Is 700-1 mill possible in neurology

[scoopdaboop]

It is possible in several specialties - quite easily infact - but I was wondering, if that's just out of the cards for a neurology practice? I've heard movement is the most lucrative fellowship in terms of money, so if you were to do a movement fellowship, and worked say like a I-cards doc; and I would imagine this means you have an outpatient gig, while doing call for a hospital, are these numbers reachable?

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[Always_Eating]

It is possible in several specialties - quite easily infact - but I was wondering, if that's just out of the cards for a neurology practice? I've heard movement is the most lucrative fellowship in terms of money, so if you were to do a movement fellowship, and worked say like a I-cards doc; and I would imagine this means you have an outpatient gig, while doing call for a hospital, are these numbers reachable?

Yes, but you will hate your life and will be working constantly with no life outside work. I've cleared 600k multiple years in clinical practice, but this was in atypical set-ups and it was not enjoyable. The only other people I know that clear those numbers have atypical set-ups too: pseudo-academic positions where they are very high-up, private practice non-employed where they are covering 4 hospitals while doing Tele while also seeing patients in their own private clinic, or true mercenaries peddling pharma talks on the side.

What you will learn once you are practicing is that anything above what covers your mortgage/car/tuition/loans and allows you to save comfortably is just vanity money and digits on a page. Your time is what becomes most valuable. The people that need to make 1 million in medicine that I know are doing so mostly because they hate clinical medicine and simply want to retire as quickly as possible from it, hence the high salary desire.

 

[Thama]

It is possible in several specialties - quite easily infact - but I was wondering, if that's just out of the cards for a neurology practice? I've heard movement is the most lucrative fellowship in terms of money, so if you were to do a movement fellowship, and worked say like a I-cards doc; and I would imagine this means you have an outpatient gig, while doing call for a hospital, are these numbers reachable?

Movement has potential to be reasonably lucrative if you don't do much movement disorders, and somehow find a practice setup where you can just do BTX and DBS without seeing all of the extremely complicated, time consuming patients with advanced neurodegenerative disorders. That's not likely unless you're a genius for scamming your colleagues, and so in general movement is pretty middle of the road for neurology compensation.

The highest paid neurologists I've seen are all MS docs who own their own infusion centers. Of course there are all kinds of aspersions of unethical referral patterns, kickbacks, etc, but so far they still make bank and are not in prison, so if you're comfortable in the dark grey areas that's an option for you.

 

[scoopdaboop]

Yes, but you will hate your life and will be working constantly with no life outside work. I've cleared 600k multiple years in clinical practice, but this was in atypical set-ups and it was not enjoyable. The only other people I know that clear those numbers have atypical set-ups too: pseudo-academic positions where they are very high-up, private practice non-employed where they are covering 4 hospitals while doing Tele while also seeing patients in their own private clinic, or true mercenaries peddling pharma talks on the side.

What you will learn once you are practicing is that anything above what covers your mortgage/car/tuition/loans and allows you to save comfortably is just vanity money and digits on a page. Your time is what becomes most valuable. The people that need to make 1 million in medicine that I know are doing so mostly because they hate clinical medicine and simply want to retire as quickly as possible from it, hence the high salary desire.

Yeah, I think that's my goal too. Work for a few years to pay off loans, have a decent fall back of wealth, then take it real easy after. I like medicine so far, but I would like to cut back in my 40s, not 50s.

 

[Postictal Raiden]

And here I am, a rising PGY-4, fantasizing about making 250k.

To answer your question, OP, yes it is very possible and I know quite a few neurologists who make that much. However it doesn’t happen without compromising one or more of the following:
Your social life
The care you’re providing for your patients
The joy you derive from performing a detailed H&P and thinking about ddx
Your morality (pharma, employing midlevels, unnecessary tests/therapy)
Location (working locum comes to mind)

Remember, with every dollar you earn past a certain point, you’ll be taking home less of it while still assuming 100% of the risks

 

[sloh]

And here I am, a rising PGY-4, fantasizing about making 250k.

Isn't >300k the norm for neurology? Even in saturated locations like SoCal

 

[Postictal Raiden]

Isn't >300k the norm for neurology? Even in saturated locations like SoCal

Yes but I don’t want to work more than 4 days a week and see more than 20 patients a day.
The guys I know in SoCal who make 300-400k see an upward of 25 patients a day 5 days a week. The one who makes 700k sees close to 50 a day working 5 days a week. I was impressed by him when I was a premed/med student but now knowing what I know, I realize he practiced very poor neurology, never took the time to understand what his patients complains were, never thought through the diagnoses, and his patients had poor satisfaction. He’s a lawsuit magnet.

 

[Minnows]

At this point, I would be happy with anything above 300k and not having to live in the boonies. If I make over 400k, I would be ecstatic.

 

[DocMom1]

Totally possible. For starting salary regardless of subspecialty you should not accept less than $325K as a lower limit, and if in academia, no lower than $300K. The upper limit is up to you

 

[Thama]

Totally possible. For starting salary regardless of subspecialty you should not accept less than $325K as a lower limit, and if in academia, no lower than $300K. The upper limit is up to you

ROFL

 

[Telamir]

I’d say from personal experience your quality of life and therefore the quality of medicine you practice starts going down after 400k. Around that point you hit diminishing returns and everything after that is hard earned and at the expense of your sanity. I made a bit more than that last year, and I’m not interested in doing that again this year.

