Questions about subspecialities outside of academics

[DrAtheist]

I'm an incoming PGY1 neuro resident at a university program who has some questions about sub-specializing in epilepsy or movement. All of my exposure to these subspecialities has been in academic settings, and I wanted to get a feel for what the specialities are like in the community.

1) For both subspecialities, what percentage of patients are likely to be general neurology patients?

2) For movement, is DBS programming done in the community or typically only performed in academic settings? Also, are most DBS surgery centers academic institutions or is it realistic to be involved in this in the community?

3) For epilepsy, I've heard that the lifestyle is significantly more hectic than most other outpatient subspecialities, is this true outside of academics? Is this primarily because of overnight emergencies?

4) Are most community epileptologists expected to admit and manage their own patients in the EMU or is that handled by neurohospitalists at this point?

I appreciate any help with answering these questions.

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[Thama]

I can answer some of the movement portion as I went through the same investigation process some years ago and met with people in private practice to compare options.

1) The PP movement people I talked to did roughly 50% movement 50% general, and were happy with that mix. They said they wouldn't do 100% movement if it was offered, because they tend to be time consuming and challenging visits. Botox for dystonia is often a big part of these people's practices as it's a nicely billable procedure and offers some variety.

2) There are absolutely private practices that do DBS programming. However, the people I talked to tended to steer away from DBS or send those people to the local academic center. The problem with DBS in the community is that it's highly unlikely for you to find a situation where you are in the OR for the case in the way that most academic centers do it. So you get a patient back from a neurosurgeon who probably had the patient anesthetized during the case (because it's easier and faster) and where you had no role in confirming accurate targeting via MER or intraop testing, and it's a guessing game what you'll get when you turn that electrode on in clinic. You really have to find a neurosurgeon who is meticulous and that you trust, or you're going to get a decent percentage of referrals back with a poorly placed lead which is an extremely difficult conversation to have.

 

[Epic786]

our program has mid levels and residents who manage the EMU with the epileptologists but I think the field like stroke is getting saturated.

 

[sice4]

Can you talk more about stroke being saturated?

 

[Neurogeneral]

Can you talk more about stroke being saturated?

I don’t think so. In the private/community world, there will always be demand for stroke trained neurologists. These are your neuro-hospitalists typically. A lot of these jobs are looking for someone to take stroke call. Some may even offer you the title of “stroke director”, which can pay an additional stipend to oversee your hospital’s maintenance of stroke certification.

 

[Epic786]

Can you talk more about stroke being saturated?

we are a rural based academic hospital and in our system there are about 10-12 stroke fellowship trained neurologists