Please help - can't decide between path and neuro.

[PathNeuroIMorFM]

Please don't say neuropath haha.

Just finished my neuro block and I was really hoping I would walk out of it with a strong enough opinion to make a decision, but I'm still confused as ever. I took a research year after M2 with a primary focus on path, but also with some neuro shaken in there and believe I have a strong application in both (Good LOR writers, research, and ECs already secured for both). I need to make a decision by January when we start applying for our 4th year rotation schedule/Sub-Is.

Neurology Pros
Definitely most interesting patient-facing specialty for me, by a mile.
Chance to work with people with physical/developmental disabilities (always an interest of mine).
Diverse array of fellowships, I think I could find something I tolerate if I didn't enjoy general neuro.
I am very, very good with patients. Bragging, I know.
Extremely employable in all settings/locations.

Neurology Cons
Kind of hate rounding. It's tolerable, but I really don't enjoy it.
Social work responsibilities are awful.
I have limited outpatient exposure.
Fewer leadership positions outside of academia.
Intern/prelim year required. More difficult residency overall.

Pathology Pros
More interesting bread-and-butter than neuro.
I think diagnostics is way cooler than therapeutics. I always struggled with learning therapeutic algorithms.
Strong leadership/admin employment opportunities. I love leadership positions and lab management is an interesting role to me.
No intern/prelim year. Better residency work-life balance.
More interesting array of fellowships. Surgical path, cytopath, molecular path are all cool as hell.
I definitely "vibe" more with pathologists. They just seem like my kind of people. Lower stress, love to teach, passionate, quirky.

Pathology Cons
Lower earning ceiling (?)
Limited geographic employment opportunities (seems primarily urban. I would like to live suburban/small city.)
No volunteer/global health/community service I could do with pathology.

Other:
I think on the whole, I really enjoy the security offered by neurology in terms of compensation and employment (the content is also neat), but I enjoy the content and workflow of path more.

I feel strongly that I do not *need* to see patients to have a fulfilling career in medicine. Patients are nice. I think I am very good with them, but I don't think I get the same instrinsic satisfaction of working with them that others do.

I will do research in residency and absolutely love to teach, but don't want to stay in academics forever.

I am debating how much I like inpatient versus outpatient. Inpatient can be very anxiety inducing and rounding sucks, but my outpatient experience in peds/OB/surgery were chill/good hours but very dull. I would get bored of it very quickly.

Despite not liking most rotations, I definitely like clinical more than preclinical. Actually doing stuff is more stimulating than watching lectures. Aside from that, I definitely did not see myself doing any of my previous rotations. Surgery was brutal for its personalities and hours, EM was way too fast paced with a frustrating patient population, peds had zero interesting pathologies/cases, FM was meh, OB kind of got boring, but GYN was okay. Still waiting on IM and psych, but I don't think I will be swayed by them.

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[Sidus1011]

It seems like you'd enjoy Pathology more just reading through, it seems like most of your hang ups are primarily in the realm of job security (which is perfectly understandable). I'm not sure if you have a pathology mentor, but I would discuss with them about their views on compensation in the field and if there is any way you can boost your pay (via fellowship or other work). I love neurology, and your pros match a lot of my own as well - but the majority of the field is working outpatient and much of the pay is geared towards how much general neuro you want to do. I'd try and get some exposure to outpatient neuro and see how much you can tolerate it - if you don't like headaches, seizure management, movement disorders, or radiculopathy - I don't think it'd be a good choice for you

*This comes with the disclaimer that I am not in clinicals yet - hopefully someone who has done a rotation in both or are in residency for either can chime in.

 

[LunaOri]

Path most certainly has employment possibilities outside of big cities—anywhere there is a hospital, there is pathology. Compensation is higher outside the big cities too. Having a fellowship won’t affect your salary, but may help in finding a job. If you want to work in a rural/small city practice, do a fellowship that is broadly applicable, like surgical pathology, hematopathology, or cytopathology (rather than something more academic like peds or neuropath). Starting salaries range from mid-200’s to mid 300’s. Probably top out around mid 400’s unless you are in a busy private practice situation. Extra pay for being a lab director/department head.

