Why did you choose neurology?

I liked the logic of neuroanatomy. I thought the presentation of many neurologic conditions was interesting. I saw that there was more ability to treat neurologic conditions than most people realized. There were several subfields of neurology that I found particularly fascinating and fun to deal with (neurophysiology, epilepsy). Unfortunately, what I didn't realize until it was too late was that most of general neurology consists of chronic pain management. I have been trying to distance myself from that aspect of things ever since, with limited success.

I actually did consider psychiatry, very seriously. Pretty much went right down to the wire between psych and neuro. Mostly I think because it was (much to my surprise) hands down the best rotation I did in med school. That rotation was also heavily focused on inpatient treatment of acute patients, which is actually the far more "satisfying" aspect of psychiatry, at least to me. Eventually chose neuro over psych because I sensed I'd really hate outpatient psych. But I must say, there is more than enough psychopathology to go around within the neurology patient population.

I also considered FP, medicine (for about 6 minutes . . . ), and, perhaps somewhat discongruently from the other specialties, pathology.

 

May I ask what you would have done differently had you had the chance?

Say, pursue a fellowship perhaps? Do you think that would have made a lot of difference? Do most neurology practices tend to allow their subspecialists to focus on their particular area? Or do most tend to "share the load" of the chronic pain management folks?

Thanks!

 

I did do fellowship. It has helped to some extent at focusing on my main areas of interest within neurology, but in the "real world" it's kind of difficult to find a 100% pure subspecialty job without any general neuro demands, which is really what my "dream job" would entail. I'm not saying they don't exist at all, but we all make compromises in terms of job, geography, salary, family issues, etc. I am thinking that over time, my current position will allow me to expand a bit more on the subspecialty side, but I doubt I'll ever be 100% subspecialized.

From reading your post in the Lounge (and BTW, cross-posting between the Neuro forum and the Lounge is punishable by death . . . ) I think you'd be happiest in neurorads, especially if there is an interventional component. I get the sense you are not entirely keen on direct, ongoing patient care, and that's pretty much the whole game in neuro and peds, even in subspecialties. Even a small rads program can get you into a fellowship if you do well. On the flip side, interventional fellowships remain pretty hard for neurologists to get at this time and that's going to remain an ongoing battle. As for peds, . . . bleh. Sure the kids are cute, but I had the same reaction as you did -- dealing with the parents sucks.

Bottom line: read my signature quote below. Every day it gets truer and truer . . . VVV

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"Patient care interferes with practicing medicine."

 

Ever think about academic medicine?

 

Keep in mind that there is a very broad range of what constitutes "academic medicine." Some programs are very large, others relatively small. Now maybe at the bigger programs, you can have more opportunity to subspecialize, but as I mentioned in the original post, we all make our compromises with regard to other factors relating to employment.

Lets just say I have not found the "100% ideal job for me," anywhere, and believe me, I looked long and hard. Not that I think that's a realistic expectation, which is why I'm reasonably satisfied with where I am now and think I can carve out more of a niche over time.

 

Thanks for the insight Neurologist! What makes dealing with chronic pain patients so bad?

 

That is understandable. I'm not even sure there is a thing as a "perfect" job. There will always have to be sacrifices/compromises, just a matter of finding which priorities you need to sacrifice the least number of (location, work hours, location, benefits, cost of living, proximity to family/friends...etc.) I just figured that "academic medicine" would give you your best shot at practicing solely within your subspecialty.

I'm curious if you wouldn't mind mentioning how large your practice is? Don't most of your partners refer to you the patients that fit under your subspecialty training?

 

You nailed it. Fix 'em up, and let 'em loose. Thats my motto.

It seems like everyone (including many folks in radiology) feels that interventional neuro will inevitably go the route of interventional cards (it might as well... not too many radiologists want anything to do with INR anyhow). But the general consensus I'm getting is that we're at least another 10 years or so before it catches on. Its all politics.

