Education Research: Challenges Faced by Neurology Trainees in a Neuro-Intervention Career Track

Discussion

This survey confirms that lack of clinical exposure and a clearly established training pathway remain significant barriers to neurology trainees interested in pursuing a career in neurointervention. Sixty percent of trainees in the survey felt that the path for pursuing a career in neurointervention was not well-structured compared to other neurologic subspecialties. The power of the survey is limited by the low number of respondents relative to the number of eligible trainees. Also, survey responders may be biased towards those interested in neurointervention, or those unhappy with their current exposure to neurointervention. These caveats notwithstanding, the results remain informative of the lack of neurointervention exposure in many neurology training curricula.

Neurointervention exposure is bound by the same constraints that all neurology subspecialties face. There is usually oblique interaction with the neurointervention service during rotation time on vascular neurology or general neurology. However, focused elective time may be more difficult to arrange, especially if the neurointervention service is housed under a different department (e.g., radiology or neurosurgery). Absence of neurology-trained neurointervention physicians also limits resident exposure to the field, and lack of faculty mentors increases the difficulty for interested residents during the career exploration and, later, the fellowship application period. Academic faculty members play an important role in encouraging the development and specialization of resident physicians, and neurology-trained neurointervention academic faculty members can be instrumental in designing a structured neurointervention exposure for neurology residents as well as during medical students' neurology rotation.⁷ This may include hands-on experiences in the angiography suite, clinical experience on the neurovascular intensive care unit and wards, simulation laboratory studies, and silicone bench models for exposure to the devices and techniques used in day-to-day practice.⁸ Virtual reality simulation has been recently reported to accelerate the learning curve in neurointervention.⁹ Neurologists in the real world are often the first (and sometimes only) specialists to evaluate and treat stroke, and so familiarity with the indications for neurointervention procedures should be considered a core competency for graduation. Early exposure to neurointervention for medical students and neurology residents is a crucial element towards producing well-trained neurologists while also bolstering the competitiveness of neurology candidates for neurointervention fellowships.

Establishing a formal training pathway for neurology to neurointervention is another key component to enable neurology residents to successfully compete for neurointervention fellowship positions. For these residents, securing a position is not straightforward. First, the application deadline for neurointervention programs varies widely, and interview dates may range from 1 to 4 years before beginning fellowship. Some programs start interviewing in the year immediately preceding the start of fellowship, while others may interview 3 or 4 years in advance of the fellowship start date. Given the heterogeneous pool of applicants, residents from different specialties are often at different stages in their training by the application date. Late deciders (e.g., VN or NCC fellows) will be excluded from programs that interview years in advance. These timing issues ensure that only neurology residents who begin residency with a plan to pursue neurointervention, or those who take gap years between residency and fellowship, will be able to apply to the breadth of available programs. Combining neurointervention with a VN or NCC fellowship application process will ease the uncertainty in applying for 2 fellowships simultaneously and make neurointervention more attainable for neurology residents.

Neurosurgery and radiology residents receive dedicated exposure to neurointervention, and their specialties have a time-established pathway to pursue fellowship and certification in neurointervention. Parity in clinical exposure and accreditation for neurology-based trainees is an issue currently undergoing active and vigorous debate, and one that would benefit greatly from the attention and involvement of the broader neurology community. Within neurology, clinical exposure to neurointervention in residency, mentorship from neurology-trained neurointervention faculty, and a straightforward path to fellowship remain sorely lacking, despite the rapidly increasing demand for stroke specialists and neurointerventionists to treat LVO. Providing a barrier-free pathway to certification for neurologists trained in neurointervention should be a priority for our specialty organizations such as the American Academy of Neurology and SVIN.

Neurologists bring an important clinical perspective to the daily practice of neurointervention. Knowledge and experience in the acute and long-term management of patients with stroke provides a balanced perspective for the neurointervention provider when faced with a difficult LVO situation, such as a patient with a low NIH Stroke Scale score, with distal vessel occlusion, or with a partially occluded vessel. This dual perspective is important for good clinical decision-making when information is incomplete and timing is critical. Many communities in the United States today do not have timely access to stroke thrombectomy. It is imperative that neurology take an active role with neurosurgery and radiology in producing qualified physicians to make these valuable and life-saving services widely available and accessible.