of jobs for $300K and 25 weeks a year, that isn't very prevalent anymore because even if they find some sucker willing to sign on for that, they know they'll just burn out and leave after making bank for a year or two. Directors don't want to see that turnover.

So the staffing has become increasingly sane, albeit for slightly lower salaries since the RVUs are distributed over more people.

Right now, most of the good academic jobs are 25-33% clinical, meaning 10-14 weeks a year-ish. Remember, that is 24h a day, 7 days a week when you are on, which is hard to compare with taking pager call for a community hospital and maybe having to come in on the weekend to do a consult. Or covering a ward service 4 weeks a year and getting paged by the residents or hospitalists for new admissions and then rounding in the AM.

The remainder of the time is admin/research/teaching, or if you are at a smaller place, neurohospitalist or stroke coverage. The smaller the place, the generally lower the acuity and therefore lower the RVUs while on service, so people looking to practice at those kind of places are going to supplement their salaries with stroke or inpatient or even (gasp) clinic. On the upside, the lower the acuity, presumably the less intense the ICU call.

Of note, neuroICU attending coverage reimburses well. You can cover a decent salary in 12 weeks a year with 18 beds and >50% critical care time in those patients.

 

[rockydoc]

Now I understand better. Thanks Typhoonegator. I didn't realize that a combo of critical care time w/ hospitalist or clinic time was also an option for private/community practice. Very interesting. Still sounds like quite the workload though, as you were saying.

 

[iridesingltrack]

^ I don't see where you trained mattering at all if going to go into private practice. Just like other fields of neurology. For academics you go to maybe 3-5 programs because that is where the research is taking place, where the research programs/grants are, where the big PI's are...etc. If you know you don't like research/academics and want to go straight to a non-academic hospital, not sure a research heavy program is the best fit except for the clinical training.

I am intrigued by some of these comments because they just don't seem to reflect what I have witnessed. It seems, from what I've seen, that there is such a demand for academic neurointensivists that far more than graduates from the "top 3-5" programs are landing great academic jobs.

I am beginning this year at a realatively new NCC program that is graduating its 5th group of fellows this year and all but one of the fellows has gone into academics, while all have been highly recruited. It seems to me that there remains many more academic jobs than the graduates of those top tier programs are able, or willing to fill, or am I missing something? With that said, I agree the landscape is rapidly changing.

iride

 

[danielmd06]

I am intrigued by some of these comments because they just don't seem to reflect what I have witnessed. It seems, from what I've seen, that there is such a demand for academic neurointensivists that far more than graduates from the "top 3-5" programs are landing great academic jobs.

I am beginning this year at a realatively new NCC program that is graduating its 5th group of fellows this year and all but one of the fellows has gone into academics, while all have been highly recruited. It seems to me that there remains many more academic jobs than the graduates of those top tier programs are able, or willing to fill, or am I missing something? With that said, I agree the landscape is rapidly changing.

iride

I think the truth lies somewhere in between, actually. I also suspect you'll find opinions vary.

From my own observation, NCC people from practically any program can write their own ticket because there is such a dearth of fellowship-trained personnel relative to jobs available (in both academics and private practice). No, I don't know that many NCC people. But pick up a green journal and you almost always see at least one NCC posting in the classified section. And I think the problem of supply/demand is heightened by a relative lack of neurology residents interested in pursuing this fellowship pathway.

Doesn't it help to have trained at a better place? Well yeah, I think it does...but only sometimes and in particular situations. It certainly helps if you have competition for that faculty spot, right? Places like UCSF probably aren't suffering from a lack of applicants, so it helps to bring the best possible CV you can to the table to further your own ambitions. I feel confident that many prestigious places might just be willing to allow a spot to remain vacant if they cannot locate a candidate of "proper" background to fill it. Of course, they'll crack eventually if they have enough trouble playing the waiting game. And from my take, this is basically exactly what TN was saying above.

Anyway, I would argue that many programs across the country are desperate for NCC people and these locales aren't going to be terribly picky about pedigree. In fact, they'll likely be much, much more picky about YOU personally. Where you want to live, how you interact with others, how you mesh with the local patient population, and how you mesh with your potential future colleagues. From the standpoint of many, these factors actually matter much more than the name of the school you trained at.

And on the tarnishing note of ending a sentence with a preposition, I'll stop.

 

[iridesingltrack]

Fair points the whole way around, danielmd.

In particular, I agree that it likely has more to do with the individual; however, I am certain that training pedgree will always be considered when a candidate is being screened for a job interview. Getting a foot in the door, so to speak, may very well be easier from the older more established programs.

iride

 

[HarveyCushing]

I am intrigued by some of these comments because they just don't seem to reflect what I have witnessed. It seems, from what I've seen, that there is such a demand for academic neurointensivists that far more than graduates from the "top 3-5" programs are landing great academic jobs.

