Neurologist and Procedures

I'm not a resident, but from what I've heard and seen there really aren't any other procedures neurologists can lay claim to. I've heard of pain management types of procedures that both anesthesiologists and PM&R docs do, but that's about it. Actually I thinkg the latter also do EMGs so that can cut into your share of these procedures.

I've been actually thinking about the future of procedures for neurologists. I can't really think of any room for new procedures for them to do. I've read about some of these brain implants for some diseases like Parkinsons, but I imagine neurosurgeons will do those. And neuro-radiologists have the claim on stroke patients and lysing the clots. Unless there is something new out there I haven't heard, I just don't think there's room for neurologists to have their own special procedures. Other fields have advanced faster than neurology and already have people trained to do stuff like I mentioned above (PM&R and Anesth, neurosurgery, radiologists). Current residents may have a better idea of this though.

 

I have heard that some private practice Neurologists are investing in the equipment so that they can perform and read their own MRIs, CTs, etc... This isn't exactly a procedure, but it is a new role, isn't it? Does anyone know how common this is?

 

I don't think anyone else reads EEGs. Then again, I don't think anyone else would want to.

 

Hmm....I'd be surprised if this were true. CT Scanners and MRI machines are very expensive and I'm not sure it makes sense from a financial standpoint for these Neurologists to purchase them. Plus, how many Neurologists are comfortable with and willing to take on the added liability of reading images themselves?

 

From what I understand, neurologists can do fellowships in neuroimaging and even neuro interventional procedures. As far as potential liability, some hospitals feel comfortable granting privileges to these neurologists to read CTs, MRIs, so doesn't that mean that they wouldn't be any more liable than radiologists?

It seems like alot of different types of specialists (in addition to neurologists) like to read their own scans, and many are taking the interventional procedures away from radiology.

Does anyone have any thoughts about this?

 

Well.....I assumed you were talking about Neurologists in private practice. Most Neurologists in private practice have not completed Neuroimaging fellowships. I just don't see it being very cost effective for them to purchase CT scanners and MRI machines. How many patients in their practice would need a CT or MRI to make it worth their while?

With regards to hospitals giving Neurologists privileges to do the official reading of films, I haven't seen it yet. I'll have to inquire about that when I'm on the Neuro service at MGH. Plus, I'm sure the Rads department at most hospitals would fight it. Additionally, what certification would they receive after such a fellowship? Radiologists can get subspecialty certification in Neuroradiology and this certification is only available to Radiologists. I've never seen a subspecialty certification in Neuroimaging (even though I know fellowships are available).

With regards to liability, I think it is an issue because malpractice insurance would certainly go up if they were to start reading MRIs. Additionally, if the Neurologist were to miss something on the MRI, I can already see what types of arguments the plantiff's lawyer would make. These same arguments probably wouldn't carry the same weight against a BC Neuroradiologist.

You're right about the fact that many physicians do prefer to read their own scans; however, the radiologist usually still gives the official legal reading.

 

Thanks for your reply, Stinky tofu! I don't know anything about this (and obviously the people I have been talking to don't either!) I was just passing along what I heard in hopes that someone could confirm,deny, or explain the situation. And you did that very well!

 

Does anyone know about the subspec. fields for Neurology, like stroke, sleep disorders, etc? How much does it add to a base pay for a neurologist?

Incidentally, the place i did my rotation (a top 5 program), the neurologists were awesome at reading images. Of course they used the radiologists' interpretation too, but I think I would be comfortable with their interpretation as well.

 

The question really isn't whether or not Neurologists can be proficient at reading images. The question is whether or not they will be allowed to do the offical reading and get paid for it in lieu of a Radiologist. Surgeons are certainly able to ascertain whether or not they've put a line or NGT in the right place without the Radiologist's input. However, it is the Radiologist and not the surgeon who will do the official read and get paid for it.

 

when i was at UT Houston interviewing for neuro. I remember being told that there was some way that residents at that program could get certified so that once they were attendings, they could bill for reading their own CT scans or MRIs. I'm not sure if it was an extra year or if it was by doing electives during the last year. If someone else can corroroborate this...

