Headache versus Sleep

[GrtWhtNrth]

So I am really split between doing a fellowship in sleep.or headache. I really like both, find both and lifestyles ate similar. One thing that I don't have a clear sense of is salary differences between the two subspecialties. Any thoughts?

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[danielmd06]

I would certainly suggest rotating on both services first. Headache medicine and sleep medicine are really rather different in terms of types of problems, work flow, and diagnostic testing. I'm curious if you have done official elective rotations in each or have merely seen a few patients from each field in a general neurology clinic.

If you have financial questions related to both, you will probably find the attendings at your institution in those respective fields can help you.

Good luck.

 

[neurologist]

You won't find any reliable published info on this.

You can try to ask people their salaries, but I doubt they'll tell you in any meaningful detail. Plus, it'll vary a lot based on multiple factors (geography, employment status, etc).

In an academic or hospital-employed situation, you may make slightly to moderately more than a general neurologist by doing sleep (because of the $$ from sleep studies). In a private neuro group or sleep practice there may be somewhat even more of a difference. However, that will change as reimbursement for studies drops and more (much less expensive) home sleep studies are done.

If you're really going to decide this based on money, and you honestly like doing headache, I would suggest doing a headache fellowship, then moving to a part of the country that has lots of crazy people with lots of money, and opening a CASH ONLY/NO INSURANCE headache clinic. Seriously. If I liked headache, that is exactly what I would do.

 

[danielmd06]

You won't find any reliable published info on this.

You can try to ask people their salaries, but I doubt they'll tell you in any meaningful detail. Plus, it'll vary a lot based on multiple factors (geography, employment status, etc).

In an academic or hospital-employed situation, you may make slightly to moderately more than a general neurologist by doing sleep (because of the $$ from sleep studies). In a private neuro group or sleep practice there may be somewhat even more of a difference. However, that will change as reimbursement for studies drops and more (much less expensive) home sleep studies are done.

If you're really going to decide this based on money, and you honestly like doing headache, I would suggest doing a headache fellowship, then moving to a part of the country that has lots of crazy people with lots of money, and opening a CASH ONLY/NO INSURANCE headache clinic. Seriously. If I liked headache, that is exactly what I would do.

The academicians I spoke with once upon a time (last year) quoted starting salaries between $180 and $240 regardless of sub-sub-specialty. But academic sleep versus academic headache is an extremely different creature and the OP should investigate this further if truly serious about the outcome. The answer should be obvious without searching for internet responses.

Private practice was no contest. Sleep adds money to a group/hospital's income
and only adds considerable leverage to contract talk unless you are horrible at negotiating...or someone has such a terrible need for HA coverage that they'll pay the difference in which case you have a big red flag waving at you to run away.

I feel that I understand where you're coming from but I respectfully urge the OP to get out there and get his/her hands dirty figuring out the differences.

And precious few can tolerate a true "headache clinic." My advice still stands.

 

[michaelrack]

in the private practice setting, sleep is currently more lucrative due to 1) the reimbursement for reading sleep studies and 2) barriers to entry- anyone can call themselves a HA specialist and treat headaches (not necessarily well). With today's accreditation rules for sleep labs, you can't really read sleep studies on a large scale without being BE/BC.

As mentioned previously, reimbursement for sleep studies can change, and portable testing will probably increase. But right now, private prac sleep is more lucrative.

disclaimer: I am not a neurologist

 

[typhoonegator]

Technology is changing the sleep diagnostic landscape very quickly. New devices which obviate the need for expensive sleep lab evaluations (for some diagnoses) are already in the pipeline or being used in research. Depending on the future reimbursement schema, this could have an impact on the remunerative benefits of the sleep specialty. Alternatively, you could view these advancements as a boon to advancing the field and getting more patients the help they need. The way you look at this may help you decide.

 

[danielmd06]

Technology is changing the sleep diagnostic landscape very quickly. New devices which obviate the need for expensive sleep lab evaluations (for some diagnoses) are already in the pipeline or being used in research. Depending on the future reimbursement schema, this could have an impact on the remunerative benefits of the sleep specialty. Alternatively, you could view these advancements as a boon to advancing the field and getting more patients the help they need. The way you look at this may help you decide.

Home sleep testing is a wonderful alternative for select patients, but is not accepted as a method for evaluating patients with medical comorbidities such as CAD, CHF, CVA, and COPD to name a few. With the exception of pediatric and young adult populations, this winds up excluding virtually 99% of your classic OSA population (who are obviously usually overweight and have HTN, HL, DMII, and PVD). Now I don't know what populations other sleep physicians are seeing, but my own practice is a part of a huge cardiology group and as such I see no pediatric cases and 90 to 100% of what I see are patients above the age of 50 with some manner of cardiovascular problem. And again, aren't these the predominant OSA patients anyway?

