I’m not saying each of these is justified or correct, but these were some of my general “negative” impressions of various subspecialties. Perhaps they could generate discussion. I’ll also include some characteristics that I liked about the field.
Behavioral. Con. Lack of really treatable conditions. Lack of procedures. Dependence on someone else doing a formal neuropsych eval. Often need to be in academics, tends to be research-based. Pro. You may see rapidly progressive dementia and have to keep in mind some of the rare genetic or metabolic differentials. You could help to develop a good way to treat AD.
Stroke. Con. Largely inpatient, and in my experience hardly any other provider in the hospital setting is capable of actually being a doctor and make decisions which entail even a small amount of risk, leading to pan-consults. ED providers can simply activate a stroke protocol without taking any history, completely abdicate patient care, and make you sort out why an 88yoF is confused—often requiring calls to a nursing home or family member. Then when there is not a slam-dunk answer when the UA comes back clean, they try to admit to your service, forcing you to “prove” it’s not a stroke, which is very unlikely given the examination is non-focal but you can’t rule out embolic shower without MRI. (Obviously still salty from residency). Pro. You see some of the best recoveries in medicine with tPA + endovascular treatment. Figuring out the etiology of the stroke can be challenging, satisfying, and really help the patient. If you only work in the hospital, your schedule enables easy vacation scheduling and you don’t have to worry about outpatient follow-ups.
Sleep: Con. Lots of OSA. Really, mostly OSA. The really interesting things like parasomnias and narcolepsy are quite rare in actual practice. You have to somehow be tied to a lab and technically you are on call overnight (though calls are rare). Can be frustrating for patients when you explain they need good sleep hygiene and perhaps cognitive behavioral therapy when they really just want a sleeping pill. Denials from insurance for in-lab PSGs. Uncertain future environment of home monitoring devices, reimbursement rates, home PSGs, etc. (Perhaps this is a pro for some as it represents an opportunity to be ahead of the game). Pro. You get to apply cardiopulmonary physiology to every day practice. There are some interesting crossovers with movement, epilepsy, NDG (REM sleep behavior disorder, restless legs, nocturnal seizures, parasomnias). You get to interpret PSGs. Many patients really do have substantial symptomatic benefit (and long-term clinical benefit) from PAP therapy (if you can convince them to use a CPAP and they can tolerate it).
Epilepsy. Con. Multiple frantic calls per day regarding breakthrough seizures requiring extra time to respond to each of these and look through the chart (non-billable). EEG reimbursement rates were recently hit with more documentation needed for EMU EEG. Often on call for cEEG in the hospital, requiring you to wake up in the middle of the night to check the EEG (which many providers just don’t do, but I think most centers have had a patient in status all night because someone wasn’t reading the EEG). If you only do epilepsy, the examination becomes largely irrelevant (maybe that’s a pro for some people). Telling people they are illegal to drive frequently (but this is common in neuro in general). Pro. Amazing armamentarium of medications. Reading EEG. Surgical evaluations with EEG, MRI, PET, SPECT, fMRI, etc. VNS, RNS. Working closely with other disciplines like neuropsych, NSG (perhaps a con).
Movement. Con. End-stage movement disorders and many etiologies of ataxia have little treatment. There is large crossover with behavioral/neurodegenerative. Pro. Many patients really benefit from treatment (whether via Botox or levodopa). Experienced movement disorder physicians may be the only ones to be able to sort out manifestations of rare disorders from functional and vice versa.
Neuro-ophthalmology: Con. Steep learning curve learning a lot of ophthalmology in one year (not only slit lamp, indirect, prisms etc but also at least basic understanding of ocular conditions). Often complex visits requiring record review. Reliance on a tech to do OCT/Humphrey visual field testing. Many other providers are apparently incapable of actually being doctors, so you may have to identify an ocular issue (monocular diplopia, greatly improved visual acuity with pinhole) and explain to the patient that they need to go back to a competent eye doctor or explain that their homonymous field defect is unlikely to get better and they are illegal to drive (which no one has told them). Triaging patients can be difficult due to many “ASAP” requests and long wait times. Pro. You are able to perform a detailed examination and evaluation using a unique combination of skills, techniques, and diagnostic tests—and there is only 1 full-time neuro-op for every 2.7million people or so in the U.S. OCT provides reliable objective data of optic nerve health which is very easy to obtain and painless. You see patients from basically every subspecialty of neurology with a fair amount of neuro-immunology. Relatively high percentage of interesting cases since you are a specialist for the specialists and you can add to the work-up as you see fit. See consults from multiple specialties like ENT, NSG, neurology, ophthalmology, rheumatology, endocrine, genetics etc.
