What is a Neuro-Ophthalmologist? How Do You Become One?

Session 51

Dr. Bryan Pham is a community-based neuro-ophthalmologist who is fresh out of training. He discusses the field of neuro-opthalmology, what drew him to it, and so much more.

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[01:30] Interest in Neuro-Ophthalmology

Bryan recalls having a difficult time in his neurology residency. It was the end of his first year in neurology, which was the beginning of his second year that he had a very busy workload without a real break.

And the next rotation coming up was neuro-ophthalmology. And for him, that rejuvenated his love for medicine and for neurology.

He likes the wide variety of disease being able to see all different areas in neurology represented within neuro-ophthalmology. There are strokes that affect vision and there are movement disorders of the eyes.

My wife, Allison, is also a neurologist and I remember in her first year of neurology is her second year of postgraduate training. And then your junior of neurology, she was destroyed that year. So this is not an uncommon thing. So expect this if you’re going into Neurology.

The first year of Neurology, the PGY-2 year, tends to be the most difficult for everybody.Click To Tweet

[03:07] Traits that Lead to Being a Good Neuro-Ophthalmologist

Bryan says that to be a good neuro-ophthalmologist, you have to take the time to think over the patient. It’s a cerebral field. Not too much in terms of procedures, but he likes the mystery of patients and trying to figure that out.

Being a neuro-ophthalmologist, you’re not actually operating on patients or conditions. Bryan explains that there are also neuro-ophthalmologists that do additional training in occulo-plastics.

Other specialties in the running for fellowship training, Bryan also considered neuro-intensive care. But he realized he doesn’t really like terribly sick patients and the intensity of it.

[04:42] Types of Patients and Neuro-Ophthomology versus Ophthalmology

Bryan describes that one-third of the brain volume is dedicated to vision. We see essentially everything that can affect vision that doesn’t come from the eye itself. These could be strokes affecting areas of the brain causing vision loss as well as different abnormalities.

Anything that affects the brain can and often does affect vision.Click To Tweet

Bryan explains their bread and butter diagnosis is a condition called idiopathic intracranial hypertension or pseudotumor cerebri.

It is where the pressure in the brain builds up that it can lead to vision loss when it puts pressure on the optic nerves causing them to swell. Nothing in the eye itself is abnormal, the problem is further.

So any conditions where the eyeball itself is normal but the vision is affected would be appropriate for a neuro-ophthalmologist.

Bryan says he often gets referrals from his colleagues in ophthalmology but he also gets a few from primary care physicians.

[06:17] The Residency Path to Neuro-Ophthalmology

There are two ways going to residency. One is the neurology residency and the other is an ophthalmology residency. Because it’s a non-surgical subspecialty, it is an option through neurology.

You do the typical neurology or ophthalmology residency and then followed by a year of fellowship in the neuro-ophthalmology. But it’s a nonsurgical fellowship.

The joke in Neurology is finding the lesion and knowing the location, or localizing the lesion. But then not being able to do anything about it. In Neuro-Optho, there are also common jokes related to this.

But Bryan clarifies that there are some things that they’re able to treat and cure. One example is benign paroxysmal positional vertigo.

Nevertheless, Bryan admits their subspecialty is the “diagnose and adios!”

[Related episode: The Role of Residency Training for Physicians.]

[07:50] Typical Week in Neuro-Ophthalmology, and Community versus Academics

Currently, Bryan deals with 80% general neurology and 20% neuro-ophthalmology. There are neuro-ophthalmologists that do it full-time but they generally consist of essentially a full day of clinic.

There are consults they need to do in the hospital depending on the setting. In academic centers, you have more inpatient consultations.

The nature of their subspecialty lends itself better to an academic setting just because there are a lot of ancillary testing available.Click To Tweet

What really drew him to community versus academic setting is the absence of research. Bryan doesn’t like the need to be constantly churning out research as well as the politics of climbing the academic ladder.

Bryan’s typical week involves 100% clinic for neuro-ophthalmology. In his practice, the inpatient consultations are handled by the general ophthalmologist on call. And if they have any issues, they will refer them to him to be seen in the clinic.

[09:30] Lifestyle as a Neuro-Ophthalmologist

In terms of taking calls, during his fellowship, Bryan served through phone call. He remembers having done it twice in the middle of the month during his fellowship so it was very manageable.

The residents would call him whenever an issue came in. A typical emergency is a condition called temporal arteritis, characterized by an inflammation in the blood vessels on the side of the head.