If and when the financial landscape of sleep medicine changes adversely (as it likely will for all diagnostic and procedural-based specialties), I still do not believe it would be enough to alter the relative monetary differences from practicing sleep versus headache (or any other branch of neurology, frankly). Or practicing those specialites of medicine that rely on procedures of one sort or another.

Maybe I'm wrong, but I feel like that argument is akin to telling someone to beware of choosing orthopaedic surgery because their overall reimbursements will drop by a certain percentage and instead to consider primary care (or general neurology). Yeah, you're right to warn prospective applicants about the drop in ortho salary potential...but it's still not a close call from a final salary standpoint.

 

[ushush]

why is it considered that headache patients are difficult to deal with? I thought if you diagnose something like tia or even migraine and prescribe them meds or something, you're doing as much a service as someone preventing a heart attack? And I would think it's not easy to differentiate between different types of headache? and if all they have is something like migraine or muscle headache, why would they be needy considering they're not all that sick?

 

[danielmd06]

why is it considered that headache patients are difficult to deal with? ...and if all they have is something like migraine or muscle headache, why would they be needy considering they're not all that sick?

Ah, youth.

I remember when I was thrilled about headache (I'm a migraineur myself). Rotate through a headache clinic and I absolutely promise you'll understand the answer to both questions.

A few points:

1) You have plenty of anxious/stressed/depressed patients who cannot be easily "fixed."

2) You have drug addicts who want their narcotic medications, benzos, muscle relaxants etc and nevermind that these might be completely inappropriate medications for their specific type of headache.

3) You have people who are suffering from medication overuse headaches from mismanagement in the community and will suffer even more when you taper them off said medications and who are very dubious about coming off of their MOH-inducing medications.

4) You have some tremendous psychiatric overlap in many, many people in this patient population that compounds the difficulty of seeing them in a timely fashion in the office or managing their complaints and medications outside the clinic (refer back to point #1).

5) Headache is potentially a life-threatening emergency when you consider the differential could include SAH, ischemic stroke, brain tumors, vascular malformations, etc. And these issues can prove impossible to differentiate by history without scanning.

6) Headache patients can be exceptionally demanding as outpatients because the keep calling, and calling, and calling, and calling because they STILL have headaches day after day after day after day. And it's always 12/10 in intensity and such. And this refers back to point #5 which only enriches the pain. Your pain, I mean.

And at that point I got tired typing so I'll reiterate what I've now said twice in the same thread:

Please check out a headache clinic for yourself if you are interested in this branch of medicine. There are some fine fellowship (1 year duration, non-ACGME accredited) opportunities out there and this truly can be an interesting topic provided you have the mettle and personality fit to do this properly.

 

[ushush]

Thank you! I am only MS1 though.

 

[Mattchiavelli]

Ah, youth.

I remember when I was thrilled about headache (I'm a migraineur myself). Rotate through a headache clinic and I absolutely promise you'll understand the answer to both questions.

A few points:

1) You have plenty of anxious/stressed/depressed patients who cannot be easily "fixed."

2) You have drug addicts who want their narcotic medications, benzos, muscle relaxants etc and nevermind that these might be completely inappropriate medications for their specific type of headache.

3) You have people who are suffering from medication overuse headaches from mismanagement in the community and will suffer even more when you taper them off said medications and who are very dubious about coming off of their MOH-inducing medications.

4) You have some tremendous psychiatric overlap in many, many people in this patient population that compounds the difficulty of seeing them in a timely fashion in the office or managing their complaints and medications outside the clinic (refer back to point #1).

5) Headache is potentially a life-threatening emergency when you consider the differential could include SAH, ischemic stroke, brain tumors, vascular malformations, etc. And these issues can prove impossible to differentiate by history without scanning.

6) Headache patients can be exceptionally demanding as outpatients because the keep calling, and calling, and calling, and calling because they STILL have headaches day after day after day after day. And it's always 12/10 in intensity and such. And this refers back to point #5 which only enriches the pain. Your pain, I mean.

And at that point I got tired typing so I'll reiterate what I've now said twice in the same thread:

Please check out a headache clinic for yourself if you are interested in this branch of medicine. There are some fine fellowship (1 year duration, non-ACGME accredited) opportunities out there and this truly can be an interesting topic provided you have the mettle and personality fit to do this properly.

Pretty spot on...there is a reason that psychiatry is an acceptable residency for a pain fellowship. I told a plastic surgeon once that pain was interesting and he said "Pain clinic? Sounds painful" since his clinic consisted of having someone else dress down patients' wounds and he would monitor recovery/healing/etc. Didn't really deal with a lot of the issues mentioned above. I think it's pretty accurate that some people do not have a high tolerance for pain patients for the mentioned reasons.

Another rheumatologist once said that when you have patients with chronic medical issues that affect day to day life, you deal with at least 1/3 psychiatric issues regardless of the etiology. Working with other people and thinking about that I have not found it to be untrue.