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Neurology or PM&R

Discussion in 'Neurology' started by Cassowary, Mar 14, 2019.

  1. Cassowary

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    MD student. Cannot decide between neurology and PM&R. The work of both appeals to me. Anyone have anything to weigh in?

    How about when it comes to practice models, compensation, and lifestyle?
    Ultimately the deciding factor will probably be compensation and lifestyle.

    Any ideas on how the work will be 10 years from now?

    I have a entrepreneurial bug, so any idea on which has better entrepreneurial opportunities?

    Am interested in private practice. Ideally open my own practice with multiple ancillaries and midlevel extenders. NIR, teleneuro, and locums stroke interest me for neruology, and pain medicine and sports/spine interest me on the PMR side. Admittedly I'm swayed by the lifestyle of PMR residency.
     
    #1 Cassowary, Mar 14, 2019
    Last edited: Mar 14, 2019
  2. Spodermin

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    You're interested in lifestyle?
    Yet you're interested in NIR and stroke? Forget the fact that NIR would be an uphill battle for the next 6-7 years of your life, but really? NIR and lifestyle don't fit together.
    Unless you want to do outpatient neurology, go for PM&R.
     
  3. OP
    OP
    Cassowary

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    Lifestyle isn’t THAT important to be honest, if comensation makes up for it and if I enjoy what I’m doing.

    I admit NIR interests deviate from my desire for lifestyle. The way I see it, at the attending level though, I don’t think it would be much worse than anything else if I set up my own practice and rent a surgery center; I could pick my own hours

    My idea was 4 years of moderate intensity neuro residency, and 2 years of high intensity endovascuar fellowship isnt too much worse than 4 yrs neuro/PMR residency + 1 yr moderate intensity fellowship
     
    #3 Cassowary, Mar 14, 2019
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  4. Spodermin

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    I think you're trolling
     
  5. OP
    OP
    Cassowary

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    Uhh ok *shrugs*
     
  6. Thama

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    This is spectacularly inaccurate. Acute stroke care is at the core of modern NIR and is the main reason why neurologists are considered to have a valid role in the subspecialty at all. NIR means that you are on call 24 hours a day for acute strokes q #partners in your practice.
     
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  7. BronxBomber

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    As someone interested in NIR, what do you mean by uphill battle? Is it really hard to convince programs to let you into their NIR/ENR fellowship? Is it hard to get hired after fellowship if you're not IR or NS?
     
  8. OP
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    I have no experience but what ive seen is yes, neurosurgeons and radiologists have a much easier time getting in. What I’ve also seen however is there is a trend in more neurologists being accepted to endovascular programs
     
  9. OP
    OP
    Cassowary

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    I wasn’t aware, thank u for correcting. They customarily work 7 on 7 off schedules then?
     
  10. Spodermin

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    NIR fellowships are controlled by radiology and neurosurgery. They don't like/want neurology expanding into their field.
    The way I see it, there's two parts as to why neurologists aren't being allowed to expand into this field.

    #1
    Neurosurgeons can do whatever they want inside the brain because when **** hits the fan, they can operate.
    Neuroradiologists have extensive experience in all imaging modalities related to the nervous system. There's a reason they spend 5-6 years reading images after all.
    Neurologists aren't trained in any procedures during residency (maybe LPs) and they aren't trained at reading images per se.

    #2
    Neurosurgery/radiology will not allow neurology to do to them what cardiology did to the their surgeon buddies.
     
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  11. Thama

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    Point 2 is far more valid than point 1. Radiologists also typically have zero patient care experience outside of a minimal intern year and are as suited to clinically evaluate a stroke patient as I am suited to perform a C-section.
     
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  12. Thama

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    Call schedules vary, but the ones I'm most familiar with are q3 or q4, etc depending on how large the practice is.
     
  13. NITRAS

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    To say that neurologist aren’t trained in images isn’t exactly accurate, but the OP sounds like they appreciate lifestyle.....and neuro-IR isn’t a lifestyle I’d want.
     
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  14. deathmerchant

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    Other than neurology being the most fascinating field in medicine (obviously we are all biased here) and being able to take care of some of the sickest people in the hospital ; PMR is better in every other way you can think of.

    NIR might be an exception in that it is more like Interventional cardiology or IR for comparisons rather than Neuro.
     
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  15. Ibn Alnafis MD

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    Beg to differ.

    Job market and demand: Neuro wins
    Diversity of pathologies: Neuro wins
    Types of practice settings: Neuro wins
    Salary: Neuro wins
    Ownership and mastery of an organ system: Neuro wins


    Lifestyle in residency and after: PMR wins
     
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  16. deathmerchant

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    Some valid points!
     