I am beginning this year at a realatively new NCC program that is graduating its 5th group of fellows this year and all but one of the fellows has gone into academics, while all have been highly recruited. It seems to me that there remains many more academic jobs than the graduates of those top tier programs are able, or willing to fill, or am I missing something? With that said, I agree the landscape is rapidly changing.

iride

My point was just that there are a handful of programs (Columbia, WashU, Hopkins, MGH, UCSF...etc.) that offer a strong research aspect to the training. I know most programs have "research" but certain programs have stronger research training based on the ongoing research and the PI's that are funded. Some fellows might be ok working in a basic science lab on a TBI/SAH model, others might be ok working on a retrospective database project, others might want to be involved in a multi-center randomized control trial. In the end, each individual has their own end goal in mind. However (I am just a MS4) there are certain programs that tend to put out stronger research than others. If you want to go into academics, and do it well, there are definitely a handful of programs that stand out from the rest. I never meant to say you couldn't go into academics if you went to a newer program or one that was not as focused on research. Sorry if my post came across that way.

 

[typhoonegator]

It also depends on how you define academic. If you just mean affiliated with a university, well then yes, there are a ton of "academic" jobs out there.

But not everyone means it that way. Some people envision a medical school affiliation and a residency and fellowship as part of what makes a hospital/department/division/position academic. There are fewer of these positions available.

And some people expect an "academic" department to have > $100 million in NIH funding, with faculty research supported, working in their labs > 50% of the time. There are fewer and fewer of these positions available in NCC these days, as many of these departments are pretty full.

Now, I'm not trying to push one definition over another. Define it how you want. But I think that is the reason for some of the confusion. Memorial Medical Center in Springfield, Illinois is affiliated with SIU School of Medicine. I grew up around there. A fine area of the country and a fine hospital. Great trauma care.

Not everyone in the world would consider a 50% NCC / 50% hospitalist position at Memorial Medical Center to be an "academic" job. But why not? You presumably would have an academic appointment at SIU as part of your package. On the other hand, you don't have a lab, you don't have research funding, and you probably aren't going to be given time to teach or write papers. So what is so "academic" about that position?

Don't flame me on this. I'm not denigrating positions like this. There is something for everyone. But you'd better believe if you want to get the new job that just opened up at Columbia/NY Presbyterian (Neeraj is leaving) and you're just coming out of fellowship, pedigree is going to matter to people like Stephan Mayer.

 

[HarveyCushing]

It also depends on how you define academic. If you just mean affiliated with a university, well then yes, there are a ton of "academic" jobs out there.

I think typhoonegator makes some great points here. We all have different opinions regarding what "academic" means and even "research." Even when certain academic institutions are looking for new faculty, I would assume they would look for certain characteristics when making a decision. Some will be more picky than others, while others will just be happy to have a body.

 

[iridesingltrack]

It also depends on how you define academic. If you just mean affiliated with a university, well then yes, there are a ton of "academic" jobs out there.

But not everyone means it that way. Some people envision a medical school affiliation and a residency and fellowship as part of what makes a hospital/department/division/position academic. There are fewer of these positions available.

And some people expect an "academic" department to have > $100 million in NIH funding, with faculty research supported, working in their labs > 50% of the time. There are fewer and fewer of these positions available in NCC these days, as many of these departments are pretty full.

Now, I'm not trying to push one definition over another. Define it how you want. But I think that is the reason for some of the confusion. Memorial Medical Center in Springfield, Illinois is affiliated with SIU School of Medicine. I grew up around there. A fine area of the country and a fine hospital. Great trauma care.

Not everyone in the world would consider a 50% NCC / 50% hospitalist position at Memorial Medical Center to be an "academic" job. But why not? You presumably would have an academic appointment at SIU as part of your package. On the other hand, you don't have a lab, you don't have research funding, and you probably aren't going to be given time to teach or write papers. So what is so "academic" about that position?

Don't flame me on this. I'm not denigrating positions like this. There is something for everyone. But you'd better believe if you want to get the new job that just opened up at Columbia/NY Presbyterian (Neeraj is leaving) and you're just coming out of fellowship, pedigree is going to matter to people like Stephan Mayer.

There are several NCC fellowship programs, and locations looking to build a program, that are looking for academic faculty (researchers, educators) and they aren't filling them exclusively with people from 3-5 programs. Are there some programs, like Columbia, that may not have open doors to all graduating fellows, of course. Does that mean that someone will not be able to get a job where the expectation is develop an NIH funded career? Absolutely not.

I am commenting in this thread because I would be disappointed if an applicant felt that if they didn't go to one of a handful of programs that they would not be able to find a job doing what they want. With that said, I am pragmatic in recognizing that not every program will be open; there are some, as TN points out, that will be more focused on training pedegree than others. I also agree that doors will open more easily from these 3-5 programs based on their more extensive alumni network, reputation, and the network of the mentor that is making calls on your behalf.

iride

 

[MemberX]

Hey all,

Came across this thread. How much has the field changed since this thread was originally posted? Wanted to get a sense where this field is going

 

[typhoonegator]

It's changed a great deal. Stephan is now at Mt. Sinai.

 

[Hellothere111]

It's changed a great deal. Stephan is now at Mt. Sinai.

From what I've heard, that might change too.


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[Cone774411]

How necessary is research for a NCC application?

I know it's program specific i'm sure, but in general, do most programs prefer neurosurgical applicants over neurology?

 

[TUGM]

How necessary is research for a NCC application?

I know it's program specific i'm sure, but in general, do most programs prefer neurosurgical applicants over neurology?

I responded to your question regarding research in the other thread.

Most programs will prefer neurologists, and maybe anesthesiologists. Surgeons want and should want to operate as much as possible.