Really struggling with decision to be generalist v specialist (specifically Neuro)

[Latteandaprayer]

I’m an M4 and it’s coming down to the wire. This is a decision that’s been really hard for me to make, especially because it’s a choice between immediately choosing to specialize (in Neuro) vs being a generalist.

This dilemma honestly comes down in part to ego. I would feel “less” of a doctor if I choose to specialize. I like the idea of seeing, working up, and treating (to a limited extent) a lot of pathology. I also enjoy coordinating care and being the first line for people. I have done sub-Is in Gen med, ICU, and primary care clinic and really loved the work. I would be choosing between IM and FM if I chose this path. No particular IM subspecialty is *that* interesting to me and I would ultimately stay a generalist (at best I would choose Sports Med fellowship to see some athletes but that’s about it). The idea of PCP is really attractive, or even a round-and-go community hospitalist. However, there are days where the last thing I want is to talk to 3 consultants and just give someone fluids while I wait for their recs. I also don’t always love seeing something interesting, working it up a bit, then ultimately punting to a specialist to definitely diagnose and/or treat.

On the other hand, I love Neurology. I love the pathology, the population, imaging, and goals of care convos inherent to the field. I love the bread and butter a lot, even boring old AMS, headache, and neuropathy is an exercise in differentials and gives me an opportunity to really make a difference in people’s lives. It would fulfill the itch of being “the last line” (or one of them) for a patient, and definitively diagnosing and treating. However, I would honestly miss thinking about other organs and hearing patient complaints and being someone’s first line. Some bread and butter PCP work like working up a thyroid nodule or treating hyperlipidemia is fun.

I have LORs for both. Research in Neuro that could easily be spun toward IM/FM. Sub-Is in IM and Neuro and FM. Any advice for decision making?

---

Members don't see this ad.

 

[djo208]

A few points for you to consider that may help you think this through:
1. You still have to think about other organs, whatever specialty you are in. The human body is a system. I am a specialist and have diagnosed UTIs, thyroid dysfunction, symptomatic vitamin deficiencies, and other diseases that are "outside my specialty," because even though I'm not an internist, an endocrinologist, or a urologist, the patients still tell me about their symptoms, and also because dysfunction in the one system causes dysfunction in the other.
2. Even though I'm a specialist, I often still need to hear the advice of and get recommendations from other specialists because I can't treat everything and our patients are complex. This again comes down to dysfunction or pharmacotherapy in one organ system affecting and being affected by other organ systems.
3. Even in knowing how to identify side effects and use medications safely and properly, I need to understand other organ systems, pathology, and pathophysiology in those systems. Here's a brief educational video to that point, and I can easily come up with more examples of situations where I need to think about other organ systems.

I don't expect that any one of those points will make the decision for you, but just having a conversation and talking it out might help move you closer to your answer. Good luck. You will figure it out!

 

[Latteandaprayer]

A few points for you to consider that may help you think this through:
1. You still have to think about other organs, whatever specialty you are in. The human body is a system. I am a specialist and have diagnosed UTIs, thyroid dysfunction, symptomatic vitamin deficiencies, and other diseases that are "outside my specialty," because even though I'm not an internist, an endocrinologist, or a urologist, the patients still tell me about their symptoms, and also because dysfunction in the one system causes dysfunction in the other.
2. Even though I'm a specialist, I often still need to hear the advice of and get recommendations from other specialists because I can't treat everything and our patients are complex. This again comes down to dysfunction or pharmacotherapy in one organ system affecting and being affected by other organ systems.
3. Even in knowing how to identify side effects and use medications safely and properly, I need to understand other organ systems, pathology, and pathophysiology in those systems. Here's a brief educational video to that point, and I can easily come up with more examples of situations where I need to think about other organ systems.

I don't expect that any one of those points will make the decision for you, but just having a conversation and talking it out might help move you closer to your answer. Good luck. You will figure it out!

That does help I guess I wish I could “have my cake and eat it too,” where I can practice PCP work AND neurology (kind of like how Sports Med FM will do PCP work as well as some sports work like injections, imaging, etc). I know that’s not possible.

When you say you diagnosed these things, do you ever work up problems like a PCP might? For example, you notice a patient is hypothyroid and has a nodule, would you personally send them to get an ultrasound (and communicate it to their PCP), or would you say “Your TSH is low and your physical exam is concerning for a nodule. Talk to your PCP”? The latter isn’t less valid than the prior, but I guess I would like to send patients for these diagnostic tests to work up complaints.

 

[cj_cregg]

From a family medicine standpoint, I also wonder if you can still engage with a lot of your neuro interests in primary care. It is really rare that I refer patients to neurology for the stuff you mentioned since you specifically mentioned enjoying the bread and butter cases.

AMS/dementia - I am pretty much always the one doing the initial workup/management for this. If I am concerned for more advanced dementia I do refer out to a geriatrician we have nearby at a memory care clinic, but even that is more so for some additional support/advice with things like discussion of advanced care planning, lifestyle interventions, counseling/anticipatory guidance, etc. - and even that could reasonably be done in my office if I wanted to make the time honestly. She doesn't tend to add much from a medical standpoint to what I've already done.
Headache - I really only refer out for patients who have tried and failed multiple preventive and abortive therapies. I have done this once in the last year.
Neuropathies - I refer out for the EMG specifically but again workup and management otherwise done by me. I have referred to neuro for a patient with numbness/tingling in a distribution that didn't really make any sense with no obvious cause (and frankly I suspect it is more psychosomatic) and a patient who actually had an mass involving a nerve, and that's all I can think of in the last year.

