Concern about Neurology

[deanSANE]

Hi guys,

I'm an MS3 currently buried in the process of what I wanna do with my career. First of all, I want to let you know I've already read a lot of the threads about the pros and cons of neurology, and I appreciate everyone's input into them.

At this point, I guess my decision has come down to IM vs neuro, leaning towards neuro. I have a general grasp of the advantages and disadvantages of both fields.

There's a lot I like about neuro, and I forsee myself working mostly in the clinic (do not like the hospital--at least as a med student). My biggest concern is the exact number of "untreatable" somatic pain/chronic pain patients. I am really concerned about the amount of dissatisfaction that's been shared on this forum about these pain patients.

So my question is: just how often are these patients encountered in primary practice, say in the suburbs. 1 out of 5, 1 out of 10, 1 out of 20? I guess I could handle seeing 1 or 2 of these types of patients a day, but if half of my patients had those complains, maybe Neurology is not the field for me. I've already read the advice that it's best to spend time in the practice setting you foresee yourself in before you sign up for it, and I am already trying to get that set up. In the meantime, I would appreciate your input on this.

Thanks so much!
your MS3 friend

PS: I think I ultimately want to practice private practice general neurology in a suburban setting, and maybe subspecialize in movement disorders or neurophysiology.

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[rockydoc]

I too am an M3 thinking Neuro vs IM, leaning towards neuro. Maybe this is a common dilemma because we are drawn to similar cognitive specialties? I have to second your reservations, partly due to the feeling that several neurologists are very unhappy with their work/life. But maybe that is just medicine nowadays and not neuro-specific? Any thoughts appreciated.

 

[typhoonegator]

You have to take some of our thoughts on this forum with a grain of salt. A lot of us do a little venting here. Difficult people are everywhere, and there is literally no service job anywhere that can completely avoid them.

Most of us are very happy with our professional choices in neurology. And once again, you can do a lot to minimize your exposure to this sort of patient, through subspecialization and adopting a more "one and done" consult model.

 

[EdLongshanks]

My biggest concern is the exact number of "untreatable" somatic pain/chronic pain patients. I am really concerned about the amount of dissatisfaction that's been shared on this forum about these pain patients.

I'm an MS1, so clinical rotations have not yet purged me of my idealism, and I realize that a lot of these intractable pain patients are drug seekers.

But, what about the patients who are suffering from intractable and unspecified real pain. Who is going to take them seriously? Surely the Dr. House types of the analytical neurology community should try their best even if everyone else shrugs their shoulders and heads out on the next cruise to the Bahamas.

 

[danielmd06]

Because the title of the thread is "concern about neurology" I think it's important to make a couple of general statements before answering your question. I'm extremely happy with my choice of neurology, despite my comments/warnings about negative aspects of the specialty. If it all were to be done over again, I would still do neurology and a sleep medicine fellowship.

I'm a private practice sleep specialist (somnologist if you like) who sees exclusively sleep medicine patients. Like TN said, subspecialization is one way of insulating yourself so to speak from areas of general neurology that you don't care for. I love sleep patients. I love the pulmonary aspect of what I do. I love narcolepsy cases, and the exotic neuroanatomy involved in sleep/wake. I love seeing people get better. I love knowing that I have made their cardiovascular and neurovascular health just a bit better (refer to my interest in stroke medicine below). I like having diagnostic testing that I am personally responsible for (ie *not* some radiologist) that pertains to patients that I personally see in clinic. I didn't want to take call, see pain patients, see headache patients, manage pseudoseizures, manage depressing intractable neuromuscular diseases, or manage terrible nervous system cancers.

Do I still have tougher patients? Yes. They're called insomniacs and they usually have alot of psychiatric overlap. You'll find that these psychiatric/pain/difficult/vague patients percolate into every specialty of medicine that exists. You just see them with different labels. Ask your gastroenterology fellows about IBS or GI pain. Depending on selected specialty, these patients may have any of a variety of complaints. Just ask your friendly neighborhood co-residents in other specialties. For the record, I see one insomniac per day at most and one per week at best.

My own personal, original interests in neurology was actually for endovascular surgical neuroradiology, followed by vascular neurology (I thought of exclusively practicing stroke in an academic setting) and neurocritical care. I liked neurosurgery, liked very sick, intubated patients, liked avoiding general neurology outpatient clinics, and liked avoiding non-ICU inpatient general neurology. But we are a heterogeneous species in neurology, and I'm quite sure you'll find a variety of loves and dislikes on these fourms if you are patient enough and lucky enough to hear a variety of responses. I even thought briefly of movement disorders, too.

Don't like outpatient medicine? Try neurocritical care. Try being a neurohospitalist. Hate inpatient medicine? Try sleep or pain or neuromuscular or headache or epilepsy. And just have an exclusive outpatient practice. One of the very greatest strengths of neurology is its amazing versatility and we often don't focus on that enough on this forum.

As far as your original question, I see zero chronic pain patients where I am responsible for taking care of their pain. From the summary I typed above I hope I communicated that this is quite hard for the rest of us to predict for you. You have to decide on sub-specialty, private practice versus academics, how large a town you want to be in, and how large a group you want to belong to. You see how this could affect your answer? Also, one needs to stipulate about headache patients. Are you counting those as pain patients, too?

As a private practice general neurologist without fellowship training (or having done a neurophysiology fellowship) I would say that you can expect to see a variable amount of pain patients where you are expected to take care of their pain depending on where you want to practice. Now, you will almost certainly be expected to see headache patients. I would estimate I saw one headache patient per half day of clinic in residency. Remember, headaches can be common, and PCP's can manage alot of the easy stuff themselves, meaning that as a neurologist you might be self-selecting for more difficult headache patients. Can you minimize seeing headache patients? Yes, but it's tricky. You could join a practice that has a fellowship trained headache specialist, or a large group with someone who manages the headache workload as a hobby. But I suspect that as a general neurologist in private practice you should expect to see headaches. It's just part of general neurology.

