There were 550+ unfilled positions in EM this year. Considering what private equity has done to EM (proliferation of emergency medicine resident positions via CMGs and the subsequent collapse of their job market, CMGs buying out small democratic groups, etc..), should we be wary that something similar will happen in Neurology? There has been an expansion of residency positions in Neuro in recent years, and I can't find data on where this increase in spots is coming from (I assume new residency programs as opposed to increasing spots at established programs). The bar to starting a residency program isn't particularly high, and imagine it wouldn't be for neuro. Now I am aware of the long wait times to see neurologists, the current market, the projected deficit in relation to an aging population, but these are all parallel arguments to what private equity has used in establishing residency programs in EM given there was an EM projected deficit in the mid-2010s. I'm genuinely curious if we should be concerned about future employment opportunities within 5-10 years.
Future of neuro employment in relation to PE
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EM job market is very, very different from neurology’s. Main issues that are unique to EM:
1) massive overproduction of residency grads (nearly doubled over the past decade)
2) a significant amount of work is being done by non-EM trained individuals. Whether it’s midlevels or FM trained doctors.
3) very limited options of work environment: ED or UC.
4) few fellowships that offer a way out: CC, pain, tox, etc
Neurology on the other hand has been severely in shortage for decades. Also as more discoveries are made, this increases demands for neurologists. A good example is the advancement in vascular neurology and how to manage acute stroke. Very dramatic changes over the past two decades led to huge demand in this area of neurology. Similar things can be said about MS, movement and epilepsy.
Yes, neurology residency positions have been increasing faster than the rate of overall increase in residency positions. But still not as dramatic of an increase as it was for EM.
Another thing, neurology is like IM, it’s vast and has many subspecialties. Also, unlike many specialties, there’s a near equal need for both inpatient and outpatient neurology, creating even more job opportunities.
In regards to midlevel invasion, this unfortunately is a problem also in neurology. Not to the same extent as it is in anesthesia or EM, but it is still prevalent.
Regarding private equity, I don’t see this happening in neurology anytime soon. Neurology is not a cash cow specialty like Derm and ophtho. It’s not a sustainable business model for PE to take place in neurology. Now one can argue that telestroke is a form of PE. I would counter that it is not. Telestroke/teleneuro is only a remedy for the workforce shortage and when push comes to shove, hospitals would much rather have a boots-on-ground neurologist than tele. Remember, big part of neurology is carrying out the tough conversations that no one wants and no one is better equipped to handle. Talking to family about goals of care or talking about a “hardware vs software issue” with a psychogenic patient. These are a significant part of my day to day work as an inpatient neurologist and I don’t see that being replaced by tele.
I’m interested to see what other neurologists here think.
1) massive overproduction of residency grads (nearly doubled over the past decade)
2) a significant amount of work is being done by non-EM trained individuals. Whether it’s midlevels or FM trained doctors.
3) very limited options of work environment: ED or UC.
4) few fellowships that offer a way out: CC, pain, tox, etc
Neurology on the other hand has been severely in shortage for decades. Also as more discoveries are made, this increases demands for neurologists. A good example is the advancement in vascular neurology and how to manage acute stroke. Very dramatic changes over the past two decades led to huge demand in this area of neurology. Similar things can be said about MS, movement and epilepsy.
Yes, neurology residency positions have been increasing faster than the rate of overall increase in residency positions. But still not as dramatic of an increase as it was for EM.
Another thing, neurology is like IM, it’s vast and has many subspecialties. Also, unlike many specialties, there’s a near equal need for both inpatient and outpatient neurology, creating even more job opportunities.
In regards to midlevel invasion, this unfortunately is a problem also in neurology. Not to the same extent as it is in anesthesia or EM, but it is still prevalent.
Regarding private equity, I don’t see this happening in neurology anytime soon. Neurology is not a cash cow specialty like Derm and ophtho. It’s not a sustainable business model for PE to take place in neurology. Now one can argue that telestroke is a form of PE. I would counter that it is not. Telestroke/teleneuro is only a remedy for the workforce shortage and when push comes to shove, hospitals would much rather have a boots-on-ground neurologist than tele. Remember, big part of neurology is carrying out the tough conversations that no one wants and no one is better equipped to handle. Talking to family about goals of care or talking about a “hardware vs software issue” with a psychogenic patient. These are a significant part of my day to day work as an inpatient neurologist and I don’t see that being replaced by tele.
I’m interested to see what other neurologists here think.
We are less vulnerable but not invulnerable. Nobody wants an NP making an ALS diagnosis, independently authorizing tPA, and there will always be skepticism/second opinions sought for an NP diagnosis of many of the collections of random symptoms we see on a daily basis, especially with anxious patients/families or with serious diagnoses like movement disorders and epilepsy. For outpatient demand is somewhat elastic- you can generate your own demand to a certain extent. Most outpatient neurology clinics are backed up 3-6 months in referrals, and these are for the people that really want or need to be seen rather than people who have that weird tremor or nagging headache but it isn't worth the trouble to wait months for an appointment to be seen. Its a different situation than EM.
Think about how many patients everyone here has seen that went to >5 different neurologists for an opinion. NPs will never be trusted to that extent, and unlike anesthesiology where patients have basically zero choice or warning in the matter they have a lot of choice in the outpatient world. Midlevels will reduce pay and the overall number/demand for neurologists however. Just not to the extent in the ED.
Think about how many patients everyone here has seen that went to >5 different neurologists for an opinion. NPs will never be trusted to that extent, and unlike anesthesiology where patients have basically zero choice or warning in the matter they have a lot of choice in the outpatient world. Midlevels will reduce pay and the overall number/demand for neurologists however. Just not to the extent in the ED.
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Your subspecialty is prone to this exposure unfortunately
As cerebral as NM is and with how much knowledge and understanding is required to do it well, the amount of bull**** peddled in it's confines is higher than any other neuro subspecialties. Over half of the routine outpatient IVIG given is for garbage diagnoses, garbage indications, and for entirely placebo benefits to the patients. Chiropractic manipulation is a significant discount in cost with probably an equivalent risk of MACE. And it is very hard to say no to these patients wanting it.
As always, I appreicate how thoughtful you are in your responses.
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In my location we have a crazy doc (happens to be academic - honestly what difference does it make) who treats conversion disorder by diagnosing either mitochondrial disease or ALS (nope, not kidding) and then treats them with - wait for it - IVIG. I've had many people come into our hospital with "mito flairs" and split midlines and all the flagrant FND stuff. After they talk with me, they leave.
