The Neurologist Is In, Episode 11, Part 1: The Role of a Neurohospitalist With Dr Mark J. Milstein

In this episode, Rachel Marie E. Salas, MD, MEd, talks with Mark J. Milstein, MD, FAAN, to discuss his hybrid clinical work as a neurohospitalist and neuromuscular specialist at Montefiore Medical Center in the Bronx, New York. 

Listen to Part 2: How to Pursue an Educator Role here!

Can't get enough of The Neurologist Is In? Make sure you're caught up on all the episodes--find the full catalogue here.

Rachel Marie E. Salas, MD, Med, FAAN, FANA, is a professor in the Department of Neurology at Johns Hopkins Medicine with a joint appointment in the School of Nursing. She is board certified in Sleep Medicine and Neurology. Dr Salas is the Director of Ambulatory Sleep Services at the Johns Hopkins Center for Sleep and Wellness. Dr Salas has been the Director of the Neurology Clerkship for over a decade. She is the Chair of the Undergraduate Education Subcommittee for the American Academy of Neurology and is an appointed member of the Alliance for Clinical Education. She is the director of the Interprofessional Education and Collaborative Practice for the School of Medicine and a Co-Director for Interprofessional Teaming for the High Value Practice Academic Alliance. Dr Salas is also the founder and Co-Director of the Johns Hopkins Osler Apprenticeship Program (in Neurology), a medical education research program for senior medical students and the Johns Hopkins PreDoc Program, a pipeline premedical college program. Dr Salas is a certified strengths coach and uses a strength-based approach and coaching to connect to, support, and develop those involved with her educational mission and clinical practice. Dr Salas is a 2019-21 Josiah Macy Scholar, a 2019-20 AMA Health Systems Science Scholar and a 2021 AΩA Leadership Fellow.

Mark J. Milstein, MD, FAAN, is Director of the Adult Neurology Residency Training Program at Montefiore and Associate Professor of Neurology and Medicine at Albert Einstein College of Medicine. His clinical work focuses primarily on neurohospitalist and neuromuscular medicine / electromyography (EMG), as well as general neurology.

After earning a degree in Biology at the University of Pennsylvania in 1997, Dr. Milstein attended Albert Einstein College of Medicine, where he received his Doctor of Medicine in 2001. Dr. Milstein completed five years of postgraduate training at Montefiore from 2001-2006, including his internship in medicine, residency in neurology and fellowship in clinical neurophysiology. Dr. Milstein was Chief Resident in the final year of his neurology training.

Dr. Milstein’s research focuses on medical education, inpatient neurology and neuromuscular medicine. His work has been published in a number of peer-reviewed journals, and includes original research, review articles, and books. Dr. Milstein has been an invited speaker at a number of national lectures and presentations.

At the 15th Annual Doctors Recognition Day in 2018, Dr. Milstein received the Peer to Peer Excellence in Medicine Award from the Bronx County Medical Society. He is a member of numerous professional societies, including the American Medical Association (AMA), the American Academy of Neurology (AAN) and the New York State Neurological Society. He holds leadership positions in the AAN and the New York County Medical Society (NYCMS).

Read the Transcript:

Dr Rachel Salas: Welcome back everyone to The Neurologist Is In. I am Dr. Rachel Salas, a sleep neurologist at Johns Hopkins, and I have the pleasure of speaking with Dr. Mark Milstein today. Mark, go ahead and introduce yourself.

Dr Mark Milstein: Thanks so much, Rachel. My name is Mark Milstein. I am an Associate Professor of Neurology and Medicine at Montefiore Medical Center in the Bronx, New York. We're affiliated with Albert Einstein College of Medicine. I split my time between clinical work as a neurohospitalist and as a neuromuscular neurologist. And the other hat that I wear is as Program Director of our Adult Neurology Residency Program.

Dr Salas: Awesome. I'm so glad to have you here. We haven't had a program director as of yet, and I definitely want to dig into that a little later, but let's get started first about your clinical practice. I think it's so interesting that you're basically a split neurohospitalist and neuromuscular neurologist. Tell me a little bit about that. How does that work? Maybe what a typical week looks like?

