Interventional neurology

[BeTheBallDanny]

What is the career outlook for Interventional Neurology? Is it impossible to obtain a fellowship as a stroke neurologist? Is the field growing/shrinking? What type of cases do you normally see when you aren't doing procedures? What is the volume of procedures and are there opportunities to do research in the field? What is the average salary like versus general neurology? Obviously the lifestyle is not as good as general neurology or other subspecialties but I find it much more interesting. I posted this in allo as well but figure you guys would know more.

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[BeTheBallDanny]

Bump

 

[Hank Rearden]

Note that I'm a stroke neurologist at a major academic center and not an inteventionalist. The career outlook is good, but lots of people are being trained now compared to the numbers that are ultimately needed. Basically it's getting harder and harder for neuro IR folks to find jobs in the major metropolitan cities simply because the jobs are already taken. There is still a great need in smaller metro areas. It is not impossible to obtain a fellowship as a stroke neurologist. Not all programs train neurologists, however, so you should search old threads to figure out which ones do. Best bet would be to do stroke fellowship at one of those programs, impress them, and then stay on as IR fellow. At a major center you'd probably see 10-20 stroke thrombectomy cases a month and the rest of the time would be spent doing diagnostic angios, coiling aneurysms, embolizing AVMs, etc. Pay is probably $100k more at academic program and $200k more in private practice, but that's only a guess.

 

[BeTheBallDanny]

Note that I'm a stroke neurologist at a major academic center and not an inteventionalist. The career outlook is good, but lots of people are being trained now compared to the numbers that are ultimately needed. Basically it's getting harder and harder for neuro IR folks to find jobs in the major metropolitan cities simply because the jobs are already taken. There is still a great need in smaller metro areas. It is not impossible to obtain a fellowship as a stroke neurologist. Not all programs train neurologists, however, so you should search old threads to figure out which ones do. Best bet would be to do stroke fellowship at one of those programs, impress them, and then stay on as IR fellow. At a major center you'd probably see 10-20 stroke thrombectomy cases a month and the rest of the time would be spent doing diagnostic angios, coiling aneurysms, embolizing AVMs, etc. Pay is probably $100k more at academic program and $200k more in private practice, but that's only a guess.

Thank you! That sounds exactly like what I would like to do. My biggest concern was just being able to get the fellowship out of a neurology background. It seems that most people recommend going the neurosurgery route but I did not find the bread and butter nsg work (spine) all that fascinating.

 

[Thama]

If you know you want to do NIR and are purely considering residency to get you to that fellowship, then you have to do diagnostic radiology. The vast majority of NIR fellowships nationwide are still run by radiology departments and radiology-trained attendings, and they are generally quite protective of their turf as they see neurologists going into NIR as a threat to their dominion of the field. They were burnt by cardiologists taking over interventional cards decades back and are determined not to let the same thing happen in NIR with neurologists.

There are spots that are neurology-friendly, and a few programs even run by neurologists, but those are the distinct minority. Even applicants from nationally elite programs that I know have had to interview at a lot of places and face quite a bit of uncertainty regarding their prospects as compared with literally every other major neurology fellowship track.

 

[neurochica]

the neurology folks i know earned around $500k for 24/7

 

[BeTheBallDanny]

If you know you want to do NIR and are purely considering residency to get you to that fellowship, then you have to do diagnostic radiology. The vast majority of NIR fellowships nationwide are still run by radiology departments and radiology-trained attendings, and they are generally quite protective of their turf as they see neurologists going into NIR as a threat to their dominion of the field. They were burnt by cardiologists taking over interventional cards decades back and are determined not to let the same thing happen in NIR with neurologists.

There are spots that are neurology-friendly, and a few programs even run by neurologists, but those are the distinct minority. Even applicants from nationally elite programs that I know have had to interview at a lot of places and face quite a bit of uncertainty regarding their prospects as compared with literally every other major neurology fellowship track.

Isn't the IR pathway going to be 9 years long with the new system compared to the 7 years it would be in neurology? I'm also not sure I'd be happy doing standard IR but I would be happy doing neurology if it didn't work out to do NIR. 9 years is a long time to plan ahead.

 

[Naijaba]

Isn't the IR pathway going to be 9 years long with the new system compared to the 7 years it would be in neurology? I'm also not sure I'd be happy doing standard IR but I would be happy doing neurology if it didn't work out to do NIR. 9 years is a long time to plan ahead.

It's worth pointing out that a significant number of standard IRs do stroke intervention without neuro-IR fellowship training. They are competent with the devices, access, and anatomy (from radiology training), and they voluntary did neuro cases during their IR fellowship. Conversely, it's exceptionally rare to have a neurologist or neurosurgeon perform neuro-IR cases without fellowship.