I know some colleagues who made 6-700. They were miserable (perpetual EEG call, huge patient loads, etc) or quite honestly a little sketchy. Some of them were slaves to the paycheck. No thanks.

 

[xenotype]

The highest paid neurologists I've seen are all MS docs who own their own infusion centers. Of course there are all kinds of aspersions of unethical referral patterns, kickbacks, etc, but so far they still make bank and are not in prison, so if you're comfortable in the dark grey areas that's an option for you.

The math on this can change fast with CMS cuts for drug reimbursements. Oncology took a huge hit in a similar fashion a few years ago over a 2% cut- big systems can weather this but a private practice previously doing well could be forced to fire sale to the local hospital fast with any major cut like this. A significant business risk especially for partners who bought in, raised capital etc. In general though I think an infusion center is a big benefit to any outpatient neurologist. You can add a bunch of cash infusions for headache too, and these really help patients and can completely avoid ER visits for the worst migraineurs or ?MS exacerbations.

Totally possible. For starting salary regardless of subspecialty you should not accept less than $325K as a lower limit, and if in academia, no lower than $300K. The upper limit is up to you

Hahahaha. The $325k part is true for most regions but $300k for academics is totally detached from reality. Try $200-225k, which is why most academic departments are desperate to keep people (except for paying more).

For OP >$600k is very possible in neurology. You just have to say yes to busy hospital coverage, busy clinics triple booked with 15 minute slots, take on more malpractice risk than you want, work all day and all night, and in general give somewhat poor care because you can't do 1hr consultations on patients that really, really need it. Plenty of neurologists practice this way with clinics >35 patients per day and hospital coverage. The benefit is they see a lot of patients. The drawback is their work often has to be repeated/second opinion by someone else because they did a shotgun work up and put down the wrong diagnosis or didn't commit to the right diagnosis. Helps the patients who don't need much, but really harms the patients who needed careful work up. Their notes rarely make much sense when they get referred elsewhere because there is just an ICD code and some lab orders under the plan. Also provides no protection when they inevitably get sued and don't remember the patient at all.

 

[Always_Eating]

The math on this can change fast with CMS cuts for drug reimbursements. Oncology took a huge hit in a similar fashion a few years ago over a 2% cut- big systems can weather this but a private practice previously doing well could be forced to fire sale to the local hospital fast with any major cut like this. A significant business risk especially for partners who bought in, raised capital etc. In general though I think an infusion center is a big benefit to any outpatient neurologist. You can add a bunch of cash infusions for headache too, and these really help patients and can completely avoid ER visits for the worst migraineurs or ?MS exacerbations.


Hahahaha. The $325k part is true for most regions but $300k for academics is totally detached from reality. Try $200-225k, which is why most academic departments are desperate to keep people (except for paying more).

For OP >$600k is very possible in neurology. You just have to say yes to busy hospital coverage, busy clinics triple booked with 15 minute slots, take on more malpractice risk than you want, work all day and all night, and in general give somewhat poor care because you can't do 1hr consultations on patients that really, really need it. Plenty of neurologists practice this way with clinics >35 patients per day and hospital coverage. The benefit is they see a lot of patients. The drawback is their work often has to be repeated/second opinion by someone else because they did a shotgun work up and put down the wrong diagnosis or didn't commit to the right diagnosis. Helps the patients who don't need much, but really harms the patients who needed careful work up. Their notes rarely make much sense when they get referred elsewhere because there is just an ICD code and some lab orders under the plan. Also provides no protection when they inevitably get sued and don't remember the patient at all.

This is the biggest thing that I think medical students and other people do not understand pre-practice. Everyone thinks they will find some gem of a job where they will get paid 600k a year, more than 200k over market value, but still have a reasonable patient load and quality of life working a regular Neuro job that pays better than everyone else. The reality is that if you are making more than your peers, it is almost always because you are doing more clinical work than your peers: reading EEGs from 9 pm to midnight after a full clinical day, taking a lot of night and weekend call or telecall, triple booking in clinic like you said. Nobody is going to pay you more for nothing. Clinical work is a mindless conveyor belt, and you will essentially be a high output factory worker on that line if you want to consistently make 700k - 1 million. I will agree that I've never seen a Neurologist making that much provide anything close to quality care.

 

[Splenda88]

And here I am, a rising PGY-4, fantasizing about making 250k.

To answer your question, OP, yes it is very possible and I know quite a few neurologists who make that much. However it doesn’t happen without compromising one or more of the following:
Your social life
The care you’re providing for your patients
The joy you derive from performing a detailed H&P and thinking about ddx
Your morality (pharma, employing midlevels, unnecessary tests/therapy)
Location (working locum comes to mind)

Remember, with every dollar you earn past a certain point, you’ll be taking home less of it while still assuming 100% of the risks

Why don't you work as a hospitalist (7 on/off) to make 350k+/yr?

250k/yr does not go far when you have 300k+ in student loan

 

[Postictal Raiden]

Why don't you work as a hospitalist (7 on/off) to make 350k+/yr?

250k/yr does not go far if you have 300k in student loan

I enjoy outpatient neurology more due to more diverse cases, seeing and managing neurological conditions at various stages of the disease, ability to perform EMG/NCS, and majority of patients are at their baseline.