Now moving onwards to the non-headache pain patients, I reiterate that it's likely going to be variable (but on the whole likely rare) to see them - especially if you tailor your practice to avoid them. For instance, try joining a large group or a group with a pain specialist (even better) and you can minimize your exposure to these people. Your practice will ultimately be what you make of it, so if you don't want chronic pain patients *ever,* then you need to establish that boundary at the beginning of your work. Tell your PCP colleagues that you don't do pain and they need to refer to a rheumatologist or pain specialist in the area. Remember that this likely won't apply to headache patients.

And there's a pitfall on permanently avoiding chronic pain (non-headache) patients, too...you might lose more than just your pain business if another neurologist is willing to manage these problems. PCP's are all about your availability, timely care, quality care, patient happiness, and your own versatility (ie the efficieny of using you for neurologic-specific work). Obviously, this will once again be variable depending on where you are, and what the PCP and neuro cultures are where you go. But just remember, no one can make you see something you don't feel comfortable seeing.

Now, if you're willing to see pain patients then again the answer is variable (seeing a pattern here?). You'll probably see more folks like this in Miami or Vegas than Des Moines, for instance, just by virtue of the particular population in a given area. Pain medications are a popular commodity in some locales.

What about academics? In academics you might get more tough cases. Certainly as a resident. But there's a silver lining. You can take advantage of more highly developed ancillary services such as neurosurgery, pain, physiatry, psychiatry, etc that some private practice people can only dream of. And please note that once again, this is dependent on the type and size of academic center you go to. The snazzy places have larger faculty populations and greater and more exotic subspecialization. Smaller teaching hospitals might have *you* as a pain doctor whether you want to be or not.

In summary, in private practice general neurology in a suburb of a large metropolitan area, I bet you can expect to see a headache patient at least once every half day, and chronic (non-headache) pain patients much, much less (if at all), and that you could likely completely avoid the non-headache people if you made a concerted effort to set up your practice this way. Perhaps others could chime in with experience?

 

[deanSANE]

Wow! Thank you so much, DanielMD! Your answer was more than anything I expected or hoped for. As a medical student in downtown Baltimore with absolutely no relatives or family friends in medicine, it can be so hard to get an accurate picture of what private practice medicine is like outside of the confines of a hospital in the heart of a city. Even though I've spoken with a couple of our neurologists about this issue, I feel like it must be a little hard for them to answer accurately when several of them attend 1-2 months a year in an academic hospital and do research the rest of the year--and in fact a few have directly said this to me.

It's such a relief to hear that the chronic pain patients will be relatively few in number. I really got the idea from some of the other posts that these almost will be a majority of my patients. I certainly would have no problems seeing a few of these patients, and headache patients as well, to see if I could think of anything their PCP had not thought of. And if I don't, then I would have no qualms with admitting the reality that Medicine does not understand nor hold a cure for every ailment, and encourage them to seek further help in their quest to alleviate their pain--whether it be a second medical opinion or complementary and alternative medicine, if they see fit.

But back to my original point, your answer has truly made a great impression on me and given me a lot of insight. Even though I was already setting up early 4th year sub-Is in neuro, I'm now relieved of a few of my concerns and certainly encouraged to push forward with my pursuit of Neurology as a career.

I'd like to nominate your post for a sticky in this forum. Like I said, although the Neurology FAQ provides a little info about what a neurologist does and sees, a lot of the "why did you go into neurology?" threads really, really paint a negative picture of the field--and convey a great deal of concern about seeing pain/headache/somatization patients all day and night (Although I do admit to only reading back to about 7 of the 51 total pages in the Neurology forum before I became concerned enough to make my own post). To have a such a thorough explanation of the flexibility of the field, as well as an explanation of how often pain/headache patients are actually encountered, would certainly be very helpful for other medical students, since I'm sure I'm not the first one to have these concerns.

Thanks again.

 

[typhoonegator]

danielmd06 gets awarded the slow clap award of the day for his uber-mensch post above.

clap....clap....clap



Seriously. Go into neurology because you like neurology. No one likes every patient that walks through the door, from cardiology to ENT to OB to preventative medicine.

Paralysis by analysis leads to poor decisions. Pick a specialty that you could see yourself writing book chapters for.

 

[deanSANE]

While I understand your line of reasoning, TN, at this point in my career, I feel as though it should be my mission to learn as much about my future specialty as possible. If 4 years ago you'd have told me that after $200,000 of debt, 4 years of med school and 3-7 years of residency and fellowship, I would have only had a 60% chance of being happy with my specialty (as the latest medscape surveys show for neurology), I would have seriously re-thought going into medicine.

Even at this point, I would be lying if I told you I didn't have serious misgiving about it. And a plurality my classmates do as well. Now, it's probably because we are all at the most vulnerable stage of medical school, just first being exposed to the world outside of the lecture halls, seeing inner-city patients who are often non-compliant, and not uncommonly being exposed to residents who are tired, agitated, pessimistic--not to negate several phenomenal residents I've been lucky enough to have. It can really put you down in the dumps about being in medicine. Not to mention all the uncertainty of the future of medical reimbursements and the "stories" we hear about dissatisfied doctors juggling patients and hiring insurance specialists.

Therefore, it's hard for me to justify simply going into neurology because I'm interested in it, just as I was interested in medicine 4 years ago. I want to be as well-informed as possible about my future field, because I hope to be in the 60% who is happy, not in the 40% who is not, because I got into neurology without fully realizing what I signed up for. And as it has been mentioned before in a thread, even if I was interested in the science of neurology--which I am--writing book chapters about it would not be my job. Seeing and managing patients would, and I'm just trying to make sure that I would be satisfied with that aspect of it.

Also, please do not see my post as a slight to you. I'm just trying to show you my line of reasoning, and the line of reasoning of many medical students these days. I've read several of your replies in the various threads of these forums and am very thankful for your input as well.

