Be my devils advocate, why shouldn't you do Neurology?

[neuro4me]

I am very interested in Neurology as a specialty choice. The nervous system, brain and all the amazing pathology. No other specialty made me want to come in on the weekend to see patients. It sounds like a great specialty choice, but as a student I only know so much about what happens in the real word. So be my devils advocate. Help me make an informed decision on a career. Is it the chronic pain patients? The relationships between other specialties? Is it the pressure put on administration to see so many patients in a little time? Tell me why I shouldn't do Neurology or at least maybe comment on the parts of your specialty that drain you?

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[Spinothalamic]

My disclaimer is that I am a neurology resident planning on doing outpatient. Most residencies are largely hospital-based.

The most frustrating thing about neurology to me is that there are very few objective tests which prevent consults to neurology from the ED. You can be consulted for the most ridiculous things, but it’s very difficult to “push back”. For instance, an ED doctor can’t consult other specialties (eg hepatology, nephrology, pulm, even often times general internal medicine) without some sort of objective tests being abnormal. Either O2 sats are down or Cr is up, etc. In neurology, a physician can consult you urgently because they are concerned the patient is having seizures or had/is having an acute stroke, neither of which may be true (only two examples of many). A negative head CT (the only quick, useful, objective, neurological test in the ED) is reassuring but very insensitive for many common pathologies that can present acutely. No other specialty is consulted so frequently for emergencies (i.e. acute stroke) multiple times per day for often subjective complaints where they are expected to drop everything (including handling a busy service) and go to the ED to make a very rapid treatment decision with life/death implications based on relatively little information.

The positive side of things is that is also what makes seasoned neurologists invaluable and currently the most in-demand specialty.

 

[neuro4me]

My disclaimer is that I am a neurology resident planning on doing outpatient. Most residencies are largely hospital-based.

The most frustrating thing about neurology to me is that there are very few objective tests which prevent consults to neurology from the ED. You can be consulted for the most ridiculous things, but it’s very difficult to “push back”. For instance, an ED doctor can’t consult other specialties (eg hepatology, nephrology, pulm, even often times general internal medicine) without some sort of objective tests being abnormal. Either O2 sats are down or Cr is up, etc. In neurology, a physician can consult you urgently because they are concerned the patient is having seizures or had/is having an acute stroke, neither of which may be true (only two examples of many). A negative head CT (the only quick, useful, objective, neurological test in the ED) is reassuring but very insensitive for many common pathologies that can present acutely. No other specialty is consulted so frequently for emergencies (i.e. acute stroke) multiple times per day for often subjective complaints where they are expected to drop everything (including handling a busy service) and go to the ED to make a very rapid treatment decision with life/death implications based on relatively little information.

The positive side of things is that is also what makes seasoned neurologists invaluable and currently the most in-demand specialty.

How do you handle that stress of life/death decisions? Does it ever wear you down?

 

[Spinothalamic]

How do you handle that stress of life/death decisions? Does it ever wear you down?

Acute stroke care can certainly be stressful, but it can be very rewarding. In my opinion, hyperacute stroke care in the ED is quite algorithmic which helps. And when I stated life/death decisions, I was really referring to the fact that IV TPA very rarely but statistically leads to a much worse outcome leading to severe morbidity or mortality when compared to no treatment with TPA. Fortunately, this is very rare and many, many patients benefit from the positive effects of IV TPA. IV tPA is standard of care for acute ischemic stroke, so it’s not really “stressful” to give it. What is more stressful is probably when patients are close to the end of the therapeutic window and you are trying to figure out if they are on anticoagulation or if tPA would be within their goals of care or gauging risk/benefit ratio with relative contraindications.

 

[Telamir]

I think Spinothalamic is spot on. Most people save neurologists are very uncomfortable with neurological disease or symptoms. Combined with CYA medicine and you get a TON of ridiculous consults both inpatient and outpatient (I only do inpatient). Couple that with the psychiatric overlay of conversion disorder and pseudoseizures and there are days where you see more pseudopathology than not.

Stroke alerts where I work are completely unpredictable. I've had days where I've had zero, and days where I've had 5 and none of them were an acute stroke. You STILL have to drop whatever you're doing to do an NIHSS, review imaging etc, and most docs once they call a stroke alert it's "all hands off deck". They go do other stuff and it's your problem now until you tell them TPA y/n and why or why not. Then they proceed to plaster your name everywhere on the chart.