 

[babybrains]

Sounds to me like your pros/cons list is heavily weighted toward preferring path. For what it's worth, neuro isn't exactly one of the high-earning specialties, so I doubt there's going to be a huge differential in terms of ceiling (though I know nothing about the path market).

As someone in peds neuro, I'll let you know that we do a lot of rounding on the inpatient side - both morning and afternoon rounds. The same is true for our affiliated adult neurology program. I'm an outpatient person myself and will be going into an outpatient-heavy fellowship, but if you don't have much exposure to outpatient neurology (where all the interesting neurology happens imo), you're missing a huge chunk of what neurology is/could be.

If you're really undecided, I'd recommend scheduling sub-Is in both, or at least seeing if you can do a chill outpatient neurology rotation to see if you'd like bread and butter neurology (outpatient seizures, headaches, strokes) before you put any eggs in that basket.

 

[mrbreakfast]

Kind of hate rounding. It's tolerable, but I really don't enjoy it.
Social work responsibilities are awful.

Before you make a major life decision based on this, keep in mind this is essentially a thing only in academics - you won't be a primary service in the community, even as a neurohospitalist. And while you still would round on patients, doing it solo goes much more quickly. Certain places will expect you to cover inpatient for a weekend or so every few months, but even in academics the majority of people do zero inpatient. At most academic centers, inpatient services are handled by neurohospitalists or outpatient people who sign up to do it a few weeks/year - they won't make you do it, especially if it's not your forte.

I have limited outpatient exposure.

~85-90% of neurology is outpatient. Why don't you try an outpatient elective?


I'll just note that compensation for path and peds neuro might be similar, but while I also don't know what the path compensation is like, starting salaries for adult private practice neurology are mid 300s-low 400s. I wouldn't let that define your choice, though. You should do what you enjoy.

 

[deleted1168269]

Sounds to me like your pros/cons list is heavily weighted toward preferring path. For what it's worth, neuro isn't exactly one of the high-earning specialties, so I doubt there's going to be a huge differential in terms of ceiling (though I know nothing about the path market).

As someone in peds neuro, I'll let you know that we do a lot of rounding on the inpatient side - both morning and afternoon rounds. The same is true for our affiliated adult neurology program. I'm an outpatient person myself and will be going into an outpatient-heavy fellowship, but if you don't have much exposure to outpatient neurology (where all the interesting neurology happens imo), you're missing a huge chunk of what neurology is/could be.

If you're really undecided, I'd recommend scheduling sub-Is in both, or at least seeing if you can do a chill outpatient neurology rotation to see if you'd like bread and butter neurology (outpatient seizures, headaches, strokes) before you put any eggs in that basket.

90% of practicing neurologists are outpatient

 

[Tenk]

Do you like talking to patients?

Yes - neuro.
No - path.

It is actually that simple.

 

[Dantes]

Like others have mentioned, don't have to worry about rounding with outpatient. Not to add to your decision making tree, but if you like diagnostics why not rads?

 

[PathNeuroIMorFM]

if you don't have much exposure to outpatient neurology (where all the interesting neurology happens imo), you're missing a huge chunk of what neurology is/could be.

If you're really undecided, I'd recommend scheduling sub-Is in both, or at least seeing if you can do a chill outpatient neurology rotation to see if you'd like bread and butter neurology (outpatient seizures, headaches, strokes) before you put any eggs in that basket.

Yeah, I'm honestly so disappointed we get zero outpatient exposure. Probably why less than 5% of students at my school don't choose it as a specialty. I did get to spend some time in outpatient physiatry for a separate thing and I wasn't a huge fan. Too much talking, not enough doing. I'm not sure if that is comparable to neuro.

Do you like talking to patients?

Yes - neuro.
No - path.

It is actually that simple.