 

[danielmd06]

Even at this point, I would be lying if I told you I didn't have serious misgiving about it. And a plurality my classmates do as well. Now, it's probably because we are all at the most vulnerable stage of medical school, just first being exposed to the world outside of the lecture halls, seeing inner-city patients who are often non-compliant, and not uncommonly being exposed to residents who are tired, agitated, pessimistic--not to negate several phenomenal residents I've been lucky enough to have. It can really put you down in the dumps about being in medicine. Not to mention all the uncertainty of the future of medical reimbursements and the "stories" we hear about dissatisfied doctors juggling patients and hiring insurance specialists.

It can be tough. Many of my medical school mentors, fellow medical students, practicing cardiologists and urologists, and finally residents in specialties as diverse as neurosurgery, internal medicine, radiology, EM, and surgery all tried to talk me out of going into neurology. Then my co-residents in neurology and every single mentor attending I had tried to talk me out of going into sleep medicine. Sometimes you just have to be honest with what you want out of life, what you don't want out of life, and make the decision that is best for you. In the end, you owe yourself this much.

The reasons for not choosing neurology vary wildly and I've actually posted on them before in this forum (among many others).

In my own humble opinion, these most often include: (1) the poor and frustrating representation that inpatient neurology offers to rotators about our specialty (just remember what I've said about career versatility, and also how many neurologists practice exclusively in an outpatient venue), (2) the overwhelming workload of many neurology programs because their residents are being asked to fill a gap in work and services that traditionally neurologists never had to do (this is fast changing as many programs add residency slots and rotators from IM, EM, neurosurg et al, and remember that neurology is essentially an exclusive consult specialty in private practice), (3) many programs *not* having charismatic attendings or residents that alot of medical students simply don't socially mesh well with (not a good reason to avoid a specialty, but it is what it is), (4) a relatively lower mean income than the majority of medical specialties (but this is fast improving, the pure neuro jobs I looked at were almost always starting at $250-330 and had potential to exceed $400, and the numbers can get better with time and also get better if you do procedures ie pain, sleep, emg), (5) lack of improvement in so many sad cases (we have new therapeutics, but this is a valid complaint against neuro AND other specialties in medicine), (6) the psychiatric overlap that is so much more prevalent in neurologic disease compared to so many other specialties (please refer to my post above about insulation), and (7) alot of folks never had good teaching lectures about neuro in medical school and don't get good explanatory lectures as residents and thus the nervous system becomes incomprehensible and frustrating (for me this issue is best exemplified by the nefarious kidney). This latter can be easily corrected by finding good mentors and good books.

Good luck. It's a wonderful specialty and most of us in it who were careful about career choices and were ruthlessly honest about what we wanted out of a career and life are extremely happy with it.

As in so many other specialties beyond neurology and indeed in all of medicine, there are unfortunates who didn't fully educate themselves about what to expect and are consequently not happy.

Thanks for the kind words from you and TN.

 

[JP2740]

were almost always starting at $250-330 and had potential to exceed $400, and the numbers can get better with time and also get better if you do procedures ie pain, sleep, emg),

I think I see the salary go up everytime someone new posts a salary! haha.

 

[danielmd06]

I think I see the salary go up everytime someone new posts a salary! haha.

This was my experience just last year. When I was a PGY-1 it was more like $180-240. The demand for neurology is growing more heated, and is downright acute in plenty of areas.

This thread posted the 2010 MGMA data:

http://forums.studentdoctor.net/showthread.php?t=817247&highlight=mgma+salary

Please note that sleep and pain are different if you exclusively practice them compared to general neurology.

 

[deanSANE]

Good luck. It's a wonderful specialty and most of us in it who were careful about career choices and were ruthlessly honest about what we wanted out of a career and life are extremely happy with it.

This is exactly what I've been trying to do and have spent a lot of time thinking about in the last few months. And it does seem like Neurology will provide me enough satisfaction and afford me enough flexibility to enjoy both my career and life outside of medicine.
Thanks again.

 

[Mattchiavelli]

I can't stress enough the importance of not letting salary figures be too high on the priority list when thinking about what you're going into. I have yet to see any practicing neurologists that are sleeping in their cars, as a mentor once said. I personally forsee a future where the dam breaks and the cash flows out of procedures like it does/used to in favor of equalizing procedural vs cognitive work. Regardless of if that happens or not that can be available through the field if that's what you want to do through sleep studies and CNS electrophys, interventional pain, cranking out the carpal tunnel EMGs, botox injections for spasticity (for people that can pay for it), etc. You could also be the next Oliver Sacks or patent some assistive device and make money with something tangentially related to clinical practice. Who knows- but if you don't really like what you do you will earn that money in a very hard way.

I am but a lowly intern but I'm getting excited to get out of my prelim year and get to the good stuff- hence my being so active on here recently. I'd say the proof is in the journals, instead of what book chapter you would write read some of the "it" journals of the field (like the green journal) and see if you could see yourself either doing a study about some of those disease processes/issues or using it to update your clinical skills. journals aren't just to keep the toilet tank warm, you will be reading them and it's best to not go into a field where you look at your main body of research and think "Oh this crap again....."

 

[JP2740]

A lot of people say that science does not equal medicine. If you like the science, it doesn't mean you'll necessarily like how the medicine in that subject is practiced.

Let me ask this question. I don't want to do surgery. I'm generally uninterested in organ systems outside of nervous system (including special senses). I mean I love biology and medicine in general. I think the heart and kidneys are really, really cool (yea I'm a nerd). But if I sized them up to nervous system, everything just very easily pales in comparison BIG TIME. Should that be part of my reason to pursue Neuro?

 

[Sye]

A lot of people say that science does not equal medicine. If you like the science, it doesn't mean you'll necessarily like how the medicine in that subject is practiced.

Let me ask this question. I don't want to do surgery. I'm generally uninterested in organ systems outside of nervous system (including special senses). I mean I love biology and medicine in general. I think the heart and kidneys are really, really cool (yea I'm a nerd). But if I sized them up to nervous system, everything just very easily pales in comparison BIG TIME. Should that be part of my reason to pursue Neuro?

