Job Market for Neurophysiology and Fellowship help!!!!

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neuronet123

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I'm a PGYII Neurology resident trying to make up my mind for fellowship and I am strongly considering doing a Neurophysiology fellowship preferably with 6mo of EEG and 6 mo of EMG or something similar. I feel like this set up would make me best suited to be a general neurologist in a community setting preferably in the suburbs or city with the ability to refer to larger academic centers for more complicated cases.

Im not going to lie though, I do care about financials and lifestyle. I want to make a good amount of money but I also dont want to kill myself doing it and constantly take calls.

What is the job outlook for someone who is trained in Neurophys in regards to average salary for a big group vs smaller private, bigger metro area vs smaller vs suburban? Its really hard to tell. A lot of the average salary data just clump neurologists into one pile and when I talk to seniors or graduating fellows they keep bragging about how much opportunity and money there is which doesnt really correlate with the average salary figures.

My priorities:
1. Good lifestyle
2. Good Pay
3. Not get bored/feel fulfilled
4. Not very stressful in regards to medical complications
5. Im very interested in procedures such as TPI, Botox, EMG, Occipital blocks. I know pain is procedural but I dont think I want to only deal with pain and deal with that sort of population exclusively. I think I will find that boring.

Thanks for the help!!!!!!!!!

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Neurophysiology has an excellent job market. Essentially, you could bill for EEG and EMG right out of neurology residency, but that doesn't mean that anyone will hire you to (especially EMG/NCS, Periph nerv ultrasound, biopsy, botox) do so. This skill set is probably one of the most "bang for your buck" fellowships there is. In just one year you will greatly expand your procedural and diagnostic knowledge skill set. You would certainly be a front runner for private practice and/or neurohospitalist jobs.

I do want to mention something however (keep in mind this is just my experience at my institute). I train at a 1200 bed hospital with an overflowing neurology clinic. Our institute uses the 6mo/6mo split docs as neuro hospitalists. They can interpret EEGs for their own outpatients and that's about it. Long term EEGs/Ambulatory/EMU studies go to the epilepsy trained docs or docs who did the neurophysiology EEG track fellow ships. Likewise, our EMG/NCS go to our neuromuscular trained physician and Neurophysiology with EMG track docs as they completed well over 500 studies in fellowship, perform biopsies, single fiber studies, peripheral nerve ultrasound, botox, and even autonomic studies. These are the docs that our hospital buys $50,000 EMG/NCS machines for when they are hired.

I'm not saying that a 6mo/6mo split is bad, especially for your own private practice or a smaller hospital but the way we are becoming so subspecialized I would pick a track. My residency was very heavy on stroke, IR, neuro critical care and epilepsy so my fundamental EEG reading is solid (meaning when I am covering my inpatient week I can tell if a patient is in status, if there is encephalopathy and/or if there is a focal abnormality). I am not ready to go beyond very basic EMG/NCS studies and thus, chose an EMG track. Despite reimbursement cuts EMG/NCS still beats EEG and is more practical (You don't have to have the tech hook everyone up, ambulatory leads come off on the weekend, etc) as the machine is in your office and you can perform them whenever you'd like to. These are just some considerations and, again, a 6mo/6mo split would work out just fine as well.

In terms of compensation, our EMU readers and EMGers can add a substantial amount of money to their income. I think more importantly though, it means you can make a nice salary, work less and have a nice work life balance. Overall this is a great field, it takes only one year (11mo if your count vacay) and is in high demand. Best of luck!
 
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Could someone comment on the feasibility of doing 1 year EEG + 1 year EMG? Would one have to take too many board certifications to keep this up?
 
Could someone comment on the feasibility of doing 1 year EEG + 1 year EMG? Would one have to take too many board certifications to keep this up?

The typical way to do this is to do a neurophysiology fellowship with an additional year to become board eligible for epilepsy or neuromuscular. You would have both skill sets from your neurophysiology training with additional training in your preferred field. doing a separate epilepsy and neuromuscular fellowship is also possible but this would likely take three years as many epilepsy fellowships are two years. I also think that people that look towards pure neuromuscular/epilepsy fellowships rather than neurophysiology are more geared towards academia versus the neurophysiology group so you would likely not be able to realistically be practicing both at a truly in depth level (The director of the EMU is not usually doing EMGs on the side).

Also realize that there is a technique and a field. EMG is a technique and neuromuscular medicine is a field. The technique of performing/interpreting EMG/NCS can be acquired from either a neuromuscular fellowship or neurophysiology fellowship (same with reading EEGs vs becoming an epileptologist which includes intraoperative monitoring, deep electrode mapping, etc). Neuromuscular medicine also includes biopsy, interpretation of pathology, learning lots of cool zebra diagnosis but will not reserve time for you to learn EEGs. The boards are tricky. here it goes

If you are neurophysiology trained and complete, I think, 200 or more EMG/NCS then you will take the neurophysiology boards and the ABEM (American board of electrodiagnostic medicine) boards. ABEM is an EMG board not a neuromuscular medicine board (tests on the technique and not the field).

