Neurology Patients in practice

[Leukocyte]

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I am a FM doc by training, but I have always liked the science of neurology. I remember from my medical school days how much I enjoyed studying neurology. When I was exposed to clinical neurology in medical school and in my FM residency, I noticed that neurology patients can be amongst the toughest and most complex patients in medicine.

My question is, would you advice a medical student who loves the science of neurology, to go into the field of neurology if they:

-Do not like dealing with pain patients?
-Do not like dealing with vague symptoms?
-Do not like dealing with patients who have psychosomatic symptoms?

Thanks.. By the way, from your experience, what % of neurology patients in clinic have psychosomatic disorders?

Thanks again.

 

[typhoonegator]

Yes, I would. That's exactly what I did. You have to get through residency, which is full of that stuff because no one (including other neurologists) want to deal with it. But after that you have the opportunity to specialize in such a way that you don't have to spend much time dealing with vague or non-neurologic complaints. Stroke/ICU and Neuro-Onc people are very similar in that we can almost always point to the problem. But god bless the people with the patience and compassion to deal with pain disorders and psychosomatic disease. We need more of them around.

All that said, I still get asked to give tPA to people with conversion disorder. So no one is really immune.

You'll have to ask others around here about what they see in clinic. I don't have one.

 

[neurologist]

I am a FM doc by training, but I have always liked the science of neurology. I remember from my medical school days how much I enjoyed studying neurology. When I was exposed to clinical neurology in medical school and in my FM residency, I noticed that neurology patients can be amongst the toughest and most complex patients in medicine.

My question is, would you advice a medical student who loves the science of neurology, to go into the field of neurology if they:

-Do not like dealing with pain patients?
-Do not like dealing with vague symptoms?
-Do not like dealing with patients who have psychosomatic symptoms?

Thanks.. By the way, from your experience, what % of neurology patients in clinic have psychosomatic disorders?

Thanks again.

-Do not like dealing with pain patients? ABSOLUTELY DO NOT GO INTO NEURO
-Do not like dealing with vague symptoms? ABSOLUTELY DO NOT GO INTO NEURO
-Do not like dealing with patients who have psychosomatic symptoms? ABSOLUTELY DO NOT GO INTO NEURO

My experience was similar to what your's sounds like. I was very drawn to neuro by the neuroSCIENCE aspect - the pathology, physiology, anatomy, etc.

In day-to-day clinical practice, especially in the "general neurology" sphere, I spend almost exactly 0% of my time consciously thinking about any of that, with exception being that a good knowledge of neuroanatomy comes in handy to recognize when the patient's symptoms are not neurologically possible (i.e., the "functional" exam).

If you "love the science of neurology," I would advise you to go into the basic (or maybe clinical) research sphere, not run-of-the-mill clinical neurology.

As for percentage of neuro patients with psychosomatic symptoms, I'd say it's fairly high, especially among those referred for seizure (up to 25% of referrals to epilepsy centers turn out to be non-epileptic spells), chronic pain, and movement disorders.

From the link I have provided below: "Around one third of new neurological outpatients have symptoms regarded by neurologists as "not at all" or only "somewhat" explained by disease."

http://jnnp.bmj.com/content/76/suppl_1/i2.long

 

[danielmd06]

I am a FM doc by training, but I have always liked the science of neurology. I remember from my medical school days how much I enjoyed studying neurology. When I was exposed to clinical neurology in medical school and in my FM residency, I noticed that neurology patients can be amongst the toughest and most complex patients in medicine.

My question is, would you advice a medical student who loves the science of neurology, to go into the field of neurology if they:

-Do not like dealing with pain patients?
-Do not like dealing with vague symptoms?
-Do not like dealing with patients who have psychosomatic symptoms?

Thanks.. By the way, from your experience, what % of neurology patients in clinic have psychosomatic disorders?

Thanks again.

I would absolutely recommend neurology to you.

I learned to hate pain patients, disliked subjective and/or vague symptoms, and positively despised psychosomatic complaints. And I picked neurology. Basically, I had to suffer through residency, slogging through this type of stuff. Many IM people are the same. They intend to go into cardiology or GI and the run-of-the-mill IM things are simply the price they pay for three or four years to get there. I suspect you won't like general neurology (neither do I). But you might be perfectly happy with sleep medicine, neurocritical care, or another highly sub-specialized area within neurology that insulates you from the items that you dislike. That's exactly what I did and I wouldn't swap places with an orthopaedic surgeon or otolaryngologist.

