Neuro v IM? Still have time to decide but feeling lost after sub-Is in both

[Latteandaprayer]

I know this is a common post but now it’s my turn. I’m at a 1-year preclinical program so M2 year was preclinical and now M3 (and M4) is for sub-Is and electives. This means last year I had 3 months of IM and 1 month of neuro. Now I am almost done with my IM sub-I, and completed my Neuro sub-I about a month ago. I told everyone I’d go into Neuro and secured letters, but now I’m not so sure.

IM pros:
- broad generalist training. I get to feel like I’m using the entire foundation of medicine, even if just “a little about a lot”
- Lots of fascinating sub-specialties, and when I’ve rotated with endo, rheum, and cards, their generalist training was still very relevant. The endo I rotated with acted like a PCP in some ways
- I really like being someone’s doctor and having that ownership of their care. I actually do enjoy coordinating care, being the first to hear about a problem, thinking through the case, then either treating them myself or referring them to the person I think could best help
- I like a lot of the bread and butter of IM. I love pancreatitis, COPD, ACS, GIB, etc

IM cons:
- Being someone’s primary can be exhausting. Lots of logistics to get patients out, lots of coordinating all the consults
- Fellowships (if pursued) are long
- I don’t love how at least in academic medicine, you’re basically there to check boxes while specialists drive care. I don’t mean to reduce it to “you just prescribe antihypertensives and insulin,” but tbh a lot of the time that’s how it feels. GI will drive their UGI bleed management, cards will weigh in on their HFrEF, nephro will treat their refractory hyponatremia, etc. It’s nice to know someone else has more expertise to help you, but it sometimes sucks when your entire plan is “consult cards, trend trops, follow the published guidelines”

Neuro pros:
- LOVE the nervous system. Coolest organ system. Love localizing
- I like how neurologists are really good at interpreting a variety of tests, including their own imaging
- I like that the exam largely drives decision making. Like tPA is often given before any imaging confirms a stroke.
- Patients are always fascinating, even the most basic bread and butters are really cool
- I like having the final say about treatment, and feeling like I’m really driving the care of patients
- Fellowships are 1 year (but tbh residency and following are gonna be 5 years, while IM is gonna be at most 6 years so it’s not a crazy difference)

Cons:
- rarely the primary team outside of residency. Most neurologists to my understanding are basically consultants. In academia this is different but I don’t want to work in academia and would be happier in the community. Tired of the rat race lol
- “Diagnose and adios” isn’t true anymore, but you have to admit treatments aren’t that great. You can’t really cure much in IM either, but you can see someone’s A1c come down and stay down forever, while someone’s Parkinson’s can be reasonably controlled but it will progress
- Lose being a generalist. Yes intern year is in IM but the attendings on Neuro were very willing to consult IM for “basic” things like HTN management.

I have research in Neuro and more general medicine, as well as bench work. I’m in both student interest groups and have made good connections. I’m feeling confident that I could match into either *somewhere.* I just don’t know which way to lean, and I’m more confused than ever. Thankfully I have 5ish months before really having to decide, but would like some input.

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[mrbreakfast]

- rarely the primary team outside of residency. Most neurologists to my understanding are basically consultants. In academia this is different but I don’t want to work in academia and would be happier in the community. Tired of the rat race lol

You are a med student, so you don't realize that this anything but a con. Trust me. You have no idea what being the "primary team" entails. Besides, why do you care about this? Statistically speaking, 90-95% of neurology is outpatient, and unless you decide to become a neurohospitalist, you will probably never step foot in a hospital again (or not more than one weekend every few months) after graduation from residency.

- Lose being a generalist. Yes intern year is in IM but the attendings on Neuro were very willing to consult IM for “basic” things like HTN management.

This is up to your own comfort level. Just keep in mind that this applies to every medical specialty, including internal medicine subspecialties.

- “Diagnose and adios” isn’t true anymore, but you have to admit treatments aren’t that great. You can’t really cure much in IM either, but you can see someone’s A1c come down and stay down forever, while someone’s Parkinson’s can be reasonably controlled but it will progress

This argument comes up time and again, despite the fact that there's no evidence or data to support it. You can cherry pick diagnoses to compare on both sides - you're probably not going to "cure" someone's hypertension or CHF, while you often can completely control common yet debilitating neurological problems - migraine, ET, seizures - with a single medication.

But this last issue is really for you to consider. Do you want to be curing people's diabetes, or do you want to be called for the tough stuff? You are correct that as a neurologist, you will make awful diagnoses. In the last 48 hours I saw a new ALS diagnosis, saw two IPHs and two LVOs, NCSE, GMB, primary CNS lymphoma, HAND, bacterial meningitis with parenchymal abscess, etc. Lot of those people are going to have a bad outcome despite our best efforts. You have to live with a lower batting average than you'd like, but you still gotta swing at every pitch, so to speak. The idea that a specialty manages conditions that are challenging to treat, or incurable, is not a reason to avoid it. If you want to see healthy patients, become a PCP.

Ultimately your decision should come down to bread and butter treatments and what you think is less boring. If you want to work in the community, you're not going to be seeing the weird stuff. For neurology, you'll see a lot of headache, neuropathy, memory loss, "I think I have multiple sclerosis," etc, in clinic; in the hospital, it'll be metabolic encephalopathy or workup of small strokes. Ultimately it comes down to picking your poison and tossing it back. Good luck.

