Role of a Neurologist

[NWwildcat2013]

I am an MS3 interested in neurology and I had a question about when other specialties deal with neurological problems and at what point a patient is referred to neurology. It seems to me like many nervous system problems are either sent to other specialties or treated/identified before neurology can get their hands on it.

I really like the neurologic problems I've seen in trauma. Brachial plexus injuries, spinal cord injuries, big brain bleeds, etc. I remember running stroke codes for suspected ischemic stroke with my team, but now that I have had trauma calls it seems like head/spinal trauma is ruled in/out by the trauma team and neurosurgery is called if needed for a big hemorrhagic bleed or spinal issues. Is a neurologist's only role taking these patient's after surgery or is there ever a role for a neurologist in the acute setting aside from tPA for ischemic stroke?

Also, how often does a neurologist initially find something like a brain tumor? It seems like at my hospital everyone complaining of a headache gets a CT in the ED and if a huge mass shows up then the patient is admitted to neurology. It takes the fun out of finding the problem if you are just sent someone with a known problem.

Below are a few other neuro topics that Im not sure when they are sent to a neurologist vs handled by a PCP/hospitalist or other specialist. How comfortable are PCPs/hospitalists working up a neurological problem and how far do they usually get before they require neuro assistance, if at all?

1. Pain. PM&R, anesthesia, ortho (lower back and/or radiculopathy), neuro?
2. Headache. Does PCP usually manage unless they can't get a handle on it?
3. Weakness. When would a PCP refer to a neurologist for this? After they check the regular culprits?
4. Sensory disturbances. Does the PCP differentiate between brain issue vs. eye/ear issue and refer appropriately?

Those are a lot of questions and slightly disorganized, but I really want to get a feel for what neurologist normally diagnose first vs. work up after significant prior workup vs. manage after the diagnosis is made.

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[deathmerchant]

I think as u move further in ur career, u will find the answer to this question yourself. Its not simple to answer because it varies tremendously based on where u are for obvious reasons- like how big the city is, who many physicians are in the place u are working, and is it a university hospital or a community/non academic hospital.
The example u gave is true for every speciality. Most traumas/head bleeds/spine injuries are not diagnostic dilemmas. They are diagnosed in ER and then appropriate services are called. Same with most medicine cases. U will probably refine the cases further.

In fact, its quite the opposite in neuro compared to other fields. Most of the time Neuro is called: its when the ER says " I don't know what the hell is going on (which happens more commonly than we wish for), can u see this patient?".
Also, Neuro is still an outpatient field and u will get a lot of referrals directly from all specialties/PCPs for diagnosing and managing complicated symptoms/ conditions, including headaches and others that u mentioned.( Who wants to see a simple case of headache or radiculopathy anyways!)
May be if u are in a city like New york, lot of ur patients will be there for 2nd or 3rd opinions.
And finally, seeing neuro injuries/head bleeds/strokes that require surgeries etc. is probably bit more common in residency or if u end up doing Stroke/NCC. Otherwise, its probably less than 5% of academic neurology.

 

[NWwildcat2013]

I think as u move further in ur career, u will find the answer to this question yourself. Its not simple to answer because it varies tremendously based on where u are for obvious reasons- like how big the city is, who many physicians are in the place u are working, and is it a university hospital or a community/non academic hospital.
The example u gave is true for every speciality. Most traumas/head bleeds/spine injuries are not diagnostic dilemmas. They are diagnosed in ER and then appropriate services are called. Same with most medicine cases. U will probably refine the cases further.

In fact, its quite the opposite in neuro compared to other fields. Most of the time Neuro is called: its when the ER says " I don't know what the hell is going on (which happens more commonly than we wish for), can u see this patient?".
Also, Neuro is still an outpatient field and u will get a lot of referrals directly from all specialties/PCPs for diagnosing and managing complicated symptoms/ conditions, including headaches and others that u mentioned.( Who wants to see a simple case of headache or radiculopathy anyways!)
May be if u are in a city like New york, lot of ur patients will be there for 2nd or 3rd opinions.
And finally, seeing neuro injuries/head bleeds/strokes that require surgeries etc. is probably bit more common in residency or if u end up doing Stroke/NCC. Otherwise, its probably less than 5% of academic neurology.