If you are neurophysiology trained and do an EEG track you will take the neurophysiology boards and will not likely qualify for the ABEM unless, in your "minor" time you can crank out 200 or more studies.

If you are neuromuscular trained you will not be able to take the neurophysiology boards but will instead take the ABEM boards (technique) and the AANEM (Neuromuscular field) boards.

If you are epilepsy trained you may qualify for the neurophysiology boards (many programs have you do a year of neurophys followed by a 2nd year of pure epilepsy) or may not and will go on to sit for the epilepsy boards.

If you did epilepsy and neuromuscular you would likely spend three years doing so and would likely sit for the AANEM, Epilepsy, ABEM and depending on the program neurophysiology boards.

All of this on top of the regular ABPN (Neurology boards) examination. My advice is pick one or the other in terms of pure neuromuscular or epilepsy or, if you like both, do a neurophysiology year (you can pick a "major" EMG of EEG or do a general neurophysiology year where you do 6mo of each).

btw..you don't actually need these boards. They look good on an application and to referring providers but many neuromuscular docs, for example, take the ABEM boards in addition to their neurophysiology boards and stop there. The AANEM is a feather in the cap. None are necessary to perform EMG/NCS beyond a good old ABPN certification. Same goes for EEG. As an aside, you do need a fellowship in sleep to bill for sleep studies on your own.

Hope that helped.
 
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The typical way to do this is to do a neurophysiology fellowship with an additional year to become board eligible for epilepsy or neuromuscular. You would have both skill sets from your neurophysiology training with additional training in your preferred field. doing a separate epilepsy and neuromuscular fellowship is also possible but this would likely take three years as many epilepsy fellowships are two years. I also think that people that look towards pure neuromuscular/epilepsy fellowships rather than neurophysiology are more geared towards academia versus the neurophysiology group so you would likely not be able to realistically be practicing both at a truly in depth level (The director of the EMU is not usually doing EMGs on the side).

Also realize that there is a technique and a field. EMG is a technique and neuromuscular medicine is a field. The technique of performing/interpreting EMG/NCS can be acquired from either a neuromuscular fellowship or neurophysiology fellowship (same with reading EEGs vs becoming an epileptologist which includes intraoperative monitoring, deep electrode mapping, etc). Neuromuscular medicine also includes biopsy, interpretation of pathology, learning lots of cool zebra diagnosis but will not reserve time for you to learn EEGs. The boards are tricky. here it goes

If you are neurophysiology trained and complete, I think, 200 or more EMG/NCS then you will take the neurophysiology boards and the ABEM (American board of electrodiagnostic medicine) boards. ABEM is an EMG board not a neuromuscular medicine board (tests on the technique and not the field).

If you are neurophysiology trained and do an EEG track you will take the neurophysiology boards and will not likely qualify for the ABEM unless, in your "minor" time you can crank out 200 or more studies.

If you are neuromuscular trained you will not be able to take the neurophysiology boards but will instead take the ABEM boards (technique) and the AANEM (Neuromuscular field) boards.

If you are epilepsy trained you may qualify for the neurophysiology boards (many programs have you do a year of neurophys followed by a 2nd year of pure epilepsy) or may not and will go on to sit for the epilepsy boards.

If you did epilepsy and neuromuscular you would likely spend three years doing so and would likely sit for the AANEM, Epilepsy, ABEM and depending on the program neurophysiology boards.

All of this on top of the regular ABPN (Neurology boards) examination. My advice is pick one or the other in terms of pure neuromuscular or epilepsy or, if you like both, do a neurophysiology year (you can pick a "major" EMG of EEG or do a general neurophysiology year where you do 6mo of each).

btw..you don't actually need these boards. They look good on an application and to referring providers but many neuromuscular docs, for example, take the ABEM boards in addition to their neurophysiology boards and stop there. The AANEM is a feather in the cap. None are necessary to perform EMG/NCS beyond a good old ABPN certification. Same goes for EEG. As an aside, you do need a fellowship in sleep to bill for sleep studies on your own.

Hope that helped.


Wow, thank you so much!
 
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Botox, trigger points, occipital nerve blocks, EMG. You could even set up IV therapy such as IV vitamins (eg. http://dripdoctors.com/ ). If you're bold enough, IV Lidocaine while having patients hooked up to tele. IV DHE. You could do all that, have your dedicated procedure days, see consults in the afternoon in the local hospital, read routine EEGs, and refer the more complicated cases to tertiary care centers. I think that sort of set up can lead to a very robust and fulfilling practice. Mind you, I'm still a resident so I have no idea if doing all the above is even feasible from a cost point of view but I think clinical neurophysiology can set you up for a very good lifestyle and robust and rewarding practice. Sometime I think I should have done it myself.
 
