Best Compensation v QoL Subspecialty?

[Chibucks15]

Hey everybody in anxiously waiting for match day I was wondering what your thoughts were on the best QoL subspecialty compared to compensation? I’m on the fence of even doing a fellowship (planning on staying in a mainly outpatient role in the Midwest) but if I do I want it to set me up well long term.

EDIT: I know billing for neurophys procedures augments outpatient well but I have a personal interest in movement and dementia, but if I have an outpatient spot I can make my roster those two areas without the fellowship if need be.

I’m a nontrad with a family and a baby on the way so I’m not super wanting to extend training and years without an attending paycheck any more than I have to. Thanks!

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[Postictal Raiden]

If you know you want to live in the Midwest (outside large cities like Chicago) then only do a fellowship if you’re truly interested in the subject matter.

For me, I want to be a general neurologist but I’m geographically restricted to the West coast. In add I feel id like to augment my diagnostic skills. That’s why I chose neurophysiology.

 

[Thama]

For compensation movement >>>>> dementia. DBS and BTX tend to bill well. A clinically-focused fellowship will give you those skills in a year.

 

[DocMom1]

Note the potential massive opportunity cost with fellowship.. you will be sacrificing 1-2 years (sometimes more) of attending salary for knowledge that might not translate into higher earnings. Here in Florida, out of residency, you can find positions in general neurology / neurohospitalist that offer starting salaries of 375-550K with potential for bonuses; this could translate into 0.5-1+ million in relative income "lost" through the opportunity cost of fellowship. Beware as some fellowships (e.g., cognitive) may box you into careers that paradoxically will lead to lower salaries if you confine your practice to that subfield. Just something to consider as you think about paying off medical school debt / supporting family / other life goals... residents unfortunately are seldom introduced to these concepts, and hospitals are better off the longer they can keep you as a trainee...

 

[sharkbaitwhohaha]

Note the potential massive opportunity cost with fellowship.. you will be sacrificing 1-2 years (sometimes more) of attending salary for knowledge that might not translate into higher earnings. Here in Florida, out of residency, you can find positions in general neurology / neurohospitalist that offer starting salaries of 375-550K with potential for bonuses; this could translate into 0.5-1+ million in relative income "lost" through the opportunity cost of fellowship. Beware as some fellowships (e.g., cognitive) may box you into careers that paradoxically will lead to lower salaries if you confine your practice to that subfield. Just something to consider as you think about paying off medical school debt / supporting family / other life goals... residents unfortunately are seldom introduced to these concepts, and hospitals are better off the longer they can keep you as a trainee...

Good points. But the other side of the coin to consider. Most residents don't get enough training in EEG or EMG. An extra year of training to become proficient in these studies to make sure you're not an incompetent goon diagnosing everyone with status epilepticus or with CIDP.

 

[scoopdaboop]

As a current med student whose interested in neurology a lot more , it's pretty nice seeing neurology salaries and qol go up.

 

[Chibucks15]

Appreciate the good points everyone! I’m wondering if I can’t use my elective time to get confident in one of the modalities then live in a Milwaukee type city. I have a mentor that did that and is in a small city and does EMG/EEG things.
The big decision I have is the opportunity cost. I already took a gap year and half before med school so adding more years with fellowship is looking less and less appealing unless I absolutely have to. I know I’ll be in the upper Midwest likely outside Chicago so I think itll be viable either way just definitely don’t wanna add years onto training if I won’t need them

 

[Telamir]

I had a med student this week tell me he was interested in psych but also was liking neuro because he thought it was "pretty chill"...Oh my sweet summer child.

 

[xenotype]

Note the potential massive opportunity cost with fellowship.. you will be sacrificing 1-2 years (sometimes more) of attending salary for knowledge that might not translate into higher earnings. Here in Florida, out of residency, you can find positions in general neurology / neurohospitalist that offer starting salaries of 375-550K with potential for bonuses; this could translate into 0.5-1+ million in relative income "lost" through the opportunity cost of fellowship. Beware as some fellowships (e.g., cognitive) may box you into careers that paradoxically will lead to lower salaries if you confine your practice to that subfield. Just something to consider as you think about paying off medical school debt / supporting family / other life goals... residents unfortunately are seldom introduced to these concepts, and hospitals are better off the longer they can keep you as a trainee...

This is key. Many residents waffle about several fellowships out of some vague interest in them, but the real key is your skills and comfort with various aspects of the entire field. If one is going to do a fellowship, there needs to be a skill or three picked up to offset the opportunity cost. Movement -> DBS, botox. CNP/NM/Epilepsy -> cEEG/ambulatory EEG, EMG, EMG guided botox. NCC for airway, tubes and lines, invasive ICP neuromonitors even EVDs at some places.

Stroke for example has limited real utility if one had plenty of acuity in residency- only benefit is directorships at hospitals with a small income bump for administrative hassle. Cognitive/behavioral has some computer based tests that are billable but outside of that it is a deep plunge in income for increased visit complexity. Neuro-optho is generally a big money loser without the surgical aspects a neurologist really can't learn. Headache really doesn't require a fellowship if your residency covered the basics.

For OP if you like movement, pick a fellowship that has a lot of botox and DBS built in as these bill well. A tidy income can be made in movement, and its really tied with NM in terms of complexity/raw clinical skill required for accurate diagnosis. The main benefit of a fellowship year is the added competence you gain.

