Training for NeuroCC

[Neuro321]

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Hello,
I’m a MS4 very interested in neurocritical care. I have been told about the availability of jointly training in Internal Medicine and Neurology at some programs, (Tulane and MCW, possibly others), which appears to be very advantageous if this is your career aspiration... My question is, with the limited Med-Neuro Combined programs out there, are/should interested candidates pursue IM residency followed by Neurology? is this an option? are there opportunities to expand upon NICU/MICU training in Neurology residency? Or is this even a concern? From my limited exposure to the NICU during my third year, there appear to be several medical complications experienced by the patients and I would be concerned with only my intern year in medicine, that this exposure may not be enough for me to feel confident in managing these acute patients.

Thank you for any and all words of advice.

 

[typhoonegator]

Hello,
I’m a MS4 very interested in neurocritical care. I have been told about the availability of jointly training in Internal Medicine and Neurology at some programs, (Tulane and MCW, possibly others), which appears to be very advantageous if this is your career aspiration... My question is, with the limited Med-Neuro Combined programs out there, are/should interested candidates pursue IM residency followed by Neurology? is this an option? are there opportunities to expand upon NICU/MICU training in Neurology residency? Or is this even a concern? From my limited exposure to the NICU during my third year, there appear to be several medical complications experienced by the patients and I would be concerned with only my intern year in medicine, that this exposure may not be enough for me to feel confident in managing these acute patients.

Thank you for any and all words of advice.

This seems to come up a lot. To put it not-so-politely, I have met many, many IM and anesthesia senior residents who know jack about management of ICU patients. Training in IM or anesthesia doesn't really prepare you to be an intensivist any more or less than neurology does (at least at big programs at hospitals that see a lot of sick patients). This is why we have fellowships (for SICU, MICU, and neuroICU) -- to prepare you as an intensivist in your chosen field. Anesthesia may have a leg up in terms of lines and intubations, but at the end of the day that is a pretty small subset of what an intensivist does.

I don't really know any medicine residents who could walk into an ICU and run ECMO or Swan a patient and manage them on 4 pressors without any assistance. They may have seen it a couple more times in their rotations than a neuro resident, but that doesn't really equate into a management skill. You learn that stuff in fellowship.

As a resident you will have the ability to shape your training to some extent, and if you are interesting in critical care you will gravitate toward those issues and patients. When I finished residency, I knew much more about managing sepsis than I did about interpreting EMGs, and I am not the least bit ashamed of that.

Some of the old-school people in NCC trained in both IM and neuro, largely because that was common back in the day. Those people are not running circles around those of us who trained in neurology alone. The field has evolved considerably, and neurology residency today exposes people to a lot of medicine and high acuity patients -- you just have to pay attention and not shy away from those teaching points as they arise.

 

[darksideone]

When I finished residency, I knew much more about managing sepsis than I did about interpreting EMGs, and I am not the least bit ashamed of that.

You are my role model.

Some of the old-school people in NCC trained in both IM and neuro, largely because that was common back in the day. Those people are not running circles around those of us who trained in neurology alone. The field has evolved considerably, and neurology residency today exposes people to a lot of medicine and high acuity patients -- you just have to pay attention and not shy away from those teaching points as they arise.

Not that I know everyone in the field, but the only IM/Neuro trained neurointensivest that comes to mind is John Lynch at MCW who trained at Duke. But he isn't really old-school. Who do you consider old-school? Diringer, Mayer, Hemphill, Suarez, Bleck, Wijdicks, Frank, Manno, Varelas...etc. are all neurology trained from what I recall. Also I think Werner Hacke is neurology only trained.

The ones that stand out from that would be Provencio @ CCF who actually did fellowship training in both NCC and CCM as did Nyquist @ Hopkins. McDonagh @ Duke did training in neurology and anesthesiology. Both Mirski and Papangelou @ Hopkins also trained in both neurology and anesthesiology.

Sure IM is helpful, but not sure by itself. If anything IM + CCM is more beneficial than just IM. I also see benefit of anesthesiology training as you mentioned above. But really, the best way to learn and be good at NCC is by doing.

 

[typhoonegator]

Neuroanesthesia --> NCC is another track, which I think is fantastic. But while they may start out with a leg up in physiology and general critical care, they have a huge amount of neurology to catch up on. But I love those guys.

 

[darksideone]

But while they may start out with a leg up in physiology and general critical care, they have a huge amount of neurology to catch up on.

McDonagh completed a residency in neurology as well as anesthesiology + fellowship in neuroanesthesiology and NCC. So I'm not sure he had a huge amount of neurology to catch up on.

Papangelou and Mirski both completed residencies in neurology + anesthesiology + fellowship. So I don't think those guys had a huge amount of neurology to catch up on either. Maybe someone who did purely anesthesiology or purely EM would.

 

[HeartNeuro]

" The field has evolved considerably, and neurology residency today exposes people to a lot of medicine and high acuity patients -- you just have to pay attention and not shy away from those teaching points as they arise."

this is an interesting observation. seems like neuro in some ways has gravitated a lot more toward IM in our generation. older neurologist clearly weren't exposed to ncc and tpa.

 

[bustbones26]

Hello,
I’m a MS4 very interested in neurocritical care. I have been told about the availability of jointly training in Internal Medicine and Neurology at some programs, (Tulane and MCW, possibly others), which appears to be very advantageous if this is your career aspiration... My question is, with the limited Med-Neuro Combined programs out there, are/should interested candidates pursue IM residency followed by Neurology? is this an option? are there opportunities to expand upon NICU/MICU training in Neurology residency? Or is this even a concern? From my limited exposure to the NICU during my third year, there appear to be several medical complications experienced by the patients and I would be concerned with only my intern year in medicine, that this exposure may not be enough for me to feel confident in managing these acute patients.

Thank you for any and all words of advice.

Somewhat in agreeance with what typhoonegator had said in his response, I would clarify the following:

Many IM docs can be credentialed at hospitals to admit to an ICU setting and even manage ventilators. However, as TN had argued, that does not make them experts at ICU care or a critical care specialist.

Whenever I was in neuro residency, we had a closed ICU. The only people that could admit to the ICU was the ICU team or the trauma team (surgical ICU). For that reason, in our PGY-3 or PGY-4 years, we were farmed out for a couple months at a sister institution to get more critical care experience. At our sister institution, their ICU was open, thus, Neuro admitted and managed ICU patients. Many residents at that sister institution went on to become good neurohospitalist and probably had admitting privileges to ICUs; however, again, as TN argued, that does not make them any kind of ICU expert.

Don't get too hung up on this!! I would suggest proceeding with neuro residency if NICU is a possible interest of yours. You probably could do a NICU fellowship if your primary specialty was Anesthesia or IM but as a neuro resident, you have some advantage on those guys. As a neuro resident, you will have much more experience with brain death evaluations, comatose patients, brain hemorrhages, complicated strokes , status epilepticus, etc. ICU docs are very good at managing "sick patients" but they suck at neurology. The goal of NICU fellowship is to learn how to manage "sick" patients while brining your neurology experience to the table.