Also add whenever someone from another specialty wants to make a non-neurologic problem your problem. I.E. completely psychiatric patient consult neurology for r/o seizures or something else asinine, or once I got called to determine if oxcarbazepine was the cause of abdominal pain on someone POD2 from kidney transplant just because hey it's on micromedex so... Hell, I've even been called for arm numbness on someone who has chest pain radiating to the jaw. The possibilities are endless.

There's also whatever you might not personally like (dementia, neuropathy for me) that you'll have to deal with but this is true of all specialties.

 

[neuro4me]

I think Spinothalamic is spot on. Most people save neurologists are very uncomfortable with neurological disease or symptoms. Combined with CYA medicine and you get a TON of ridiculous consults both inpatient and outpatient (I only do inpatient). Couple that with the psychiatric overlay of conversion disorder and pseudoseizures and there are days where you see more pseudopathology than not.

Stroke alerts where I work are completely unpredictable. I've had days where I've had zero, and days where I've had 5 and none of them were an acute stroke. You STILL have to drop whatever you're doing to do an NIHSS, review imaging etc, and most docs once they call a stroke alert it's "all hands off deck". They go do other stuff and it's your problem now until you tell them TPA y/n and why or why not. Then they proceed to plaster your name everywhere on the chart.

Also add whenever someone from another specialty wants to make a non-neurologic problem your problem. I.E. completely psychiatric patient consult neurology for r/o seizures or something else asinine, or once I got called to determine if oxcarbazepine was the cause of abdominal pain on someone POD2 from kidney transplant just because hey it's on micromedex so... Hell, I've even been called for arm numbness on someone who has chest pain radiating to the jaw. The possibilities are endless.

There's also whatever you might not personally like (dementia, neuropathy for me) that you'll have to deal with but this is true of all specialties.

For those “unneeded consults” can’t you say after evaluating the patient this is not neurological in nature, sign off and pass the the ball back to the ED physician?

 

[Thama]

For those “unneeded consults” can’t you say after evaluating the patient this is not neurological in nature, sign off and pass the the ball back to the ED physician?

Yes, but you still have to see and evaluate. To have an hour or so of your time wasted many times per day just because an ER or IM doctor can't be bothered to spend 5 minutes thinking about the CNS as anything other than "black box must call neurology stat" gets real old real fast.

 

[deathmerchant]

I am very interested in Neurology as a specialty choice. The nervous system, brain and all the amazing pathology. No other specialty made me want to come in on the weekend to see patients. It sounds like a great specialty choice, but as a student I only know so much about what happens in the real word. So be my devils advocate. Help me make an informed decision on a career. Is it the chronic pain patients? The relationships between other specialties? Is it the pressure put on administration to see so many patients in a little time? Tell me why I shouldn't do Neurology or at least maybe comment on the parts of your specialty that drain you?

Completely agree with Spinothalamic and Telamir above. These are the biggest burnout factors in neurology.

This might end up becoming a Venting thread for neurologists. I think sometimes as a neurologist, when we take care of patients, we make a lot of complex decisions for diseases that are life threatening and life altering; and these decisions require a lot of knowledge, experience and are high risk. But on paper we might not have much to show or document unlike other specialities.

 

[neuro4me]

Completely agree with Spinothalamic and Telamir above. These are the biggest burnout factors in neurology.

This might end up becoming a Venting thread for neurologists. I think sometimes as a neurologist, when we take care of patients, we make a lot of complex decisions for diseases that are life threatening and life altering; and these decisions require a lot of knowledge, experience and are high risk. But on paper we might not have much to show or document unlike other specialities.

Is Neurology a heavy CYA medicine? Is it a very litigious specialty?

It is really tough to make a life altering decision with maybe only 6 weeks of 3rd year experience and 1-2 month of a Sub-I. There is no way I can expect to know what it would be like to be a Neurologist day in and day out. The fact this is one of the highest rated burn out specialties does scare me. I appreciate all the answers and I look forward to continue the discussion.

