Neuro vs PM&R or something else for an M1

[annasofttofu]

I’m an MS1, and I’m trying to decide what specialty I should do research with this summer and for the rest of this year.

Neuro pros:
- I love how you get to be really detective-y and you get to do a lot of the diagnosis work. I’m someone who really needs intellectual stimulation, and I would consider myself a pretty cerebral person. I really felt this while shadowing outpatient neurology, and it was really interesting seeing new patients with Parkinson’s or MG.
- I’m someone who really needs variety (for the intellectual stimulation) and I think neuro has that more than many other specialties, although I’m not sure.
- I really want to have a researcher-clinician academic career, especially doing CS engineering research, and this seems like a big thing in neuro. I studied applied math and machine learning before med school and then worked in tech, and I want to combine that with medicine/research.
- I really want to be able to live in the SF Bay Area where my family is, and I’ve seen elsewhere on SDN or reddit that the neuro job market is great, so this seems more possible with neuro.
- I really want to be able to spend a decent chunk of time per patient doing a thorough H&P and physical and work up, and I feel like those parts of a patient encounter are more emphasized in neuro than a lot of other specialties.

Neuro cons:
- Some neuro pathologies terrify me, particularly dementia. Also people with serious CNS pathologies like coma or incurable brain disorders.

PM&R pros:
- I really enjoy MSK and biomechanics. I’m pretty sure I’d pick sports if I went into PM&R, and I love the idea of helping people with MSK pathologies because it’s so common and you can really localize it and then fix it (ideally).
- Also a lot of tech/engineering/ML research

PM&R cons:
- Real de-emphasis on the diagnosis portion, which takes so much of the fun out of it.
- When I shadowed, I felt that sports PM&R was pretty repetitive where almost every appointment was someone just getting an ultrasound guided injection wherever they’re feeling pain.
- PM&R doesn’t seem like a research-heavy field with a lot of academic job openings for someone like me.
- I’ve read on SDN that the PM&R job market isn’t looking too great in places like the SF Bay Area.



Maybe I could combine the MSK piece of PM&R with the intellectual stimulation of neuro and do neuromuscular medicine?

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[sloh]

I’m PM&R. Based off your post I recommend Neurology. The “tech” in PM&R is overhyped and you aren’t really “fixing” athletes like that. Many pain and ultrasound procedures are theatrical placebo. PRP and stem cells are largely scams. Not to mention unless you’re a team physician, athletes will make up a very small sliver of your “sports medicine” practice.

 

[Telamir]

You’re an M1. Things will change a ton by M3.

 

[annasofttofu]

I’m PM&R. Based off your post I recommend Neurology. The “tech” in PM&R is overhyped and you aren’t really “fixing” athletes like that. Many pain and ultrasound procedures are theatrical placebo. PRP and stem cells are largely scams. Not to mention unless you’re a team physician, athletes will make up a very small sliver of your “sports medicine” practice.

The athletes part of sports medicine doesn’t matter to me, I just meant I liked the idea of working with relatively commonplace MSK problems like back pain or shoulder/elbow pain. I actually started out wanting to do ortho for this reason, but I changed my mind after seeing how much work and life dedication ortho required compared to the average specialty.

I’m not a big fan of doing pain injections in general though, so I was disappointed when I shadowed sports PM&R.

You’re an M1. Things will change a ton by M3.

That’s definitely true, and I’m trying to stay open minded because I know I’m liable to change my mind. I just want to feel relatively good about whatever specialty I decide to spend my summer on.

 

[differentiating]

I’m an MS1, and I’m trying to decide what specialty I should do research with this summer and for the rest of this year.

