Choosing intern year electives

[PhakeDoc]

Ok, so along the lines of the MS4 electives, as an intern, I have 4 months of electives available along with the following requirements (didn't see anything regarding intern year scheduling via the search): (incidentally, the only residencies at my prelim hospital are medicine, gen surg, and ER)

3 mos Gen Med (which admits all the med services with specialty consults)
1 mo Medical ICU
1 mo CCU
1 mo ER
1 mo Ambulatory
4 mos Electives (1 can be a surgical month)

I was thinking Cards, Rheum, ID, and Ophtho.

Or, if possible, do you think doing 1/2 blk Rheum and 1/2 blk Endocrine would be better?

What about Heme (without the Onc, the latter of which I don't either enjoy nor do I think is necessarily important for me unlike heme).

Also, would doing 1 mos CCU plus 1 mos Cards be too much cardiology?

I'd love it if some PGY2+, fellows, and attendings shared their experiences.

Thanks folks!

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[typhoonegator]

Floor cards is pretty different from CCU cards, and I would recommend both. You see a lot of floor cards-style issues on an inpatient neuro service.

Agree with rheum, ID, and ophtho.

You're lucky to have so much elective time. All my elective time as a prelim turned into sick call coverage, manifest as an additional oncology-ICU month and MICU. I think I had 2 days of cardiology elective my whole intern year.

 

[PhakeDoc]

Thanks for your input. One of the reasons why I chose this particular prelim was the flexibility of electives to hone in on things I needed/lacked.

So you don't think I'll be "missing" out on anything by not taking a neurology or neurosurgery elective during intern year? My thinking was that this year's purpose was to get as much medicine as possible under my belt, with the subsequent 3 (and lifetime) years to get the neurology. I just don't want to be behind the 8-ball the day PGY-2 starts in my advanced program.

 

[typhoonegator]

Well, there are plenty of people on this forum who think you should never miss an opportunity to learn more neurology, even during internship.

Personally, I think by getting as much medicine knowledge during internship as possible, you can fall back on that knowledge during residency and free your mind up to focus on the neurology then. If you are freaking out about how to manage AF with RVR all the time during your junior year, then you won't be able to think as much about the cardunculus lesion that may be causing that phenotype.

I did my internship at a hospital with a pretty small neurology department, and so IM interns all had to rotate through neurology to help with the inpatient service. I did not learn very much during those 2 two week blocks that helped me when I showed up as a PGY-2. Believe me, your seniors are going to assume a very low knowledge level when you show up on the first day of neuro residency. I basically escorted my juniors around for the first month or so. Don't worry about it -- it's all part of the progression. Obviously, the more you know, the easier the transition will be, but I still think having a good medicine base will be the most helpful in your PGY-2 year, particularly if you are at a ward-heavy program. Neuro peeps are pretty sick, and get lots of cardiac, pulmonary, and GI problems on service.

 

[DOctorJay]

A good rotation for you would be inpatient rehab (PM&R). This would allow you to see what happens to the stroke patients who make it out of acute care but can't go home.

 

[PhakeDoc]

TN - (or should it be TE?) - that's good to know. I guess my upper levels will have to deal with my non-neuro/medicine-only self then at that time!


DO - I will actually be doing a required PM&R rotation during my PGY2 year, so I guess I'll just leave it till then. Thanks for taking the time to offer your suggestion.

 

[maddog2020]

PhakeDoc,
It is indeed great to have so much flexibility in your preliminary year, but remember that neurology requires an internship to have "a) eight months in internal medicine with primary responsibility in patient care, or b) six months in internal medicine with primary responsibility in patient care and a period of at least two months time comprising one or more months of pediatrics, emergency medicine, internal medicine, or family medicine. Residents must spend no more than two months in neurology during this year."
Assuming your ambulatory month is medicine, you still need to devote at least one of your electives to one of the above (rheum, ID and cards are all good).
Best wishes

 

[PhakeDoc]

MD - thank you for bringing those rules to my attention - had quite forgotten about them. Yeah, the ambulatory rotation is in medicine. Thank you for the advice - it's fantastic seeing more attendings on here! And yeah, it's great to be able to think I'll get those electives (based on the schedule) instead of being forced to adhere to a strict regimen.



