where is neurology going in the future

[what?]

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I'm a 2nd year med student and my very strong interest in neurology is convincing enough to go into it for my career. but one thing that i am worried about is that many docs, including some IM's etc that are at my school at Wayne State, say that neurologist can diagnose but can't treat. i understand that neuro is the most compex and difficult discipline by the shear nature of it...but is all this research going to pay off in the form of new treatments and procedures? or do is it going to be like this a long time? i realize that eventually treatments HAVE to emerge by the law of research and technology, but sometimes i think that neurology treatments seem to be the exception to this rule! i want to be able to treat, cure, or successfully manage my chronic patients...and not be known as some know it all guy that can't treat. is the salary for neurologists going to change (also depends on the availibilty of treatments)?? i just wanted to start some sort of exhange of opinions where people can express what they think and if they have insights...to be able to share them. Thanks everyone. have a great day.

 

[doc05]

All that neuro research probably will pay off at some point. The trouble is figuring out when that will be. For example, right now, there are tons of newfangled treatments for MS. And they don't work very well. MS patients still suffer, except that now they're shelling out big bucks on drugs that don't work.

 

[neurologist]

I'm a 2nd year med student and my very strong interest in neurology is convincing enough to go into it for my career. but one thing that i am worried about is that many docs, including some IM's etc that are at my school at Wayne State, say that neurologist can diagnose but can't treat. i understand that neuro is the most compex and difficult discipline by the shear nature of it...but is all this research going to pay off in the form of new treatments and procedures? or do is it going to be like this a long time? i realize that eventually treatments HAVE to emerge by the law of research and technology, but sometimes i think that neurology treatments seem to be the exception to this rule! i want to be able to treat, cure, or successfully manage my chronic patients...and not be known as some know it all guy that can't treat. is the salary for neurologists going to change (also depends on the availibilty of treatments)?? i just wanted to start some sort of exhange of opinions where people can express what they think and if they have insights...to be able to share them. Thanks everyone. have a great day.

You are setting yourself up for the classic frustrating paradox of medicine that pretty much everyone realizes sooner or later in their medical career. Sure, you want to "treat, cure or successfully manage my chronic patients," but guess what: #1, Yeah, I don't cure too many people, but let's have a reality check here: "chronic patients" are by definition incurable (how many diabetics, hypertensives or arthritics get their one-time "cure" and walk out the door smiling? And #2, "treatment" and "successful management" depend on the context, which needs to be realistically approached by both the patient and the doc. If all some guy needs is a little lisinopril to keep his BP down, that's great, but if medicine were that simple, wouldn't need doctors would we? "Successful" migraine or MS management, for instance, doesn't mean that the patient will never have another headache or MS exacerbation, just that on average, you have reduced or minimized their level of disability. And that can take a lot of time and effort and patient education. And remember, like it or not, many diseases (both neuro and non) are progressive and disabling. We've all seen our share of chronic renal failure, CHF, COPD, etc etc etc. Except for the occasional transplant, none of these are getting cured.

If you can't deal with seeing patients who stay sick and want to be a one-time wonder-worker, you need to stay far away from neuro or any other medical specialty and be a surgeon instead. And even they have plenty of dissatisfied customers. Believe me, there are many days when just about every doc wishes they'd done that path residency!

As for neurology salaries, yes, they are going to change. Like all other medical salaries, they will be going down, drastically, when our screwed up health care financing system finally collapses in another 10-15 years.

 

[Rite]

I think neurology is changing as we speak. There has been a movement towards neurocritical care and interventional fellowships that will draw those who are very interested in the science of neurology but feel they want to have a more active part in the treatment of patients. This is only one example.

 

[Bonobo]

I remember talking to a neurosurgeon once who told me that 8 times out of 10 he doesn't do anything for the patient but provide some sense of control over their disease and cost them a lot of money. 1 time out of 10 he might actually help a patient be relieved of particularly annoying or troublesome symptoms and another 1 time out of 10 make a patient's life considerably worse.

I think it is easy to be jaded no matter what specialty you end up going into. The medical system as a whole, however, *does* work and all doctors are important components. No matter what specialty you go into, you are still a part of that system.

Neurology specifically gets a bad rep however. Most doctors recognize that there is still some value to the diagnostic skills of neurologists since often times a patient will get many unnecessary procedures and tests until they finally see one of these "cerebral" physicians. With the diagnosis comes relief and a feeling of control over the disease despites its likely chronicity...

