What are the top EEG Epilepsy programs in the country?

[Dr. Bruce Banner]

I am applying to EEG and Epilepsy 2 yr fellowship and I'm trying to gather unbiased ideas as to which programs in the country are the top ones. I know only a handful of places have MEG. I don't know if that is gonna be the future, but I would like to at least get familiar with it during my fellowship. I am highly leaning towards Cleveland Clinic and Michigan due to proximity to families.
Other consideration include Yale and Mayo since I have very strong connections to both, but don't really want to live in New Haven or Rochester again if possible.
I would really appreciate your thoughts and any constructive comments.

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[xenotype]

Do you want to do academics or are you open to anything post fellowship? If not planning on doing research losing 1 year of income is a big hit, and 1 year will be adequate for most to function clinically at a level IV center. I would personally never want to live in New Haven or Rochester. The miracle whip offshoots are in really nice places- Phoenix and Jacksonville but I don't know how great the EEG training is there. Jacksonville is a big enough center I would think there would be reasonable volume and complexity.

Yale, Columbia, and Cleveland Clinic would be the historical thought centers for epilepsy, but I believe you can get good training anywhere that has a level IV center with decent surgical volume. MEG is quite specialized and most people rarely use it. Insert-community-hospital-here building a referral epilepsy center will not care at all where you trained.

If there is any chance of you being more of a general neurologist at some point- forgoing EMG training entirely leaves a big gap in your knowledge base but will make you better at surgical epilepsy.

 

[chickensoupdr]

Just how competitive are these places? How many top tier programs and mid tier programs would you recommend applying to?

 

[xenotype]

Just how competitive are these places? How many top tier programs and mid tier programs would you recommend applying to?

It is going to have a lot of year to year variability in the level of interest and internal candidates are often preferred at most places. I can't really give you a number. If you want epilepsy fellowship at a specific place, it might be competitive depending on random factors beyond your control that fluctuate based on the year (eg how many well qualified people want that spot that year). If you want an epilepsy fellowship with decent training and surgical exposure somewhere in a geographic region, that is not difficult at all to get and you probably don't have to apply to more than a handful of places even as an average resident with no research. I also like to mention CNP as an alternative as there is no real difference between CNP and epilepsy at many places, and CNP can be structured to include EMG time if desired.

 

[chickensoupdr]

Does doing CNP and taking neurophysiology board exam affect career later on? Would it limit where you can work, schedule, etc.? I read somewhere it is a field that is becoming less common and less popular. Any insights?

 

[xenotype]

Does doing CNP and taking neurophysiology board exam affect career later on? Would it limit where you can work, schedule, etc.? I read somewhere it is a field that is becoming less common and less popular. Any insights?

Unlikely to have any effect or real difference in practice for the foreseeable future.

 

[Thama]

Unlikely to have any effect or real difference in practice for the foreseeable future.

That's not quite true - a lot of larger academic practices only hire epileptologists for EEG.

 

[xenotype]

That's not quite true - a lot of larger academic practices only hire epileptologists for EEG.

Depends on how prestigious, how much existing research funding one is bringing with them, how desperate even a prestigious location is for faculty, and who one knows in personal connections. Many variables. A selective enough location will not hire epileptologists who trained at less regarded epilepsy fellowships. In today's market, there are very, very few centers who can afford to be this selective with a 6 month waiting list and a private hospital across the street eating their lunch in patient volume. 20 years from now? Who knows, but forgoing any EMG training means losing a lot of flexibility for private practice. If one wants to be on the cutting edge of epilepsy research at a prestigious location, an epilepsy fellowship with research built in is obviously the best choice. Not the best choice at all for a 3 person practice in Kansas making double the academic income where they also want you to do EMGs.

 

[Thama]

Its not just research - well-known university practices regularly prefer epilepsy training to CNP for pure clinical care. Sure, maybe Southwest Rectangular State Tech's "neurology department" doesn't differentiate any more than the 3 person practice across the street, but to say that CNP doesn't limit options at all is still an overstatement.