With that said, I also like the acuity of inpatient neurological presentations (stroke, cerebral edema, status, MG exacerbation, garden variety of acute encephalopathies and encephalitis)

 

[A Mysterious Stranger]

Why don't you work as a hospitalist (7 on/off) to make 350k+/yr?

250k/yr does not go far when you have 300k+ in student loan

This is what I’m wondering. 7 on and 7 off plus telestroke in the intervening weeks.
Any ideas on income potential here?

 

[Splenda88]

This is what I’m wondering. 7 on and 7 off plus telestroke in the intervening weeks.
Any ideas on income potential here?

I am not a neurologist but I see salary for neurohospitalist in the 350-400k, so it would not be extremely difficult for a neurologist to make 450k-500k/yr if that person want to engage in some moonlighting.

 

[A Mysterious Stranger]

I am not a neurologist but I see salary for neurohospitalist in the 350-400k, so it would not be extremely difficult for a neurologist to make 450k-500k/yr if that person want to engage in some moonlighting.

I’m considering doing 24-hr telestroke in the two weeks off, since I enjoy it and it’s not too hard. I definitely don’t want to do a poor job, but I was hoping to clear 600k.
What income is typical for 14 days per month of telestroke? And is that feasible for working in conjunction with a 7 on/off neurohospitalist job?

I have no social life FYI and enjoy working.

 

[Splenda88]

I’m considering doing 24-hr telestroke in the two weeks off, since I enjoy it and it’s not too hard. I definitely don’t want to do a poor job, but I was hoping to clear 600k.
What income is typical for 14 days per month of telestroke? And is that feasible for working in conjunction with a 7 on/off neurohospitalist job?

I have no social life FYI and enjoy working.

Not sure what telestroke docs make, but I have seen numbers from 130-180k/yr. If you are ok to work on your 2wks off, I dont see why you should not make ~600k/yr.

Why are you aiming for such high salary? Do you have a big student loan? If you are still in med school, you should pursue radiology. Night time radiologist 1 wk on and 3 weeks off can make 400k+/yr.

 

[A Mysterious Stranger]

Not sure what telestroke doc meds make, but I have seen numbers from 130-180k/yr. If you are ok to work on your 2wks off, I dont see why you should not make ~600k/yr.

Why are you aiming for such high salary? Do you have a big student loan? If you are still in med school, you should pursue radiology. Night time radiologist 1 wk on and 3 weeks off can make 400k+/yr.

Life has taught me that good things don’t last… so I’m going to work my butt off for the first few years to establish a nest egg. I graduated last week. Rads didn’t hold up as a great long term career choice, like EM and Gas. Too much outsourcing potential.

Thank you for answering my questions

 

[xenotype]

Not sure what telestroke docs make, but I have seen numbers from 130-180k/yr. If you are ok to work on your 2wks off, I dont see why you should not make ~600k/yr.

Why are you aiming for such high salary? Do you have a big student loan? If you are still in med school, you should pursue radiology. Night time radiologist 1 wk on and 3 weeks off can make 400k+/yr.

Your numbers are way, way low for a telestroke/teleneurology full time gig. They are more in line with the neurohospitalist figures.- 300-400k. Also- doing 24hr 'telestroke' is unworkable from a lifestyle perspective. You can't be available all the time, and you need to answer stroke questions immediately and thoroughly. Yes, if you take little time off and work 14 hour days 5-6 days every week you can easily break $600k, even $700-800k would be possible. With most neurohospitalist/locums/teleneurology jobs you can easily sign up for extra coverage. You'll burn out quickly unless you are one of the special few that can tolerate that level of abuse. That is residency lifestyle with higher patient volume than residency, and no 'easy rotation blocks' to sort out your life and relax.

 

[Splenda88]

Your numbers are way, way low for a telestroke/teleneurology full time gig. They are more in line with the neurohospitalist figures.- 300-400k. Also- doing 24hr 'telestroke' is unworkable from a lifestyle perspective. You can't be available all the time, and you need to answer stroke questions immediately and thoroughly. Yes, if you take little time off and work 14 hour days 5-6 days every week you can easily break $600k, even $700-800k would be possible. With most neurohospitalist/locums/teleneurology jobs you can easily sign up for extra coverage. You'll burn out quickly unless you are one of the special few that can tolerate that level of abuse. That is residency lifestyle with higher patient volume than residency, and no 'easy rotation blocks' to sort out your life and relax.

I am glad my numbers were way off because I would not do that job if I were a neurologist for these numbers (130-180k) given the high stake of that job.

 

[curiousneuro]

I am glad my numbers were way off because I would not do that job if I were a neurologist for these numbers (130-180k) given the high stake of that job.

Yup I'm starting a telestroke/teleneuro gig full time right after fellowship in about 2 months from now...expecting about 360-400k based on normal volumes, with the option of working more if I want.

 

[Always_Eating]

I’m considering doing 24-hr telestroke in the two weeks off, since I enjoy it and it’s not too hard. I definitely don’t want to do a poor job, but I was hoping to clear 600k.
What income is typical for 14 days per month of telestroke? And is that feasible for working in conjunction with a 7 on/off neurohospitalist job?

I have no social life FYI and enjoy working.

If you work a full-time FTE in-person and the equivalent of a full-time FTE doing Tele, you will be working pretty much 24/7/365. You should easily be able to clear 700k a year doing this. I did something similar in the past and was clearing 600k easily, and I was not even doing the equivalent of 14 days of Tele a month. However, there is no way you will be able to do 14 days * 24 hrs = 336 hrs of Tele a month. It is way too busy and unless you are an amphetamine abuser you will crash physically. You can get 6 stroke consults in 5 minutes while on for Tele. More likely you will do 12 hrs of call a day in your off-service weeks. Even doing this, you should clear 600k a year easy.