Dr Milstein: Absolutely. I think I was a beneficiary of luck and timing to a degree. At the end of my residency training, I went into my neuromuscular fellowship fully intending to finish and join an academic, predominantly outpatient practice. And I was looking around at different opportunities interviewing with several locations in New York City when this opportunity became available. And now we're talking 2006, so this really is while hospitalist medicine existed in grade form; at that point neurohospitalist medicine was still in its very early stages. And my department was looking to build a small neurohospitalist division and they offered me this wonderful hybrid position where I would get to work on the neurology consult team, work with the residents almost every time I was on service, and still carve out a significant portion for me to do neuromuscular medicine. And really it's kind of been a dream come true because it's allowed me to keep all of my interests going. As much as I love neuromuscular neurology, I really did have a special passion for inpatient neurology too, and being allowed to continue to do that is wonderful. So I have weekly obligations that go throughout the whole year and that includes spending time in the EMG lab, doing neuromuscular consultations and working with our neuromuscular fellows, working in our Myasthenia Gravis Clinic, and also precepting in the Residents Clinic once a week, too. About half of the year, however, I'm also on service on our neurology consult team predominantly on the resident consult team, so I get to keep my teaching hat on, too, and that really keeps me happy.

Dr Salas: Wow. It seems like everything's so integrated there. Tell me a little bit about neurohospitalist. Is that now a formal training? I know that that's something that a lot of people might be interested in. So how do you become a neurohospitalist now?

Dr Milstein: Absolutely. I think there's a number of roots and it's really been exciting to see how the field has developed over the last decade. When I started, there was no such thing as neurohospitalist training, as a neurohospitalist fellowship, for instance, and those exist in several programs across the country right now. So people are coming to it from different routes. Some people are going through standard fellowship training, and that usually amounts to doing time on an inpatient ward, doing time with consultation neurology, maybe spending some time in a neuro ICU, and usually in the fellowship program spending some time on acute stroke care as well.

Other people are coming to it from the same direction I came to it which is doing fellowship training in another subspecialty and adding that onto their practice when they come and join as a neurohospitalist. It's still pretty system-specific. So for instance, at Montefiore, we have a large, well developed, and very robust vascular neurology team. So they still handle the overwhelming majority, 99% of acute stroke care. And that's something that was appealing for me coming in as a neuromuscular specialist. I didn't want to be doing the acute stroke care. Other people are very excited about that, and there are many systems where the neurohospitalist really is used predominantly to take that acute stroke call, particularly during the day when an outpatient neurologist might not be able to rush to the emergency room quickly to see their patient.

Dr Salas:

Wow. Yeah, no, I can definitely relate to that being very outpatient myself. Is this neurohospitalist fellowship one of the ACGME and if it's not, do you think that's where it's going to be going in the next few years?

Dr Milstein:

So it isn't an ACGME accredited fellowship yet, but I believe that is definitely the future of the field. The people who are running these fellowships right now are very dedicated to creating an integrated education plan for their fellows, having some consistency between programs so that really the same educational plan as being offered. Of course, every system and every hospital has their own unique traits. But I think that is generally the best route for most fellowship training. We've seen a number of subspecialties that have started out as non-accredited fellowships and become accredited either through UCNS or the ACGME. And I think that really is the route because that benefits the fellows a great deal because there's an education program that has to be developed. But also I think it really benefits both the health system and the training program that is associated with that fellowship. So I can just say from personal experience here, as we've seen fellowship programs develop, our most recent one that we've developed here at Montefiore, we have an application in right now to start our neurocritical care fellowship program, and I'm already seeing the benefits that are going to come to my residents from that, not just from being exposed to fellows who are training in this field, but being exposed to a more integrated and more well developed educational curriculum. So I think that's the direction for neurohospital medicine too.

Dr Salas: Great. Great. That's that's really nice to hear. I mean, our field is just really expanding with all the possibilities for further specialization and interprofessional work, too, working with different type of healthcare professionals.

Dr Milstein: Absolutely.

Dr Salas: So Mark, I'm always curious. I think what what's nice about these in podcasts, is a conversation about what you do, but then also about you.

Dr Milstein: Sure.

Dr Salas: And I'm curious, I want to know what brought you to neuro and then why you did a neuromuscular fellowship? Tell us about that.

Dr Milstein: Absolutely. I think I have what would be called a pretty traditional journey to medicine, but it has its of course unique weigh stations along the train tracks as I like to say. I grew up in a medical house. So my father is a physician, finally retired at 79 right before the pandemic, much to the delight mostly of my mother, but to the whole family. And so I was exposed from a very early age. I always give him a hard time. He was a very busy nuclear medicine radiologist, but he was home for dinner every single day. He was at all of my baseball practices, basketball games, he'd come to the theater productions. Everything, he was always there. He was a very present parent. Both of my parents were. And so I got this view of medicine that was pretty idyllic. I said, "Wow, you can be a hardworking physician and have a full family and be totally integrated outside of your hospital life." When I got to medical school, I realized that it does depend what you choose to do, but I think that's helped inform some of the decisions that I've made later in life. And I'm certainly happy to talk about those a little bit later.

