Is a Neuromuscular fellowship worth it financially and how competitive is U of M Neuromuscular?

[Dr. Bob Saget]

My wife and I are talking about career options after residency (I am a DO neurology resident) and we have a bit of a disagreement.

I am considering neuromuscular but the only program in Michigan is U of M. As a DO, I don't know if I will be competitive enough for them.

When I told her we may have to go out of state for a fellowship she asked me if it is worth it (given the cuts to EMG/ NCS) to move the family to a different state to lose out on a year of attending pay for no significant change to income (I plan to practice outpatient community/ private practice neurology).

I don't want to leave my home state if I can help it, but I enjoy neuromuscular medicine. I guess I am looking for some justification to take the neuromuscular path despite the added expense of packing everything up and moving the family to God knows where.

I looked at the clinical neurophysiology (EMG focus) programs at Wayne and Henry Ford as a compromise (we, God willing, stay in Michigan but I get to do some neuromuscular). Any thoughts on those programs?

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[Thama]

Just because income won't likely be significantly different doesn't mean it's not worth doing. If you like NM, then doing a fellowship and then landing a job that will let you build a NM clinic might keep you from burning out seeing migraine and neuropathy every day for the rest of your life. Annual income isn't the only factor affecting lifetime earnings - longevity does this too.

That said, neuromuscular fellowships aren't generally all that competitive. Lots of spots go unfilled all the time. Even if you don't land a spot at Michigan, there are a lot of programs between Chicago and Cleveland that wouldn't be much of a move. You're at a point where your family needs to accept that you're probably going to be moving for work once or twice as you find the right career fit before you can settle down more permanently.

 

[Dr. Bob Saget]

Just because income won't likely be significantly different doesn't mean it's not worth doing. If you like NM, then doing a fellowship and then landing a job that will let you build a NM clinic might keep you from burning out seeing migraine and neuropathy every day for the rest of your life. Annual income isn't the only factor affecting lifetime earnings - longevity does this too.

That said, neuromuscular fellowships aren't generally all that competitive. Lots of spots go unfilled all the time. Even if you don't land a spot at Michigan, there are a lot of programs between Chicago and Cleveland that wouldn't be much of a move. You're at a point where your family needs to accept that you're probably going to be moving for work once or twice as you find the right career fit before you can settle down more permanently.

Thank you. That was my line of reasoning as well. I would be much happier in neuromuscular and it would lead to me doing better than I could in general neuro. I also enjoy procedures and I feel like I would get a lot of that in neuromuscular than I would general neuro.

We have little ones and moving out of state would be a challenge (I didn't anticipate a desire to do a fellowship until I got to residency), would you know how different my career would be with a neurophysiology (EMG tract) fellowship instead? ↓↓

Clinical Neurophysiology (EMG) Fellowship Portal

www.aanem.org

 

[Sage of Pale Bones]

Just because income won't likely be significantly different doesn't mean it's not worth doing.

Wouldn't an EMG-CNP or NM-trained outpatient doctor (or even EEG-CNP/ Epilepsy or Movement) outearn a general neurologist for the same hours worked because they have more procedures and have to refer patients out less?

 

[Thama]

We have little ones and moving out of state would be a challenge (I didn't anticipate a desire to do a fellowship until I got to residency), would you know how different my career would be with a neurophysiology (EMG tract) fellowship instead? ↓↓

Clinical Neurophysiology (EMG) Fellowship Portal

www.aanem.org

I think this really depends on the kind of practice you end up in long term. In a small practice with only a few partners, probably not much as either way you'll probably be essentially a general neurologist who can do EMGs for the group. Maybe a few extra NM cases make their way to you if you advertise yourself as a NM specialist. In a larger group practice that's recruiting a NM subspecialist, you'll probably have more leeway to reserve segments of your time for NM work as some of your partners will probably want to send things that they don't feel comfortable with to you - e.g. motor neuron disease, difficult to manage myasthenia, etc. You can also siphon off referrals that would have gone to nearby academic centers as wait times there are often long and NM-trained neurologists tend to gravitate to academic practice.

 

[Thama]

Wouldn't an EMG-CNP or NM-trained outpatient doctor (or even EEG-CNP/ Epilepsy or Movement) outearn a general neurologist for the same hours worked because they have more procedures and have to refer patients out less?

