Practice, Patient populations Lifestyle & Typical cases Psych/Neuro

[NeuroKlitch]

In my ongoing quest to decide between Neurology and Psychiatry, I've decided that in the future i would most likely want to have a private practice and wanted your help in comparing the two by answering a few questions about a typical Neurology practice.

1 . I've heard that most neurologist require hospital privileges for one reason or another, so most Neurologists with Private practices will also have some sort of call schedule with the hospital.. not sure if this is true.

2. Life style: i hear its pretty flexible for the most part, minus the call if 1 is true.

3. Pay: with both specialties, i'm assuming 250-400 is the range of incomes expected over ones career if the practice is not run into the ground. Is the higher end of the pay range acheivable without doing a fellowship such as sleep/pain/eeg/emg?

4. Can a stroke neurologist also have a private practice for general neurology . or is this asking for burn out/ unrealistic due to stroke call and so on.

5. What are the bread and butter patients?

6. How much cross over with Psych is there in Neurology. I Love disorganized thinking, delusions, and hallucinations. I know dementia patients allow for some of this, as well as huntingtons pts to an extent. But as a Stroke neurologist, is there any long term follow up with the patients to learn more about how the lesions in their brain have affected their behavior/cognitive abilities and life. Or is it treat and release (which i assume it is).

7. I have been hearing from many of my attendings that this is a good field to go into as the future is bright for the field, and there are now more procedures that are done by neurolgoists other than LP's. Can anyone expand on what these new procedures are? I can only think of maybe INR, EEG and other Fellowship dependent procedures. Are there any procedures that are now regularly done by general neurologists. thanks.

I know all these questions will be answered in a few months when i Finally can do my Neurology elective. But It really is exhausting going back and forth between these specialities and honestly i dont think i will ever be able to declare a winner... but maybe this can help in the process. thanks

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[dr_axolotl]

6. How much cross over with Psych is there in Neurology. I Love disorganized thinking, delusions, and hallucinations. I know dementia patients allow for some of this, as well as huntingtons pts to an extent. But as a Stroke neurologist, is there any long term follow up with the patients to learn more about how the lesions in their brain have affected their behavior/cognitive abilities and life. Or is it treat and release (which i assume it is).

Why not both?

I will have to disagree with the majority of people, and say that knowing neurology is extremely important to provide the best patient care. All kinds of pathologic processes which are considered in the domain of primary neurology masquerade as purely psychiatric at times. Understanding a full differential may entirely change a patient's outcome. Some examples off the top of my head include the 3% of all new onset psychosis which turns out to be autoimmune encephalitis, processes on the Morvan continuum where patients may present with acute psychosis and insomnia which looks similar to bipolar disorder, knowing semiology of epileptic seizures vs PNES, etc. The appropriate diagnosis and treatment are paramount in many of these cases. In a patient with NMDA-r Ab+ encephalitis, purely calling them psychotic and starting a neuroleptic is not enough. This person may end up even needing inpatient psychiatric hospitalization (which happens), and ultimately they could have been "cured" with immunomodulatory therapy.

There are countless answers to this question, but I find it naive and a bit lazy to suggest that it is not important to know neurology well. Both specialties are based in the same organ system. The brain doesn't discriminate. Knowing neurophysiology, anatomy, pathology, etc. is extremely important. Psych and neuro comorbidities run hand in hand, and it is best to have a good base in both areas. I recently got to have lunch with the Editor-in-Chief of JAMA Psychiatry who is from Germany, and he pointed out that his friends in Europe often tease him because in their psychiatry residency they do two years of neurology and learn how to read MRIs, EEGs, etc. while here in the states we get two months in a categorical psych residency.

Can you get by without the knowledge? Sure. Will you be as good of a doc? Maybe. But as someone training in both paths, I think I have a unique perspective coming from both camps and I'm able to tell you it is entirely eye-opening and improves my diagnostic acumen and clinical skills handily.

-A

I believe the following places offer a joint residency program (source):

Psychiatry/Neurology
Brown University
Medical University of South Carolina
New York University School of Medicine
University of Massachusetts
University of Texas Southwestern

 

[Hank Rearden]

It would be highly unusual for a stroke doc to want to just do clinic all day. Most of us go into stroke because we like taking care of patients emergently and managing them in the throes of a potentially devastating disease. Outpatient stroke is really boring - oh, you're still taking your ASA and statin, that's great! Usually we see them once after their acute hospitalization and then refer them to their PCP for long term management. Don't get me wrong, there are exceptions like the Moya Moya patients and such, but in general we don't go into stroke to see patients in clinic. I know of a few stroke trained people who almost strictly work in the outpatient setting and see a mix of stroke and general neurology patients, but that is rare. We also don't do a lot of behavioral neurology in stroke. We do see many patients with aphasias, vascular dementias, etc. While we learn to deal with all of these issues we are tyically not neurobehavioral experts. If that is truly your interest you might consider getting some specialized training in behavioral neurology.

On the other hand, if you truly want to do private practice you might think twice about the behavioral neurology focus. Most dementia experts cannot survive outside of academics. One told me he would make $60k / year if his practice was limited to dementia patients with their 90 min consultations and extensive coordination of care. If you want to do stroke and private practice, consider joining a group that does neurohospitalist work, seeing stroke patients and other inpatients with neurological disorders. These folks make a salary in the range you describe and the call is tolerable if the group is large enough to spread it around. I think I have posted on this before - please search old posts on this site for more info.