 

[Postictal Raiden]

If you work a full-time FTE in-person and the equivalent of a full-time FTE doing Tele, you will be working pretty much 24/7/365. You should easily be able to clear 700k a year doing this. I did something similar in the past and was clearing 600k easily, and I was not even doing the equivalent of 14 days of Tele a month. However, there is no way you will be able to do 14 days * 24 hrs = 336 hrs of Tele a month. It is way too busy and unless you are an amphetamine abuser you will crash physically. You can get 6 stroke consults in 5 minutes while on for Tele. More likely you will do 12 hrs of call a day in your off-service weeks. Even doing this, you should clear 600k a year easy.

Or you could locum half the year and clear just as much

 

[Always_Eating]

Or you could locum half the year and clear just as much

These days you actually make more doing Tele than Locums. I've done both in the past. You can clear 4k+ a day in Tele. Hard to clear more than 3k a day in Neuro locums unless doing NCC. Add-in the travel to undesirable location for Locums and it is not really a close competition for which to choose.

 

[curiousneuro]

These days you actually make more doing Tele than Locums. I've done both in the past. You can clear 4k+ a day in Tele. Hard to clear more than 3k a day in Neuro locums unless doing NCC. Add-in the travel to undesirable location for Locums and it is not really a close competition for which to choose.

4k/day? I would need to see a TON of patients to get that in a 12 hour shift...but it's technically doable...

 

[Postictal Raiden]

These days you actually make more doing Tele than Locums. I've done both in the past. You can clear 4k+ a day in Tele. Hard to clear more than 3k a day in Neuro locums unless doing NCC. Add-in the travel to undesirable location for Locums and it is not really a close competition for which to choose.

Do you need to be stroke trained to do these tele-neuro jobs?

 

[Splenda88]

4k/day? I would need to see a TON of patients to get that in a 12 hour shift...but it's technically doable...

Even 3k/day is good. Not that difficult to make 600k/yr then if one is willing to work ~17 days/month.

 

[curiousneuro]

Most companies, yes, or they could let you do it if you have "significant experience", like 5-10 years post training.

 

[curiousneuro]

Even 3k/day is good. Not that difficult to make 600k/yr then if one is willing to work ~17 days/month.

Yes it can be quite lucrative if you want it to be, but the nice thing is that you can add more and be busier if you feel like it. So it has some pluses similar to locums, but the commute is better.

 

[BoolaBoola]

Do you need to be stroke trained to do these tele-neuro jobs?

You do not, but you should. Many places require it, some do not. Those companies usually have poor raps. It actually make a big difference in your ability to provide the best pt care. I have seen some egregious errors leading to major morbidity/mortality from non-fellowship telestroke docs who simply have inadequate knowledge/skills to do this job. It's crooked on both the docs' & companies' end. Patient are human beings. We take the Hippocratic Oath. To honor this we should be proficient in what we do to try to help them. Do you really want that on your conscience if you hurt someone & it was preventable? Similarly, I would not want a general surgeon to do any transplant if I needed one.

 

[curiousneuro]

You do not, but you should. Many places require it, some do not. Those companies usually have poor raps. It actually make a big difference in your ability to provide the best pt care. I have seen some egregious errors leading to major morbidity/mortality from non-fellowship telestroke docs who simply have inadequate knowledge/skills to do this job. It's crooked on both the docs' & companies' end. Patient are human beings. We take the Hippocratic Oath. To honor this we should be proficient in what we do to try to help them. Do you really want that on your conscience if you hurt someone & it was preventable? Similarly, I would not want a general surgeon to do any transplant if I needed one.

I completely agree. Honestly, the landscape of stroke has/is changing drastically and quickly with extended windows, advanced imaging, etc - I honestly would not do this without doing a stroke fellowship first.

 

[Always_Eating]

You do not, but you should. Many places require it, some do not. Those companies usually have poor raps. It actually make a big difference in your ability to provide the best pt care. I have seen some egregious errors leading to major morbidity/mortality from non-fellowship telestroke docs who simply have inadequate knowledge/skills to do this job. It's crooked on both the docs' & companies' end. Patient are human beings. We take the Hippocratic Oath. To honor this we should be proficient in what we do to try to help them. Do you really want that on your conscience if you hurt someone & it was preventable? Similarly, I would not want a general surgeon to do any transplant if I needed one.

Yes, agree. There are some low-end Tele companies that hire physicians with "significant stroke experience" to do TeleStroke. In my experience, these doctors are usually unqualified, get overwhelmed easily, and are obvious weak links in the chain. The more reputable companies only hire Stroke or NCC fellowship-trained, boarded Neurologists.

 

[BoolaBoola]

Many of the above replies are over-thought & biased towards one or two possibilities. The bottom line is, it all depends on your contract & practice type.

These numbers are definitely possible & it takes different amounts & types of effort to reach them depending on your compensation structure. There are now almost innumerable different Neurology job types. It does NOT matter the specialty/fellowship. It's about the job. It's a buyer's market for this field. Period.

