The need for IM in neurology

[ThomasHendricks]

I have been a member for a few years now, but I felt like I should start fresh with something that doesn't link to a lot of identifying information.

I am an M3, and have spent the whole year arguing with myself about what direction to go in for residency. Like many others at my stage, I didn't have any rotations that didn't come with at least some enjoyable aspects, and I was loath to give up on the fantasy of "doing it all". Obviously I spent a lot of time considering things like FM, EM, and almost everything else too. But the more I thought about it, the more I realized that I wanted to be "the expert" in an area; and of all the areas neurology is the one I enjoyed the most. Also, I feel like the farther along I get the less I know, and the thought of being in a very broad area makes me more and more uncomfortable.

So now to make this into a question. I have been looking at various programs via FREIDA, and have noticed the IM/Neuro programs (all two of them) and I am wondering how much of a boon this would be if one were to do something like neurohospitalist/neurointensive care/neuro-oncology, which I think would be areas I would enjoy more (things that involve more of an inpatient based practice). It seems like it would be an advantage, but is it something that is really necessary? Or does one get all the requisite training via PGY1 and fellowship to feel comfortable with some of the general medical issues?

My third year clerkship for neurology was very short (four weeks), and pretty slow - but with some great cases, I think. I am set up for a JI that (I hope) will be busier and maybe give me a better idea of the general medical issues involved, but frankly our neurology dept. is not what I would describe as a powerhouse, and so I think I may need to do an away rotation somewhere to get a better feel for all of this.

Any input appreciated.

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[primadonna22274]

Sorry to see you got no responses to this thread. I struggle with the very same quandary...love neuro but love IM too. My pet interests lean towards geriatric neuro...dementia, movement disorders etc. of course there's a huge psych component there too but I don't want to do just psych. I hope this bump gets an answer from someone in the know.

 

[Hank Rearden]

This is a tough question to answer. For some of the specialties you mention, particularly neuro-onc and neurohospitalist, there is no doubt that doing a full IM residency would help. Having said that, you're already headed to many years of schooling if you include a fellowship which could be anywhere from 1-3 years. In my mind the small benefit from the extra year or two of IM is not outweighed by the further delay in getting on with your life and career.

A second item to consider is the quality of these combined programs. I don't remember off hand which 2 they are, but I remember them being somewhat middle of the road. I think you'd be much better off ditching the combined program if it means receiving better neurology training at another institution. It will be easier to get into your choice of fellowship, and the additional IM training probably doesn't carry much weight with fellowship directors.

 

[primadonna22274]

Thank you Hank Rearden (smashing moniker btw).
Follow-up: what about combined psych-neuro? Yes, long, and very few of them, but seems like a nice option for my interests--dementia, cognitive disorders, neuro degenerative problems etc. MUSC has a program that's 6 yr. I'm intrigued but also wonder if really necessary...I will be 40 when I graduate med school and would like to get back to my life sooner if possible, but I can see myself in academic medicine in which case that would be my life
Thanks

 

[Iliopsoas]

I do think that all aspects of Neurology do have overlap with IM, some more than others. Certainly Neurointensivists & Neurohospitalists have the most overlap, but you will need to know fundamental IM as a general neurologist as well. Having said that, I don't think you need to do a combined residency to master the concepts of IM that overlap with Neurology. I went to an academic internship and learned a ton of IM. I felt like after 1-year of really investing myself in my intern year, I learned a sufficient amount of IM to be a well-rounded neurologist. I have talked to people that have done combined IM/Neuro and a lot of them regret the decision because it is 2 extra year and they end up doing a fellowship on top of that.

Just because FREIDA lists 2 programs that are accredited for joint IM/Neuro doesn't mean that you can't do that at other institutions as well. Most residencies will be flexible with you if that is what you want to do. I don't think it is widely advertised because it's just not that popular.

You ultimately have to decide what is right for you. You can do IM and be an expert in a lot of topics if you do a fellowship. Most Pulmonary/CC doctors I know are well-rounded on most topics. I understand the appeal of doing a residency where you masted 1 subject. The benefit of choosing Neurology is that you truly master the nervous system by the time you are done with residency/fellowship. However, there are times when I wish I had just done IM and done a Pulm/CC fellowship where you get a broader exposure in the ICU. But, that's my personal experience. Just don't take your decisions lightly. By doing a lot of research and different clinical experience in med school may eliminate problems that may arise later. I highly recommend talking to residents at your program as well. They are probably the best resources. I am usually very open to giving advice to the medical students that want to do Neurology at my institution.

