The Unrecognized Value of Neurohospitalist Fellowships-Reframing Perspectives

Neurohospitalist medicine is a nuanced, complex subspecialty of neurology focusing on the care of hospitalized patients with neurologic disorders or high-acuity neurologic disease. Despite its growing importance, neurohospitalist medicine has long lacked a dedicated fellowship training pathway. With 9 such programs now in place and a full accreditation process established through the Neurohospitalist Society, many neurologists recognize the need for formalized training. However, resistance to these fellowships persists, with skepticism among neurology trainees. Educators and leaders in the field of neurology must ensure that these training opportunities are properly framed and supported.

Historical Perspective

The development of the neurohospitalist subspecialty model has been well described^1-5 and was influenced by several factors. It was initially inspired by the medicine hospitalist model, which predated neurohospitalist practice by about a decade. The development of acute thrombolytic therapy for ischemic stroke in 1995 also led to a great push for in-person rapid assessment of stroke, and therefore a hospital-based neurologist presence. Acute stroke care continued to increase in complexity with the rapid expansion of data supporting the use of thrombectomy procedures in the 2010s.

During this time, increasing economic pressures heightened the focus toward decreasing lengths of stay, using resources more efficiently, and managing hospitalized patients with increasing disease complexity. Internal medicine hospitalist and emergency medicine colleagues were seeking subspecialty consultative support more frequently.⁶ Hospitals had financial incentives to admit neurologic patients (and avoid transferring them to tertiary centers), including substantial reimbursement for thrombolytic and thrombectomy-treated strokes, as well as facility fees for the numerous brain imaging studies that accompany acute neurologic illness. Meanwhile, the increasing time and financial pressures on clinic-based neurologists made it challenging for them to fit inpatient consultations into their busy outpatient practices. In addition, the increased focus and scrutiny across all inpatient medicine on quality metrics, safety, and patient satisfaction led to a unique and increased workload for physicians caring for these patients.

Unprecedented Growth

The neurohospitalist field has experienced rapid growth. The American Academy of Neurology created a Neurohospitalist Section in 2009, and at one point noted it was the fastest-growing section in the American Academy of Neurology’s history, with 5-fold membership growth in its first 4 years. Neurohospitalists soon had their own professional organization with the creation of The Neurohospitalist Society and its associated journal, The Neurohospitalist, which were founded in 2011. The Neurohospitalist Society has estimated that in 2025, there will be a need for 20,000 neurohospitalists in the United States, and the gap in need will continue to increase.^6a

As the neurohospitalist model has expanded, there is increasing evidence that the model is addressing the pressures that led to its creation. Recent studies demonstrated that using a neurohospitalist model led to reduced length of stay, even with shifts toward higher-acuity neurologic admissions, although without significant changes in in-hospital mortality, complications, or readmission rates.^7-9 Although there is evidence suggesting typically worse patient satisfaction scores when more specialist consultants are involved in inpatient care,¹¹ patient satisfaction is increased¹⁰ or unchanged⁸ with a neurohospitalist model. Stroke quality metrics, such as those used for Joint Commission Stroke Center certification and American Heart Association award targets, were improved in centers with a neurohospitalist model in place.^9,10,12

The increasing presence of academic neurohospitalists has generated interest in the career path among neurology trainees. However, formal training opportunities were nearly nonexistent until recently. As of October 2024, there are 9 active neurohospitalist fellowship programs. The majority of currently practicing neurohospitalists are fellowship trained, but their training is mostly in other subspecialty areas, such as vascular neurology, clinical neurophysiology/epilepsy, and neurocritical care.^2,13,14

Does neurohospitalist practice warrant its own fellowship? Two overarching points suggest that the answer is yes: (1) like other specialties, there are depth and nuance to be learned from additional focused training, and (2) neurohospitalists typically fill roles within a hospital system that are not taught in traditional residency programs.

The Need for Focused Training

For neurology residencies, the Accreditation Council for Graduate Medical Education (ACGME) requires “at least 6 months of inpatient experience in clinical adult neurology,” and mandates an 80-hour average work week limit.¹⁵ Although many residency program curricula include more than the ACGME minimums, there may continue to be a loss of inpatient experience for neurology residents as other demands on their time compete for the same 80 hours in the increasingly complex and subspecialized clinical neurology landscape. The “drinking from a firehose” adage is apropos here. A solution to the reduced clinical experience during residency is to offer fellowship programs that focus exclusively on inpatient care. Neurology educators have been suggesting this since the development of the neurohospitalist practice models which were established nearly 15 years ago.¹

The core principles of neurology training are consistent, but the specific experiences and opportunities afforded to trainees may vary widely across different programs, despite the confines of ACGME oversight. This includes potential variability in inpatient rotation structure and duties; hospital case mix and volume; teaching and supervision structure; exposure to inpatient-relevant specialties, such as neurocritical care and neuro-oncology; research opportunities and resources; and experience with transitions of care. In many teaching institutions where a neurohospitalist model is not used, inpatient services may be staffed by outpatient-based subspecialists or clinical researchers, resulting in a lack of trainee exposure to neurohospitalist role models and mentors. In addition, the neurohospitalist practice has developed its own literature base, with expanding focus on quality improvement (QI), education, and other aspects of inpatient care delivery.