Neuro pros:
- I love how you get to be really detective-y and you get to do a lot of the diagnosis work. I’m someone who really needs intellectual stimulation, and I would consider myself a pretty cerebral person. I really felt this while shadowing outpatient neurology, and it was really interesting seeing new patients with Parkinson’s or MG.
- I’m someone who really needs variety (for the intellectual stimulation) and I think neuro has that more than many other specialties, although I’m not sure.
- I really want to have a researcher-clinician academic career, especially doing CS engineering research, and this seems like a big thing in neuro. I studied applied math and machine learning before med school and then worked in tech, and I want to combine that with medicine/research.
- I really want to be able to live in the SF Bay Area where my family is, and I’ve seen elsewhere on SDN or reddit that the neuro job market is great, so this seems more possible with neuro.
- I really want to be able to spend a decent chunk of time per patient doing a thorough H&P and physical and work up, and I feel like those parts of a patient encounter are more emphasized in neuro than a lot of other specialties.

Neuro cons:
- Some neuro pathologies terrify me, particularly dementia. Also people with serious CNS pathologies like coma or incurable brain disorders.

Maybe I could combine the MSK piece of PM&R with the intellectual stimulation of neuro and do neuromuscular medicine?

So, you definitely don't have to do dementia if you go into neuro, particularly if you sub-specialize; the only possibility is if you still want to do some gen neuro to get exposure to the variety, you'll probably see some as well. But I agree you're putting the cart a little before the horse. It doesn't sound like you've had any non-shadowing experience in neurology, which is helpful to know if you'd enjoy the bread and butter (can you handle a lot of headaches?). Neuromuscular is really more about the peripheral nervous system and muscles rather than true MSK, so you won't see back/shoulder/joint pain but weakness/numbness issues, but again, you have plenty of time before deciding on a residency, much less a fellowship.

It definitely is a research-welcoming field, though, so if you're interested in doing neuro research/considering neuro as a potential option, it's not a bad idea to do it after MS1.

 

[Thama]

I’m an MS1, and I’m trying to decide what specialty I should do research with this summer and for the rest of this year.

Obviously we're all going to tell you that it's way too early to be trying to make a specialty decision, but following an interest in this way is a great idea at this stage.

- I love how you get to be really detective-y and you get to do a lot of the diagnosis work. I’m someone who really needs intellectual stimulation, and I would consider myself a pretty cerebral person. I really felt this while shadowing outpatient neurology, and it was really interesting seeing new patients with Parkinson’s or MG.

Absolutely true - neurology has a much more involved diagnostic process than pretty much any other specialty, with extra layers of localization and phenomenology that you rarely get outside of neurology. That said, while most of us go into neurology with this as a part of our decision, you will rarely find a 4th year resident who is still waking up in the morning super excited to be intellectually stimulated by their massive patient census. At the end of the day, a job is a job, and neurology is a difficult job.

- I’m someone who really needs variety (for the intellectual stimulation) and I think neuro has that more than many other specialties, although I’m not sure.

Neurology has a ton of variety compared with other specialty fields, especially other organ system centric specialties. Compare us with cards/pulm/GI/etc and there's absolutely no contest. However, the real kings of variety are PCPs and EM - we can't touch the variety they get.

- I really want to have a researcher-clinician academic career, especially doing CS engineering research, and this seems like a big thing in neuro. I studied applied math and machine learning before med school and then worked in tech, and I want to combine that with medicine/research.

As a physician scientist that does a lot of CS and math with a lot less background in it than you have, I can tell you first hand that this a huge thing in neurology. And in particular, board certified neurologists who also have this skill set are rare birds in the research world with many opportunities.

- I really want to be able to live in the SF Bay Area where my family is, and I’ve seen elsewhere on SDN or reddit that the neuro job market is great, so this seems more possible with neuro.

Neuro job market is great. Neuro job market in SF Bay and other ultra-saturated markets is much much much less great. Getting a job at UCSF or Stanford as a physician scientist is not trivial at all.

- I really want to be able to spend a decent chunk of time per patient doing a thorough H&P and physical and work up, and I feel like those parts of a patient encounter are more emphasized in neuro than a lot of other specialties.

The time required for this kind of thoroughness is hard to find in the private practice world, and much more likely to find at larger academic centers (though with correspondingly lower salaries).

- Some neuro pathologies terrify me, particularly dementia. Also people with serious CNS pathologies like coma or incurable brain disorders.