 

[Postictal Raiden]

As a PGY-2, who’s in the thick of the gruesomeness of the residency, here are some of the reasons that make neurology (residency) challenging, and perhaps, unappealing:

• Long hours. Neurology is known to have the worst schedule of nonsurgical fields. History taking and physical exam are the core of Neurology but they are very time consuming. Don’t underestimate how long it takes to carefully assess someone’s gait or muscle strength. In neurology, you can’t get away with “CV- rrr, no murmurs; neuro- CN II-XII intact b/l”. You need to be very descriptive in documenting your physical exam. People use “lethargic” and “obtunded” interchangeably but they are very different.
• The knowledge is vast. You need to have a very solid knowledge of neuroanatomy. Contrast this to fields like GI, where knowing your organ system anatomy is important but you don’t really need to know the detailed anatomy of every centimeter of the GI tract because a peptic ulcer is a peptic ulcer regardless of its precise location. However, as you know, every little area of the brain has a distinct function. In addition, you need to be able to read your own radiological images (CT, MRI, CTA, MRA, DCA, Cerebral perfusions). By the end of your residency, your neuroradiology skills are better than most non-neuroradiology trained radiologists. Moreover, the list of drugs used to treat neurological conditions is longer than that of any other specialty (aside from general IM, ofc). You need to know AED’s, pain/neuropathy meds, stroke management/prevention meds, neuromuscular modulators, immunomodulators, neurodegenerative disease meds, etc.
• Very vague chief complains. Dizziness, weakness, numbness, confused, etc… what do they even mean? I can’t tell you how many times people describe someone aphasic as “confused”, or weakness as “numb”
• Like mentioned above, many neurological conditions are clinical diagnosis and can’t be objectively diagnosed. This is where skilled history taking and physical exam come in handy. It’s very frequent that we give patients AED’s to treat seizure even though EEG doesn’t show one.
• Tough conversations. In neurology we often give grim prognoses. Delivering such news takes a skill that many lack. You need to know how to balance between professionalism and sympathy, and between truth and hope.

With that said, Neurology remains to be a field that attracts those who are fascinated by complexity and intrigued by ambiguity. I don’t regret my decision one bit.

 

[Telamir]

Is Neurology a heavy CYA medicine? Is it a very litigious specialty?

It is really tough to make a life altering decision with maybe only 6 weeks of 3rd year experience and 1-2 month of a Sub-I. There is no way I can expect to know what it would be like to be a Neurologist day in and day out. The fact this is one of the highest rated burn out specialties does scare me. I appreciate all the answers and I look forward to continue the discussion.

Is it very litigious? I'd say not really. There are studies for this and we are in the middle of the pack regarding potential litigation. Out of what we do I'd say stroke is potentially the more litigious thing. The burnout is high, and I was miserable in training but it's better now that I'm out in practice. That being said...caveat emptor.

 

[deathmerchant]

Is Neurology a heavy CYA medicine? Is it a very litigious specialty?

It is really tough to make a life altering decision with maybe only 6 weeks of 3rd year experience and 1-2 month of a Sub-I. There is no way I can expect to know what it would be like to be a Neurologist day in and day out. The fact this is one of the highest rated burn out specialties does scare me. I appreciate all the answers and I look forward to continue the discussion.

Cya medicine- yes,
litigious- not more than average for non surgical specialists; might even be better because there are no fixed guidelines about many things and you can make a case for many different approaches to management. (other than gross negligence ofc)
Although I haven’t looked at actual statistics. May be if someone here has it that would be cool to see!?

There is a recent thread here on sdn about burnout in neuro, that would answer many of your questions. Burnout is high and the reasons for it are complex; but many of us here are extremely happy with Neurology ( see the thread on burnout for details about that)

 

[deleted496821]

I am very interested in Neurology as a specialty choice. The nervous system, brain and all the amazing pathology. No other specialty made me want to come in on the weekend to see patients. It sounds like a great specialty choice, but as a student I only know so much about what happens in the real word. So be my devils advocate. Help me make an informed decision on a career. Is it the chronic pain patients? The relationships between other specialties? Is it the pressure put on administration to see so many patients in a little time? Tell me why I shouldn't do Neurology or at least maybe comment on the parts of your specialty that drain you?

1) A near complete dissociation between basic Neuroscience (why many students are drawn to Neurology in the first place) and practical day-to-day Neurology. If you enter Neurology thinking you are going to contribute to explaining one of science's final frontiers (the human mind) and you end-up writing Lyrica scripts all day, seeing TIA consults for "5 minutes of non-specific tingling", and dealing with a huge volume of functional cases, then this alone will make Neurology a bad choice. Neurology residency/training can train you to do clinical research at-best on average. Even most "Academic Neurologists" in the U.S. make their career from case reports, review articles, and observational studies.

