Packamylase

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Hey Everybody!

I'm a MSIII DO student interested in a number of specialties (Path, EM, Psych, Neuro) who needs to figure out his future specialty ASAP. I really liked the neuroscience section in med school and I really like various aspects of all the aforementioned specialties.

My question for you fine folks is 2-fold:

1. Will you please share some neurology diagnosis/treatment success stories you've personally witnessed? Resolved headaches, Greatly improved stroke symptoms, Greatly reduced Parkinson's symptoms?, etc?

2. If you can remember back when you were
in med school and you were debating specialty choices, what other fields were you considering and why did you ultimately choose neurology over the others?

Thanks so much for your thoughtful responses!
 
9

95439

Hey Everybody!

I'm a MSIII DO student interested in a number of specialties (Path, EM, Psych, Neuro) who needs to figure out his future specialty ASAP. I really liked the neuroscience section in med school and I really like various aspects of all the aforementioned specialties.

My question for you fine folks is 2-fold:

1. Will you please share some neurology diagnosis/treatment success stories you've personally witnessed? Resolved headaches, Greatly improved stroke symptoms, Greatly reduced Parkinson's symptoms?, etc?

2. If you can remember back when you were
in med school and you were debating specialty choices, what other fields were you considering and why did you ultimately choose neurology over the others?

Thanks so much for your thoughtful responses!

I'll tell you some success stories I've seen since that seems to be the biggest knock on Neuro (that there's little or no cure for the diseases). Headaches are tricky, usually success is a reduction in frequency and severity of symptoms. But I've seen numerous patients with something like 5 migraines per week, go down to 1 per month with treatment. I saw a patient 10 minutes after a stroke in her hospital room, unable to speak or move the right side of her body, given tPA and was almost 100% by the next day. I've seen a TON of epilepsy patients have no seizures after being put on the right medication. Seen alot of Multiple Sclerosis patients in an exacerbation given IVIG or Plasmapheresis with very significant improvement. Even steroids given to the right MS patient makes a huge difference. I've seen parkinson's tremors disappear, vertigo cured, the source of dizziness/fainting revealed, and at the extreme, I saw a patient with Stiff Man Syndrome unable to move a joint in his body without tremendous pain/difficulty, able to walk after treatment.
I just talked about this with a family practice doctor today - he said "Neurology of my generation isn't the same as Neurology today" (of course he said this after asking me "Why would you want to go into Neurology?", which everyone will say about any profession that isn't their own...). I'm honored to be a part of this field, it's the next frontier in medicine and we get to be a part of it!
 
9

95439

In regards to your 2nd question - I was debating between ER, IM, and Neurology. I didn't get a chance to do an ER rotation before applying for residency so that was out (and when I did do an ER rotation, I enjoyed it but there's no continuity, and SUCH a big part of it is getting rid of druggies and dealing with psychos, although the hours are great). I was going back and forth about whether to do IM or Neuro, and it came down to a couple of things: 1) IM is just too general, and to get into a subspecialty you have to do a fellowship (and I don't like the cardiology 'lifestyle', and GI kind of disgusts me lol). Neurology is (in a way) already it's own subspecialty. At least I know that if I want to specialize in a certain area, I could hopefully, possibly, have a chance at becoming an 'expert' in that area. I think that's hard in Internal Medicine, where the scope of pathology is just way too broad. 2) General IM docs work very hard to make an 'average' living. Neurologists don't make a ton of money, but the return seemed better - better salary on average, better lifestyle, etc. Also, as stated above, I think Neurology is the wave of the future in medicine. It's an exciting time to be a part of it.
Honestly, don't not go into Neurology just because you think it's 'hard', go into it if you think it's challenging but worth it. I definitely didn't breeze thru my undergraduate Brain and Behavior course, or even Neuroscience in medschool, but I loved it and was passionate about learning the material. And once you get past the basic anatomy of the CNS/PNS, it does get alot more managable, IMHO. Hope that helps!
 

typhoonegator

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Just as an FYI, IVIg is not an established treatment for multiple sclerosis flares. While well-tolerated, it does not seem to have any efficacy. It could be used as a tertiary agent for those with contraindications to both steroids and immunomodulatory therapy. While there was some preliminary evidence that it might help, this most recent paper rigorously examined this treatment and found no efficacy.

Fazekas F, Lublin FD, Li D, Freedman MS et al. Intravenous Immunoglobulin in Relapsing-Remitting Multiple Sclerosis: A Dose-finding Trial. Neurology. 2008;71(4):265-271.

Plasma exchange may be helpful, but given the fluid shifts and large indwelling catheter, has significant risk associated with it. It should likely only be used if steroids have failed and/or the disease is causing massive inflammation, midline shift, or major life-altering symptoms. They have a more prominent role in Marburg disease and ADEM.

