Neurology FAQ

[GopherBrain]

It is time for a Neurology FAQ.

Anyone with any FAQ ideas, or anything they want to say, please PM me! This should be a communal project.

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What is a neurologist?

Neurologists are those physicians whose interests and practice are devoted to the care of persons with disorders of the central and peripheral nervous systems. Neurologists diagnose and treat conditions of the brain (strokes, epilepsy, Alzheimer's disease, Parkinson's disease, multiple sclerosis), spinal cord (tramatic injury, inflammatory disorders), motor neuron (amyotrophic lateral sclerosis), neuromuscular junction (myasthenia gravis), muscle (muscular dystrophy, myositis), and peripheral nerve (Guillain-Barré syndrome, peripheral neuropathies).

During the last half of the 20 th century, neurology grew from being a primarily diagnostic discipline to one in which pharmacological or other interventions are available for almost every neurological condition. Neurologists are now able to stop seizures, prevent or reduce the damage from strokes, ameliorate the abnormal movements of Parkinson's disease, modify the natural history of multiple sclerosis, prolong useful function in Alzheimer's disease, relieve painful neuropathies, and prevent crippling migraines. New and powerful diagnostic techniques range from imaging modalities that actually show the brain as it is functioning to genetic tests that can pinpoint rare diseases.

Neurologists are specialists who usually function as consultants to a patient's primary care physician. A neurologist may be called upon to make an initial diagnosis for neurological disease and then provide ongoing care for chronic or recurrent conditions. However, for patients who do not have significant other medical conditions requiring non- neurological care, the neurologist may be the principal care physician as well.


How do I become a neurologist?

Neurology training takes four years after graduation from medical school. The first year is an Internal Medicine Internship, the next three are training in Neurology. Some neurology residency programs guarantee you all four years, other places just provide PGY2-PGY4, and you are on your own for PGY1. More on this later.

Once residency is over, you can get a job, or complete a fellowship. Neurology, much like IM, is a field where different physicians can practice in radically different ways. This flexibility is one of the great things about the field.

After residency, many neurologists elect to do fellowship training in a subspecialty area. Examples of fellowship opportunities include:

Advanced Clinical Neurology
AIDS
Alzheimer's Disease
Behavioral Neurology
Cerebrovascular Disease/Stroke
Clinical Neurophysiology
Dementia
Epilepsy
Geriatric Neurology
Headache
Interventional Neurology
Movement Disorders
Multiple Sclerosis
Neuroepidemiology
Neurogenetics
Neuroimaging
Neuroimmunology
Neuro- Intensive Care
Neurologic Critical Care
Neuromuscular Disorders
Neuro-Oncology
Neuro-Ophthalmology
Neuro-Otology
Neuropathology
Neuropharmacology
Neurorehabilitation
Neurovirology
Pain
Peripheral Neurology
Sleep Disorders
Spine

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[GopherBrain]

Now that I know I am interested in becoming a neurologist, how do I make myself a strong residency candidate?

Get Involved—Learn more about the field! Join your medical school's chapter of the Student Interest Group in Neurology (SIGN). If your school doesn't have a chapter, start one! See the American Academy of Neurology (AAN) website for more information at www.aan.com .

The Clerkship—You will want to take the required clerkship in mid-to-late third year, or early as possible in fourth year. Don't take it too early, you want some solid clinical experience (i.e. at least Medicine I) beforehand. I won't insult your intelligence by going into too much depth on how to do well in a clerkship. Work hard, do your reading, show enthusiasm - enough said. If your medical school doesn't allow you to take Neurology until year 4, don't worry. A lot of people are in your shoes. Just take it as early as practical, and don't be shy about asking for letters of recommendation as soon as it is over.

Research—You do NOT need to do research to be competitive for neurology. That said, it helps - especially for the more academic programs. If you have any interest in research, block off some elective time in your MS3 year or early in your MS4 year to complete a project. Talk to your advisor for help in finding a basic science or clinical research opportunity. If you have time to do research between first and second years of medical school, consider applying for funding from the AAN. They have a research scholarship for medical students.

USMLE—Good news, Neurology isn't Derm (or even Rads). The average USMLE Step 1 score of students matching into neurology in 2006 was 219. Don't worry if your score is lower than this, board scores are less important in neurology than in many other specialties. You can take the USMLE Step 2 CK and CS at any time, as programs do not require that you submit your score before match day. You may wish to take them early if you are trying to compensate for poor Step 1 score. If you are satisfied with your Step 1 score, there is no good reason to submit Step 2 scores prior to the match.