 

Hmm....I still have my doubts. Even if they could get the Rads department and a hospital to agree to let them use the CT scanners and MRI machines, there might be reimbusement issues as well. Maybe the Radiology moderator and residents can chime in as well. I'll let a couple of them know this thread exists.

 

I have heard of this, but it depends on the state and the CON rules. The southern states are a little more lax in this regard. The most common situation is the radiology group buying the scanner and then leasing it or essentially giving it to the neurologists. The neurologists collect the professional fee (for reading the scans) and the rads collect the technical fee without doing any work at all. There is a very good possibility that this is self referral though and some groups have been investigated and punished by doing this.

A little known fact is that it does not take board certification of any kind to read MRI, CT...etc. Any resident in training can go out and buy a scanner (if the state will let him) scan people and read them his own self. Indeed a family practice resident could go out and read neuro MRI or any other radiology study (except for mammo) on the side as long as it is OK with the hospital and the state. The only thing the training gives you is board certification and a reputation. Virtually nobody has the guts to do this for several reasons. First it obviously takes multiple years of training in any specialty to be able to efficiently practice; radiology being no exception, so to go out with minimal training would be professional suicide, especially when it comes to reading films. Second, no insurance company in their right mind would insure you to do something you are not trained for, the lawyers would have a field day. Third, it is hard enough to keep up with your own patients let alone have enough time to read films. Fourth, there is a lot of expenses in producing an MRI or a CT and to make money you have to do a lot of them. It would not pay to buy a 2mill magnet and use it to scan 2 or 3 medicare heads a day, you would lose money.

So the bottom line is that yes it does happen but it is pretty rare and will likely remain so as long as there are enough radiologists to go around (which is problematic) So I encourage all of you budding doctors to take a look at radiology. (said with caution in a neurology forum) We have excellent relationship with our neurologists. I think most of them are busy enough and make almost as much money to not even think of taking an extra couple years of training and venture into a risky venture just to make maybe an extra 30-40K a year.

Remember to disseminate your knowledge base. It is your responsibility to share your speciality with other specialities. It fosters good relationships with the referring doctors and it virtually always produces more business. The best thing about it is it is actually good for your patients!

It is very easy to be a poor reader of films but very difficult to do it very well. The neuroradiologists/musculoskeletal/abdominal radiologists in an average university department have far greater ability to read MRIs due to the fact that they see thousands every year as well as this is what we do all the time! Remember that it is not what you see that will come back to hurt you but what you don't that will. I think that if the whole situation were explained to the patients the vast majority would prefer their films being read by a board certified rad. Just the same as the patients preferring that their neurology patients be seen by a real neruologist as opposed to some generalist.

 

I'm not sure it would be that much of a stretch liability-wise for Neurosurgery or Neurology to interpret some of their own studies.
Multiple fields routinely interpret studies related to their field without radiology input (GYN- ultrasound, GI - EUS & ERCP, Ortho- plain films & some MR/CT, Vascular surgeons- arteriograms/MRA & doppler/duplex studies, Gen Surg- cholangiograms, FAST scans, intraoperative & breast U/S)

 

I still think that you would have a hard time defending errors unless you could substantiate your extensive training. I do know that whenever the orthopods or surgeons get sued they claim to know nothing about intrepretation of imaging studies.

I agree a lot of this especially surgical intrepretation is done by other doctors, I used to do some intraoperative ultrasound myself as well. Again I think that dissemination of knowledge is helpful and almost never hurts the radiologist. Some people used to say NMR (old term for MRI) stood for No More Radiologists!

It is a minority of cases. About 90% of imaging studies are still intrepreted by a radiologist. But there is plenty of business to go around. Every speciality seems to think that new technology or new ways of doing things will kill their income. That just doesn't happen. This has been especially true in radiology. If others want to intrepret mammos, plain films, ED ultrasounds, operative ultrasounds, ercp, etc... I will still be too busy. Especially with all the new radiology technology that is coming at all times. This glut of business will continue for all of us with the aging population. I feel I am fortunate to be in the golden age of medicine and radiology in particular.

