4th year electives you would recommend?

[hwliang]

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What 4th year electives would you recommend for a MS3 interested in neuro? The list from First Aid for the Wards is as follows:

Recommended:
Psych AI
Radiology
Geriatrics

Related:
Neurosurg
Emergency

Interestingly, FA recommends Psych AI for Neuro, and Neuro AI for Psych. Why do you think that is the case?

Many thanks,
W

 

[PhakeDoc]

The 4th year electives I'm taking/took are Neurology Sub-I, NSICU, and Clinical Neurology. I thought about taking Ophtho and Radiology, but didn't want to do all the surgeries in Ophtho (was more interested in the retina clinic/neurophtho and will still do that under the Clinical Neuro rotation) and would have had to do general Rads (more CT abd, CXR, etc) than just neurorads (we can't take that until after a general Rads elective). I figured I see scans no matter which elective I'm in, so figured I'd nix that one. I would recommend the NSICU since most programs do have rotations through those as residents and it's good to know about the needs of a neuro critical care pt, if just for the sake of terminology, before residency starts.

FYI - I'm off-schedule since I came back later from finishing my dissertation than expected, so I have less time to do electives. If I did have more time, I would probably have taken the Rads rotation along with another medicine month, such as MICU, cards, or rheum, since all those have elements directly applicable to neuro as well as things you'll see during your intern year and beyond.

 

[typhoonegator]

I agree with the above poster; the best way to get to be a good neurologist is to develop your medicine foundation now, so you aren't trying to catch up when you actually are supposed to be learning neurology. No one is going to expect you to walk into the first day of neurology residency and give a talk on neuromyelitis optica. But they certainly will expect you to know how to read a CXR and manage acute hypertension.

I know everyone is excited about their specialty, but when I was a PGY-2, I doubt I could even have still told you what rotations I did in my fourth year of medical school. I remember medicine and neuro -- that's about it.

So, I would recommend the following: Take a neuro elective to prove you're serious about it and get some good letters. Maybe try to write a case study or something to get published. Focus the rest of your elective time on the stuff you won't have the luxury of formally learning again later. Like radiology, cards, rheum, and ID. Take derm -- rashes are everywhere.

Psych and neuro have a lot of interrelation between eachother, which I'm sure is why your book tells each to rotate with the other service. However, you will definitely rotate through psych during your residency, and I fail to see how rotating on the psych C/L service as a med school elective will really enhance your neurologic training as much as a medicine elective.

 

[neurologist]

Interestingly, FA recommends Psych AI for Neuro, and Neuro AI for Psych. Why do you think that is the case?

Because most neuro patients have psych issues as well. The opposite isn't necessarily the case, but shrinks are big on "ruling out organic disease" before they admit that their patient really does have a psych problem.

I'd recommend definitely taking psych, cardiology (vascular disease is vascular disease, whether it happens in the heart or the brain, and almost all your stroke patients will have cardiovascular issues as well), and neurosurgery. Geriatrics is an interesting suggestion, maybe think about it. I wouldn't waste your time on rads unless it's specifically neuro-rads. Contrary to what the other poster commented, nobody is ever going to expect you to read a chest x-ray.

 

[typhoonegator]

Contrary to what the other poster commented, nobody is ever going to expect you to read a chest x-ray.

When you have 50 inpatients on the neurology service, many of which have NGTs that you placed, and are placing your own central lines in the neuroICU, you will most certainly be reading your own CXRs, rather than waiting several hours for the radiologists to get around to it. There is no other way.

This is not an opinion, and this is not my first rodeo. Please try to keep an open mind about the breadth and scope of modern neurologic training. I don't have problem with your recommendations, but not all residents train in the same environment.

 

[neurologist]

When you have 50 inpatients on the neurology service, many of which have NGTs that you placed, and are placing your own central lines in the neuroICU, you will most certainly be reading your own CXRs, rather than waiting several hours for the radiologists to get around to it. There is no other way.

