What does everyone want to do Epilepsy?

[chickensoupdr]

I'm posting from having very little experience in the field of epilepsy so I want to know what are some factors that draw people into this specialty.
What interested you in the first place? Any experience working with an epileptologist? Do they work generally in a clinic setting and do outpatient EEGs or work alongside an inpatient service?

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[sharkbaitwhohaha]

I'm neuromuscular. But enjoy eeg reading. But I really dislike seeing seizure patients

 

[Thama]

Reasons to do epilepsy:
1) EEGs are a reasonably fun billable procedure
2) Relatively chill OP clinic, epilepsy follow-ups are super quick and easy 95% of the time
3) Involvement in surgical workups can be cool and rewarding - topectomy, VNS, etc

Reasons not to do epilepsy:
1) Pseudoseizure patients make up a large part of the practice, with this being by far the most common form of functional neurological disorder in most of the developed Western world. This is painful.
2) Inpatient video EEG is dominated by the above type of patient
3) People I know that do epilepsy often find it clinically monotonous after a while and look to develop either academic interests or more of a general practice

 

[GuillainMollaret]

At least where I trained, very few people went into epilepsy, despite having an excellent epilepsy division. Stroke was the most popular fellowship, probably followed by movement.

In my opinion, epilepsy patients are the most challenging patient population in neurology for various reasons.

 

[sharkbaitwhohaha]

Another important point.

Most neurologist go into neuro because its heavy in the history and the neurological exam.

With epileptics, the history is all **** since they are unconscious and you're asking a non medical family member or witness to describe different types of body movements. Also, neuro exam is 99% normal so that's also boring.

If I didnt like the exam, I'd be a nephrologist.

 

[neglect]

The first time I saw an EEG, I knew I hated reading them and epilepsy wasn't for me. I really loved some of my epilepsy mentors (and didn't like some others); found their clinics less frustrating than migraine, if rarely interesting; and was horrified by the EMU, full of functional patients, weird recordings, crazy surgeons (we couldn't take that out, there is a vein there), and interesting PhD students.

Ultimately I'm also confused by the recent flood of applicants into epilepsy. Not to yuk anyone's yum, but - why? It just isn't that interesting, follow ups are boilerplate, new patients are boilerplate, everyone gets a 48 hour ambulatory EEG for any spell, and although there are tons of drugs most are highly derivative and refractory epilepsy mostly remains refractory. Many seizure docs seem like technicians: who cares about history, let me see those waves, let me feed the machine.

 

[sharkbaitwhohaha]

The first time I saw an EEG, I knew I hated reading them and epilepsy wasn't for me. I really loved some of my epilepsy mentors (and didn't like some others); found their clinics less frustrating than migraine, if rarely interesting; and was horrified by the EMU, full of functional patients, weird recordings, crazy surgeons (we couldn't take that out, there is a vein there), and interesting PhD students.

Ultimately I'm also confused by the recent flood of applicants into epilepsy. Not to yuk anyone's yum, but - why? It just isn't that interesting, follow ups are boilerplate, new patients are boilerplate, everyone gets a 48 hour ambulatory EEG for any spell, and although there are tons of drugs most are highly derivative and refractory epilepsy mostly remains refractory. Many seizure docs seem like technicians: who cares about history, let me see those waves, let me feed the machine.

interesting observation.

 

[OddNath]

One year of neurophys (or epilepsy) fellowship is high yield, even for the sole purpose of being able to get a job reading IOM remotely and never seeing patients again. This is a somewhat hidden gem within neurology (and medicine). It’s nice to have options.

 

[DerpyNeuroMD]

One year of neurophys (or epilepsy) fellowship is high yield, even for the sole purpose of being able to get a job reading IOM remotely and never seeing patients again. This is a somewhat hidden gem within neurology (and medicine). It’s nice to have options.

Any idea what a full time remote iom job would pay?

 

[Postictal Raiden]

Any idea what a full time remote iom job would pay?

Someone I know does this full time and claims he makes low 300s

 

[Staphylococcus Aureus]

Another important point.

Most neurologist go into neuro because its heavy in the history and the neurological exam.

With epileptics, the history is all **** since they are unconscious and you're asking a non medical family member or witness to describe different types of body movements. Also, neuro exam is 99% normal so that's also boring.

If I didnt like the exam, I'd be a nephrologist.

What in your opinion is the best area of neuro for the lovers of the history and exam?

 

[Postictal Raiden]

What in your opinion is the best area of neuro for the lovers of the history and exam?

It’s a personal preference.

For me, epilepsy definitely satisfies my liking to delve into the details of the history. To a lesser extent, headache had an interesting history component.

In regards to physical exam, nothing is as gratifying as stroke. You get a very good appreciation of the brain when you perform a physical exam on an acute stroke patient. In the outpatient setting, I enjoy the physical exam of movement disorders.

Again, this is a personal preference.

 

[sharkbaitwhohaha]

What in your opinion is the best area of neuro for the lovers of the history and exam?

For neuro exam heavy fields:
-movement
-neuromuscular medicine
-stroke

 

[sharkbaitwhohaha]

For neuro exam heavy fields:
-movement
-neuromuscular medicine
-stroke

I feel stroke sometimes is less exam heavy and more, "doesn't look like a stroke from exam, but lets MRI anyway". That way of practicing neurology is super stupid and degrades us to note writers and MRI impression readers.

For true neuro exam glory (ie. theres no other test to give you a diagnosis)...stick with movement or neuromuscular medicine.

