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New opportunities, new challenges--After neurology residency(ZT)
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发表时间:2007-12-06
更新时间:2007-12-06
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发信人: acne (ARBITRAGE), 信区: MedicalCareer
标 题: After neurology residency(ZT)
发信站: BBS 未名空间站 (Wed Dec 5 19:55:43 2007)

New opportunities, new challenges

Beau M. Ances, MD PhD
From the Department of Neurology, Hospital of the University of Pennsylvania
, Philadelphia.

Address correspondence and reprint requests to Dr. Beau M. Ances, Department
of Neurology, Hospital of the University of Pennsylvania, 3 West Gates
Building, 3400 Spruce Street, Philadelphia, PA 19103-4283; e-mail: beau.
[email protected]

An ever-increasing number of choices are now available for the neurology
house officer after completion of residency. Most residents pursue a
fellowship (74%), enter into a neurology practice (19%), or proceed directly
into an academic position (5%). Of those who obtain further training, many
continue in academics (57%), some will join a private practice (39%), and a
few are employed in industry (1%).1

A fellowship can provide core research training and expertise within a
subspecialty of neurology that may assist the trainee for a future career
within academic, industrial, or private practice arenas. This training can
also provide the necessary requirements for board certification within
subspecialty areas and can shield the trainee from the already long-deferred
confrontation with the real world. A close relationship with a senior
mentor may also be forged during this time and can allow for the shaping of
future career goals. This article examines the different options that are
available after completing a neurology residency. The table provides a
summary as well as additional information concerning possible careers after
completing residency.

Academic neurology
Overall, about one half of all neurology residents (44%) intend to pursue a
career in academics.1 Those pursuing an academic career will be required to
successfully balance clinical, research, and teaching obligations. Three
possible options are available for the resident interested in pursuing a
career in academic neurology: basic neuroscientist, teacher/clinician, or
patient-oriented researcher.

Basic neuroscientist Interest in the basic sciences section of academic
neurology may be related to burgeoning treatment options and expanding
neuroscience research that has occurred during the Decade of the Brain.
Focused research within a particular area of interest may help define future
pathways as a basic scientist and can lead to a strong mentorship
relationship. Funding mechanisms, from those supported by NIH (K02 and K08)
to smaller funding organizations within a particular field, exist for those
interested. Involvement in local and national meetings (specialty
subsections) can allow for further definition of a career as well as provide
additional contacts and collaborations with investigators and institutions.
Basic scientists usually spend most of their time performing research (50
to 85%), with some clinical responsibilities (5 to 30%) and teaching
obligations (10 to 15%).

Salary is often garnered through grants and is usually less than what could
be obtained in private practice. Patient interaction is limited (often
clinic once a week and attending for 1 month a year) and is usually focused
within a particular field of expertise in neurology. Night call is usually
not required and the degree of interaction with house staff through teaching
and attending responsibilities varies depending on the institution.

Teacher/clinician tract As a higher percentage of residents are pursuing
careers in neurology, fiscal challenges are increasing for academic centers
as they compete within health care markets. A potential solution has been
created by the addition of teacher/clinician tracts. This new field offers a
great diversity to those interested in academic neurology. Teacher/
clinicians are members of an academic department at major teaching
institutions and are actively involved in diagnosing and treating patients
with poorly differentiated neurologic symptoms. Teacher/clinicians spend
most of their time on clinical responsibilities (50 to 70%), with additional
time allocated for teaching residents and medical students (20 to 40%), and
some time devoted to research (5 to 10%). Individuals in this field have
direct contact with house staff and are actively involved in teaching the
nuances of neurology. These individuals are the molders of the future
leaders of neurology. Night call is not usually required and the degree of
attending responsibilities varies with institution.

Additional fellowships in medical subspecialties (i.e., rheumatology,
cardiology, infectious disease) may be pursued with knowledge gleaned from
these subspecialties applied to neurology. A career as a teacher/clinician
is relatively new and quite undeveloped with no national organization
existing and relatively few mentors present. General neurology fellowships
are currently being created that will provide those interested in this area
greater flexibility. At the present time limited funding mechanisms exist
for pursuing a career within this area of neurology but additional funding
opportunities should be created.