IIRC since the EMG cuts, there's not much difference in earnings between someone who does EMGs and someone who doesn't as the RVU density between EMG and new/return visits isn't all that much anymore.

 

[Sage of Pale Bones]

IIRC since the EMG cuts, there's not much difference in earnings between someone who does EMGs and someone who doesn't as the RVU density between EMG and new/return visits isn't all that much anymore.

Okay, so I am a bit ignorant on this so please correct me if I am wrong. Don't the cuts apply to medicare only? So if work for a private practice that doesn't take medicare or has less medicare than private insurance wouldn't reimbursement be closer to what it was before the big cuts?

Also, if you are salaried rather than on production (so say an outpatient NM doc employed by a hospital) could you leverage your extra fellowship skills for a better contract?

Thanks in advance, I'm still trying to pan out how all these things work.

 

[Spinothalamic]

Don’t forget about a very nice perk of procedures like EMGs—they don’t generate patient calls, EMR messages, or follow-up labs or imaging on subsequent days.

If you are interested in doing EMGs I would seriously consider doing a fellowship or I am concerned you would regret missing out on that opportunity. In my opinion the availability of EMGers in the community is going to drop given that unfortunately almost no neurologists do EMGs without a fellowship anymore (which is good if they don’t get adequate experience in residency!). Also, half the time the EMGs done by other specialties either aren’t properly designed studies or are abnormal and then the patients get punted to neurology for consults. I think it could add a ton to your practice if you are interested.

 

[Thama]

Okay, so I am a bit ignorant on this so please correct me if I am wrong. Don't the cuts apply to medicare only? So if work for a private practice that doesn't take medicare or has less medicare than private insurance wouldn't reimbursement be closer to what it was before the big cuts?

Almost all insurances base their payments off of Medicare to some degree. Most commonly they use a multiplier, which can vary by specialty, health system, etc. But a cut to something in Medicare generally reverberates through all payors.

Also, if you are salaried rather than on production (so say an outpatient NM doc employed by a hospital) could you leverage your extra fellowship skills for a better contract?

I think you'll find that pretty much everything in neurology is in a lot of demand, so unless you do something that really bills far better than the norm, your negotiating power will be similarly strong regardless of fellowship. Do fellowship because you want to do the thing that fellowship trains you to do, not because you anticipate a predictable increase in salary due to that fellowship. Reimbursements change year to year, and what looks like easy money one decade can get cut hard the next. The most bitter doctors I've ever met are anesthesiologists who only went into that field because it was so absurdly lucrative in the 90s, and once the market and CMS caught up, they ended up crying pitifully into their suddenly reduced (but still really large) stacks of cash.

 

[Sage of Pale Bones]

Almost all insurances base their payments off of Medicare to some degree. Most commonly they use a multiplier, which can vary by specialty, health system, etc. But a cut to something in Medicare generally reverberates through all payors.



I think you'll find that pretty much everything in neurology is in a lot of demand, so unless you do something that really bills far better than the norm, your negotiating power will be similarly strong regardless of fellowship. Do fellowship because you want to do the thing that fellowship trains you to do, not because you anticipate a predictable increase in salary due to that fellowship. Reimbursements change year to year, and what looks like easy money one decade can get cut hard the next. The most bitter doctors I've ever met are anesthesiologists who only went into that field because it was so absurdly lucrative in the 90s, and once the market and CMS caught up, they ended up crying pitifully into their suddenly reduced (but still really large) stacks of cash.

Thank you for this. I find it funny that I have been in school for quite a while now and have yet to have a single lecture on how physician finance works.

I appreciate all the insight.

 

[JBM16BYU]

Just because income won't likely be significantly different doesn't mean it's not worth doing. If you like NM, then doing a fellowship and then landing a job that will let you build a NM clinic might keep you from burning out seeing migraine and neuropathy every day for the rest of your life. Annual income isn't the only factor affecting lifetime earnings - longevity does this too.

Don’t forget about a very nice perk of procedures like EMGs—they don’t generate patient calls, EMR messages, or follow-up labs or imaging on subsequent days.

