Epilepsy subspecialty career/fellowship advice

[neurophila]

Hi all,

I am a neurology resident considering pursuing epilepsy, hoping to get some advice.

I find EEG and its use to find the seizure focus very interesting, and also found treating seizure patients rewarding in clinic. ICU and inpatient EEG also interests me greatly. The idea of working patients up for surgical resection also sounds very interesting although I haven't had much exposure to this, and I like the idea of being able to make someone seizure free or at least reduce their seizure frequency significantly with a surgical workup.

I am wondering about how epilepsy specialists work around the psychiatric comorbidity with the refractory epilepsy patients. In my center there is very little support for these individuals and makes it hard for the neurologists to focus on the epilepsy.

Also curious about 1 vs, 2 year fellowships, and what it's like to work in a surgical epilepsy centre vs. more community epilepsy.

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[Telamir]

I'll bite since no one has responded to you yet. Caveats to my answer are as follows: I did neuro residency at a name brand institution, and did a CNP-EEG fellowship at the same place, on the last year you could get grandfathered into epilepsy. My fellowship was functionally epilepsy, with lots of clinic, decent exposure to epilepsy surgery, but somewhat limited when it came to RNS. VNS was fine. I've worked as a neurohospitalist since graduating, had a "conventional job" for 3 years, quit and now doing locums/per diem full time. Ok? Cool.

There is a very high burden of psychiatric comorbidity in epilepsy patients. There are many psychological aspects to epilepsy, and they are exhausting to deal with. You are not alone in this though, a very significant portion of neurology patients with a wide variety of pathology are this way. With epilepsy though you will have the patients who are refractory epileptic, those who are psychogenic, and the ones who are a mixture of both. You will get people reaching out because of medication side effects, breakthrough seizures, "auras", you name it. A significant portion of your patients will be noncompliant, and some will be women who may get pregnant on non-ideal meds.

As with any field of neurology, some of your patients WILL be mad at you. Some of them WILL be dissatisfied with care, and they will be upset. This is a fact of life. You will not be able to run away to an EMU or read EEGs all day and avoid them. This isn't radiology. The closest thing to that would be to do CNP and do IOM all day. In academic and in private practice you will have to do a lot of clinic. Maybe less than some colleagues who don't do "procedures", but a lot of clinic nonetheless. Typically expect a portion of your day blocked for reading EEGs, but this is all purely up to you and your time management.

Unless you are at an academic center or you get hired by a group/open a practice that is specifically geared to ONLY epilepsy you will see general neurology, at least until you build up a panel of epilepsy. You can throttle this as much as you want or as much as your group is willing (they may have hired you to run Hogwarts (spells clinic) after all).

Centers who are busy doing epilepsy surgery, VNS, RNS, and intracranial EEG will typically have neurologists who essentially devote themselves to that. It's extremely time consuming, and you better have all your ducks in a row before you go around chopping brain. It's almost a specialty on itself, and so to your last point this will typically require a 2 year fellowship, or a 1 year with EXTENSIVE exposure to surgical epilepsy. In my opinion you do not need a 2 year fellowship to do cEEG, ICU EEG, or EMU but it would certainly come in handy if your practice is surgery heavy.

Edited a bit for formatting

 

[dennis-brodmann]

@neurophila First year epilepsy fellow here. Regarding sEEG and epilepsy surgery, it is very interesting but definitely time consuming as @Telamir said.

Once you're in the real world, you need to be in a center with the volume and have a good working relationship with the neurosurgeon. Know that neurosurgeons' training can vary and some may or may not feel comfortable with techniques that you may have been exposed to during your fellowship. Lastly, if you want to make a career out of epilepsy surgery, hopefully you will be in a place with the infrastructure to allow you to focus on that sub-subpeciality. I was talking to a co-fellow of mine and one of their attending physicians in residency did intracranial monitoring on top of her other clinical responsibilities. It seemed like a lot of work.