Thanks for your questions!
The level of charting is always something you can expect to do when seeing any patient, doing any procedure or managing a telephone encounter. So in that regard every speciality has to perform regular charting. I think I have decent insight into this questions as I have friends from many specialties and I myself was an internal medicine resident my intern year (if you did not know, Neurology is a four year program with the first year being completed as either a preliminary medicine resident or a transitional year resident). Neurology, and most specialties outside of general specialties (IM, Peds, Family, etc) do not have to manage the extensive primary care issues that primary care docs do. This can be a massive task in a large practice. Everything from Handicapped passes, walkers (and which one/what kind), driver license issues for the geriatric populations, school/work notes, refills, Med recs, PT/OT, etc falls on your hands. You place all consults (or the vast majority. I'll go ahead and consult a subspecialty of neurology or neurosurgery if I need their input). As a PCP you have to implement most recs (for example, I'll start the antiepileptic, headache, Parkinson's meds, etc, but if I hear a murmur or they have a high creatine, then I send them to their PCP and write something. Like "Pcp may consider nephrology input for the patient elevated creat level"). Also when a patient is admitted specialists like neurology write a much more brief and focused note then the massive H&Ps detailing every Med, condition, surgery, image, etc that primary teams like IM, Peds have to write. In that regard neurology is great. I have templates for most things and can finish a note quickly.
I never get burned out...Neurology is the Wild West friend. We see the most interesting and unbelievable things happen on a regular basis. Take a clot out of a pregnant woman's left MCA, stop someone's seizures or MS so that they go on to do anything they want in life, stop a Myasthenic or GBS patient from dying using plasmapheresis or IvIG, make a diagnosis that no one else has even heard of and then say something awesome like "elementary exam revealed pure word deafness which narrowed the differential diagnosis to those diseases causing cortical deafness", coil an aneurysm, embolize a vessel feeding a brain tumor which shrinks it small enough so that the surgeon won't hit the language areas anymore when they attempt to remove it, perform a muscle or nerve biopsy, read an EEG and diagnose non-convulse seizures, complete an EMG and change the "suspect carpal tunnel" referral to a "Multi focal motor neuropathy with conduction block, perform a trans cranial Doppler, intubate someone in the NsICU perform a lumbar puncture on a new born in the NICU and save their life and development, perform EMG guided Botox into tiny or dangerous areas to alleviate movement disorders, spasms, spasticity, dystopia or rigidity or, lastly, stop the debilitating migraines of a single working parent who has to drive in the sunlight while in excruciating pain because they have a child a school by using Botox or other expert approaches including nerve blocks, infusions and medications. All while enjoying great pay, the number one in demand specialty per practice link and relatively 8-5 hours. No way do I get burned out.
The jurisdiction of neurology is the nervous system on paper but we are called into al types of medical, pediatric, obstetric or surgical situations. Head trauma is managed by neurosurgery if they go to surgery but many do not (if they are not injured enough to merit it or if they are too injured to benefit from it) and then they go to the Neuro Icu or the neurology advanced care unit ("the impatient neurology ward"). Also we are involved in head trauma if there was any syncope, seizure, stroke, dissection or thrombus or aneurysm/AVM involved in the trauma. We are also called for prophylactic seizure medication management. We are often called to see athletes with concussion, plexopathies, stretch or other peripheral nerve injury and for post concussive syndrome.
In your scenario where there is not a neurologist then whatever doctor is there "ED, IM, etc) will usually call us and arrange transfer. Remember that the new guidelines state that stroke should bypass all non-stroke centers to get to a primary stroke center or stroke ready center (has CT, telestroke and TPA capabilities with ability to immediately transfer to a stroke center after tPA or non tPA decision is made) so that scenario is not as common. We perform telestroke, tele neuro imaging, and tele EEG for many rural hospitals so most hospitals have access to us and use us. Most are happy to transfer a complicated neurology or even a more straight forward one to see a neurologist. Doctors are not cavalier at the expense of our patients and we all want the best trained person available for that situation to see the patient and help them. I have people referred to cardiology when I hear a pathological murmur, it's not a pride thing. Internists, ED docs, etc are no different. They are generally happy to consult neurology to put themselves, the patient and their families are ease when the nervous system may be potentially involved.
Remember a neurologist can also admit a patient to the hospital myself instead of consulting to the hospitalist if I wanted to. In that cause I would have full jurisdiction.
Psych cases that are not totally straight forward usually merit a neurological evaluation as you wouldn't want to miss a neuropsychiatric issue from a systemic or neurological disease. Psychiatric diseases are typically a diagnosis of exclusion to ensure the safety of the patient.
I do not agree that the hospital would function just fine. We can earn multiple accreditations for the hospital such as various levels of stroke certification, epilepsy center certification, MDA/ALS, MS center, to name a few. Without us you can't get them and if you don't then other hospitals will and the hospital will not gain in reputation or financially. We are often a core rotation or elective in medical school so without a neurologist on staff if would be hard for an academic institute to associate with the hospital. Also their would be no EEG or neuro critical care resulting in tons of transfers. If you see the trends around the world, neuro ICUs, epilepsy monitoring units, sleep centers, interventional pain centers (yes you can do pain and sleep from neuro and yes we do match these spots), Neuro interventional units (yes from neurology, all three where I trained were neurology) and headache centers to name a few are being built everywhere. These facilities require, often multi million dollar investments and people don't invest that kind of money into specialities that are not needed. Additionally, in many communities, the standard of care (what the average physician in that community would do in that situation or a similar situation) would be to have a neurologist involved in certain illnesses. Going against the standard of care is not something any of us would typically advise. Having a specialist involved in the area that he or she trained does not make the patient less safe and often results in shorter length of stay and better outcome.
The neurohospitalist field is growing rapidly. We have two at my hospital. They both work two weeks monthly and make 305K. One also has a fellowship in sleep so he reads studies for one of his off weeks and then takes a week off. He said he takes home another 100k for the sleep studies. It's not a bad gig. You could do it as a general neurologist limiting your training to four years after medical school or try to add value to your contract and expand your skills in a specific area by doing a fellowship.
Thank you for these question. I hope this helped!
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