Neuro as a "cognitive" field??

[YellowRose]

Hello everyone,

I have read on a few post that neuro is a cognitive field. I know what the term cognitive means, but i'm unsure how this applies to the practice of neurology. Are they referring to the patient, since neurology affects brain function? Or referring the the practice of neurology as requiring cognitive ability? If so, can someone give me an example of cognitive functioning as it applies to the practice of neuro? Thanks, from a curious student.

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[jimdo]

The term "cognitive" is referring to the reputation of neurology as a field for those that enjoy thinking. You may also hear the term "cerebral" in description of neurology. This is not intended to insult those of other specialties...obviously all physicians must think. However, when one must regularly locate a neurologic lesion based solely upon signs and symptoms, a great deal of thought is necessary. The brain is beautifully complex, and it can prove difficult localizing a problem with such complex anatomy and function.

 

[YellowRose]

thanks jimdo,

i was giving up hope on this thread. i though people were ignoring me happy new year!!

 

[jimdo]

Same to you. Any other questions, Id be glad to help.

 

[oldandtired]

Recent advancements in radiology are making the cognitive aspects of neurology disappear. Neurologists are mostly triage nurses for radiographic studies of the CNS. They do not localize lesions anymore. MR/CT etc. and the radiologist localizes the lesion.

They read the radiologists report or attempt to read the study themselves and as the old adage goes, diagnose then adios! Well, sometimes they send the patients to walgreens for an aspirin

 

[Neurogirl]

To Oldandtired,

Boy, you ARE old and tired and pretty bitter about something.
You obviously haven't spent time with any well trained neurologists. In fact, you sound like you haven't spent any time on a neurology service. If you had, you'd know that, yes, we still localize and that with a fair number of conditions, radiology plays only a small role (sometimes no role) in the diagnosis.

FYI, we read our own studies and act on them, often before the radiologist has even seen the films! Afterwards, we usually do look at the report, just to make sure they haven't missed anything.

Seriously though, at my facility, we are fortunate to have fellowship trained neuroradiologists and they are an amazing group. However, in the REAL world, I would never rely on general radiologists. It's been my experience (and I get warned...on a daily basis) that they just don't have sufficient training.

 

[oldandtired]

In the REAL world my friend, the only thing that matters is who bills for the $tudy. And yes, there are neurlogists who bill for their own maging studies. They are probably practicing in places that are either not able to recruit rads or where the hospital administration is composed mainly by neurologists. These are far and few between.

Training wise, the general radiologist is leaps and bounds above the neurologist. While you may see many cases during your residency covering many areas of CNS pathology, the radiologist is trained to recognize and diagnose diseases across the whole spectrum including trauma, bone lesions (temporal bone, skull base, etc), diseases of the sinuses, surgical issues, etc which often fall outside the domain of the neurologist.

You do not dictate cases and have months of formal concentrated intensive neuroradiology training. You do not have an oral exam at the end of your residency where you are specifically tested on neuroradiology. You do not have training in the physics of MR and CT. You will get your ass kicked in court if one of your official reads is wrong.

 

[Neurogirl]

Actually, by the end of my residency, I WILL have had months of formal neuroradiology training. We have formal didactics every week (by fellowship trained neuroradiologists) and of course, I see, and am pimped on, head and spine films nearly everyday. The fact is, we see alot more than the general radiology residents...as they themselves will tell you. Also, if I'm not mistaken, neurorads IS part of the neurology boards.

Finally, I never said I was interested in billing for my readings. I'm only interested in making the correct diagnosis. I'm curious, what kind of physician are you? Could you be...gasp...a general radiologist?

 

[jimdo]

Leave it to a radiologist to imply that he is more important than all the rest. Is cardiology next? Perhaps derm too. Radiology certainly plays a role, but to claim that Neuro is somehow subpar and implying that it is becoming obsolete is misleading and factitious. Radiology is a tool that aids the neurologist in making and confirming a diagnosis, pure and simple. Any neurologist that cannot read his own films is not doing the field a service and in my experience is rare to non-existent. Granted, I have not yet begun residency, but have spent substantial time on both neuro and rads services.

BTW, neurogirl, Im pretty certain that neuroradiology is a component of the boards, although I have not yet officially begun my residency training.

