Pros and cons of neuromuscular fellowship?

[deleted1081396]

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I'm an MS4 applying to neurology and am highly considering either a neuromuscular or neurophysiology fellowship in the future. I know a bit about neurophysiology but not so much about neuromuscular and I'm curious what the big pros and cons of it are. I strive to find an attending position with a very good work/life balance even if it means a cut in pay and I also find neuromuscular diseases and EMG interesting, so it seems like it might be a good fit for me. With my currently limited knowledge, the pros and cons of it seem to be:

PROS:
- Interesting work, I like EMG
- Good lifestyle, doesn't really seem like it would have a lot of call or emergencies
- Good job market
- Decent salary

CONS:
- Not as versatile as neurophysiology
- Possibly more tied down academic centers (?)
- Possibly more vulnerable to changes in reimbursement policy than the former (?)
- Have to compete with PM&R docs for patients and procedures

What are some others?

 

[Thama]

- Not as versatile as neurophysiology

I would argue that in the ways that matter, you are more versatile coming out of NM than CEP. The part of CEP that is difficult to learn well is EMG. You'll have basic competence in reading EEGs by completing a high-volume residency - no, you won't be an epileptologist, but CEP fellowship won't make you that either. With NM fellowship you won't just be a dime-a-dozen proceduralist, you'll own the disease from diagnostic workup to treatment and actually know how to use the EMG to do more than "insert pattern here, please correlate clinically".

- Possibly more tied down academic centers (?)

Kind of the other way around. You are more attractive to academic centers with NM training than CEP, and some larger and more prestigious centers don't hire CEP at all for EMG or EEG, preferring NM or epilepsy trained people. But you're still plenty attractive to private practice with NM training, and many larger groups are eager to hire someone with NM/MS/movement/epilepsy training to establish a niche and provide an outlet for complex patients other than just punting to the local academic center.

- Possibly more vulnerable to changes in reimbursement policy than the former (?)

EMG already got cut. Doesn't matter which training you had. Don't know why you would think this.

- Have to compete with PM&R docs for patients and procedures

I don't really know where you are going with this. Where does PMR fit into patients with neuropathy, myopathy, NMJ disorders, or motor neuron disease? There's far more overlap between movement and PMR with adult CP, dystonia, spasticity.

 

[xenotype]

I would argue that in the ways that matter, you are more versatile coming out of NM than CEP. The part of CEP that is difficult to learn well is EMG. You'll have basic competence in reading EEGs by completing a high-volume residency - no, you won't be an epileptologist, but CEP fellowship won't make you that either. With NM fellowship you won't just be a dime-a-dozen proceduralist, you'll own the disease from diagnostic workup to treatment and actually know how to use the EMG to do more than "insert pattern here, please correlate clinically".



Kind of the other way around. You are more attractive to academic centers with NM training than CEP, and some larger and more prestigious centers don't hire CEP at all for EMG or EEG, preferring NM or epilepsy trained people. But you're still plenty attractive to private practice with NM training, and many larger groups are eager to hire someone with NM/MS/movement/epilepsy training to establish a niche and provide an outlet for complex patients other than just punting to the local academic center.



EMG already got cut. Doesn't matter which training you had. Don't know why you would think this.



I don't really know where you are going with this. Where does PMR fit into patients with neuropathy, myopathy, NMJ disorders, or motor neuron disease? There's far more overlap between movement and PMR with adult CP, dystonia, spasticity.

Agree for the most part but residency only EEG training can be quite bad depending on the program, many community outpatient jobs specifically require both EEG and EMG skills, and a 10 month CNP focused on EMG is functionally no different than an NM fellowship at many institutions other than the name. Agree with everything else- NM is definitely the right choice if one knows 1) they like outpatient 2) they like EMG. For OP based on your list- just do NM. You won't be competing with PM&R for anything- they'll be sending you patients.

 

[Thama]

There's a lot more to NM fellowship than EMG. The clinical spectrum in NM is broad and something that most residencies won't expose you to very much due to the inpatient focus. NM training also frequently involves training in neuropathology with nerve and muscle biopsies, and comfort with a lot of immunotherapy for immune neuropathies and inflammatory myopathies that you definitely won't feel comfortable with coming out of residency. 10 months of CNP would only be comparable to a really bad NM fellowship.

 

[sharkbaitwhohaha]

There are several PMR doctors doing EMGs for neuropathy. Probably location dependent. But they are definitely doing them.

 

[xenotype]

There's a lot more to NM fellowship than EMG. The clinical spectrum in NM is broad and something that most residencies won't expose you to very much due to the inpatient focus. NM training also frequently involves training in neuropathology with nerve and muscle biopsies, and comfort with a lot of immunotherapy for immune neuropathies and inflammatory myopathies that you definitely won't feel comfortable with coming out of residency. 10 months of CNP would only be comparable to a really bad NM fellowship.

I don't agree at all. A CNP fellowship with 10 months dedicated to EMG in most locations will teach all of that as a significant portion will be NM clinic/didactics etc. I received exposure to all of that in CNP fellowship including muscle pathology slides, and I only did 50/50. Maybe the EMG portion of the CNP fellowship (if there is one) at your institution is structured very poorly.

 

[Thama]

I don't agree at all. A CNP fellowship with 10 months dedicated to EMG in most locations will teach all of that as a significant portion will be NM clinic/didactics etc. I received exposure to all of that in CNP fellowship including muscle pathology slides, and I only did 50/50. Maybe the EMG portion of the CNP fellowship (if there is one) at your institution is structured very poorly.

CNP is very much the red headed step child of NM where I am, and nobody from our residency does it. 6 months of pure 100% EMG is considered barely enough to achieve minimal competence, so there's no time for NM clinic, neuropath, etc.

 

[xenotype]

CNP is very much the red headed step child of NM where I am, and nobody from our residency does it. 6 months of pure 100% EMG is considered barely enough to achieve minimal competence, so there's no time for NM clinic, neuropath, etc.

It is a common choice where I trained but it'd be rare for anyone to get '100%' EMG in a given rotation- more like 60% EMG 40% clinic. I do agree 6 months is absolute bare minimum for competency. Again the main advantage is the extra EEG time/epilepsy exposure as the reality of community practice is that you are expected to do both in many places. It is hard to do 'general' neurology well with no EMG background at all, or insufficient EEG training, and there is no subspecialty filter in most community practices as you are the first stop from the PCP/ED etc. Sure in a big private practice/academics with an excellent system for managing referrals you can select only your subspecialty patients but this is not how the majority of neurology is actually practiced in nice, clean silos. Hence there is a strong rationale for CNP, just not in places like Boston.