Feb 12, 2013
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Hi folks,

I'm posting in hopes of getting some insight into neurology as a practice. I'm currently a student at the end of the third year and I'm having a hard time solidifying a choice. This isn't necessarily a problem as I have some additional time to really explore some specialties in medicine a bit more, but my experience at my home institution probably only offers a limited view of what each field has to offer, including neurology.

I know you all are a fan of the search function, so I'll preface my questions by saying that I've probably read almost every "is neurology for me?" related thread on the archives of SDN. What I haven't gotten a sense of yet from either reading the forums or my clerkship experience are the small details that distinguish day-to-day practice as an *in-patient focused neurologist* from other practices. Namely,

1. Is there a lot of stimulating case VARIETY? I ask this question because both on my general and consult services, the primary issue tends to be about altered mental status or seizure. Occasionally, there are some strange movement disorder related questions and headache, but most are AMS or seizure - and worse, we tend to not find answers for these patients and sit on them for a while.

2. On inpatient services do you see a lot of challenging and stimulating cases (that you eventually figure out)? I felt that I had to qualify this question because often I found that we DO get a lot of very interesting presentations, but it is just as frequent that we do not come to a convincing diagnosis. I know this can be argued for many other fields of medicine, even general IM, but it seems to be commonplace in neuro, particularly with all the encephalopathic patients.

3. Do you guys feel like you're making a significant difference in management that can positively affect outcomes, particularly as a consulting neurologist?

4. Does assessment of the patient with the neurologic complaint stay interesting? This one is a little vague, I know. But, from my (very) limited experience it often feels like CT/MRI imaging in neurology is so powerful that it often seems to take away the challenge of putting little pieces of the puzzle together to find the diagnosis which elegantly explains the patient's clinical presentation (which is something I found that I really like about IM).

Sorry for the somewhat long post, and I apologize if many of you will feel compelled to rehash what you've already told countless other students in the past, but I think your perspectives would be really helpful. Thanks.
 

DD214

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Run, don't walk - the field of neurology was just dealt a massive blow by Medicare threatening practice as we know it, and this is before ObamaCare takes effect. Do yourself a favor and pick a different specialty. If you don't believe me, check out AAN.com and read "Neurology in Crisis" written by the current AAN president.
 

typhoonegator

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Not all of us feel the same way about our specialty. There will certainly, however, be some evolution in the coming years. Enumerated responses to your questions are as below:

1. A patient in the ED was once presented to C. Miller Fisher at MGH. The resident prefaced the case as "a standard lacunar stroke". Fisher immediately stopped the presentation and said, "I have never seen one of those. We should go to the bedside at once!" He spent the next several hours (!) performing a detailed history and physical examination, revealing to the neurology team all the details that made the case unique, and the ways in which the patient could teach them about the disease. The point here is that the more you know and the more inquisitive you are, the less each case seems mundane. 10 cases with carotid stenosis and stroke are not the same case 10 times, I can assure you. Even in the ICU, where trauma, stroke, bleed, SAH, post-op make up a huge percentage of the cases, I never feel like I can just compartmentalize them and run on autopilot.

2. You will not always get a diagnosis on every patient. But case reports and series eventually can lead to new discoveries, so even cryptogenic etiologies can contribute to the field if rigorously recorded. I still think neuro has some of the best rare cases that diagnoses can be accessible for.

3. Absolutely, even if that contribution is prognostic and helps families and LARs make decisions about what to do with/for their loved ones. Being able to convince a CCU team that a patient actually has a decent prognosis after VF arrest and cooling can be very rewarding. And let's not forget the neurologic sequelae of many drug therapies, which can be readily diagnosed by the consulting neurologist.

4. An MRI is worthless at best, and dangerous at worst, without a history to accompany it. I can't tell you how often a radiologic interpretation is misleading or wrong, not because the neuroradiologist is unskilled, but because they lack the benefit of putting the picture together with the story. Plus, so often the imaging comes back normal, but that doesn't mean the complaint isn't real.

I'm a clinician-scientist, besieged by NIH budget cuts on one side, and Affordable Care Act changes on the other, but I couldn't be more excited about the future of our specialty. Uncertainty certainly breeds discontent, and I very much understand that people need to put food on the table, but the world will continue to need neurologists tomorrow, and the day after that.
 

libihero

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Sep 19, 2008
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Not all of us feel the same way about our specialty. There will certainly, however, be some evolution in the coming years. Enumerated responses to your questions are as below:

1. A patient in the ED was once presented to C. Miller Fisher at MGH. The resident prefaced the case as "a standard lacunar stroke". Fisher immediately stopped the presentation and said, "I have never seen one of those. We should go to the bedside at once!" He spent the next several hours (!) performing a detailed history and physical examination, revealing to the neurology team all the details that made the case unique, and the ways in which the patient could teach them about the disease. The point here is that the more you know and the more inquisitive you are, the less each case seems mundane. 10 cases with carotid stenosis and stroke are not the same case 10 times, I can assure you. Even in the ICU, where trauma, stroke, bleed, SAH, post-op make up a huge percentage of the cases, I never feel like I can just compartmentalize them and run on autopilot.

2. You will not always get a diagnosis on every patient. But case reports and series eventually can lead to new discoveries, so even cryptogenic etiologies can contribute to the field if rigorously recorded. I still think neuro has some of the best rare cases that diagnoses can be accessible for.

3. Absolutely, even if that contribution is prognostic and helps families and LARs make decisions about what to do with/for their loved ones. Being able to convince a CCU team that a patient actually has a decent prognosis after VF arrest and cooling can be very rewarding. And let's not forget the neurologic sequelae of many drug therapies, which can be readily diagnosed by the consulting neurologist.

