Neuromuscular Medicine Questions

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JBM16BYU

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As background, I'm a current preliminary medicine intern who has already matched into PM&R and will be matriculating July 2020. I've posted this on the PM&R thread, but I'd like feedback from the Neurology thread. I'm curious about the world of neuromuscular medicine in regards to PM&R:
(1) Would a neurology-trained neuromuscular specialist vs. PM&R-trained neuromuscular specialist practice in pretty similar ways?
(2) What kind of procedures do neuromuscular specialists perform?
(3) What kind of practice setting would you be in if a neuromuscular specialist?
(4) Some neuromuscular fellowships specifically mention that they accept PM&R residents, while others do not specify. Is it safe to assume that only ones that specifically mention PM&R are the ones who do, or do you stand a chance at one that doesn't specifically say it?
(5) How sought after are neuromuscular fellowships right now?
(6) Neuromuscular ultrasound vs. MSK ultrasound. Obviously one has the word "neuro" in it, but are there benefits in being certified in both?

Thanks in advance!

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1) If you went to a neuromuscle fellowship that is taught by neurologists but takes PM&R, probably. You'd have a lot of neurology knowledge to catch up on.
2) EMG/NCS is the main one. Some do muscle biopsy. Others do autonomic testing, muscle ultrasound, other e-phys.
3) Outpatient predominantly, some scheduled admissions for certain infusions most likely. Can be either academic or a private group.
4) Can always ask, but neuromuscle is a core neurology subspecialty, not one that is generally considered to be split between 2 specialties (like sleep between neuro and pulm).
5) Most neurology fellowships aren't super competitive, and I've never heard of NM being an exception.
6) dunno
 
As far as I understand, neuromuscular medicine fellowships do not participate in a match, correct? Do you happen to know which programs are considered the "top" programs in NM? What type of things would you look for a NM fellowship to have to be considered a "top" program?

Thanks!
 
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Wash U is probably the best known. Mayo and Hopkins are also top level from what I've heard. I'm sure there are other great places too.

What you look for depends on what you want to do. If you want to be a researcher, a large population in particular diseases of interest, strong neuropathology training and plenty of mentored research time with faculty that have similar areas of research interest would be important. If you want to be a pure clinician, adequate training in a variety of procedures including things like ultrasound and biopsy (plus EMG which everywhere will have) would be things to look for.
 
As background, I'm a current preliminary medicine intern who has already matched into PM&R and will be matriculating July 2020. I've posted this on the PM&R thread, but I'd like feedback from the Neurology thread. I'm curious about the world of neuromuscular medicine in regards to PM&R:
(1) Would a neurology-trained neuromuscular specialist vs. PM&R-trained neuromuscular specialist practice in pretty similar ways?
(2) What kind of procedures do neuromuscular specialists perform?
(3) What kind of practice setting would you be in if a neuromuscular specialist?
(4) Some neuromuscular fellowships specifically mention that they accept PM&R residents, while others do not specify. Is it safe to assume that only ones that specifically mention PM&R are the ones who do, or do you stand a chance at one that doesn't specifically say it?
(5) How sought after are neuromuscular fellowships right now?
(6) Neuromuscular ultrasound vs. MSK ultrasound. Obviously one has the word "neuro" in it, but are there benefits in being certified in both?

Thanks in advance!

1. Yes. But I've always been struck by the limits of PMR with NCV. I'm sure this is person dependent, but I was told explicitly by the hospital's PMR groups that "I'm not comfortable with ALS or myopathy" so she would DO THE EMG, then send them for a second opinion. I didn't point out that to do a test when the results are futile is not only wasteful but harmful. Very bad taste in my mouth. But also consistent with PMR as a whole: not a diagnostic specialty.
2. Something to do with electricity and nerves. But from my viewpoint, a neuromuscular specialist also must diagnose and manage the weird myopathies, neuromusc jxn disease, odd-ball causes of neuropathy.
3. Outpatient, but rarely you'd do NCV for GBS, critical care illness neuropathy/myopathy.
4. The reason for this is that you'll see plenty of cases referred to you for numbness who have central causes. When I was a resident we bascially diagnosed MS in a patient coming in for CTS eval. Although neuromuscular refers to tissue distal to spine, from roots on out, it actually includes the entire neuroaxis.
5. IDK.
6. IDK.
 