  17. OP
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    Neuro really wins salary? I know statistics are veeery general, but I thought they are about equal with maybe PMR coming out on top.
     
  18. Spodermin

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    Have you ever seen how a stroke code runs? The neurologist evaluates the patient. The radiologist interprets the images and plans the procedure. Who said anything about radiologists evaluating stroke patients clinically? You don't need patient contact during residency to interpret an MRI/CT/angio and plan a thrombectomy.

    Neurologists spend what, 2 or 3 months on neuroradiology during residency? You really think that's enough to claim that you are "trained" at interpreting images? I've seen neurologists who call up the radiologist to argue about their report, and I've also seen neurologists who couldn't care less about opening the images and rely entirely on the report. So yeah I don't think neurologists are trained to read images, I think its an interest that some choose to develop during their career while others focus on developing their clinical skills.
     
  19. Asklepian

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    I think this sounds a bit naive.
    Yes, it does depend on your institution and your level of dedication to your career, but as a rule, neurologists read their own films. As a resident, I've outcalled our radiology residents (and sometimes attendings) many times, oftentimes totally changing the treatment plan for the patient. Last time this happened was, let me think...two days ago. And I would say the same for my colleagues, as well. Neuroimaging also highly tested on the RITE exam and even has Continua entirely dedicated to it. So it's a bit disingenuous to poo-poo the training neurologists have in reading our own films just because we aren't in a rads residency.
     
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  20. Thama

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    Actually, I've personally run hundreds of stroke codes over the course of residency. None of them involved a radiologist in any way unless we asked for their help for a thrombectomy. In that case they relied 100% on our clinical assessment and were there purely to suck out a clot and return the patient immediately to our care. That model works at large academic institutions with 24 hour in house neurology residents. It doesn't work in the private world when they are calling you as "the stroke guy" and there is neither time nor patience to call 2 other consults because you never trained sufficiently to assess and treat patients outside of the cath lab.

    Neurologists at my program got 4 years of neuroradiology, as we use imaging daily and interpret 100% of it ourselves. From talking to people at other good programs, that's pretty standard. It was more common for us to go to neuroradiology and ask them to change a read that is absurd and may interfere with insurance coverage of ongoing treatment than for us to rely on their read over our own.
     
  21. Ibn Alnafis MD

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    At my program (newish university program), we almost never look at the radiology report. We read images ourselves, specially during the evaluation of code stroke.

    With that said, from time to time, we visit the radiology department to discuss with neuroradiologists the ddx of atypical MRI findings.
     
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  22. Ibn Alnafis MD

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    I don't have data to support this, but from what I have seen and told, nearly every neurology new grad is getting offers 250K+, vast majority 300K+ in private sector. PMR grads on the other hand are getting offers of low 200's.

    Surveys do show that PMR makes high 200's on average, but keep in mind that this maybe due to the fact that a good number of them go into pain.

    All in all, I agree with you, I'll retract what I said about salary. It's equivocal at best.
     
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  23. deathmerchant

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    I think if you look closely, PMR wins salary. The average reported salary of PMR is about 10% higher. And in fact, neuro salaries are falsely driven up right now (as I had mentioned in a previous post) because of very high demand. Neuro is indeed one of the highest in demand specialty with many type of practice settings open. As a neurologist you can pretty much get a pretty good salary if you go to small and medium sized places.

    On the other hand, PMR jobs are mostly in big cities. If you compare salaries of PMR and Neuro in medium and big sized metro academics- PMR will be much better.
     
  24. deathmerchant

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    Like others, I would disagree too. Everywhere I have personally worked or talked to any of my colleagues- we do not have time to wait for radiologist to look at images before planning emergent stroke care. Most neuro residents are well trained in imaging by 6-12 months of residency.
    It is a vital backup for sure. Because in haste, I have missed things that radiologist catches. This is esp true of non CNS things on head imaging. I once missed a nasopharyngeal mass on an CTH in an acute stroke patient that the radiology PGY2 caught.
    For Gen neuro cases, I Very frequently disagree with radiologist's report. No hate, but radiologists really just give a large differential diagnosis and then we have to figure out what that exactly is. Half the time I could use radiopedia for that differential. I personally suck at CNS tumors.

    That being said, I would not work in a setting where there is no radiologist or preferably neuro radiologist in the hospital, helping us out and to discuss complex cases with. And obviously radiologists are the ones driving new research in imaging. I highly appreciate their input.
     