But neurology is finally taking on more impressive roles as well. The most gratifying and important function of a physician that cannot be done without significant skill, training, and specific medical expertise is in performing complicated procedures that lead to significant symptomatic relief or cure of a patient's condition. In reply to the above post, such procedures are NOT limited to surgeons, no matter how much they want to control this turf. More and more medical physicians are able to do interventional procedures well beyond the cardiologist and radiologist, including neurologists, pulmonologist, gastroenterologist, PM&R, etc. Botox injections and nerve blocks are also coming to the domain of neurology, and these procedures can be somewhat complicated, for example, in the treatment of dystonias. Neurosonology (e.g. TCD enhanced thrombolysis) might be another area where neurologists can make a significant difference in acute stroke intervention. Finally, neurologists will soon be boarded in intensive care and be directing most NICU's.

There is a new breed of neurologists out there that is redefining the field. Along with the maturation of the tremendous amount of research in the field, neurology *will* be the place to be in the future--much like cardiology is today...

B

 

[bustbones26]

lesson number one, never listen to what other specialist say about other specialties, just go with your gut. I have figured out that most docs think that their specialty is the best and has a wisecrack for all others.

 

[shrink]

It's easy to say that neurology does not have solutions but that is not exactly true. Look at epilepsy and Parkinson disease.
Given the array of drugs and new ones coming out at the rate of 1 a year we have drugs to cater to a large number of needs and also not just control seizures but also have a minimum of side effects. In this was now seizure disorders are like high blood pressure. If you can t manage seizures with meds there is vagal nerve stimulation and epilepsy surgery. Again you cant make every one better but you can bring significant relief to a large number of people. Again there are a number of meds for early Parkinson's, then sinemet for mid stage disease, COMT inhibitors for late stage and deep brain stimulation for end stage disease. This is very much like DM where you can manage with diet early on then oral meds and then various insulin formulations. I agree that stroke and MS dont have this kind of profile but remember that in the last 10 years we have seen the wonders of tPA and that drug itself is used sparingly. As research progresses we will see more and more solutions. Even in MS there are new meds that may slow the disease.
Remember the brain is the most complex and difficult structure in the body. The blood vessels are leaky thereby limiting endovascular procedures, the brain cannot be replaced unlike the heart, kidney or liver and diagnostic imaging is still far from perfect. That's why neurology is the queen of the clinical specialties and in the coming decades treatment options will multiply just they did in cardiology starting in the sixties.

 

[Bonobo]

Whether neurology succeeds in developing a strong reputation among the specialties or not I think will entirely depend on how they deal with the acute treatment of stroke in the coming years. There are roughly 700,000+ strokes in the US alone every year. Most lead to death or grave disability, and together, strokes cause more disability than any other disease period. Disability is the bane of Medicare. Hope you can see where there is going--the U.S. needs to prevent disability from stroke as much as possible.

Where are neurologists currently with acute treatment of stroke? tPA? Ultrasound? We have tried and failed with so many neuroprotective agents, that we will be lucky to even have one or two that work over the next few years. We still have bitter and pedantic debates about anticoagulation and blood pressure control following ischemic stroke.

I think the money is in interventional techniques. Yes, blood vessels are leaky (and more importantly, there are many vulnerable end capillaries that lead to brain damage which, unlike damage to small areas of the heart, leads to significant disability). But I believe (and hope) that we will discover how to use endovascular techniques to acutely treat stroke. I should note that neurologists will have to do this. Neurosurgeons and radiology-trained INR docs simply don't have the understanding or training in stroke treatment that neurologists do. (Though they are clearly superior when it comes to aneurysms and AVMs).

If we as neurologists are to prove ourselves, I think we must do it in the acute and likely interventional treatment of stroke. If we succeed, we will be the cardiologists or the 21st century. For those reading this and wondering if neurology is for them, consider the role of neurology in the battle against stroke--a battle that will clearly be a top (if not THE top) priority in US healthcare in the coming years.

B

 

[what?]

strokes are the major cause of disability and therefore cost tons of money for insurance companies. that is a potential grounds for care improvement by neurologists...but also...what about the aging population and inevitable increase incidence of parkinsons and alzheimer's? in order to succeed as a speciality, i believe that these diseases need to screened and managed successfully.

 

[Bonobo]

I agree that Parkinson's and Alzheimer's will be more prevalent and we need to learn to manage them better. However, successful treatment of Parkinson's will either be from functional neurosurgery and/or newer pharmaceutical treatment. Alzheimer's will be the same. Stem cell treatment and gene therapy are also distinct cool possibilities, but again will require neurosurgery for treatment.

The reason I make this distinction is perhaps my personal biased opinion. But here it is anyway: Neurologists may garner a great reputation as researchers that discover and develop new useful treatments. But in order for them to develop a great reputation *clinically* they have to prove their worth beyond simply pill-pushing. Infectious disease doctors, for example, haven't developed a great clinical reputation yet even though they can treat most of the cases that they see. Neurologists will be successful if they can provide complex treatments of their own requiring skills that go way beyond diagnosis and choosing the right drug.

