Neurocritical care practice pathway

[Lots of Snow]

I'm a neurologist who recently completed training. I consider myself a general neurologist and a incipient neurohospitalist. I find inpatient&vascular neurology to be an engaging field, but I am not interested in pursuing fellowship in this area because I obtained plenty of experience with inpatient neurology and acute stroke in residency. However, my impression is that there is a growing trend for acute stroke management to be a domain reserved exclusively for those board certified in vascular neurology or neurocritical care. For the moment, there are plenty of job opportunities for a general neurologist to take stroke call, but I am at the very beginning of my career and I wonder if I'm doing my longer term career harm without securing the credentials for credentials' sake. Vascular neurology previously had a practice pathway, but it is now closed. Neurocritical care's practice pathway remains open. I think I can obtain the prerequisite hours in neurocritical care time from managing status epilepticus, stroke alerts, encephalopathy consults on uremic MICU patients, and stroke alerts on uremic MICU patients. I acknowledge such experiences do not encompass the entire breadth of neurocritical care practice. However, I've observed board certification in neurocritical care has been obtained by many pulmonologists, anesthesiologists, and sundry intensivisits through the practice pathway without detailed expertise in neurology, so I don't think I'm doing anything seriously subversive. I certainly don't plan to represent myself as the type of intensivist who does bronchoscopies and central lines, I just want to future-proof my career as a neurohospitalist.

Has anyone else pursued this pathway?

Does the APBN "vet" reported prerequisite experience, such as by requesting letters from employers or colleagues? Is there reason to think hours spent seeing stroke alerts would somehow count less towards experience prerequisites than hours spent managing ventilators?

I consider myself a good exam taker, do you think a dedicated individual could study for and pass the written boards? Are there oral neurocritical care boards?

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[Lots of Snow]

Any thoughts?

 

[Postictal Raiden]

Why not contact the board and ask? Doubt anyone here has this type of information for you

Why are you worried about your future in neurohospitalist career? You have already been practicing in the field without issues. Traditionally, those with work experience have always been grandfathered in when new there are requirements.

Our healthcare system is so bizarre. On one hand, you see midlevel with online degrees practicing independently in every field of medicine (now even in radiology). On the other hand, a board certified neurologist who did 4 years of gruesome residency and had few years of post training experience under his/her belt feels inadequate and in need to add on more certifications. Absolutely ridiculous

I blame academicians who fail to inspire confidence in their trainees. Instead they keep pushing for more and more training.

 

[Telamir]

I thought about doing this since I met the requirements but ultimately I am not a neurointensivist. I am a neurohospitalist. I don't know how to titrate pressors, intubate, manage a ventilator, etc and even if I did learn that stuff for the board I feel it would be irresponsible to represent myself as a neurointensivist and realistically would hurt someone if I took a job with that scope.

So I didn't do it.

 

[Lots of Snow]

Why not contact the board and ask? Doubt anyone here has this type of information for you

Why are you worried about your future in neurohospitalist career? You have already been practicing in the field without issues. Traditionally, those with work experience have always been grandfathered in when new there are requirements.

Our healthcare system is so bizarre. On one hand, you see midlevel with online degrees practicing independently in every field of medicine (now even in radiology). On the other hand, a board certified neurologist who did 4 years of gruesome residency and had few years of post training experience under his/her belt feels inadequate and in need to add on more certifications. Absolutely ridiculous

I blame academicians who fail to inspire confidence in their trainees. Instead they keep pushing for more and more training.

ABPN website has nothing which is specific to my scenario, and contacting them results in them directing me to their website. I fully agree that excessive training is over-emphasized for neurologists currently, but I do feel like I have reason to be concerned about my career as a neurohospitalist. Lack of vascular/NCC board certification has demonstrably limited my career options, as I have interviewed for jobs at multiple hospitals which have bluntly told me that I would not be allowed to practice in the area of acute stroke neurology without such a certification. This has included hospitals which I know did allow general neurologists to practice acute stroke within recent (~past 5 years) past, so I get the sense this stance is increasingly prevalent.

I thought about doing this since I met the requirements but ultimately I am not a neurointensivist. I am a neurohospitalist. I don't know how to titrate pressors, intubate, manage a ventilator, etc and even if I did learn that stuff for the board I feel it would be irresponsible to represent myself as a neurointensivist and realistically would hurt someone if I took a job with that scope.

So I didn't do it.

I think there’s many pulmonologists who read up enough on tPA to pass the neurocritical care boards, but who have never made the executive decision about administering tPA for stroke in real life. So analogously, I would read up on vent management enough to pass the boards, but never represent myself as someone who has that scope. It does make me somewhat uncomfortable, but the idea of going back to fellowship sounds more noxious.

 

[Telamir]

I agree, and they are typically not the best neuro intensivists, and at least 2 have confided in me that they passed the boards but still do not feel comfortable with anything neuro. Even then, they are learning a particular niche of critical care whereas for us critical care is pretty far off our training.

I've never been turned down for a job due to not being stroke/ncc boarded so far, and I've had a few. Granted, I've mostly worked at comprehensive stroke centers typically, and I make sure to mention and lean on that when looking for another job. I've been doing inpatient work for 5 years so the experience side of it certainly is in my favor. The jobs that are divided may still "let" you do inpatient general neuro though.

The other thing I've noticed (and this is only anecdotal) I've met some stroke neurologists who were kinda hopeless/uninterested entirely in general neuro, and I don't think that's a good thing. One hospital I worked at where stroke and general were separate I was consulted by stroke neurology for a headache on one of their patients.

 

[CnsCrit]

My sense with the practice pathway is that it's only useful for older attendings who were grandfathered into NCC but likely only did stroke fellowships during formal training years. Like Telamir said, your best bet is to keep up your skills by working at CSC and trauma centers and letting the experience speak for itself.

Seems like there are lots of hospitalist jobs that take general neurologists, but there may be good reason if they really want people with fellowship training. For example, if you're doing a lot of cardiac arrest neuroprognostications, status consults, brain death evaluations, complex stroke evals, or severe TBI/ consults, a NCC fellowship comes in really handy. We manage these to some extent in residency, but these cases are often super complex. Every health system is different, in some places these consults are handled by neurohospitalists and in some places all ICU level consults go to NCC. It may be controversial here but I think it's actually valuable to have a NCC trained person evaluating most/all ICU level neurology consults. If the hospital is smaller and transfers certain cases out, then obviously NCC isn't available but otherwise I think we have a unique perspective. Our field isn't big enough yet, so I think theres still a role for experienced neurohospitalists who enjoy ICU level stuff.

In my neck of the woods there aren't any IM/EM trained folks who want to go anywhere near NCC, most pulm/crit folks are very happy to send neuro patients elsewhere.