Things to look for in a neurology program before finalizing the ROL

[bonran]

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Pointers to pick a good neurology residency:

a) Be strong in all the following 4-stroke, NM, epilepsy & NICU. Preferably have fellowships in all 4.

b) NICU should be neurology run with exposure of neurology residents to acute emergencies for at least 2-4 months of their training. They should also be managing post-op NSx & other NSx cases (aneurysms, tumor surgeries). There should preferably be a NIC fellowship.

c) Stroke should be supported by a Neurointervention (aka Comprehensive Stroke Center) service, preferably run by Neurology or Neurosurgery, where the stroke neurologist is the boss of how the stroke-intervention is run.

d) There should be an EMU with continuous monitoring facility & an epilepsy surgery program.

e) The NM program should have NM-Pathology/Medicine supporting it.

f) There should be a decent pediatric neurology program for exposure to that aspect of neurology.

g) Work responsibilities should be balanced with adequate didactics, specially in epilepsy, dementia, NM, pediatric neurology & neuroophthalmology.

h) Call should be no greater than Q 4 in the PGY-2 yr & should go down in the PGY-3 & 4 yrs. Essentially what that means is there should be 5 or more residents per year.

i) There should be a night float system.

j) The faculty should be a mix of young (stroke & NICU) & old (gen., NM, NOphth,NOnc, MS, Movement, Dementia etc) so that one can learn about the new aggressive treatment oreinted approach & the classical "thinking through" approach of clinical neurology.

k) The faculty should be affable, approachable & knowledgable about their sub-specialties. They should be able to teach on rounds & show what a bedside neurological exam is. They should be confident in interpreting neuroimaging on their own. They should be confident about dealing with neurological emergencies.

The other specialties- movement disorders, MS, Neuro-onc, infections, dementia/behavioural, neuro-ophthalmology can be learned on the job, from books & clinics.

Beware of any program selling themselves without atleast the following points: a-d,h,i,j & k. You will be cheated into poor training & a miserable 3 years.

 

[pazu]

Pointers to pick a good neurology residency:

b) NICU should be neurology run with exposure of neurology residents to acute emergencies for at least 2-4 months of their training. They should also be managing post-op NSx & other NSx cases (aneurysms, tumor surgeries). There should preferably be a NIC fellowship.
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Hmm, this point has been raised in other threads, but I know of several strong programs (Rochester, Pitt, Michigan, Maryland, UNC) that do not have their own closed Neuro ICU, but they still see ICU patients...of course, this means they serve more as consultants and are not the primary care team. I didn't get the impression that the residents at these programs were especially weak in critical care as a result of not having their own Neuro ICU, although if you planned to do neurocritical care, then you might want to do an elective elsewhere. It should be mentioned that many of those places are looking to hire neurocritical care docs in the near future.

Btw, thanks for answering my PM--I think the criteria you mention are very helpful 👍

 

[typhoonegator]

Speaking as a neurocritical care fellow at a major institution with a neurology-managed ICU, I can say unequivocally that you don't absolutely need to drop 10 subclavian CVLs in your very own NCCU during your junior year to be a good neurologist. The vast majority of practicing neurologists do not need to know how to manage EVD tract hemorrhage and SAH-associated ARDS.

I am biased, and I agree that having exposure to a full-on neuroICU as part of your training is very useful, but it certainly is not mandatory. As an example, UCSF is one of the truly great neurology residency programs in this country, and I certainly would not exclude them from consideration just because they do not have a neurology-managed ICU. And it should be noted that their neurocritical care fellowship and staff are absolutely top notch, and their publication record strong, despite not having their own private sandbox.

If you're strongly considering NCC as a subspecialty, then yeah, it might be nice to have a dedicated NCCU at your residency, but even if you don't, you'll have the elective time to explore other venues in your senior years anyway.

Bonran, I'm not trying to denigrate your opinions. I'm just adding a slightly different perspective.

 

[bonran]

Respectfully disagree.
With the aggressiveness in stroke thrombolysis & in refractory epilepsy surgery & their complications being the way of the future of neurology, I think NICU training is important for any future neurologist in making. Being able to manage neurological emergencies along with their medical complications makes one more competent clinically.

In my view a neurology residency without built in neurocritical care training in today's day is like doing internal medicine training in the UK (sans MICU training-which in UK is mostly under anaesthesia). There is a huge gap in the competency & clinical aggressiveness of US & UK internists, having seen both sides of the coin first hand. Similarly, I have seen a big difference between residents trained in a program with built in NICU training & those without, again having been in both types of programs. Besides, there is not much innovative medicine coming out of UK. Innovation in neurological subspecialties in the past has come from programs that have traditionally been aggressive in managing disease problems. Look at the institutions listed in the NINDS iv-TPA or the PROACT II trials. Studies that have turned acute stroke care on its head in the last 15 years. From throwing an aspirin at stroke patients, neurologists are doing IA thrombolysis, clot retrivals, stenting, declotting carotids & coiling aneurysms at major centers. Look at similar studies in Neurocritical care on hypothermia, cerebral microdialysis, endovascular therapy & the institutions where they are done; almost all of them have neurologists training in NICU care. One is not going to be trained well in a traditional EMG/EEG/hammer & tongs neurology program whose attendings want to keep their hands off any acute patients because they are afraid of a "poor outcome" without even having tried or tested a hypothesis.