1. Yes. But I've always been struck by the limits of PMR with NCV. I'm sure this is person dependent, but I was told explicitly by the hospital's PMR groups that "I'm not comfortable with ALS or myopathy" so she would DO THE EMG, then send them for a second opinion. I didn't point out that to do a test when the results are futile is not only wasteful but harmful. Very bad taste in my mouth. But also consistent with PMR as a whole: not a diagnostic specialty.
2. Something to do with electricity and nerves. But from my viewpoint, a neuromuscular specialist also must diagnose and manage the weird myopathies, neuromusc jxn disease, odd-ball causes of neuropathy.
3. Outpatient, but rarely you'd do NCV for GBS, critical care illness neuropathy/myopathy.
4. The reason for this is that you'll see plenty of cases referred to you for numbness who have central causes. When I was a resident we bascially diagnosed MS in a patient coming in for CTS eval. Although neuromuscular refers to tissue distal to spine, from roots on out, it actually includes the entire neuroaxis.
5. IDK.
6. IDK.

On "1." you mentioned limits of PMR with NCV. Were these PMR folks you dealt with fellowship-trained in neuromuscular medicine or were they general PMR physicians? I'm more curious about PMR who have gone through NM fellowship.
 
On "1." you mentioned limits of PMR with NCV. Were these PMR folks you dealt with fellowship-trained in neuromuscular medicine or were they general PMR physicians? I'm more curious about PMR who have gone through NM fellowship.

Sorry, PMR folks who have gone through a neuromuscular fellowship are rare enough such that I don't believe I've ever seen a case - like Fabry's.
 
Personally answering these questions now as a neuromuscular fellow, 3 years later, in case any PM&R residents are considering neuromuscular medicine fellowships.
1) They can practice identically. All but one neuromuscular fellowships are currently under a neurology department. My current fellowship would not differ if I was PM&R vs. Neurology. There are PM&R neuromuscular physicians who practice identically to neurology-trained ones. There is a small number of us throughout the US, and we are definitely the minority in the field of Neuromuscular Medicine. The vast majority are Neuromuscular Neurologists. Some differences may be comfort level in treating non-neurological disorders (MSK issues in neuromuscular patients) and not being able to take neurology call. Like neurology, PM&R can be board certified in Neuromuscular Medicine through ABPMR. The board examination is administered with ABPN.
(2) Primarily EMG/NCS, but can also incorporate neuromuscular ultrasound, Botox injections, skin/nerve/muscle biopsies, etc.
(3) Academic or private. Whatever you are interested in. Inpatient consults may present, usually in the form of inpatient EMG for GBS, new-onset myasthenic crises, or critical illness neuropathy / myopathy.
(4) There is 1 PM&R run neuromuscular fellowship at UC Davis. Every other fellowship is run under neurology. That being said, many neuromuscular fellowships are equipped to, comfortable with, and have trained PM&R fellows previously. Ones that do not specifically list on website that they train PM&R may still do so. You can always ask.
(5) Great programs are competitively sought after, like in any specialty. There is now a match through AANEM. Applications typically start in January, I believe interviews start in March or April, and the match is beginning of June. Neurology and PM&R residents interested should apply during their PGY-3 year.
(6) Neuromuscular and musculoskeletal ultrasound are similar but different entities. I learned interventional and diagnostic musculoskeletal ultrasound during my PM&R residency, focusing on joints, ligaments, tendons and bursa. Neuromuscular ultrasound is more solely diagnostic and focuses on nerve and muscle. It is used WITH EMG/NCS, seldom without. It can be used for a variety of things, including (A) evaluating the cross-sectional area of nerve to look for focal enlargement, (B) look for reasons for mononeuropathies (ex. Ganglion cysts, AV fistulas, schwannomas, neuromas, foreign bodies, etc.), (C) can evaluate muscle for fasciculations (ex. Genioglossus in ALS), (D) can evaluate muscle for sick, diseased, atrophied, or denervated muscle in patterns (ex. FDP, FPL affected in IBM), (E) evaluate thickness ratio and movement of diaphragm muscle in hemidiaphragm paralysis cases, (F) and can even be used for EMG-needle-guidance to ensure correct testing of hard to find or atrophic muscles (ex. Teres minor). The MSK ultrasound skills I acquired in a PM&R residency complement the NMUS skills acquired in a neuromuscular fellowship.