 

[Hank Rearden]

To Primadonna - my advice to you really depends on how you see your career unfolding. I've only met one neurologist with dual Neuro/Psych residency training and this allowed him to carve out a nice niche. For example, if you are interested in non-epileptiform seizure patients and patients with conversion disorder I think that would be the way to go. Very few people are studying this and most of us have no good options on where to send these patients. If, on the other hand, you are more interested in studying dementia, the Psych residency would help, but you'd probably be better off investing those years in a good cognitive fellowship.

 

[primadonna22274]

Thanks Hank...I really appreciate that.
I didn't know about cognitive fellowships and will look into that.
I do have a genuine interest in psychiatry but don't want to do it exclusively. My brother has struggled with severe schizophrenia for the past 24 yr and I am interested in aging schizophrenics & dementia risk (not much published on this I have found).
I have taught in a PA program before returning to medical school (a big part of "why med school?" for me was to become a better teacher) and I would be happy in academic medicine, perhaps as residency faculty etc.
It's a long road and 6 yr residency starting at 40 seems foolhardy since I gave up a well-paying career to become a physician and haven't had kids yet. OTOH I have the world's least selfish and most long suffering husband
Appreciate your advice.
Lisa

 

[typhoonegator]

There are a few other threads that go into detail about the +/- of neuro-psych combined programs. I personally don't see the need for it, but do what you want. Most people end up doing one or the other, and a good behavioral neurologist can handle the vast majority of psychiatric comorbidities that he/she routinely encounters in his/her patients. The idea that a cognitive neurologist can't manage impulsivity in FTD, or a movement disorders neurologist can't manage depression in his PD patients, just isn't real.

I am a neurointensivist. I did not do an IM residency. 7 years of post-graduate education seems like enough to me, and I can and do routinely manage codes, sepsis, ARF with CVVH or HD, open bellies, heart failure, etc with the training I have. Do a hard intern year, and a hard fellowship, and you will see plenty of good cases and learn enough to be self-sufficient in a large variety of issues. The fact that there are only 2 of these Neuro/IM programs tells you something about how necessary they are to the vast majority of neurologists. It's not like Columbia, MGH, Hopkins, and UCSF are training incomplete neurologists who can't manage medical issues.

I'm sure there are people who benefit from this extended training, but you should not feel like you can't become a good neurocritical care or neurohospitalist physician without them.

 

[ThomasHendricks]

Thanks a lot for the replies. I meant to give this a bump, but the transition to fourth year has kept me preoccupied. We don't generate many neurologists at my institution. I think one person matches into neuro every other year at best, so there isn't much in the way of other students to talk with. Of course I guess the benefit of that is that the neuro faculty seem excited to talk with people.

I think ya'll really got to the heart of the issue, in that after internship, residency, and fellowship, the one extra year of IM from a combined residency might be negated in terms of benefit. Plus I guess you would lose out on elective time. I still may put in the work to apply to those places, to see how they work, but I guess I don't need to feel as though that is the only path to becoming a strong neurologist.

I am just now settling into the idea of doing neurology. I originally was interested in FM, but decided it was just too much stuff for me to learn well. Plus I prefer taking care of sick patients, and I like the idea of being an "expert" in an area. I was also on the EM bandwagon for a while, which is actually what I am doing a JI in now, and while I like the acuity - and the opportunity to pick up all the stroke patients! - I have found I actually don't care for the sporadic work schedule, the lack of continuity, and the feeling that you are at the mercy of the admitting services sometimes. I have always enjoyed my neuro patients, but I was a little leery of being too "specialized". I guess in the end I like the benefits of specialization more than those of being a generalist.

Also, I am glad Hank Rearden and Thomas Hendricks can have a conversation. Nice.

 

[ThomasHendricks]

I guess I will also add that I see myself more interested in NCC or stroke because I like procedures, which also explains why I had a penchant for FM/EM initially. And I think for me that was the largest downside to neurology in general initially. LPs are fun, of course, but those alone don't go far enough in satisfying this urge. Heck, I seriously considered surgery or some kind of surgical sub, but I just couldn't stand the lack of medicine.

That's one thing I am enjoying about this EM month; I spend about 25% of my time suturing, which when the NPs/PAs leave at night, is a great way to pass the time between patients. It's also a nice way to avoid people coming in at 3am for "cough for the last 2 months"