Its not just about putting in lines & Swan-Ganz, more about being comfortable with managing an acutely sick patient & understanding the pathophysiology of the underlying disease process. When do residents get to see herniations, SE, hemorrhagic conversions, florid meningitis or ruptured aneurysms on floor rotations, EMG clinics or in EMUs? And why should not neuro residents be learning to manage these in the acute setting, rather than giving opinions on consult rounds? Do you think an neurosurgeon is in a better position to pick out the nuances of the neurological exam, seizure semiology or differentiate between headache of a migraine vs expanding hemorrhage? In my experience they put patients on Vanc & Zosyn for a white count of 11,500 regardless of abscence of other symptoms.

It is the same arguement that endovascular neurologists give for being better than neuroradiologists at their procedures, if its your disease learn how to treat it, study it & develop new ways to get better outcomes. Invasive cardiologists did it in the past. Stroke & epilepsy neurologists are doing it today. Why is it that the remaining neurological sub-specialties want to be staid about acute neurological patient care? Is it that they are not confident of managing these problems because their training lacked exposing them to these situations??

 

[typhoonegator]

We're saying almost the same thing. I personally agree that a closed, neuro-managed NCCU is superior to a NCC consult service. I have one, and I love it. There are complex and often political reasons behind why all tertiary care centers do not have such a system. I agree that there are benefits to training within a closed system, as you have outlined.

I only take issue with your statement that you need a neuroICU (with fellows) in order to avoid "poor training and a miserable 3 years". This is a hyperbolic statement, and is disrespectful to a number of absolutely top-tier programs.

I don't think we can project our own values onto everyone else and say they NEED that ICU training in order to be a good neurologist in whatever specialization they desire. I've never met an interventional neuro-otologist, and I don't think I want to. The field is changing, and some of us are spearheading that change through a more proactive and aggressive approach to neurologic care. But for the majority of neurologists who will continue to practice in an outpatient setting and never need to worry about these things, I'm not sure it's fair to argue against them going to a reputable program with an open ICU, or even (gasp!) no dedicated NCCU.

 

[aaddnl]

I respectfully disagree with many of these statements.
It is clear that you are a neuro-intensivist or Vascular neurologist, and that's great but several of your statements are just off.
-What about a strong Movement Disorders group involved in DBS surgery? And learning to distinguish MD phenomenology from "books and clinics" is probably not as good as also learning it with good MD attendings.
-?"Neurologists must know how to take care of post-op Epilepsy surgery patients"? The complication rate for these surgeries should be pretty low. Not sure why you need to train at babysitting Neurosurgical post-op patients to be a good neurologist.
-Pathology/Medicine supporting NM? Why is that a requirement for a good program? What about having good NM staff doing lots of EMG and clinic, muscle biopsies, ALS center, etc.?
-I know both of you are involved in NICU so dont take offense but I did 3 months of NICU in residency and put in lines and intubated and managed EVD's and all that and there's not a lot I learned during those three months that is applicable in Neurology practice. I had good teachers and I learned about Neuro critical care, and they do good work seeing and treating what they treat, but it's just not what most neurologists do. That's great if it's what your interested in, but if you are looking to go to a good neurology residency, I dont think you need a bunch of NICU training unless that's what you are going to do. In fact, those NICU months would be better spent learning clinical neurology. I learned a lot Medicine, Anesthesia, and post-op care those months.
-I agree that any general neurologist should know how to take care of Neurologic emergencies but you should learn that at any decent residency program regardless how much time you spend in the NICU.
-The rant about how MS, dementia, MD neurologists need to be aggressive in MS, dementia, MD, etc? The nature of those diseases and subspecialities does not lend itself to aggressive emergent ICU care like Stroke, SAH, etc. I dont think the comparison is valid. So, criticizing those neurologists for not being more aggressive and involved in acute care? That's comical.
-I'm not sure most Epileptologists deal with a lot of "acute/emergent" cases. Patients in status usually get initial treatment before/while the neurologist is called. Epileptologists spend most of their time in clinic/EMU.
-In addition to clinical skills, EMG/EEG is what a lot of neurologists in practice do. So I think exposure to this in residency is important. I know you dont think EMG/EEG is important in neurology residency training, but most private practices hiring neurologists require their applicants to be trained and competent in this.

 

[typhoonegator]

aaddnl, if you check my above post, I think you'll find that we're in agreement on many of these issues.

I contend that having a neuroICU is great, but most of neurology is not performed in, or even related to, the ICU environment. So be careful not to put too much weight on ICU criteria when choosing a residency (unless, of course, you're already dead-set on becoming a neurointensivist).

