Just completely lost about fellowship

[deleted1208015]

---

Members don't see this ad.

Hello everyone, current neurology resident here who is completely lost about deciding on a fellowship to pursue.

My main concern is that many fellowships pigeonhole you into a specific setting or role. Doing a stroke or NCC fellowship means you’re signing up for a fully inpatient career. Doing autonomic, movement, or neuro-onc means your signing yourself up for something very niche that limits job opportunities in bigger cities. Sleep and neuromuscular have a lot of overlap with other specialties that potentially low your marketability. And then with headache, NP/PAs are increasingly dominating the workforce.

CNP seems like a good option but I know that for academic medicine a CNP may not take you very far. However, my main concern is a growing number of even private employers who prefer a fully NM or Epilepsy trained specialist to do EMGs or EEGs, respectively, over someone CNP trained.

My main goal is to practice community general neurology in a mixed outpatient and inpatient setting. I know this is very difficult to find outside of an academic medicine setting so if I had to pick I would say outpatient.

If I had to summarize it, I guess I want to “do it all” in neurology and be a general neurologist despite neurology being an ever-growing field, which now that I’m typing it out seems naive.

 

[DrStephenStrange]

Once you complete a fellowship, you can definitely still do some general neurology (inpatient or outpatient or both). So outside of maybe NCC/Neuro IR, you do not necessarily pigeon hole yourself. Not unless you want to.

 

[Spinothalamic]

This is an excerpt from my post on a recent thread:

“I did neuro-ophthalmology and also practice general neurology. My residency provided great general neurology training and I do EMG/EEG, nerve blocks, Botox for migraine/HFS/bleph/spasticity as well as a few patients with cervical dystonia. That being said, if you want to do general outpatient neurology, I would highly recommend you do a one-year clinical fellowship… The one year of deferred salary isn’t that big of deal if it helps to prevent long-term burnout. Also, it will help to be embedded in a clinic setting for one year as you will be exposed to how an efficient clinic runs, odd cases, difficult patients, etc. Vast majority of neurology residents don’t get enough clinic experience. Consider 6 months of intermittent Locums after fellowship and you will be doing very well.”

I think the degree of general neurology that is practiced by many practicing general neurologists is dying. By that I mean that I don’t think new grads, by and large, are prepared to practice “full-spectrum” general neurology at a competent level. I worked hard in residency, fellowship, and in the first couple years of private practice to try to achieve this, and I am overall happy with the balance of being able to only make subspecialty referrals for perhaps 1/75 patients. This is how many current general neurologists practice, but many have slowly been able to absorb the vast amount of information regarding diagnostic and therapeutic advances in medicine year by year. For new grads, this is extremely tough. It is doable, but you have to work hard and have a lot of confidence or strong support.

But it is really awesome to see such a variety of patients. I may have a patient with new-onset MS for which we are starting Ocrevus followed by a patient with early AD discussing risks/benefits of Leqembi followed by a few stable headache or PD patients followed by a couple Botox patients for chronic migraine. Then in the afternoon I may have a couple EMGs, do a bilateral greater/lesser ONB, and see an urgent follow-up for antibody-positive generalized MG. And that’s just in a day. With the neuro-op background, add in interpreting OCTs/visual fields, dilating patients/fundus photos if needed, and seeing a fair amount of IIH/cranial nerve palsies. You can also go pretty deep in terms of the work-ups, if you want. I’ve diagnosed a few genetically confirmed CPEO, CMT, and a couple families (one with episodic ataxia type 2, with life-changing responses to Diamox for multiple family members spread around the country; the other with a type of myopathy called DNM2 centronuclear myopathy). Found colon cancer as the mechanism for multiple recurrent stroke in a 60yoF, which stopped after Lovenox and cancer treatment. Ordering mediastinal lymph node biopsies for PET-avid lesions to provide supportive evidence of neurosarcoid. Finding neurosyphilis presenting in a 42yoM with vision loss, hearing loss, and severe headaches.

However, you need to know when to refer obviously. Additionally, you are also seeing many patients with some combination of what we currently call FND/fibromyalgia/chronic fatigue/long COVID. You are dealing with difficult patients. Furthermore, I think there are serious concerns with reimbursement in private practice neurology. If you don’t do EMGs or have a ton of Botox patients/EEGs, assuming you don’t have extra income from MRIs, APRNs, or other services, good luck making the average physician salary and staying sane (I am speaking about outpatient here). Many new patients are complex and you can’t churn through them like other specialties. All the paperwork, chart messages, and patient calls are not reimbursed. The new G2211 complexity add-on code for patients with a single, serious, complex condition only bills for like $12 which is ridiculous when compared to the reimbursement for procedures. All of the prolonged time codes are also laughable given that you can spend 90 minutes with an extremely complex Medicare patient and bill for about the same amount as a 30-minute EMG that diagnosed mild CTS. In my opinion, there isn’t near enough conversation regarding this at the top levels of organized neurology because so much representation is from academics or the seasoned private practice neurologists who still “do it all” (which means they do procedures and can make average physician salary).

