Article In Brief
Six programs applied for and received accreditation from the Neurohospitalist Society after it launched the first accreditation program for the fellowships last year.
Since the first neurohospitalist fellowship program in the United States launched in 2009 at the University of California, San Francisco (UCSF), Weill Institute for Neurosciences, other academic medical centers—including Stanford University, the University of Colorado, the Cleveland Clinic, Northwestern University, the University of Pennsylvania, and the University of Texas-Houston—have added similar fellowships.
Others are in development, and the AAN Neurohospitalist section today has nearly 1,200 members. But even as hospital medicine became one of the fastest-growing subspecialties within neurology no accreditation program for neurohospitalist fellowships existed.
That changed in 2022, when after a year of development and peer review, the Neurohospitalist Society (NHS) launched the first accreditation program for neurohospitalist fellowships. Six programs applied for and received accreditation during the first cycle, according to Vanja Douglas, MD, a professor of neurology at UCSF and the institution’s first neurohospitalist fellow, who helped spearhead the development of the accreditation program.
“I have been very impressed by the quality of the programs that submitted for accreditation. I think it’s a fantastic opportunity for graduates who are looking for neurohospitalist training,” he said. “It’s very positive to see the response from different fellowship programs and the growth in programs that has taken place just in the past few years.”
As a relatively new and small subspecialty, the society decided that seeking an accreditation program from the Accreditation Council in Graduate Medical Education (ACGME) for neurohospitalist fellowships wasn’t the way to go.
“We did consider pursuing fellowship accreditation through the United Council for Neurologic Subspecialties (UCNS), but after a lot of productive discussion, we chose to have the society be the accrediting body,” said Carl Gold, MD, clinical associate professor of neurology and neurological sciences at Stanford and director of Stanford’s neurohospitalist fellowship.
“We made that decision primarily because we wanted to leverage the expertise and enthusiasm of our members to support these fellowships as they grow, for accreditation to be a collaborative process and one that’s essential to the mission of the society.”
“Stroke by far and away will always be the bulk of acute inpatient neurology, and different hospitals have different ways of managing stroke. That’s one of the reasons you can’t just directly translate the UCSF model to other systems; at Penn, our stroke program is very separate from the neurohospitalist program, while at UCSF, it is more integrated.”—DR. ANNE DOUGLAS
Program directors sought formal accreditation for neurohospitalist fellowship programs for several reasons, Dr. Douglas said, including “to ensure a high-quality educational experience.”
“Also, there are many institutions where funding for fellowships depends on accreditation, so if the field is to grow, providing a mechanism for accreditation is important to help develop more fellowship opportunities and programs,” he said. “We also wanted to provide our fellows to have the opportunity for a training experience that was comparable to other subspecialties in neurology.”
“Also, for programs that have less experience with the neurohospitalist model and may have directors that did not graduate from a neurohospitalist fellowship themselves, having an accreditation program offers models, structure, and opportunities for mentorship,” Dr. Gold added. “It allows for the kind of community building that is so essential to why we housed the program within the Society.”
The NHS began developing the accreditation program by assembling core program and institutional requirements, modeled on other accreditation programs. “We reviewed ACGME accreditation models, the UCNS accreditation models, and other individual society models,” Dr. Douglas says. “Once our requirements were complete, we had them reviewed by education experts, including the deans of education at UCSF, Stanford, and the University of Colorado.”
After that first round of peer review and edits, the accreditation program went through a period of public comment from NHS members and another round of edits before final approval by the NHS.
“The vision behind the accreditation is to provide oversight and create standard expectations for these fellowships, while still allowing each program to have its own character,” said Maulik Shah, MD, associate professor of neurology at UCSF, where he serves as medical director of adult inpatient neurology and the adult integrated transfer center. “We did not want to be excessively prescriptive, but still wanted to ensure that fellows are receiving appropriate clinical training and experience as well as oversight.”
