M3 wanting to go into neurology but not 100% sure

[WalkingOnTheSun]

I'm an M3 about 80% sure about neurology. I was wondering if the seasoned veterans on this forum could help me make sure it's right for me (specifically -- are the cons serious enough that I should consider a different field?)

Pros:
-My favorite rotation
-Did neuroscience in undergrad and loved it
-Love the research in neurology, I think there's gonna be a lot of up and coming stuff in the next two decades. Diseases like Alzheimer's interest me from a research perspective (but not a clinical perspective)
-Love the physical exam, how thorough it is and how it helps you
-Liked the people I met in neurology, felt like they were all really committed to teaching and that's what I want to be in the future.
-I like the emergency neurology conditions (seizures, strokes, etc)
-I like how much time you get to spend with patients -- I felt like on my neurology clinic days, I was able to really form a connection with patients in a way that I couldn't in primary care (not enough time, and too many demands in primary care)
-I like procedures, and there are some procedures I could do in neuro
-I liked being able to help patients who were really scared by what was happening to them (i.e. helping people with serious conditions)
-I'm pretty passionate about cholesterol, diabetes, and blood pressure management (which of course is something an internist should enjoy managing but these are also diseases that neurologists concern themselves about as well)

Cons:
-Apparently neurology has the highest burnout rate?? what's up with that? I felt like neurology clinic was a more relaxed pace than other outpatient clinics
-I don't mind functional neuro patients right now... but I've also only encountered a couple of them.
-The stereotype of not being able to treat things, which of course isn't true but there is a lot of progress to be made. (I was in a dementia clinic and that was a bit depressing).
-Sometimes inpatient, I felt like there was a shotgun approach to any serious uncertain neuro condition
-Not sure I would like the neuro ICU or doing a brain death exam
-Part of me wonders if neurosurgery would be what I would enjoy more, or if neurosurgeons will be taking over many of the exciting innovations in brain science over the next couple decades
-Insurance hassles -- how often do you have to fight to get MRIs and other testing ordered for your patients.

Thanks!

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[Thama]

Pros:
-My favorite rotation

Cool.

-Did neuroscience in undergrad and loved it

That's nice, but clinical neurology isn't neuroscience. The knowledge base and skillsets overlap surprisingly little.

-Love the research in neurology, I think there's gonna be a lot of up and coming stuff in the next two decades. Diseases like Alzheimer's interest me from a research perspective (but not a clinical perspective)

People have been saying that we'll have a cure for AD in a decade for more than a couple of decades now, and this will remain true as long as the bulk of the AD field continues repetitively ramming its collective head against the steel-reinforced brick wall of the A-beta hypothesis. But other areas are much more promising. Neurology research in general is a major plus, but don't believe what people say will be available when you graduate residency.

-Love the physical exam, how thorough it is and how it helps you

I swear to god that neurologists are the last doctors left that actually care about a history and exam. Even in internal medicine, if the history says COPD exacerbation, the exam says COPD exacerbation, and the labs say pancreatitis, then the admitting diagnosis will be pancreatitis and it's a coin flip whether lungs are mentioned in the problem list at all.

-Liked the people I met in neurology, felt like they were all really committed to teaching and that's what I want to be in the future.

That sounds more like you just got a good group that you enjoyed being around. One of the hardest things about 3rd year of med school is separating out how you liked the individual residents/attendings you worked with from what you liked about the specialty itself.

-I like the emergency neurology conditions (seizures, strokes, etc)

So do I, just be aware that most neurology is clinic based and most neurologists don't deal with acute problems all that often. You'll see a lot of acute neurology as a resident and far, far less for the rest of your life unless you are a neurointensivist.

-I like how much time you get to spend with patients -- I felt like on my neurology clinic days, I was able to really form a connection with patients in a way that I couldn't in primary care (not enough time, and too many demands in primary care)

That's a great point and something that draws a lot of us in. Be aware that there are time pressures on us too, but often a little less than in primary care and we can focus on 1 problem instead of having 16 dumped on us.