That was a long post and turned into a rant, sorry! But I applaud your goal. It is possible but very challenging. I would consider neuromuscular fellowship or CNP and getting as much exposure in residency to movement, EEG, and neuro-immunology as possible. Also learn nerve blocks/botox for migraine. Don’t pick research electives or waste too much time because you will literally pay for it later (via income that you are not earning).

 

[deleted1208015]

This is an excerpt from my post on a recent thread:

“I did neuro-ophthalmology and also practice general neurology. My residency provided great general neurology training and I do EMG/EEG, nerve blocks, Botox for migraine/HFS/bleph/spasticity as well as a few patients with cervical dystonia. That being said, if you want to do general outpatient neurology, I would highly recommend you do a one-year clinical fellowship… The one year of deferred salary isn’t that big of deal if it helps to prevent long-term burnout. Also, it will help to be embedded in a clinic setting for one year as you will be exposed to how an efficient clinic runs, odd cases, difficult patients, etc. Vast majority of neurology residents don’t get enough clinic experience. Consider 6 months of intermittent Locums after fellowship and you will be doing very well.”

I think the degree of general neurology that is practiced by many practicing general neurologists is dying. By that I mean that I don’t think new grads, by and large, are prepared to practice “full-spectrum” general neurology at a competent level. I worked hard in residency, fellowship, and in the first couple years of private practice to try to achieve this, and I am overall happy with the balance of being able to only make subspecialty referrals for perhaps 1/75 patients. This is how many current general neurologists practice, but many have slowly been able to absorb the vast amount of information regarding diagnostic and therapeutic advances in medicine year by year. For new grads, this is extremely tough. It is doable, but you have to work hard and have a lot of confidence or strong support.

But it is really awesome to see such a variety of patients. I may have a patient with new-onset MS for which we are starting Ocrevus followed by a patient with early AD discussing risks/benefits of Leqembi followed by a few stable headache or PD patients followed by a couple Botox patients for chronic migraine. Then in the afternoon I may have a couple EMGs, do a bilateral greater/lesser ONB, and see an urgent follow-up for antibody-positive generalized MG. And that’s just in a day. With the neuro-op background, add in interpreting OCTs/visual fields, dilating patients/fundus photos if needed, and seeing a fair amount of IIH/cranial nerve palsies. You can also go pretty deep in terms of the work-ups, if you want. I’ve diagnosed a few genetically confirmed CPEO, CMT, and a couple families (one with episodic ataxia type 2, with life-changing responses to Diamox for multiple family members spread around the country; the other with a type of myopathy called DNM2 centronuclear myopathy). Found colon cancer as the mechanism for multiple recurrent stroke in a 60yoF, which stopped after Lovenox and cancer treatment. Ordering mediastinal lymph node biopsies for PET-avid lesions to provide supportive evidence of neurosarcoid. Finding neurosyphilis presenting in a 42yoM with vision loss, hearing loss, and severe headaches.

However, you need to know when to refer obviously. Additionally, you are also seeing many patients with some combination of what we currently call FND/fibromyalgia/chronic fatigue/long COVID. You are dealing with difficult patients. Furthermore, I think there are serious concerns with reimbursement in private practice neurology. If you don’t do EMGs or have a ton of Botox patients/EEGs, assuming you don’t have extra income from MRIs, APRNs, or other services, good luck making the average physician salary and staying sane (I am speaking about outpatient here). Many new patients are complex and you can’t churn through them like other specialties. All the paperwork, chart messages, and patient calls are not reimbursed. The new G2211 complexity add-on code for patients with a single, serious, complex condition only bills for like $12 which is ridiculous when compared to the reimbursement for procedures. All of the prolonged time codes are also laughable given that you can spend 90 minutes with an extremely complex Medicare patient and bill for about the same amount as a 30-minute EMG that diagnosed mild CTS. In my opinion, there isn’t near enough conversation regarding this at the top levels of organized neurology because so much representation is from academics or the seasoned private practice neurologists who still “do it all” (which means they do procedures and can make average physician salary).