I hope this is helpful!
 
Thank you @JBM16BYU for the follow up! There are not a ton of resources out there for PM&R residents when it comes to pursuing a neuromuscular fellowship.
Not sure if you will see this post, but some other questions I had as a PM&R resident considering neuromuscular fellowship are...
Do you feel that the neuromuscular fellowship will greatly change your practice setting compared to not doing the fellowship?
Are you able to do a mix of neuromuscular and general PM&R clinic after fellowship? Or do most people after fellowship just focus on neuromuscular conditions afterwards
How did you prepare for neuromuscular fellowship?
Is there bias in hiring of Neuromuscular neurologists vs Neuromuscular physiatrists given PM&R cannot take neuro call?
 
Thank you @JBM16BYU for the follow up! There are not a ton of resources out there for PM&R residents when it comes to pursuing a neuromuscular fellowship.
Not sure if you will see this post, but some other questions I had as a PM&R resident considering neuromuscular fellowship are...
Do you feel that the neuromuscular fellowship will greatly change your practice setting compared to not doing the fellowship?
Are you able to do a mix of neuromuscular and general PM&R clinic after fellowship? Or do most people after fellowship just focus on neuromuscular conditions afterwards
How did you prepare for neuromuscular fellowship?
Is there bias in hiring of Neuromuscular neurologists vs Neuromuscular physiatrists given PM&R cannot take neuro call?

I do feel that a neuromuscular fellowship will change my practice. I am much more comfortable with neuromuscular conditions in practice now than previously. As PM&R, we get pretty comfortable with prescribing therapies, DME, orthotics, prosthetics, pain, etc. What we aren't as good at, typically, is a wide neurologic differential and diagnostic work-up. What labs to order to evaluate neuropathies? When to order biopsies? When to order SFEMG? etc. Also, my neurologic physical exam has improved x1000 as a work with neurologists. You kind of have a foot in both worlds.

Things I definitely didn't know much about coming from PM&R: immunosuppressant medications, IVIG/PLEX, genetics, muscle/nerve/skin biopsy pathology and interpretation, wide WIDE neuromuscular differential

In addition, in a typical PM&R residency, your EMG experience will likely be focused on more carpal tunnel syndrome, radiculopathies, ulnar neuropathies, and maybe identifying polyneuropathies. However, one of my goals in a neuromuscular fellowship was to be able to critically think through whatever EDX test can come through the door. Things like facial neuropathies, NMJ disorders, demyelinating neuropathies, motor neuron diseases, complex plexopathies, parsonage-turner syndrome, traumatic nerve/plexus injuries, myopathies, myositis, inpatient/ICU EMGs for myasthenic crisis or GBS, and even pediatric EMGs are things you become much more familiar with during fellowship. Single-fiber EMG is also something that you won't typically learn in residency and is usually acquired during a fellowship. Also, knowing when you can alter the tests when you need to and how to interpret an altered test is important (for example, it's kind of hard to do a median antidromic sensory NCS to digit 2 if digit 2 has been amputated. What will you do then? How will you evaluate the median sensory then?) If I didn't do a Neuromuscular fellowship, I would not feel as comfortable evaluating and working up these things.

Even having fantastic MSK ultrasound experience during residency, my neuromuscular ultrasound (NMUS) skills have just amplified my prior ultrasound skills even more!

After fellowship, the type of job you practice is completely up to you. You can practice as a neuromuscular medicine physician (just like our neurology colleagues); you can practice as an electrodiagnostic physician; you could practice in a mix of 1/2 general PM&R 1/2 neuromuscular. Really, whatever you would like to do and however you will in that niche. I know of PM&R neuromuscular docs who practice primarily research, ones who do research with heavy ALS clinic, ones who do pure neuromuscular, ones who do ALS clinic with musculoskeletal clinic, those who do EMG with peripheral nerve injury clinics, etc.