 

[bonran]

Neurological clinical skills (specially CNS signs) can best be learned in the neuro ICU because it is a rapidly changing senario in patients who have stroke's, bleeds, mass shifts & epilepsy.

I dont agree that most epilepsy specialists see status after it has been controlled. Wait till you begin your neurology residency before you see what real status is & how difficult it is to control. It is certainly not the run of the mill seizures or alcohol withdrawal seizures in the ER which gets mislabled as SE. How often have you seen a 5 minute seizure or 3 seizures in a row in 10 minutes? You seem to have not been exposed to intractable epilepsy which gets operated upon & sent to the EMU otherwise you wouldnt be making a cavalier statement about "babysitting post-op surgical patients". I agree, it is certainly turning out to be a comical discussion.

I do agree that most of the general neurology private practices look for people with EEG/EMG skills & these you will learn in any residency. But not all neurology programs have a built in NICU training or strong stroke or epilepsy programs. This is what I was trying to bring out in the discussion. One does not need to be trained in an EEG/EMG fellowships to do or interpret run of the mill EEGs or EMGs. Just as one doesnt need to do a vascular fellowship for treating a subacute or chronic stroke.

Besides neuromuscular medicine is sitting pretty much where it was 15 yrs ago. There is a limited number of treatments for AIDP, CIDP, MG, DM/PM & drug-induced myositis. The remainder are treated with a concoction of shaman therapy not backed by any evidence. Again, your naiivete shows up in your reasoning. Any NM/EMG program is supposed to do "do a lot of EMGs". Not all do muscle & nerve biopsies. Not all neuropathologists or NM people are good at interpreting results of these extremely complex tests. Which is why one needs to pick a program which has a reputation in doing these. Of course, if you are trying to diagnose "Fukuyama's myopathy" or "Lafora's disease" your specialized EEG/EMG skills may be required; but then what??

Learning about DBS placement is good. There are some "hypotheses" for why it works & you will learn that in a fellowship. But it has to be proved based on clinical evidence before it becomes a part of standard of care. I have seen DBS work for a few years in advanced PD & one case of severe Tourette's but no MDS expert can venture beyond hypotheses yet as to where the DBS elements need to be placed & why the thing works. It needs to be explored & researched- not something that you do in a residency unless thats what you are going into in your fellowship. And its bad form to do a neurology residency with the assumption that you are an MD specialist. Like I said before, run of the mill stuff like PD, PD+, tic disorders, ataxias & dystonic disorders are tought in almost all programs & can be learned from going through the RITE & books. Of course, if there is good MDS faculty to teach them to you, it is an added plus, but it is not the largest part of the patients you see in a residency. Barring PD & its mimics, the remaining are rare even in general neurology practices. There too what one ends up doing is adjusting times of dopamine, adding or removing agonists, treating the complications of dopamine including adding & removing seraquel for hallucinations & treating the medical issues that worsen PD. 70% of inpatient neurology will still be acute stroke most of which will end up going to a high dependency unit like an ICU & many will get complications. that is why programs with good stroke, ICU & epilepsy departments are what you need to look out for. NM & MD are mostly outpatient problems.

Again, if you land up in a good residency program trying to make well rounded general neurologists (hence, having good EMG/EEG/Stroke/NICU set ups) you will see a fair amount of epilepsy surgery, WADAs, brain mapping etc. You will also see NM pathology. Why these are important is something you will understand as you go through your residency & take the RITEs & the boards. Of course I dont expect to see more than 2 each of Fukuyama & Lafora's in my neurology practice throughout my life, but knowing about them was important for me as a resident now that I will never come across them in my vascular/ICU practice. Yes, understanding movement disorders & MS is good too but again all neurology programs are geared to teach you that. Not all are geared to teach you NICU care, comprehensive stroke care or epilepsy surgery.

However, if it is bread & butter neurology one wants to train in, you dont even need to open this link. With fairly decent scores & CV, you can close your eyes & put your finger on the map. You will land a spot in that neuro program & learn EMG, EEG, PD & MS.

 

[aaddnl]

Typhoonegator--i do agree with what you said.

The most common epilepsy surgery--amygdalohippocampectomy or temporal lobectomy should have a very low rate of post-op major complcations. If it's done at an experienced center as most of them are, it should be very low, like 1%, so, yes these pts are generally not requiring major post-op interventions or management. It's the preselection of the right candidates for surgery and ongoing outpatient management that is done by the epileptologists. Yes, epileptologists sometimes treat refractory status, but any neurology program should train someone to treat status.
Even though you dismiss it, treating refractory myasthenics, dermato, CIDP as well as managing difficult PD pts or MS pts primarily in the outpatient setting (and occasionally when they are hospitalized) takes clinical skill not routinely gained at "any" neuro residency program, particularly those that dont even have faculty in those areas.
Not to mention neuro exam findings that are not usually picked up in the ICU environment when the primary concern is do they need a scan now or tomorrow morning. I could go on and on but i dont feel like it.
So, we can agree to disagree, to each his own, I know that neuro ICU is great for you and that's wonderful but there are other perspectives and a good neurology residency program should be well-rounded.