This is where you need to get exposure. However, there aren't many fields in medicine where you aren't going to be exposed to some degree to demented and brain injured patients. Common things are common.

- Real de-emphasis on the diagnosis portion, which takes so much of the fun out of it.
- When I shadowed, I felt that sports PM&R was pretty repetitive where almost every appointment was someone just getting an ultrasound guided injection wherever they’re feeling pain.
- PM&R doesn’t seem like a research-heavy field with a lot of academic job openings for someone like me.

Yes yes, but have you heard of "Plenty of Money And Relaxation"?

Maybe I could combine the MSK piece of PM&R with the intellectual stimulation of neuro and do neuromuscular medicine?

These really aren't that similar. And the neuromuscular docs I know end up feeling like neurorheumatologists half the time, which sounds like my own personal hell.

 

[JBM16BYU]

I will throw my hat into the ring here. It sounds like you potentially want a clinical-research based career that allows you intellectual stimulation, diagnosis, a chance to help people, a mix of musculoskeletal and neurologic diagnoses with the ability to be ideally in San Francisco. I am a PM&R physician in a Neuromuscular Medicine fellowship. In my post-fellowship job I will be (A) heavily involved in research, (B) in academia, (C) doing lot's of musculoskeletal (MSK) and neuromuscular (NM) diagnosis through clinic, physical exam, diagnostic MSK and NM ultrasound and EMG, plus ultrasound-guided injections and (D) I will definitely be able to help people through painful or debilitating (weak, numb, tingling) diagnoses and make a difference in their day-to-day life. It's a niche field. But, like others have said, enjoy medical school, shadow both neurology and PM&R in multiple settings, pay attention to what you like and don't like, and see if things become clearer along the way. You've got time and there is some overlap. Feel free to PM if you have questions.

 

[annasofttofu]

But I agree you're putting the cart a little before the horse. It doesn't sound like you've had any non-shadowing experience in neurology, which is helpful to know if you'd enjoy the bread and butter (can you handle a lot of headaches?). Neuromuscular is really more about the peripheral nervous system and muscles rather than true MSK, so you won't see back/shoulder/joint pain but weakness/numbness issues, but again, you have plenty of time before deciding on a residency, much less a fellowship.

It definitely is a research-welcoming field, though, so if you're interested in doing neuro research/considering neuro as a potential option, it's not a bad idea to do it after MS1.

Is it possible to get any non-shadowing experience as an MS1?

As for the research front, I'm definitely considering starting neuro research this year and doing it for the summer, although I've heard that it might be better to start with a more competitive field as an MS1. I'm not super interested in any of the really competitive fields though, besides ortho although I know I'm not really seriously interested in that; I just really like biomechanics and quality of life stuff.

I just really want to try to start early with neuro or PM&R to get a strong application going, although I would like some more experience with them if I can. So far it's just been shadowing and talking to some of the advisors/attendings/residents.

Neuro job market is great. Neuro job market in SF Bay and other ultra-saturated markets is much much much less great. Getting a job at UCSF or Stanford as a physician scientist is not trivial at all.

Is this true for all specialties, or is the neuro job market in big metros especially bad?

Absolutely true - neurology has a much more involved diagnostic process than pretty much any other specialty, with extra layers of localization and phenomenology that you rarely get outside of neurology. That said, while most of us go into neurology with this as a part of our decision, you will rarely find a 4th year resident who is still waking up in the morning super excited to be intellectually stimulated by their massive patient census. At the end of the day, a job is a job, and neurology is a difficult job.

What would you say makes it a difficult job compared to IM or PM&R, for example?

Yes yes, but have you heard of "Plenty of Money And Relaxation"?

I have seen the Medscape lifestyle/compensation reports, and I do see that PM&R works much much less than neurology, and that physiatrists are pretty happy while neurologists are among the least happy. That definitely scares me, although I'm not sure what other specialties I'd really consider.

