why is neurology noncompetitive?

[MSV MD 2B]

Hi! in the specialty books i have read, neurology programs have been listed as non competitive? why is that? is there something inehrent int he field that makes it undersirable like lifestyle or something? It seems very interesting and much needed in light of the aging population so this surprises me. any insights in to this woudl be helpful.

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[md_student10021]

Originally posted by MSV MD 2B
Hi! in the specialty books i have read, neurology programs have been listed as non competitive? why is that? is there something inehrent int he field that makes it undersirable like lifestyle or something? It seems very interesting and much needed in light of the aging population so this surprises me. any insights in to this woudl be helpful.

Lifestyle is good; there are very few neurological emergencies. Income is not great, however.

The thing about neurology is that there is a lot of diagnosis, but unfortunately treatments are very limited. This makes the field very frustrating for some.

 

[oldandtired]

#1. Relatively low income
#2. Similar lifestyle to IM during residency. Average lifestyle post-residency. In some places a neurologist is consulted every time a stroke comes to the ER. Often do consults after office hours in the hospital.
#3. Few procedures or therapeutic options
#4. The neurological physical exam is long dead with the advent of sophisticated imaging available now and on the horizon


There are other reasons. Dont make a mistake and go into this field. Dont think that because you like studying the brain and find it fascinating that you will like neurology. Read medical student's survival guide by Poe for more insight into the different fields.

 

[ajl102]

It is probably non-competitive because people rely heavily on "old and tired" stereotypes to make career decisions. Many of these present-day stereotypes come from well-established bibles like the book by Polk, which is already 15 years out of date.

Physical examination is only dead in the most theoretical sense. Obviously every patient that comes into a clinic does not have every square inch of their body visualized by MRI. The neurologist's observations can direct the follow-up procedures. These observations and decisions are based on a special body of expertise. Also, interpreting neuroimages is definitely a big part of a neurologist's day - whether in a group practice or a hospital. See the string on neuroimaging for ad nauseum debate.

Diseases like chronic epilepsy, Parkinsons, MS - these diseases had zero therapeutic options not too long ago. The anti-epileptic drugs allow people who would otherwise follow a predicable and terminal course to live long productive lives. The management of this therapy is challenging and involved.

Regarding procedures, many group practices have their own MRI and in-house radiologist. EEG's are also a billable procedure, useful for determining seizure type, dealing with sleep disorders, determining neural damage due to trauma. And they are happily non-invasive, unlike coronary stints and balloon angioplasties, and so carry way less liability. I've heard of neurologists in private groups or partnerships doing volume practice pulling down a lot of money. And all without cutting anyone open.

Personally I can't decide whether to believe the stereotypes. In any field you write your own ticket to some extent. The compensation stats you read are just averages. Neurology seems like a field where you can create your own career, moreso than others. Academic neurology is one option, hospital neurology is another, group practice and private practice neurology is another.

Read some of Oliver Sacks' works. If you find this stuff fascinating, maybe that's enough to draw you into the field. The details of your career would still be relatively open-ended, from what I've seen.

 

[HessExpress]

Did you read Oliver Sacks' The Island of the Colorblind? Great book.

 

[ajl102]

Nope. I did read "Anthropologist on Mars" and "The Man Who Mistook..." as an undergrad (a while ago). Sounds like another in that series.

 

[surfnvb7]

Anyone want to speculate the role of a neuropsychologist vs. a neurologist? Besides the obvious that the neurologists can prescribe and perform clinical procedures.

I know several post-doc neuropsychologists doing internships at hospitals, and it sounds like they are the work horses for the neurologists, i.e..they do all the screening and interviewing of patients, and if its serious enough they refer them to the neurologist to be hospitalized. Sounds like they work very closely together, and the neuropsychologist probably "knows" more in diagnosing, but the neurologist just has more power in treating, given there is even a suitable treatment option.

Also, seems alot of people are going into private practice in clinical psychology in order to avoid the bureaucracy in practicing as a medical doctor.

 

[Sanman]

Good question surf. I was kinda wondering this my self since I am considering both professions.

 

[panch]

agree w/ ajl102 in that there are lots of paths and many more treatment options. To a great extent those are oldandtired stereotypes based upon bad/old data. Do a Neurology rotation at a hospital w/ a strong Neurology dept and look around, you'll see much more of the breadth of current neurology practice. And shocker: people use the "outdated" neurologic exam ALL THE TIME. Scanning everyone is not necessary, and many neuro pts have "clean" imaging but real disease.