Bottom line: As of October 1st, 2016, you are not required to be fellowship trained in neuro-IR to do stroke interventions. From this document:

Baseline training and qualifications:
1. Residency training (in radiology, neurology or neurosurgery)...required.
2. Dedicated training in Interventional Neuroradiology...It is preferred that this is a dedicated time (minimum of one year), which occurs after graduating from residency (i.e., a fellowship). A training program accredited by a national accrediting body is also strongly preferred but not required."

 

[TUGM]

Some corrections to the above:
- NIR is being dominated by neurosurgeons. Radiologists have already essentially lost the turf battle since surgeons and neurologists control the referral system (aneurysms, strokes). There are a few scattered programs around the country that remain exclusive to radiologists (UCSF, UTSW, WUSTL, etc.). Neurologists continue to have an uphill battle in securing these positions, but it's pretty doable if you prepare for it.

- It is the exception that peripherally trained IRs do neurointerventions. Might be more prevalent in the community, but at the large academic centers (ideally where you want to train and practices) this is simply not the case.

- Salary 350k +

 

[Neurointerventionalist]

"NIR is being dominated by neurosurgeons. Radiologists have already essentially lost the turf battle since surgeons and neurologists control the referral system (aneurysms, strokes)"

Actually, not.
(Neuro)Radiologists still represent the majority of neurointerventional practitioners, the majority in the most prestigious hospitals (Stanford, Johns Hopkins, Harvard/MassGen, UCSF, UCLA, NY-Presbyterian) and the majority in the most important (by far) neurointerventional society in the US (SNIS).
It is certainly true that neurosurgeons' and neurologists' share is increasing and maybe neurosurgeons will take the lead in a few years, but radiologists are far from "losing the turf battle" as they control most angio suites and endovascular devices, and "body" interventional radiologists are entering the field of stroke thrombectomy.

Also NeuroIR is still known as "Interventional Neuroradiology" and practiced at 99% by neuroradiologists in UK, France, Germany, Italy, Netherlands, Switzerland, South Korea and in most parts of Europe and World (with the exception of Japan).

Anyway, it is REALLY SAD how the "turf battle" is perceived by other specialties, even more because neuroradiologists have always been open to train them (back in the 80', 95% of neurointerventionalists where radiologists even in the US; then they decided to train anybody interested to learn); it is bad for patients but it is also very bad for practitioners, as in the US the job market becomes fragmented (interventional neuroradiologists VS endovascular neurosurgeons VS interventional neurologists, depending on the department that is offering the job - totally crazy for such a small field).

That's why, e.g., I really don't understand the need for a "Society of Vascular and Interventional Neurology" when ASA and SNIS already exist.
I'afraid that in the US the neurointerventional practice is too much influenced by business and doctors' Ego.

Just my 2 cents (an interventional neuroradiologists that now works in Europe and hope for the end of turf battles).

________


BeTheBallDenny:
If you like the field, go into it. Many "neurologist-friendly" fellowship today and it is really exciting.
Just be ready for the lifestyle (being on call a lot, long hours sweating under a lead apron, high burnout rate).

 

[Blackdogue]

"NIR is being dominated by neurosurgeons. Radiologists have already essentially lost the turf battle since surgeons and neurologists control the referral system (aneurysms, strokes)"

Actually, not.
(Neuro)Radiologists still represent the majority of neurointerventional practitioners, the majority in the most prestigious hospitals (Stanford, Johns Hopkins, Harvard/MassGen, UCSF, UCLA, NY-Presbyterian) and the majority in the most important (by far) neurointerventional society in the US (SNIS).
It is certainly true that neurosurgeons' and neurologists' share is increasing and maybe neurosurgeons will take the lead in a few years, but radiologists are far from "losing the turf battle" as they control most angio suites and endovascular devices, and "body" interventional radiologists are entering the field of stroke thrombectomy.

Also NeuroIR is still known as "Interventional Neuroradiology" and practiced at 99% by neuroradiologists in UK, France, Germany, Italy, Netherlands, Switzerland, South Korea and in most parts of Europe and World (with the exception of Japan).

Anyway, it is REALLY SAD how the "turf battle" is perceived by other specialties, even more because neuroradiologists have always been open to train them (back in the 80', 95% of neurointerventionalists where radiologists even in the US; then they decided to train anybody interested to learn); it is bad for patients but it is also very bad for practitioners, as in the US the job market becomes fragmented (interventional neuroradiologists VS endovascular neurosurgeons VS interventional neurologists, depending on the department that is offering the job - totally crazy for such a small field).

That's why, e.g., I really don't understand the need for a "Society of Vascular and Interventional Neurology" when ASA and SNIS already exist.
I'afraid that in the US the neurointerventional practice is too much influenced by business and doctors' Ego.

