Advice on Neurology Vs Family Med

[MooCowJoe]

Hello, I'm currently an MS3 close to having to decide on fourth year schedules and wanted to ask for advice in regards to choosing to go into neurology or family medicine.

A little background on my current position, etc. I'm currently at an allopathic school, have done all of the core rotations and neuro with only surgery left and have gotten honors so far for the year. I have pretty extensive community service work, a step 1 in the 230's, and a first author pub and a couple others. I really want to have an outpatient based practice, see my own patients, follow them long term, and develop relationships with each of them. I think that because of the decline in starting a private practice, joining a group of physicians and joining up in partnership would probably be ideal. Lifestyle is also pretty important to me, as family becomes a greater piece of my life. I really desire something that's stable, 40-50 hours a week, and without much call. I know pay would probably suffer in both specialties, but I'm not really worried as growing up in a single parent home comfortably on 50k a year reassures me that with either specialty I wouldn't be wanting for much after making at least 3-4x that.

Long story short, I think these are the pros and cons that I am weighing in choosing between the two:

Neuro
My first rotation of third year was neurology, and I really put it first because I hated the class during second year and just wanted to get over the requirement. Going through it though, I realized that I really enjoyed the subject matter in clinical practice. I enjoyed being able to use a quick exam and deduce the localization of a patients lesion and come up with differentials on the pathology, while being reaffirmed with imaging/studies. I also enjoyed being on the team that was being consulted, and in that regards having the answer most of the times at the end.

Some things that have cropped up that I've heard/thought about however are things like degenerative diseases. I know that things like GBS, myasthenia, and MS have come along way, but I'm currently involved in a parkinson's project that follows the patients throughout their clinical course and it worries me that many diseases in this field have this sort of prognosis. I'm also worried about becoming too specialized and losing the breadth of medicine that I have acquired or have the potential to acquire. This also inspired something that is somewhat counter intuitive to those who think family is boring, as I'm worried that the diseases and treatments for those seen in neuro might become too routine. Also, after talking to a private general neurologist I am concerned about the lifestyle after he mentioned that almost all private neurologist require hospital privileges and have to be on call for admissions, ED coverage, and rounding in the morning pushing work hours even greater. (Is this pretty much true? I know there are probably the few unique jobs that are the exception, but is this pretty regular? What are the work hours like for those practicing in the field?) Lastly, I'm worried about some who say that chronic pain and psychosomatic complaints make up the majority of a general neurologists day.

Family
I love the variety that each day and patient brings. I enjoy how one room can be the 60 year old COPD, chronic hypertension, and a-fib, while 15 minutes later a 2 month well child, and 15 minutes later a pregnant woman for pre-natal care. I like that you never have to say something like "you're going to have to bring that up with your PCP", as if someone has 10 questions you could probably answer 8/10 and know the two people they need to go to for the other 2 while helping them make arrangements for it. I enjoy how you get to grow with your patients, and that sometimes you even get to know an entire family. The treatable psych cases of depression and anxiety are also a plus. I also really like the prospects of the lifestyle (8-5, no call, and no weekends). The small procedures that don't last for hours and can be done in the office are also a plus (skin biopsies, small lacerations, endometrial biopsies, etc).

Some downsides I've found are that there is a lower assumed prestige among other specialist (had an ophthalmologist tell me I should have gone to PA school if I was gonna do family for example), more competition than neuro among PA's and NP's. I'm also not too keen on OB (though I know many family docs who don't do any OB). I'm also slightly afraid to not choose/lose neurology, I'm not sure why, but maybe its the finality of the decision and being afraid of being the guy who "only manages blood pressure and diabetes."

Thank you in advance for reading this long winded dilemma I've hit in choosing what I want to go into. I appreciate you taking the time to read this, while helping to share your opinions. I've been mulling this over for quite some time, and now as the time draws nearer to finalize our fourth year schedules its causing me greater worries. Lastly, if this is not the right area for this post, I'd appreciate the help of anyone moving it!

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[MemberX]

Hello, I'm currently an MS3 close to having to decide on fourth year schedules and wanted to ask for advice in regards to choosing to go into neurology or family medicine.

A little background on my current position, etc. I'm currently at an allopathic school, have done all of the core rotations and neuro with only surgery left and have gotten honors so far for the year. I have pretty extensive community service work, a step 1 in the 230's, and a first author pub and a couple others. I really want to have an outpatient based practice, see my own patients, follow them long term, and develop relationships with each of them. I think that because of the decline in starting a private practice, joining a group of physicians and joining up in partnership would probably be ideal. Lifestyle is also pretty important to me, as family becomes a greater piece of my life. I really desire something that's stable, 40-50 hours a week, and without much call. I know pay would probably suffer in both specialties, but I'm not really worried as growing up in a single parent home comfortably on 50k a year reassures me that with either specialty I wouldn't be wanting for much after making at least 3-4x that.