I'm not sure. I don't actively dislike talking to patients, but it's also rarely the highlight of my day, either.

Do you enjoy doing the neuro physical exam?

Yeah, it's pretty cool. It is part of the reason why I like neuro much more than other patient facing specialties. Really speaks to my interest in diagnostics.

Before you make a major life decision based on this, keep in mind this is essentially a thing only in academics - you won't be a primary service in the community, even as a neurohospitalist. And while you still would round on patients, doing it solo goes much more quickly. Certain places will expect you to cover inpatient for a weekend or so every few months, but even in academics the majority of people do zero inpatient. At most academic centers, inpatient services are handled by neurohospitalists or outpatient people who sign up to do it a few weeks/year - they won't make you do it, especially if it's not your forte.


~85-90% of neurology is outpatient. Why don't you try an outpatient elective?


I'll just note that compensation for path and peds neuro might be similar, but while I also don't know what the path compensation is like, starting salaries for adult private practice neurology are mid 300s-low 400s. I wouldn't let that define your choice, though. You should do what you enjoy.

I think I'll try an outpatient elective if I have time. 4th year scheduling is just such a pain in the butt and we have to decide by January, even though 4th year starts closer to May. It's nuts.

Because I am trying very hard to break back into my home region - which is not my school region - my dean advised me that no matter what I should spend all of June through September doing Sub-Is and aways in my specialty of choice and getting LORs from my top choice programs. I should have mentioned geographic preference is also a major concern for me.

 

[PathNeuroIMorFM]

Like others have mentioned, don't have to worry about rounding with outpatient. Not to add to your decision making tree, but if you like diagnostics why not rads?

This is a very good question and my only answer is simply I do not like medical imaging.

I get excited about different stains, frozens, genetics, biopsies, surgical specimens, the lab environment and lab management/leadership. The diversity in path and neuro definitely speaks to me more.

Rads is really cool, similarly awesome tech as path/neuro, nice work life balance, and a very stable career option, but I just do not get excited about interpreting scans all day.

 

[JBM16BYU]

Not that you necessarily want to choose a primary specialty based on a fellowship option, however, from neurology you could pursue a neuromuscular medicine fellowship. Neuromuscular medicine is very diagnostic heavy, including utilizing physical exam, lab tests, MRI, electrodiagnostics, neuromuscular ultrasound and biopsy results. You do get trained extensively on interpreting muscle and nerve biopsies, which would satisfy the pathology interests. You get trained in interpreting genetic tests and results. It is more outpatient heavy, which you stated you don’t have much experience in, but there is no rounding and you get lots of patient care, one-on-one time. Just something to consider if you end up choosing neurology.

 

[mrbreakfast]

Because I am trying very hard to break back into my home region - which is not my school region - my dean advised me that no matter what I should spend all of June through September doing Sub-Is and aways in my specialty of choice and getting LORs from my top choice programs. I should have mentioned geographic preference is also a major concern for me.

You're deciding between neuro and path, right? I wouldn't necessarily go against your advisor's advice, but not sure you will need to do multiple aways. Unless you want to end up at a prestigious program in a specific big city on either the east coast or California, you probably don't need an away in neuro, and I'm assuming the same is true for path.

Ultimately it's going to be challenging to "logic" your way into choosing a specialty. You need to experience things yourself. Ending up where you want is important, but not as important as choosing a career you'll be happy in for the next 35 years. Just my opinion.

 

[Dral]

A key thing to think about outside of actually just seeing the patients, is the stuff associated with it. I was IM vs Neuro in med school. My neuro rotation changed my mind. I didn't want to practice medicine that way. Maybe I didn't have the best experience, but not for me.

I ended up Derm and dermpath. I'm currently about 80% path. I'm good with patients and enjoy my time in clinic, but a lot of the other things that go along with it wore on me after awhile (like insurance issues). Also, I enjoy structuring my path days how I want. On clinic days, your day is dependent on when patients get there (early, on time, or late). On path days, I can decide any time I want to take a break and go get a coffee. I didn't realize how much I valued that part of my work day.