 

[felson]

I agree that newly minted neurologists have had ample training in neuroradiology. My interactions with neurologists have been been mostly complementary - a team approach. And many times, the diagnoses have been made by the neurologists based on PE alone.
It is a testament to the ability of up-to-date neurologists and neurosureons that neuroradiology fellowships and Certificate of Added Qualifications were established in order to win turf battles. But we all have seen neurologists with inadequate training who wanted to get in on the action. This smacks of self-referral and is unbecoming. I have had films brought to me by neurologists for second opinions, and I know full well that these physicians went back and dictated what I told them.
What neurologists lack when compared with radiologists is the ability to perform invasive procedures such as angiography, myelography, angioplasty, vertebroplasty etc. So yes, neurologists do need radiologists' expertise.

 

[GenMed]

This is something I've always wondered about. Why is it that cardiologists do interventional procedures themselves, while neurologists have simply allowed rads to take interventional neuro(radio)logy? Do neurologists have hands that can't pass arterial lines?

I think there are many areas in medicine that are "boderline", and that may be practiced safely and effectively by doctors from different specialties. For example, spine surgery can be done by orthopods and neurosurgeons (after both have spine fellowships or adequate experience). Skull base surgery can be done by neurosurgeons and otolaryngologists. Interventional cardiology can be done by cardiology, as well as sufficiently trained radiologists.

There doesn't seem to be any reason why neurologists can't train to do interventional neurology. After all, no one - not neurosurgeons, not neurorads - understands the brain as deeply as neurologists. What I don't understand is why havent neurologists taken the initiative as a profession to do the procedures? Are there programs out there that allow neurologists to do interventional neuro(radio)logy fellowships? I doubt it. But neurologists should develop programs on their own, if the rads blokes are too childish (and greedy) to adopt a fair attitude to training future neuro physicians.

 

[mandownunder]

Cardiologists train 2-3 years and perform hundreds of coronary angiograms in their training. Yet there is a still subtantially higher rate of complication following angios performed by cardiologists compared to interventional radiologists.
To be credentialled for angiography, the physician must demonstrate knowledge of physics, must have performed hundreds of procedures under supervision, understand the physiology (contrast, flow), anatomy etc. Be able to handle the not infrequent complications. The physician must also be knowledgeable of complementary modalities (US, MRI, CT, NM) in order to tailor the workup or therapy.
Neuroangio is the most dangerous of all interventional procedures. One mishap will lead to infarction. The physician must be able to do embolization and other therapeutic interventions that are indicated. One has to enter from the femoral arteries, advance through the aorta and position the catheters at the origins of the cerebral vessels. What if a clot is showered distally and occludes the digital arteries, would that physician be able to handle the situation? What if there is a dissection, anomalous vascular anatomy?
Interested neurologists are always welcome to enter Radiology residencies where they receive appropriate in depth training. If they attempt to establish their own training programs, this will be a disservice for their patients and a boon for ambulance chasers. One can make a case for the neurologists since they can correct any misadventure that they may have caused. However, they are also quite busy and a second opinion plus guidance from radiologists are thought valuable.

 

[mandownunder]

Meant neurosurgeons, not neurologists in the last comment.

 

[felson]

Originally posted by GenMed
[ [/B]Why is it that cardiologists do interventional procedures themselves, while neurologists have simply allowed rads to take interventional neuro(radio)logy? ... After all, no one - not neurosurgeons, not neurorads - understands the brain as deeply as neurologists... Why havent neurologists taken the initiative as a profession to do the procedures?... Neurologists should develop programs on their own that allow them to do interventional neuro(radio)logy fellowships if the rads blokes are too childish (and greedy) to adopt a fair attitude to training future neuro physicians.B]

Angiography and Interventional Radiology were developed by radiologists. They did not take interventional neuro(radio)logy from neurologists.

Rad blokes are too childish (and greedy)??? To safely perform dangerous procedures, standards of training must be set. It is not see one, do one, teach one. Even radiologists who have been well trained in residency defer to interventional radiologists when they have not done sufficient procedures to maintain their skills. These skills are maintained by performing vascular procedures involving the entire body, multiple times each day. These skills cannot be maintained by doing a carotid angio case twice a month.