You prepare for fellowship by paying attention and performing well in residency. Every rotation in residency has something you can use in fellowship. Just some examples:
-Pain Medicine- some neuromuscular conditions are inherently painful and so it's important to be able to evaluate pain, learn your neuropathic pain medications and be comfortable prescribing them, be able to talk about the different types of spine injections, read spine MRIs, and be able to talk about chronic pain
-Sports Medicine- ultrasound is widely used in both fields. Learn how to use an ultrasound machine, the knobology. Learn a good MSK exam because there are lot's of neuromuscular patients who have joint contractures, painful joints, and mimickers of neurologic conditions.
-Pediatric rehab- at least at my fellowship we do see children at the pediatric MDA clinic, including children with CMT, Duchenne's, Congenital myopathies, SMA, Myotonic dystrophies, etc. Learn a good child exam, learn the appropriate milestones (especially gross and fine motor). Learn appropriate orthotic prescription management.
-Neuro rehab- Learn spasticity management for your ALS/PLS/HSP patients. Learn a neurologic exam (and then get taught even more of a neurologic exam during fellowship). Feel comfortable with ordering therapies, DME, orthotics, wheelchairs, etc. Learn botox injections, both EMG-guided and ultrasound-guided (If available). Be able to assess gait and fall prevention.
-Amputee- amputations are a very real risk for patients with neuropathies, especially inherited neuropathies. Evaluate for wounds. Be able to counsel on proper footwear, wound prevention, fall assessments. I have had several patients with neuropathies who have undergone amputations at one point in their life and it's important to try and prevent more.
-Inpatient PM&R- many NMD patients show up on rehabilitation units, particularly those with Guillain-Barre Syndrome, ALS, critical illness myopathies, critical illness neuropathies, etc. Learn as much as you can about their presentations, their work-up, and then their rehab course when you get them.
-SCI- get really comfortable with wheelchair assessment and management. It'll be incredibly helpful for your ALS, PLS, SMA, Duchennes, myopathies, IBM, etc. (you get the picture) patients.
-EMG- obviously this is a big one. Just do as much as you can. See as much variety as you can. Be able to do the NCS and EMG. I personally really like the Preston & Shapiro textbook and am reading that cover-to-cover during fellowship.

Your last question about bias in hiring. Perhaps? Like I said earlier, PM&R neuromuscular physicians are a rare breed. There are not many of us. In fact, out of all of the fellows this year in neuromuscular fellowships, there are currently 5 PM&R fellows. During the job hunt I found that every place wanted a PM&R neuromuscular physician that I asked, both in academia or in private practice (more as THE EMG guy), but many do not understand exactly what it is that we do. It takes a lot of education, both to the neurologists about your PM&R training and how your unique skills can be valuable to their fellowship and also to the PM&R physicians that you are more than the carpal tunnel/radiculopathy EMG guy. It is a niche, and in my personal bias, a hidden gem. In this world of neuromuscular medicine, you are truly helping people to maximize their function despite their acquired or inherited neuromuscular conditions. It is very satisfying.
 
@JBM16BYU thank you for all the replies and information!

I am a current M4 interested in PM&R, but on my last rotation of M3 year I was introduced to Neuromuscular medicine from the Neurology perspective and really enjoyed the diagnostics involved. I'm interested in working in Performing Arts Medicine but also potentially in Neuromuscular Medicine in the future, and I'm encouraged to hear your response about the flexibility in structuring your practice.

I do have a few questions. First, is there geographic restriction in terms of practicing Neuromuscular Medicine after fellowship, or areas of higher demand in general in the US? Second, I realize you already shared how many rotations in PM&R residency can help prepare one for Neuromuscular Medicine, but I wanted to know if you could have gone back in time to residency, what would be the biggest changes you'd make to best prepare? Third, do you find that neurologists "look down" on Neuromuscular-fellowship trained PM&R physicians? Through my interactions with my medical school's neurologists, anytime I've mentioned my interest in PM&R they've tried to talk me out of it through painting PM&R in a negative light, whereas my school's physiatrists have mainly encouraged my PM&R interest without painting Neurology in a negative light. Just wondering if this is just a regional issue at my program or if it is more widely spread in the fields.

Thank you so much in advance!
 
We (neurology) look at PMR with envy. I have nothing but good things to say about PMR docs and the field in general. Super exciting especially research. The one thing I’ll say about PMR is it’s not certainly a fast adrenaline rush field in the way stroke and neurocritical care are. A lot of neurology is headed in this direction especially recently, so I can see if you’ve met a few of these types of physicians they might not be able to say very good things about PMR lol.
 
I agree that PM&R is not a fast adrenaline rush field. You get the opportunity to sit down, think about an issue, and then choose a path forward. Unlike Neurology, there are not as many life or death choices you need to make on the spot.