"The Island of the Colorblind" is very cool book. "Uncle Tungsten" tells about his childhood and love of science. Oliver Sacks seems to be in the vein of old-school neurologists as Freud began.

Neuropsychologists are consulted in different ways and by different teams depending on the hospital. Where I am, Psychiatry is much larger than Neurology and has a Section of Neuropsychiatry (where I did my psych rotation). Neuropsych had ~2 or 3 Neuropsychology interns and 2 Neuropsychologists as well as 3 Neuropsychiatrists. Neuropsychology seemed to be consulted on all Neurosurgery patients to evaluate them (prob for documentation of pre- and post-). They didn't seem to do a hell of a lot else in the hospital, of course they were also doing research and writing and prolly therapy/rehab. The Neuropsychiatry team was consulted by Neurosurgery on nearly all patients (which can be pretty cool to evaluate), while medicine or another service may occasionally consult them.

Where there is an imbalance the other way and/or a Section of Behavioral Neurology, you can expect neuropsychology to be represented in Neurology as well. If it's a small Psych dept, Neurology may train them as well.

Bottom line though: they're not clinicians with an md's or a do's training and exposure. e.g. they don't know how to work up acute renal failure, obscure demyelinating d/o of the nervous system, or do a well child checkup.

Thus, I find it hard to believe that Neurology would use Neuropsychologists to triage neuro patients. Perhaps in the small subset who have a primary psychiatric or neurobehavioral d/o, but not all pts.

Private practice for a neuropsychologist is very different from that of a neurologist (even setting aside the bureaucracy).

 

[tofurious]

If not, you're sure glad there are neuropsychologists around to do the full cognitive work-up. THe situation is very similar to what the anesthesiologists went through with the CRNAs. Are the CRNAs going to replace anesthesiologists? People said yes, and the salaries of anesthesiologists went through the roof. Now there are more anesthesiologists again, and nobody is concerned that CRNAs are going to give it another try to take over anesthesia. Neurologists deal with so much more than just mental status and there is a long way for a neuropsychologist to go before the latter can match his skills with the former. (Within the special field however, just like an ICU nurse is probably better at putting in an IV line than a surgeon due to daily practice, a neuropsychologist can probably better describe a cognitive deficit than a neurologist *at times*)

 

[Sanman]

tofurious, I think its a little arrogent to say that neurologists know much more than neuropsychologists and comparing cognitive evaluations to starting IV's. I will give you that the two specialities have different training and that neurologists deal with much more than pt's with cognitive diffuculties, but in those cases in which workups are done for tbi's, ADHD, LD's, etc. Neuropsychologists are far better than neurologists and are considered the gold standard in diagnosis. I would venture to say that neuropsychologists are more diagnosticians for cognitive problems , while neurologists are more for treatment. Neither will probably take the others job because they have different functions.

 

[JDENTHOPEFULL]

bump

 

[NewGuyBob]

Oldandtired says:
The neurological physical exam is long dead with the advent of sophisticated imaging available now and on the horizon


The neurology atending at the hospital I did my neuro rotation always use to say "There are two main reasons to get a neurology consult. The first is an abnormal MRI, the second is a normal MRI." In neurology you ALWAYS must "know" the diagnosis before you even look at the imaging studies, if you try to go the other way around, you are dead in the water. If you dont know how to perform a thorough neuro physical all the imaging in the world won't give the diagnosis.

 

[Voxel]

I won't discredit the value of a good neurological history and physical exam as it can cut the differential diagnosis on MRI/CT down. However, you can have a completely normal neurological exam and have 50-60% of your brain replaced with a mets. I've seen the MRI scans to prove it. MRI is as good or better than most any physical exam for most significant structural lesions.

 

[Vader]

I tend to view a history, physical exam, and lab tests/imaging as complementary aspects to a proper patient workup. To be sure, MRI has revolutionalized the field of neurology. However, we should all strive to order fewer unneeded tests, for both patients' and the health care system's sake.

In neurology, the first question you ask yourself is "where is the lesion?" The history and physical exam allows you in most cases to localize the lesion to a limited area. The next question is "what is the lesion?" MRI provides an answer in some, but not all, cases. However, simply seeing a tumor on MRI does not give you information on how the patient is doing. As you said, a patient may have a massive tumor/mets and yet show very few symptoms and signs. On the other hand, it would be important to know whether the patient is showing lateralizing or focal neurologic signs, or is experiencing features that would suggest an emergent situation. In other cases, MRI will tell you little or nothing about the diagnosis nor the patient's status.