For example, ER docs get their reputation from handling trauma. Particularly when they do things like thoracotomies (as seen on TV) even though these procedures have no or limited proven value. Cardiologists are known for their interventional abilities as well as their skills with echo's and nuclear scans. GI docs? They have pills for everything, but it is the colonoscopy and EGDs (along with ERCP etc) that makes them well known to other clinicians and the public alike.

I think neurologists have this opportunity with stroke. They missed the boat with interventional pain. We could be doing on our burr holes and do much of our own functional neurosurgery (cardiologists tap into the pericardial space, pulmonologists do their own chest tubes, etc), but we missed this boat also. They are attempting to gain ground with neurointensive care (with EVD's, TCDs and ICP management being their main expertise) though neurosurgeons are fighting this trend. But with stroke, we have the chance to be interventionalists and gain a place alongside all the other interventionalists in medicine. We, as a specialty, would be foolish to miss this grand opportunity.

B

 

[kita]

what about baclofen pumps, dbs, and even interventional pain (recup the boat 🙂 )? do you think we will be able to perform these or other procedures??

 

[Bonobo]

what about baclofen pumps, dbs, and even interventional pain (recup the boat 🙂 )? do you think we will be able to perform these or other procedures??

Interventional pain--yes. Neurologists can already perform interventional pain procedures after completing an anesthesiology-run interventional pain fellowship. Depending on where you do your neurology residency, it isn't difficult to get such a pain fellowship position somewhere, though currently your options will certainly be limited. Some pain fellowships teach you how to put in spinal drug-injection pumps (which could include baclofen), but these are fairly uncommon--especially for programs that traditionally take neurologists. Unfortunately, neurology depts have left the pain fellowships to be run by anesthesiologists for the most part (BIDMC being a notable exception), so I don't forsee neurologists taking over the field. I think that neurologists may discover more interventional methods of dealing with headaches, including migraine. Botox may have some role in this, as well as other agents. I think interventional treatment for headaches will eventually take-off and be a considerable source of income and prestige for neurologists. But that is pure speculation.

DBS requiers the help of neurologists, but the actual surgery will still be done by a neurosurgeon. The major complicaitons of DBS (infection and hemorrhage) will probably always make a neurosurgeon necessary for this elective procedure. The only time where a neurologist can bore through the skull is in putting in EVDs or emergent bolts in the NICU. This is acceptable because 1) these neurologists are trained to deal with the complications of this procedure, and 2) it is an emergent procedure.

Again, the main role for neurologists in doing procedures is almost certainly interventional stroke. But this is a huge role. Neurologists are THE experts in the acute management of stroke, they are THE experts in the #1 complication of neurointerventional procedures (stroke), and the US needs interventional stroke more than pretty much any other new medical field out there.

B

 

[Tre Cool]

i'm a post-bac student applying this year for Fall 2006. i'm not sure how competitive i am so i'm considering the caribbean schools along with US schools. just wondering how difficult it will be in the next 5 years, in your opinions, to get a neurology residency? i know it's harder to get any residency from the carib but will it get super competitive in 5 years? thanks.

 

[RADRULES]

Neuro is going down the toilet. Neurointervention and neuroimaging is the domain of neuroradiology and neurosurgery.

 

[Rite]

Neuro is going down the toilet. Neurointervention and neuroimaging is the domain of neuroradiology and neurosurgery.

Some one is truly insecure. What then would you say about those neuroradiologists and neurosurgeons who are training neurologists? Have they joined a losing cause? Radrules, learn how to play with others on the play ground.

 

[sacrament]

Radrules has a history of going bonkers in cardio and neuro threads that even allude in passing to anything that might take work away from radiologists.

 

[automaton]

It'll be sweet if in the future we can have stem cells and figure out a way to re-grow neurons to treat neurological disorders like Parkinson's or spinal cord lesions. Think of how sweet interventional neurology would be like. Even if neurosurgeons perform these procedures, you would need a neurologist to monitor progress and manage the long term care of these patients. It would be the coolest damn thing in medicine. A nice pipe dream, at least.

 

[als]

From what I've heard from my IM attendings, the older IM attendings felt like the neurologists diagnosed conditions, but didn't treat. Some of the newer Attendings know the new medications in Epilepsy, Parkinsons, Alz, MS, etc (giving complex regimens of medications is still tx, right?)

 

[neglect]

Radrules has a history of going bonkers in cardio and neuro threads that even allude in passing to anything that might take work away from radiologists.

Like India?