Neurology as a career choice

[ehel27]

I'm a 5th year medical student (Europe) thinking about neurology as a career choice later. Though I'm stuck choosing between neurology, radiology and pathology (weird combination, I know). I have some questions that I would be incredibly happy if some people from neurology could comment on

1. How heavy is neurology in terms of end-of-life conversations and difficult interpersonal stuff (compared to other fields in medicine)? I'm kind of an introvert, and using half my day for difficult conversations would probably drain me a little. That's the main reason why I'm also considering more clinically distant fields like radiology and pathology.

2. Is the everyday work containing a lot of "intellectually stimulating" diagnostics, or is it mainly following up on chronic patients and endless rounding?

3. What should be the number one motivation for entering neurology? I find the CNS the most amazing organ system (by far), and I love reading about neuroanatomy, research in neurology and neuroscience. However, I'm worried that my love for theoretical neurology wouldn't be enough for being happy in the everyday work.

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[Thama]

Let's break this down. You consider interpersonal interactions to be difficult and do not find anything intellectually stimulating about patients, reserving this term for diagnostic testing. You like neuroscience though.

Have you done your neurology rotation? Europe is a big place with lots of different systems (telling us your nationality to begin with would help) but in most of the US and most Western European systems neurology is a core rotation and you'll have a better idea of whether you like it when you actually do it.

In terms of structure (rounding, patient interactions, sorts of treatments available, etc) neurology is fairly similar to internal medicine. There are patients who are devastated but the overall number of GOC discussions is probably smaller than in fields like oncology, for example. Most people you see are treated and/or improve and leave the hospital, either to home or rehab. It's a clinical field where the most important parts are history and examination, so if humans make you cringe and looking another person in the eyes is like staring into the face of the sun, then a dark basement specialty like rads/path may be more your speed and both of those conveniently have neuro fellowships. Neurologists are weird, but not typically the "can't make eye contact or wear deodorant and has notebooks of strange ideas hidden from the FBI" kind of weird, but rather more of the "makes a little too much eye contact and can't wait to tell you about the new Star Wars movie" kind of weird.

 

[ehel27]

Let's break this down. You consider interpersonal interactions to be difficult and do not find anything intellectually stimulating about patients, reserving this term for diagnostic testing. You like neuroscience though.

Have you done your neurology rotation? Europe is a big place with lots of different systems (telling us your nationality to begin with would help) but in most of the US and most Western European systems neurology is a core rotation and you'll have a better idea of whether you like it when you actually do it.

In terms of structure (rounding, patient interactions, sorts of treatments available, etc) neurology is fairly similar to internal medicine. There are patients who are devastated but the overall number of GOC discussions is probably smaller than in fields like oncology, for example. Most people you see are treated and/or improve and leave the hospital, either to home or rehab. It's a clinical field where the most important parts are history and examination, so if humans make you cringe and looking another person in the eyes is like staring into the face of the sun, then a dark basement specialty like rads/path may be more your speed and both of those conveniently have neuro fellowships. Neurologists are weird, but not typically the "can't make eye contact or wear deodorant and has notebooks of strange ideas hidden from the FBI" kind of weird, but rather more of the "makes a little too much eye contact and can't wait to tell you about the new Star Wars movie" kind of weird.

Thanks for the reply!

It's not completely true that I don't find any joy from seeing patients. I like doing history and examination, and have few problems with the patient interaction in this way. But it's more the difficult conversations and follow-ups that come after that I'm insecure about. I've usually gotten a good reputation for being a "good listener" from patients in the places I've worked or done internships. But I think they like me a bit better than I like them

I'm either working in Germany or Scandinavia later, where I think the hospital system is quite similar to the US. I have done a neurology hospital rotation (only 2 weeks however) and liked it. I also like that neurology is a rapidly progressing field, where it's probably a lot of interesting stuff happening in the next 10-15 y. However, I've been put off by a lot of colleagues (and docs) saying that I shouldn't enter neurology, because it's "few available treatments, depressing patients and almost no procedures".

I think rads or path would be a perfect match if I could be doing neurorads or neuropath. But I'm so quite much more interested in the CNS than other fields of medicine, so I would not be happy if my work consisted of looking at 30 prostate biopsies or abdominal-CT's every day. I think the spots for a neuro subspecialization in these fields are very few around here.

What I see as my best option right now is to just start neurology and then eventually, if I find the clinical work unsatisfying, rather try to do a PhD and go into research. This could be economically disappointing, but I would at least be in a field I find interesting.

 

[Thama]

Saying "few available treatments, depressing patients and almost no procedures" about neurology today is like saying "all you do is give poison that kills tumors slightly faster than it kills people" about oncology. It's a statement which is so utterly divorced from reality that it says nothing about the field while impugning the intelligence of the person who said it. The only neurology subspecialty where this is currently true at all is dementia, and current trials would suggest that this too will change within our careers. Every other major field in neurology has effective treatments, neurology patients are not on average any more depressing than internal medicine patients (liver bombs and ESRD patients are a nightmare compared to almost any neuro patient), and there are more neurology fellowships with billable procedures than ones without them if that's what's important to you.

 

[ehel27]

I also think people who say this should have another thought about how things in medicine in general are working. Not so many parts of medicine actually "cure" diseases anyway. I don't generally listen to these comments so much, but I have noted a striking negativity towards neuro among fellow students.

Procedures don't matter so much to me, as I'm more a thinker than a practically oriented person. But it would perhaps feed some variety into the everyday work if some small procedures had to be done now and then. As I understand it, in general neuro lumbar puncture is common, together with EMG and EEG.

How is it with neuroimaging, do neurologists ever interpret their patients scans themselves? For instance simple CT's to exclude hemorrhage in acute CVA, are neurologists checking this themselves when on call?

 

[Thama]

I look at every one of my patient's scans myself, and if I disagree with the radiologists report then will talk to the attending. I regularly make clinical decisions based on my read of MRI and CT well before even a preliminary report comes in. The same applies for EEG in the acute setting. You'll probably come out of intern year able to to LPs independently and will do tons during residency. Most neurologists I know do this sort of thing particularly within their own area of specialization (I don't think MS specialists even really care what the radiologists say in most cases).