 

[xenotype]

Its not just research - well-known university practices regularly prefer epilepsy training to CNP for pure clinical care. Sure, maybe Southwest Rectangular State Tech's "neurology department" doesn't differentiate any more than the 3 person practice across the street, but to say that CNP doesn't limit options at all is still an overstatement.

Again, I think it depends on what one's goals are as not having any EMG exposure at all can significantly limit one's options in community practice in a great many locations. For academic departments sure prestigious locations will prefer epilepsy training. However this is complicated- if they need hospital coverage one may read their own cEEGs but not manage the EMU as technically outside the epilepsy department. Some universities will privilege both cEEG and EMG provided one has evidence of competency in both. For many academic departments they cannot find enough epilepsy trained and will gladly consider CNP trained depending on what one's EEG experience is. Many CNP fellowship EEG tracks are 10+ months of EEG with some IOM anyways.

Essentially if you choose epilepsy you give up overall flexibility in exchange for better EEG credentials/more EEG time in training. 90% of places even academic these better EEG credentials will not matter, and you will get locked out of any community practice setting that demands both EMG and EEG experience if you have only an epilepsy background. These community jobs pay far better than academics, but obviously this is bread and butter neurology at a high volume. There are trade-offs to any decision. If one hates EMG, sure epilepsy is better but know that if you do general neurology you'll really struggle with every bad neuropathy or weakness complaint that walks (or rolls) into the exam room.

 

[ananasmed]

Again, I think it depends on what one's goals are as not having any EMG exposure at all can significantly limit one's options in community practice in a great many locations. For academic departments sure prestigious locations will prefer epilepsy training. However this is complicated- if they need hospital coverage one may read their own cEEGs but not manage the EMU as technically outside the epilepsy department. Some universities will privilege both cEEG and EMG provided one has evidence of competency in both. For many academic departments they cannot find enough epilepsy trained and will gladly consider CNP trained depending on what one's EEG experience is. Many CNP fellowship EEG tracks are 10+ months of EEG with some IOM anyways.

Essentially if you choose epilepsy you give up overall flexibility in exchange for better EEG credentials/more EEG time in training. 90% of places even academic these better EEG credentials will not matter, and you will get locked out of any community practice setting that demands both EMG and EEG experience if you have only an epilepsy background. These community jobs pay far better than academics, but obviously this is bread and butter neurology at a high volume. There are trade-offs to any decision. If one hates EMG, sure epilepsy is better but know that if you do general neurology you'll really struggle with every bad neuropathy or weakness complaint that walks (or rolls) into the exam room.

Slightly off topic, but I imagine there is a similar dynamic for neuromuscular vs. CNP training for those more interested in EMG?

 

[xenotype]

Slightly off topic, but I imagine there is a similar dynamic for neuromuscular vs. CNP training for those more interested in EMG?

Emg is really hard to master. If you plan to be a true subspecialist taking referrals from the community NM is best, especially if you really love EMG. If you plan to be a general neurologist in the community, CNP with eeg time is advantageous to increase comfort with long term EEG while still getting EMG exposure. EMG really needs to be >50% of the CNP fellowship if you plan to do them unless one has some significant residency exposure to the basics.

 

[sharkbaitwhohaha]

I'm NM trained in private practice.

I didn't start feeling competent with EMGs until about 6 to 8 months in.
CNP with a heavy EEG split will not be that helpful.

Not saying that EMG is harder than EEG, but for outpatient, community settings (not reading LTMs), EEG is easier to learn on your own. Thats NOT possible with EMG.

 

[xenotype]

I'm NM trained in private practice.

I didn't start feeling competent with EMGs until about 6 to 8 months in.
CNP with a heavy EEG split will not be that helpful.

Not saying that EMG is harder than EEG, but for outpatient, community settings (not reading LTMs), EEG is easier to learn on your own. Thats NOT possible with EMG.

