Neurocritical Care Fellowship Training in the USA: Challenges and Potential Solutions

Neurocritical Care (NCC) has evolved into an essential multidisciplinary subspecialty in close collaboration with Vascular Neurology, Endovascular Neurology, and Neurosurgery. Following the formal recognition of NCC by the United Council for Neurologic Subspecialties (UCNS) in 2005 and the first NCC certification examination in 2007, the fellowship training programs expanded rapidly. However, recent data demonstrate a significant diminution in the number of accredited fellowship training programs and graduates. This article analyzes historical trends and recent data in the NCC fellowship training to identify challenges related to declining interest and posits practical solutions. Analysis of published surveys, publicly available annual reports of UCNS-accredited NCC fellowships (2008-2024) was performed. These data were compared with those from Vascular and Endovascular Neurology fellowship training programs by the American Board of Medical Specialties (ABMS). Temporal trends in the fellowship positions, graduate certification, and rates of attrition from accredited training programs are presented. The number of UCNS-accredited NCC fellowship training programs declined from 76 in 2021 to 66 in 2024, with a 17% reduction in fellowship graduates and a concomitant 89% drop in UCNS NCC certifications. Factors contributing include introduction and transition to the Accreditation Council of Graduate Medical Education (ACGME), reduced applicant interest, migration to other acute neurology subspecialty fellowships, limited institutional funding, and variable competency standards in clinical skills and procedures leading to inconsistent skill acquisition. NCC is undergoing a challenging transition. By adopting standardized accreditation, investing in early career exposure and mentorship, and technology-enabled care, the current attrition rates may be reversed toward developing a sustainable NCC workforce.