Actually experiencing both clinic and path first hand and adjusting my schedule over the years I've been practicing, I can say it is more nuanced than just 'like interacting with patients vs not'. The interacting with and educating patients is my favorite part about being in clinic, but I still prefer path more largely based on reasons I laid out above.

 

[babybrains]

Unfortunately, it's fairly common for many, if not most, medical students going into neurology to not get to experience neurology on the outpatient side. The vast majority of neurology rotations are inpatient. Kinda sucks, especially when 90% of practicing neurologists are inpatients lol.

My med school didn't have an "official" outpatient neuro elective, but I reached out to my neuro department and was able to convince them to create a 2-week outpatient adult neuro rotation that I piloted. I think there are ways to get exposure, but it may require being more proactive, unfortunately. I'm still amazed that not all med schools have neuro as one of their core rotations to begin with!

Yeah, I'm honestly so disappointed we get zero outpatient exposure. Probably why less than 5% of students at my school don't choose it as a specialty. I did get to spend some time in outpatient physiatry for a separate thing and I wasn't a huge fan. Too much talking, not enough doing. I'm not sure if that is comparable to neuro.

...

I think I'll try an outpatient elective if I have time. 4th year scheduling is just such a pain in the butt and we have to decide by January, even though 4th year starts closer to May. It's nuts.

Because I am trying very hard to break back into my home region - which is not my school region - my dean advised me that no matter what I should spend all of June through September doing Sub-Is and aways in my specialty of choice and getting LORs from my top choice programs. I should have mentioned geographic preference is also a major concern for me.

Physiatry is pretty different, from my prior experiences. I'd also echo that, at least from a neuro perspective, doing multiple aways seems like overkill... but I don't know the details of where you're coming from, so that may be a factor.

 

[deleted1168269]

A key thing to think about outside of actually just seeing the patients, is the stuff associated with it. I was IM vs Neuro in med school. My neuro rotation changed my mind. I didn't want to practice medicine that way. Maybe I didn't have the best experience, but not for me.

I ended up Derm and dermpath. I'm currently about 80% path. I'm good with patients and enjoy my time in clinic, but a lot of the other things that go along with it wore on me after awhile (like insurance issues). Also, I enjoy structuring my path days how I want. On clinic days, your day is dependent on when patients get there (early, on time, or late). On path days, I can decide any time I want to take a break and go get a coffee. I didn't realize how much I valued that part of my work day.

Actually experiencing both clinic and path first hand and adjusting my schedule over the years I've been practicing, I can say it is more nuanced than just 'like interacting with patients vs not'. The interacting with and educating patients is my favorite part about being in clinic, but I still prefer path more largely based on reasons I laid out above.

Just out of curiosity, what kind of insurance issues are there in pathology?

 

[Dral]

Just out of curiosity, what kind of insurance issues are there in pathology?

There are some, but not nearly as many as in clinical medicine. I believe private practice may deal with it a bit more than academics as well. In my experience it is not nearly as much as with clinical practice. This could change very quickly as molecular and more personalized medicine is starting to hit the scene (and isn't cheap).

 

[JBM16BYU]

My med school didn't have an "official" outpatient neuro elective, but I reached out to my neuro department and was able to convince them to create a 2-week outpatient adult neuro rotation that I piloted. I think there are ways to get exposure, but it may require being more proactive, unfortunately. I'm still amazed that not all med schools have neuro as one of their core rotations to begin with!



Physiatry is pretty different, from my prior experiences. I'd also echo that, at least from a neuro perspective, doing multiple aways seems like overkill... but I don't know the details of where you're coming from, so that may be a factor.

Physiatry and neurology are different. Many patients are shared in between the two specialties but the focus and goals of treatment and diagnostic approach differ. It also depends on what subspecialty of physiatry and neurology you are seeing, since practices can vary quite a bit in that way too. Signed your friendly, neighborhood neuromuscular physiatrist.