-I like procedures, and there are some procedures I could do in neuro

Training in neurology for the procedures is like reading Playboy for the articles. They do exist, but...

-I liked being able to help patients who were really scared by what was happening to them (i.e. helping people with serious conditions)

Neurology has this in spades to be sure.

-I'm pretty passionate about cholesterol, diabetes, and blood pressure management (which of course is something an internist should enjoy managing but these are also diseases that neurologists concern themselves about as well)

Cons:
-Apparently neurology has the highest burnout rate?? what's up with that? I felt like neurology clinic was a more relaxed pace than other outpatient clinics

The most burned out docs I've personally met have been anesthesiologists, ER docs, and intensivists of all varieties. I mostly know academic neurologists but I don't think we're particularly burned out. I don't know what drives the Medscape numbers or how they get their sample.

-I don't mind functional neuro patients right now... but I've also only encountered a couple of them.

Like most of us, you'll learn sympathy for the conversion disorder types and white hot rage for the malingerers. There are equivalents in most specialties.

-The stereotype of not being able to treat things, which of course isn't true but there is a lot of progress to be made. (I was in a dementia clinic and that was a bit depressing).

Yeah, that's spectacularly stupid. If faculty at your med school still admits to believing that nonsense then I'm afraid your medical education may be lacking in general.

-Sometimes inpatient, I felt like there was a shotgun approach to any serious uncertain neuro condition

That's one thing that differentiates a good neurologist from a bad neurologist - good neurologists know why they are ordering things and do so in a logical fashion based on their history and exam. That said, in my experience, with difficult neurological cases the logic of why things are being done is often many levels over the heads of just about any med student.

-Not sure I would like the neuro ICU or doing a brain death exam

You can join the "I hate the neuro ICU" club. It's populated by most people who have done a neurology residency.

-Part of me wonders if neurosurgery would be what I would enjoy more, or if neurosurgeons will be taking over many of the exciting innovations in brain science over the next couple decades

Maybe you would enjoy neurosurgery more. It's a very, very different field from neurology, but you should probably rotate there in med school. Regarding "taking over exciting innovations" - it doesn't take much perusing of neurosurgical journals to realize that their research standards are really poor compared to the equivalent neurology, neuroscience and neuroimaging journals. Physician-scientist neurologists and non-clinical neuroscientists are largely the ones moving the research needle. Neurosurgeons are too busy to be really high quality scientists - they just can't commit the percent effort that's required.

-Insurance hassles -- how often do you have to fight to get MRIs and other testing ordered for your patients.

Insurance companies are literally Hitler. This doesn't change based on specialty.

Thanks!

 

[Telamir]

Not as good at formatting as my colleague above me but I'll give it a try. Keep in mind, I do inpatient neurology ONLY.

-My favorite rotation
Always a good start.

-Did neuroscience in undergrad and loved it
As mentioned above, bench/textbook neuroscience is not neurology. I think this is a good thing. Honestly what you need is an interest for the subject and a good head on your shoulders to think of problems in an orderly fashion. I personally didn't like my neuroscience course as an M1.

-Love the research in neurology, I think there's gonna be a lot of up and coming stuff in the next two decades. Diseases like Alzheimer's interest me from a research perspective (but not a clinical perspective)
I'm not too interested in dementia, so I can't comment. That being said, there are other areas that we are understanding better such as neuroimmunology.

-Love the physical exam, how thorough it is and how it helps you
I am a STICKLER for a good history and exam. I agree with the above poster. This is key, and I feel like as a neurologist I'm the only one to actually TALK to a patient or even touch them. It is a big point of frustration for me. That being said as you go along in your training you will find that you can hone in your exam to your complaint. For example, I'm not testing vibration/proprioception on everyone.

-Liked the people I met in neurology, felt like they were all really committed to teaching and that's what I want to be in the future.
It's good you had a good subjective experience on the rotation.