The core program requirements stipulate that a board-certified neurologist must be named fellowship director and given an appropriate allocation of protected time to administer the fellowship. Fellowships must have at least three board-certified faculty members (including the fellowship director). Programs must be not less than 12 and not more than 24 months; they may take on as many fellows each year as they can accommodate in their training environment but must specify the range of fellows they will train each year.
Curriculum requirements mandate a program that ensures fellows graduate with a level of entrustment that allows fully independent practice as a neurohospitalist in the six core competencies defined by the ACGME (patient care, medical knowledge, interpersonal and communication skills, professionalism, practice-based learning and improvement, systems-based practice) as well as a set of neurohospitalist core competencies developed by the society. The curriculum section of the accreditation also lays out requirements for clinical schedule, didactics, and learner, faculty, and program evaluation. Written policies regarding supervision; moonlighting; and diversity, equity, and inclusion (DEI) are required. Accredited fellowships must also comply with requirements regarding learner well-being, educational tools, patient safety, and quality improvement.
Not Just an Extra Year of Residency
Anne Douglas, MD, assistant professor of neurology at the University of Pennsylvania Perelman School of Medicine, completed her neurohospitalist fellowship at UCSF in 2022 before returning to Penn, where she had done her undergraduate medical education and residency, to lead its new neurohospitalist program and help spearhead its accreditation process.
“While I was in California, our division chief here at Penn got approval to have our first neurohospitalist fellow, so there is a resident graduating this year who has committed to stay and do the fellowship next year,” she said. “So when I returned, I dove right into formalizing our objectives and goals and documentation to round out the educational framework of the fellowship, both to get the accreditation but also to get support from internal governing bodies at Penn that also have to approve the fellowship. All of this was happening in parallel, and one helps the other.”
Dr. Anne Douglas frequently is asked if a neurohospitalist fellowship is “just an extra year of residency.”
“I just said yesterday to a colleague that I feel like I keep encountering new people [to] whom I have to convince or justify the existence of the fellowship,” she said. “But some of our biggest explicit learning points in these fellowships is how to become a steward of inpatient neurology resources, how to admit patients from colleagues vs. how to accept transfer requests from local referring physicians, and how to work with neurosurgery and medicine and other services to determine who needs a neurology bed vs. a neurology consult—the kind of systems issues that don’t get as much focus in a residency.”
Neurohospitalist fellowships also focus on training the leaders in hospital-based neurology, said Karen Orjuela, MD, assistant professor of neurology and program director of the neurohospitalist fellowship at the University of Colorado Anschutz Medical Center.
“For programs that have less experience with the neurohospitalist model and may have directors that did not graduate from a neurohospitalist fellowship themselves, having an accreditation program offers models, structure, and opportunities for mentorship. It allows for the kind of community building that is so essential to why we housed the program within the Society.”—DR. CARL GOLD
“There is a clinical neurology skill set that is very specific to the hospital setting, including how to handle time-sensitive situations, that neurology residents are exposed to during their training,” she said. “But it’s less evident during one’s residency how neurology operations work in the hospital, how we can effectively look at quality and equity in our inpatient services, how to establish a new service line, and how staffing and reimbursement works. Those are the kinds of things that our fellows are involved in. We need to show how we add value to the hospital, drive this movement forward, and help to create partnerships between the United States and other international centers that could drive improvements in inpatient neurologic care.”
At UCSF, for example, the description of the fellowship stipulates that while it will “obviously involve continued education regarding the complex neurologic cases that we see on the inpatient service, there are numerous other goals for our fellows, including: thinking critically about the transition to an academic faculty position; including team management and leadership skills; and trouble-shooting pitfalls; education of residents and medical students; and development of teaching style and formal lectures; and research endeavors, including critical assessment of hospital efficiency and protocols in the care of neurologic patients.”
“Research is a key component of neurohospitalist fellowships,” Dr. Orjuela said. “For example, our current fellow is focusing research on how to improve the diagnostic process for encephalitis of unknown etiology in the hospital. We are the first neurologists who will see those patients and sometimes they can have a length of stay measured in months, if it’s anti-NMDA-related, or other paraneoplastic process. These patients require a lot of therapy and supervision and typically experience multiple complications. Optimizing every step of these patients’ hospital stay is a quality process in itself.”