The listed CCs above are things I'm seeing multiple times a week if not a day. That is not to mention things like patients with stroke history with or without residual deficits, concussions and longer lasting issues from TBI history, tremors, sleep issues, etc - these again are things I'm rarely referring out for and see a decent amount of.

That's not to say that nobody ever needs to see a neurologist. Some things that are definitely going to see neurology are epilepsy/seizure disorders, uncommon stuff like MS, muscular dystrophy, myasthenia gravis, Huntington's, etc. And certainly if the stuff listed above is more complex for whatever reason, I'm referring like I said. But, I think a lot of "bread and butter" neurology conditions, including the things you listed, can be (and are) done in the primary care office.

 

[Hollow Knight]

You seem to enjoy aspects of both fields. Have you thought about $$$ and lifestyle?

I’m the biggest FM guy ever, but if I loved, say, psychiatry or etc more than primary care, that’s probably what I’d go for. Primary care is the hardest job in medicine for typically lower (but still really, really high) pay.

Now, I don’t think you should choose a field primarily based off money and lifestyle. Do what you love. But if you could truly see yourself enjoying both, do what would be best for your life outside of medicine. Just my 2 cents.

 

[Latteandaprayer]

From a family medicine standpoint, I also wonder if you can still engage with a lot of your neuro interests in primary care. It is really rare that I refer patients to neurology for the stuff you mentioned since you specifically mentioned enjoying the bread and butter cases.

AMS/dementia - I am pretty much always the one doing the initial workup/management for this. If I am concerned for more advanced dementia I do refer out to a geriatrician we have nearby at a memory care clinic, but even that is more so for some additional support/advice with things like discussion of advanced care planning, lifestyle interventions, counseling/anticipatory guidance, etc. - and even that could reasonably be done in my office if I wanted to make the time honestly. She doesn't tend to add much from a medical standpoint to what I've already done.
Headache - I really only refer out for patients who have tried and failed multiple preventive and abortive therapies. I have done this once in the last year.
Neuropathies - I refer out for the EMG specifically but again workup and management otherwise done by me. I have referred to neuro for a patient with numbness/tingling in a distribution that didn't really make any sense with no obvious cause (and frankly I suspect it is more psychosomatic) and a patient who actually had an mass involving a nerve, and that's all I can think of in the last year.

The listed CCs above are things I'm seeing multiple times a week if not a day. That is not to mention things like patients with stroke history with or without residual deficits, concussions and longer lasting issues from TBI history, tremors, sleep issues, etc - these again are things I'm rarely referring out for and see a decent amount of.

That's not to say that nobody ever needs to see a neurologist. Some things that are definitely going to see neurology are epilepsy/seizure disorders, uncommon stuff like MS, muscular dystrophy, myasthenia gravis, Huntington's, etc. And certainly if the stuff listed above is more complex for whatever reason, I'm referring like I said. But, I think a lot of "bread and butter" neurology conditions, including the things you listed, can be (and are) done in the primary care office.

Thanks for the input! So I mentioned the bread and butter mostly because any time I talk about the more complex stuff people push back and talk about how I need to focus more on the bread and butter lol. I realllly love epilepsy and the more rare movement disorders and autoimmune conditions. However I recognize that because I plan on working in outpatient community, 80% of my workload is probably going to be bread and butter and the Huntington patients are gonna be rare

 

[Latteandaprayer]

You seem to enjoy aspects of both fields. Have you thought about $$$ and lifestyle?

I’m the biggest FM guy ever, but if I loved, say, psychiatry or etc more than primary care, that’s probably what I’d go for. Primary care is the hardest job in medicine for typically lower (but still really, really high) pay.

Now, I don’t think you should choose a field primarily based off money and lifestyle. Do what you love. But if you could truly see yourself enjoying both, do what would be best for your life outside of medicine. Just my 2 cents.

Yes, both are important to me. Ideally I’d work an 8-5 M-F and then go home to my family. I’d want enough money to go on one “big” vacation a year (like Disney World, not a month long Europe trip lol), and be comfortable enough financially that I don’t have to stress about every little money decision. I grew up on food stamps and relying on food pantries/soup kitchens, and the biggest trips my family took was like an hour away to visit a bigger city for a day. I want to give my kids/husband a better life than that, and that includes being around for big life events and the little ones too as much as possible.

 

[Hollow Knight]

Yes, both are important to me. Ideally I’d work an 8-5 M-F and then go home to my family. I’d want enough money to go on one “big” vacation a year (like Disney World, not a month long Europe trip lol), and be comfortable enough financially that I don’t have to stress about every little money decision. I grew up on food stamps and relying on food pantries/soup kitchens, and the biggest trips my family took was like an hour away to visit a bigger city for a day. I want to give my kids/husband a better life than that, and that includes being around for big life events and the little ones too as much as possible.

You and I had similar upbringings. You’ll have plenty of money to live the life you want in either field.