-I like the emergency neurology conditions (seizures, strokes, etc)
I like the treatment of acute stroke and seizures. Like I said, I do inpatient neurology exclusively, and so I deal with this quite often. Keep in mind, most "acute neurology" tends to be stroke/seizure/AMS/bleeds. Also keep in mind, out of all the docs you will run into in the hospital in my experience most don't know neurology above the most basic level. You will get consults for asterixis, and for physiologic tremors, etc.

-I like how much time you get to spend with patients -- I felt like on my neurology clinic days, I was able to really form a connection with patients in a way that I couldn't in primary care (not enough time, and too many demands in primary care)
Everyone gets time constraints/time demands. This is more for the outpatient folks. On the inpatient side it depends; the more complex cases may take me 40-50 minutes, but there are followups I can do in 10-15 or less (if the patient isn't conscious)

-I like procedures, and there are some procedures I could do in neuro
Procedures in neuro: EMG, EEG (reading only) LPs (IF you do them), and DBS/VNS programming. If you were to do epilepsy you might find yourself in the OR when epilepsy surgeries are taking place. EEG reimburses very well, EMG does not. VNS/DBS reimburses well enough. With CNP (EEG/EMG) training is vital. It is very easy to do/read them poorly.

-I liked being able to help patients who were really scared by what was happening to them (i.e. helping people with serious conditions)
You will encounter a good amount of this. A lot of conditions are just things you "deal with" but won't kill you, and can be minor annoyances. It's very common to comfort someone that their tremor is a benign essential tremor and not Parkinson's Disease. You might also reassure someone an imaging incidentaloma is just an incidental finding. Cure sometimes, relieve often, comfort always.

-I'm pretty passionate about cholesterol, diabetes, and blood pressure management (which of course is something an internist should enjoy managing but these are also diseases that neurologists concern themselves about as well)
Not gonna lie. Ew. I managed them in training due to having a primary service. I don't deal with these now.

Cons:
-Apparently neurology has the highest burnout rate?? what's up with that? I felt like neurology clinic was a more relaxed pace than other outpatient clinics
I myself was pretty burned out during training. Personally it was the long hours, difficult patients (most of our patients are disabled in one way or another due to their condition), abundant psychopathology where I trained (tons of conversion disorder, no psych), and competing responsibilities (you're getting slammed inpatient, someone calls that gabapentin makes them sleepy, needs to talk to you, etc). I'm much better now that I'm out in practice.

-I don't mind functional neuro patients right now... but I've also only encountered a couple of them.
These personally frustrate me, especially when I consult psych and they either a) do nothing, or b) try to make it neurological despite me ruling them out. That being said, there are functional patients and there are functional patients. Some are more enjoyable than others. Some patients actually get better and that can be rewarding.

-The stereotype of not being able to treat things, which of course isn't true but there is a lot of progress to be made. (I was in a dementia clinic and that was a bit depressing).
Again, a lot of specialties say we don't cure. If you think about it there are VERY FEW cures for anything besides something that's surgically correctable or an infection. Dementia/ALS are particularly tough to deal with, but in medicine most of what everyone does is treat symptoms as best as you can. This is evolving, and at this time we have more treatments than we ever have had before.

-Sometimes inpatient, I felt like there was a shotgun approach to any serious uncertain neuro condition
Like I mentioned before, this goes both ways. Someone who was encephalopathic cause they're septic jerked? Oh snap, put them on Keppra and call Neuro. You can get primary teams freaking out at the mere thought of a neurological condition and shotgunning a workup/consult. On the other end, in neurology sometimes you will encounter patients where yeah...you order a battery of immunologic testing because the MRI is normal, the EEG shows encephalopathy, and there's no obvious other cause. You work things in a logical way, but eventually you will be left with a bunch of zebras to test for. That can feel like shotgunning tests, but there is a method to the madness. Remember, sometimes you will be dealing with exceptionally rare stuff.

-Not sure I would like the neuro ICU or doing a brain death exam
You get over it. I personally like the refractory status, super refractory status. I didn't like SAH as much, but I did like stroke management, etc. Brain death or persistent vegetative state is a reality of life. You will do a few of these exams and you will get used to them. Approach all these situations emphatically with the family, but also learn to distance yourself. The patient is the one with the disease.