Just my 2 cents (an interventional neuroradiologists that now works in Europe and hope for the end of turf battles).

________


BeTheBallDenny:
If you like the field, go into it. Many "neurologist-friendly" fellowship today and it is really exciting.
Just be ready for the lifestyle (being on call a lot, long hours sweating under a lead apron, high burnout rate).

I'm just dying to ask this mate, how open are European neuroradiologists to training neurologists to become neurointerventionalists? Why are there so few neurologists doing interventions? Are they not interested or are things harder for them than it is in the U.S.? I'm particularly interested in German speaking countries.

 

[Neurointerventionalist]

I'm just dying to ask this mate, how open are European neuroradiologists to training neurologists to become neurointerventionalists? Why are there so few neurologists doing interventions? Are they not interested or are things harder for them than it is in the U.S.? I'm particularly interested in German speaking countries.

It depends on the attitude of each senior INR, but they are generally open.
I've worked a full year in a large italian center with many neurologists accepted.
ESMINT (european society of INR) has not "neuroradiology" in the name and accept neuros and nsg.

I think the two main reasons for the small number of neurologists and neurosurgeons in INR are the following:
1) in western Europe the "health market" (as many markets) is much more regulated than in US; scientific societies are more tightly linked with government authority to regulate who can do what and how: in many countries you have to be a radiologist to work in an angio suite.
2) in UK, France (the country where so many INR techniques developed - Debrun, Djindjian, Merland, Manelfe, Picard, Lasjaunias, Moret), Germany, Switzerland, Spain and northern Italy neuroradiologists are already organized to provide a neurointerventional service in most stroke centers.

For German speaking countries:
in Germany, back in 2015 (!), all the 107 regional stroke centers (and 127 hospital nationwide) already had radiologists with neurointerventional training 24/7 (look for "German Curriculum in Interventional Neuroradiology—How Many Interventionalists are Necessary? Did We Need Support from Other Societies for Stroke Treatment?" - I can't attach the link)
Same in Switzerland (9 stroke centers there).
In Austria IDK.
(if you need more informations, please tell me)

_________

A spine surgeon with nsg-background is WAY similar to a spine surgeon with ortho-background, just as an interventional neurologist and a neuroIR. Yet, if you are a nsg, it will be VERY difficult for a ortho dept to hire you. Same for neurologist in a neurorad dept (and that's why few neuros enter INR in Europe), or neurorad in nsg, or nsg in neuro and so on.
And what if a neuroIR wants to train in vascular neurology or neurosurgery? ... a radiologist? No way! (even if we talk about people with a deep knowledge of neurovascular anatomy and pathology who admit and treat hundreds of patients with aneurysms or strokes a every year).

After residency, physicians are "branded" and deeply segregated even when they converge to the same fields from different pathways: really stupid to me, as we all are physicians with similar interests and skills.

 

[Blackdogue]

Thank you very much for the info. So in Germany you are allowed to train as a neurologist, but noone would hire you in a radiology-run INR department? Is that what you are saying? I would like to get as much info as possible on this subject, because I'm currently looking for a residency spot in Germany, and a huge factor in choosing neurology is whether or not interventional is an option.

 

[Neurointerventionalist]

Thank you very much for the info. So in Germany you are allowed to train as a neurologist, but noone would hire you in a radiology-run INR department? Is that what you are saying? I would like to get as much info as possible on this subject, because I'm currently looking for a residency spot in Germany, and a huge factor in choosing neurology is whether or not interventional is an option.

I never worked in Germany, but I can ask to german colleagues/friends (but they are neurorad so may be biased).

If what I read and listen is correct, I fear you can only enter official INR training from radiology; the path is well described in the paper I posted.
There are centers that accept unofficial fellows, but it is hardly useful to be hired in a rad dept.
Things may rapidly change as UEMS and ESMINT are now opening to neurologists and nsg to become neurointerventionalist, but each country decide how to implement guidelines and IDK german situation.

Brief excursus:
In Europe we are moving towards 2 definite figures in stroke treatment: stroke physicians (neurologists represented by EAN and ESO) and neurointerventionalists (neurorads represented by ESNR and ESMINT); ESO-ESMINT-ESNR work together to improve collaboration between neurologists and INR, as in the "Stroke Winter School" in Bern.
ESNR and ESMINT are also lobbying european govs to recognize neuroradiology as a specialty, and maybe the booming of neurointerventional practice will help.

So:
If you want to be a full time INR in Germany, neuroradiology is the way (I can totally guarantee it is a REALLY exciting job).
If you want to be a vascular neurologist AND, if possibile, a neurointerventionalist, go into neurology (and ESMINT training) and cross your fingers.

Tschüss, lieber Kollege!

 

[Blackdogue]

Nocheinmal Vielen Dank für ihre Hilfe!