Llufriu S, Castillo J, Blanco Y, Ranio-Torrentia L, et al. Plasma Exchange for Acute Attacks of CNS Demyelination: Predictors of Improvement at 6 Months. Neurology. 2009;73(12):949-953.

Intravenous steroids are the mainstay of treatment for acute symptomatic exacerbations. They do seem to help. The use of PO steroids is more controversial. Here is a recent paper comparing the treatments.

Martinelli V, Rocca MA, Annovazzi P, Pulizzi A, et al. A Short-Term Randomized MRI Study of High-dose Oral vs Intravenous Methylprednisolone in MS. Neurology. 2009;73(22):1842-1848.

Sorry to hijack the thread with this little public service announcement.
 
Last edited:
9

95439

Just as an FYI, IVIg is not an established treatment for multiple sclerosis flares. While well-tolerated, it does not seem to have any efficacy. It could be used as a tertiary agent for those with contraindications to both steroids and immunomodulatory therapy. While there was some preliminary evidence that it might help, this most recent paper rigorously examined this treatment and found no efficacy.

Fazekas F, Lublin FD, Li D, Freedman MS et al. Intravenous Immunoglobulin in Relapsing-Remitting Multiple Sclerosis: A Dose-finding Trial. Neurology. 2008;71(4):265-271.

Plasma exchange may be helpful, but given the fluid shifts and large indwelling catheter, has significant risk associated with it. It should likely only be used if steroids have failed and/or the disease is causing massive inflammation, midline shift, or major life-altering symptoms. They have a more prominent role in Marburg disease and ADEM.

Llufriu S, Castillo J, Blanco Y, Ranio-Torrentia L, et al. Plasma Exchange for Acute Attacks of CNS Demyelination: Predictors of Improvement at 6 Months. Neurology. 2009;73(12):949-953.

Intravenous steroids are the mainstay of treatment for acute symptomatic exacerbations. They do seem to help. The use of PO steroids is more controversial. Here is a recent paper comparing the treatments.

Martinelli V, Rocca MA, Annovazzi P, Pulizzi A, et al. A Short-Term Randomized MRI Study of High-dose Oral vs Intravenous Methylprednisolone in MS. Neurology. 2009;73(22):1842-1848.

Sorry to hijack the thread with this little public service announcement.

Ok, well obviously that's off topic. Thanks TN! I've personally witnessed massive improvement in a patient by using IVIG after steroids failed. But I'm just a medstudent, what do I know...
 

Packamylase

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That was very, very helpful! Thank you very much.

I'll tell you some success stories I've seen since that seems to be the biggest knock on Neuro (that there's little or no cure for the diseases). Headaches are tricky, usually
success is a reduction in frequency and severity of symptoms. But I've seen numerous patients with something like 5 migraines per week, go down to 1 per month with treatment. I saw a patient 10 minutes
after a stroke in her hospital room, unable to speak or move the right side of her body, given tPA and was almost 100% by the next day. I've seen a TON of epilepsy patients have no seizures after being put on the right medication. Seen alot of Multiple Sclerosis patients in an exacerbation given IVIG or Plasmapheresis with very significant improvement. Even steroids given to the right MS patient makes a huge difference. I've seen parkinson's tremors disappear, vertigo cured, the source of dizziness/fainting revealed, and at the extreme, I saw a patient with Stiff Man Syndrome unable to move a joint in his body without tremendous pain/difficulty, able to walk after treatment.
I just talked about this with a family practice doctor today - he said "Neurology of my generation isn't the same as Neurology today" (of course he said this after asking me "Why would you want to go into Neurology?", which everyone will say about any profession that isn't their own...). I'm honored to be a part of this field, it's the next frontier in medicine and we get to be a part of it!
 

Packamylase

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I can totally relate to your selection process. I am doing my first neurology rotation this August. Do you think I'll have any problems getting LORs for ERAS, getting and scheduling interviews, etc? I'm about to finish up 3rd year and interviews and appplications are coming up fast!



In regards to your 2nd question - I was debating between ER, IM, and Neurology. I didn't get a chance to do an ER
rotation before applying for residency so that was out (and when I did do an ER rotation, I enjoyed it but there's no continuity, and SUCH a big part of it is getting rid of druggies and dealing with psychos, although the hours are great). I was going back and forth about whether to do IM or Neuro, and it came down to a couple of things: 1) IM is just too general, and to get into a subspecialty you have to do a fellowship (and I don't like the cardiology 'lifestyle', and GI kind of disgusts me lol). Neurology is (in a way) already it's own subspecialty. At least I know that if I want to specialize in a certain area, I could hopefully, possibly, have a chance at becoming an 'expert' in that area. I think that's hard in Internal Medicine, where the scope of pathology is just way too broad. 2) General IM docs work very hard to make an 'average' living. Neurologists don't make a ton of money, but the return seemed better - better salary on average, better lifestyle, etc. Also, as stated above, I think Neurology is the wave of the future in medicine. It's an exciting time to be a part of it.
Honestly, don't not go into Neurology just because you think it's 'hard', go into it if you think it's challenging but worth it. I definitely didn't breeze thru my undergraduate Brain and Behavior course, or even Neuroscience in medschool, but I loved it and was passionate about learning the material. And once you get past the basic anatomy of the CNS/PNS, it does get alot more managable, IMHO. Hope that helps!
 

typhoonegator

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Ok, well obviously that's off topic. Thanks TN! I've personally witnessed massive improvement in a patient by using IVIG after steroids failed. But I'm just a medstudent, what do I know...
That's why they do the studies. Glad your patient got better, but the plural of anecdote is not data.

