Yet another "Fellowship vs General Neuro?" thread.

[DrStephenStrange]

Hello there, fresh PGY-2 here, and as if the stroke service and call schedule weren't enough stress already, I started looking into fellowships just to make matters worse. I seriously cannot imagine myself having to decide on a subspecialty a year from now, but yet here we are. Part of me just wants to forgo more training and just go straight into general Neuro, but with majority of people going into fellowships nowadays, part of me also feels like I may regret it. Especially when most subspecialties are just one more year of training.

I really am not interested in any research or academia, and I just want to work in a community setting doing both inpatient and outpatient most preferably. I also want to live comfortably with a good income (hopefully at least >350K) and have good work/life balance. I may be asking for too much on that last part.

Anyway, at first, I was thinking just getting good at one particular extra skill set like EEG or EMG by pursuing Epilepsy or NM, but so far these specialties are not really fitting quite well in my mind yet (maybe I need more exposure). Also, the thought of learning the whole human anatomy again for NM/EMG is daunting to me. Then recently, I started looking at Movement disorders, to be honest, I felt like this is the kind of patients and topic I would enjoy the most, but then I learned reimbursement sucks for movement docs (with salaries more in the 200K's), and I would honestly hate to go into one extra year of training only to decrease my salary (or maybe I am thinking about this wrong). I've also thought about Neuroimmunology (MS), but I have not had any exposure in it yet to really form an opinion. Mixed or single track CNP feels like they just give you enough skills to be Ok at EEG, EMG, or both, but you're not really an expert at anything (so not sure if they are worth it or not). Sleep medicine sounds like a good gig with decent pay, but it just seems very monotone to me with everything coming through the door being sleep apnea, and it also seems to be mostly geared towards outpatient.

I know for sure I don't want to pursue NCC, Stroke, pain, or NIR. Right now, I just need some insights on the different subspecialties to be able to structure my second year better and hopefully make up my mind by 3rd year (or maybe I just need a Hoorah moment). I would appreciate any advice or insight in this thread. Thank you for your participation already!

Edit: Aso have no idea about fields like neuro-onc, behavioral neuro, dementia, Neuro-infectious disease, neuro-otology, or neuro-ophtho.

(Edited to make it more readable...hopefully lol)

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[Telamir]

Wow. Nice freak out sesh.

Take a deep breath, dude. You've got to decide in a year but as a PGY-2 it's super overwhelming. All you get exposure to is hospital/stroke inpatient side of things and minimal exposure to anything else. Also, paragraphs are your friend.

You'll get various opinions here. I personally think if you can stomach the 1 year I'd do it. It sets you apart a little more and if you do it on something that gives you a skill (CNP, NM, Epilepsy) then you come out ahead. I think CNP gets you a good foundational knowledge of EMG and EEG and is helpful for people who want to be in private practice or general neurology as outpatient mainly. In regards to "learning the anatomy", you'll have to do it anyway to evaluate for radiculopathies and plexopathies in clinic, and it's honestly not that daunting. It seems like it now cause you're a PGY2 and everything is daunting.

Movement disorders tends to be a little more "academic", but it won't slash your pay. You'd likely end up somewhere where you're doing general neuro and movement disorders so if you find it interesting feel free. Some places may have enough demand to justify you doing it full time.

Dementia and behavioral neuro you probably know how it is.
Neuroimmune is mainly outpatient, but difficult population. I'd do an elective before you figure out if you like it.
Neuro Ophtho is mainly academic. Very small field.
Neuro Onc is mainly outpatient, and it's exactly what it sounds like.

I think you need to take a deep breath and do the following:

Inpatient vs outpatient? Sounds like you wanna do outpatient. General vs specialized, and go from there.

 

[johnwandering]

Just a heads up that if you want to do inpatient at all, Epilepsy is secretly a great fellowship to take.

I did my residency at a very stroke heavy program (stroke service census alone was often 20-30 pts) so was very comfortable with it. But I wanted to learn to read EEGs so I did a fellowship in Epilepsy.

Im now a neurohospitalist, and the lions share of inpatient consults are stroke, AMS, seizures - and I feel that the combination of comfortable with Seizures and Stroke (esp being able to read all my own EEGs and expertly manage the meds) allows me to handle just about anything comfortably.

I work one week on/off - reading all the EEGs on my off weeks while watching TV for extra $$$ (and I love reading EEGs, theyre incredibly fun) - the EEG income alone I bring in an extra ~200K annually, I break 600K.
I think I have the best life possible (for me), wouldnt have it any other way.