Long story short, I think these are the pros and cons that I am weighing in choosing between the two:

Neuro
My first rotation of third year was neurology, and I really put it first because I hated the class during second year and just wanted to get over the requirement. Going through it though, I realized that I really enjoyed the subject matter in clinical practice. I enjoyed being able to use a quick exam and deduce the localization of a patients lesion and come up with differentials on the pathology, while being reaffirmed with imaging/studies. I also enjoyed being on the team that was being consulted, and in that regards having the answer most of the times at the end.

Some things that have cropped up that I've heard/thought about however are things like degenerative diseases. I know that things like GBS, myasthenia, and MS have come along way, but I'm currently involved in a parkinson's project that follows the patients throughout their clinical course and it worries me that many diseases in this field have this sort of prognosis. I'm also worried about becoming too specialized and losing the breadth of medicine that I have acquired or have the potential to acquire. This also inspired something that is somewhat counter intuitive to those who think family is boring, as I'm worried that the diseases and treatments for those seen in neuro might become too routine. Also, after talking to a private general neurologist I am concerned about the lifestyle after he mentioned that almost all private neurologist require hospital privileges and have to be on call for admissions, ED coverage, and rounding in the morning pushing work hours even greater. (Is this pretty much true? I know there are probably the few unique jobs that are the exception, but is this pretty regular? What are the work hours like for those practicing in the field?) Lastly, I'm worried about some who say that chronic pain and psychosomatic complaints make up the majority of a general neurologists day.

Family
I love the variety that each day and patient brings. I enjoy how one room can be the 60 year old COPD, chronic hypertension, and a-fib, while 15 minutes later a 2 month well child, and 15 minutes later a pregnant woman for pre-natal care. I like that you never have to say something like "you're going to have to bring that up with your PCP", as if someone has 10 questions you could probably answer 8/10 and know the two people they need to go to for the other 2 while helping them make arrangements for it. I enjoy how you get to grow with your patients, and that sometimes you even get to know an entire family. The treatable psych cases of depression and anxiety are also a plus. I also really like the prospects of the lifestyle (8-5, no call, and no weekends). The small procedures that don't last for hours and can be done in the office are also a plus (skin biopsies, small lacerations, endometrial biopsies, etc).

Some downsides I've found are that there is a lower assumed prestige among other specialist (had an ophthalmologist tell me I should have gone to PA school if I was gonna do family for example), more competition than neuro among PA's and NP's. I'm also not too keen on OB (though I know many family docs who don't do any OB). I'm also slightly afraid to not choose/lose neurology, I'm not sure why, but maybe its the finality of the decision and being afraid of being the guy who "only manages blood pressure and diabetes."

Thank you in advance for reading this long winded dilemma I've hit in choosing what I want to go into. I appreciate you taking the time to read this, while helping to share your opinions. I've been mulling this over for quite some time, and now as the time draws nearer to finalize our fourth year schedules its causing me greater worries. Lastly, if this is not the right area for this post, I'd appreciate the help of anyone moving it!

My opinion is biased (obviously) but I think you should choose neurology based on what you are saying. As a neurologist, you will be well trained to handle general medical issues (like in FM) but also an expert in Neurology. The field is growing exponentially and these previously untreable diseases are now on the cusp of being treated (parkinsons, MS, etc). Also neurology is very broad and has multiple subspecialties that are lifestyle friendly and allow you to follow your patients longitudinally (movement, behavioral, headache). My best advice is to do an outpatient neurology away elective to get exposure to the different fields in neurology and ask the attendings about their lifestyle. Hope this helps.

 

[MooCowJoe]

My opinion is biased (obviously) but I think you should choose neurology based on what you are saying. As a neurologist, you will be well trained to handle general medical issues (like in FM) but also an expert in Neurology. The field is growing exponentially and these previously untreable diseases are now on the cusp of being treated (parkinsons, MS, etc). Also neurology is very broad and has multiple subspecialties that are lifestyle friendly and allow you to follow your patients longitudinally (movement, behavioral, headache). My best advice is to do an outpatient neurology away elective to get exposure to the different fields in neurology and ask the attendings about their lifestyle. Hope this helps.

Hey, thank you very much for your reply. I appreciate it. I think those are all very good points. Would you be able to speak more as to the call duties of a neurologist who prefers to be outpatient based? I know there may be exceptions and rare jobs, but more in general when a general neurologist takes an outpatient position is it usually required that they also cover the hospital, round on patient, or cover the ED? Thanks again.