No kiddin.

 

I went into Neuro because the pathology fascinated me, not so much the localization but the presentation. I still remember the first time I elicited the Babinski! I also honestly enjoy performing the neuro exam, so there
I did consider psychiatry, but I just feel I was more suited for neurology. I can deal with the schiz and the bipolars, but the anxious middle aged housewives just drain me.

 

There are 9 of us, plus a couple of PAs. Two of the MDs (one is the chief and one has been here forever, so they get to do pretty much whatever they want) seem to do almost 100% subspecialty work. The other MDs all do about 50% subspecialty work and 50% general neuro. Unfortunately, we don't have anyone with specific pain/headache interest/training, or anyone doing 100% catch-all "general neuro" in our group, so those patient populations (which are large) have to get split up between everyone.

While the practice tries to funnel new patients toward the appropriate subspecialist, this isn't always easy given that, #1, we often get limited information from the patient or refering physician regarding the actual nature of the problem, and #2, any given patient can have multiple problems (i.e., headaches and seizures, myopathy and sleep apnea, etc). Also, some of the subspecialties are booked months and months in advance while others are not, and patients would rather see anyone sooner rather than wait for a specific doc or subspecialist. We will sometimes refer to others within our group, but this is not really as frequent or as easy as you might think, primarily due to schedule issues.

As for inpatient, everyone takes turn in rotating on the inpatient service.

Well, it's really a matter of preference. Honestly, some people love it, God bless them.

The main issues as I see it are these:

First, there is a huge disconnect between what most patients expect from pain treatment (i.e., "make all my pain go away, now, with no side effects.") and what we can actually deliver (i.e, "we can reduce your pain by X percent but never completely eliminate it, so you need to learn to live with it to some degree"). This sets up a lot expectational dissonance between provider and patient. They are frustrated that we can't "fix" them. We are frustrated that not only can't we fix them, but that they can't or won't understand that, or in some case do much in terms of lifestyle change to help themselves (i.e., losing that extra 50 lbs can do wonders for back pain . . .). After a while, this wears you down. Occasionally you hit a home run and the patient gets better with a nerve block or a little bit of gabapentin, but these are few and far between.

Second, many chronic pain patients have associated Axis 1 or 2 behavioral issues, often times under- or even untreated. This makes them even more difficult to deal with on an ongoing basis.

Third, a chunk of them are very needy/clingy/dependent, need a lot of handholding, and take up a lot of time, which, frankly, many of us don't have or don't honestly have the personality for. You really have to be willing to invest a lot of time in many of these patients. If you don't have that outlook, you will not be happy with this field or patient population.

Fourth, there is a lot of potential for medication abuse/misuse, which can become a vast quagmire that many clinicians would prefer to avoid at all costs. Pretty much nobody in my current practice prescribes opioids, ever, for anything.

I'm sure others could add to the list. There was someone floating around here a couple months ago named Snowdog or Snowhound or something like that who I think might have some interesting perspectives on this as well. Or, you can go visit the Pain Forum.

 

Hey Neurologist

Thanks for the insightful posts.

I was wondering, as a neurologist, how comfortable are you dealing with and treating psychiatric comobidities in neurology patients. For example, I know that you probably wont deal with primary schizophrenia but would you feel comfortable treating the depression or anxiety in a patient with Alzheimer's or other Neurological condition? Would you even go as far as to treat schizophrenia in a Neurology patient or is that beyond your realm? I noticed that a lot of neurologists have interest in behavior and that many neurological patients in turn have psychiatric disorders

thanks!

 

Hey Terpskins

I hope you are right

At my school, where there is an Interventional NEUROLOGIST, there is a lot of buzz and excitment about this particular field. More than likely I am going to go into Neurology and try to do NIR later on after neurocritical care/stroke. I like how cardiologist get to mix in diagnostic medicine and procedures but just like the brain more than the heart