Patient-oriented researcher Great concern has existed regarding the
disconnection between the translation of new advances in basic neuroscience
and the delivery of better health care. The patient-oriented research tract
has been created to meet this demand. Those attracted to this area are
trained to conduct high-quality clinical research within neurology. Often a
MA or PhD in epidemiology and health services research is obtained during
the further training phase. The goal of these additional educational studies
is to prepare patient-oriented researchers with a basic understanding of
biostatistics, epidemiology, outcomes research, and other public health
issues. Attending responsibilities, degree of protected time, and
interaction with house staff may vary with institution.2

Support for research is through grants and scholarships from funding
agencies as well as partnerships with industry. Often research activities
are multifaceted and involve both basic science and clinical departments.
Currently, only a limited number of institutions offer this type of program
and no national organizations have been created within neurology. Limited
funding from the NIH (K23 and K24), mounting regulatory burdens, fragmented
infrastructure, and a shortage of qualified investigators and patients are
constraining factors for those interested in pursuing a career in this area.
3

Private practice neurology

The average neurologist in private practice works about 58 hours a week with
more than three quarters of this time devoted to patient care.4 A career in
private practice neurology allows an individual to see a variety of
patients. A number of billable procedures can be performed leading to a well
-compensated career with a flexible schedule. Depending on the privileges
and type of practice, a spectrum of interaction and support with house staff
can exist. The amount of night call and coverage of other partners varies
depending on the size of the practice and the status of the individual
within the practice.

In a private neurology practice long-term relationships with patients can be
nurtured. However, increasing changes in health care delivery system have
resulted in greater interaction with managed care institutions and more time
spent on paperwork. The result has been less time available for evaluating
patients. A high patient volume is often required for maintaining a superior
income. In addition, increased financial acumen is required to successfully
navigate administrative demands, negotiate contracts, establish dictation
services, and create reliable medical records and billing services. Overhead
costs (including hiring of additional staff, renting office space) and
determination of the type of practice (solo practice, small group, large
group, or multispecialty) should be considered. Difficulties in obtaining
malpractice insurance and rising rates need to be considered within certain
states.

Pharmaceuticals Increasing political pressure has led to the development of
administrative, regulatory affairs, or marketing areas within pharmaceutical
industry. As a member of a pharmaceutical or biotechnology company an
individual can help bring needed therapeutic interventions to medicine.
Neurologists involved in pharmaceutical or biotechnology firms may serve as
an insightful conduit for research funding into new developing areas of
neuroscience research. This career path allows the individual to assist in
the discovery, development, manufacturing, and selling of a particular drug.
Working in industry provides challenge and opportunity to operate in a
dynamic environment as a part of an interdisciplinary team. The ability to
succeed within a firm depends on familiarity with a broader range of
scientific, medical, and business issues that are seen during a neurology
residency. Excellent skills in scientific writing, an ability to interpret
and synthesize data, and good interpersonal skills are required. Prior
research in a particular area of interest as well as previous experience in
research and development within a pharmaceutical company are beneficial and
can lead to more focused future directions and greater financial benefits. A
well-compensated career with significant potential for future earnings
awaits an inquisitive individual who is able to synthesize information
gleaned from the bench and apply it to the bedside.

Acknowledgments

The author thanks Drs. Dennis Choi, William Freeman, and Martin Samuels for
their assistance with this article.

References


Larson WL, Holloway RG, Keran CM. Employment-seeking experiences of
residents in 1996. A window into the neurology marketplace. Neurology. 2000;
54: 214–218.[Abstract/Free Full Text]
Moskowitz J, Thompson JN. Enhancing the clinical research pipeline: training
approaches for a new century. Acad Med. 2001; 76: 307–315.[Medline]
Sung NS, Crowley WF, Genel M, et al. Central challenges facing the national
clinical research enterprise. JAMA. 2003; 289: 1278–1287.[Abstract/Free
Full Text]
Holloway RG, Vickrey BG, Keran CM, et al. US neurologists in the 1990s:
Trends in practice characteristics. Neurology. 1999; 52: 1353–1361.[
Abstract/Free Full Text]


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