A New Breed of Neurologists...

[Bonobo]

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I was talking to a neurologist friend last week who will be starting an endovascular fellowship this July, and the idea of a 'new breed' of neurologists came up. One of the main arguments against neurologists in the ICU and as interventionalists has been that their personality doesn't fit. Looking at many of the academic neurologists at my school and others, I can see where this view comes from.

But things are changing. Stroke care is clearly undergoing a revolution that will probably evolve rapidly over the next ten-twenty years. The primary care of subarachnoid hemorrhage and head injury has begun to fall in the hands of neurointensivists. I've seen neurologists perform intubations, throw in lines within minutes, even EVDs.

On the interview trail, I found several other applicants who were like me--choosing neurology over neurosurgery--interested in the thrills that neurology could provide rather than its traditional role as the grand cerebral tickler. I can see the new breed growing.

Maybe I am wrong. I still note the many applicants, especially at the top programs, who would rather play with mice than with a respirator. As we can see in these forums, almost everyone else in medicine still cannot see the neurologist as a hardcore, masochistic, adrenaline-craving physician. But if neurology is providing a path for such physicians, maybe we can begin to change all this.

I believe that us future neurologists can help this new breed grow. I don't think this is necessary for neurology to survive. We will still need EMGs, care for MS patients, etc in the future. But I think that our patients will benefit from this. Cardiology underwent this type of revolution just twenty years ago and it paid off with huge dividends for their patients and cardiologists alike. I believe that it will for neurology as well.

Please let me know what others here think. How can we help this breed grow?

B

 

[PhineasGage]

Maybe I'm just a crumudgeon, but I got interested in Neurology for its contemplative pace, and challenging (if not intractable) problems. Certainly, this produces interesting possibilties for research, though the mouse still can't give me the kind of history I can get from a patient in clinic. 😉 Nonetheless, my affinity for the intricacies and elegance of the nervous system and the uniquely interesting patients we see drew me to the discipline -- more so than the desire to be poised on the precipice between life and death (OK, sorry if that's melodramatic).

Nonetheless, I think the trend towards acute/critical care is a positive development for our field, though it may not be relevant to me personally (check back with me during residency). Expanding the range of procedures/interventions we perform may help our image, and more importantly, our patients, immeasurably. On a more abstract level, this trend may provide a more multisystem approach to neurology. Just as basic neuroscience is increasingly recognizing the role of glia in brain functions (its not just neurons anymore!), neurology could benefit from greater consideration of multiple systems/variables -- as is common in critcal care unit settings.

It is interesting that we have concurrent (yet divergent) trends in neurology right now -- both an increased focus on critical care, and a movement towards more outpatient treatment. While some might see this as a schism, I view it as extremely promising -- the diversification of our chosen field.

- PhineasGage

PS Bonobo, I think we met on the interview trail.... Either I'm the "other" Bonobo, or you're another PhineasGage. Wondering how the match turned out for you... PM me if this rings a bell.

 

[sacrament]

I was talking to a neurologist friend last week who will be starting an endovascular fellowship this July, and the idea of a 'new breed' of neurologists came up. One of the main arguments against neurologists in the ICU and as interventionalists has been that their personality doesn't fit. Looking at many of the academic neurologists at my school and others, I can see where this view comes from.

But things are changing. Stroke care is clearly undergoing a revolution that will probably evolve rapidly over the next ten-twenty years. The primary care of subarachnoid hemorrhage and head injury has begun to fall in the hands of neurointensivists. I've seen neurologists perform intubations, throw in lines within minutes, even EVDs.

On the interview trail, I found several other applicants who were like me--choosing neurology over neurosurgery--interested in the thrills that neurology could provide rather than its traditional role as the grand cerebral tickler. I can see the new breed growing.

Maybe I am wrong. I still note the many applicants, especially at the top programs, who would rather play with mice than with a respirator. As we can see in these forums, almost everyone else in medicine still cannot see the neurologist as a hardcore, masochistic, adrenaline-craving physician. But if neurology is providing a path for such physicians, maybe we can begin to change all this.

I believe that us future neurologists can help this new breed grow. I don't think this is necessary for neurology to survive. We will still need EMGs, care for MS patients, etc in the future. But I think that our patients will benefit from this. Cardiology underwent this type of revolution just twenty years ago and it paid off with huge dividends for their patients and cardiologists alike. I believe that it will for neurology as well.

Please let me know what others here think. How can we help this breed grow?