This can present vision loss or impending vision loss. This is one instance they have to act quickly to get the appropriate treatment started.

Bryan describes having a great work-life balance as a neuro-ophthomologist, more so now that he’s out of training than he was in training since you’d have to be 24/7. Nevertheless, he has always thought he’d do things around the city and not have to worry.

[10:55] Neuro-Ophthomology Fellowship Programs

Bryan describes there is generally one fellow a year at an institution, although some may have two. But only one program has three fellows a year. So it’s a very small community. If you go to a fellowship and you’re the only one, you really are 24/7 for that year.

Bryan describes this can get better over the course of the year. Through the middle and end of the year, the residents are well-seasoned, so they tend to wait until the morning to call rather than 2 am.

In terms of competitiveness, Bryan says it varies by the year. During his year, they had most of the spots filled. The following year, which is this year, they have a lot of open spots available.

If this is something you’re interested in, Bryan’s advice to become competitive is to make it to their national conference called NANOS (North American Neuro-Ophthalmology Society).

Because it’s a small community, everybody knows each other and so get your face out and meet the other neuro-ophthalmologists out there. Bryan thinks this is the best way to get ingrained in the field. It’s all about networking, which I’m a huge believer of.

[12:45] Bias Against DOs in Neuro-Ophthalmology, and Special Subspecialty Opportunities

Bryan says a lot of the leaders in NANOS come from osteopathic medical schools.

Moreover, Bryan mentions other opportunities out there to further subspecialize. Johns Hopkins, for instance, does the neuro-otology fellowship where they focus on dizziness. He further jokes that it has its own punishment.

Other groups have their own niche as well such as those specialized in the people. Others focus on eye movement abnormalities and eye movement recordings. There are also those that scale in for more vision loss disorders.

[Related post: MD vs DO: What Are the Differences?]

[14:30] Working with Primary Care and Other Specialties

What Bryan wants primary care doctors to know is that examining people with your own eyes is important. There are things that can wait in neuro-ophthalmology so his advice to primary care docs is to not be shy about reaching out to them whenever they’re concerned about any issues.

If it’s not appropriate for neuro-ophthalmology, they will direct you otherwise. But they’re always willing and open to answering any questions.

'Examining people with your own eyes is important, no pun intended.'Click To Tweet

Just like general neurology where there is the need for the primary care physicians to know a good neuro exam, you need to know how to look at an eye or the retina. You need to get some sort of differential going.

Bryan recommends resources like the online database called NOVEL (Neuro-Ophthalmology Virtual Education Library). They have examples of all the things you need to read about going to medical school.

Other specialties they work the closest with are neuro-surgery, neurology, and ENT.

Special opportunities he sees outside of clinical medicine would be clinical trials. You can look into treatments for some of these neuro-ophthalmic diseases. It’s mostly clinical practice as the end game.

[18:50] What He Wished He Knew and What He Likes Best About Neuro-Ophthalmology

Although he is still relatively new to this, there is an end game. During his fellowship where he’d like to call it quits, he was glad he didn’t at this point.

What he likes about being a neuro-ophthalmologist is the variety of cases. There’s a little bit of different areas in neurology in neuro-ophthalmology. So every day, there is something new to learn, specifically the continuity of patients.

What he likes the least, on the flip side, is the charting.

In terms of any major changes that he sees in the field, it’s still a relatively new subspecialty. So he feels there are two peaks for the neuro-ophthalmologists practicing out there. The first generation is starting to get through their retirement now. And there’s this newer generation that’s coming through.

This said, there will be a lot of turnover in terms of the field. They will be losing a lot of their mentors. Nonetheless, he doesn’t think this will change the practice of neuro-ophthalmology.

'There will be a lot of turnover in terms of the field. We will be losing a lot of the mentors that we had.'Click To Tweet

If he had to do it all over again, Bryan would still choose the same specialty. Finally, Bryan leaves with some words of wisdom.

He recommends students to come to a neuro-ophthalmology clinic and check it out. He never thought about it before his rotation. And here he is now!

[18:40] Last Thoughts

I actually didn’t know that the majority of neuro-ophthalmologists out there were diagnostic physicians. They don’t operate.

When I think of ophthalmology, I think of a surgical subspecialty. But when you add that neuro on the front of it, then you lose the surgical part of it and you don’t get that training.

Finally, please share this podcast in your Facebook group for your class (if you have any) or if you have some sort of email list or email group. Please let them know about this podcast.

If you know anybody who is a physician and should be on this podcast, shoot me an email at ryan@medicalshoolhq.net and we will make it happen.