This is not an opinion, and this is not my first rodeo. Please try to keep an open mind about the breadth and scope of modern neurologic training. I don't have problem with your recommendations, but not all residents train in the same environment.

I'm well aware of the scope of modern neurologic training. I'm also well aware that there's a big difference between looking at a CXR to see if the NGT is in the stomach and looking a CXR because the patient complains of "shortness of breath." Just make sure you know your limits.

 

[typhoonegator]

There is no need to be inflammatory. I made no insinuation that a neurologist's opinion on a CXR was commensurate with a radiologist's.

However, to illustrate my point, I will relay this vignette. Just last week, one of my junior residents reviewed a CXR, and despite the small PNA, surmised that it was "too good" for the patient's clinical condition. She ordered a CT chest, and found the PE she was looking for. Could a radiologist do that? No, because she/he hadn't seen the patient.

My chairman often gives a very popular lecture at AAN about the intersection of medicine and neurology. He did residencies in both. Pretty much every day in morning report, he demonstrates that a broad understanding of medicine is a huge asset to neurologic diagnosis and, more importantly, care of the patient. Medical school is perhaps the most important time to develop one's foundation in clinical medicine. If you honestly think that using that time to take only neurology-centric courses rather than strengthening the breadth of your knowledge, then I will give up on this forum and never post again.

 

[neurologist]

If you honestly think that using that time to take only neurology-centric courses rather than strengthening the breadth of your knowledge, then I will give up on this forum and never post again.

See, this kind of thing is called histrionics. But just to call your bluff, I will say . . .

YES!!!! I HONESTLY THINK THAT USING THE TIME TO TAKE ONLY NEUROLOGY-CENTRIC COURSES RATHER THAN STRENGTHENING THE BREADTH OF YOUR KNOWLEDGE . . . . hey . . . wait a minute . . . you didn't even write a properly constructed sentence there . . . what the hell are they teaching you at Harvard anyway? Damn. Now I can't make you disappear.

I completely agree with your point that we should ideally be broadly educated, if for no other reason than to make sure we don't do something that's just incredibly stupid and kill someone. So, yeah, you should know how to recognize a PE or MI or cellulitis around one of those lines you put in. But let's face it, if someone is dead set on being a neurologist, the more they are exposed to it, the better. And as you get further and further away from med school, you'll find that #1) most of what you learned will become obsolete, and #2) if it's not really your primary area of interest or practice, you'll inevitably end up seeing less and less of it, and forget it anyway. Honestly, I doubt that you, as a neurologist, will be regularly perusing the derm or OB literature 10 or 20 years from now just to keep up on things. Whereas if you start focusing on "neuro-centric" stuff early on , you can grow with it over time.

And that reminds me . . . as a followup to the OP: I would strongly, strongly advise you to do an elective in pain medicine, preferably one that exposes you to both interventional and noninterventional treatments. Pain is easily 50% of neurology practice, so get used to it.

 

[typhoonegator]

It seems that we may have conflicting opinions here. Also, taking pot shots at Harvard education is classy, and don't let anyone tell you otherwise.

The antibiotics used to treat fever in neutropenia might be different in ten years, but diagnoses like TTP and Trousseau's syndrome will not change much. (By the way, did you know that Trousseau actually diagnosed his own disease in himself? Years after writing his paper on "phlegmasia alba dolens", he himself developed painful white edema, and correctly surmised that he had a GI malignancy. Incredible.)

I agree that if you're running a headache clinic or doing Botox or whatever, you probably won't be drawing on this information much. But there are 4 years of residency to get through first, and in my opinion, knowing your medicine up front lets you spend MORE time focusing on the neurology, not less. Also, areas like stroke and neuroICU draw heavily from medicine. Our ICU docs have to stay current on ID, pulm, critical care, and neurology literature.

Saying it isn't worth learning because you'll just forget it is pretty nihilistic. You may just as well have said "Who cares what electives you take, we're all going to die anyway." 🙂

Neurologist, can we stop arguing now? I really should be spending this time working on my K-23!