I'm also struggling with the same question. Could someone shed some light on the similarities/differences between neuroscience and neurology?
I guess my main concern is whether I can attain the satisfaction I derive from neuroscience in a day to day practice of neurology?

Thank you all for such great feedback.

 

[copes]

A lot of people say that science does not equal medicine. If you like the science, it doesn't mean you'll necessarily like how the medicine in that subject is practiced.

Let me ask this question. I don't want to do surgery. I'm generally uninterested in organ systems outside of nervous system (including special senses). I mean I love biology and medicine in general. I think the heart and kidneys are really, really cool (yea I'm a nerd). But if I sized them up to nervous system, everything just very easily pales in comparison BIG TIME. Should that be part of my reason to pursue Neuro?

I'm also struggling with the same question. Could someone shed some light on the similarities/differences between neuroscience and neurology?
I guess my main concern is whether I can attain the satisfaction I derive from neuroscience in a day to day practice of neurology?

Thank you all for such great feedback.

I think you'd have to do a rotation and see for yourself. It definitely depends on the person. You could love neuro but hate rounding, sitting around talking about patients, or doing the neuro exam. The day to day of neuro residency will involve at some point rounding, managing patients, and clinic. I did a neuro away and we rounded for 4-5 hours everyday on the consult service. Most of the time we couldn't figure out what the patient had exactly, so you'd have to be ok with that. In my experience (and mine only), the neuroscience for the residents sort of took a backseat to getting the work done. You get to learn a lot of cool diseases, and sometimes there are really good cases, but it's not like the residents needed to know obscure functions of each cranial nerve. When the residents were busy it was more about following protocol (order tests and following up on them) than neuroscience. There are other specialties with different day to days like neuroradiology where you can indulge in your passion for neuro. So I think you need to like the day to day as well as the neuro, and if you like neuro don't limit yourself to neurology.

 

[neglect]

There are many thoughtful and fine replies here. I would only add: while the experience of med students is very limited, my personal resident experience was also fairly limited. I did residency in a city, and the people who came to the resident clinic had a large range, for the most part they were horrible. So many were poverty stricken, ungrateful, entitled, and unable to form a therapeutic relationship with the residents, which was no surprise, because I'm positive the residents came across as poverty stricken, ungrateful, and entitled.

That all changed when I did a sub-specialty in a different city. And now, as an attending, I see people who are deeply affected and afflicted by neurologic diseases, who are generally grateful for my care, and with whom I can partner easily.

I saw this because I remember hating entire disease segments when I was a resident: MS, migraine, pain. My impression of an MS person was a frontal, dis-inhibited crazy person with 20 chief complaints. Migraine was even worse.

Now things are very different. So don't let the system grind you down too much. There really is a light at the end of the tunnel, even if you can't see it.

 

[typhoonegator]

The further you subspecialize, the more your clinical neurology will resemble your neuroscience interests. In a general clinic you might see 10 different multifactorial headache patients in a day. You can help many of those people and improve their quality of life, but you might not spend a lot of time thinking about the neuroscience behind their chronic fatigue, caffeine and medication overuse. In a dystonia clinic, you might be able to spend a lot more time thinking about the circuits involved in their disease. But after you practice in that clinic for a few years, you're going to realize that once again, you can help at least some of these people, but your ability to help them doesn't necessarily mean you need to spend much of your time thinking about the globus pallidus.

There is this naive thought process in some students, that you're going to become a neurologist because "gee, consciousness is amazing, like, wow, man." Talk to any primarily clinical neurologist who has been practicing for a few years, and I can guarantee that they aren't thinking about the biochemical foundations of consciousness on a daily basis. That is because it is self serving, and it doesn't help their patients achieve more headache free days per month, or prevent them from having another stroke, or allow them to ambulate without a walker.

Don't become a professional basketball player because you like air-travel and staying in hotels. Don't become a neurologist because you think the brain is "like, totally fantastic". Do it because you like taking care of patients with neurologic disease -- and not just as a resident, but as a real doctor, which is how you will actually spend your real career.

There is a way around this, where you can keep your intellectual idealism and still be a neurologist, and that path is research. If you love the globus pallidus and don't want to turn into a professional titrater of dopaminergic drugs, then go into research. Make a contribution to the field, and manage patients at the same time. It is cutthroat, you won't make nearly as much money, and you may be geographically restricted, but you won't have to worry about losing track of the neuroscience.

/rant.

 

[exgatr]

Pain patients go to pain management. You'd be surprised how well the "I don't feel comfortable prescribing chronic narcotics" or "I'm not allowed to prescribe those drugs under my license" works.

As far as headaches go, you can try some things on them (topamax, botox, greater occipital nerve blocks, etc...) but there's inevitably a lot of psychogenic overlay in these patients and they don't get better. In which case, they go to pain management.

I think that patients are like a giant bowl of party mix: there are tons of nuts no matter what way you cut it -- you just have to choose the type of nut you like the best.

 

[Strokeguy]

All excellent replies for med students to think about. Looking at the other side, IM has its own fair share of dissatisfied pts. GI clinic has lots of IBS pts that are difficult to treat. Cardiology clinics full of recurrent chest pains (with negative work ups). Rheum with full of joint pains. ID with multple HIV pts who have several coexisting psychosomatic issues. Pulm with COPDs responding poorly to many agents. This happens in every speciality/subspeciality whether medical or surgical. You MUST like/love what you do. This is the only way to stay professionally happy and productive in the long term.

 

[DocVapor]

Just want to say thanks to everyone posting here for such a great thread. I'm an Osteopathic MSI and currently have Neurology as one of my top specialty choices. It seems like every couple weeks my wife and I have a discussion about possible specialties for me to go into. My wife doesn't like the idea of me doing a residency or residency/fellowship combo beyond 4 years long, and looking at financials (among other things) I am inclined to agree with her. We would also like to have a farm so she can ride horses, and we would like to start a family by the end of my residency then (we are both 28).