Please do not choose your specialty based on money; you WILL be miserable. Do what you love, then when the job search / contract negotiation time comes, work on it then. Get a financial advisor who specializes in physicians. Also, it's not about the direct compensation alone. That way you immediately give yourself a ceiling based on your time/resources. Invest. Get a side gig; medical or otherwise. A smart investor makes money in their sleep. If your only income is your MD job, then it's a house of cards if anything happens....to it, you, or the field / industry.

But, yes, you can make this from direct income from your MD job, possibly not immediately, but within 3-5 years of practice. In. Any. Subspecialty. Worry about it when the time comes. The field may be different when you get there. Consider other people's advice / experiences, but you will have to make your own path. Everyone has different priorities & circumstances. If you try to copy someone else's verbatim, you're in for likely miserable failure.

 

[Splenda88]

Epilepsy vs. stroke. Which of the 2 is more lucrative? Based on this thread, it seems like stroke docs can make a lot of $$$ (>500k) without working insane amount of hours

 

[Telamir]

I heard dementia docs make eleventy billion dollars for 30 hours a week!

Ive known epilepsy docs making 5-600k and stroke docs who make that. As above…it depends on the job. Stroke also carries higher malpractice risk.

 

[Always_Eating]

Epilepsy vs. stroke. Which of the 2 is more lucrative? Based on this thread, it seems like stroke docs can make a lot of $$$ (>500k) without working insane amount of hours

No, if you are making >500k as a Stroke doctor it is only because you are working insane hours. That is exactly what we have been saying. Standard pay for Stroke is 300-350ish a year for 1.0 FTE. Now if you want to make > 500k, it is because in your off weeks you are taking Tele call or doing per diem or locums . . . aka you are working all the time. Stroke call is terrible, even with residents/fellows taking first-call. You are constantly getting called about B.S. Most people in Stroke choose to take the 350k and call it a day because they want a life.

I will echo what BoolaBoola said: Do not pick your specialty based on money (within reason). Unless you are a morally bankrupt apathetic mercenary, there is no amount of money that will make you happy working a job that you do not like or even worse find undignified.

 

[Splenda88]

No, if you are making >500k as a Stroke doctor it is only because you are working insane hours. That is exactly what we have been saying. Standard pay for Stroke is 300-350ish a year for 1.0 FTE. Now if you want to make > 500k, it is because in your off weeks you are taking Tele call or doing per diem or locums . . . aka you are working all the time. Stroke call is terrible, even with residents/fellows taking first-call. You are constantly getting called about B.S. Most people in Stroke choose to take the 350k and call it a day because they want a life.

I will echo what BoolaBoola said: Do not pick your specialty based on money (within reason). Unless you are a morally bankrupt apathetic mercenary, there is no amount of money that will make you happy working a job that you do not like or even worse find undignified.

My definition of insane hours is > 55 hrs per week.

 

[bigamygdala]

And here I am, a rising PGY-4, fantasizing about making 250k.

To answer your question, OP, yes it is very possible and I know quite a few neurologists who make that much. However it doesn’t happen without compromising one or more of the following:
Your social life
The care you’re providing for your patients
The joy you derive from performing a detailed H&P and thinking about ddx
Your morality (pharma, employing midlevels, unnecessary tests/therapy)
Location (working locum comes to mind)

Remember, with every dollar you earn past a certain point, you’ll be taking home less of it while still assuming 100% of the risks

any plans for fellowship?

 

[Postictal Raiden]

any plans for fellowship?

Neurophysiology (EMG/EEG)

 

[Telamir]

Yes!

It seems like we’re telling them making 500K+ is doable but horrible for your quality of life and it seems the takeaway is “omg neurology new lifestyle specialty 500k easy money pushing aspirin let’s gooooo”.

Reminds me of Lloyd in dumb and dumber “So you’re saying there’s a chance!”

 

[xenotype]

You do not, but you should. Many places require it, some do not. Those companies usually have poor raps. It actually make a big difference in your ability to provide the best pt care. I have seen some egregious errors leading to major morbidity/mortality from non-fellowship telestroke docs who simply have inadequate knowledge/skills to do this job. It's crooked on both the docs' & companies' end. Patient are human beings. We take the Hippocratic Oath. To honor this we should be proficient in what we do to try to help them. Do you really want that on your conscience if you hurt someone & it was preventable? Similarly, I would not want a general surgeon to do any transplant if I needed one.

One of the biggest companies is 2/3rds non-stroke boarded neurologists. I don't think this is accurate, and I don't think the binary nature of acute stroke care is that complicated. Stroke work-ups and crytogenic stroke have a much more complex debate that certainly rewards a stroke fellowship, but every neurology resident should leave residency comfortable with acute stroke management and basic stroke work up- including 'advanced imaging'. I know there are several that have chimed in on this, but this just isn't reality. tPA is a yes or no question with very well spelled out criteria. Bleeds can be turfed to neurosurgery. Anything outside of stroke- which is >50% of 'stroke alerts' you are poorly trained for as a stroke neurologist and carry the same liability for 'violating the hippocratic oath'. I've seen stroke neurologists dump on other services because they don't know how to dose IV dilantin. One of the neurohospitalists posting in this thread does about 50% stroke from a neurophysiology background and I'm sure you all think they are incompetent .

Feel free to flame me- but missing a GBS or a non-convulsive status in a hospital consult as a 'stroke neurologist' who has to take all ER questions can do as much if not much more harm- only those are not binary 'yes or no tPA; yes or no ask interventionalist' questions acutely. >50% of hospital neurology is NOT stroke, yet stroke neurologists on these tele consults absolutely take those consults routinely. Some of them read EEGs with no experience in EEG interpretation.