I will throw my hat into the ring here. It sounds like you potentially want a clinical-research based career that allows you intellectual stimulation, diagnosis, a chance to help people, a mix of musculoskeletal and neurologic diagnoses with the ability to be ideally in San Francisco. I am a PM&R physician in a Neuromuscular Medicine fellowship. In my post-fellowship job I will be (A) heavily involved in research, (B) in academia, (C) doing lot's of musculoskeletal (MSK) and neuromuscular (NM) diagnosis through clinic, physical exam, diagnostic MSK and NM ultrasound and EMG, plus ultrasound-guided injections and (D) I will definitely be able to help people through painful or debilitating (weak, numb, tingling) diagnoses and make a difference in their day-to-day life. It's a niche field. But, like others have said, enjoy medical school, shadow both neurology and PM&R in multiple settings, pay attention to what you like and don't like, and see if things become clearer along the way. You've got time and there is some overlap. Feel free to PM if you have questions.

Why did you choose PM&R over neuro, and would you happen to know what the job market is like in large metros for PM&R or NM?

 

[Thama]

Is this true for all specialties, or is the neuro job market in big metros especially bad?

The neurology market is comparatively good, it's just that all specialties are saturated in some of these areas. If you are the kind of person who insists on cramming yourself into the handful of metros that don't need more doctors in a nation full of metros and non-metro areas that desperately do need more doctors, you're going to pay a high price to do so if you can find a job there at all.

What would you say makes it a difficult job compared to IM or PM&R, for example?

Compared to PM&R? Jesus, like everything. Hours, complexity, patient expectations, pay...

Compared to IM? Neuro residency is definitely much harder than IM residency. For them, intern year is their hardest year and it goes down from there. For us, we do the same intern year that they do but it's basically a vacation compared with our PGY-2 year, which has all the problems of intern year but with far fewer protections in terms of call schedule, caps, etc. My wife did IM at the same institution where I did neuro, and I can tell you from direct comparative experience that neurology training is vastly more difficult than IM training.

On the back end once you get to practice, I wouldn't say that neurology in general is harder than IM in general. There are IM subspecialties that are not as hard and those that are very hard. Being an IM PCP is among the hardest jobs in medicine, IMO. Neurology tends to fall somewhere in the middle on that spectrum once you get to attending life.

I have seen the Medscape lifestyle/compensation reports, and I do see that PM&R works much much less than neurology, and that physiatrists are pretty happy while neurologists are among the least happy. That definitely scares me, although I'm not sure what other specialties I'd really consider.

Plenty of money and relaxation. It sounds pretty good to me right now. Neurology tends to be toward the lower end of those scales because we see a lot of sick people and our patient interactions can be difficult. A job is a job in the end. As far as other things to consider - psychiatry is an extremely easy residency and is probably the biggest shortage specialty nationwide (with lots of opportunities to hang out a shingle and take cash only from the worried well wealthy). Radiology is also pretty nice.

 

[JBM16BYU]

Why did you choose PM&R over neuro, and would you happen to know what the job market is like in large metros for PM&R or NM?

I went to medical school knowing that I wanted to do PM&R (considered going to physical therapy route, but found PM&R and I was sold). PM&R also opened up routes to Sports Medicine and Pain Medicine, both of which I was initially interested in and kind of simultaneously prepared for during the latter half of medical school and into residency for sports coverage, research in both, etc. I ended up choosing Neuromuscular Medicine because I fell in love with performing, analyzing, talking about, and studying electrodiagnostic studies (EMG). Plus, add on neuromuscular ultrasound to the musculoskeletal ultrasound exposure from residency and I was sold. Had I found this during medical school, perhaps I would have considered neurology, but ultimately having the background in musculoskeletal medicine and ultrasound from PM&R (which is helpful in the EMG lab since some things come in and it is obviously pain from their hip osteoarthritis, greater trochanteric bursitis, thumb arthritis, tennis elbow, etc.) as well as neurorehabilitation to help my patients in ALS and MDA clinics has been a great fit for me.