2) Relatively low pay, relatively high liability

3) CYA cases from non-Neurologists: Literally nobody in the hospital/clinic will put a sprinkle of effort into diagnosing a problem before calling you for utter and total nonsense. This happens in both academia and in private practice. In academia my team would get consulted for "New Myasthenia Gravis since this patient can't swallow", only to have to inform the primary team that the patient has an esophageal obstruction. I won't even describe how bad private practice consults are.

4) There is no safe-haven in Neurology. If you do acute Neurology (NCC, Stroke), you end-up at the mercy of Neurosurgery/Stroke (NCC) or you end-up having arguably the worst quality-of-life in medicine (Stroke/Neurointerventional). Additionally, due to the 24-hr window for MT, essentially any Neurologic symptom (or commonly non-central neurovascular symptoms) that any patient has will be called as a Stroke code. Outpatient is not any better where you will drown in functional neurologic disorders.

 

[neuro4me]

1) A near complete dissociation between basic Neuroscience (why many students are drawn to Neurology in the first place) and practical day-to-day Neurology. If you enter Neurology thinking you are going to contribute to explaining one of science's final frontiers (the human mind) and you end-up writing Lyrica scripts all day, seeing TIA consults for "5 minutes of non-specific tingling", and dealing with a huge volume of functional cases, then this alone will make Neurology a bad choice. Neurology residency/training can train you to do clinical research at-best on average. Even most "Academic Neurologists" in the U.S. make their career from case reports, review articles, and observational studies.

2) Relatively low pay, relatively high liability

3) CYA cases from non-Neurologists: Literally nobody in the hospital/clinic will put a sprinkle of effort into diagnosing a problem before calling you for utter and total nonsense. This happens in both academia and in private practice. In academia my team would get consulted for "New Myasthenia Gravis since this patient can't swallow", only to have to inform the primary team that the patient has an esophageal obstruction. I won't even describe how bad private practice consults are.

4) There is no safe-haven in Neurology. If you do acute Neurology (NCC, Stroke), you end-up at the mercy of Neurosurgery/Stroke (NCC) or you end-up having arguably the worst quality-of-life in medicine (Stroke/Neurointerventional). Additionally, due to the 24-hr window for MT, essentially any Neurologic symptom (or commonly non-central neurovascular symptoms) that any patient has will be called as a Stroke code. Outpatient is not any better where you will drown in functional neurologic disorders.

Do you regret your choice? What aspects of Neurology do you like?

 

[GuillainMollaret]

There are outpatient jobs with a 4 or 4.5 day work schedule with either no inpatient call responsibility or coverage of a weekend every 2 months or so (and this can even exclude stroke calls when you're on which would go to tele for example).

These opportunities offer the best lifestyle in neurology and much less liability.

I could personally never do neurohospitalist for many of the reasons that people have stated above.

 

[Splenda88]

Yes, but you still have to see and evaluate. To have an hour or so of your time wasted many times per day just because an ER or IM doctor can't be bothered to spend 5 minutes thinking about the CNS as anything other than "black box must call neurology stat" gets real old real fast.

IM docs are not blameless, but ER docs are the ones who consult for any bogus stuff. I am a PGY2 IM doing an EM rotation and just can't wrap my mind around of some of the stuff that ED docs do. The ED is a colossal waste of $$$

 

[Thama]

IM docs are not blameless, but ER docs are the ones who consult for any bogus stuff. I am a PGY2 IM doing an EM rotation and just can't wrap my mind around of some of the stuff that ED docs do. The ED is a colossal waste of $$$

Honestly, I find it far less forgivable coming from IM than EM. EM is supposed to be specialized in acute rescucitation and triage, all of the other stuff they do (urgent care stuff, being told to work up cases themselves when they should just be admitted for workup) is not what the ED is set up for. It isn't ideal that they often call garbage consults, but it's understandable given the untenable logistics of the modern ED.

IM, OTOH, is supposed to be trained to step back and think a little about problems anywhere in the body. Usually you guys do this well, except for some reason I know a grand total of zero internists who consider anything north of C2 to be something worth thinking about at the same level you would think about any other organ. When I see IM residents calling consults for "syncope on standing, rule out seizure" in someone with a SBP of 80 on a dobutamine gtt, and subsequently treating their ACGME mandated neuro rotation like a de facto vacation, then I stop seeing those consults as understandable and start seeing them as willful ignorance.