So when I got to college, I said, "I think I want to be a doctor so I'm going to be a biology major." And as it happened, my freshman year, I signed up for a psychology course which I thought was super exciting. And I was thinking about becoming a psychology minor. And I had this realization during a behavioral psychology lecture that I really wanted to know how the wiring worked. I was intrigued about what happened after the wiring changed, but I realized I was much more excited about the wiring. And that's when I took a left turn towards neuroscience in college. And that was all she wrote when it comes to neurology. I got to medical school. I said I was going to keep an open mind. I absolutely did not. I loved medical school. I really did enjoy most of my clerkships, but I was pretty certain early on that I was going to be a neurologist. I like thinking about what makes people anatomically tick, as it were. And I like the puzzle that the history and the physical exam in neurology provides to us. I love the relationships we have. And I will say if there are any senior medical students listening to this, if it sounds a lot like a personal statement, I can tell you all that that hasn't changed in 20 years, that that's still what the students are talking about on their personal statements. And I get it because that's what excited me when I was ready for neurology.

Neuromuscular medicine, that was the next step. I got to residency training and everything was fun. I was excited to be a neurology resident. I knew I had arrived where I wanted to be, and I had to try to figure out what the next step was going to be. For me, neuromuscular medicine was just a natural progression of that puzzle solver. It was, for me, one of the harder puzzles for me to try to solve as a neurology resident, I think many neurology residents face that challenge with neuromuscular localization and thinking about electrodiagnostic testing. And that was an exciting challenge for me. And being quite honest, I really had fantastic mentorship. The people that I looked up to the most in the department had a passion for neuromuscular medicine. And I admit that I wanted to emulate what they were doing and where their careers were going, and the field excited me, so it was a natural fit.

Dr Salas: That's really great. I mean, I could just hear the passion and excitement that you still have all this time even later. And I love hearing why people are drawn to our field. And the field is just booming. Do you want to talk a little bit about that? How things have changed from when you and I trained and now where things are.

Dr Milstein: I really think it's been incredible. I'm sure you remember this from the interview circuit and early in training being told, "Oh, you're so lucky. The next 10 or 15 years of neurology are just going to be an explosion of therapeutics and you're really getting in on the renaissance of neurology." I think it was true with a little bit of a delay tag. I think that's actually happening now. And so I do feel a little bit like I'm a broken record with the medical students and with the residents telling them how lucky they are, but really just looking at what has happened, even for diseases we understand and have understood for a long time when I was a neurology resident. And now we're getting up on almost 20 years ago. We had TPA for acute stroke and we almost never used it. And I worked at a very busy coordinated care referral center, takes care of the majority of the patients in a large urban setting, and we had a robust vascular neurology division then. And it just wasn't standard of care. People weren't getting to the emergency room in time. We needed to work on education with our patients. We needed to work on education of our referring providers both from outside the hospital and in the emergency room. And we had to work on ourselves to say, "This is something that we've proven works and we need to be using it." And to look from there to 2022, where a week doesn't go by without a couple of thrombolysis cases like intraarterial thrombolysis, clot retrieval, where we're working with our radiologists and neurosurgical colleagues in a really fantastic multidisciplinary setting, just watching that has really just been incredible. I've really enjoyed watching that. And while it creates a little bit more in real time stress, I think the trainees are very excited about it, too, because they see in real time what they are doing to change a patient's life. So that's talking about a disease that we've understood entirely for a very long time.

If you get into some of the new genetic therapies that we're using, some of the new pharmacologic options that we have, some of the discoveries we've made about are more esoteric conditions, take an autoimmune or paraneoplastic encephalitis, this is a list that we could, we could spend the next 30 minutes talking about, all the things that we didn't know a lot about when we were training and know so much about and can treat right now. I think it's been very exciting. I always congratulate the medical students when they've made a decision about their future career, particularly if it's going to be in neurology. And when they choose neurology, I say, "Congratulations. I want you to know you haven't closed any doors. You're just opening them all up right now." And I think that's going to continue to be the state of neurology for the next 20 or 25 years, at least.

Dr Salas:

Yeah. I couldn't agree more. I mean, there's just so many opportunities. We have over 30 different ACGME fellowships and those are just the ones that are through ACGME, but there's a lot of them that are very specific that aren't ACGME yet, like some of the neuroimmunology ones. I know Movement is working maybe to become ACGME, but we have so many, neuropalliative care, neurogeriatrics. So there's a little piece for everyone in neurology, whether you like inpatient, outpatient, or the combo, like you.