-Part of me wonders if neurosurgery would be what I would enjoy more, or if neurosurgeons will be taking over many of the exciting innovations in brain science over the next couple decades
Lol....no.

-Insurance hassles -- how often do you have to fight to get MRIs and other testing ordered for your patients.
As an inpatient neurologist, I don't.

 

[Chibucks15]

Thanks to both of you for responding so thoroughly. I’m gearing up for step but fully thinking neuro (as long as I do okay on boards). Very much appreciated to have such a great rundown

 

[mrbreakfast]

As someone who recently made this decision in med school, I'll try to share a few of my "insights."

-Apparently neurology has the highest burnout rate?? what's up with that?

I'd take this this with a chunk of salt.

-I don't mind functional neuro patients right now... but I've also only encountered a couple of them.

These people are sick in their own way and you can(try to) help them. That's been my mindset.

-Part of me wonders if neurosurgery would be what I would enjoy more, or if neurosurgeons will be taking over many of the exciting innovations in brain science over the next couple decades

No. If you are even remotely considering a field other than NS, you should not do NS.

-My favorite rotation

-I liked being able to help patients who were really scared by what was happening to them (i.e. helping people with serious conditions)

-I like how much time you get to spend with patients

-Love the physical exam, how thorough it is and how it helps you

These were among the reasons I chose neurology. If you can't decide, go with the field on which clerkship you spent the least amount of time staring at the clock and felt the least exhausted at the end of the day.

 

[WalkingOnTheSun]

Thank you for the very thorough replies, I really appreciated it!!

 

[liquidshadow22]

If you enjoy sitting in front of a computer, clicking in orders and writing notes do neurology. If you like cutting **** and sewing, do neurosurgery.

 

[Postictal Raiden]

If you enjoy sitting in front of a computer, clicking in orders and writing notes do neurology. If you like cutting **** and sewing, do neurosurgery.

This is maybe accurate describing a hospitalist job but not neurology. I'd say 50% or more of your day in neurology is talking to patients and doing physical exam. Maybe 25% going over imaging/EEG and the other 25% note writing/putting orders.

 

[liquidshadow22]

This is maybe accurate describing a hospitalist job but not neurology. I'd say 50% or more of your day in neurology is talking to patients and doing physical exam. Maybe 25% going over imaging/EEG and the other 25% note writing/putting orders.

I guess it depends if youre a resident or attending. I would say 50% note writing/orders as a resident at least.

 

[Postictal Raiden]

I guess it depends if youre a resident or attending. I would say 50% note writing/orders as a resident at least.

Also depends on the program. At my program, writing notes takes less than 25% of the day. Rounding takes longer.

 

[liquidshadow22]

Have u done consults?

 

[Postictal Raiden]

Have u done consults?

Yes. Again it's program dependent. Average # of patients a neuro resident carry at my program is ~6 (more on weekends). Usually progress notes are done prior to rounding around 9am. Then new consult notes are completed after rounds. On average, a progress note shouldn't take more than 10-15 mins. H&P/consult notes 20-30 mins.

Now in IM, writing notes, putting orders, following up on labs and consults, and doing social work stuff can easily eat up 3/4 of the day.

 

[Telamir]

God, I'd kill for a 6 patient census. No diss, just saying.

 

[Thama]

Yeah, that's an unusually light program.

 

[Postictal Raiden]

Yeah I kinda lucked out.

However there are few programs out there that have even lower census.

 

[Dr. Basketball]

Can anyone speak to the relative amount of autonomy in neurology? Or does that just depend on which hospital or clinic you work at?

 

[Telamir]

You can do an autonomic fellowship and see a LOT of autonomy.

Seriously though what does the question mean?

 

[Little Green Mensch]

No. If you are even remotely considering a field other than NS, you should not do NS.

If the OP has had a neurosurgery rotation and is still leaning toward neurology, I'd definitely agree. If he hasn't had any exposure to neurosurgery and is seriously considering it, he needs to either do an elective or some shadowing. If he's a rising M4, this is really late in the game to line up away rotations, etc.