  25. OP
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    Interesting; i read neuro salaries are falsely driven down bc of the high number of neuro people in academic vs private practice
     
  26. neglect

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    Wow just wow. I think you saw one stroke code at one place involving a LVO. You don’t need patient contact to interpret an MRI and plan a throbectomy? This is so wrong I don’t even know where to start. Let’s just start with patient contact. So let me tell you that stroke is highly variable. Even if a CTA looks favorable, the patient might not, might have CA, an EF of 5%. Time plays a real role, and while imaging generally is consistent with this, so does timing, to which you have to add door to puncture and door to recanalization time. Or sometimes the patients look too good, and although the M1 looks fully occluded, they have an NIHSS of 3 from 10 after tPA. You gonna take that patient up to the cath lab? So tell me clinical context doesn’t matter - it does if you want to consent the patient and their family!

    Let’s go to the fact you think an MRI comes prior to thrombectomy. CTA is the imaging modality of choice for large vessel occlusion. MRI does not image vessels. MRA could, but the lost time will cost brain tissue.

    Meanwhile, the neurologist evaluates the patient. We can tell within a moment if the patient should be treated, then we look for exclusions, once CT shows no blood, we order. If I’m giving tPA and there’s a formal head CT report in the chart, then there’s been a significant time delay.

    Neurologists could spend no time on formal neuroradiology. But every single day trainees spend all day on correlating imaging, incorporating imaging, grasping the power, pitfalls, measurements and degrees of mismeasurements, nuances and predictive values of imaging.

    Silly post, obviously got me going.
     
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  27. Telamir

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    Echoing what everyone else says above, mostly:

    Since residency, I've always looked at my own scans, MRI or otherwise. Residents who do this get pretty good at neuroimaging just by virtue of how many are ordered and interpreted. Similarly, I now do inpatient neurology and during a stroke code I look at the images as they are being acquired after a short initial NIH assessment. I make decisions based on my own interpretation of the images the vast majority of the time, with only a few cases where I might ask if there's a small vessel occlusion (think M3, P2, etc) that won't get intervened on anyway. I am more than capable of finding the usual baddies (proximal occlusion, dissection, etc), but like the poster above the decision to give TPA is really only based on the CT Head W/O.

    Similarly, when it comes to MRIs, I read my own images first and THEN look at the report. You have the advantage of putting the findings in a "clinical correlation". That being said, I definitely appreciate my neuroradiologist colleagues and I call them frequently to discuss images during my shifts.

    Two of my best friends did PM&R and Psych. They both have pretty good lifestyles. My PM&R friend does inpatient only and it's more of a 10-4 type job, but he's paid in kind (180k ish). That being said he's so Type B he doesn't care since his job is easy peasy.

    Overall, OP I think you're a bit misinformed when it comes to NIR and their "lifestyle". Neurology is certainly not lifestyle focused. Is it as bad as some other specialties? No. If you want to do inpatient you can get the typical 7 on 7 off gig, which isn't bad. If you're more on the clinic side then it's kind of the same for both specialties, I think. The only difference that comes to mind is no "emergencies".
     
  28. mrbreakfast

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    Two cents for someone who decided between the two by doing rotations in both. Personal opinion:

    -PM&R has better to much better lifestyle. Inpatient rehab is extremely cushy.
    -Neuro is much more interesting/intellectually stimulating, both inpatient and outpatient. I felt like I could be happy doing anything in neuro, from NCC to general inpatient to general outpatient to something unpopular like headache or neuro-ophtho. The only thing I liked in PM&R was interventional stuff, like spinal stim placement.

    I'd recommend spending some time in both fields. One of my closest med school friends is doing PM&R, and we jokingly poke fun at one another.
     
  29. Preictal

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    Maybe I'm arguing over semantics, but how is high demand "falsely" raising salaries? If high demand isn't a substantive reason for salaries to increase over less in-demand specialties, what is?
     
  30. deathmerchant

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    You are right, its just Semantics. Its just a different way of looking at it. I just meant to say that right now Neurologists (and other in-demand specialities) are getting higher compensation compared to the amount of money/RVU we bring to a hospital compared to some other specialities. And it seems like at least for the near future, the demand will only increase. That is one of the reasons why there is big salary diff between academic jobs and a private small town job.

    And I'm not complaining!
     
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  31. Preictal

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    Understood, sorry to be picky about wording! I think it could be argued that supply/demand is the more important factor to have in a specialty's favor, since RVU's can change relatively quickly whereas supply versus demand of a specialty can take years to reverse.
     
  32. Ibn Alnafis MD

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    Correct me if I’m wrong, but this doesn’t apply to outpatient reimbursement, right?

    The neurologists I know who are killing it are almost exclusively doing outpatient. I guess it’s all about volume/efficiency.
     
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