That was a long post and turned into a rant, sorry! But I applaud your goal. It is possible but very challenging. I would consider neuromuscular fellowship or CNP and getting as much exposure in residency to movement, EEG, and neuro-immunology as possible. Also learn nerve blocks/botox for migraine. Don’t pick research electives or waste too much time because you will literally pay for it later (via income that you are not earning).

Thank you for the extremely thoughtful and kind response.

I definitely agree that the cognitive challenge of doing general neurology is very high and unique in medicine. What do you think about big medical groups hiring general neurologists? I feel like the doing general neurology and then trying to run a private practice on top of that is too much to handle, at least for me.

 

[s5260205]

Thank you for the extremely thoughtful and kind response.

I definitely agree that the cognitive challenge of doing general neurology is very high and unique in medicine. What do you think about big medical groups hiring general neurologists? I feel like the doing general neurology and then trying to run a private practice on top of that is too much to handle, at least for me.

You will find an abundance of jobs for outpatient general neurology no matter where you go because of the shortage of neurologists around the country. Depending on the group you are joining, the patients you see can be tailored to your subspecialty. The larger the group (such as academic centers), the more subspecialty-specific patients you can have, as the bigger groups can offer enough referrals for you to build a panel of patents of your interests, versus the smaller groups, you are likely seeing a mix of everything.

You can really tailor your practice to be the expert in a very small subset of patient versus a jack of all trade seeing anything and everything. I for one disdain how some academic centers practice neurology, where a patient may see 3 neurologists for 3 different issues (e.g., stroke, migraines, epilepsy) when they can all be taken care of by 1 neurologist. As an example, I see this not infrequently where the stroke neurologist would punt the patient to headache neurology for headaches, and vice versa the headache neurologist would punt a migraine patient to behavioral or general neurology for memory complaints. What is the purpose of doing 4 years of neurology residency if you can't or are unwilling to provide comprehensive neurology care?

 

[Spinothalamic]

Thank you for the extremely thoughtful and kind response.

I definitely agree that the cognitive challenge of doing general neurology is very high and unique in medicine. What do you think about big medical groups hiring general neurologists? I feel like the doing general neurology and then trying to run a private practice on top of that is too much to handle, at least for me.

Yeah, there are many multi-specialty groups that are hiring neurologists and this can be a good option. However, one popular approach in the private practice world is joining/creating a neurology group to pool resources and split common diagnostic testing modalities such as MRI/EEG or even things like infusions. I think this is the way going forward given neurology subspecialization trends. However, someone has to triage the referrals and there could be issues regarding variable compensation for different neurology subspecialties.

Either way, just keep in mind that you may be enticed by an initial salary but that goes away after a couple of years typically and then you are going on production. This isn’t a big deal if you are okay with moving if things don’t work out, but it is important to keep in mind if you are geographically tied.

 

[CnsCrit]

Hello everyone, current neurology resident here who is completely lost about deciding on a fellowship to pursue.

My main concern is that many fellowships pigeonhole you into a specific setting or role. Doing a stroke or NCC fellowship means you’re signing up for a fully inpatient career. Doing autonomic, movement, or neuro-onc means your signing yourself up for something very niche that limits job opportunities in bigger cities. Sleep and neuromuscular have a lot of overlap with other specialties that potentially low your marketability. And then with headache, NP/PAs are increasingly dominating the workforce.

CNP seems like a good option but I know that for academic medicine a CNP may not take you very far. However, my main concern is a growing number of even private employers who prefer a fully NM or Epilepsy trained specialist to do EMGs or EEGs, respectively, over someone CNP trained.

My main goal is to practice community general neurology in a mixed outpatient and inpatient setting. I know this is very difficult to find outside of an academic medicine setting so if I had to pick I would say outpatient.

If I had to summarize it, I guess I want to “do it all” in neurology and be a general neurologist despite neurology being an ever-growing field, which now that I’m typing it out seems naive.

Couple of things: Doing stroke or NCC definitely does not pigeon hole you into inpatient medicine forever. After either fellowship you can easily do general neuro or stroke clinic or hospitalist, in fact many many stroke docs also do clinic and also see some general patients, including academics. I practice NCC and if I told my chair I was interested in outpatient clinic, they would be ecstatic, clinic is backed up everywhere. The issue is getting inpatient neurologists to agree to do clinic, which many don't want to do (including me).

I don't think its far fetched to want to practice both outpatient and inpatient general neuro. In academics, no one wants to see general patients so there is a need for people who have this niche, and in a less subspecialized general practice you will see more general patients anyways.

My advice is to chose the fellowship you're most interested in, think about what mix of OP/IP you want, consider academic vs private vs hybrid, and pitch that to employers. I don't think you'll have a hard time at all.