 

[Postictal Raiden]

I've seen stroke neurologists dump on other services because they don't know how to dose IV dilantin.

One of my old attendings says “titrate Dilantin to nystagmus”

I asked my question regarding the need for stroke fellowship to do teleneurology to stimulate this discussion.

In my program, and I’m sure this is true for most programs, by end of PGY-2, let alone residency, you have managed enough acute strokes that you can almost do them in your sleep. Like you said, the aftermath work up to find the etiology and determine the best secondary prevention does require a higher level of knowledge and experience. However from the teleneurology prospective, the acute decisions, tPA/BP parameters/initiation of osmotic therapy/get NSG involved or not, should not require a fellowship. But hey, I’m a lowly resident and I’m very happy to be wrong and educated accordingly.

 

[BoolaBoola]

One of the biggest companies is 2/3rds non-stroke boarded neurologists. I don't think this is accurate, and I don't think the binary nature of acute stroke care is that complicated. Stroke work-ups and crytogenic stroke have a much more complex debate that certainly rewards a stroke fellowship, but every neurology resident should leave residency comfortable with acute stroke management and basic stroke work up- including 'advanced imaging'. I know there are several that have chimed in on this, but this just isn't reality. tPA is a yes or no question with very well spelled out criteria. Bleeds can be turfed to neurosurgery. Anything outside of stroke- which is >50% of 'stroke alerts' you are poorly trained for as a stroke neurologist and carry the same liability for 'violating the hippocratic oath'. I've seen stroke neurologists dump on other services because they don't know how to dose IV dilantin. One of the neurohospitalists posting in this thread does about 50% stroke from a neurophysiology background and I'm sure you all think they are incompetent .

Feel free to flame me- but missing a GBS or a non-convulsive status in a hospital consult as a 'stroke neurologist' who has to take all ER questions can do as much if not much more harm- only those are not binary 'yes or no tPA; yes or no ask interventionalist' questions acutely. >50% of hospital neurology is NOT stroke, yet stroke neurologists on these tele consults absolutely take those consults routinely. Some of them read EEGs with no experience in EEG interpretation.

I can see how many think that acute stroke seems cookie-cutter or per a protocol/guidelines, but that is NOT the case.

There are indeed many straightforward cases, which we have all seen as trainees & in attending practice. However, guidelines are SUGGESTIONS (based on evidence), not RULES, (quote from Bill Powers, lead author of acute stroke guidelines). The difference is understanding what is happening with your patient, at least to the best extent you can in the acute setting & then using your clinical judgement to make decisions using those guidelines (or not, as long as it is medically justifiable...there are many things that are not found in guideline)...not just the tPA / thrombectomy itself...but leading up to this decision in the acute setting as well.

If you believe that tPA is ONLY binary w/ yes/no with very well spelled out criteria & nothing more every time, then you are demonstrating that you do not know what you do not know.

The specificity of "stroke alert" varies greatly by institution / system & by the skill set of the person calling the alert. Stroke alerts are NOT >50% non-stroke globally. Yes at some places, but surprisingly not at most. And it is up to the responding neurologist, stroke-trained or not, to be able to tell the difference.

"Turfing" is popular in training.
Collaboration is what you do as an attending.

I have been doing this for a hot minute & continue to be humbled despite training & later practicing in several high-volume, big-deal places (both brick & mortar & tele); including under people that wrote the criteria & others that have done some of the seminal work in the extended window treatment over the past 5 years. They are my mentors that taught me this & I am grateful for it.

They also all think outside of any "box," which was also a great lesson.

I agree every general neurologist *should* complete residency with a certain amount of skill in acute stroke, but there is variety b/w trainings (& trainees). That is life. However, even with the best, highest-volume, big-name mentor places, it is simply not possible to become a master in a subspecialty during a 3-year general neurology residency when you are trying to become the jack of all the other trades in the field. This is not just for stroke.

The jobs for non-fellowship trained general neurologists will require skills in all the subspecialties, that's what you're supposed to know a little about a when you graduate residency. This includes acute stroke.

The end of residency is not the END, but the BEGINNING of learning. Residency gives you the foundations to understand the things you will learn afterwards, both in fellowship &practice.

Any residency-trained board-certified neurologist is expected to know basics of stroke codes...and EEGs...and EMGs, etc & can do this occasionally, maybe semi-frequently. However, the difference is, if you are taking a job as a *specialist* DEDICATED to the specialty, such as a dedicated telestroke job with will obviously have high-volume & with it, high-variety of stroke alerts, then you should be a *specialist* with specialist skills & a board-certification. The board exists for a reason.

Can a general neurologist do neuro TeleICU? Everyone in residency does at least a couple of months of ICU, some of us in a dedicated Neuro ICU.

The same is true for dedicated reading of EEGs, EMGs, etc. NO ONE is on specialty level after a general neurology residency. You're not supposed to be.
However, a specialty-trained neurologist must know general neurology to do a little bit of everything some of the time.

Every board-certified vascular (or any other specialty) neurologist is a board-certified general neurologist (required for subspecialty boards)
Every board-certified general neurologist is not specialty certified unless they have been fellowship trained.

