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A career in stroke medicine

Authors: Daniel Davies, Anthony Pereira, Martin Brown, David Werring 

Publication date:  09 Jun 2010


Stroke has become a major NHS priority. Daniel Davies and colleagues look at a career in the area

Although stroke has been recognised for a long time (it features as “apoplexy” in the writings of Hippocrates), it has not enjoyed mainstream status until now. It is one of the most common conditions in patients admitted on the medical take, the third most common cause of death, and the most common cause of adult disability in the West. More than 100 000 people each year have a major stroke in the United Kingdom. As such, stroke has become a top NHS priority in the past few years.

Many exciting innovations and improvements are taking place, making stroke medicine a vibrant discipline. The development of stroke units and new hyperacute treatments such as thrombolysis has energised stroke clinicians; there has never been a better time to consider a career in stroke medicine.

Developments in the organisation of stroke services

The National Audit Office report, the National Stroke Strategy, and the Royal College of Physicians National Sentinel Audit of Stroke have led to an unprecedented reorganisation of UK stroke services. The clear ambition is to identify stroke as an emergency in the community and to manage it at a high standard by a multidisciplinary team on a stroke unit and back in the community. In London and other cities, services are being reorganised within the cardiac and stroke networks to deliver acute care in centralised hyperacute stroke units, with further care delivered in dedicated local stroke units. There is an increasing demand for a well trained, dedicated staff of stroke specialists to provide care from hyperacute intervention to end of life palliative care.

What do stroke physicians do?

Stroke medicine is one of the best examples of team work in medicine. The stroke physician contributes skilled acute care and advice on rehabilitation as part of a multidisciplinary team; liaison with acute physicians, neuroradiologists, neurosurgeons, neuropsychologists, and rehabilitation physicians is an important part of the job. The work is flexible and could include acute stroke care, rehabilitation, prevention, or any combination of these. Stroke medicine combines the diagnostic skills of neurology and the excitement of acute medicine with the satisfaction of working within a skilled multidisciplinary team. The training programme recognises this great variety but expects specialists to attain core knowledge and skills in all areas of diagnosis, investigation, and treatment.

Advantages and disadvantages of a career in stroke medicine

Advantages

  • Varied work allows development of many skills

  • Good and rapidly evolving evidence base for management

  • Wide ranging research opportunities

  • Interdisciplinary collaboration with neuroradiology, neurosurgery, and vascular surgery

  • Huge range of clinical presentations, which provides constant interest and challenges

  • Satisfaction of altering the natural course of serious disorders by thrombolysis or successful rehabilitation

Disadvantages

  • Can be busy

  • Can be emotionally draining

  • Entails a lot of people with clipboards measuring what you are doing

  • Resources not necessarily equitably distributed so real world care may lag behind the latest available treatments

Training in stroke medicine

Stroke medicine is a subspecialty training programme open to trainees who hold a national training number in a recognised parent specialty: geriatric medicine, neurology, rehabilitation medicine, clinical pharmacology, general (internal) medicine, or acute medicine. Membership of the Royal College of Physicians or equivalent is essential. Training (full time or part time) may take place at any stage after appointment to parent specialty training. To attain consultant level it is expected that two years’ work orientated to the stroke medicine curriculum will be required. At least one year must be advanced training (attached to a comprehensive stroke service, comprising hyperacute and acute rehabilitation units and transient ischaemic attack clinics); the greatest benefit may be achieved if this is in the later years of specialty training to build on expertise already gained in the main specialty.

Stroke medicine training is designed to be integrated with the main specialty. The opportunity for subspecialty stroke training should be indicated to applicants at the time of appointment to parent specialty training. Trainees should express an interest in stroke training before their final year to have enough time for the two year course and must register with the Joint Royal Colleges of Physicians Training Board before subspecialty stroke training so that it can be prospectively approved. The first year of stroke training will then be incorporated into the main specialty programme.

The additional year of advanced stroke medicine training is open to all appropriate national training number holders within (or outside) a deanery and is managed by competitive interview. Currently, there are two to three candidates for every post. Preference is given to those who have shown a commitment to stroke. The two year programme should be prospectively coordinated between training programme directors in the parent specialty and those in stroke medicine. To provide equitable opportunity for trainees wishing to undertake stroke training in a different deanery, many posts are advertised nationally. After satisfactory completion of subspecialty training in stroke medicine, trainees will be eligible to have the stroke medicine subspecialty included in their entry in the specialist register alongside the certificate of completion of training in their parent specialty.