(See medsRus - it is possible to have an entire thread without quoting! Speaking of which, where did you disappear to today?)

 

[lanzarlaluna]

He is busy looking for a new job.

 

[PhakeDoc]

Seriously? He's not even started his "new" one! Good luck to him.

 

[BlackFrancis33]

I am one who believes in doing as much neuro as possible. If you have 4 electives I recommend at least 1 neuro rotation. An outpatient neurology rotation if available would be nice if a good mentor is available as you could focus on learning the exam. Neurosurgery would be another consideration although if this rotation is a real ballbreaker you may want to do something with more time off. Inpatient neurology as stated above provides plenty of opportunity to learn some medicine along with neurology. I hate to say it, but a Psych rotation wouldn't be the worst idea either. Man I hated admitting that...

Why are we the only specialty I can think of that implores interns and medical students to avoid exposure to our specialty early in training? Can you imagine medicine or surgery residents being told that? I have the view that you learn the medical management pertinent to neurology PGY2-4. I agree that a basic medicine background is important, but I think it is over-emphasized while neurology experience is discouraged. I don't get it. I am not trying to be contrarian just giving my opinion.

 

[typhoonegator]

Fundamentally, I agree completely with this sentiment. We're neurologists, we should be exposed to as much neurology as possible. From a purely practical standpoint, however, I think it does depend somewhat on the structure of your junior neurology year, and the size of your service. I went to a very inpatient heavy neuro residency, with cross-coverage of 30+ patients overnight along with floor and ICU admissions. As a junior, I would have been an ineffective resident had I tried to learn the important medicine along the way. I therefore relied heavily on my medicine training from internship. When the patients were still alive in the morning, then I could think more about the neuro. Might not be the best system, but it worked for me.

However, in a more relaxed environment, with smaller services and more outpatient exposure, I certainly agree that you could pick up what medicine you need during residency, without spending too much time on medicine issues you are unlikely to have to manage on your own (why do I still know the fluid resuscitation algorithm for acute pancreatitis?)

 

[danielmd06]

Why are we the only specialty I can think of that implores interns and medical students to avoid exposure to our specialty early in training?

This statement really stopped me in my tracks and made me think.

My own residency was horrendously busy, with 20-50 admissions collectively between a general and stroke service and as many more patients as consults. To be honest it was inpatient-heavy, with most of us functioning as internists/intensivists with extra knowledge in neurology rather than pure specialists.

To make matters busier (not necessarily worse mind you), there are no ENT or Ophthamology residency programs at my hospital - only the attendings for these respective departments. This led to lots of "neuro" otology and "neuro" opthamology consults overnight (particularly from the ER where anything could be a stroke until proven otherwise).

Like TN above, I feel that the electives I always encourage helped me tremendously as a resident. But with fellowship and private practice/academics looming I see the wisdom of focusing more solidly on the nuances of our specialty.

I suppose it comes down to your own fellowship goals, your own weaknesses that need to be improved, and the specifics of the program you are joining.

 

[Iliopsoas]

You might consider doing a month of Psychiatry during your intern year. Since you are doing it at an ACGME-certified hospital, it counts towards your ACGME Neurology requirements. All residents are required to do 1-month of Psychiatry during their residency. This would open up elective time during your PGY-4 & add a month of light call to your intern year.

 

[BlackFrancis33]

OK now to take this on a more argumetative slant. If you use the logic of doing medicine to prepare for your intern and PGY2 year (see also the previous post on MSIV elective recommendations) you miss out on a lot of neurology exposure. Stay with me here...

If you give the follwing advice to an MSIII: do medicine-related rotations MSIV to prepare him/her for internship, then recommend that during internship to do more medicine rotations to prepare for the PGY2 year, and then the PGY2 year is dominated mainly by inpatient care doing medicine with the hope that said resident will have time to think about the 'neurology of it all' the next day, is this really good advice and even more importantly is this the best way to train a neurologist?

I think the MSIV and intern years should consist of as much neurology exposure as allowable. I don't think that PGY2s starting with a cursory knowledge and little exposure to neurology is a good thing. I think this represents a problem. This only allows 2 years, PGY3 and PGY4 to do neurology electives and learn the nuances of our expansive specialty. We have long been separated from internal medicine. Internists learn less and less neurology during their residencies (this was the least tested specialty on the last internal medicine in-training exam at my institution). I think we should value what we do and encourage up and coming neurologists to get as much neurology exposure as possible MSIII-intern years.

