In pursuing a career in neurology, trainees revisit the “decision tree” that all medical students face when deciding on a specialty. Nearly every practice setting, lifestyle, and hands-on vs. hands-off approach to patient care is available depending on which subspecialty path is chosen. So what draws trainees to neurocritical care (NCC) these days, and what considerations do they have when looking to the future of the field?

Brendan Baugher, a new junior trainee contributor to Currents, offers his own answers to some of these questions below. Meanwhile, if you’re a trainee interested in or currently training in neurocritical care, we invite your perspectives too.

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Michael: What were your early impressions of inpatient neurology as a career?

Brendan: Most students interested in neurology don’t typically seem to be interested in chasing high-acuity or “hands-on” careers, but I have never assumed that my interest in the nervous system , and a lack of interest in surgery, destined me to an outpatient role. The viable subspecialty pool does shrink for those interested in inpatient and acute care, though. Add a desire for procedural training, and NCC essentially stands alone. I’m sure I’m not especially unique in my professional interests, so I do wonder why NCC isn’t a more common choice among young neurologists when discussing career opportunities.  

Michael: Do you have any thoughts on why this is? What experiences inspired you?

Brendan: I feel it’s most likely due to a lack of quality exposure. Even though I spent over six months of my fourth year in medical school on neurological rotations, my trips to the NCCU were brief and infrequent. These visits were typically to assess patients for whom we were consulted just to “keep an eye” on them until they were transferred to a step-down unit. Initially, I felt quite lost in examining these often minimally responsive patients as the physical exam was so different than what I had been taught and exposed to early on. Luckily, two preceptors did take the time to thoroughly explain the vast amount of neurological information that can be gleaned from even a comatose patient. Because of these teachings, I sought out critical care-specific rotations later in the year. Several other kind residents/advanced practice providers then allowed me to get involved by allowing me to help place lines and teaching me to use tools like pupillometers.

Michael: Have you encountered any obstacles while exploring your interest in neurocritical care?

Brendan: I would say hearing about burnout has played a role. My preference for inpatient care has been met with innumerable scoffs, knowing glances, head shaking, and even an eye roll here and there. Residents have said things like “Do you want to live in the hospital?”, “You don’t want to see your family?”, and “You like being stressed out?” But I contrast this with the outlook of my NCC, neurohospitalist, and vascular neurology mentors who seem to love their work. The few residents I have met who expressed interest in neurocritical care or inpatient work in general also seem excited for the future, not acting as if they have been doomed to a life of misery from an irresistible compulsion towards their subspecialty.

Michael: Why do you think some residents feel this way?

Brendan: My best guess on why negative feelings toward inpatient work prevail among these residents is that the busiest and most stressful parts of residency early on are predominantly on inpatient services. As residents progress, they are allowed more freedom to pursue outpatient interests and probably feel more settled in their roles. Their feelings might also later be exacerbated by “senioritis”-induced cynicism. Of course, inpatient, high-acuity care is generally more “intense,” but this doesn’t necessarily guarantee a more stressful or less satisfying life. It is likely many of these residents simply were more suited to outpatient practice and were expressing a resentment toward the inpatient focus of their training.

Michael: What has made you enjoy the inpatient environment so much?

Brendan: I have enjoyed inpatient and critical care for many reasons: the immediate impact of care, frequent interprofessional collaboration, a diverse schedule, and treating interesting pathologies at their most acute presentations. But maybe the strongest factor has been my inclination toward palliative care, which has driven me further toward the high-acuity subspecialties.

Michael: Can you tell me more about your interest in palliative care?

Brendan: I hesitate to even call it “palliative” due to the negative connotations often associated with the term. When I’ve heard someone say, “let’s get palliative on board,” that often translates to “we need to talk about code status.” But my experiences on palliative care rotations have been transformative. I saw how powerful a palliative approach can be in augmenting patient experience and outcomes when implemented at an appropriate time, and how these conversations with patients and families were often ones on which the entire primary treatment plan hinged.

I adopted an additional set of assessments from palliative mentors when entering every room, especially in intensive care units. “Who here needs support right now, the patient or a family member/friend?” “Are we seeing any nonverbal signs of pain?” “How can we use conversation today to educate/prepare without overwhelming?” I came to see the palliative mindset as simply an extra level of humanistic care that all patients should be afforded when resources allow. Within neurology, NCC is an obvious field in which opportunities to practice these skills arise regularly. Both acute and chronic incurable diseases are common, and there is room for creativity in pain and symptom management. And of course, family meetings require nuanced approaches to emotionally intense topics.

Michael: What kinds of things worry you when thinking about a career in neurocritical care?

Brendan: I do wonder how time constraints will restrict my ability to have comprehensive and meaningful humanistic interactions with patients and their families as part of a busy neurocritical care practice. And how will these time constraints affect my ability to perform high-quality physical exams and procedures? I know eventually I will need to learn how to delegate and collaborate with other providers, but I hope I’ll still be able to get to do the things that I find most exciting about neurocritical care.

I also worry about how an increasing focus on efficiency will impact the structure of healthcare employment. For example, an aspect of the field that appeals to me is the potential for unique scheduling, such as the “7 on/7 off” setup. But if the aging population continues to exacerbate healthcare shortages as predicted, I worry about a “squeeze” on intensivists that may lead to even more demanding clinical service requirements. And even if these options do survive, they may become less sustainable later in my career.

Then there’s the rising post-COVID animosity toward the medical community and growing tendency towards misinformation. Conversations between providers and patients in “protected” settings are routinely being misinterpreted and shared online, contributing to widespread misinformation and distrust. Without the voice of clinicians to counter this narrative, physicians’ competence and even their inherent morality have come into question. Social media algorithms have exacerbated this phenomenon, as they are heavily geared toward controversial content over the comparatively mundane posts of earnest educators.

Michael: Is there anything specific to neurocritical care that you think is especially prone to this kind of misinformation?

Brendan: I think this has become particularly problematic with brain death, which has been a hot-button topic. The most prevalent materials on social media regarding brain death testing are worst-case scenarios and discussions questioning the motives behind medical decision-making. This is, of course, an area in which providers should be held accountable, where clinical understanding continues to evolve, and in which clinicians should fully engage with patients’ families. However, this may be increasingly difficult due to misinformation and suspicion. I hope we can continue to collectively respond to the changing times by increasing our emphasis on education, patient satisfaction, and transparency.

Michael: How else do you think neurocritical care will be evolving in the future?

Brendan: I think leaders in the field are doing a great job of integrating AI and data analytics into the future of neurocritical care, and in advertising the potential benefits of this integration to trainees. I am optimistic that AI-driven decision-support tools will allow clinicians to focus their expertise where human judgment is irreplaceable.

Michael: Do you have any advice for preceptors and mentors with respect to junior trainees who are interested in neurocritical care?

Brendan: I would encourage established physicians to be voices of motivation and mentorship for interested trainees. And I encourage those with the time, even on consulting services, to explain their critical care exam and insights to trainees who express curiosity. My experiences were ultimately positive due to this type of guidance. It took a relatively small investment from preceptors to pique my interest and generate the drive to pursue more time in the unit.

While honesty about the demands of the field is warranted, we are not in danger of anyone mistaking NCC for an easy path. Know that candidates begin to weigh the pros and cons early and will benefit immensely from realistic discussions about the current state and future of neurocritical care.