Day in the life of a stroke registrar

0830 Arrive with coffee and doughnuts. Discuss patients admitted overnight with night registrar

0845 Meeting with staff to plan day’s work

0900 Ward round with team. Consultant sees new patients

1000 Fast bleeped to resuscitation room in accident and emergency: 84 year old woman presenting 2 hours 10 minutes into dominant hemisphere cortical stroke. Patient randomised into International Stroke Trial 3

1100 Referral from medicine: 38 year old woman with headache, vomiting, and mild left arm weakness. Computed tomography scan shows sagittal sinus abnormal. Cerebral venous sinus thrombosis diagnosed on magnetic resonance imaging

1230 Rejoin ward round with other registrar

1300 Lunch

1330 Day case patient with transient ischaemic attack seen and treated

1400 Stroke prevention clinic with specialist nurse

1700 Back to ward to check results from the day and plan tomorrow’s multidisciplinary team meeting

1730 Meet evening specialist registrar and then go home. At home, read about cerebral venous thrombosis

Qualities needed

Training in stroke medicine is designed to equip physicians with the knowledge, skills, and attitudes to be a consultant within specialist stroke services. The background specialty is less important than the development of the appropriate expertise. Stroke encompasses elements of neurology, cardiovascular disease, general and geriatric medicine, and rehabilitation. Stroke physicians should acquire:

  • The ability to apply knowledge and skills in diagnosis and management to ensure safe and independent expert practice as a stroke consultant

  • The ability to distinguish and appropriately manage acute stroke and non-stroke illness

  • The expertise to create management plans for stroke patients including treatment, rehabilitation, health promotion, secondary prevention, and long term support

  • The attitudes and communication skills to work effectively in a comprehensive multidisciplinary stroke service in hospital, in the community, or both

  • The abilities to advise on, develop, and evaluate local stroke services.

New curriculum

The Postgraduate Medical Education and Training Board has recently revised the curriculum for stroke medicine. Explicit standards and assessment tools for the knowledge, skills, and behaviours required in the stroke specialist have been outlined. Training has three main components.

Acute stroke Here you learn to differentiate stroke from its mimics, interpret vascular imaging studies, give thrombolysis, subtype stroke syndromes, and tease out stroke aetiology; for example, carotid dissection, cardiac embolism, or large vessel thromboembolism. Given that stroke is so common, rare causes crop up surprisingly frequently. Trainees should also learn the role of neurosurgery (for example, hemicraniectomy) and conquer their fear of communicating with neurosurgeons.

Stroke prevention In this module you learn to identify and treat people having transient ischaemic attacks or strokes to avoid subsequent major strokes. Topics include rapid assessment clinics, carotid endarterectomy, anticoagulation and antiplatelet drugs, treatment of hypertension and diabetes, and vascular dementia.

Stroke rehabilitation This entails training in multidisciplinary and goal oriented rehabilitation within a team, including nursing, physiotherapy, occupational therapy, speech and language therapy, and neuropsychology. This essential part of stroke care is an active process aimed at maximising functional recovery. There are opportunities to learn about the development and organisation of stroke services, both in hospital and in the community, and contribute to teaching stroke medicine locally.

Clinical research is an essential part of stroke medicine, and time spent in research is actively encouraged. An understanding of evidence based medicine is a must, because it underpins UK stroke practice. Stroke physicians should be familiar with research methods and keep up to date with this rapidly evolving field. The UK Stroke Research Network coordinates UK stroke research and has increased the proportion of stroke patients able to participate in clinical studies. Fellowships or funds for research projects are available from the Stroke Association, British Heart Foundation, British Geriatrics Society, Medical Research Council, and Wellcome Trust.

Stroke is a complex and endlessly fascinating condition. Stroke medicine is undergoing a real rejuvenation in the UK. Trainees will acquire a wide range of expertise that can be deployed flexibly as a consultant in order to find a niche that supports a truly fulfilling career.

Workplace based assessments

  • Mini-clinical evaluation exercises in all aspects of the curriculum

  • Procedural skills directly observed, for specific skills both verbal and practical

  • Case based discussion in all aspects of the curriculum

  • Mini-peer assessment

  • Assessment of teaching and grand round presentations

  • Audit project

  • Log book of cases

Flexible consultant practice

  • Outpatient based—for example, transient ischaemic attack clinic or complex cerebrovascular disease clinic

  • Hyperacute—for example, thrombolysis

  • Ward based—for example, stroke unit

  • Rehabilitation/community based

  • A combination of these

Further information

Competing interests: None declared.

Daniel Davies stroke specialty trainee  Department of Neurology, St George’s Hospital, London SW17 0QT
Anthony Pereira consultant neurologist  Department of Neurology, St George’s Hospital, London SW17 0QT
Martin Brown professor of stroke medicine  UCL Institute of Neurology, London WC1N 3BG
David Werring clinical senior lecturer in neurology  UCL Institute of Neurology, London WC1N 3BG

Correspondence to: D Davies  dhjd2@medschl.cam.ac.uk

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