 

[fanondelaterre]

When I saw this question my first instinct was make sure you take as much medicine as possible. But what some of the others have said makes sense. I might be in the minority, but I like to see neurology as being another part of internal medicine. For example, as a neurology resident it is good to be able to understand the cardiac system extremely well- think of all your stroke patients with hypertension, arrythmia, atrial fibrillation w/ RVR, as well as diabetes. But it goes beyond that, how about when you are consulted for a patient for possible dysautonomia and note that they also have renal failure, heart failure, and see an EKG that shows low voltage and suggest working up for amyloidosis... that is not necessarily something that you will pick up from neurology training alone. How about the autoimmune disorders/rheum that overlap with neurologic conditions? A decent understanding of the respiratory system is important for the neuromuscular emergencies (granted eventually ICU will come to the rescue). Or understanding the various medical conditions and medications patients are taking (think oncology/hematology) and how they can affect the neurological system or how your recommendations for their neurological ailment might affect their other medical problems. Maybe like someone else might have said, a good balance between the two is the best solution because I agree, I wish I had known a little something about neurology before my PGY II year; but I had a rigorous internal medicine intern year with 3 ICU months, one CCU month, one cardiology month and missed out any electives because I had to cover another intern which despite being rough makes me very comfortable dealing with the medical issues of the patients as well as the neuro-ICU patients I admit or cross cover.

having said that: I recommend a cardiology/CCU (usually required), ICU (usually required), infectious diseases, rheumatology, and to highly consider heme/onc (in patient).

 

[BlackFrancis33]

[OK, now I'm flat arguing with ya. But I do enjoy the intelligent discourse...]

Neurology is not an internal medicine subspecialty. This assertion sets us back 20 years or more. Subspecialists in internal medicine spend 3 years in internal medicine training and fellowship. Neurology is its own residency with some neurologists pursuing fellowship training to become neurology subspecialists. Neurology is not 'internal medicine for the brain' it is its own completely separate specialty with no ties to internal medicine or the board that governs internal medicine.

I do not argue that internal medicine training is necessary. This is already required during med school and internship. Cardiology, ICU, inpatient medicine exposure are required. But internal medicine exposure should not, however, completely eclipse trainees exposure to neurology. Rotations in rheum, cards, ID are all good ideas, I did electives in all of these. I still did 2 neurology rotations with a neurology continuity clinic throughout my internship. I'm totally with ya on the hem/onc exposure as I'm soon to enter neuro-onc fellowship.

Neuro-vascular, Neuro-ID, neuro-onc, Neuro-ID, neuro-immuno etc. are best learned from fellowship trained neurologists in those specialties. Internal medicine subspecialists consult me when there are rheum, onc, or ID diseases w/ neuro manifestations. In my experience, I know the neuro stuff as well, almost always better, than the medicine sub-specialists. I rely on those specialists heavily in the same way ie rheum manifestations in a patient presenting with some type of neurovasculitis etc. We need each other, in other words...isn't that sweet?

I don't think we are really disagreeing, necessarily. Yes, you need internal medicine training including subspecialty exposure. But this should not be at the complete expense of getting some neurology exposure during one's formative years. I will never agree with you that I am an internal medicine sub-specialist. I am not, no where on my certification does it say internal medicine. It is bad enough that I have to put up with it mentioning psychiatry before neurology on my ABPN certificate.

 

[exgatr]

I could only elect to do what I was told and like it during my intern year

 

[fanondelaterre]

ya, I think like you said we are pretty much agreeing. As for what I said "neurology as being another part of internal medicine" I do not mean it as a subspecialty within medicine- I too am happy that it is separate and fortunately attend a program not bound by internal medicine but I meant that neurology remains part of the body connected and influenced by all the other organs which is not always appreciated or atleast dismissed at times. I think we probably have to understand medicine better than (of course) orthopedics, ENT, etc. who do not have to take a medicine pre-lim but also better than dermatology, ophthalmology who do have to take a year of internal medicine (I am torn on radiology... they probably should know their medicine pretty well).