Away "Audition" Rotations—Highly optional. If you are set on a specific program, it may make sense to go there and really try to impress them. If you are not committed anywhere in specific, you can use this time to do research or take fun electives without the pressure of trying to prove yourself.


I'm not sure whether I will be able to match into neurology, what do you think? My stats are....

Please don't ask this question. Anyone has a chance of getting into neurology. It's not a very competitive specialty. That being said, the top programs in any specialty are hard to get into. In short:

Neurology = Fairly Easy
Top 5 = Quite Hard

The only way you will know whether you can get into a specific program (or neurology in general) is to apply and test your luck.


What are the average stats (USMLE, GPA, AOA%) at Program X?
This information just isn't available. Don't ask the program, they won't tell you. Don't ask us, we don't know. We can't even give you the ranges for "the top ten". Sorry.

 

[GopherBrain]

Can you give me an overview of how the process works?

As you now know, neurology residency consists of one year of medicine, followed by three years of neurology training. Some neurology programs only offer training for the PGY2-PGY4 years. This leaves you on your own to find a PGY1 (intern) spot. Fortunately, many neurology programs actually have either a formal or implied guarantee of an intern spot at the same institution. The number of "combined" programs is increasing each year.

There are three general categories of programs with respect to PGY-1:

1) Guaranteed, and highly encouraged
In these programs (UMinnesota or Mayo for example) a PGY-1 year is assured if you match for PGY2-4. In fact, you ought to have a pretty good reason to do PGY-1 elsewhere. Some places, such as UCSF, have prelim slots guaranteed for the vast majority of residents but let people with compelling reasons do their internships elsewhere.

2) Guaranteed PGY-1 Interview, but NO Guaranteed Spot
These programs will coordinate a guaranteed medicine interview with your neurology interview day, so you only have to come to town once. If you don't match at the neurology program, the medicine program will not rank you. If you do match in neurology, you are highly likely to be ranked in medicine, but you better have a back-up plan just in case.

3) Sorry sucka, you are on your own...
Partners and Hopkins typify this approach (although they are not alone). They don't provide a PGY-1 spot (period). You are welcome to apply for a prelim medicine spot at Hopkins or MGH, but the neuro department doesn't offer much more than encouragement. It is not uncommon for applicants to get interviews with the neurology department and not get interviews at the same institution for their medicine prelim year. Even if you do get an interview, it may be weeks away from your neurology interview, meaning yet another expensive interview trip. In short, you had better send a couple of prelim year applications to non-competitive programs (and your home school), so you don't get left out in the cold.

In the end, you may end up doing your PGY1 year at program X, and PGY2-PGY4 at program Y. There is nothing intrinsically wrong with this, it is just a pain in the neck. As long as you choose a reasonably strong medicine program, you will not be at a disadvantage for the rest of your training.


What Types of PGY1 Years are Acceptable?
From the American Board of Psychiatry and Neurology Website
A full year of ACGME-accredited training in internal medicine, or as an acceptable alternative, a full year in an ACGME-accredited program in which a minimum of six months of training must be in internal medicine, the details of which must be documented by the training director. The composition of these six months may NOT include rotations in neurology, family medicine, or emergency medicine. To ensure that these six months constitute a high quality experience, they should emphasize progressive responsibility for the resident. At least two of the addition six months must be spent in internal medicine, pediatrics, and/or emergency medicine. For candidates entering neurology residency training on or after July 1, 2001, at least two of the additional six months must be spent in internal medicine, pediatrics, family medicine, and/or
emergency medicine. No more than two of the remaining four months may be spent in neurology.

 

[GopherBrain]

Creating your Residency Application
It is never too early to start working on a CV and personal statement. You will want to have them both reasonably complete before you ask for letters of recommendation.

Letters of Recommendation
Most programs request three letters of recommendation (although more are allowable, it is typically not helpful to load down your application with extraneous LORs). So, who should you choose? The most common solution is to submit two letters from neurologists and one from anyone else you think would supply you with a strong recommendation.

In the past, some residency programs required a letter from the chair of the neurology department at the applicant’s medical school. While this is no longer mandatory, many applicants feel that a chair’s letter greatly strengthens their application, so you may wish to ask your chair for a letter. This is more or less thought of as part of a chair's job, so don't feel like you are imposing too greatly. It is also common to request a letter from the attending you had the best relationship with during your neurology clerkship.

