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Business of Neurocritical Care: Choosing a First Job after Fellowship: Review of Practice Models from a New Grad Perspective

By Currents Editor posted 02-09-2022 09:35


Aleksandra Yakhkind, MD MS
is a neurointensivist who graduated from the University of Pennsylvania in June 2021. She is doing locums before she starts at Tufts Medical Center in 2022. Her interests include writing and burnout prevention. In her spare time, she enjoys surfing, hiking and skiing.

Christa O’Hana S. Nobleza, M.D., MSCI is the Medical Director of the Neurocritical Care service of Baptist Memorial Hospital, affiliated with University of Tennessee Health Sciences University. Her interests include mentorship and diversity, cerebrovascular diseases, quality of life and patient outcomes in Neurocritical Care.

Ryan Hakimi, DO, MS, NVS, RPNI, CPB, FNCS
is the Director of the Neuro ICU and TCD Services and an Associate Professor at the University of South Carolina School of Medicine-Greenville/Prisma Health-Upstate. He is also a Certified Professional Biller (CPB) through the American Academy of Professional Coders and CPT Advisor to the AMA and RUC. 

This series will be a running feature highlighting billing, coding, practice management, and other business aspects of neurocritical care.

I remember sitting down with my ICU director at the start of my second year of fellowship to talk about jobs. He said something like, “go to a quiet peaceful place, look into the deepest parts of your heart, and decide what is right for you.” 

He made it sound so easy, but like most things your mentors advise, it is always harder in practice. I was like most fellows in the sense that I had only practiced medicine in academic settings. I had heard rumors that physicians outside of academia get paid lots of money, but didn’t know what that actually meant. 

I started looking for jobs in the midst of the pandemic. While I love teaching, most academic centers had hiring freezes at this time. I reached out to a recruiter who connected me with different kinds of neurocritical care units. Each was unique compared to the others and from what I was used to. Below is an overview of what I learned through the process. I hope that this can help Fellows and those looking to change jobs better understand the models of practice that are out there and be more informed in their decisions of what is right for them. 

The Established Academic Neurocritical Care Unit

  • The People: You are joining an existing team of neurointensivists with embedded mentorship
  • The Time:
    • Your clinical time spans 10-21 weeks a year
    • Your non-clinical time is protected for research, education or administration
    • The lower the clinical time, the more likely you are to have to buy out your time with research grants
    • There is an obligation to serve under the School of Medicine (SOM) affiliated with your NCCU (lectures, meetings, mentorship etc.)
  • The Work:
    • You will rarely care for patients without the help of a Trainee or Advanced Practice Provider (APP)
    • Policies and protocols exist which have been refined over the years
    • You will likely have a pharmacist on rounds
    • There may be an obligation to be involved in the affiliated SOM. As such, you may be asked on your days off to participate in SOM activities.
  • The Place: A tertiary referral center from which you rarely have to transfer patients out
  • They Pay: Salary range $90,000 (as an instructor) to $270,000 annually, and part of your salary may come from the Institute of Higher learning (IHL) 

The New Academic Neurocritical Care Unit

  • The People: You are one of the first 1-3 neurointensivists with little to no local mentorship
  • The Time: 18-26 weeks service weeks. If you are the medical director, you will have to work on policies, protocols, and unit building at all times. If you are not, your non-clinical time is free.
  • The Work
  • Prepare to create the identity of a section or division. Services that took care of these patients prior to your arrival (Medical Critical Care, Surgical Critical Care, Trauma, Neurosurgery, or Anesthesia) may challenge your existence and necessity citing years of care without a neurointensivist
  • You may need to hire and train APPs as there likely will not be sufficient house staff support
  • You likely will not have an established multi-disciplinary specialists like pharmacists rounding with you
  • Rounding times and practices are yet to be set (e.g. there may not be a set rounding time with neurosurgery)
  • There may be an obligation to be involved in the affiliated SOM. As such, you may be asked on your days off to participate in SOM activities.
  • The Place
    • Often a tertiary referral center with a complex array of patients
    • Sometimes a satellite campus of a large academic center
  • The Pay: Expect to be paid more than a traditional academic job, $250,000-$380,000 annually, and to work much more.

 Both of the above models usually involve work during the day and overnight call from home. Some groups have adopted night shifts in which attendings work an evening shift and take call from home so that the attending who rounds is more well-rested. Most of these are 7-day work stretches, but some have evolved into working shorter more frequent groups of 3-5 shifts in a row. Some academic centers have incorporated tele-stroke and tele-ICU duties. Some have incorporated them into the compensation while some give extra compensation for tele-stroke or tele-ICU shifts.