Like anything in medicine, it becomes more saturated in large cities and less so in the suburbs and rural. Neuromuscular medicine is pretty sought after everywhere, since even a lot of general neurologists don't feel comfortable managing patients with ALS or immunotherapies for our CIDP / myasthenia gravis patients. PM&R / NM would open you up to a mix of MSK/EMG throughout PM&R departments, orthopedic clinics, spine clinics, pain clinics, etc. It just depends on what you want to do. I will say that for other subspecialties off of PM&R, like Sports and Pain, it does become A LOT more saturated in certain areas of the country. Sports medicine feeds from FM, EM, IM, Peds, and PM&R. Pain feeds from Anesthesiology, Neurology, Psych, EM (even FM for some places now) and PM&R. Finding a desirable job in certain locations in either of those fields can be difficult, but it depends on what you want. You can google San Francisco and just see how many practices are in the area to get a good feel.

 

[Bostonspine]

Just FYI there are other areas of PM&R beside Pain/Sports, like Peds, Cancer, TBI/stroke, inpatient, outpatient subacute setting. What I’m saying is work on you resume do a broad in both and you’ll be well positioned

 

[differentiating]

Is it possible to get any non-shadowing experience as an MS1?

As for the research front, I'm definitely considering starting neuro research this year and doing it for the summer, although I've heard that it might be better to start with a more competitive field as an MS1. I'm not super interested in any of the really competitive fields though, besides ortho although I know I'm not really seriously interested in that; I just really like biomechanics and quality of life stuff.

I just really want to try to start early with neuro or PM&R to get a strong application going, although I would like some more experience with them if I can. So far it's just been shadowing and talking to some of the advisors/attendings/residents.

Some medical schools start at least small clinical experiences in various clinics in MS1, where you take histories/examine patients. But it sounds like yours may be different.

If you're not interested in a competitive field, don't waste your time doing research in that field. You don't need research in neuro or PM&R to match, especially since they're both fairly non-competitive fields in my experience, but it will help your application for sure. I think you can't go wrong with doing research in either to start with, and you can always pivot to research in your field of interest later if that changes.

 

[JBM16BYU]

Just as a counterpoint, with the increase in medical schools nearly every medical specialty has become more competitive to match into than previously. This is apparent in the fill rates both pre- and post-SOAP. You’re competing with US MD, US DO, IMG, etc. Research will help your residency application. In addition, the most competitive and “top” programs within each specialty are often at academic centers, are very competitive to get into, and research is almost 100% required for consideration. My 2 cents is to put in the time and get research with accompanying presentations and publications just in case you need it.

 

[Aldertonghen]

Obviously we're all going to tell you that it's way too early to be trying to make a specialty decision, but following an interest in this way is a great idea at this stage.



Absolutely true - neurology has a much more involved diagnostic process than pretty much any other specialty, with extra layers of localization and phenomenology that you rarely get outside of neurology. That said, while most of us go into neurology with this as a part of our decision, you will rarely find a 4th year resident who is still waking up in the morning super excited to be intellectually stimulated by their massive patient census. At the end of the day, a job is a job, and neurology is a difficult job.



Neurology has a ton of variety compared with other specialty fields, especially other organ system centric specialties. Compare us with cards/pulm/GI/etc and there's absolutely no contest. However, the real kings of variety are PCPs and EM - we can't touch the variety they get.



As a physician scientist that does a lot of CS and math with a lot less background in it than you have, I can tell you first hand that this a huge thing in neurology. And in particular, board certified neurologists who also have this skill set are rare birds in the research world with many opportunities.



Neuro job market is great. Neuro job market in SF Bay and other ultra-saturated markets is much much much less great. Getting a job at UCSF or Stanford as a physician scientist is not trivial at all.



The time required for this kind of thoroughness is hard to find in the private practice world, and much more likely to find at larger academic centers (though with correspondingly lower salaries).



This is where you need to get exposure. However, there aren't many fields in medicine where you aren't going to be exposed to some degree to demented and brain injured patients. Common things are common.



Yes yes, but have you heard of "Plenty of Money And Relaxation"?



These really aren't that similar. And the neuromuscular docs I know end up feeling like neurorheumatologists half the time, which sounds like my own personal hell.

regarding the last sentence- can you elaborate on neuromuscular docs feeling like neuro rheumatologists (and why that’s not great)?