To the OP, there are plenty of success stories in neurology, you just sometimes have to be realistic about your expectations. I've seen people get half their brain blown out, and walk into clinic 6 months later. They don't walk fast, and they sound "funny" when they talk, but I would call that an incredible success.

Some people will always roll their eyes when you characterize the ability to identify basic shapes as a "great outcome", but you have to consider the alternative. One's neurologic status is a huge part of quality of life, and your entire life experience passes through our organ of interest, so you sometimes have to be a little existential about how you view progress and outcomes.

In terms of unqualified successes, I've seen literally dozens of people come in with horrible stroke syndromes, or even locked in, who after treatment were 100% normal by the next morning. Maybe that would have happened regardless of our treatment, but still a great outcome. I've seen GBMs melt away for months or even years, giving back QALYs to people with an otherwise poor prognosis. On the office practice side, treating headache and seizure can be very rewarding (but sometimes frustrating), and while we can't "cure" neurodegenerative disease, mitigating symptoms and maximizing QOL can be very rewarding to both patient and practitioner.

I chose between neurology and neurosurgery. Loved them both. I enjoyed the ICU more than the OR, so I went with neurology. I never considered any other field.
 
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"Glad your patient got better, but the plural of anecdote is not data."

I'm splitting hairs, but the OP requested 'success stories you've personally witnessed'.
 

typhoonegator

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Relax. I just cringed when I read "Seen alot of Multiple Sclerosis patients in an exacerbation given IVIG or Plasmapheresis with very significant improvement. Even steroids given to the right MS patient makes a huge difference".

Steroids are the standard therapy, IVIG is unproven in MS. Just trying to provide a teaching point to counter your observation.
 
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Honestly I figured someone would mention that after I re-read it. Steroids are the definitive treatment for MS exacerbations, it was just in this one instance I saw a DRAMATIC improvement with IVIG, so it stuck with me...
 

typhoonegator

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Totally fine. I meant in no way to invalidate your experience. We've all seen amazing things that fly in the face of convention. I only wanted to call attention to the available evidence, to help avoid any cognitive anchoring (to which we are all susceptible).
 

Packamylase

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That's why they do the studies. Glad your patient got better, but the plural of anecdote is not data.

To the OP, there are plenty of success stories in neurology, you just sometimes have to be realistic about your expectations. I've seen people get half their brain blown out, and walk into clinic 6 months later. They don't walk fast, and they sound "funny" when they talk, but I would call that an incredible success.

Some people will always roll their eyes when you characterize the ability to identify basic shapes as a "great outcome", but you have to consider the alternative. One's neurologic status is a huge part of quality of life, and your entire life experience passes through our organ of interest, so you sometimes have to be a little existential about how you view progress and outcomes.

In terms of unqualified successes, I've seen literally dozens of people come in with horrible stroke syndromes, or even locked in, who after treatment were 100% normal by the next morning. Maybe that would have happened regardless of our treatment, but still a great outcome. I've seen GBMs melt away for months or even years, giving back QALYs to people with an otherwise poor prognosis. On the office practice side, treating headache and seizure can be very rewarding (but sometimes frustrating), and while we can't "cure" neurodegenerative disease, mitigating symptoms and maximizing QOL can be very rewarding to both patient and practitioner.

I chose between neurology and neurosurgery. Loved them both. I enjoyed the ICU more than the OR, so I went with neurology. I never considered any other field.
Thank you. Much appreciated! I am strongly considering neurology at this point.
 
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A while ago there was this patient that arrived at the ER, mutistic with fever and cold shivers. According to his wife he suffered from severe headaches that day before she found him on bed, not replying. We performed a lumbar punction that showed turbid CSF after which we immediately started with dexamethason and antibiotics. The CSF showed a pleocytosis of >5000. Patient was brought to the ICU for close monitoring.

Next day I visited him: sitting up in bed, smiling and listening to the radio :D

I've also seen a lot of tPA's having excellent results.
 

buckley

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Something simpler...How about LP in an NPH patient? :) made me want to be an LPologist...lol...In his words, "I don't know what you did to me Doc, but I have never felt this good in ages. Stick me again, anytime!"