Thanks for the answer.

I had another question as well that I forgot to include. In an academic setting, neurology is super specialized into movement disorders, neuromuscular, MS, dementia, even headache, etc. I have yet to meet a general neurologist at my institution, so I have no framework for what all they can see/do.

If you work as a neurologist in a large city that has academic medical centers will all of the Parkinson's or MS patients end up going to a movement disorder or MS specialists or would you be able to get and retain these types of patients?

Right now the breadth of a general neurology practice is not known to me, so I've thought about reaching out to a community physician and asking if I could see a day in their clinic.

 

[deathmerchant]

Thanks for the answer.

I had another question as well that I forgot to include. In an academic setting, neurology is super specialized into movement disorders, neuromuscular, MS, dementia, even headache, etc. I have yet to meet a general neurologist at my institution, so I have no framework for what all they can see/do.

If you work as a neurologist in a large city that has academic medical centers will all of the Parkinson's or MS patients end up going to a movement disorder or MS specialists or would you be able to get and retain these types of patients?

Right now the breadth of a general neurology practice is not known to me, so I've thought about reaching out to a community physician and asking if I could see a day in their clinic.

Yes its true, in a big academic center/ big city the role of general neurologists( in a classic outpatient setting) has diminished and is going to continue to do so , mainly because it is impossible to stay on top of the whole breadth of neurological disorders. If u do find such position, u will end up seeing patients that other specialists don't want or don't fall into one subspecialty ( and psychosomatic patients) U can probably work as a neuro-hospitalist and manage most stuff of inpatient neurology though.
In a small town, u can probably do a bit of everything and end up referring only the most complicated patients.

 

[kchan99]

Yes its true, in a big academic center/ big city the role of general neurologists( in a classic outpatient setting) has diminished and is going to continue to do so , mainly because it is impossible to stay on top of the whole breadth of neurological disorders. If u do find such position, u will end up seeing patients that other specialists don't want or don't fall into one subspecialty ( and psychosomatic patients) U can probably work as a neuro-hospitalist and manage most stuff of inpatient neurology though.
In a small town, u can probably do a bit of everything and end up referring only the most complicated patients.

I heard that 25% of neurology involves patients with functional neurological symptoms. Of course, this is subspecialty dependent. I suspect that this figure is much higher for "general neurology" than for neurocritical care or interventional neuroradiology.

 

[Elipsis]

I heard that 25% of neurology involves patients with functional neurological symptoms. Of course, this is subspecialty dependent. I suspect that this figure is much higher for "general neurology" than for neurocritical care or interventional neuroradiology.

I would say it's more like 10%, but when you're tired it feels like 25%. Unfortunately every specialty has their unique brands of functional patients, they just have different names for it and the patients complain about different things. Dissociation through somatization comes in an almost infinite variety of forms.

 

[NWwildcat2013]

From Wikipedia:

"There is some overlap with other specialties, varying from country to country and even within a local geographic area. Acute head trauma is most often treated by neurosurgeons, whereas sequelae of head trauma may be treated by neurologists or specialists in rehabilitation medicine. Although stroke cases have been traditionally managed by internal medicine or hospitalists, the emergence of vascular neurology and interventional neurologists has created a demand for stroke specialists. The establishment of Joint Commission certified stroke centers has increased the role of neurologists in stroke care in many primary as well as tertiary hospitals. Some cases of nervous system infectious diseases are treated by infectious disease specialists. Most cases of headache are diagnosed and treated primarily by general practitioners, at least the less severe cases. Likewise, most cases of sciatica and other mechanical radiculopathies are treated by general practitioners, though they may be referred to neurologists or a surgeon (neurosurgeons or orthopedic surgeons). Sleep disorders are also treated by pulmonologists and psychiatrists. Cerebral palsy is initially treated by pediatricians, but care may be transferred to an adult neurologist after the patient reaches a certain age. Physical medicine and rehabilitation physicians also in the US diagnosis and treat patients with neuromuscular diseases through the use of electrodiagnostic studies (needle EMG and nerve conduction studies) and other diagnostic tools. In the United Kingdom and other countries, many of the conditions encountered by older patients such as movement disorders including Parkinson's Disease, stroke, dementia or gait disorders are managed predominantly by specialists in geriatric medicine.