My question is - does anyone know what might be the lower population limit for an area to have a decent general neurology practice? I know that the prospects for private practice in neurology seem to not be looking too great right now, but there are several big systems that I could probably join and offer to start a satellite office for them (if things work that way). I am already planning on taking the USMLE, regardless of the upcoming ACGME/AOA partnership, but am going to wait a little longer before starting to contacting programs about their "DO friendliness" since that might all be changing as well.

I was a neuroscience major in undergrad and absolutely loved it, and my neuro block is starting in January. I know it's a possibility that I may not end up liking it, especially once I do my neuro rotation, but I would love to be able to bring this information to my wife next time we have the "specialty discussion."

 

[typhoonegator]

My question is - does anyone know what might be the lower population limit for an area to have a decent general neurology practice? I know that the prospects for private practice in neurology seem to not be looking too great right now, but there are several big systems that I could probably join and offer to start a satellite office for them (if things work that way). "

Really complicated question. Solo practice? Joining a small group? How saturated is the area? Are you looking to join as a part-owner or salaried? Hospital-based or entirely brick-and-mortar outpatient? There are so many variables, and so many ways to be successful (or completely insolvent). My parents live in a farm town in the rural midwest. Very small, but incorporated township at the county seat. There is a small community hospital there, with a 2 person (I think) neurology practice affiliated with it. They do fine, and anything they can't manage they can refer up the road to the regional medical center. Remember, the cost of living is roughly proportionate to the population density (as I am so often reminded of in the Boston area).

 

[DocVapor]

Thanks so much for the reply. There are definite things that I still need to learn about how the field works. My wife is a big planner, so even any new questions that I can bring to show her that I am thinking about our life long and hard can help to relieve the anxiety she has about not exactly knowing where we are going to be four years from now. The market saturation question was especially good, and I really don't know why I subconsciously assumed that the market anywhere we would be looking would be saturated already.

 

[Sye]

Thank you everyone for all the great feedback!

Thank you Typhoonegator for your reply. I think your comment is very right on. And although I haven't quite experienced what you're talking about yet, I can see how the clinical practice of taking care of the patient with a certain type of disease, is different from the scientific/intellectual curiosity in that field.
But then my concern is how do you deal with the fact that so many neuorologic diseases are incurable, and/or there aren't even any significant treatment options available. I understand that there has been significant advances in the field, but would you say, there are enough treatments of neurologic diseases in the field that will make one satisfied/fulfilled in the field?

 

[bustbones26]

Thank you everyone for all the great feedback!

Thank you Typhoonegator for your reply. I think your comment is very right on. And although I haven't quite experienced what you're talking about yet, I can see how the clinical practice of taking care of the patient with a certain type of disease, is different from the scientific/intellectual curiosity in that field.
But then my concern is how do you deal with the fact that so many neuorologic diseases are incurable, and/or there aren't even any significant treatment options available. I understand that there has been significant advances in the field, but would you say, there are enough treatments of neurologic diseases in the field that will make one satisfied/fulfilled in the field?

There are a number of medical conditions that have no cure or poor outcomes in general. We deal with it. Trust me, if tomorrow, neurologists starting making 500K per year or more, suddenly everybody would forget about the "incurable" side of the house.

While we may not have a cure for everything, we have very good treatments and are becoming more advanced everyday. Whenever I graduated from residency, it was pretty much a guarantee that if you had MS, you were going to be making yourself a pin cushion for the rest of your life if you opted for treatment. Now we have two FDA approved oral medcations, more down the road, and I can hardly keep up with this stuff anymore!!

The beauty of neurology is that we are still a great frontier and thus, there is much room to grow for developing better treatments and possible cures down the road.

After my UCNS certification came through, I can now officially call myself a headache specialist. Can we cure migraines? No, but I have to say a patient that experiences 20 or more severe headaches per month and reducing this to about 3 to 4 episodes per month is a victory!

On the flip side, we do have some "bad patients" with difficult personalities. Dealing with these individuals is an art but can be done. I take full notice that these difficult patients storm out, go and see another neurologist, realize that the grass is not always greener and the next thing you know, they are back to see me again 3 to 4 months later?

Medicine as a whole is becoming customer oriented and patients forget that they are ultimately in charge of their bodies. For example, I recall while during an IM rotation as a student there was this 450+ pound man that ate fast food daily, checked his blood sugar maybe once per week at best, and his A1c was higher than my bank account. Whenever the internist prescribed him another medication, this response was something like this, "Another medication? Why can't YOU guys just fix my blood sugar?" To this day I will never forget that remark, YOU GUYS. How about losing weight? Eating better? Actually taking your medication? Monitoring your blood sugar? Don't blame us!!

Also, it does not matter what specialty you choose, somebody can always find a reason to talk you out of it.

 

[neurolddoc]

I have been in practice in a single specialty group for over 20 years. Let me give a spot sample of what my office hours were like this morning. Not a day of chronic pain and headache.

7:00 in office,clean out in basket with studies from Friday.
7:45 start patients;
First patient follow up MS with OSA, RLS and CTS.
2nd, new patient with unsteadiness after an episode of syncope with MRI in hospital showing old watershed CVA
3rd, young woman with neck/arm pain ? radiculopathy
4th group home patient with seizure f/u
5th young woman with recent cva. Also had back pain that she didn't mention to me since she was seeing a "spine doc" ie anesth pain doc. He ordered MRI that showed a thoracic cord compression that he did not do anything about. Off to NS for her.
6th, middle age woman with hemi visual sx followed by hemi-paresthesia.
7th f/u for dementia eval. dx Alzh.
8th, new patient lumbar radic & DM neuropathy
9th, Man sent in for cts but had weakness outside median distribution, MRI c-spine showed HNP with lateral cord compression.

Phew. Lucky I had 2 no show patients so I could keep up with notes in EHR. Along the way I had discussions with my partner about how to get the new PQRS module in the ERH to work.

GTG Afternoon patients starting.

Summary. Neuro is actually fun after all these years.

 

[NeurologyICU]

I have been in practice in a single specialty group for over 20 years. Let me give a spot sample of what my office hours were like this morning. Not a day of chronic pain and headache.