Another possibility for you, if you truly love neuroanatomy, would be radiology with a fellowship in diagnostic or interventional neuro.

 

[Leukocyte]

Yes, I would. That's exactly what I did.

-Do not like dealing with pain patients? ABSOLUTELY DO NOT GO INTO NEURO
-Do not like dealing with vague symptoms? ABSOLUTELY DO NOT GO INTO NEURO
-Do not like dealing with patients who have psychosomatic symptoms? ABSOLUTELY DO NOT GO INTO NEURO

I would absolutely recommend neurology to you.

Thank you all for your helpful posts. It seems that there are Neurologists who also share the feeling that I have towards pain and psychosomatic patients.

I have been told before, however, not to go into a specialty just because of the fellowships it offers. this is because:

-theres is a chance that I may not be accepted to fellowships
-and even if I were to complete a fellowship, some employer/practices might also want the fellowship trained neurologist to practice general neurology at times.

Thank you again

 

[Yoyomama88]

Personally, I'm a bit torn between psychiatry and neurology. I feel like I might enjoy these types of patients.

Can you explain why you hate them so much? Is it because you feel they are wasting your time and energy?

 

[typhoonegator]

Personally, I'm a bit torn between psychiatry and neurology. I feel like I might enjoy these types of patients.

Can you explain why you hate them so much? Is it because you feel they are wasting your time and energy?

Not "wasting" energy, and most of us don't "hate" any patients. We try to make people better, often at substantial emotional and physical cost. But some patients don't have any discernible condition that we can treat, and it can be very frustrating.

 

[Leukocyte]

You'll have to ask others around here about what they see in clinic. I don't have one.

Typhoohegator, do you spend all your time working in the ICU?

Thanks.

 

[danielmd06]

Personally, I'm a bit torn between psychiatry and neurology. I feel like I might enjoy these types of patients.

Can you explain why you hate them so much? Is it because you feel they are wasting your time and energy?

Well, I don't "hate" the people/patients, but during training I learned that medicine is about more than just your own interests (or what you think you like). Your own personality and ability to interact with your fellow human beings plays a role in how effective you are reaching and treating certain people and certain diseases. They may also partially dictate those patients or problems that you are particularly skilled in working with. That's all.

For instance, I had a tremendously hard time emotionally coping with sick pediatric patients. These kids might have had lung cancer or a spinal tumor. But they might never have smoked, or done anything wrong. It was just bad luck, or bad genetics. Often, they were just the sweetest kids. Yet, they might die within a year. They might have been slated, despite the best of care, to never walk, never see again, or be permanently disabled in some way due to their illness. I just found it crushingly draining. I was a grown man, but I would cry some nights thinking about those children. So, I realized that while I loved them as people, I was not the best person to be taking care of their malady. Not because of anything wicked on my part or theirs, but because my personality is what it is.

To be more precise in my answer, I've increasingly had a hard time with neurologic complaints that are subjective. I suspect that many doctors in general (and many neurologists) feel similarly. Personally, I found that I just didn't have as much patience, sympathy, or empathy as I thought I needed to be a good physician for chronic pain patients or psychosomatic problems. The problems can obviously become serious. These people obviously need good doctors. I just realized I wasn't going to be the best one to serve their needs.

 

[danielmd06]

Thank you all for your helpful posts. It seems that there are Neurologists who also share the feeling that I have towards pain and psychosomatic patients.

I have been told before, however, not to go into a specialty just because of the fellowships it offers. this is because:

-theres is a chance that I may not be accepted to fellowships
-and even if I were to complete a fellowship, some employer/practices might also want the fellowship trained neurologist to practice general neurology at times.

Thank you again

Well, I think your comments offer the opportunity to try and make some important observations.

There are plenty of people who go into orthopaedic surgery to exclusively practice spinal surgery. They may not even take call for general orthopaedic problems. There are people who go into IM to exclusively practice GI. And there are those who go into neurology to expressly practice within a subspecialty. So, I have no compunction about recommending that you select a specialty just based on fellowship, and I don't think I would be the only one.