 

[CnsCrit]

I think fellowship is a good idea, it'll increase your skills by a lot in a short amount of time. If you're not that interested in inpatient, then neurophys is probably the way to go. Most fellowships are slanted towards either NM or EEG - for example some will be basically NM fellowships with extra EEG training, and I know attendings who have done this and practice as NM specialists with a bonus of a little extra EEG knowledge for those inpatient weeks. They are very competent EMGers and function at the same level of someone who has done just NM. At that point, it's more about the way you want to practice rather than competence. CNP will give the broadest training for OP gen neuro or neurohospitalist for someone who doesn't really like stroke/ICU/IR.

 

[Aldertonghen]

There was a survey article from the AAN a few years ago that looked into burnout by subspecialty and type of practice- and epilepsy was the only specialty that had a significant lower burnout ( NCC had a higher burnout, and all the others were in the middle and not statistically different). Academic did better than private burnout wise despite salary difference. As a new PGY-2, I can see why that would be the case- being able to handle stroke (from residency- I’ve already given 3 tenecteplase haha), and seizures/encephalopathy (EEG fellowship) is the bulk of consults inpatient, and epilepsy is useful outpatient too.

Here is the article: https://www.aan.com/siteassets/home...tter/neurology-2017-neurologists-burn-out.pdf

Academic Epilepsy is probably the cushiest job in neurology imo (maybe with sleep- but that’s mostly OSA), and if you’re not an academic person (don’t like teaching), then a 1 year EEG fellowship is very versatile and useful.

Epilepsy fellowship applications also start the earliest (early 3rd year), so you have to decide a bit sooner than say movement (late 3rd year).

Neuromuscular is also really nice- I’ve only had a couple of EMG days so far, but the approach is fascinating. It’s basically an extension of the Neurologic exam imo. But I dislike the sensory exam overall.

That being said I can’t get over the rush of TnKs and the midnight thrombectomies- it’s just unreal getting to witness dramatic on-table improvement once they suck off the clot (and got TnK beforehand). The efficacy of TnK alone is staggering for me so far.

 

[Aldertonghen]

Double post but what are people’s thoughts on doing a fellowship after 3 years of neurohospitalist post residency? My visa requirements really restricts my options to try to use fellowship as a springboard into academic research (which is what I want to do)- this is because I have to serve 3 years in a community in the middle of nowhere prior to getting rid of my J1 visa requirements. Now I know some lucky people are able to do research and complete visa requirements, but I’ve seen enough talented people not get lucky and suffer a 3 year setback as well.

If I finish my neurohospitalist requirements, I can do an extended research fellowship and use that to start an academic career.

The other thing I could do is do a 1 year stroke/EEG fellowship, then finish my 3 year waiver, get green card, then do the 2nd year of an epilepsy/ vascular research fellowship that’s more geared toward research. Is this a better option?

 

[WhereMyLiberalsAt]

I work one week on/off - reading all the EEGs on my off weeks while watching TV for extra $$$ (and I love reading EEGs, theyre incredibly fun) - the EEG income alone I bring in an extra ~200K annually, I break 600K.
I think I have the best life possible (for me), wouldnt have it any other way.

If a mod PMs you about this message being taken down for anti-Semitic rhetoric with racist undertones and misogynistic dog whistles…. I did it for the team.

*you can repost after a match and pull up the ladder

 

[Postictal Raiden]

If a mod PMs you about this message being taken down for anti-Semitic rhetoric with racist undertones and misogynistic dog whistles…. I did it for the team.

*you can repost after a match and pull up the ladder

I’m confused

Did you respond to a wrong comment or is this an inside joke I’m not aware of?

 

[WhereMyLiberalsAt]

I’m confused

Did you respond to a wrong comment or is this an inside joke I’m not aware of?

I would say it’s an inside joke to anyone applying this cycle (and possibly the class under me.) I thought the hyperbole would read as sarcasm. But, I believe the majority of folks think I truly reported the comment…

 

[Postictal Raiden]

I would say it’s an inside joke to anyone applying this cycle (and possibly the class under me.) I thought the hyperbole would read as sarcasm. But, I believe the majority of folks think I truly reported the comment…

I hadn’t seen the italicized sentence.

Anyways, his/her set up is rare. In large cities, there isn’t enough EEGs or a shortage of neurologists who can read them to generate 200k from a side gig