 

I know of a neurology group who just bought an MRI scanner, and of course they will then use on anything comming through the door and quickly make up the money. They pay some radiologists per case who read the films from home. Its a great system. And I agree - radiologists should read the films - there's too much liability otherwise. As you all know, today's ditzel becomes tomorrow's GBM which turns into next week's punitive damages.

In addition to EMGs, LPs, EEGs, many neurologists are doing transcranial dopplers, which they read themselves.

But perhaps the best thing with neurology is that there really aren't that many procedures. Instead, we get the most interesting of patients and get faily well compensated as specialists simply for our exam and opinion without having to get into boring medicine/flea details (for the most part).

 

How well compensated are neurologists, exactly? I've heard they are fairly low on the pay scale..but what do I know.

Alicia

 

They are paid next to nothing! One med student told me that neurologists at the hospital she rotated at are paid ~$18 for a consult. I wouldn't wish that on anyone.

 

Ouch!! Can anyone verify or deny this fact? That seems outrageous that they would be paid so little.

Perhaps that $18 is what medicaid or medicare or some other insurance is willing to pay for a consult?

Alicia

 

$165,000-$185,000

can't tell you about consults, but here the students do the consults (with the doctor checking them afterwards of course) and the docs get more money because the students are more thorough in the exam. Maybe it's $18 for just the neuro exam and assessment, but more money for one where the student does a neuro exam and review of systems and complete PE. Just my guess

 

Oh yeah, I forgot BOTOX. That's crazy money. Like 500 a pop - it takes 5 minutes. And neurologists use it for lots of things in addition to dystonias, hemifacial spasm - some are using it for migraine. Some are using it for derm things and there's recently been some editorializing in the journals about this trend.

Anyway, I think the average of the averages places neurology at a solid 150. But look it up on google or the AMA website. I don't know any doctors who would do a consult for 18 dollars unless they were doing charity. Its certainly inconsistent with 150,000. The bottom line is the lifestyle is good and if you want to make money and if you have to pay off debt, then neuro is a good option.

But of course, its better than that because brain is interesting 9 times out of 10. Gomer failure to thrive is not. And that's why you have to get into it - if you find it interesting. If you love, ugggh, urosepsis, then you have to do it - even for 18 dollars a case.

 

How good is the lifestyle really?

There are plenty of emergencies in neurology. Status epilepticus, CVA, etc.

As for interesting cases, i recently did a consult month in neurology. For two straight weeks all I saw were consults for mental status changes. we never really did figure out what was wrong with these people.

Did you ever notice that the specialties medical students choose to apply to often reflects how strong the department was at their school. For example, at Rush and SUNY downstate, the neuro programs are quite strong and so many students applied to neuro last year. Whereas at schools with weak neuro departments, only 1 or 2 students applied. It makes me wonder what would happen if we went to different schools.

Here's a great story about one of my interviews at a highly esteemed neuro program. The dept chair sits all 12 interviewees at one large table for a group interview. He then asks us one by one about why we chose to apply to neurology. we all give elaborate answers about the science, helping people, the fascinating brain, etc. Later in the session, one of the interviewees asks the chair about why he chose to enter the field of neurology. He replies that as a foreigner in the 1960s, neurology was one of the easisest specialties to enter so as to stay in the country. We were quite surprised by that response.

Anyway, about salary. I heard that in metro Chicago, the average starting salary for a neurologist is ~$85-95K. It becomes more, ~$120 the farther away from Chicago you get.

