I don't understand why people are still debating the value of neurology.
First of all, I want to point out that diagnosis, in and of itself, is one of the most important functions of any doctor. If this was all that neurologists did, they would still be of great service to many patients who are often misdiagnosed and then incorrectly treated (e.g. the conversion d/o patient receiving tPA, or the patient with convulsive syncope being put on dilantin). Misdiagnosis by many studies occurs 15% of the time. I bet the incidence is far higher with neurological illnesses. Anyone in neurology knows that even if you were to get a whole spine and brain MRI in every patient with a central nervous system disorder, the diagnosis is still not apparent in a good proportion of them without a good neurologist involved.
Second, like any other specialist, neurologists help provide *optimal* treatment. The question is how good is this "optimal" treatment compared to the "sub-optimal" treatment from a generalist? There are provocative data in the stroke literature suggesting that morbidity is reduced significantly by putting patients onto a dedicated stroke service. Anecdoctally, I have seen many instances where the ED physician wants to or does not want to give tPA, and we neurologists end up deciding otherwise based on the NINDS criteria and clinical judgement. Applying NINDS criteria strictly is proven to improve outcomes. Outside of stroke, epilepsy treatment requires knowledge of the various epilepsies and anticonvulsants (e.g. a friend recently was correctly diagnosed with JME as opposed to simply "seizure disorder" and thereby put on treatment that completely stopped her seizures). Many more examples of this exist.
Third, deciding who and who does not get surgery for epilepsy, movement disorders, or stroke/ICH, requires not just a neurologist, but probably a sub-specialist within neurology. The literature carries reports and case series of patients being incorrectly referred for surgery primarily because a proper expert was not involved.
Fourth, neurointensive care is revolutionary. While they may not be the best general intensivists (although exceptions exist), treatment of SAH, TBI, status epilepticus, and GBS, among other illnesses, has revolutionized with the NICU. Studies suggest a 30% morbidity/mortality reduction with dedicated NICU's at certain institutions.
Fifth, necessary procedures that neurologists regularly perform include EEG, EMG/NCS, and intraoperative electrophysiology. Other studies such as evoked potentials, sleep studies, lumbar punctures, etc. are often best performed by neurologists. The usefulness of an EEG is obvious. The EMG/NCS is useful for diagnosis, so see my first comment.
Sixth, I would beg the question. Why have generalists when there are enough specialists to take care of each specific problem? An internist can manage diabetes, but an endocrinologist usually does so better. Similarly, an internist can work up a stroke, but a neurologist will usually do so better. They are more aware of the current literature and can catch rare findings more easily (e.g. we recently diagnosed a patient with FMD clinically leading us to send her for angio, confirming the diagnosis, and finally referring her for renal artery and peripheral artery imaging to treat her renal artery stenosis--previously missed by her internist.) Finally, the neurological exam, while obviously useful diagnostically, is perhaps even more useful in helping to follow the patient's progress over days, months, and years.
And finally, seventh, people regularly underestimate the value of neurologists and overestimate the value of other specialties due to historical and economic reasons. Neurology historically has been a slower specialty to progress, primarily due to the BBB, the rigid bony structures surrounding the central nervous system, and its vastly greater complexity compared to other organ systems. This is now changing, and over the next few decades the growth in neurology will make it as powerful as any of the "elite" medical specialties (e.g. cardiology, transplant surgery). I predict revolutions including immunotherapy for dementia, DBS for epilepsy, DBS for coma and possibly even TBI (which may also benefit from certain forms of immunotherapy!), and of course, my favorite, interventional means to treat stroke. Economically, the medical system has generally favored procedures and quantity over quality. This is now changing as people are realizing the importance of making the right diagnosis from the start, the importance of having an expert in making the right diagnosis, and the usefulness of longer more thorough clinic visits in avoiding further costly procedures. For now neurologists are relatively poor compared to other specialists, but this will likely change.
So the stereotype is far off the mark. In my opinion, the main thing propogating the stereotype is economics and the fact that the best medical students are swayed by the opportunity to make more money in other specialties.
B