B

Bonobo, this is an excellent post and something I've been thinking about quite a bit. I've been interested in neurologic disease since the beginning but had sort of crossed neuro off my "possible career" list because I cannot stand the notion of holding clinic every day and dealing with chronic headache patients. Only recently have I started to learn about the "new breed." There is a neurointensivist at the institution I'm currently doing my medicine rotation at, and his job is fascinating. Neuro + fast-paced, hands-on work? Apparently it can be done. Will neurology be able to claim the same non-invasive ground that cardiology was able to in their field?
Not everybody is excited about this. I met with our student advisor for neurology a couple of weeks ago, and his knowledge and interest in talking about neurointensivist work was minimal. He didn't seem to view it as a "hot field." I'd be more than happy to help prove him wrong; this is heady stuff, fascinating, exciting.

 

[Bonobo]

Bonobo, this is an excellent post and something I've been thinking about quite a bit. I've been interested in neurologic disease since the beginning but had sort of crossed neuro off my "possible career" list because I cannot stand the notion of holding clinic every day and dealing with chronic headache patients. Only recently have I started to learn about the "new breed." There is a neurointensivist at the institution I'm currently doing my medicine rotation at, and his job is fascinating. Neuro + fast-paced, hands-on work? Apparently it can be done. Will neurology be able to claim the same non-invasive ground that cardiology was able to in their field?
Not everybody is excited about this. I met with our student advisor for neurology a couple of weeks ago, and his knowledge and interest in talking about neurointensivist work was minimal. He didn't seem to view it as a "hot field." I'd be more than happy to help prove him wrong; this is heady stuff, fascinating, exciting.

Clearly, developing this new breed will require surpassing many hurdles--one being other neurologists who went into the field for the outpatient-lab based career. Interestingly, I just met with a current leader in interventional cardiology and he believed that neurology will be entering the interventional arena much more in the future. Before I had chosen my path, he had strongly recommended me to choose neurology over radiology. Interestingly, so had the neuroradiologist at my school--so here I am now. It is sad that a neurologist is the one discouraging you from entering this 'new breed'... but non-invasive neurologists will soon love the idea themselves when they begin to realize how much money it will bring to neurology departments in the future (AND they need the money!).

Turf issues are present and will have to be handled appropriately. Fortunately, I think the demand for neuro-interventionalists is going to be high enough that both radiologists and neurologists will be able to do what they want. Seriously, our biggest challenge is probably internal with neurologists who don't ever want to put a line into a patient. (Neuroradiologists are facing a similar battle with many radiologists preferring to live out their $300,000/yr 50-hr/wk lifestyle.) But with people like us entering neurology, I am confident that we will be able to hold our own and create this new breed of neurologists for the future benefit of our patients.

If you are unsure about neurology, I would recommend that you strongly consider doing an away rotation in vascular neurology or neurocritical care at a place where this new breed exists. Examples include UCSF, Columbia, Hopkins, and MGH. WashU, UCLA, Univ of Virginia, Univ of Chicago, and the Cleveland Clinic are other places to check out. PM me if you want more info about some of these places...

B

 

[kws888]

many neurologists know that inpatient work are not very financially rewarding. You can't survive if you spend too much time in ICU if you are in private practice.

kws

 

[jimbo21]

This is exactly the kind of feild i'm interested in. Are there any programs in the southeast that are strong in vascular/interventional neurology? I'm looking at vandy, uab, unc, etc...but I dont know much about any of these programs at all yet. would it be better for me to just try one of the west coast, or northern programs? also, which chicago program were you referring to...UIC?
thanks!

 

[Bonobo]

Financial reward in neurology is changing--as it will for the rest of medicine. If you want to make money as a neurologist, you still either need to be a good businessperson (e.g. design an efficient well-run practice, perform multiple EMG studies, run a sleep center, etc.), or become an interventionalist (there will be 25+ practicing interventional neurologists by next year). Being a neurointensivist will be as lucrative as being any type of intensivist--though I suspect reimbursement rates for intensive care will rise very soon given the number of ICU's opening up throughout the nation, the new guidelines by the Leapfrog Group, and the lack of intensivists out there.

More importantly for neurology reimbursement, however, will be stroke. Stroke is the leading cause of disability and one of the largest drains of CMS funds period. The NINDS is extremely well-funded, and the number of funded stroke trials out there is rising very fast. Stroke reimbursement has gone up, and doubles if you treat with tPA. As trials expand the treatment time window, stroke reimbursements may become a significant source of income for many hospitals. Furthermore, stroke patients bring money to hospitals by encouraging echocardiograms, carotid studies and potentially CAS/CEA procedures, transcranial ultrasounds, and eventually endovascular and neurosurgical stroke treatments. All of this is big business, and the neurologist will be at the center of it.