I highly disagree with the archaic and misguided assessment that neurology is a field of diagnosis with very little treatment. Perhaps this used to be the case, but with modern treatments, there are a multitude of therapeutic options, even for the neurodegenerative diseases. Remember, neurologists also see patients with seizures, headaches, nerve palsies, meningitis, and other very treatable disorders.

 

[Mitogen79]

I think its completely irrelevent whether neurology is a noncompetitive residency or not. If you truly love, then go for it. Personally, there is nothing more that I would want to do other than doing a residency in neurology and a subsequent fellowship in neuro-oncology.

MRI/CT may be great advents, but keep in mind that radiologists can read, but they cannot treat. The medical management of neurology patients is complex and with the advent of newer therapeutics, neurologists will be able to do a lot more than what is currently available. Also consider the fact that the population is aginig. There will be a good demand for neurologists.

 

[neurologist]

Neurology is a noncompetitive residency because so many med students have absolutely horrible med school experiences with neuroanatomy and clinical neurology rotations. Neuroanatomy is usually taught by some old fossil who emphasizes drilling every obscure detail and 500 different anatomic pathways in to your head with no clinical correlation. The clinical rotations usually emphasize inpatient care (i.e, stroke) which gets pretty redundant after a while and for which there really is no effective treatment (sorry, I'm not a big fan of TPA). So med students are left with the impression that neurology is all about memorizing obscure neural pathways and seeing patients you can't do anything for. If med schools focused more on clinical relevance during the class-based years and outpatient neurology during the clinical years, I bet there would be quite a difference in students' attitudes.

Neuro salaries aren't bad -- average is at least 180k after a couple years in practice. Remember, as in all medicine: procedures = $$$$. EMG, sleep studies, inpatient epilepsy monitoring, botox can be big money makers. Call can be highly variable, depending on where you work and if are a generalist or sub-subspecialist; some places the FP or internist is 1st call and admitting physician, with the neurologist acting just as a consultant. Other places the neurologist gets called for everything that's even remotely possibly neurologic and admits to their own service. Bottom line: the more money you want, the harder you will work.

As for the neurologic exam being "dead" and replaced by imaging, well, there are plenty of consults from primary care docs that sound like: "patient with (fill in the neurologic symptom) and has normal MRI; please evaluate." There are also only about several thousand neurologic problems in which imaging is totally irrelevant; can you tell me, please, what the MRI abnormalities are in myasthenia or absence epilepsy or Guillain-Barre? Along the lines of one of the prior posts, one of my favorite quotes on this topic is "the neurologist's job starts when the MRI comes back normal."

OK, enough for now. Just my 2 cents worth

 

[unregistered]

Originally posted by Mitogen79
I think its completely irrelevent whether neurology is a noncompetitive residency or not. If you truly love, then go for it. Personally, there is nothing more that I would want to do other than doing a residency in neurology and a subsequent fellowship in neuro-oncology.

MRI/CT may be great advents, but keep in mind that radiologists can read, but they cannot treat. The medical management of neurology patients is complex and with the advent of newer therapeutics, neurologists will be able to do a lot more than what is currently available. Also consider the fact that the population is aginig. There will be a good demand for neurologists.

This first statement assumes one already has a complete understanding of a field prior to entering it. I wanted to ask the same question too since neurology is interestng to me as a subject but it seems like few people want to go into it. Also, does anyone know why PMR is also non-competitive. There is some overlap between what PMR's and neurologists do so I was wondering if anyone could shed some light. the pmr forum on this board is not too active.

thanx

 

[ent_doc]

Originally posted by NewGuyBob
Oldandtired says:
The neurological physical exam is long dead with the advent of sophisticated imaging available now and on the horizon


The neurology atending at the hospital I did my neuro rotation always use to say "There are two main reasons to get a neurology consult. The first is an abnormal MRI, the second is a normal MRI." In neurology you ALWAYS must "know" the diagnosis before you even look at the imaging studies, if you try to go the other way around, you are dead in the water. If you dont know how to perform a thorough neuro physical all the imaging in the world won't give the diagnosis.

Hmm. That's a different take on "Neurology is what you do until you get the MRI back."