 The Established Private Hospital-Based Practice

    • The People: You will be joining a large group of neurointensivists with embedded mentorship
    • The Time: 18-22 weeks annually
    • The Work:
      • May or may not be affiliated with an academic center, but importantly it is not governed by a university
      • There are established pathways and protocols, often more efficient than large academic centers, and the section or division is well-respected in the institution
      • Often have in-house night shift attendings, so your time on service is not 24h call, but you need to work night shifts
      • Often work with established APPs or solo without APP or housestaff support
      • You may or may not have multi-disciplinary specialists like pharmacists on rounds
      • There may be set rounding times already established which may be less flexible (e.g sign out at 7am, rounds with neurosurgery)
    • The Place: Often a tertiary care center but may transfer out to academic centers for select subspecialized care

The Pay: $300,000-$500,000 annually, may or may not be RVU-based

At some of the new and established programs, providers do consults in other ICUs in addition to primary ICU attending time. At some programs, this is in addition to ICU time, i.e. 34 total weeks, half of which are consults. In other programs, consults are done at the same time as primary ICU time. The weeks at these programs tend to be busier because you are responsible for your patients and consults. It is important to ask about the provider support in these cases. The programs in which consults are additional require more clinical weeks, but the consult weeks generally have a lighter schedule. Usually, anything extra that you do beyond the agreed upon weeks can be paid with additional compensation.

 The New Private Hospital-Based practice with or without academic affiliation

  • The People: You will be the first or second neurointensivist at this medical center. There is limited mentorship that will often come from critical care or neurosurgery
    • The Time: Sometimes 24/7, 365 days a year, or can negotiate to hire 2-3 providers to split up the time; when you are off, that is your own time, however some hospitals may not give PTO because of this arrangement.
    • The Work
    • May start out as a consultant service until staffing can allow the unit to be closed
    • You will have to establish an identity, write policies, protocols, and negotiate with other services who have previously been caring for these patients, and educate nurses and hire APPs
    • You will often be appreciated because of the specialty care that you provide
    • Systems may not be set up to take care of patients the way that you are used to. For example, you may need to wait for a biplane to be purchased and neurointerventionalists to be hired before you start to see post-thrombectomy and aneurysmal SAH patients
    • Ask about services you take for granted at established centers, such as if they have 24/7 EEG, if they can they do TCDs, and who will read them
    • Some may already have had established services such as 24/7 EEG, Comprehensive Stroke Center designation with Neuro-IR, and Neurosurgery. However, they now need a focused neurointensivist for the Neurocritical care unit because of increased volume
    • Building a fellowship program is a potential while residents can rotate if there is an academic educational affiliation.
    • The Place: May not be a tertiary referral center, complex cases may have to be transferred out.
  • The Pay: Salary can approach $500,000 annually, may or may not be RVU-based. There may be an administrator stipend for the Medical Director on top of the salary. 

Locum Tenans Neurocritical Care

    • The People:
      • You will work with other locums providers, but also sometimes at established private and academic practices that are short staffed
      • You will work fairly independently and often have to rely on people outside of placement for mentorship
    • The Time: Flexible, on your schedule, no guarantee of placement
      • The Work:
        • Work as an independent contractor (1099 employee) to fill in the gaps in neurocritical care units when and where there is a need
        • Varies, can work as consultant, primary intensivist, alone or with APPs
        • Must be willing to do things “their way” and not be too opinionated
      • The Place:
        • All different kinds of units—academic, hospital-based, new unit
      • The Pay: Salary $250-$400/hour, negotiable, no CME, no benefits, malpractice usually covered
      • Recommend checking out the White Coat Investor and Physician On Fire blogs for more information about this option

In summary, I’ve learned that the more clinical time you have, the more you’ll get paid. There is obviously a spectrum and other skills such as administration, educational leadership, EEG, transcranial doppler lab, neurointervention, and stroke expertise that can all play into salary and time commitment negotiation. The ranges of weeks and salary are averages and there are exceptions. A huge thank you to the many people with whom I’ve interviewed and worked whose perspectives informed this article. 

I welcome comments, questions and corrections to this piece. What kind of unit do you work in? Do any of these points ring a bell or does your unit run differently than I described? My hope is to start a discussion and increase knowledge and transparency about the job application process for neurointensivists.


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