Fellowship is designed to teach you subspecialty skills & knowledge in a systemic way. There is a standardized list of competencies that must be met to graduate. Simple experience in practice is not a substitute. You will learn things, but it is not the same.

Never forget that the stroke (or other subspecialty) specific work you did in training as a resident...you did in training. As a resident. Under someone. It's a leap to go from graduating high school (even with good grades), to being the principle.


When you think you "got this" is when you become dangerous to your patients.

It's not about liability for the Hippocratic Oath.
It's ethics.

Medicine is more than just money & malpractice.

 

[xenotype]

I don't disagree with what you are saying, but cases that are not straightforward can easily be discussed with a colleague, and what you are a proponent of just isn't reality. There are not enough vascular trained neurologists available to take care of the vast amount of neurological patients presenting to EDs. My second concern is the 50% of ER consults that are not stroke- these will majority be epilepsy and perhaps 10% neuromuscular and the same serious mistakes can be made with these patients by a stroke trained neurologist who lacks additional fellowship training. These consults are common as the entire ED and sometimes the hospital as well is covered by teleneuro services. More training is always great, but you have to set a minimum bar somewhere. You cannot rely on only vascular trained neurologists to see these patients- stroke cannot easily be split off and dissected from the rest of neurology, and the rest of neurology has much more complexity (particularly NM and epilepsy in the hospital setting). I suppose you believe some of the biggest companies involved in teleneuro services are flagrant malpractice? Unethical? You are right but the standard you set is simply unrealistic, and makes serious compromises in other areas of hospital neurology. We've all seen stroke neurologists get 'deer in the headlights' with a foot drop or abnormal movements they presume to be status. I've seen obvious pnea patients wind up intubated because of stroke neurologists, and nonconvulsive status missed.

 

[deleted1081396]

If you work a full-time FTE in-person and the equivalent of a full-time FTE doing Tele, you will be working pretty much 24/7/365. You should easily be able to clear 700k a year doing this. I did something similar in the past and was clearing 600k easily, and I was not even doing the equivalent of 14 days of Tele a month. However, there is no way you will be able to do 14 days * 24 hrs = 336 hrs of Tele a month. It is way too busy and unless you are an amphetamine abuser you will crash physically. You can get 6 stroke consults in 5 minutes while on for Tele. More likely you will do 12 hrs of call a day in your off-service weeks. Even doing this, you should clear 600k a year easy.

Can you pretty much make your own schedule with tele? How do you balance it with anothet full-time job? 7 on 7 off with tele when you want during your 7 off?

 

[BoolaBoola]

I don't disagree with what you are saying, but cases that are not straightforward can easily be discussed with a colleague, and what you are a proponent of just isn't reality. There are not enough vascular trained neurologists available to take care of the vast amount of neurological patients presenting to EDs. My second concern is the 50% of ER consults that are not stroke- these will majority be epilepsy and perhaps 10% neuromuscular and the same serious mistakes can be made with these patients by a stroke trained neurologist who lacks additional fellowship training. These consults are common as the entire ED and sometimes the hospital as well is covered by teleneuro services. More training is always great, but you have to set a minimum bar somewhere. You cannot rely on only vascular trained neurologists to see these patients- stroke cannot easily be split off and dissected from the rest of neurology, and the rest of neurology has much more complexity (particularly NM and epilepsy in the hospital setting). I suppose you believe some of the biggest companies involved in teleneuro services are flagrant malpractice? Unethical? You are right but the standard you set is simply unrealistic, and makes serious compromises in other areas of hospital neurology. We've all seen stroke neurologists get 'deer in the headlights' with a foot drop or abnormal movements they presume to be status. I've seen obvious pnea patients wind up intubated because of stroke neurologists, and nonconvulsive status missed.

I think you may may have missed my point. Throughout my argument I am talking about telestroke only, which is what my original post was about. Perhaps that got lost in the length of my reply.

That is the topic. Nothing more. The rest is supportive talk. I added some examples, experiences, even philosophy, b/c I thought it was supportive & that some of the extras might be useful to someone, especially the many trainees & students that read these posts trying to make some sense of the clusterf*ck & chaos of the field they are entering.

My point is telestroke specifically should be done by stroke neurologists. Not that all stroke ever in the whole world should be done by exclusively stroke neurologists. There is a difference.

In telestroke, 99% of the time you do not have the time to d/w colleagues. It's hyperacute & often in these telestroke gigs, you are often doing 2-3 simultaneous ones on different computer monitors. Or if you're working in a hospital doing one or more in-person +/- a tele on top of this. My point is that telestroke jobs specifically are specialty jobs.

It is not the same as what you do in residency training. Even if you have some tele exposure as a trainee. This is fact.

This has nothing to do with medical error made by stroke neurologists mismanaging non-stroke general neuro...which they are just as board-certified in. You don't magically lose your general neuro knowledge when you specialize in something. You might from lack of use (or personal choice)...but that is different.

Docs of any type will miss things outside and inside of their specialty. It is unreasonable to have an expectation of absolute perfection for anyone regardless of their training & that is absolutely not what I am saying.

I am also not calling stroke neurologists superlative physicians, nor ranking or comparing stroke neurologists against anyone else in anything else. How some individual that you or I or anyone else saw do something somewhere to a patient is anecdotal, not generalizable. It does not matter on this topic.