Now, that being said, neurology and neurosurgery are two example of specialties that are often exceptions to this general rule. Someone may do a fellowship in skull base surgery, but they still expect to take neurosurgical call and see a wide range of neurosurgical patients. Someone may do a fellowship in epilepsy, but they still plan on taking general neurology call, and seeing general neurology patients in clinic. This is the most common scenario in both academics and private practice. But it's not the only way. Pain medicine, sleep medicine, and neurocritical care are three possibilites that would allow you to exclude those who would classically be considered "general neurology patients." Or at least they would have you in a different role for these patients than the classical general neurologist. I've heard of it being done with interventional and stroke neurologists, too. These individuals see exclusively stroke patients in clinic, or on the wards, and may or may not take general neurology call. It's not the majority of jobs, but situations like this most certainly exist.

On my interview trail for fellowship, I saw plenty of neurology attendings who exclusively practiced sleep medicine, and either didn't take general neuro call whatsoever, or took a pittance of general neurology call (like two weeks per year). Nor did they see general neurology patients in clinic. The same went for private practice opportunities.

I'm not trying to twist your arm to look at neurology here. When I was a medical student, I thought I would be comfortable with chronic pain, psychiatric overlap, etc. It was only during training that I began to notice how my attitude was changing. So I simply readjusted my career pathway a bit. No worries.

This job is ultimately what you make of it. Your own geographical and financial concerns may more strongly govern how you tailor your future practice.

And for the record, you're going to find that vague/pain/psychiatric-type complaints follow you in just about any branch of medicine you select...

 

[typhoonegator]

Typhoohegator, do you spend all your time working in the ICU?

Thanks.

I do.

And I agree entirely with DanielMD. Residency is supposed to give you exposure to everything, which is crucial. But you have the opportunity to really be specific with what you do once you finish. Not everyone has this opportunity depending on practice patterns and your desirability. But its out there.

I applaud general neurologists who have the breadth of knowledge to run a nonspecific clinic. It seems ridiculously hard to me.

 

[Acherona]

Every single specialty has "functional" patients. Cardiology, GI, Pulm all can have their own versions of psychogenic complaints. Crazy patients are everywhere in medicine and I don't think you can ever "get away" from them.

I used to feel like the psychogenics were wasting my time, but now I just consider it another disease in my differential and find it fun to figure out which symptoms are "real". I find these patients actually teach you a great deal about neurology. They are also usually very sad people and can actually get better if someone actually cares enough to treat them.

The pain patients do get under my skin and I am happy not to have to deal with them in my subspecialty.

 

[Mattchiavelli]

And for the record, you're going to find that vague/pain/psychiatric-type complaints follow you in just about any branch of medicine you select...

THIS! People who went into clinical medicine and thought they could avoid this better have gone into anesthesia/

The real problem in general neurology I have is when a referring physician only explores the patient issue long enough for it to sound vaguely neurologic and then sends for a referral without a proper medical workup- sorry, I'm not doing an extensive rheumatalogic workup because I don't have a lot of training in that. Example- patient has hip pain, pain is felt by the nervous system, send patient to neurologist without even a plain film X-ray and the hip has a stress fracture. Or, a patient I had referred for fatigue that was really just anemic and the PCP didn't bother doing any workup at all, oh and they were giving her 6 fioricet with codiene a day for her medication overuse/rebound headaches.

I think you can still stay in a lot of neuroscience if you do electrophysiology- you can be competent in it without knowing a lot about the science that drives your tests but if you do you can really become a master in it which I think is very impressive. Neuropath, which is very heavy in behavioral neurology, is also science-y and neuroradiology has a lot of neuroanatomy.

I've had a deal of life experiences dealing with crazy and also dealing with situations where the choice is be defeated or do the best you can with what you have, which I think are two skillsets helpful with general patients 😉 I can say it is easier to deal with when you know where the limits of your diagnostics are and can confidently tell a patient "hey, we looked at everything available and everything was normal. There are some things we don't have the technology to test for yet, but we gave a good effort and this is what we got."