sub-specialty with best prospects: stroke or neuro-onc?

[darksideone]

Any one have an idea which of the two will have the best prospects in the future regarding demand for physicians, research, treatment options, reimbursement?

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[GopherBrain]

Any one have an idea which of the two will have the best prospects in the future regarding demand for physicians, research, treatment options, reimbursement?

Demand for physicians: obviously stroke >> brain tumors

Research: Edge to Neuro-oncology.

Treatment Options: Edge to Neuro-oncology, but both exciting.

Reimbursement: Definitely stroke. Neuro-Oncology almost demands an academic center, while lots of private groups want stroke docs.

Then again, I am going into neuro-oncology, so I may be biased. I think it is the most exciting field within neurology.

 

[dl2dp2]

Demand for physicians: obviously stroke >> brain tumors

Research: Edge to Neuro-oncology.

Treatment Options: Edge to Neuro-oncology, but both exciting.

Reimbursement: Definitely stroke. Neuro-Oncology almost demands an academic center, while lots of private groups want stroke docs.

Then again, I am going into neuro-oncology, so I may be biased. I think it is the most exciting field within neurology.

So I hear that the academic centers are DESPERATELY looking for neuro-onc right now. I think they are even willing to raise salary for them.

 

[BrainWorks]

Just a thought, but with neuroonc and rad onc evolving I wonder if as neuroonc attendings they could be granted privileges to help direct gamma knife centers... any thoughts?

 

[Bill_Brasky]

Demand for physicians: obviously stroke >> brain tumors

Research: Edge to Neuro-oncology.

Treatment Options: Edge to Neuro-oncology, but both exciting.

Reimbursement: Definitely stroke. Neuro-Oncology almost demands an academic center, while lots of private groups want stroke docs.

Then again, I am going into neuro-oncology, so I may be biased. I think it is the most exciting field within neurology.

What is a neuro-oncologist going to offer that an oncologist or neurosurgeon or radonc can't? how would they change management or offer super-special neato neurology insights?

actually that question goes for stroke docs too, what super special stuff are they going to be really good at, it seems like stroke is a disease you can't really do much for that a IM guy couldn't...?

 

[michaelrack]

actually that question goes for stroke docs too, what super special stuff are they going to be really good at, it seems like stroke is a disease you can't really do much for that a IM guy couldn't...?

It's been a while since I've been a med student/resident, but back then the neurology residents used four 325 mg aspirin for stroke prophylaxis while the IM residents used 1 (for pts who had already had a stroke).

 

[Strokeguy]

It's been a while since I've been a med student/resident, but back then the neurology residents used four 325 mg aspirin for stroke prophylaxis while the IM residents used 1 (for pts who had already had a stroke).

Is this guy joking? May be ignorant. Vascular neurology has evolved and come a long way. So you need to evolve too.
Aspirin, plavix, aggrenox are now for primary care physicians. In major cities running a stroke center is a full time job. In this day and age,most 'aspirin prescriber' neurologists want to sit in the clinic and do outpt practice. This move towards outpt practice has created a vacuum for emergency stroke 'treatment'. The IV TPA treatment rates are barely 2%, so now telemedicine has stepped in. This has created full time jobs for stroke neurologists. Stroke treatment has now moved from just IV TPA alone. How do you 'treat' stroke patients who wake up with stroke or with symptoms of no clear time onset? How do you use TCDs to make treatment decisions? How do you evaluate stroke risk in patients with intracranial stenosis? A neurovascular practice is very busy and is a full time job. Of course, some stroke neurologists are becoming interventionalists as well.
Even for academicians- stroke gets the most research funding among all neurologic diseases. This has largely got to do with disease incidence and economic burden.

 

[michaelrack]

Is this guy joking? May be ignorant. .

Please note that I said "back then", which was about 10 years ago. The post was meant to be humorous.

 

[michaelrack]

Aspirin, plavix, aggrenox are now for primary care physicians. In major cities running a stroke center is a full time job. In this day and age,most 'aspirin prescriber' neurologists want to sit in the clinic and do outpt practice. quote]

Don't be so quick to dismiss outpt treatment. Many more strokes have been prevented with ASA, plavix, and aggrenox than have been salvaged with acute interventions such as TPA.

 

[GopherBrain]

What is a neuro-oncologist going to offer that an oncologist or neurosurgeon or radonc can't? how would they change management or offer super-special neato neurology insights?

Neuro-oncology is an odd field in that it can be entered by neurologists, or by medical oncologists. Neurologists usually do a 2-3 year fellowship after residency, while medical oncologists do 1-2 years.