7:00 in office,clean out in basket with studies from Friday.
7:45 start patients;
First patient follow up MS with OSA, RLS and CTS.
2nd, new patient with unsteadiness after an episode of syncope with MRI in hospital showing old watershed CVA
3rd, young woman with neck/arm pain ? radiculopathy
4th group home patient with seizure f/u
5th young woman with recent cva. Also had back pain that she didn't mention to me since she was seeing a "spine doc" ie anesth pain doc. He ordered MRI that showed a thoracic cord compression that he did not do anything about. Off to NS for her.
6th, middle age woman with hemi visual sx followed by hemi-paresthesia.
7th f/u for dementia eval. dx Alzh.
8th, new patient lumbar radic & DM neuropathy
9th, Man sent in for cts but had weakness outside median distribution, MRI c-spine showed HNP with lateral cord compression.

Phew. Lucky I had 2 no show patients so I could keep up with notes in EHR. Along the way I had discussions with my partner about how to get the new PQRS module in the ERH to work.

GTG Afternoon patients starting.

Summary. Neuro is actually fun after all these years.

How do you do it so quickly? 9-11 patients in ~ 4 hours, including new patients. Share with us some of the secrets for this efficiency (not a sarcastic comment, I would really like to know)?

 

[typhoonegator]

How do you do it so quickly? 9-11 patients in ~ 4 hours, including new patients. Share with us some of the secrets for this efficiency (not a sarcastic comment, I would really like to know)?

He doesn't have to wait to staff them with an attending.

 

[bustbones26]

He doesn't have to wait to staff them with an attending.

He actually has help. Whenever I was on staff at a military consult, I had to everything myself: place consults, review consults, fax papers, fill prescriptions, answer all phone calls, etc.

In the private world, this is why God invented medical assistants.

 

[neurolddoc]

We schedule 30 minutes for new patient and 15 minutes for follow up. Before I see the new patient, they have spent 30 minutes or so filling out a detailed history, PHM,FH SH ROS etc.
Also not every patient has CIDP or Miller Fisher syndrome. I can see a woman who developed nocturnal paresthesias in the middle 3 fingers while she was pregnant in less than 30 minutes so it all works out if one patient takes longer.Also 2 decades of experience makes it slightly easier.

 

[neurologist]

How do you do it so quickly? 9-11 patients in ~ 4 hours, including new patients. Share with us some of the secrets for this efficiency (not a sarcastic comment, I would really like to know)?

If you notice from his patient list, they were all "real neurology" patients too -- no chronic pain/chronic daily headache/fibromyalgia/psychosomatic crap. I want to know how he manages THAT!!!!! My (so far) 15 yrs in neuro would be a whole lot more fun too . . .

 

[neurolddoc]

I make it clear to patients that come in that my role is to diagnose the underlying process that is causing the pain. I treat the correctable underlying mechanism of the pain and prescribe medications or therapy that treats the cause or ameliorate the symptoms. I do NOT prescribe chronic narcotics and rarely acute narcotics. That alone seems to have a weeding out effect for a lot of patients, selecting for "real" patients. People that need that are sent to one of the plethora of anesthesia pain docs in my area for monitoring of their narcotics. Doing the narcotics contract, urine monitoring thing is not how I want to spend my time.

 

[neurologist]

I make it clear to patients that come in that my role is to diagnose the underlying process that is causing the pain. I treat the correctable underlying mechanism of the pain and prescribe medications or therapy that treats the cause or ameliorate the symptoms. I do NOT prescribe chronic narcotics and rarely acute narcotics. That alone seems to have a weeding out effect for a lot of patients, selecting for "real" patients. People that need that are sent to one of the plethora of anesthesia pain docs in my area for monitoring of their narcotics. Doing the narcotics contract, urine monitoring thing is not how I want to spend my time.

Wow. You live somewhere where "a plethora" of "pain docs" actually manage meds? Lucky you. Here there's like 2 small groups that are just procedure mills and won't write rx's for anything . . .

I don't often rx narcs either, but that doesn't stop primary MDs from sending the patients apparently hoping that I will . . .

 

[bustbones26]

I make it clear to patients that come in that my role is to diagnose the underlying process that is causing the pain. I treat the correctable underlying mechanism of the pain and prescribe medications or therapy that treats the cause or ameliorate the symptoms. I do NOT prescribe chronic narcotics and rarely acute narcotics. That alone seems to have a weeding out effect for a lot of patients, selecting for "real" patients. People that need that are sent to one of the plethora of anesthesia pain docs in my area for monitoring of their narcotics. Doing the narcotics contract, urine monitoring thing is not how I want to spend my time.

I have a patient policy that I make patients sign that states that I will not prescribe opioids. Some see this and do not show. This weeds out a lot of bad patients.

The TRUTH is, I will prescribe opioids. I am not an unreasonable man. For example, I have no problems letting a person say with a SEVERE neuropathy take a Percocet at night on a RARE occasion if the pain interferes with sleep and the amount I dispensed is exceptionally limited.

If a patient starts to slog down a bottle of Vicodin per day, I will not feed their need and insist that they are referred to a pain specialist.

Overall, I just try to set the tone on my website and clinic intake that I am anti-opioids to weed out the bad ones. It has worked!!

 

[Paddington]

Hi guys,

I'm an MS3 currently buried in the process of what I wanna do with my career. First of all, I want to let you know I've already read a lot of the threads about the pros and cons of neurology, and I appreciate everyone's input into them.

At this point, I guess my decision has come down to IM vs neuro, leaning towards neuro. I have a general grasp of the advantages and disadvantages of both fields.

There's a lot I like about neuro, and I forsee myself working mostly in the clinic (do not like the hospital--at least as a med student). My biggest concern is the exact number of "untreatable" somatic pain/chronic pain patients. I am really concerned about the amount of dissatisfaction that's been shared on this forum about these pain patients.