 

The subject of salary/lifestyle has been discussed in the past. If you do a search you'll find at least one or two lengthy threads. Depending on location, payor mix and number of proceedures (EMG/NC, EEG, LPs, BOTOX, EDSI, nerve biopsies), one can easily make $200,000-250,000 or more (granted...not great compared to some specialties). STARTING salaries for new residents are usually in the range of $140,000-160,000 (more if you get a production bonus). These numbers are from journals, recruiters and practicing clinicians. In general, income is better in the midwest and southern states and especially in smaller cities and towns. Income is less in large cities, but I can't imagine ANYONE (except an academic) accepting a salary of only $85,000. Academic physicians do make much less, but I know at least some of them have private patients to suppliment their income. If you can get into a large group or share call with another group, the lifestyle is pretty good. When you are on call, it's usually not that bad. I'm at a large academic center which is also a regional referral center and about half the time, I'll get 1-2 admissions or consults per night. The other half of the time I might get 2-3 calls and never even have to even go in. Hope this info helps.

Neurogirl pgy-2

 

There was an interesting presentation @ the Amer. Soc. of Plastic & Reconstructive surgery last year from Case Western Univ (Cleveland) re. migrane headache tx.

A recognized phenomena that came from aesthetic surgery patients with migranes -> many people said their headaches were better after being treated with BOTOX for forehead wrinkles as well as a number who improved after endoscopic brow-lift procedures. This led to a innovative series they did @ CWRU with the neurologists & PRS divisons where they used BOTOX as screening tool for migrane patients who might benefit from surgical tx. of their migranes. It really showed dramatic relief of their symptoms after the endoscopic surgery if they responded pre-op to BOTOX. This is pretty innovative & exciting potential surgical treatment for what can be a debilitating neurologic condition & provides a superior & more cost-effective result than maintainance tx. with the BOTOX treatments.

 

What procedures can Neurologists do?
Well, I just finished a Neurology rotation at my school and one of the attendings there spends one day a week doing Botox injections for torticollis and other spasmodic dystrophies. He saw about 20 patients that day and also drove to another office every other week to do a Botox injection clinich there. Also, Botox injections are becoming more frequently used for some patients with Migraines. I understand that this is fairly new, but I am imagining that it will be more widely performed in the future.

 

I agree that many subspecialists are very good at interpreting images, even MRI. The main difference, in my opinion, is that radiologists are trained in the physics of CT and MRI and can better understand how this can affect MRI images. In general, radiologists are also more thorough. Clinical physicians will focus on the large finding that most doctors can pick up on, while radiologists review the whole film. Many times this can affect treatment.

 

Any clinician who only focuses on the large abnormality and ignores all else is a quack. Right from med school, we are all thought a systematic way of viewing images.

 

Sorry, I meant taught not thought

 

reviving the ancient thread, where have the treatment options and the procedures spectrum reached now?

 

I'm credentialed to do the following (all for adults only):
Direct endotracheal intubation, fiber-optic intubation, bronchoscopy, chest tube placement, lumbar puncture, epidural anesthesia, central venous catheter placement, PA catheter placement, hemodialysis catheter placement, arterial catheter placement, thoracentesis, paracentesis, muscle biopsy, skin biopsy, IV conscious sedation.

 

i am really interested in neurology. i am just exploring the field, no offense. my concern is, all of these procedures can be done by other specialists, right? is there any procedure for which we exclusively need neurologist?

 

i am really interested in neurology. i am just exploring the field, no offense. my concern is, all of these procedures can be done by other specialists, right? is there any procedure for which we exclusively need neurologist?

 

Only in so much as training and reimbursement gives preference to one or two specialties. EMG/NCS is pretty much strictly in the purview of neurology today because they are trained to do them and can be paid to read them, but it's not like neurologists are the only people smart enough to perform or interpret the studies. Anybody and their mother can do Botox these days, and physiatrists have really run with that ball for neurorehabilitation (which I am totally in favor of).

Context matters. The ability to perform procedures is fine, but it's the knowledge and experience of how to apply them and when to use them that makes specialists effective. That's how we prove our worth, and why we are "exclusively" needed. Sure, the procedural library of neurointensivists, pulmonary critical care intensivists, and anesthesia critical care intensivists are highly overlapping, but the training and experience are sufficiently different that outcomes have been demonstrated to be better for patients matched to ICUs tailored to their disease.