 

[ACSurgeon]

I know this is a common post but now it’s my turn. I’m at a 1-year preclinical program so M2 year was preclinical and now M3 (and M4) is for sub-Is and electives. This means last year I had 3 months of IM and 1 month of neuro. Now I am almost done with my IM sub-I, and completed my Neuro sub-I about a month ago. I told everyone I’d go into Neuro and secured letters, but now I’m not so sure.

IM pros:
- broad generalist training. I get to feel like I’m using the entire foundation of medicine, even if just “a little about a lot”
- Lots of fascinating sub-specialties, and when I’ve rotated with endo, rheum, and cards, their generalist training was still very relevant. The endo I rotated with acted like a PCP in some ways
- I really like being someone’s doctor and having that ownership of their care. I actually do enjoy coordinating care, being the first to hear about a problem, thinking through the case, then either treating them myself or referring them to the person I think could best help
- I like a lot of the bread and butter of IM. I love pancreatitis, COPD, ACS, GIB, etc

IM cons:
- Being someone’s primary can be exhausting. Lots of logistics to get patients out, lots of coordinating all the consults
- Fellowships (if pursued) are long
- I don’t love how at least in academic medicine, you’re basically there to check boxes while specialists drive care. I don’t mean to reduce it to “you just prescribe antihypertensives and insulin,” but tbh a lot of the time that’s how it feels. GI will drive their UGI bleed management, cards will weigh in on their HFrEF, nephro will treat their refractory hyponatremia, etc. It’s nice to know someone else has more expertise to help you, but it sometimes sucks when your entire plan is “consult cards, trend trops, follow the published guidelines”

Neuro pros:
- LOVE the nervous system. Coolest organ system. Love localizing
- I like how neurologists are really good at interpreting a variety of tests, including their own imaging
- I like that the exam largely drives decision making. Like tPA is often given before any imaging confirms a stroke.
- Patients are always fascinating, even the most basic bread and butters are really cool
- I like having the final say about treatment, and feeling like I’m really driving the care of patients
- Fellowships are 1 year (but tbh residency and following are gonna be 5 years, while IM is gonna be at most 6 years so it’s not a crazy difference)

Cons:
- rarely the primary team outside of residency. Most neurologists to my understanding are basically consultants. In academia this is different but I don’t want to work in academia and would be happier in the community. Tired of the rat race lol
- “Diagnose and adios” isn’t true anymore, but you have to admit treatments aren’t that great. You can’t really cure much in IM either, but you can see someone’s A1c come down and stay down forever, while someone’s Parkinson’s can be reasonably controlled but it will progress
- Lose being a generalist. Yes intern year is in IM but the attendings on Neuro were very willing to consult IM for “basic” things like HTN management.

I have research in Neuro and more general medicine, as well as bench work. I’m in both student interest groups and have made good connections. I’m feeling confident that I could match into either *somewhere.* I just don’t know which way to lean, and I’m more confused than ever. Thankfully I have 5ish months before really having to decide, but would like some input.

Do you want to do inpatient or outpatient work?

If inpatient work appeals to you, then neuro-critical care might be perfect for you. You get to be a neurologist AND the primary team. The good neuro-intensivists I know are very smart and broad based in their medical knowledge.

 

[Latteandaprayer]

You are a med student, so you don't realize that this anything but a con. Trust me. You have no idea what being the "primary team" entails. Besides, why do you care about this? Statistically speaking, 90-95% of neurology is outpatient, and unless you decide to become a neurohospitalist, you will probably never step foot in a hospital again (or not more than one weekend every few months) after graduation from residency.


This is up to your own comfort level. Just keep in mind that this applies to every medical specialty, including internal medicine subspecialties.


This argument comes up time and again, despite the fact that there's no evidence or data to support it. You can cherry pick diagnoses to compare on both sides - you're probably not going to "cure" someone's hypertension or CHF, while you often can completely control common yet debilitating neurological problems - migraine, ET, seizures - with a single medication.

But this last issue is really for you to consider. Do you want to be curing people's diabetes, or do you want to be called for the tough stuff? You are correct that as a neurologist, you will make awful diagnoses. In the last 48 hours I saw a new ALS diagnosis, saw two IPHs and two LVOs, NCSE, GMB, primary CNS lymphoma, HAND, bacterial meningitis with parenchymal abscess, etc. Lot of those people are going to have a bad outcome despite our best efforts. You have to live with a lower batting average than you'd like, but you still gotta swing at every pitch, so to speak. The idea that a specialty manages conditions that are challenging to treat, or incurable, is not a reason to avoid it. If you want to see healthy patients, become a PCP.

Ultimately your decision should come down to bread and butter treatments and what you think is less boring. If you want to work in the community, you're not going to be seeing the weird stuff. For neurology, you'll see a lot of headache, neuropathy, memory loss, "I think I have multiple sclerosis," etc, in clinic; in the hospital, it'll be metabolic encephalopathy or workup of small strokes. Ultimately it comes down to picking your poison and tossing it back. Good luck.

Thanks for the response! I think neurology as a whole is more interesting

 

[Latteandaprayer]

Do you want to do inpatient or outpatient work?

If inpatient work appeals to you, then neuro-critical care might be perfect for you. You get to be a neurologist AND the primary team. The good neuro-intensivists I know are very smart and broad based in their medical knowledge.

Unsure which setting. I like the clinic a lot because the schedule is more regular and I really appreciate longitudinal care, but as a med student hospital med gives me time to think which I like.