So my question is: just how often are these patients encountered in primary practice, say in the suburbs. 1 out of 5, 1 out of 10, 1 out of 20? I guess I could handle seeing 1 or 2 of these types of patients a day, but if half of my patients had those complains, maybe Neurology is not the field for me. I've already read the advice that it's best to spend time in the practice setting you foresee yourself in before you sign up for it, and I am already trying to get that set up. In the meantime, I would appreciate your input on this.

Thanks so much!
your MS3 friend

PS: I think I ultimately want to practice private practice general neurology in a suburban setting, and maybe subspecialize in movement disorders or neurophysiology.

"Chronic" patients is what pays the bills, bro. Do you know how hard it is to keep bringing in new patients to a practice? And the amount of effort it goes into new patient encounters?

 

[neurologist]

He doesn't have to wait to staff them with an attending.

Perhaps they all speak English too. High proportion of my patients need interpreters, which nearly doubles the time needed for a visit.

 

[neurolddoc]

Wow. You live somewhere where "a plethora" of "pain docs" actually manage meds? Lucky you. Here there's like 2 small groups that are just procedure mills and won't write rx's for anything . . .

I don't often rx narcs either, but that doesn't stop primary MDs from sending the patients apparently hoping that I will . . .

I have some pain docs that I work with and there is an understanding that if I am going to send them the patients that need the blocks/steroids, then they have to also manage meds on those as well as other patients.

 

[mnf1985]

Hi guys,

I'm an MS3 currently buried in the process of what I wanna do with my career. First of all, I want to let you know I've already read a lot of the threads about the pros and cons of neurology, and I appreciate everyone's input into them.

At this point, I guess my decision has come down to IM vs neuro, leaning towards neuro. I have a general grasp of the advantages and disadvantages of both fields.

There's a lot I like about neuro, and I forsee myself working mostly in the clinic (do not like the hospital--at least as a med student). My biggest concern is the exact number of "untreatable" somatic pain/chronic pain patients. I am really concerned about the amount of dissatisfaction that's been shared on this forum about these pain patients.

So my question is: just how often are these patients encountered in primary practice, say in the suburbs. 1 out of 5, 1 out of 10, 1 out of 20? I guess I could handle seeing 1 or 2 of these types of patients a day, but if half of my patients had those complains, maybe Neurology is not the field for me. I've already read the advice that it's best to spend time in the practice setting you foresee yourself in before you sign up for it, and I am already trying to get that set up. In the meantime, I would appreciate your input on this.

Thanks so much!
your MS3 friend

PS: I think I ultimately want to practice private practice general neurology in a suburban setting, and maybe subspecialize in movement disorders or neurophysiology.

Hey guys - just to expand on some of these concerns, I had a question about the neurology residency itself as a deterrent to entering the field. Did any of you find it difficult essentially serving as a junior resident two years in a row (i.e. as an intern during PG-1, and as a junior neurology resident during PG-2)?? Also, I ask the following question because I have heard SO many opposing opinions: Do you think that the neurology residency tends to be more or less benign than a residency in internal medicine (e.g. in terms of case load, hours, etc.)?

 

[typhoonegator]

Hey guys - just to expand on some of these concerns, I had a question about the neurology residency itself as a deterrent to entering the field. Did any of you find it difficult essentially serving as a junior resident two years in a row (i.e. as an intern during PG-1, and as a junior neurology resident during PG-2)?? Also, I ask the following question because I have heard SO many opposing opinions: Do you think that the neurology residency tends to be more or less benign than a residency in internal medicine (e.g. in terms of case load, hours, etc.)?

The double internship does suck, but can be mitigated by either doing a cush internship or a cush residency, if you're into that sort of thing. I found that the second time around was way better (even though it was just as hard for me) because it was in the field I actually was going to spend my career practicing.

For your second question, it totally depends. IM residency at Hopkins can be rough, while neuro residency at places like UCSF or MGH can be tough as well. I would say that at the busiest programs, neuro residency and medicine residency can be equally rough. Neuro often has no cap, while IM has such an army of residents that their services cap and they're done admitting. IM also doesn't really know the glory of the ED consult, although their inpatient consult service can be really rough.

You can find easy residencies in every specialty, comparatively. But after a certain point, easy is a problem and a symptom of a larger disease. Finding that point is difficult.

 

[Mattchiavelli]

I make it clear to patients that come in that my role is to diagnose the underlying process that is causing the pain. I treat the correctable underlying mechanism of the pain and prescribe medications or therapy that treats the cause or ameliorate the symptoms. I do NOT prescribe chronic narcotics and rarely acute narcotics. That alone seems to have a weeding out effect for a lot of patients, selecting for "real" patients. People that need that are sent to one of the plethora of anesthesia pain docs in my area for monitoring of their narcotics. Doing the narcotics contract, urine monitoring thing is not how I want to spend my time.

That is why I have liked my VA clinic patients- that pain contract is a pretty awesome tool in the arsenal of "hey, I'm just following the rules and how about you do too" that the VA has

 

[bustbones26]

Hey guys - just to expand on some of these concerns, I had a question about the neurology residency itself as a deterrent to entering the field. Did any of you find it difficult essentially serving as a junior resident two years in a row (i.e. as an intern during PG-1, and as a junior neurology resident during PG-2)?? Also, I ask the following question because I have heard SO many opposing opinions: Do you think that the neurology residency tends to be more or less benign than a residency in internal medicine (e.g. in terms of case load, hours, etc.)?

Many specialties have to do that "double internship" so neurology is not alone. I for one feel as if neurology was very similar to internal medicine as for as work hours, case load, etc. because as odd as if seems.

In the residency setting you essentially run a neurology ward, so a lot of basic medicine on your neurology patients. In the private world, I am a consultant only. Its great, and you will get their someday. The junior years, taking a beating on hours, etc is just a rite of passage for residency in general. In my opinion, the ER tends to have a lower threshold for pushing for admitting nonsensical crap whenever there is somebody carrying a neurology admit pager 24/7, which in turn creates for nonsenical workload for residents/interns.

How grueling your residency varies from institution to institution. While on the interview trail, just ask residents if they are happy. If they are hesitant, you can always gauge by a few observations. I for one felt as if the workload gradually decreased as I gained senority, but I have to say, I felt as if my neurology attendings were more malignant than internal medicine. But hey, that was just my institution.