 

I just happened to see this. Where do you get your figures from in regards to EMG/NCS strictly being the purview of neurology? EMG training is required at all ACGME accredited PM&R residency programs. I'm not aware of this being the case for neurology residencies.

 

I was trained as a neurology resident to do EMG/NCS/evoked potentials, but I certainly wouldn't feel comfortable doing them solo without specialty training. There was plenty of EMG/NCS interpretation on my boards, if I recall correctly. Interpretation of EMG/NCS findings is part of the Neurology ACGME milestones project. There's an entire neurophysiology fellowship through ACGME for those that want to do it professionally.

The neurophysiology lab at my hospital is run by neurology. The American Board of Physical Medicine and Rehabilitation lists 11,433 total diplomates certified as of 2014. They aren't all doing EMGs. Just since 1992, there have been > 2500 clinical neurophysiology diplomates. I know there are PM&R people out there who do EMG/NCS, but they certainly don't make up a big part of the practice in my area.

 

Thanks. I guess it does depend on region as to who is doing the majority of the EMGs. It does seem though the EMG/NCS is more of a focus in PM&R residency compared to neurology. In addition to EMG/NCS being on our board exams, residents are required to perform at least 200 EMGs during their residency. Many PM&R residents graduate and start doing EMGs without any additional training. However, most of these studies tend to be more eval for radiculopathy, plexopathy, CTS or other peripheral nerve entrapment. Things like single fiber, evoked potentials, and more advanced studies seem to be done either by physiatrists with additional EMG training or neurologist with additional training.

 

Yeah, that sounds about right. I certainly didn't do 200 EMG/NCS during residency, and I'm pretty sure neurologists need to be neurophys fellowship certified before they can legitimately bill for them.

 

If u combine all of Neuro and further fellowships -

Interventional Neuro - Mechanical thrombectomy Intraarterial tpa , Diag cereberal Angio, Carotid Stenting, WADA scans, head and neck aneurysm stenting, embolisation and coiling, venous sampling, Head and neck AV malformations and Fistulas, shunts coiling/embolisation etc.. etc.

Neurocritical care: All of what Typhoonegator said

Neurophys: EEGs, Intracranial EEGs( w Neurosurg), IntraOP EEGs, VNS Interrogations, TCDs , Evoked Potentials (VEP, SSEP, AEPs), EMGs, NCS, Botox, Sleep Studies, Intraoperative NCS

Movt : Botox, Baclofen Pump Interrogations, DBS Interrogations
Pain : all interventional pain procedures,

 

Nope! In some states, chiropractors and physical therapist are doing them. Some PM&R docs may apply for certification through the ABEM; however, a good number do not and still bill for their services.

I think all residencies have strong points and weak points. There are some programs out there that are strong with EMG training intra-residency and of course, some that are not. I would argue that any neurology resident that had six months of hands on EMG training (and I mean "real" hands on) is adequate to perform basic studies in their office, such as ruling out carpal tunnel versus cervical radiculopathy. Single fiber EMG studies on myasthenic patients? Let's leave those to the experts!

Oddly, this may come as a shock to most of you reading this. Okay, ready? Brace yourself! Here goes! Some of the most renowned, nationally recognized, neuromuscular experts do NOT perform their own electrodiagnostic studies!! Gasp!! Some large academic, tertiary centers have the luxury of a very skilled non-physician neurophysiologist that will perform the NCS portion of the study and trust me, knows more about how to use the machine and software than does the doctor. (Can anybody say Sanjeev Nadedkar?). Of course, most private or non-academic hospital owned practices simply cannot afford such a luxury.

 

the more i read opinions about neurology the more i get the impression that if one wants to invent/discover something in the field of neurology, he/she is definitely looking for non medical-PhD field. people going into neurology for interest in research seem to regret later.

 

I'm not sure how this thread has anything to do with inventions / discoveries in the field. As a neurologist who went into it with an interest in research and now does research I can tell you that I do not regret it. I know many straight PhDs who are doing great work, but struggle because without the clinical context they can't see the big picture and therefore have a hard time honing in on what is important to study / explore.