Also, it is very poor discussion/debate to "suppose I believe" anything. That choice of words comes off as aggressive, attacking, arrogant, & is putting your words in someone's mouth & attributing opinions to them that are not theirs. This is a non-personal debate; let's keep it that way. (That's like saying vaccinated people can take their makes off so I suppose that means the pandemic is completely over.) I never said anything about any company engaging in "flagrant malpractice." Those words are yours.

My points:
-Acute ischemic stroke is not simple. This is not debatable.
-It has high acuity, morbidity, & mortality. Stakes are high.
-Most neurologists have basic ability to adequately manage most straightforward (& some not) cases in most settings.
-Telestroke is a very specific type of job that I believe is most safely done by fellowship trained stroke neurologists.
-Many telestroke companies require their neurologists to be stroke-trained, others do not.
-Many of those that do not deliver suboptimal care.
-Telestroke companies are businesses; and yes, many do have unethical practices (as can any business).
-In my opinion, it IS unethical for a physician of any sort to practice beyond their skillset.
-In my opinon, it IS unethical for any employer to expect a physician to practice beyond their skillset
-MOST non-stroke trained neurologists lack the adequate skillset for telestroke
-Telestroke skillset is not just about fellowship-trained knowledge (there are plenty of stroke docs that cannot do it well either), there is more to it, but that is a different topic
-This is only about a telestroke consult for management of acute ischemic stroke. For the non-treatment cases the acute management is on the ED (i.e. ABCs). If it is a different neuro emergency & they call a TELEstroke code, the stroke doc can help depending on the situation, we have those skills from residency (status, increased ICP, whatever), but you are no longer treating a stroke, you are just doing emergent teleneuro.
-I am not talking about non-stroke non-emergency teleneurology. The care of non-emergent epilepsy, or neuromuscular pts is irrelevant to this topic.

Again,
You do not need to be stroke-trained to do telestroke, but in my strong opinion, you should.
For the small novella of reasons in these last few posts.
And I'm sticking to it

 

[xenotype]

-Most neurologists have basic ability to adequately manage most straightforward (& some not) cases in most settings.

I mean no disrespect or offense, and I agree ideally stroke fellowship provides the best preparation- for stroke patients. 'Telestroke' jobs and hospital contracts almost always involves coverage of every patient that arrives to the ER with neurologic symptoms for most hospitals that receive teleneurology services. Is general neurology board certification enough to take care of all of these other neurologic problems patients can present with? Sure. Is it ideal when a patient comes in with status when a stroke neurologist takes care of them? Absolutely not, and there are stroke neurologists that deliver very suboptimal care for epilepsy patients. Would this weigh on your conscience if an epilepsy patient died from status or never woke up under your care? Do you provide care to new onset status and epilepsy patients in the emergency departments you cover? Is treating status formulaic and simple- unlike stroke? Are the stakes high? This is a two way street as stroke neurologists always end up treating other neurologic emergencies. Providing emergency neurology coverage is 50% not stroke and I would argue carries the same stakes for disability for patients.

You seem to acknowledge in your post that the average general neurologist is capable of managing acute stroke, just not at the level of volume that occurs with telestroke. Is my understanding incorrect? Are residency programs in neurology massively underpreparing neurologists for treatment of acute stroke? You are simultaneously arguing that general neurologists are not qualified to take care of acute stroke patients but acknowledging that they are capable of handling the majority of cases that commonly present.

I have one question I would really like you to answer, even if you think everything I just wrote was garbage.
1) Are there enough board certified stroke neurologists to provide telestroke coverage to every patient that needs it right now?

Most patients today presenting with acute stroke concerns still get a telephone discussion between a neurologist and an EM provider- hopefully a physician but often not. Some get no neurologist opinion at all. Again, I do not believe 'general neurology' can be dissected out of providing teleneurology coverage including stroke. And I do believe that other fellowships are not worthless and potentially as useful as stroke in hospital neurology.

How are all the patients in BFE supposed to get anything resembling modern stroke care if you mandate the handful of only vascular neurologists see them? What happens to all the other patients that don't have stroke (whether it is a 'telestroke' call or not)? The vascular neurologists were right because those cases were straightforward?

If there were plenty of vascular neurologists available, telestroke was widely available even in remote areas with very poor patients, and stroke was entirely split off from the rest of hospital neurology- especially epilepsy and GBS patients that have complex needs I would agree with you completely. This isn't reality in 2021.

 

[neurochica]

-In non academic, I know plenty of people making $400's, $500s and $600s and few friends making $700s (partners in a neurosurgery group). Most of these jobs are located in major cities in the Midwest, or the South, including Florida. I saw a neurohospitalist job in Palo Alto in the $500s last year.

-Keep in mind that, unless you are a partner, you will need to work hard. I was once offer a neurohospitalist job in Mid-Atlantic for $600 7/7 in a large hospital that sees 1500 strokes a year. plus ability to take extra shifts.

From a locum perspective, You can easily average $2700 a day. just show up and work.....my best friend works 20 days a month at this rate...she is single and a workaholic. I do most of my legwork and contracting and I average between $$4500-$5500. While i have the ability to earn a boat load of money as I set up my contracts open ended, I usually earn around $630K a year working around 115 days a year.

Keep in mind that most neurologists are dinosaurs and hate inpatient neurology. You can use this to your advantage and negotiate extra call in your practice. You can also use this to grow your patients etc.

If I can give advice to the young me in residency, I would say to seek out more EEG and EMG time during my off time and learn about the business of medicine.