 

[Telamir]

Yup.
I’d say neuromuscular or movement.
Stroke isn’t about the “exam and localization” anymore. It’s about a quick/dirty NIH and door to needle times. For all other BS they might call you for the answer is typically “I dunno, get an MRI”. Then if there is an actual stroke it’s basically review lipid panel, A1C, echo, vascular studies etc. I’d say stroke isn’t very history or exam heavy at all.

 

[xenotype]

Stroke is often not a real exam, and you can get away with cursory very targeted history. The MRI is used as a truth teller (even moreso than it actually should, given you can miss things on MRI that you can find on exam especially an MRI performed too early).

Neuromuscular a detailed, classic neurologic exam is essential and the only way to make a diagnosis. Even EMG is just a component/extension of it as EMG can't find things like HSP and only tells half the picture of ALS. It also can be helpful in the hospital setting for GBS, MG crisis et cetera.

Movement the exam also has to be detailed, but you can get away with less detail than NM as things like sensory findings are less important and a few tricks can often make some of the more common diagnoses like IPD and tremors. The history is just as important as NM and often has to be very detailed.

There can be a significant overlap between NM and movement. EMG guided botox is a wonderful skill to have that can really help a lot of patients, and you really need to do a bit of movement as NM to do it well and vice versa.

 

[chickensoupdr]

As a headache specialist, what kind of procedures, besides botox, could you do?
Do big centers look for headache specialist or can a general neurologist manage most headaches...

 

[xenotype]

As a headache specialist, what kind of procedures, besides botox, could you do?
Do big centers look for headache specialist or can a general neurologist manage most headaches...

In my residency we received a lot of dedicated mandatory rotations with board certified headache attendings, which included botox, occipital and other nerve blocks. Most residencies you'll admit chronic headache exacerbation patients to the hospital. There are plenty of tricks you'll learn if you do a headache fellowship, but in my opinion most residencies with a headache attending available and some rotation time will teach you the basics you need- botox, ONB, criteria for antibody drugs, and initial prophylaxis/abortive therapies as well as how to counsel patients. You'll be responsible for recognizing and first line therapy for trigeminal cephalgias anywhere as these are routinely tested on the boards. Some programs also have interventional pain exposure that can at least teach you the procedures available for other conditions and more advanced things that can be done for facial pain. In my program most residents were comfortable by the end of PGY3 independently doing botox or nerve blocks, and were allowed to do nerve blocks in the ED under credentialed attendings.

 

[Telamir]

For the truly refractory patients I think you can also charge for doing the rain dance or ancient voodoo rituals cause that’s what some headache regimens seem like to me.

Obviously a joke but I remember seeing some therapies by my headache attendings that made me raise an eyebrow. Seemed to work, though!

 

[Staphylococcus Aureus]

Average neurologist salary (non academic)

Can you guys mention about average neurologists salary in non academic outpatient/inpatient setting? Thanks

forums.studentdoctor.net

Judging by this isolated data linked in that thread, epilepsy pays less than both stroke and general neurology, is this consistent with what you all have seen?

 

[Telamir]

That thread has pathetically little information with a very small and self selected sample size.

In my experience they get paid the same to slightly more if on RVU/production in a place with EEG over-utilization.

 

[chickensoupdr]

Just super duper generally speaking, is there even a difference between general neurology, epilepsy, movement disorder, headache, neuroimmunology, etc? Often feels like there is much overlap within a small bracket, which ultimately translates to the same salary throughout all of those.

 

[Postictal Raiden]

Generally, you make based on how much you produce. You see 15pts a day vs 20. Also, if you do procedures, read EEG, do EMG, injections, etc

The number of pts you see per day and the procedures you do are influenced by your specialty.

Neuro cognitive and movement specialists tend to spend significantly more time with their patients than a headache specialist. Yes, they can bill higher per encounter but, in most cases,
that won’t offset the difference in RVUs due to seeing, say, 15 vs 25 pts.

Latest MGMA survey I have (2019) shows that general neurologist make more than some specialists.

Stroke neurologists, per MGMA, made significantly more than other neurologists. I’m sure they earned every dollar of it taking stroke calls Q other week.

Keep in mind, there are other ways to make money than relying on RVUs. Many neuro immunologists make money from infusions. Some make money from giving talks about new treatments. Others make that from clinical trials.

In almost every survey, neurology is right in the middle of the spectrum when it comes to compensation. I wouldn’t go into the field expecting to make on par with Rads and GI, without having to work significantly more than the average, do locum work, get involved in clinical trials, or do some shady stuff.

 

[sharkbaitwhohaha]

Generally, you make based on how much you produce. You see 15pts a day vs 20. Also, if you do procedures, read EEG, do EMG, injections, etc

The number of pts you see per day and the procedures you do are influenced by your specialty.

Neuro cognitive and movement specialists tend to spend significantly more time with their patients than a headache specialist. Yes, they can bill higher per encounter but, in most cases,
that won’t offset the difference in RVUs due to seeing, say, 15 vs 25 pts.

Latest MGMA survey I have (2019) shows that general neurologist make more than some specialists.

Stroke neurologists, per MGMA, made significantly more than other neurologists. I’m sure they earned every dollar of it taking stroke calls Q other week.

Keep in mind, there are other ways to make money than relying on RVUs. Many neuro immunologists make money from infusions. Some make money from giving talks about new treatments. Others make that from clinical trials.

In almost every survey, neurology is right in the middle of the spectrum when it comes to compensation. I wouldn’t go into the field expecting to make on par with Rads and GI, without having to work significantly more than the average, do locum work, get involved in clinical trials, or do some shady stuff.

How do private practice doctors make money from clinical trials?

 

[Postictal Raiden]

How do private practice doctors make money from clinical trials?

One told me he gets 5k per patient per year for enrolling a patient in a new drug trial and keeping detailed documentation of response/side effects.