 

actually, i am happy with what you said because i am torn between IM and neurology and i really want to pick neurology with intentions of research and doing clinic time together.
the PhD thing i derived is not from this thread only but from other people`s opinion also. i once asked a neurologist about neurologists` input into cutting age neuro research, he told me straight to go for PhD or neuro-related engineering field.

 

Hmmm...this is an interesting statement, mostly since "outcomes have been demonstrated" implies there's good research out there to support this common assertion.

Although I have not done an exhaustive search through the NCC literature, I'm currently in a department that studies and publishes and discusses ad nauseum intensivist staffing and outcomes and I have never heard of such research. In fact, most research indicates the opposite is true.

Please share.

HH

 

To date, there NEVER has been any double blinded randomized controlled trials that have EVER demonstrated that it is any safer to jump out of a crashing airplane with a parachute then without one. Why? Because there never has been a control group. Could we formulate such a study? Sure, but good like finding volunteers for your control group.

That being stated, if you were in an airplane that was going down, and somebody offered you a parachute, would you refuse because there is no good evidence?

 

Yes, that was a funny article playfully mocking EBM extremists written more than 10 years ago in BMJ. The authors are probably pleased you enjoyed it so much and have incorporated it into your mindset. (they may be less pleased you have passed this off as a novel or original thought)

The potential and unlikely outcomes benefits from "specialized intensivists" is not similar to the potential benefits of a parachute in sky diving. This is a secondary point of those authors, I suspect. It requires readers and scientific thinkers to consider EBM a little more deeply and arrogant or undeveloped thinkers to be less dismissive.

Let's now return to the putative benefits of intensivists implied to be supported by evidence in the post by typhoonegator.

Thanks, HH

 

Intensive Care Med. 2013 Aug;39(8):1405-12. doi: 10.1007/s00134-013-2960-6. Epub 2013 May 24.
The effect of secular trends and specialist neurocritical care on mortality for patients with intracerebral haemorrhage, myasthenia gravis and Guillain-Barré syndrome admitted to critical care : an analysis of the Intensive Care National Audit & Research Centre (ICNARC) national United Kingdom database.
Damian MS1, Ben-Shlomo Y, Howard R, Bellotti T, Harrison D, Griggs K, Rowan K.

Neurocrit Care. 2013 Jun;18(3):305-12. doi: 10.1007/s12028-013-9818-1.
The effect of a neurocritical care service without a dedicated neuro-ICU on quality of care in intracerebral hemorrhage.
Burns JD1, Green DM, Lau H, Winter M, Koyfman F, DeFusco CM, Holsapple JW, Kase CS.

Neurocrit Care. 2012 Feb;16(1):63-71. doi: 10.1007/s12028-011-9620-x.
Impact of a neurointensivist on outcomes in critically ill stroke patients.
Knopf L1, Staff I, Gomes J, McCullough L.

Neurocrit Care. 2011 Dec;15(3):477-80. doi: 10.1007/s12028-011-9539-2.
How does care differ for neurological patients admitted to a neurocritical care unit versus a general ICU?
Kurtz P1, Fitts V, Sumer Z, Jalon H, Cooke J, Kvetan V, Mayer SA.

Neurocrit Care. 2010 Apr;12(2):149-54. doi: 10.1007/s12028-009-9302-0.
Impact of pattern of admission on ICH outcomes.
Naval NS1, Carhuapoma JR.

 

The idea is not to place this concept into our mindsets, EBM is very important to consider; however, sometimes, we do have to be practical.

As you pointed out, perhaps skydiving has nothing to do with medicine, so perhaps I should use a different example. Consider NMO? Last I checked (and I will admit that it has been a while), there are no randomized double blinded studies that demonstrated efficacy for any particular agent? There are no FDA approved therapies for this condition?

 

Procedures I do

1) botox for headache/spasticity/hemifacial spasm/bruxism
2) spinal tap
3) intrathecal chemotherapy
4) occipital/suboccipital nerve block

...that's honestly about all I do