 

[dadaddadaBATMAN]

My disclaimer is that I am a neurology resident planning on doing outpatient. Most residencies are largely hospital-based.

The most frustrating thing about neurology to me is that there are very few objective tests which prevent consults to neurology from the ED. You can be consulted for the most ridiculous things, but it’s very difficult to “push back”. For instance, an ED doctor can’t consult other specialties (eg hepatology, nephrology, pulm, even often times general internal medicine) without some sort of objective tests being abnormal. Either O2 sats are down or Cr is up, etc. In neurology, a physician can consult you urgently because they are concerned the patient is having seizures or had/is having an acute stroke, neither of which may be true (only two examples of many). A negative head CT (the only quick, useful, objective, neurological test in the ED) is reassuring but very insensitive for many common pathologies that can present acutely. No other specialty is consulted so frequently for emergencies (i.e. acute stroke) multiple times per day for often subjective complaints where they are expected to drop everything (including handling a busy service) and go to the ED to make a very rapid treatment decision with life/death implications based on relatively little information.

The positive side of things is that is also what makes seasoned neurologists invaluable and currently the most in-demand specialty.

On the other end of things, I will readily admit many of our consults (ed) are garbage. They are also mandated by the institution

Exercise one iota of clinical judgement and get it wrong (or even get it right sometimes) and you spend the next six weeks receiving “re-education” from some ***** in a suit about why the vague numbness and tingling in left upper extremity for two weeks didn’t get stroke alerted.

And when the consults are garbage, it’s great when you just say that rather than requesting a mri/mra/mrv like our neurologists often do.

 

[neglect]

IM docs are not blameless, but ER docs are the ones who consult for any bogus stuff. I am a PGY2 IM doing an EM rotation and just can't wrap my mind around of some of the stuff that ED docs do. The ED is a colossal waste of $$$

Honestly, I find it far less forgivable coming from IM than EM. EM is supposed to be specialized in acute rescucitation and triage, all of the other stuff they do (urgent care stuff, being told to work up cases themselves when they should just be admitted for workup) is not what the ED is set up for. It isn't ideal that they often call garbage consults, but it's understandable given the untenable logistics of the modern ED.

IM, OTOH, is supposed to be trained to step back and think a little about problems anywhere in the body. Usually you guys do this well, except for some reason I know a grand total of zero internists who consider anything north of C2 to be something worth thinking about at the same level you would think about any other organ. When I see IM residents calling consults for "syncope on standing, rule out seizure" in someone with a SBP of 80 on a dobutamine gtt, and subsequently treating their ACGME mandated neuro rotation like a de facto vacation, then I stop seeing those consults as understandable and start seeing them as willful ignorance.

We are all tethered to our immediate experience at our facility. I got an IM inpatient consult for family history of a neurodegenerative disease recently from internal medicine. That was very stupid. But things are so bad that I just shrugged and did it. When I was a resident I had a huge amount of disdain for the ED attendings, worse after seeing them declare by fiat, "stroke." Then I spent an hour to find that they had anything but -> turf battle. One time I had to admit a patient PRESENTING with stage 4 lung CA to neurology for ER dx of stroke (where I think I recall crashing and going to MICU anyway).

Anyway, @neuro4me, good luck. My general advice is not to look at the field for the best and worst neurology can offer you. Neurology can be horrible, particularly inpatient neurology. You'll tell parents their kid is brain dead. And an HOUR LATER you'll tell someone with conversion disorder that they have a psychogenic condition (or you lie) and they will hate you. Then you'll see a stroke that you can't help, then one you can, then tell someone with syncope that they fainted and you didn't need to be there at all. Then a seizure patient and you have to pull their license and they get agitated, become an internet bully on your Press Ganey (BS) and other Yelp scores.

Clinic is better, but it is still hard. I tell someone very bad news nearly every day.

Don't look at that. Look inward. The ways to tell if neurology is for you: knowing that neurology CAN be miserable, can you see yourself doing anything else? Are you a better fit for anything else given the way you think, your temperament, your interests, your life goals. Are you driven by money or other status? Or are you intellectually driven? What sort of external validation do you need? Can you stand the thought of reading films, doing procedures, or admitting another case of urosepsis for the rest of your life?

