Have you noticed a shift in interest towards inpatient neurology?

[SnowBrain]

I’ve been wanting to be a neurologist ever since I shadowed one back in 2013 as a freshman in college, and here I am as a PGY-1 in 2025 (wow oh my god that was painful to type out).

Back when I was in college I was interested in learning more about the landscape of neurology and it seemed like back then everyone was gearing towards outpatient neurology. I remember a statistic something like 90+ percent of neurologists are outpatient.

But now it seems like the interest in neurohospitalist is booming. Not sure if this is because Neuro IR is more attainable for neurologists now. Or whether it’s because neurologist run closed NCC units have become more common. Or if it has to do with pay structure with Medicare on a national scale? I’ve just noticed, anecdotally, that there’s been a massive shift in interest of people now wanting to pursue inpatient neurology.

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[Spinothalamic]

Anecdotally, yes.

Inpatient currently generally pays better. Inpatient is seen as “cooler” to many trainees (which is typically synonymous with higher acuity). No Inbasket/phone messages with inpatient. Finally, outpatient general neurology is too hard (partly because vast majority of neurology training is inpatient and then you are thrown to the wolves; partly because outpatient general neurology encompasses thousands of possible presentations/diagnoses.)

 

[s5260205]

Majority of students applying to neurology whom I've interviewed want to do stroke, NCC, or NIR. I think this is quite skewed due to students being mostly inpatient with limited exposure to other subspecialities within neurology.

When it comes times to residency, people are exposed to outpatient mostly through their resident clinic which unfortunately is filled with "leftover" patients after all the subspecialists pick out their own share of patients they want to see. These resident clinic patients would often have chief complaints that are vague and likely psychogenic. Many people then become quite jaded seeing these patients throughout residency. With the increase in purely inpatient neurohospitalist positions, especially the 7-on and 7-off schedule, people are naturally drawn toward inpatient.

I should say that as attending however, you will be able to see and manage many different neurologic conditions. Certainly, psychogenic complaints abound still, but there will be a plethora of other interesting patients you will encounter. For more general neurology positions, you won't be able to customize your patient panel. However, if you join a larger neurology practice, you will be able to do so. In large hospital-based or academic practice, you can even limit what chief complaints or diseases you will see. In short, outpatient is so much more rewarding being the primary neurologist managing your patients and following along throughout their disease course. This is in contrast to inpatient neurology where you are constantly under the pressure of all the hospital politics. There are pros and cons to each position, but I always like to tell residents that outpatient is not as bad as resident clinic experience.

 

[Aldertonghen]

- No inbasket messages, refills, and phone calls (which can take upto 10-20% of your clinic time per day)
- 7 days on, then 7 days in Hawaii sounds great to me in the middle of a gruelling residency
- Patients improve over days and you can see the improvement right away instead of waiting 3 months follow up.
- Less functional presentations, especially if neurocrit or NIR.
- more $$$ unless you’re doing pain, or sleep+EEG study outpatient.
- Resident clinic is a terrible wastebasket mostly for specialists to throw all functional patients into

 

[Neurogeneral]

There is no real “free lunch” no matter whether you do inpatient or outpatient. I did both for several years and they both come with their pitfalls. Having said that, over a year ago, I left my job and gave up inpatient completely and it has been liberating to say the least. In retrospect, I did not find inpatient neurology professionally satisfying. Seeing altered mental status patients became the bane of my existence. There has also been an explosion of new medications and treatment options but you hardly ever get to prescribe these as a neurohospitalist. In my clinic, I prescribe all kinds of AEDs, migraine meds, dopaminergic meds, MS drugs, amyloid beta monoclonal antibodies, etc.

Inpatient is great if you want to work real hard and make more money. You work more hours, see more patients, work weekends, take call, etc.

When I talk to my inpatients friends the weeks they are on, they are usually stressed and getting slammed. The seven days off course though is a huge plus for them and may be worth it. But I am usually done by 3:30 on weekdays and have my weekends completely off. I dont ever feel overwhelmed with seeing patients and doing notes. I don’t get called or paged outside of office hours.

And yes you are likely gonna see less functional patients as a neurohospitalist but you will not be spared this completely and you will often have to see these patients multiple days in a row for the duration of their hospitalization.