 

[MasterStroke]

If you like more of a intellectual challenge, pick neurology. To put things in perspective, as an MS4 my FM preceptor gave me half her patients, and I managed them all on my own without problems, it was pretty easy. Not something you need residency for at all. You can probably do neurology residency and practice FM.

Work hours are about the same between the two specialties. Neurologists get paid more, but do have a longer residency. The residency is much more challenging. It's for smart people.

 

[DocMom1]

If you like more of a intellectual challenge, pick neurology. To put things in perspective, as an MS4 my FM preceptor gave me half her patients, and I managed them all on my own without problems, it was pretty easy. Not something you need residency for at all. You can probably do neurology residency and practice FM.

Work hours are about the same between the two specialties. Neurologists get paid more, but do have a longer residency. The residency is much more challenging. It's for smart people.

FM in fact can be more challenging than neurology simply because the variety of illnesses and organ systems with which one has to be aware is generally more broad, and includes children and adults, whereas neurology is only adults, unless you're doing child neurology, in which case you'd be dealing with only children. As a FM doc you'd be responsible for kids and adults, and might even have the opportunity to follow pediatric patients into adulthood, whereas in the neurology world you'd be handing them off to another provider. Residency is not necessarily more challenging, but it is longer. There are challenging FM programs and not-so-challenging neurology programs. It all depends. Do not make this decision based on some warped perception that one specialty is for smarter people than the other, there can be nothing more false. Also consider that as an FM doc you could do some bread and butter neurology, such as basic headache, pain, sleep, behavior, etc, but as a neurologist you almost certainty will not be doing bread and butter FM, nor will you be doing procedures you mention you find appealing such as skin biopsies, small lacerations, endometrial biopsies, etc.

 

[qwerty89]

I like that you never have to say something like "you're going to have to bring that up with your PCP"

This is actually one of the perks of other fields. You will learn soon enough...

 

[tirral]

Hopefully you understand the inherent bias youre going to get in answers on a neurology forum.

FM is not for stupid people and Neuro is not necessarily for smart people. I have seen clear exceptions to both stereotypes. My dad is a family doc and one of the most knowledgeable physicians I know.

Do not make the decision based on what your colleagues will think. Their opinion matters just about nil in terms of your professional satisfaction. Far more important to how you feel at the end of the day is the esteem of the patient in front of you. Frequently patients love their PCPs and may sometimes tend to distrust specialists.

I struggled with the same decision. It is not clear cut and you could have a great life in either specialty. the thing that nobody likes to admit is that the choice is at least a little arbitrary. Everyone likes to think their own autobiography makes sense.

 

[MooCowJoe]

FM in fact can be more challenging than neurology simply because the variety of illnesses and organ systems with which one has to be aware is generally more broad, and includes children and adults, whereas neurology is only adults, unless you're doing child neurology, in which case you'd be dealing with only children. As a FM doc you'd be responsible for kids and adults, and might even have the opportunity to follow pediatric patients into adulthood, whereas in the neurology world you'd be handing them off to another provider. Residency is not necessarily more challenging, but it is longer. There are challenging FM programs and not-so-challenging neurology programs. It all depends. Do not make this decision based on some warped perception that one specialty is for smarter people than the other, there can be nothing more false. Also consider that as an FM doc you could do some bread and butter neurology, such as basic headache, pain, sleep, behavior, etc, but as a neurologist you almost certainty will not be doing bread and butter FM, nor will you be doing procedures you mention you find appealing such as skin biopsies, small lacerations, endometrial biopsies, etc.

Thanks a lot. It's great to hear your perspective on what MasterStroke posted and I think it's something that I totally agree with. I'm really trying to figure out if my interests in the nervous system outweigh the breadth available in family. Thank you also for the point about being able to do some neuro as a family doc, I think it's pretty helpful to put things in perspective like that.

Would you mind commenting on what your day to day life is like as a neurologist? (Your patient base, practice setting, hospital duties, call, etc.) Thank you for the advice and for helping out!

 

[MooCowJoe]

Hopefully you understand the inherent bias youre going to get in answers on a neurology forum.

FM is not for stupid people and Neuro is not necessarily for smart people. I have seen clear exceptions to both stereotypes. My dad is a family doc and one of the most knowledgeable physicians I know.

Do not make the decision based on what your colleagues will think. Their opinion matters just about nil in terms of your professional satisfaction. Far more important to how you feel at the end of the day is the esteem of the patient in front of you. Frequently patients love their PCPs and may sometimes tend to distrust specialists.