I don’t believe there is a regional bias. Neuromuscular, in general, is sought after everywhere and is vastly underserved in the US. Many of our patients are waiting 3-4 months to get in to see us for new consults (although things like expected ALS we usually fit in pretty quickly). Neuromuscular PM&R is no different.

I would not change anything about my residency, I was trained at a fantastic place that prepared me for whatever I wanted to do. From a studying standpoint, maybe I would have taken things “one step further.” For example: diagnosed someone with a sensorimotor axonal peripheral neuropathy. In residency, that was that but I didn’t question the “why” they had this. Fellowship has helped me form that question and evaluate further. In addition, another example would be when you perform an ultrasound guided injection. In that state of mind, typically you are looking at the target and avoiding things you don’t want to hit. One step further would be knowing what each structure on the ultrasound screen is if someone were to press freeze on the machine.

Generally I don’t think neurologists look down on PM&R and vice versa. If you look at AANEM, the this organization shows neurology and physiatry working cohesively for the betterment of the field. These two specialties work hand in hand for so many different patients and pathologies. But, like you mentioned, there may be some in any field of medicine who talk down about another field, but in Neuromuscular I’d say that’s more rare.
 
Despite some commonalities in fields such as neuromuscular medicine, day-to-day practice of a neurologist versus a physiatrist is vastly different, and each field offers much more than neuromuscular medicine in terms of potential subspecialty choices. I would not pick a residency based on how well it prepares you for a fellowship as you very well may change your mind as you go through residency and gain exposure to other subspecialties. Through residency interviews, I'm always amazed by the number of students who are interested in stroke, NCC, or NIR, and I wonder if it relates to how student exposure to neurology is primarily inpatient and most do not realize the potential call burden and job limitation (NCC and NIR).
 
Despite some commonalities in fields such as neuromuscular medicine, day-to-day practice of a neurologist versus a physiatrist is vastly different, and each field offers much more than neuromuscular medicine in terms of potential subspecialty choices. I would not pick a residency based on how well it prepares you for a fellowship as you very well may change your mind as you go through residency and gain exposure to other subspecialties. Through residency interviews, I'm always amazed by the number of students who are interested in stroke, NCC, or NIR, and I wonder if it relates to how student exposure to neurology is primarily inpatient and most do not realize the potential call burden and job limitation (NCC and NIR).
I think with super extended window with thrombectomies with last known well>24 hours, and lack of need for CT perfusion with standard extended window strokes (all the large core trials), stroke and NIR jobs are primed to explode (stroke already is). I look at job opportunities based on how many J1 waiver jobs exist for any subspecialty (as these are tougher to get than normal jobs), and the number of stroke and endovascular jobs have never been greater. Call will be even more terrible but now that most institutions are hiring a 4th, or even 5th endovascular person, the call is paradoxically decreasing (but more busy during call).
 
I agree that PM&R is not a fast adrenaline rush field. You get the opportunity to sit down, think about an issue, and then choose a path forward. Unlike Neurology, there are not as many life or death choices you need to make on the spot.

I don’t believe there is a regional bias. Neuromuscular, in general, is sought after everywhere and is vastly underserved in the US. Many of our patients are waiting 3-4 months to get in to see us for new consults (although things like expected ALS we usually fit in pretty quickly). Neuromuscular PM&R is no different.

I would not change anything about my residency, I was trained at a fantastic place that prepared me for whatever I wanted to do. From a studying standpoint, maybe I would have taken things “one step further.” For example: diagnosed someone with a sensorimotor axonal peripheral neuropathy. In residency, that was that but I didn’t question the “why” they had this. Fellowship has helped me form that question and evaluate further. In addition, another example would be when you perform an ultrasound guided injection. In that state of mind, typically you are looking at the target and avoiding things you don’t want to hit. One step further would be knowing what each structure on the ultrasound screen is if someone were to press freeze on the machine.

Generally I don’t think neurologists look down on PM&R and vice versa. If you look at AANEM, the this organization shows neurology and physiatry working cohesively for the betterment of the field. These two specialties work hand in hand for so many different patients and pathologies. But, like you mentioned, there may be some in any field of medicine who talk down about another field, but in Neuromuscular I’d say that’s more rare.

Thank you for your answers! I appreciate your detailed viewpoint.
 
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