At UCSF, neurohospitalist fellows work with faculty tackling research topics including the management of status epilepticus and seizures in non-academic hospital centers, how to better support patients who need to be transferred to an academic center, and how to standardize practice around the country.
“These are the kinds of systems issues—the best ways to care for patients, standardize practice, and ensure that all patients have access to our hospital’s resources—that are at the heart of neurohospitalist training and practice,” Dr. Shah said.
Different Systems, Different Fellowship Programs
How the neurohospitalist service works will differ hospital by hospital, and so will neurohospitalist fellowships, Dr. Anne Douglas noted.
“For example, stroke by far and away will always be the bulk of acute inpatient neurology, and different hospitals have different ways of managing stroke,” she said. “That’s one of the reasons you can’t just directly translate the UCSF model to other systems; at Penn, our stroke program is very separate from the neurohospitalist program, while at UCSF, it is more integrated. Wherever you are, in figuring out your goals for your neurohospitalist fellow, you have to consider how to use your health system’s structure to make sure the fellows are getting the experiences they need.”
Having an accreditation program should help drive the growth of neurohospitalist fellowships, which in turn should help with the recruitment of more fellowship applicants.
“Back when there were only three programs—at UCSF, Stanford, and Colorado—graduating residents thinking about a neurohospitalist fellowship would always have to have another subspecialty as a backup option because there just weren’t enough,” she said. “Now that there are more programs, there will hopefully be enough that everyone who is interested in a neurohospitalist fellowship can pursue one.”
The longstanding programs are growing larger as well. UCSF now has as many as eight faculty members working full-time in its neurohospitalist division, all of whom have completed the fellowship there.
“It’s very much a homegrown program,” Dr. Shah said. “We have typically had just one fellow each year, although there were a couple of years when we took two. Our applicant pool has been growing so much that we’ve decided that we should consistently be taking at least two fellows, and next year we are going to have three.”
Meanwhile, national educational programs are drawing more attention to the development of neurohospitalist fellowships and the prospect of accreditation. At the 2022 NHS annual meeting, some 30 attendees participated in a workshop on accreditation co-led by Dr. Gold and Shefali Dujari, MD, clinical assistant professor of neurology at Stanford Healthcare, who completed Stanford’s neurohospitalist fellowship in 2021.
“Some came from existing programs and others from institutions that are just thinking about starting programs,” Dr. Dujari said. “There was a lot of enthusiasm.”
The NHS also sponsors a virtual neurohospitalist fellows’ conference series, co-chaired by Dr. Dujari and Dr. Orjuela and held three times yearly.
“Our applicant pool has been growing so much that we’ve decided that we should consistently be taking at least two fellows, and next year we are going to have three.”—DR. MAULIK SHAH
“It’s very positive to see the response from different fellowship programs and the growth in programs that has taken place just in the past few years.”—DR. VANJA DOUGLAS
“This year we have six fellows in NHS-accredited programs, so two fellows will be presenting at each conference. We invite not only fellows and faculty from programs that have existing fellowships, but also medical students and residents who might be interested, as well as the neurohospitalist community at large via the NHS. It’s a great opportunity to get the neurohospitalist community together and think about challenging cases.”
As the hospitalist model has become a dominant paradigm of care for internal medicine and pediatric hospital medicine in both academic and community practice, Dr. Gold believes the same will become true of the neurohospitalist.
“As you look at the job postings and the expertise and some of our board members, it seems that this is the model of the future for hospital-based neurologic care,” he said.
“It’s very exciting for people interested in a neurohospitalist career to have the opportunity to train in accredited fellowship programs,” Dr. Douglas said. “Seeing the options expand is a fantastic thing for our field. If you envision yourself as having a future leadership position in hospital neurology, these fellowships are something you should pursue.”