 

[Thama]

regarding the last sentence- can you elaborate on neuromuscular docs feeling like neuro rheumatologists (and why that’s not great)?

It's kind of a joke, but not entirely. There are 2 primary sides to neuromuscular medicine - the diagnostic side which is what gets people into the field - EMG, muscle ultrasound, neuropath, etc. And then there's the treatment side, which ends up being a lot of giving immunosuppressants to people, often for vague sensory/pain/fatigue complaints. People get pulled in by the diagnostic side and then spend a lot more of their time than they thought they would on the treatment of vague symptoms with steroids, IVIG, etc, which ends up feeling a lot like rheumatology clinic. Those neuromuscular docs I know who are burned out are burned out due to this, although I certainly don't mean to suggest that all neuromuscular docs hate their job or anything like that.

 

[Aldertonghen]

It's kind of a joke, but not entirely. There are 2 primary sides to neuromuscular medicine - the diagnostic side which is what gets people into the field - EMG, muscle ultrasound, neuropath, etc. And then there's the treatment side, which ends up being a lot of giving immunosuppressants to people, often for vague sensory/pain/fatigue complaints. People get pulled in by the diagnostic side and then spend a lot more of their time than they thought they would on the treatment of vague symptoms with steroids, IVIG, etc, which ends up feeling a lot like rheumatology clinic. Those neuromuscular docs I know who are burned out are burned out due to this, although I certainly don't mean to suggest that all neuromuscular docs hate their job or anything like that.

But isn’t that a possibility with every neuro specialty? A lot of times I’m not sure if the person really needs the anti seizure medications I’m giving/continuing, trying to titrate carbidopa/levodopa and it’s different formulations and timings sometimes feels futile, MS exacerbations of dizziness/vague symptoms being treated with immunosuppression. Stroke is the only one unique in this regard and even then TIAs are vague.

 

[annasofttofu]

Just as a counterpoint, with the increase in medical schools nearly every medical specialty has become more competitive to match into than previously. This is apparent in the fill rates both pre- and post-SOAP. You’re competing with US MD, US DO, IMG, etc. Research will help your residency application. In addition, the most competitive and “top” programs within each specialty are often at academic centers, are very competitive to get into, and research is almost 100% required for consideration. My 2 cents is to put in the time and get research with accompanying presentations and publications just in case you need it.

I’m definitely trying to put in the work and get publications, go to conferences, etc no matter what I choose.

It's kind of a joke, but not entirely. There are 2 primary sides to neuromuscular medicine - the diagnostic side which is what gets people into the field - EMG, muscle ultrasound, neuropath, etc. And then there's the treatment side, which ends up being a lot of giving immunosuppressants to people, often for vague sensory/pain/fatigue complaints. People get pulled in by the diagnostic side and then spend a lot more of their time than they thought they would on the treatment of vague symptoms with steroids, IVIG, etc, which ends up feeling a lot like rheumatology clinic. Those neuromuscular docs I know who are burned out are burned out due to this, although I certainly don't mean to suggest that all neuromuscular docs hate their job or anything like that.

I didn’t realize this was a thing. How often are you able to make a clean diagnosis that satisfies you and the patient, and how often are you just unsure what the patient has?

 

[JBM16BYU]

I’m definitely trying to put in the work and get publications, go to conferences, etc no matter what I choose.


I didn’t realize this was a thing. How often are you able to make a clean diagnosis that satisfies you and the patient, and how often are you just unsure what the patient has?

Between using physical exam, labs, CSF, specific antibody testing, genetics, muscle/skin/nerve biopsies, needle electromyography, nerve conduction studies, neuromuscular ultrasound, MRI, etc, I would say that you actually get to make a clean diagnosis a lot more than you might think. We do still have patients with "idiopathic peripheral neuropathy" or some undefined reason for their weakness or variants of uncertain significance (VUS) on genetic testing that may or may not play a role in their symptoms, however, I have been pleasantly surprised how often a formal diagnosis is actually achievable.