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Please note that you don't need a fellowship to bill your own EEGs. Just get comfortable with them, either do extra electives or spend some time in the lab when you have some time. I read my own EEGs and so do the other 7 neurologist in my group. We have one who is fellowship trained but works part-time. Everyone in my group are easily breaking $400k working 8-5 monday to thursday and half day friday. they do tons of procedures. I am a neurohospitalsits but again, i read about 90% of my own studies. EMG is another story.
 
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OP, you could do Botox for headache and occipital blocks from just elective time in residency- they are easy because the anatomy is not difficult and they're pretty similar procedure to procedure. I haven't done TPI before since no one in my department when I trained did them. Part of the reason I did fellowship for neurophysiology is to develop some skills I wasn't able to in residency. Some old co-residents took jobs without fellowship and while they were doing EEG electives during residency I was doing Headache and Botox clinics/procedure days.

I'm in neurophysiology fellowship right now (EEG side). I probably won't do a lot of EMGs when I'm finished mostly because I think seeing general neurology hospital consults/doing clinic is more fun and interesting than doing EMGs and thinking about spinal levels and neuromuscular medicine. Doing the extra training will give me flexibility in how I use my work time to build up my RVU's- I like variety in my work and think doing just regular clinic for 4.5 days a week with no procedures would be very boring.
 
Please note that you don't need a fellowship to bill your own EEGs. Just get comfortable with them, either do extra electives or spend some time in the lab when you have some time. I read my own EEGs and so do the other 7 neurologist in my group. We have one who is fellowship trained but works part-time. Everyone in my group are easily breaking $400k working 8-5 monday to thursday and half day friday. they do tons of procedures. I am a neurohospitalsits but again, i read about 90% of my own studies. EMG is another story.

Not every neurophysiology fellowship is the same, not every program is the same.

My general neurology residency required three months of EEG/EMG and we were very hands on! I would say that all graduating residents were competent to perform a simple EMG on their own. I had elected to do extra time and in my practice I have no problems doing an EMG (and billing for it) if it is a question of say cervical radiculopathy versus carpal tunnel, etc. That being stated, if I start to suspect some strange neuropathy beyond the typical or some off the wall neuromuscular illness, I defer the EMG. Yeah, I could do it, but if I do end up referring the patient to a neuromuscular clinic, I know they would want to repeat it so why put the patient through pain twice?

EEG, same thing. I feel competent reviewing a basic 20 to 40 minute EEG. Would I do epilepsy monitoring? No, would not dream of going down that road without the proper training. I must admit, its very tempting as a number of these companies "clip" prolonged studies, but I think of the liability involved as at the end of the day, I am not a neurophysiologist.

My program was strong on headache, so I essentially swam in botox and did many nerve blocks during residency. I suppose I could claim that botox is simple, but if one is not comfortable, Allergan is always happy to set you up with training if needed. Many reputable insurance companies will not pay for occipital nerve blocks!! You have to be very savvy as to how you submit your superbills. Sometimes, I do a "trigger point injection" of the suboccipitalis muscles. I mean if I am injecting a trigger point of the suboccipitalis and just happen to accidentally block the occipital nerve, oh well? ;) Trigger points are easy to bills for, but do not bring in as much as nerve block CPT codes, but better than nothing I suppose? For what it is worth, I always look for TMJ and jaw pain on my headache patients. Many patients respond to 64400 trigeminal nerve block (I do the auriculotemporal branch) and this reimburses well.

Sphenopalatine nerve blocks can be a little tricky. Now that we have all of these nifty devices out there, the companies are pushing docs to do more and more of these and makes thousands of dollars on reimbursement? Sound to good to be true? It is, so again, you have to be savvy as to how you bill. You MUST document facial pain and use the proper ICD codes else you do not stand a chance of making a penny back! The old way of doing these with a cotton tipped applicator is VERY SIMPLE and costs about $1.80 in overhead costs, but is not very comfortable for the patient. If you are going to use a device that cost anywhere from $55 to $70, you better reimburse properly!
 
My residency had mandatory 3 months EEG and EMG each. I ended up doing almost 6 months of EMG and 4 months of EEG including reading EMU, ambulatories and ICU studies. Studied under several epileptologists and can safely say that I had no issues even reading the "complicated ones". Always made it a point to read EEGs when I could, even while on other rotations {Online access makes it easy to open studies from anywhere}. Graduated and now am doing private practice where I have no trouble doing EMGs or reading EEGs. I miss reading the ICU studies but don't miss the 3am status patient. Point is, if you went to a strong residency and apply yourself beyond stroke, you can get alot done during residency if you are aiming for private practice. Just be sure of your skills and don't do sham reads. I see EMGs done everyday by other neurologists who wont even stimulate above the elbow to check for the second most common mononeuropathies in the outpatient world! While some EMGs can be complex and should be referred, there is no reason that you cant do it for the common problems. I don't do Botox because of insurance issues. I do occipital nerve blocks as they can be very effective in the right patient and are so easy. In PP, you will need to go through a bigger volume of patients to earn a buck. Good luck
 
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