 

[MrChance2]

I would have only had a 60% chance of being happy with my specialty (as the latest medscape surveys show for neurology), I would have seriously re-thought going into medicine.
.

After getting to know more and more med students and doctors my guess is this has more to do with the person than the specialty. I think some people in my class wouldn't be happy unless they could just lay hands on someone and cure their cancer with the whole room stopping to worship their intelligence and years of dedication while bathing them in gold coins. For some reason I think people that go into medicine can sometimes have unrealistic expectations for themselves.

 

[pietachok]

If 4 years ago you'd have told me that after $200,000 of debt, 4 years of med school and 3-7 years of residency and fellowship, I would have only had a 60% chance of being happy with my specialty (as the latest medscape surveys show for neurology), I would have seriously re-thought going into medicine.

I'm merely an MS IV, so I don't have a great contribution to your question. However, I'll throw in $.02: I don't simply care what percentage are happy. I care what percentage liked neurology as a field, felt they made an informed decision to pursue neuro, went to a residency they felt prepared them well for the type of practice they are doing, and then still were(n't) happy. Neuro is not a highly competitive field, so there are people who have gone into the field because it is the one they most liked among the few they fields they could successfully match into -- indeed, I have met FMGs along the interview trail who had applied to 3 or 4 fields, who had barely any neuro experience, and/or who were practicing surgical subspecialists in their home country. What is the pre-test probability such an individual will be happy in neuro? Probably not very high. You have to ask how much that might impact the 60% before you get too down on that number . . . and then I suppose you have to ask how much their unhappiness was set up by where they trained, their prior decision to leave another field (i.e. are they just negative), whether they had realistic expectations.

 

[neurologist]

I'm merely an MS IV, so I don't have a great contribution to your question. However, I'll throw in $.02: I don't simply care what percentage are happy. I care what percentage liked neurology as a field, felt they made an informed decision to pursue neuro, went to a residency they felt prepared them well for the type of practice they are doing, and then still were(n't) happy. Neuro is not a highly competitive field, so there are people who have gone into the field because it is the one they most liked among the few they fields they could successfully match into -- indeed, I have met FMGs along the interview trail who had applied to 3 or 4 fields, who had barely any neuro experience, and/or who were practicing surgical subspecialists in their home country. What is the pre-test probability such an individual will be happy in neuro? Probably not very high. You have to ask how much that might impact the 60% before you get too down on that number . . . and then I suppose you have to ask how much their unhappiness was set up by where they trained, their prior decision to leave another field (i.e. are they just negative), whether they had realistic expectations.

Meh. 50% of everyone hates their job (or 90% of everyone hates 50% of their job), whatever the field. Medicine is no exception.

 

[neurodoc]

The further you subspecialize, the more your clinical neurology will resemble your neuroscience interests...
/rant.

I must resoundingly agree with your comment...I believe it is absolutely true, but I would substitute The more you get into neurology for The further you specialize. Neuroscience and functional neuroanatomy provide the basis for clinical clinical neurology. I suppose it's possible to practice "general" neurology without much knowledge of modern neuroscience, by just following cookbook rules for diagnosis and treatment.

But to be a really good neurologist, you have to understand the structure and function of the nervous system.

It's true that any physician needs to understand the structure and function of the human body, especially it's specific organs for
'specialists" like cardiologists, nephrologists, etc. And of course they need to understand the "basic science" related to human
physiology.

But neurology has historically placed an emphasis on a unique approach to diagnosis, the so-called neurologic method. This places
a great emphasis on the neurological examination to elicit symptoms and signs of neurologic dysfunction. The goal of the neurologic
method is to neuroanatomically locate the lesion. This basically is a matter of using the symptoms and signs to criss-cross the lesion
to some point in the horizontal-vertical neuroanatomic pathways. This answers the question of where is the lesion. The next question is
what is the lesion? The history of symptoms will help answer this question.

I chose to become a neurologist in part because I love the neurological method of diagnosis. YMMV.

 

[Yoyomama88]

Is it really possible to have a 100% outpatient based practice as a neurologist 9-5, without any call?

 

[neurodoc]

Is it really possible to have a 100% outpatient based practice as a neurologist 9-5, without any call?

Sure. Try the "private practice option"---Hang out your shingle and advertise your practice directly to the public, like many of our chiropractic colleagues (e.g. via ads in the Yellow Pages) as "Outpatient Neurologist, Office hours 9AM to 5PM Monday thru Friday only (I presume you don't want to be bothered on weekends). You might get more business by establishing a relationship with local hospitals and physician (and chiropractic) colleagues for patient referrals. You will want to make it clear to these folks that you are available only 9 to 5 (M-F, except when you decide to go fishing or play golf) and of course they can't expect you to be "on-call." Nothing is stopping you from pursuing this option.

Or you could try the Civil/Governmental Service option, where you are essentially a salaried "public sector" employee (like the helpful folks at the Post Office and the DMV). Such opportunities may become more available to physicians under Obamacare.

 

[typhoonegator]

Seriously. The VA has jobs that approximate a 9-5 M-F schedule.

 

[anbuitachi]

Seriously. The VA has jobs that approximate a 9-5 M-F schedule.

But you also take a big pay cut.. =( at least for the VAs near me

 

[typhoonegator]

Ah, so you want 9-5 M-F with no call and no weekends and no real sense of responsibility or obligation, but you also want people to seek out your care and pay you exorbitant amounts of money for it. Now we're getting somewhere. Sounds like a boutique headache/botox practice on the upper east side. They'll probably hire you right out of residency.

"I want you to know that I care deeply about you and your neurologic condition, and that I will continue to do so for the duration of this 25 minute new patient visit. By the way, we're cash-only and don't accept Medicare. Oh, and if you need to reach me after hours, please just go to the Emergency Room or call your PCP's answering service. I'm really just here to make as much money as I can while contributing as close to nothing as humanly possible."