 

[Thama]

I had a med student this week tell me he was interested in psych but also was liking neuro because he thought it was "pretty chill"...Oh my sweet summer child.

At my very old-school, beat your ass down with q4 28 hour call and 10+ solo admits/night residency, we occasionally got PGY2 transfers from medicine to neuro who were looking for something "less intense". Never mind that the medicine program at the same institution was basically a beach resort compared to our program. The inevitable looks of "I've made a huge mistake" on their faces by month 2 were always precious.

 

[scoopdaboop]

At my very old-school, beat your ass down with q4 28 hour call and 10+ solo admits/night residency, we occasionally got PGY2 transfers from medicine to neuro who were looking for something "less intense". Never mind that the medicine program at the same institution was basically a beach resort compared to our program. The inevitable looks of "I've made a huge mistake" on their faces by month 2 were always precious.

But attending lifestyle is chill though right.

 

[Thama]

But attending lifestyle is chill though right.

More chill than residency, sure. But this isn't derm. You're going to be seeing complex stuff in the same time slot that internists see a hypertension patient in, and unlike many specialties you have to fit a real exam in there somewhere.

 

[scoopdaboop]

More chill than residency, sure. But this isn't derm. You're going to be seeing complex stuff in the same time slot that internists see a hypertension patient in, and unlike many specialties you have to fit a real exam in there somewhere.

Yeah not a big deal. I think more important than that is hours etc. working nights etc.

 

[Epic786]

With the new billing code, everything is changing. You can bill much higher for dementia patients just based on the time you spend with them with out doing a complete neurological exam and writing PHX and going over ROS.
Pain has the highest income potential but difficult to get in.
You cannot do neurohospitalist for ever---it is too much stress.

 

[Thama]

Yeah not a big deal. I think more important than that is hours etc. working nights etc.

That kind of thing varies completely by your practice setup. The ludicrous salary numbers you'll hear splashed around here occasionally are usually in settings where you'll be working a lot of weekends and covering a ton of call while being expected to see a volume of patients that's not possible without taking half your day's work home with you. In a quality large private/academic practice the call burden is typically pretty manageable.

 

[Telamir]

At my very old-school, beat your ass down with q4 28 hour call and 10+ solo admits/night residency, we occasionally got PGY2 transfers from medicine to neuro who were looking for something "less intense". Never mind that the medicine program at the same institution was basically a beach resort compared to our program. The inevitable looks of "I've made a huge mistake" on their faces by month 2 were always precious.

So I'm not the only one who got some sort of sick pleasure of watching people break?

Don't get me wrong...I was helpful, I wasn't malignant, I didn't make anyone's life harder than they had to be...but I did like that moment when they finally broke. That look....

 

[Staphylococcus Aureus]

Does stroke fellowship really not add that much?

 

[Telamir]

Ah, the finer points of aspirin 81 vs 325.

 

[GuillainMollaret]

QOL is going to be dependent on the group you join rather than what fellowship you did. Some groups have no call. Some groups have q4 night stroke call and rounding at the hospital every other weekend.

As an aside, one fellowship not mentioned is neuro-immunology. No procedural skills gained, but it seems like every neuro practice is looking for an MS person and I'd argue that this is the most in-demand subspecialty right now.

 

[Thama]

Does stroke fellowship really not add that much?

For the vast majority of strokes you'll see, no it doesn't. Hell, everything beyond the first 2-3 months of residency doesn't add much.

But for that 5% of cases that are really weird or involve a rock and hard place, it can be helpful to teach you how to think through them and get comfort with the difficult cases.

 

[dramw]

How about tele stroke? Can you pick how many days per week to work? Is it shift work? How do you pick which case to see? Also, how much does it pay per day and do you get extra pay for seeing a case?

 

[Telamir]

Google.com

seriously there are threads discussing this on the forum and not all that old. Please search. There’s also members who do tele Neuro exclusively; PM them.

 

[Staphylococcus Aureus]

For the vast majority of strokes you'll see, no it doesn't. Hell, everything beyond the first 2-3 months of residency doesn't add much.

But for that 5% of cases that are really weird or involve a rock and hard place, it can be helpful to teach you how to think through them and get comfort with the difficult cases.

Sorry what I meant to say is does a stroke fellowship really not necessarily add to compensation and job competitiveness/opportunities?

 

[Telamir]

Job opportunities eh maybe a little. Not much in compensation in my experience. There’s no procedure or other skills associated with the fellowship.

 

[Thama]

Sorry what I meant to say is does a stroke fellowship really not necessarily add to compensation and job competitiveness/opportunities?

A lot of neurohospitalist jobs especially in competitive markets will either require or strongly prefer vascular fellowship.

 

[xenotype]

A lot of neurohospitalist jobs especially in competitive markets will either require or strongly prefer vascular fellowship.

Often because they need a stroke center director to maintain accreditation. Oh, and they also expect you to read 16 hours of EEG with a seizure on it so good luck with that after doing a stroke fellowship. And 50% of the consults/stroke alerts you see won't be stroke, they'll be mostly AMS and epilepsy. Bigger places can afford to try to split this up, but it is never a perfect split.