Completely agree- and I feel emg is more challenging. 6 months full time is bare minimum for basic EMG competence (or about 200 supervised studies) which also happens to be the AANEM minimum for board cert. Some people will be naturally better than others as it is very anatomy heavy. The difference between eeg and emg is that eeg is highly standardized- you won't see something in the recording that makes you tell the tech to slap extra leads on so it really is only about your subjective interpretation of what was already recorded. Emg on the other hand if one didn't know to check infraspinatus for a specific diagnosis or thoracic paraspinals outside the usual screening muscles...you can miss the diagnosis completely. Emg is technically more difficult as well to get good data- and 'good' data can have subtle but substantial artifact that you'll miss with inexperience and deem pathologic incorrectly.

 

[Thama]

Also, you're going to get quite a bit of EEG experience just during residency in the normal flow of inpatient work and will probably feel comfortable with most routine EEG reads when you graduate. Unless you seek out a LOT of EMG experience, that's probably not the case with EMG.

IMO the fellowship that adds the most if you want to be a kick-ass general neurologist is a neuromuscular fellowship. You get to actually be good at EMG (beyond "vague findings here please correlate clinically" - **** you're a neurologist not a radiologist), you get very comfortable with inpatient and outpatient immunotherapy, you learn neuropathology, etc.

 

[ananasmed]

Thanks all for the input, this is very helpful for a PGY3 interested in neuromuscular. Have been debating CNP for the alluring flexibility, but really not particularly enthused about EEG and have been worrying about whether or not I'd get sufficient practice with EMG, as well as exposure to NM pathology/treatment. Good to hear that NM fellowship can still allow marketability as a general neurologist, depending on how my career unfolds.

 

[xenotype]

Also, you're going to get quite a bit of EEG experience just during residency in the normal flow of inpatient work and will probably feel comfortable with most routine EEG reads when you graduate. Unless you seek out a LOT of EMG experience, that's probably not the case with EMG.

IMO the fellowship that adds the most if you want to be a kick-ass general neurologist is a neuromuscular fellowship. You get to actually be good at EMG (beyond "vague findings here please correlate clinically" - **** you're a neurologist not a radiologist), you get very comfortable with inpatient and outpatient immunotherapy, you learn neuropathology, etc.

Thanks all for the input, this is very helpful for a PGY3 interested in neuromuscular. Have been debating CNP for the alluring flexibility, but really not particularly enthused about EEG and have been worrying about whether or not I'd get sufficient practice with EMG, as well as exposure to NM pathology/treatment. Good to hear that NM fellowship can still allow marketability as a general neurologist, depending on how my career unfolds.

Yeah the comfort with immunotherapy is invaluable- really for any area of neurology outpatient one may need to use cellcept, maintenance IVIG/SCIG etc and feel comfortable. Autoimmune epilepsies do exist for example. Overall, I think NM/EMG is more helpful for outpatient neurology and EEG/epilepsy is more helpful for inpatient so it depends what mix one wants to have, how much continuity etc. Additionally- CNP fellowships with 10 months of EMG and 2 months EEG are very common (some are 10 months EMG, 1 month IOM, 1 month EEG/sleep etc). The key with CNP is the flexibility to form it into exactly what one needs or wants training wise whereas epilepsy or NM is about full immersion into that realm (at the expense of everything outside it). NM is a perfectly valid/nearly optimal choice for being a general outpatient neurologist, and may occasionally come in handy inpatient as well. Just know that CNP is also an option for 50/50 or 80/20 mix if desired, especially if you plan to read EEG for example a little extra time can make a big difference in the quality of your reads. The whole 'anyone can read a routine EEG' is true but also is why a lot of the community routine EEG reads are totally incorrect- just the same as the community EMGs.

 

[waveforms1202]

The NIH Clinical Center has a smaller but strong CNP-EEG track and epilepsy program. MEG evaluation is a part of the typical pre-surgical pipeline. If you have direct interest in getting familiar with MEG this would also be a great option. There are currently at least 15 epilepsy surgeries performed here with intimate experience in surgical planning with stereo, grid/strips, in conjunction with use of fMRI and MEG. Please DM if you would like additional information.