 

[Spinothalamic]

Anecdotally, yes.

Inpatient currently generally pays better. Inpatient is seen as “cooler” to many trainees (which is typically synonymous with higher acuity). No Inbasket/phone messages with inpatient. Finally, outpatient general neurology is too hard (partly because vast majority of neurology training is inpatient and then you are thrown to the wolves; partly because outpatient general neurology encompasses thousands of possible presentations/diagnoses.)

FYI, I was answering quickly with some of the perceived benefits of inpatient. The post above discusses some of the downsides pretty well. I will say that with outpatient it is extremely nice to have open weekends all of the time and never have to worry about missing things in the evenings!

 

[deathmerchant]

I’ve been wanting to be a neurologist ever since I shadowed one back in 2013 as a freshman in college, and here I am as a PGY-1 in 2025 (wow oh my god that was painful to type out).

Back when I was in college I was interested in learning more about the landscape of neurology and it seemed like back then everyone was gearing towards outpatient neurology. I remember a statistic something like 90+ percent of neurologists are outpatient.

But now it seems like the interest in neurohospitalist is booming. Not sure if this is because Neuro IR is more attainable for neurologists now. Or whether it’s because neurologist run closed NCC units have become more common. Or if it has to do with pay structure with Medicare on a national scale? I’ve just noticed, anecdotally, that there’s been a massive shift in interest of people now wanting to pursue inpatient neurology.

First, congrats on achieving your dream!! Next 2 years will likely be the worst, but it will improve rapidly after that, if you make the right decisions.
Some good points above. I do both inpatient and outpatient so my 2 cents-

Inpatient can be very busy and cause burnout fast if working at a busy stroke/tertiary center. It can also be very easy/relaxing if you pick the right job (like mine). Round for few hours and go home. Work 14 days/month and get paid well. No baskets/tasks/refill/patient calls. - I can also round whenever I want, some days I round in the evenings if I'm playing golf and service is not busy, other days early in the morning. The flexibility is very helpful when kids are involved too. I suggest if you are work hard/party hard type of person or not very social/patient/good listener or you feel like a weekend is not enough off time for you (like me). Pick inpatient.

Outpatient has a higher ceiling to make money, esp in certain sub-specialties. But, you have to see a lot more patients to make more than inpatient. Essentially you can control how much you make as outpatient to some extent. But by god its annoying. If you are in a subspecialty it might not be that bad. But by the time I see the 5th AD or migraine or dizziness patient, I don't have much left in me.

Bad analogy but outpatient is like you own a nice restaurant and patients are patrons. you have to satisfy them every time with good food and service and cost and wait times etc. Some are annoying and extra demanding and might even leave a bad review or keep calling afterwards as well. Inpatient is more like food delivery, you drop-off the food and you get out !!

 

[SnowBrain]

First, congrats on achieving your dream!! Next 2 years will likely be the worst, but it will improve rapidly after that, if you make the right decisions.
Some good points above. I do both inpatient and outpatient so my 2 cents-

Inpatient can be very busy and cause burnout fast if working at a busy stroke/tertiary center. It can also be very easy/relaxing if you pick the right job (like mine). Round for few hours and go home. Work 14 days/month and get paid well. No baskets/tasks/refill/patient calls. - I can also round whenever I want, some days I round in the evenings if I'm playing golf and service is not busy, other days early in the morning. The flexibility is very helpful when kids are involved too. I suggest if you are work hard/party hard type of person or not very social/patient/good listener or you feel like a weekend is not enough off time for you (like me). Pick inpatient.

Outpatient has a higher ceiling to make money, esp in certain sub-specialties. But, you have to see a lot more patients to make more than inpatient. Essentially you can control how much you make as outpatient to some extent. But by god its annoying. If you are in a subspecialty it might not be that bad. But by the time I see the 5th AD or migraine or dizziness patient, I don't have much left in me.

Bad analogy but outpatient is like you own a nice restaurant and patients are patrons. you have to satisfy them every time with good food and service and cost and wait times etc. Some are annoying and extra demanding and might even leave a bad review or keep calling afterwards as well. Inpatient is more like food delivery, you drop-off the food and you get out !!

Thanks for the response. Do you practice general or sub-speciality neurology?