The Neuro-oncologist has a lot to offer the patient that is unique from what a neurosurgeon or radonc will provide. For one, the Neuro-onc makes the plan and directs the patients to the appropriate therapy. It's (basically) true that the treatment for newly diagnosed GBM is pretty standard. Any MD with a passing familiarity with the literature knows what to do. (Resection + XRT + concurrent and adjuvant temodar). The art come into knowing how to treat recurrent disease (and they all reoccur). Plus, there is the full spectrum of less common tumors without clearly data-proven therapy. If you send them to see the surgeon, guess what will happen? Ditto with Rad onc. The neuro-onc might send the patient for surgery, or radiation, but is just as likely (ok, more likely) to use options such as experimental VEGF or EGFR inhibitors.

Also, what are the complications of brain tumor? Seizures, hemorrhage, hemiparesis, spasticity, etc. Things that neurologists are comfortable with.

 

[UMED122]

How often would a general (non-fellowship trained) neurologist see/treat brain tumors, if at all? I know that general neurologists see stroke fairly often whether they do a stroke fellowship or not. Also, do fellowship trained neuro-oncs just treat brain tumors, or do they typically mix in other neurology patients as well?

 

[Bill_Brasky]

Neuro-oncology is an odd field in that it can be entered by neurologists, or by medical oncologists. Neurologists usually do a 2-3 year fellowship after residency, while medical oncologists do 1-2 years.

The Neuro-oncologist has a lot to offer the patient that is unique from what a neurosurgeon or radonc will provide. For one, the Neuro-onc makes the plan and directs the patients to the appropriate therapy. It's (basically) true that the treatment for newly diagnosed GBM is pretty standard. Any MD with a passing familiarity with the literature knows what to do. (Resection + XRT + concurrent and adjuvant temodar). The art come into knowing how to treat recurrent disease (and they all reoccur). Plus, there is the full spectrum of less common tumors without clearly data-proven therapy. If you send them to see the surgeon, guess what will happen? Ditto with Rad onc. The neuro-onc might send the patient for surgery, or radiation, but is just as likely (ok, more likely) to use options such as experimental VEGF or EGFR inhibitors.

Also, what are the complications of brain tumor? Seizures, hemorrhage, hemiparesis, spasticity, etc. Things that neurologists are comfortable with.

Thanks for the great reply!!

 

[Yoyomama88]

In terms of research opportunities and privileges to provide gamma-knife radiation treatments, where do people see neuro-oncology headed?

 

[bustbones26]

What is a neuro-oncologist going to offer that an oncologist or neurosurgeon or radonc can't? how would they change management or offer super-special neato neurology insights?

actually that question goes for stroke docs too, what super special stuff are they going to be really good at, it seems like stroke is a disease you can't really do much for that a IM guy couldn't...?

Yeah, sure, a high speed cancer center is likely going to sick a neurosurgeon, rad-onc, medical onc onto you and I am sure that the job they perform is adequate.

That being stated, just bear in mind that sometimes we pursue fellowships based upon our interests. I am sure that most neurologists that are now neurooncologists did not know the day that they entered PGY-1 year that this was what they wanted. They probably developed a fascination and interest in treating brain tumors during residency and a fellowship would fill in the internal medicine gaps that they were never exposed to during residency (e.g. managing chemotherapy).

So be it!!

Now, onto stroke. Okay, yeah, what are you going to do after tPA and an antiplatelet? In my opinion, if you graduate from residency as a general neurologist and are not comfortable managing a stroke, then you misssed something along the way. That is an attitude that some develop. However, as pointed out by others, some receive neurosonology training and extensive training in vascular anatomy. This would be a launch pad for those that want to go on further into neurointerventional training. Of course, many larger hospitals love to have ful time neurologists at stroke centers. My current model in the community is to act as a consultant only. Bluntly and truthfully, this leads to VERY POOR care and I do not particularly enjoy this. Many hospitalists around here are "cowboys" and admit "TIA/Stroke" on their own and never call me until days into the admission or possibly never!! I feel that all hospitals should push toward better stroke care and who better to run a stroke center than somebody that wants to be there?

 

[typhoonegator]

Please be aware that this is a resurrection of a post from 2008.

 

[neurologist]

Please be aware that this is a resurrection of a post from 2008.

And that "Bill Brasky" was an epic troll back in the day . . .
Wouldn't even bother responding to anything posted by him, especially 5 years after the fact!!!

We can only hope that your response doesn't awaken the sleeping demon . . . .

 

[deleted102545]

Well since this thread has been resurrected, might as well use it! I've found that patient's with brain tumors and the sequelae are fascinating to me so I'm considering pursuing a neuro-onc fellowship. But it's hard to find data on the demand, exact scope of practice, and types of positions open. Is there anyone who can offer some guidance as to what kind of lifestyle (work and personal) a neuro-oncologist has? How about the future of the field? And since I am considering it as a life long career, is the compensation on par with general neuro or is it any more or less? What's the application and interview process like? Is it more of a "who you know" to get a good fellowship spot? I'd really appreciate it!