Neuro-immunology: Con. Tend to absorb all of the really difficult cases because if the answer isn’t clear “it must be autoimmune”. A lot of symptom management with MS which may not be that successful. MS patients may think that every symptom they have is related to MS and reach out to you before their PCP. Lots of lab monitoring. Pro. A lot of interesting, treatable disorders. Growing armamentarium for MS. Great new therapies for NMO.
Neuromuscular: Con. Fair amount of disorders without good treatment. A lot of supportive care. Pro. Procedures with EMG/NCS provide objective data which is relatively easy to obtain and provide some variation within the day. Examination is important and detailed. Broad differential for many presentations. You learn to be comfortable with neuro-immunology given the need to treat MG, CIDP, and inflammatory myopathies.
Endovascular: Con. Requires 3-4 years of training after residency. Extremely steep learning curve. With great power comes great responsibility. Very frequent overnight call. The need to live much of life with a pager. Pro. You can provide amazing life-saving treatment in someone’s greatest moment of need. With great responsibility comes great power.
Pain: Con. You see pain patients. Pro. You do procedures.
Neuro-onc: Con. GBM is still for the most part a poorly treatable condition which is rapidly fatal. This is a major portion of the practice. Academics and research-based (perhaps this is a pro for some). Consults for brain metastases where there wasn’t much to offer outside of referring to NSG or rad-onc. Pro: A very unique specialty that is in demand. You can prescribe chemo. You have to keep an open mind because the referrals may be mimics of neoplastic disorders.
Autonomic: Con. You see a lot of patients who have been diagnosed with POTS, often erroneously, who are floridly functional and have many other symptoms without much objective dysfunction. These patients have probably been told by 4 or 5 other doctors that the problems are all “autonomic”, leading to difficult conversations when you 1) don’t think there is an autonomic disorder or 2) don’t have much to offer in terms of treatment besides PT, wearing tight socks, and drinking a lot of water. Autonomic testing can be confounded by the use of many medications which patients are often using. Older patients with autonomic disorders may have diabetes or a NDG condition which is poorly treatable. Pro. Autonomic testing in a legitimate lab is objective, unique, and often helpful, and you are the only one that can interpret it. You have a test that you can say is normal which lets you send the patient back to the referring doctor. There are some occasional rare, interesting pathologies.
Headache: Con. Nearly sole reliance on a subjective symptom. Psychiatric overlay frequently clouds treatment effect. You typically only see the most difficult headache patients, and the ones that are responsive to typical therapies stay with their general neurologist. Pro. Sometimes you are the only one that really listens to the patient and figures out they don’t have migraine but rather hemicrania continua and put them on indomethacin which resolves their headache for the first time in 40 years. You often can at least expand the work-up and obtain MRA/MRV or cervical spine imaging which may detect an undiagnosed issue. Procedures.
Neuro-ID: Con. Relatively high levels of morbidity and mortality. Only available in large academic centers, often research-based. Pro. You get to use a lot of medicine training outside of conventional neurology. See a lot of interesting cases which may or may not be neuro-infectious in nature. You are very subspecialized and probably pretty sharp.
Neurocritical care: Con. Working in the hospital, frequently being on call. Steep learning curve. Relatively high levels of morbidity and mortality despite modern-day medicine. Pro. You get to use a lot of medicine outside of traditional neurology. You are relatively shielded from ridiculous consults and functional patients—getting to focus on treating real disease. For the treatable patients, you were the doctor that was with them in their darkest hour and made them better. Procedures.
Palliative care neurology: Con. Palliative care. Pro. Neurology.
Sports neurology. Con. Neurology. Pro. Sports.