 

[GenMed]

Originally posted by mandownunder

To be credentialled for angiography, the physician must demonstrate knowledge of physics, must have performed hundreds of procedures under supervision, understand the physiology (contrast, flow), anatomy etc. Be able to handle the not infrequent complications.

You misunderstand my point. I am not saying that newly trained neurologists should simply start practicing IN. Everything that we do in medicine requires training, whether that means looking at a patient and diagnosing cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy or looking at an x ray and diagnosing a toe fracture. I am not denying that one should be superbly trained to practice in the various fields of medicine.

However, there are many areas of medicine where the specialties overlap. It is at these borders that silly turf wars ensue. What I feel is that one specialty should not have a monopoly over
the educational process that leads to good practice.

Yes, you need to know the physiology of cerebral blood flow to do IN.
Yes, you need to do hundreds of procedures.
Yes, you need to understand how to treat IN complications.

AND THAT IS WHAT A FELLOWSHIP SHOULD BE FOR.

I don't think that a neurologist is incapable, with good training, to do IN. Cardiologists have been doing IC for decades. The problem is that because of the politics of turf wars, he can't even get fellowship training. An IN fellowship for a neurologist may have to be longer, perhaps three years, to ensure sufficient technical education and procedural experience, but it should at least be available to those who want to do it.

Currently, however that is out of the question, except for the ridiculous suggestion that a neurologist start a residency in radiology first. This is silly because you DON'T need to know GI radiology to practice IN, you DON't need to know pregnancy ultrasounds to do IN, etc.

The hypocrisy of the current situation is seen with respect to neurosurgeons who want to do an IN fellowship. I have a friend who trained as a NS, and then did an IN fellowship at a neuroradiology department in VA. The fellowship lasted one year.
In spite of the fact that neurosurgeons don't do any more radiology than neurologists while in residency, this is possible. And I think that's sensible, because you don't need to know the whole of general radiology to do IN. Of course, a neurologist will probably need more training time because IN is a procedural thing. so be it. two years, or three years. It should definitely be possible to teach the physics, skills, different imaging modalities (relevant to the NS!) etc.etc. that is required of an IN in that timeframe to someone who has already spent 4 years, after medical school, studying the brain and its diseases more thoroughly than anyone else.

What should NOT be happening is for one specialty to monopolize fellowship training in a "borderline" subspecialty and keep it only open to graduates of that specialty.

 

[GenMed]

Originally posted by felson
Angiography and Interventional Radiology were developed by radiologists. They did not take interventional neuro(radio)logy from neurologists.

You will be interested to know that IN (I am not talking about IR in general) was not developed by radiologists. It was first developed by neurosurgeons and neurologists. The first IN procedure was performed by Al Lussenhop and Bill Spence of Georgetown. This was if memeory serves right in the late fifties.


[/QUOTE] These skills are maintained by performing vascular procedures involving the entire body, multiple times each day. These skills cannot be maintained by doing a carotid angio case twice a month. [/QUOTE]

The first good point from the rads in this discussion. I agree. However, even this is not a reason to deny suitable IN fellowship training to neurologists. I have 3 responses:

1. This is the province of recertification. It should not be a reason to restrict fellowship training. Continued recertification in procedural specialties should hinge on how often and how well someone does his procedures (in this case IN). If an IN who originally trained as a neurologist practices in a setting where he does 10 procedures a week, I think he'll be a better interventionist than an IN who originally trained as a radiologist and then did an Neurorad fellowship, but now spends most of his time in diagnostic NR and does 1 procedure a week.

2. "Entire body"? You mean a neurosurgeon who does a one year IN fellowship, after training for seven years as a brain surgeon, does vascualr procedures throughout the "entire body" in that one year fellowship. Surely you jest.

3. "Multiple times each day"?
The Head of Radiology at my institution is a neurorad and has published heaps in IN. I know for a fact that even HE doesn't do "multiple procedures each day". I guess neurosurgeons who do their 8 cases a week must be terrible in the procedures they do.