 

[hannelore]

ditto on those questions -
I'm in the similar situation where I'm 99% sure that I want to go into neuro-oncology but the only neuro-oncologists I've seen are academic physicians. Is there any possibility of private practice? Not that I'm interested only in those positions, but would be good to know your options. and what's the demand like in different areas? are urban centers already saturated with neurooncologists or is there still demand for it?

lastly - do all fellowships give you training on writing your own chemo? i've heard there are neuro-oncologists that do not write your own chemo.

 

[BlackFrancis33]

Lots of questions that are hard to answer in brief format. Most Neuro-oncologists take Academic positions, as that is where most of the jobs are at. There are also jobs at large, private hospitals with cancer centers, some with academic ties. Either way you are a salaried employee. Purely private practice in neuro-oncology exists, but that is the exception. You typically need an affiliation with a cancer center to draw in enough patients due to the rarity of the disease. There is still demand at academic centers, universities, and cancer centers, especially in the South and midwest (likely an over-generalization). Most academic jobs seem to be all neuro-onc, maybe with a few weeks of covering the neuro wards. If there is less business in the area, you will likely have to spend time doing some general neuro as well.

It has always been said that at Mayo the Neuro-Oncologists don't prescribe chemo, but that is the exception as far as training programs. I wouldn't train at a program where you don't write chemo, and I wouldn't take a job where that isn't in the job description. All the neuro-oncologsists I know write for chemotherapy. Maybe it would be more of a 'turf war' in a private setting.

I think, in general, oncology patients require more time. The hours can be long. You have to call other physicians, pharma companies, patients etc. If you are trying to be a successful academician on top of 75% time in clinic, you are going to work really hard. But that is what the field demands. I am not trying to discourage you. I think it is worth it.

 

[deleted866843]

Lots of questions that are hard to answer in brief format. Most Neuro-oncologists take Academic positions, as that is where most of the jobs are at. There are also jobs at large, private hospitals with cancer centers, some with academic ties. Either way you are a salaried employee. Purely private practice in neuro-oncology exists, but that is the exception. You typically need an affiliation with a cancer center to draw in enough patients due to the rarity of the disease. There is still demand at academic centers, universities, and cancer centers, especially in the South and midwest (likely an over-generalization). Most academic jobs seem to be all neuro-onc, maybe with a few weeks of covering the neuro wards. If there is less business in the area, you will likely have to spend time doing some general neuro as well.

It has always been said that at Mayo the Neuro-Oncologists don't prescribe chemo, but that is the exception as far as training programs. I wouldn't train at a program where you don't write chemo, and I wouldn't take a job where that isn't in the job description. All the neuro-oncologsists I know write for chemotherapy. Maybe it would be more of a 'turf war' in a private setting.

I think, in general, oncology patients require more time. The hours can be long. You have to call other physicians, pharma companies, patients etc. If you are trying to be a successful academician on top of 75% time in clinic, you are going to work really hard. But that is what the field demands. I am not trying to discourage you. I think it is worth it.

Thanks for the input.
I have a question: given the fact that many brain tumors are actually mets, how confident a neuro-oncologist (coming from oncology route) addressing the primaries in the management plan or there will be enough exposure to this during the 2-3 years of fellowship? Thanks!

 

[deleted866843]

Thanks for the input.
I have a question: given the fact that many brain tumors are actually mets, how confident a neuro-oncologist (coming from oncology route) addressing the primaries in the management plan or there will be enough exposure to this during the 2-3 years of fellowship? Thanks!

** coming from neurology route

 

[typhoonegator]

You've revived a thread that is 5 years old. Most brain mets are managed by the primary medical oncologist in concert with RadOnc and Neurosurgery. While neuro-onc is sometimes asked to weigh in particularly in more complex cerebral and spinal metastatic cases or when intrathecal chemo is indicated, I've not seen a neuro-oncologist take over management of lung cancer just because the patient has a brain met. They wouldn't want to, and they aren't trained to. This is specific to neuro-background neuro-oncology. I guess if you trained in med-onc and then did a separate neuro-onc fellowship, then you can do whatever you want.

 

[deleted866843]

You've revived a thread that is 5 years old. Most brain mets are managed by the primary medical oncologist in concert with RadOnc and Neurosurgery. While neuro-onc is sometimes asked to weigh in particularly in more complex cerebral and spinal metastatic cases or when intrathecal chemo is indicated, I've not seen a neuro-oncologist take over management of lung cancer just because the patient has a brain met. They wouldn't want to, and they aren't trained to. This is specific to neuro-background neuro-oncology. I guess if you trained in med-onc and then did a separate neuro-onc fellowship, then you can do whatever you want.[/QUOT

Thank you for your reply and clear explanation.

 

[3vilgenius]

thank you for the insight everyone.