The Many Hats of a Neurohospitalist

In many hospitals and health care systems, neurohospitalists serve a number of crucial roles extending beyond what is typically covered in traditional residency training programs. For example, neurohospitalists frequently serve as key members of a hospital’s QI program. Neurohospitalists are often responsible for implementing QI initiatives and ensuring that quality standards are met, including those required for Joint Commission Stroke Center certifications.¹⁶ Neurohospitalists frequently assume administrative and leadership positions within health care institutions, serving as medical directors and members of mission-vital committees; participate in resource utilization management; and contribute to strategic planning efforts alongside hospital system leadership.

Another crucial role of neurohospitalists includes leading multidisciplinary teams to ensure coordinated and effective patient care. Interdisciplinary collaboration often contributes to the development of comprehensive, disease-specific care plans. Furthermore, ensuring high-quality care and optimizing outcomes are central responsibilities of neurohospitalists. This QI mentality is incredibly valuable in the inpatient setting, since economic pressures and reimbursement models are increasingly tied to quality metrics and patient satisfaction. By extension, neurohospitalists are uniquely positioned to contribute to policy and guideline development at local, regional, and national levels, playing a pivotal role in establishing practice standards that promote consistent and high-quality care.

In teaching hospitals and academic centers, neurohospitalists provide hands-on supervision and training during inpatient rotations and play a vital role in education and training, mentorship of students and residents, and development of didactic criteria on inpatient neurology and neurologic emergencies.

Neurohospitalist medicine has a rapidly growing literature base, with a unique focus on inpatient QI, outcomes, education, and medical economics, as well as management of acute neurologic disease. Fellowship training is an ideal time for trainees to develop their research prowess and skillset. There is no formal training in most residence programs to develop these skills. Residents rarely gain in-depth experience or insight into hospital administration, protocol development and policy writing, or QI research. Intentional leadership training is largely absent. Many of the typical roles of a neurohospitalist are nearly invisible to trainees, who are trying to learn all facets of clinical neurology in a limited time period.

Neurohospitalist Fellowship Candidates

A neurohospitalist fellowship is not for everyone. A neurohospitalist fellowship is not strictly necessary to practice in a neurohospitalist capacity. However, for a select group of neurologists, the neurohospitalist fellowship represents a worthwhile endeavor. The Box includes specific groups of trainees who would find considerable value from a neurohospitalist fellowship.

Reframing

The current generation of residents and medical students are wary of exploitative experiences, feel vulnerable within the medical training apparatus, and are reluctant to accept additional years of training without assured substantial added value.¹⁷ In a recent survey of residents examining their knowledge and familiarity with neurohospitalist training and careers,¹⁷ a large number of residents expressed these feelings clearly. The word “scam” was used in a number of open-ended responses (from multiple programs and regions of the United States), suggesting a widespread propagation of this idea and the language around it. Other residents voiced misunderstanding regarding the financial underpinnings of such a fellowship, implying it benefited the hospital or program financially to have a neurohospitalist fellow over an attending physician, as opposed to the typical reality of the difficulty of funding such a position. In this same survey, residency program directors indicated limited familiarity with neurohospitalist fellowships and careers, and their residents had even lower familiarity scores.

It seems clear that we are failing to inform, and to correct misinformation among, our resident trainees. Learners have little, if any, understanding of funds flow, billing, and institutional functions. Therefore, it is easier to believe the misconception of a hospital “getting an attending at fellow prices” or that fellowships are in some way exploitative—neither of which has a factual basis. On the contrary, and especially for an inpatient-based training program, the presence of the trainee is unlikely to generate substantial additional revenue for the health system or hospital in the way the presence of an additional attending physician would. Meanwhile, the cost of the fellowship typically exceeds $100,000 per trainee per year (eg, salary, benefits, continuing medical education).

Educators must find ways to reframe training paradigms, acknowledge residency program shortcomings on providing at least minimal understanding of health care and hospital economics, and shed light on the benefits of focused fellowship training years. We must frame this training period as a protected time to begin research paths, fill in knowledge gaps, explore health economics without focusing on relative value unit generation, learn leadership techniques, and explore administrative roles with mentors steeped in the neurohospitalist space.

Conclusion

Neurohospitalist fellowships enhance clinical expertise and provide a firm foundation in leadership, research, and systems administration, which empowers future neurologists to thrive in an evolving health care landscape while improving patient outcomes. It is incumbent on current leaders and educators to frame the value of such experiences properly and actively combat misinformation among trainees and colleagues.