Neurology Subspecialties & Other Specialties

[culturenmusic03]

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I posted a similar but different question about some concerns I've had about neurology (and can't seem to get an honest answer from anyone), but here, I'm wondering about the different neurology subspecialties and considerations for other specialties in general. I love learning about the brain preclinically and so far, other than oncology, has been one of my favorite modules in school.

However, there are some aspects of neurology that don't seem to be appealing, at least from the pre-clinical perspective.
- not many hands-on procedures
- not much you can do in the acute setting
- doesn't feel like you can ever cure anyone, just palliative care, despite many interesting cases

I've considered NSRG, but for many reasons like post-residency lifestyle and the minimal patient connections you can make, have reconsidered. I've heard you can do Neuro-IR where you're doing clot-busting procedures in the brain, but other than that, don't know much about the ins and outs of many of the subspecialties even after shadowing them all. Would love to hear anyone's perspectives on the types of patients, lifestyles, or anything else that anyone can provide for the different subspecialties that isn't always obvious from rotations/shadowing!

Or if any non-neurology heads (like neurosurgery or ophtho!) have career paths that are neuro-related but hit some of the points I'm worried about, would love that!

 

[operaman]

Sounds like you need to spend a little time shadowing some general neuro folks at your institution. Some people really do love the work, but it definitely comes with some drawbacks. I think they do have some hands on procedures - Botox, EMG/ncs, focused ultrasound, etc. but it really is more of a cognitive speciality. And you’re right that it’s often more palliative than curative and lots of watchful waiting.

Neuro IR/neurointerventional work is a nice option. Good money, lots of procedures. Lifestyle not so good either just due to the call - lots of true emergencies. Depending on the patient population you can build some deep and lasting relationships with patients in this space. I’m part of a skull base team with a group of ent, neurosurg, neuroIR and we’re stupidly busy (our wait list recently passed 500 people) but patients very grateful and outcomes pretty darn good usually.

I’m a surgeon so I’m biased, but if I were a student again and interested in neuro then for me it would be neuro IR vs neurosurg with embedded IR fellowship. Keep ent on the radar as well. Broad scope of practice if you want it and you’re good, and lots of neuro adjacent work if you want too. I do a lot of skull base work whether anterior skull base approaches and repairs, infratemporal fossa approaches, weird c spine exposures, etc where I work with neuro on problems we can actually fix.

Would definitely err on the side of procedures if possible, whatever you decide. It’s the most AI and midlevel safe space you can find. The money potentially is also much greater when you aren’t limited only to E&M codes.

 

[Dral]

I think it is good to always be thinking about specialty for sure; but if you are in your pre clinical years, you may get a lot more clarity when to start going through your clinical rotations.

I was into Neurology in the pre clinical years. However, that changed pretty quickly when I did my Neurology rotation 3rd year. While I was attracted to the problem-solving portion of it, especially in the pre clinical years, the practice of it was a lot different than what I expected. Of course we all get different exposures during clinical rotations and maybe I just did not see the right portions of it. However, as I said, I very quickly ruled it out during my clinical exposure to it.

However, I do remember that I thought sleep medicine was pretty cool when I rotated through it (only for a day or two iirc).

As much as I hate to admit, I agree with the above that it is advisable to go for procedure heavy stuff - at least if you are between two things and one is more procedure heavy than the other. It's just so hard to predict where things are going, especially with AI.

 

[JBM16BYU]

PM&R/Neuromuscular. While not a surgical subspecialty, in practice I do perform a whole host of procedures in a very procedurally heavy practice. If you do sports or pain medicine, you will also had other procedural skill sets to apply hands on procedures. Plus, you can scratch the neuro itch with brain injury, strokes, spinal cord injury, cerebral palsy, neuromuscular conditions, nerve injuries, etc. Worth a consideration.

 

[Sidus1011]

Hey there!
Current Neuro resident chiming in and just want to address some of these points

- not many hands-on procedures: Most neurologists are not drawn to the field because of procedures, however those who are procedurally minded can find their niche. NeuroICU can offer a lot of the similar training in intubations, lines, etc as other paths to ICU. NeuroIR is another path with you driving the catheter, although the schedule is brutal (Q2 call in a lot of places) as nearly everywhere wants to be a comprehensive stroke center and the volume is huge. Interventional pain is accessible through Neurology, especially as the competition has decreased in pain over the years. Botox for spasticity and DBS in the OR, EMG in Neuromuscular (which takes a ton of practice and skill to develop good technique and consistent read), etc can all scratch that itch too. Nerve blocks in headache clinic as well.

- not much you can do in the acute setting
The EXTEND trial has shown you can do thrombolytics up to 9 hours in acute stroke and AHA Stroke guidelines now reflect that alongside thrombectomy for LVO within the first 24 hours, corticosteroids and IVIG in acute autoimmune settings can save someone from complete decompensation, herniation syndromes in the NeuroICU setting require rapid response and quick thinking alongside discussion with neurosurgery, and talk to any IM doc about status (especially non-convulsive status) and they will say they appreciate their Neuro colleagues.

- doesn't feel like you can ever cure anyone, just palliative care, despite many interesting cases
When was the last time anyone has ever actually cured anyone? COPD is an end-stage condition, diabetes is rampant and unless patient's are aggressive with it it will likely never be 'cured', HTN and atherosclerotic disease doesn't just go away once they are placed on a medication regimen. Heart failure, CKD and ESRD, nearly everybody is getting sicker and sicker.

Medicine is not about curing anyone. Medicine is about being there to bear witness to someone's distress and trying to provide someone with whatever modicum of relief we have to offer. Neurology may not be able to offer a lot of treatment for diseases like ALS and other forms of motor neuron disease, and Neurodegenerative conditions will continue to trudge through someone's life until it takes everything, but these patient's need someone there to advocate for them and provide them clarity on what exactly their life will be moving forward. The diagnosis can therapeutic in and of itself, especially in cases where 5-6 doctors have tried before and somehow no one thought to get an MRI with contrast or an EMG. Further there is a lot of momentum for DMT in the field. Just look at MS in the past 30 years, you can place someone on Ocrevus now with radiographically isolated syndrome and prevent them in some cases from ever even developing a flair. And people after age 60 can even be taken off of DMT if they have no signs of inflammatory activity for 5 years.

You will figure out what you want on rotations pretty quickly, don't sweat it. However, don't close your door on Neurology before you've even done a rotation. Especially if you are interested in the brain. Optho barely gets actual brain training beyond optic neuritis and increased ICP management. Neurosurgery is cool, but they think about things as either surgery or no surgery, and you will not follow the cases that do not warrant surgery beyond that. I highly recommend doing a Neuro rotation if your school doesn't require it.