I struggled with the same decision. It is not clear cut and you could have a great life in either specialty. the thing that nobody likes to admit is that the choice is at least a little arbitrary. Everyone likes to think their own autobiography makes sense.

Thank you for the post, it's helpful to hear from someone who went through the same decision. I understand its the neuro forum and I think your points on the perceptions of others is totally valid. I'm really trying to figure out what I want to do for the next 40-50 years and it's great to hear from everyone. I have also seen the distrust some patients have with specialist, even having some ask the PCP their opinion of the specialist while considering which to choose.

Would you mind commenting a little bit on how you ended up choosing neurology? Also what your lifestyle/practice is like? I'm really interested in what your patient base, practice setting, call, and hospital duties would be like. Thank you again.

 

[tirral]

Thank you for the post, it's helpful to hear from someone who went through the same decision. I understand its the neuro forum and I think your points on the perceptions of others is totally valid. I'm really trying to figure out what I want to do for the next 40-50 years and it's great to hear from everyone. I have also seen the distrust some patients have with specialist, even having some ask the PCP their opinion of the specialist while considering which to choose.

Would you mind commenting a little bit on how you ended up choosing neurology? Also what your lifestyle/practice is like? I'm really interested in what your patient base, practice setting, call, and hospital duties would be like. Thank you again.

The reason(s) I ended up choosing neurology are sort of complicated. I have been on every-other-day 28-hr call the past week so I didn't really have time to answer before.

I went through medical school thinking I was going to do FM. I got all the way to the end of my 3rd year and this still seemed like a good choice. I liked all the specialties about equally, maybe IM a bit more than peds/OB/surgery, but I liked the variety of FM and I could still see myself being happy in primary care. However, towards the end of M3/beginning of M4, I had a gnawing suspicion that I was missing out on something. My (USMD) medical school did not have a neurology clerkship in the 3rd year. There was an optional neuro day, once a week for 8 weeks, as part of the IM clerkship, and I participated in that and thoroughly enjoyed finding the lesion. I also really enjoyed the neuroscience curriculum in M1 which most of my classmates loathed. So I wanted some more exposure to neurology before I made the decision.

For the first four weeks of my M4 year, I worked with a general outpatient private neurologist who also took hospital call. I found his practice to be stimulating and challenging. He still liked what he did after a thirty year career. I could very easily see myself doing what he did. And I gradually came to see myself more as a neurologist than a family doctor.

I was also laboring under the (perhaps mistaken) impression that Family Medicine really shines in rural areas. My wife wants an academic career in her field which pretty much restricts us to mid- or large-sized cities. So I would've been doing FM in a more urban or suburban setting, where (it was my impression) there is more competition with specialists for managing complex/interesting cases. In the sticks, if you're a family doctor, you see and do it all. In the city, you end up referring out a lot of your cool cases because the specialists are available and it's the standard of care, assuming your patients have the access / insurance.

I still think I could've been perfectly happy doing family medicine, even in an urban/suburban setting. I no longer think of it as being quite so dichotomized (rural fun, urban not fun). I felt a certain amount of guilt for not being the change I wished to see in the world. Our healthcare system needs more generalists a lot more than it needs more specialists. To get to a sustainable system that works for most Americans, over half of graduates should go into primary care fields. Currently that number is more like 20-25% if you exclude all the IM residents who end up specializing. That trend is not sustainable. I had strong ideological reasons to go into primary care. But ideology will not make you a happy person. Doing what you love will make you a happy person, and happy people have the freedom to use their ideology in productive ways outside their career (donating money to causes, staffing a free clinic, etc). I love diagnosing people based on their exam findings, when other physicians are baffled as to what's going on. I love pushing tPA and watching someone's deficits resolve. I even like all the reassuring we do (to the ED and to the patient) when people don't have a localizable lesion.

I'm just a PGY-2 so I can't really comment on the work-life balance questions. My call schedule is somewhat brutal. When I am on a "28-hour" call, I frequently rack up a to-do list which keeps me working about 30-31 hours straight. This past week, that happened every other day (to allow half our residents the week off for New Year's - the other half did this so I could have Christmas week off). So my circadian rhythm is pretty messed up right now, and my appreciation for the work is low. Even so, I like what I'm doing. I suspect I'll end up like that general neurologist with whom I worked in M4 year - mid-sized outpatient practice, plenty of partners to share call, with the occasional excitement of the hospital but mostly the continuity (and easier schedule) of the clinic. I expect to work about 60 hours a week for most of my career. I won't get much sleep some nights, and I may not be quite as available a parent as if I did pure outpatient FM. But I think I will be pretty happy professionally.

 

[smq123]

Cross posted in the Family Medicine forum. As that one has more replies, I will close this one.