But what about the neuroICU? It is difficult to predict exactly what will happen to this field in the future. But if we look at trends, this is what I predict. Proceduralists are becoming more and more scrutinized regarding monitoring their outcome rates. Though some worry that this will encourage proceduralists to operate more in patients who are likely to have a better outcome, this trend is growing. If you want carotid stents to perform, you will soon have to report your peri-CAS stroke, MI, and mortality rates, and prove that they are good enough. Same with all endovascular and neurosurgical procedures, as well as for acute stroke treatment. Along with this trend is the trend that ICU's, and the neuroICU in particular, improve outcomes among stroke (particular ICH) patients. The corollary is that if you want a stroke center with good overall outcomes, then a neuroICU might be a very good investment.

A lot of this will admittedly occur only for the 100 or so large academic centers out there. But that is still quite a bit, and will likely change as the baby boomer's age and the CMS becomes more and more financially strained.

B

 

[docgrog]

As a neurologist with 20+ years experience, I've always been considered the oddball that thrived on inpatient work. I agree that unless you're at a major medical center, you're not going to be a neuro-intensivist. On the other hand, you can do quite nicely at a moderate size hospital as a neurology hospitalist.
That involves seeing a fair number of routine dizzy/woozy patients, loads of "acute mental status changes" patients (usually nursing home or "granny" dumps with UTI's), and the occasional Jakob-Creutzfeldt that presents as one of the above (like I had yesterday).
Mixed in will be a few acute strokes and status epilepticus players that will let you play interventionalist.
In terms of income, I'm not making what an interventional cardiologist makes, but it is about 150% of what the average neurologist makes based on national statistics. The key is NO office overhead (takes up 30% of your income)
It might not be glamerous, but it beats treating headaches and backaches in the office all day. Plus, it is very emotionally rewarding, especially when you deal with the families.
To do it, you have to love uncertainty, the never knowing what is going to happen between the time the answering service calls with your overnight consults and the time you finally sign your last note

 

[Bonobo]

As a neurologist with 20+ years experience, I've always been considered the oddball that thrived on inpatient work. I agree that unless you're at a major medical center, you're not going to be a neuro-intensivist. On the other hand, you can do quite nicely at a moderate size hospital as a neurology hospitalist.
That involves seeing a fair number of routine dizzy/woozy patients, loads of "acute mental status changes" patients (usually nursing home or "granny" dumps with UTI's), and the occasional Jakob-Creutzfeldt that presents as one of the above (like I had yesterday).
Mixed in will be a few acute strokes and status epilepticus players that will let you play interventionalist.
In terms of income, I'm not making what an interventional cardiologist makes, but it is about 150% of what the average neurologist makes based on national statistics. The key is NO office overhead (takes up 30% of your income)
It might not be glamerous, but it beats treating headaches and backaches in the office all day. Plus, it is very emotionally rewarding, especially when you deal with the families.
To do it, you have to love uncertainty, the never knowing what is going to happen between the time the answering service calls with your overnight consults and the time you finally sign your last note

Thank you for your perspective. The concept of neurology hospitalist is very new to me, and I suspect new to others. Do you know of any other resources regarding this type of work? How easy is it to set up a practice like this? How many hours do you end up working a week?

If being a neurology hospitalist is not very difficult, I would imagine that this would be a great type of job for future neurointensivists planning to staff the neuro-ICU at moderate sized hospitals, but needed more to do.

B

 

[mcandy]

will most (decent sized) hospitals look to employ CC neurologists or will this specialty be limited to only the biggest centers? Thanks in advance

 

[Bonobo]

will most (decent sized) hospitals look to employ CC neurologists or will this specialty be limited to only the biggest centers? Thanks in advance

I asked a friend who just completed her neuroICU fellowship about this, since she was looking for private positions at relatively smaller centers. What she told me was that she was aware of a couple different possibilities. First is the neurology hospitalist route where you also consult on neuroICU patients in the hospital's ICU and in the ER. The second is finding a neurosurgery group. These are already hiring neurointerventionalists and electrophysiologists, and will likely be hiring specialized neurointensivists soon to manage their post-op patients, the SAH's/ICH's, and the bad epilepsy patients.

I should note that she was given several offers for positions in large centers that are all striving to find 2nd and third neurointensivists.

B