Clinical neuropsychologists are often called upon to evaluate brain-behavior relationships for the purpose of assisting with differential diagnosis, planning rehabilitation strategies, documenting cognitive strengths and weaknesses, and measuring change over time (e.g., for identifying abnormal aging or tracking the progression of a dementia)."

This sums up my concerns. Look at all that overlap and potential to be squeezed out. Do other specialties face this and I'm just aware of it more in neuro or is this a potential problem for neurology? It seems many think neuro will begin to assert its ownership over some of these things as is starting to happen with stroke. I hope that is the future rather than an erosion of neurology territory.


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[Mattchiavelli]

So much depends on the culture of the place you're practicing. In residency we got a lot of "is there anything else to think about/do?" type consults and the answer was usually "no," but every now and then you'd find something missed that doesn't pop into the minds of the medicine types like subclinical seizures, venous sinus thromboses, weird paraneoplastic thing like anti-NMDA receptor encephalitis, dystonic reaction to starting compazine for headache abortive, ACTUAL SEROTONIN SYNDROME (serotonin syndrome was my lupus in residency).

Now that I'm working with a private practice at a non-academic tertiary care hospital I'm seeing more stuff that medicine would have handled where I did residency, but I'm thinking that's because everyone's work is made very inefficient by a crap EMR. We get a lot of consults where you can tell it's more about "well this person's body isn't working right and the nervous system controls the body so I guess it's time for a near consult." Also, your buddy wikipedia says having neurology in house is one of the markers of a tertiary care hospital, so you get to raise the bar of any place you practice.

This has the mirror in the outpatient world- if you have a good referral base from a bunch of overworked PCPs, you will see a lot of high level new patient consults that you can send back once you help them discover that eating within 8 hours of waking will help keep them from having headaches in the early afternoon. It can also be more rewarding than just that, like being able to tell someone they don't actually have CJD because they have a mild tremor. Then there's the fact that in the american health care system, a patient can self-refer themselves for about anything they want.

IMO though, as a medical specialty, we make our mark by knowing the most about the diagnostics and therapeutics we offer... no one is going to start reading EEGs. There are neurologists that can't read EEGs.

 

[NWwildcat2013]

So much depends on the culture of the place you're practicing. In residency we got a lot of "is there anything else to think about/do?" type consults and the answer was usually "no," but every now and then you'd find something missed that doesn't pop into the minds of the medicine types like subclinical seizures, venous sinus thromboses, weird paraneoplastic thing like anti-NMDA receptor encephalitis, dystonic reaction to starting compazine for headache abortive, ACTUAL SEROTONIN SYNDROME (serotonin syndrome was my lupus in residency).

Now that I'm working with a private practice at a non-academic tertiary care hospital I'm seeing more stuff that medicine would have handled where I did residency, but I'm thinking that's because everyone's work is made very inefficient by a crap EMR. We get a lot of consults where you can tell it's more about "well this person's body isn't working right and the nervous system controls the body so I guess it's time for a near consult." Also, your buddy wikipedia says having neurology in house is one of the markers of a tertiary care hospital, so you get to raise the bar of any place you practice.

This has the mirror in the outpatient world- if you have a good referral base from a bunch of overworked PCPs, you will see a lot of high level new patient consults that you can send back once you help them discover that eating within 8 hours of waking will help keep them from having headaches in the early afternoon. It can also be more rewarding than just that, like being able to tell someone they don't actually have CJD because they have a mild tremor. Then there's the fact that in the american health care system, a patient can self-refer themselves for about anything they want.

IMO though, as a medical specialty, we make our mark by knowing the most about the diagnostics and therapeutics we offer... no one is going to start reading EEGs. There are neurologists that can't read EEGs.

Appreciate this thorough response. It was very helpful.