No matter who you choose, be prepared. Bring a CV, a transcript, and the latest draft of your personal statement to your meeting with the letter writer (and schedule an appointment, don’t just try to catch them after rounds). You should give your writers at least a month, preferably more, to work on your letter.

The Personal Statement
You didn't get where you are today by not being able to write one of these things.

 

[GopherBrain]

Where should I apply - i.e. "What are the best programs?"
There are approximately 120 neurology training programs in the United States (not counting the combined neuro/psych, neuro/med, neuro/whatever programs). In 2006 the average applicant applied to 24 programs (probably more for IMGs, less for US students). So, how do you decide which programs to send your application to?

Keep in mind that the residency match process is very expensive. There are plenty of smart ways to save money, but applying to too few programs is not one of them. Apply to anywhere you might wish to go. It is easy to turn down interviews. When making your final application list, you want to include all of your “dream” programs while also maximizing your odds of matching. A good way to do this is by sending ~1/3 of your applications to programs that are long-shots, ~1/2 to programs that are in your range, and the last ~1/6 to back-up programs.

Many people are happy to offer you their list of the “best” neurology programs— without asking you about your professional goals first. In fact, the best programs for an aspiring academic neurologist are different from the best programs for a private practice neurologist. Ask your advisor for advice, but don’t stop there. Get as many perspectives as possible. Ask the neurologists and neurology residents you met in your clerkship.

This topic has been discussed extensively in the past, a few links are given below.

http://forums.studentdoctor.net/showthread.php?t=48320
http://forums.studentdoctor.net/showthread.php?t=164050

Just take these with a grain of salt... A lot of people throw out opinions, without full disclosure of their biases. Anybody that claims any one of the top five or so programs is clearly superior to the other four is going to have a very tough time justifying that statement. Same with the next 5, and so on. That being said, anyone that knows anything about neurology agrees that UCSF is #1!

 

[GopherBrain]

Interview Invitations/Planning
Once you have submitted your application, it is time to sit back and wait for the interview invitations to roll in. Some come by mail, some by email, others by telephone. Try not to get too excited the first day that you check your mailbox and find it stuffed with letters from programs, they will likely all be form letters acknowledging receiving your application and telling you to expect a decision in the next month or so.

Once the real invitations begin to arrive, you may find yourself with a happy problem—more interview invitations than you can possibly schedule. How many should you actually complete? The average neurology applicant had 6.5 interviews in 2005, although 8 or 9 may be more reasonable if you are applying to a lot of competitive programs.

When scheduling interviews, there are two schools of thought. Some people prefer to make arrangements ASAP after the interviews are offered in order to get the most desirable dates, while others prefer to wait until they have multiple invitations and attempt to schedule geographically similar programs at the same time. Another factor to consider is whether it is best to interview early or late in the season. The early advocates think that applicants can make a bigger impression when the interviewers are haven’t talked to dozens of prior applicants. The late applicants want to be seen as close as possible to the final ranking meeting so they are “fresh” in interviewer’s minds. Enough people swear by each of these options that it probably doesn’t really matter. Just don’t schedule your top choice first—take a couple of interviews to “warm up”.

 

[GopherBrain]

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[GopherBrain]

Interview Day
Congratulations. You have made it past all of the paperwork, and it is time to visit the programs in person.

Typically you will arrive in night before your interview and go out to dinner with the other applicants and several residents. This is a great opportunity to learn about a program, so make every effort to attend. Dress is business casual. Leave the suit at your hotel.

On interview day most programs schedule 5-7 (20 to 30 minute) interviews per applicant. These are pretty casual. You will be asked about future plans (academic vs. private medicine, fellowship interests) and about any research you have done. Many people will ask you to present an interesting patient. The vast majority of interviews, however, are just small-talk. During one interview, your author (GopherBrain) recommended the movie “The Big Lebowski” to the chairwoman of neurology at Massachusetts General Hospital.

You will also likely see some manner of rounds or lecture. These can be fascinating, or mind-numbing. Most are somewhere in between. Don’t feel like you are expected to participate. This is your chance to observe, and nobody is likely to be too impressed by your knowledge of ataxia anyhow.