4. An MRI is worthless at best, and dangerous at worst, without a history to accompany it. I can't tell you how often a radiologic interpretation is misleading or wrong, not because the neuroradiologist is unskilled, but because they lack the benefit of putting the picture together with the story. Plus, so often the imaging comes back normal, but that doesn't mean the complaint isn't real.

I'm a clinician-scientist, besieged by NIH budget cuts on one side, and Affordable Care Act changes on the other, but I couldn't be more excited about the future of our specialty. Uncertainty certainly breeds discontent, and I very much understand that people need to put food on the table, but the world will continue to need neurologists tomorrow, and the day after that.
*applause*
 

bustbones26

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Jul 26, 2003
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Hi folks,

I'm posting in hopes of getting some insight into neurology as a practice. I'm currently a student at the end of the third year and I'm having a hard time solidifying a choice. This isn't necessarily a problem as I have some additional time to really explore some specialties in medicine a bit more, but my experience at my home institution probably only offers a limited view of what each field has to offer, including neurology.

I know you all are a fan of the search function, so I'll preface my questions by saying that I've probably read almost every "is neurology for me?" related thread on the archives of SDN. What I haven't gotten a sense of yet from either reading the forums or my clerkship experience are the small details that distinguish day-to-day practice as an *in-patient focused neurologist* from other practices. Namely,

1. Is there a lot of stimulating case VARIETY? I ask this question because both on my general and consult services, the primary issue tends to be about altered mental status or seizure. Occasionally, there are some strange movement disorder related questions and headache, but most are AMS or seizure - and worse, we tend to not find answers for these patients and sit on them for a while.

2. On inpatient services do you see a lot of challenging and stimulating cases (that you eventually figure out)? I felt that I had to qualify this question because often I found that we DO get a lot of very interesting presentations, but it is just as frequent that we do not come to a convincing diagnosis. I know this can be argued for many other fields of medicine, even general IM, but it seems to be commonplace in neuro, particularly with all the encephalopathic patients.

3. Do you guys feel like you're making a significant difference in management that can positively affect outcomes, particularly as a consulting neurologist?

4. Does assessment of the patient with the neurologic complaint stay interesting? This one is a little vague, I know. But, from my (very) limited experience it often feels like CT/MRI imaging in neurology is so powerful that it often seems to take away the challenge of putting little pieces of the puzzle together to find the diagnosis which elegantly explains the patient's clinical presentation (which is something I found that I really like about IM).

Sorry for the somewhat long post, and I apologize if many of you will feel compelled to rehash what you've already told countless other students in the past, but I think your perspectives would be really helpful. Thanks.
Residency and GME can be exhausting sometimes and drag down your hopes that you will never live out a life of nothing more than getting dumped on with consults for every pseduoneurological complaint in the world. But then, there is the real world!!

In my private practice, I think I see more diversity and variety than I ever did as a resident (unfortunately). Yeah, I still get that altered mental status or seizure call on a drunkard. Yeah, I still get called for altered mental status on a 90+ year old patient that acts goofy at night time. But those are in and out consults.

CT/MRI are great tools, but just part of the diagnostic work up. Without an exam or clinical suspicion, they do not help.

Somedays I do not feel like I make a difference. Today I had a patient that smelled like marijuana, does not take her antiepileptics, and constantly shows up in the ER drunk. She wanted me to help her get disability. Ended the day with a 21 year old sperm receptacle that won't take her antiepileptics and somehow feels that she deserves SSI. But hey, we all have to deal with this crap. Yeah, I know that interventional cardiologists make more money than I will ever see, but even they still have to deal with the atypical chest pain fibromyalgia patients that are always passing out. The only difference is, after they do an echo, holter, event monitor, stress test, and maybe even a cath, thus sucking thousands of dollars out of their pockets, then they shrug their shoulders and say, "Gee, I don't know, go see a neurologist". We do an EEG for $120 and have to tell them they just have an anxiety disorder.

Anyways, back to the point, yes, we can and do make a difference because even after we deal with those exhausting patients, we do also have patients with real medical problems and sometimes it seems as if we are the only physicians that actually want to take care of them, and we do. They do appreciate this.

You have to keep an open mind whenever practicing in neurology. I currently live in central texas, I am on of four neurologists in my town and there is no competition. Truth is, we all have to play nice with one another because if one of us got run out of town, the call schedule would be a disaster!! If I was practicing in Houston, Dallas, San Antonio, Austin, then I'd just be another "dime a dozen" neurologist. Okay, so I don't have an art museum or wine bar in my town, but if I want that stuff, it is a short drive away and I don't mind.

Yeah, the AAN cut rates on EMGs. But unlike the city of Houston, I am not one of over a hundred neurologists that can do an EMG, so I still make money. True, I don't make as much for an EMG as a used to, but I still make money!! Yeah I see a lot of headache patients as this is my supposed specialty, but I actually do make money on in-office infusions and very short procedures that insurance companies pay for!! Believe it or not, most insurances actually pay me more for a nerve block than botox!! Up in Dallas, there are at least six specialized headache clinics (that I can think of off the top of my head, thus, probably more) that provide such a service while in my community, well, I am the only one.

I am only adding a little bragging in here just to point out that it is still possible to survive as a neurologist, yes, even after EMG cuts, you just have to play the game right. If you think that all you have to do is score high on your inservice exams during residency, publish a couple of papers, and sit back and let the world beat a pathway to your door, then you are dead wrong. As a talented musician once said, "Talent will only take you so far, and theeeeen you have to work!!".