 

[felson]

I will end this discussion here before you make a further fool of yourself - radiology "blokes", greedy etc.
Frankly, you don't know what the hell you are talkng about.
You want to get in on the action without adequate training. The obvious route to be a legitimate interventional neuroradiologist is appropriate training - 4 ys rad, 2 yrs neurad and 1yr neurointerv rad. There a numerous chiefs of Neurorad sections in academic institutions who are boarded in both Neurology, Neuroradiology and CAQ in Neuroradio Interv. They will tell you to do it honestly, the right way.
Just because you can not get into a Rad residency, you shouldn't try to abtain radiology training that you are not qualified for, and are not entitled to (the word "greed" you used before is more appropriate here)
And NEVER equate your ability to that of neurosurgeons, despite your boasting that you know more about the brain than anyone else (hot air here). They train 6 to 7 years, and have vast experience in their training and can handle any misadventure they might have caused.
The arguments you made and some of the information you quoted - Did you pick them out of thin air?
I know you love radiology (harder to reach) and like neurology (easier to reach). If you like to do procedures, why don't you try neurosurgery (hard to reach). Otherwise, buckle down and study to improve your chance of getting into a rad res program where your aspirations can be legitimately realized.
THE END

 

[GenMed]

I don't know who you are, what your level of training, if any, is, and will not stoop to post bullsh*t about your person when responding to your opinions. I initially expected the same of an intelligent person like you, but it appears that was too much to hope for.

The obvious route to be a legitimate interventional neuroradiologist is appropriate training - 4 ys rad, 2 yrs neurad and 1yr neurointerv rad.

That is not the ?obvious? route. It is currently the only route (in large measure). This does not mean that it may be the only route to train a good, safe interventionist. This is the distinction I have been trying to make, but which seems so difficult for geniuses such as yourself to follow.

When specialties and subspecialties are born, the early practitioners are often trained very differently from the way future generations are trained. A neurosurgeon in Cushing?s time was someone who had spent years and years in general surgery, and then did a year or so of brain surgery, apperenticed to someone with experience in the filed. Today, no neurosurgeon does five years of general surgery before embarking on neurosurgery training. It simply isn?t necessary to know how to do a Wipple?s when you are going to spend your life doing brain surgery. Of course, if one made a suggestion at that time that a neurosurgeon should spend time in neurology, neuropath etc and do mostly NS cases in his residency, he?d have been called names too.


You want to get in on the action?
I know you love radiology (harder to reach) and like neurology (easier to reach). If you like to do procedures, why don't you try neurosurgery (hard to reach). Otherwise, buckle down and study to improve your chance of getting into a rad res program where your aspirations can be legitimately realized?

Wow. Have you always been so presumptuous? You seem to have a habit of shooting your mouth off on things you know nothing about. I do not want to ?get in on the action?. I do not ?love radiology?, ?like neurology? and do not want to ?try neurosurgery?. The only specialty I?ve really loved is Internal Medicine, which I?m going into. As to you advice on ?buckling down and studying?, as someone who scored > 260 on both steps, made AOA, and honoured every clerkship except Obgyn, I think your advice is a little misplaced. You may keep your advice to yourself, and your assumptions about others? aspirations up your ***.

Just because you can not get into a Rad residency?
See above.

And NEVER equate your ability to that of neurosurgeons, despite your boasting that you know more about the brain than anyone else (hot air here).

I?m afraid the air is between your ears. Your panties are twisted so tight you?re contradicting your own gibberish now. So now you think I?m not a medical student just praying to get into rads, but a neurologist. FYI:
1.I never equated my own current ?ability to that of a NS?
2.I never equated the ?ability? of a neurologist to that of a NS. Good neurosurgeons and neurologists are great in their respective fields. I would not expect a neurosurgeon to diagnose and treat SUNCT, just as I would not expect a neurologist to treat AVMs surgically. In my own opinion, people from both specialties ?have the ability? to practice IN once trained for it if they wish, along with neurorads, the only difference being the length of time a fellowship should be for a NS, neurol, and radiologist. This is the main point I have been making, but you don?t seem to understand it.

The arguments you made and some of the information you quoted - Did you pick them out of thin air?
No. The arguments are the result of cognition, and the information was gained from my reading. If you need references for this information, and don't know how to find it, let me know.

I find it very interesting that inspite of all you have posted, you did not respond to a single point I made. Scroll up and read what you wrote and what I wrote. All you have done is (a)call me names and (b) told me what I think and aspire to.

 

[YellowRose]

thanks for the responses....very informative.