Both of these are great statements that I agree with. If you enjoy EMG and like the NM population, then go for it! No matter what branch of neurology you end up choosing, you're going to spend time at work and then spend time at home. You want to be generally happy at work so you don't bring negativity from a less-than-ideal workday home to your family. Plus, I'm biased, I think EMG's are a super fun procedure and puzzle.

 

[Dr. Bob Saget]

In a larger group practice that's recruiting a NM subspecialist, you'll probably have more leeway to reserve segments of your time for NM work

That is the tricky part. NM seems better for what I want to do but if the difference between neurophys-EMG and NM is only noticeable in large group practices or academia, does it warrant relocation?

Would you know if hospital-based groups/ outpatient clinics have any preference?

 

[Thama]

That is the tricky part. NM seems better for what I want to do but if the difference between neurophys-EMG and NM is only noticeable in large group practices or academia, does it warrant relocation?

Would you know if hospital-based groups/ outpatient clinics have any preference?

As far as just landing a job, I don't think that most non-academic practices will care as long as you are competent to perform EMGs.

As far as the kind of practice you want to build, it's kind of up to you what makes most sense.

 

[Dr. Bob Saget]

Thank you everyone for your feedback. With the combined AANEM match, I have decided to apply to neuromuscular programs in/ near Michigan and a few of the EMG neurophysiology programs as a backup options.

Still got to persuade my wife, but I am certain she will come around.

I also wanted to quote @Neurogeneral and add their advice here for anyone else who had the same question and is reading this post in the near future:

My CNP fellowship was 6 months of eeg and emg. So there was obviously less time spent on NM than the typical one year CNP dedicated EMG or NM fellowships.

If you want to treat neuromuscular cases, the best way to get there would be to do a bonafide neuromuscular fellowship. Of course, doing a dedicated EMG CNP fellowship is a viable second option to accomplish that goal. Just make sure, you do enough NM clinic as opposed to just spending the entirety of your time doing EMGs (which they do typically accommodate/provide accordingly).

Now, if you want to practice in a big well known academic center, they will likely want you to be neuromuscular boarded, which is obviously easier to achieve by doing a neuromuscular fellowship from what I have heard. Outside of that type of practice setting, however, it won’t matter if you do a NM or CNP fellowship as long as you have obtained that level of knowledge/expertise.

Doing a fellowship is definitely worth it if there is a subspecialty and/or procedures that interest you. The more you enjoy your job, the more likely you are going to want to work hard (i.e see more patients in clinic and do more EMGs) which means more RVUs and likely more compensation. If you graduate from a neurology residency but don’t really care for doing general neurology clinic or neurohospitalist work on a daily basis, then dissatisfaction and burnout is inevitable.

Doing a fellowship which provides training in procedures like emg and/or eeg also gives you a big edge in finding jobs compared to other applicants.

Edit: Additional advice from @sharkbaitwhohaha

I went through a similar situation with my wife. She was mostly against a fellowship due to loss of income and prolonging an attending salary and the struggles of not known where we would end up.

However, my points included
1. generally, every one does SOME type of fellowship. From a strictly competitive standpoint, i would've been "behind" others in terms of academic rigor, clinical expertise and in the most important sense, behind from a procedural competency standpoint.
2. fellowship could potentially limit midlevel encroachment when the eventual "Nurse Neurologist"
3. Would potentially allow me in the future to go for an academic position
4. subspecializing can help protect from burnout (see less functional issues/PNES and more selective in patient panel). So I think ultimately it IS a good ROI. Since it could provide you with more joy and a longer career.

Ultimately, she was convinced that it was a good idea (but thankfully i had essentially a guarenteed NM spot at my home program. So from that sense, i cant relate to the potential for moving. Moving would have been a major counterpoint)

I really wanted the name of NM vs CNP. But my program was very heavy on the epilepsy part and light on the NM part (even if 50:50 in writing). But if you could get program near home that is skewed in toward EMG (70/30 or so) then that would almost essentially be the same as a NM fellowship.

So if you're thinking private practice, CNP is essentially the same. You'd both get the best of both worlds, not moving, fellowship training, getting proficient in emg/eegs.

I would highly recommend either CNP or NM, but I wouldn't move for 1 year JUST for NM over CNP.