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Specialty careers profile: stroke medicine

Dr Hedley Emsley, consultant neurologist with a special interest in stroke neurology at Lancashire Teaching Hospitals NHS Foundation Trust, shares his experience of working in stroke medicine, how he was inspired to choose the specialty, and what it's like to train and work in stroke medicine.

What influenced you in choosing stroke medicine?

As with all these things, my career path was influenced by serendipity. I was fortunate that a clinical research fellow post in stroke medicine came up in Manchester just as I passed my MRCP whilst completing a senior house officer (SHO) post in neurology at Queen Square. There’s no doubt that this ensured my on-going interest in neurology and stroke – as well as consolidating my interest in research and teaching.

What training do you have to do to get into stroke medicine?

Many current stroke physicians – whether from geriatrics, neurology, or other backgrounds – have moved into their current roles after developing an interest in stroke. Newly appointed consultants will now usually be expected to have completed stroke medicine training. Entry to an approved stroke training programme over 2 years is possible for trainees with a national training number in any of the parent specialties, leading to the award of sub-specialty status in stroke medicine upon completion of training in the parent specialty.

What rotations did you do in your training and what did you find helpful?

Apart from my general professional training, and 3 year research fellow post, I spent 5 and a half years as a clinical lecturer in neurology at the University of Liverpool and The Walton Centre, with my time divided between neurology training as a specialist registrar, research and teaching.

I was fortunate to do neurology and transient ischaemic attacks (TIA) clinics, as well as acute stroke assessment throughout my research fellow post – in addition to the further training in stroke and TIA as a neurology trainee.

Do you work closely with other specialties?

Absolutely – perhaps what is surprising is the sheer diversity of how many specialties we work with including emergency medicine, acute medicine, radiology (including diagnostic and interventional neuroradiology), vascular surgery, neurosurgery, cardiology, rehabilitation medicine and community services.

What are the best things about working in stroke medicine?

For me it is the diversity of my work – covering clinical neurology and stroke practice, research and teaching.

Few interventions in medicine can be as satisfying as helping neurological deficits and the resultant disability due to stroke melt away with urgent treatment or prevention of disabling stroke through prompt assessment of TIA. There is close working within a multidisciplinary team and high clinical standards to aim for across the stroke pathway.

New treatments are constantly under development for acute, prevention and rehabilitation aspects. Stroke medicine provides a challenging and rewarding career with constant variety and intellectual stimulation.

What are the main challenges of working in stroke medicine?

The biggest challenges are the same as those facing everyone working in the NHS. In particular, the organisation of services from urgent response through to long term secondary prevention requires communication with a large number of professionals.

What are your typical working hours?

I work Monday to Friday, as well as being on the neurology on call rota, plus some flexible work in the evenings or weekends at home. Generally achieving a sensible ‘work/life’ balance is not too challenging. Acute stroke on call can result in some disturbed sleep, but at consultant level this is usually through telemedicine contact.

Are there opportunities for teaching or lecturing?

Of course, there will always be opportunities to contribute to both undergraduate and postgraduate education. Stroke and TIA are core components of the Foundation and core medical training (CMT) curriculum so there is always local training to be done. Due to the prominence in clinical services, stroke should be in every medical school curriculum.

Are there opportunities for research?

There are plenty of opportunities for research, but the extent of your involvement will of course vary with the particular post. In recent years, the UK Stroke Research Network (part of the National Institute for Health Research) has helped to dramatically increase the number of stroke patients recruited to research studies and in particular randomised controlled trials. Opportunities usually exist to recruit patients to network studies – and many stroke physicians do also develop their own research.

Do you work closely with other healthcare colleagues or groups?

I work with a very wide rangem when one considers hospital based medical specialties, GPs, managers and professions allied to medicine.

Examples include work with the Lancashire and Cumbria Stroke Network at a particularly fascinating time – with the introduction of a network telestroke service for providing out of hours stroke thrombolysis assessment, and work on a Department of Health Stroke Improvement Programme project to develop the local TIA service.

I work on a number of research projects with colleagues, including research supervision of undergraduates and postgraduates, and these generate publications in peer-reviewed journals.

What is the required mix of skills for stroke medicine?

Stroke medicine will particularly suit trainees who relish emergency clinical work across a broad group of neurological presentations. Team work is important, in order to work with other medical specialties and professions allied to medicine, as is the ability to work in a mixture of clinical settings including inpatient and outpatient, acute and rehabilitation.

In my junior doctors, I like to see enthusiasm for working out why people have developed their symptoms, as well as problem solving and attention to detail, and being keen to work as part of a large team.

What changes have you seen in your specialty during your career?

Stroke services have undergone a national revolution in recent years to now command significant clinical – and political – attention. Stroke medicine is a medical subspecialty in its infancy, recognised since 2007, and encompasses emergency assessment and treatment of acute stroke, stroke prevention (including TIA assessment and treatment) and rehabilitation. The care provided for individual stroke patients is now reported in national league tables, so it is a high priority to organisations.

Are there typical patient groups? What are they like?

One of the fascinating aspects of stroke care is the huge variation in stroke related deficits and the broad age range. This is why stroke care has to be tailored towards the individual through a multidisciplinary approach. Some patients require a very urgent response where minutes matter, whereas others require support towards long term goals or palliation. So a broad range of skills is provided through stroke medicine training.

Does your job involve decision making?

Yes of course – everyday. Arguably it is rapid decision making in the acute setting that sets stroke neurology apart from other aspects of neurology. The passage of time has often been used as an arbiter in traditional neurological practice – hardly an option in the heat of an emergency room thrombolysis decision, for example. Some decisions also require careful consideration of ethical aspects, especially in team decisions about nutritional support and rehabilitation goals.

What are the common misconceptions about working in stroke medicine?

I’d say the most commonly held misconception about the specialty relates to transient ischaemic attacks (TIA) – generally thought to be a straightforward diagnosis, but the reality is that it is often anything but easy. Stroke has traditionally been considered to be an untreatable, inevitable result of ageing, but in fact a quarter of patients are less than 65 years old and even the oldest can benefit from organised stroke care.

What advice would you give to someone considering a career in your specialty?

Stroke medicine provides a challenging and rewarding career with constant variety and intellectual stimulation.