There is only one guarantee. By your last interview, your will want to scream whenever some well-meaning faculty member says “So, do you have any questions about the program for me?”

 

[GopherBrain]

Common Interview Misconceptions
#1: You will be pimped. Most programs do not have any interviewers who like to “pimp”, although it is not unheard-of. Programs have plenty of information available by which to judge your academic quality. They want to use the interview to meet you as a person. On top of that, programs don’t want to leave you with an impression they are malignant. One prominent program in Chicago developed a reputation for harshly pimping applicants in the 2004-2005 interview season. On match day, they filled only 1 of their 5 slots. Ouch.

#2: The residents are secretly evaluating you at dinner. This has some basis in reality. At many programs one or two residents sit on the evaluation committee, and residents sometimes formally or informally report back to the PD with their impressions of candidates. They are not, however, trying to catch you off guard at dinner. Most residents will tell you up front that they have no say in your chances, and you can believe them. However, use common sense. Don't badmouth other programs or applicants, stay positive, and don't abuse the waitstaff. The corollary to #2 is that you should never drink alcohol at the interview dinners, as this is a “red flag”. If this were true, 3/4 of all applicants would go unmatched. Just don’t get drunk and dance on the table.

#3: Everyone at the interviews is smarter than you are. Most everyone feels this way. At some of the more competitive programs it seems that everyone has a PhD or a dozen published articles in Science. Just remember, the programs would not have invited you to interview if they were not interested. You have as much of a shot as anyone.

 

[GopherBrain]

Thank You Notes/Cards
Believe it or not, there is actually a debate over whether it is better to send typed letters or cards after an interview. Some people feel that a hand-written card is better because it appears more personal, others think that a type-written letter seems more professional. A third group says that an email is the best way to go, because you are more likely to get a reply from the program director. As usual, when there is this much debate it is indicative that there is no truly correct answer. In fact, some medical schools advise their applicants not to contact programs at all after the interview day. In the end, most applicants end up sending some sort of letter.

Take a moment after each interview to jot down notes about your conversation. By the end of the day your interviews will blur into one, and having specific points to mention in your letters will be invaluable. Then, send a personal note/letter/email to each interviewer. Does this really help? Maybe not. Does it hurt? Not likely. In the end, it is common courtesy to thank anyone who took the time to meet with you.

 

[GopherBrain]

Creating your Rank Order List (ROL)

RANK PROGRAMS IN THE ORDER IN WHICH YOU WOULD WISH TO MATCH!!!

Anyone that tells you otherwise does not understand the match algorithm. There is absolutely no risk in taking a chance and ranking a long-shot at #1. NONE! NADA!

This is all you need to know. There is no strategy, and no way to beat the system. Rank the places where you want to go highly, even if they seem out of your range. If you don’t you may always wonder if you could have had a spot, if only you had tried.

On the other end of the spectrum, don’t rank any programs you do not want to go to. This should seem obvious, because it is. The match agreement is legally binding, and if you change your mind about a program after the match you are in a very tough situation. In a worst case scenario, there is always next year. Work on your application and try again, don’t settle for the bottom of the barrel.

 

[GopherBrain]

Contacting Programs (and vice versa) prior to Match Day
Many programs will tell you during your interview that you will not be contacted before match day, as they feel this violates the spirit of the match process. Others will send a form-letter thank you note. Still others will contact you and offer unsolicited flattery in an attempt to convince you to rank them highly. Do not be swayed by any of this. While it is good for the ego to have programs trying to recruit you, there is no good reason to bump them up your ROL for this behavior.

So, if you have your heart set on a certain program and they haven’t contacted you, should you call/write the program director? Many applicants do. It is a fairly common practice to let your #1 program know that they are #1. Some contact other top programs and tell them that they are ranked “highly” or some variation on that theme. This may be counterproductive. When you say “highly”, it is likely that all a program hears is “not #1”. It really comes down to personal preference.

The author of this FAQ was not contacted by his #1 program, nor did he contact them in any way. This apparently did not matter, as he matched at the program in question. So, no matter what you decide, it doesn’t seem likely to make much difference.

 

[GopherBrain]

Match Day
It all comes down to this. A computer decides your fate for the next four years of your life.

Now you can relax. The seemingly un-ending process is actually over.

Remember, a lot of people helped make your match possible. After you recover from your match day celebration, you should contact your advisor and letter of recommendation writers to let them know how things turned out.