Personally, I love the job I've created for myself. If I have regrets, I had "premature diagnostic closure" about myself. I didn't explore the other fields that have amazing lifestyle/money/satisfaction (without totally being a useless "cracked polystyrene man" and doing plastics or cosmetic derm, which is good as they would have been torture for me) like eyes, gas, ortho, ENT, XRT, etc. I looked inward very quickly, realized that neurology was a great fit for me, locked on it, wanted to learn EVERYTHING about it ASAP. Again, personally, I'm really not at all interested in anything else, so it wouldn't have made a difference.

 

[Neuro244]

1) A near complete dissociation between basic Neuroscience (why many students are drawn to Neurology in the first place) and practical day-to-day Neurology. If you enter Neurology thinking you are going to contribute to explaining one of science's final frontiers (the human mind) and you end-up writing Lyrica scripts all day, seeing TIA consults for "5 minutes of non-specific tingling", and dealing with a huge volume of functional cases, then this alone will make Neurology a bad choice. Neurology residency/training can train you to do clinical research at-best on average. Even most "Academic Neurologists" in the U.S. make their career from case reports, review articles, and observational studies.

2) Relatively low pay, relatively high liability

3) CYA cases from non-Neurologists: Literally nobody in the hospital/clinic will put a sprinkle of effort into diagnosing a problem before calling you for utter and total nonsense. This happens in both academia and in private practice. In academia my team would get consulted for "New Myasthenia Gravis since this patient can't swallow", only to have to inform the primary team that the patient has an esophageal obstruction. I won't even describe how bad private practice consults are.

4) There is no safe-haven in Neurology. If you do acute Neurology (NCC, Stroke), you end-up at the mercy of Neurosurgery/Stroke (NCC) or you end-up having arguably the worst quality-of-life in medicine (Stroke/Neurointerventional). Additionally, due to the 24-hr window for MT, essentially any Neurologic symptom (or commonly non-central neurovascular symptoms) that any patient has will be called as a Stroke code. Outpatient is not any better where you will drown in functional neurologic disorders.

I think as a pre-med point 1 really resonates with me. I don't like that there's a big disconnect between basic neuroscience and the actual clinical practice of Neurology. You're saying even as an academic neurologist you would still be very detached from using neuroscience and seeing more unique diagnoses? If that's the case, then neurology is quite offputting even though I love the brain more than any other organ.

 

[Telamir]

Quite honestly, if you're a pre-med don't even worry about this stuff until you're an MS3. It's pointless at your stage. I don't mean this to be rude or anything don't get me wrong, but when you start med school you'll actually be exposed to the gamut of medicine and you're likely to change your mind multiple times, I know I did.

 

[Neuro244]

Quite honestly, if you're a pre-med don't even worry about this stuff until you're an MS3. It's pointless at your stage. I don't mean this to be rude or anything don't get me wrong, but when you start med school you'll actually be exposed to the gamut of medicine and you're likely to change your mind multiple times, I know I did.

That's what I've heard many times yeah lol. At this point I'm debating if med school is still worth it for me personally due to how old I'll be upon finishing residency (41) and how many more hard years filled with sacrifices are ahead of me.

 

[neuro4me]

I was going to post this in the terrible consults thread but I dont want to go off topic. I see in a lot of academic centers where there is a lot of volume that those terrible consults would go to the PA or NP. Do you think that will help alleviate some of the burden. I know physicians have to protect their terf, but NP or PA is not going away so why not use it to our advantage?

The same thing happens in Surgical fields where the NP/PA sees everyone first and if they think it’s worth their surgeons time then they pass it on.

 

[Thama]

I was going to post this in the terrible consults thread but I dont want to go off topic. I see in a lot of academic centers where there is a lot of volume that those terrible consults would go to the PA or NP. Do you think that will help alleviate some of the burden. I know physicians have to protect their terf, but NP or PA is not going away so why not use it to our advantage?

The same thing happens in Surgical fields where the NP/PA sees everyone first and if they think it’s worth their surgeons time then they pass it on.

Those fields are usually ones where the subject matter is narrow and initial evaluations can be algorithmic. Even the best NPs I know would not be very useful flying solo on neurology consults, they would miss way too much.