ARTICLE IN BRIEF:
Neurohospitalist programs aim to share resources and expand fellowship training opportunities. Several program directors discuss what they're doing to support that initiative.
Neurology Today first started writing about the emergence of in-hospital neurologists—so-called neurohospitalists—in 2010, and three years later, focused on the growing pains of the specialty to define itself and its niche within academic and community-based medicine.
Then, as now, the specialty was faced with a conundrum: The interest in the niche area was there among newly minted neurologists but the formal training opportunities were few and far between. In the last few years, the tide has begun to turn, and the specialty has begun to more formally train for its future.
At the University of Colorado Anschutz Medical Center, positions for the one-year fellowship program to become neurohospitalists have been filled for the 2018-2019 and 2019-2020 academic years, and the application period for the following year recently closed.
At Stanford Medicine, the first neurohospitalist fellow will start in July. They join a similar fellowship program at University of California, San Francisco (UCSF), which has graduated 10 fellows over the past decade.
As neurohospitalists proliferate in hospitals across the country, particularly in academic medical centers, residents are increasingly being introduced to the relatively new career path.
“Every year I get more and more emails from residents around the country asking about the fellowship and trying to understand whether it is a good fit,” said Maulik Shah, MD, director of UCSF's neurohospitalist program.
While the number of applications has not necessarily increased in proportion to the inquiries, he expects that they will as the specific focus of a neurohospitalist fellowship becomes more well-known.
Generally, most neurohospitalists are fellowship-trained in another subspecialty, according to a survey, which was published online in December 2018 in a quarterly, peer-reviewed journal, The Neurohospitalist. The survey, by John C. Probasco, MD, medical director of the inpatient general neurology service at Johns Hopkins Hospital and colleagues, found that 89 percent of the 105 respondents reported being fellowship-trained, most commonly in cerebrovascular neurology. Only 13 percent of respondents were trained in neurohospitalist neurology.
A neurohospitalist fellowship is designed for neurologists who are focused on advancing inpatient care through careers in academic medicine.
“It's really for trainees who are looking to become leaders in the neurohospitalist field,” said Carl Gold, MD, director of Stanford's fellowship program.
Many fellows who train in the UCSF program are interested in resident education, Dr. Shah said, adding: “Neurohospitalists have a unique opportunity in academic centers to work a lot with residents and do a lot of teaching.”
Some want to find ways to systematically improve patient outcomes, patient safety, and patients' experience of care, working within the medical center to identify things that need attention and leading quality-improvement projects to address them, he said. Others want to do clinical research on how to improve care in the inpatient setting.
“We have fellows who are conducting research to better understand acute neurologic emergencies and diseases that are often only seen at tertiary and quaternary academy centers,” Dr. Shah said. “And they are trying to develop protocols that can be used across the country.”
Neurohospitalists In Context
Neurologists began specializing in inpatient care only two decades ago, and the field has grown quickly. But Jana Wold, MD, president of the Neurohospitalist Society, considers the subspecialty to still be somewhat in its infancy.
“How to start a program is still not completely established,” said Dr. Wold, a neurohospitalist at the University of Utah. “So we spend part of our annual meeting each year talking about building a practice and what a practice can look like.”
How many neurohospitalists are in practice? She cited an estimate—1,800—from David Likosky, MD, a neurohospitalist at EvergreenHealth in Kirkland, WA, who is considered one of the fathers of the neurohospitalist movement.
Neurohospitalist programs at academic medical centers are typically initiated by faculty members who want to improve inpatient care, Dr. Wold said, while administrators at community hospitals often recruit neurohospitalists to make sure they have coverage for stroke and other neurologic conditions.
Dr. Gold chairs the AAN's Neurohospitalist Section, established in 2009, which has grown to include more than 600 members.
“Once an institution puts a dedicated neurohospitalist program in place, there is a shift in perception,” he said. “We become the constant presence in the hospital, and many other services become interested in having us involved in the care of their patients.”
Neurohospitalists are a key part of a hospital's quality program, responsible for implementing quality-improvement initiatives and making sure quality standards, such as those required for designation as a comprehensive stroke center, are met.
“So individuals who spend most of their time in the hospital need to be aware of all these different metrics and make sure we are doing a good job,” Dr. Wold said.
Neurohospitalists also collaborate with other clinicians across disciplines, whether that is working on hospital-wide initiatives or sharing responsibility for seriously ill patients.
“The delivery of care is different in a hospital setting as opposed to a clinic setting, so that's why it is important to have training in team-based care,” Dr. Wold said.
Despite the increasing demand for neurohospitalists in both community hospitals and academic medical centers, fellowship programs have been slow to take off, however. A handful of programs have been created but they either never filled the positions or became inactive after a short time.
Despite that, leaders of academic neurology departments support advanced training specifically for neurohospitalists. In a survey of department chairs or residency program directors at adult neurology training programs that were accredited by the Accreditation Council for Graduate Medical Education (ACGME), most (65 percent) respondents indicated that neurohospitalist neurology should be an ACGME-accredited fellowship. The findings were published in 2014 in The Neurohospitalist. But not much has changed since then; ACGME does not currently accredit neurohospitalist fellowships.
Survey respondents identified stroke, epilepsy, and consult neurology as the three most important clinical elements of neurohospitalist training. The three most important system-based practice elements of neurohospitalist training, according to respondents, were patient safety, patient communication, and professional communication.
Calling All Trainees
As demand for neurohospitalists continues to grow, Dr. Shah expects to see more fellowship programs emerge. In the meantime, the existing programs are beginning to work together on several initiatives.
They have started a joint educational program, conducted quarterly via video conference, to focus on a challenging diagnosis in inpatient neurology. In the first session, held last December, the current fellows at UCSF and UC-Denver each presented a case involving refractory status epilepticus for discussion among all participants.
“We learned that different places are treating a similar disease differently,” Dr. Shah said. “It's helpful to get insight as to what other places are doing, and maybe over time, we can think about clinical trials and developing a protocol that becomes more standardized across the country.”
Future sessions will be open to all neurology residents, offering them a chance to become more acquainted with the neurohospitalist career path and fellowship programs. “We want to expand the community,” Dr. Gold said.
Beyond that, Dr. Shah hopes neurohospitalists can develop a consensus as to what a neurohospitalist fellowship program should entail. “That includes which rotations are the most important for fellows, topics they need to get exposed to, and electives we should offer,” he said.
Toward that end, leaders of the Neurohospitalist Society are working on a survey to ask neurohospitalists, in both academic and community settings, what they wish they had learned during residency that would have better prepared them for their positions. They also intend to survey leaders of academic neurology departments to determine how many currently use neurohospitalists and how many are planning to create fellowship programs.
Indeed, the program directors interviewed for this article all agreed: As the field and demand continues to grow, the hope is that so too will the training opportunities.