Thinking about neuromuscular fellowship, but asking for advise

[Alpetragius]

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Good evening

Im thinking about doing neuromuscular fellowship, as I love the procedural part about it and the pathology it includes, howver I have been thinking beyond the diagnosis, interms of being able to help patients.

My idea about the field in my 3 years of residency is that we do the diagnosis but we usually dont have the ability to offer much help for those patients. We either refer to pain medicine or surgery. Compared to other fields, for example epilepsy or MS, which each has 20 different medications, however neuromuscular remains around steroids, IVIG, or referral.

Does anyone have more detailed idea about the neuromuscular practice? And how often you feel that you help those patients instead of diagnosing and referring them to other specialities ?

Thank you

 

[Thama]

Neuromuscular is about on par with most neurology subspecialties (other than dementia) in treatments offered to patients. You are right that most treatable neuromuscular diseases are immune in origin, but the idea that it's just steroids or IVIG really isn't true. PLEX and a fairly wide variety of steroid-sparing agents (cytoxan, cellcept, rituxan, etc) are frequently used at my institution. There are also a fairly large number of nutritional neuropathies and myelopathies with those treatments, and neuromuscle is one of the areas seeing targeted therapies for degenerative disorders like SMA, DMD, and ALS.

I'm also confused about the tendency to refer people out you talk about - what on earth would you be referring them for? The NM specialists I know take care of setting up all their own infusions, all of their electrodiagnostics and most of their own biopsies, and do basic PFTs right in their own clinic. They also take care of neuropathic pain meds.

 

[Telamir]

The way I look at it is: You clearly like it, right? You like the diagnoses and you like the procedural aspect of it, right?

So what if you don't have that many treatments to offer? Neuromuscular deals with some pretty obscure stuff, some rare diseases as well as some bread and butter stuff. I'd rather have a doc that knows about them and is interested in diagnosing/treating those conditions. Like with dementia, and MS, and to a certain degree epilepsy/stroke our training goes beyond the diagnosis/treatment of these conditions. We are also aware of some of the unique challenges that conditions pose to our patients and often times guide them through the symptoms/specialists/referrals. Think of MS with neurogenic bladder/mobility/PT/Rehab etc, and dementia w/ family counseling, genetic counseling etc. There are more ways to "make a difference", I guess.

Just my 0.02

 

[Alpetragius]

Neuromuscular is about on par with most neurology subspecialties (other than dementia) in treatments offered to patients. You are right that most treatable neuromuscular diseases are immune in origin, but the idea that it's just steroids or IVIG really isn't true. PLEX and a fairly wide variety of steroid-sparing agents (cytoxan, cellcept, rituxan, etc) are frequently used at my institution. There are also a fairly large number of nutritional neuropathies and myelopathies with those treatments, and neuromuscle is one of the areas seeing targeted therapies for degenerative disorders like SMA, DMD, and ALS.

I'm also confused about the tendency to refer people out you talk about - what on earth would you be referring them for? The NM specialists I know take care of setting up all their own infusions, all of their electrodiagnostics and most of their own biopsies, and do basic PFTs right in their own clinic. They also take care of neuropathic pain meds.

Thank you for your reply. I meant by referrals nerve impingements and pain clinic.

 

[Alpetragius]

The way I look at it is: You clearly like it, right? You like the diagnoses and you like the procedural aspect of it, right?

So what if you don't have that many treatments to offer? Neuromuscular deals with some pretty obscure stuff, some rare diseases as well as some bread and butter stuff. I'd rather have a doc that knows about them and is interested in diagnosing/treating those conditions. Like with dementia, and MS, and to a certain degree epilepsy/stroke our training goes beyond the diagnosis/treatment of these conditions. We are also aware of some of the unique challenges that conditions pose to our patients and often times guide them through the symptoms/specialists/referrals. Think of MS with neurogenic bladder/mobility/PT/Rehab etc, and dementia w/ family counseling, genetic counseling etc. There are more ways to "make a difference", I guess.

Just my 0.02

Thank you for your reply. This is an interesting way to look at this issue from a different angle

 

[Thama]

Thank you for your reply. I meant by referrals nerve impingements and pain clinic.

If you mean referring out for surgical or pain medicine treatment of radiculopathies, then that's not really a neuromuscular disease in the first place. Everyone refers out for things outside their own scope of practice.