Neuro resident trying to decide which neuro speciality to go into

[Phaedoc]

I'm new to posting here, so hello everyone! Sorry if this is redundant. I'm a PGY2 Neuro resident starting to think about what type of practice I would like to go into. I'm having a hard time, because my thoughts keeps jumping back and forth about what I would like to do. Thought maybe you all could give me some pros and cons about various subspecialities.

I do know that lifestyle is important to me, because my family is high priority for me. In general, not too excited about procedures (I do kinda like EMG/NCS though). I thought I might like sleep, but concerned that there maybe limited opportunities for this subspecialty. But then again, Neuromuscular and Movement Disorders sound interesting. But, then, at times I like the pace in a hospital environment (Neurohospitalist not NCC). I considered that I would enjoy joining or starting a headache practice with a holistic approach. Ie. a center with psychologists, anesthesia, other naturopathic medicine (acupunture?). With this, though, I'm sure I would end up with a significantly lower salary and of course headache is saturated with pysch patients. I don't think that MS or Epilepsy are for me, but I haven't done a dedicated rotation yet in these fields. I know that I do not enjoy research. As you can see, I am all over the place. Any thoughts??

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[bustbones26]

I'm new to posting here, so hello everyone! Sorry if this is redundant. I'm a PGY2 Neuro resident starting to think about what type of practice I would like to go into. I'm having a hard time, because my thoughts keeps jumping back and forth about what I would like to do. Thought maybe you all could give me some pros and cons about various subspecialities.

I do know that lifestyle is important to me, because my family is high priority for me. In general, not too excited about procedures (I do kinda like EMG/NCS though). I thought I might like sleep, but concerned that there maybe limited opportunities for this subspecialty. But then again, Neuromuscular and Movement Disorders sound interesting. But, then, at times I like the pace in a hospital environment (Neurohospitalist not NCC). I considered that I would enjoy joining or starting a headache practice with a holistic approach. Ie. a center with psychologists, anesthesia, other naturopathic medicine (acupunture?). With this, though, I'm sure I would end up with a significantly lower salary and of course headache is saturated with pysch patients. I don't think that MS or Epilepsy are for me, but I haven't done a dedicated rotation yet in these fields. I know that I do not enjoy research. As you can see, I am all over the place. Any thoughts??

How about neurology? There is no law that you have to subspecialize.

A neurophysiology program that is 50/50 mix of EEG/Neuromuscular, with some sleep may be a good option if you are undecided.

As for headache, well, got bad news for you, neurology is saturated with psych patients in all speciality areas and I'd make a good argument that MS and Epilepsy have just as many psych issues as headache patients. If not more so in my region. Headache is my speciality and is now becoming slightly more popular as individuals are starting to see the procedural side of this. There are a number of up and coming things such as neuromodulation, transcranial magnetic stimulation, etc. Some are now starting to see the value of mixing interventional pain in with headaches; however, interventional pain will be the next specialty to take a payment hit this upcoming year.

Lastly, do not be in a rush to decide on anything. It would not hurt you to go out and take a job as a general neurologist for a year or two while you are thinking about it.

 

[typhoonegator]

Headache can be lucrative in a boutique multidisciplinary center. There are many examples out there. I wouldn't do it in a million years, but the pay issue alone shouldn't dissuade you.

 

[Mattchiavelli]

of course headache is saturated with pysch patients

I truly don't understand what you mean by this.... if you mean headache clinic has a lot of conversion patients, you feel there is a disproportionate amount of axis-II personality disorder that makes these patients hard to deal with, or if you think there is a lot of comorbid axis-I stuff going on. If psych isn't your thing though Movement is a poor choice because you will often be sifting through a bunch of psych history in DBS referral patients trying to figure out if a "Bipolar disorder" diagnosis is actually code for "got overdosed on Mirapex and had a manic episode then saw someone that didn't know what they were doing" in addition to the natural behavioral issues that come with Huntington's and Parkinson's etc

You can set up some kind of headache/pain treatment spa deal if you want, but it will require a lot of legwork or a mentor to help get all the business side in order. The big issue is while someone's insurance will pay for a clinic visit to a neurologist it may or may not cover the CAM treatments you would offer

Also neuromuscular and movement are going to gain you more clinic time as you will be expected to see a lot of new clinic patients for diagnosis as that what ends up being your forte from fellowship. They tend to not add a lot to the inpatient neurology experience/skillset

 

[bustbones26]

I truly don't understand what you mean by this.... if you mean headache clinic has a lot of conversion patients, you feel there is a disproportionate amount of axis-II personality disorder that makes these patients hard to deal with, or if you think there is a lot of comorbid axis-I stuff going on. If psych isn't your thing though Movement is a poor choice because you will often be sifting through a bunch of psych history in DBS referral patients trying to figure out if a "Bipolar disorder" diagnosis is actually code for "got overdosed on Mirapex and had a manic episode then saw someone that didn't know what they were doing" in addition to the natural behavioral issues that come with Huntington's and Parkinson's etc

You can set up some kind of headache/pain treatment spa deal if you want, but it will require a lot of legwork or a mentor to help get all the business side in order. The big issue is while someone's insurance will pay for a clinic visit to a neurologist it may or may not cover the CAM treatments you would offer

Also neuromuscular and movement are going to gain you more clinic time as you will be expected to see a lot of new clinic patients for diagnosis as that what ends up being your forte from fellowship. They tend to not add a lot to the inpatient neurology experience/skillset

Anxiety, Depression, Personality Disorders are prominent in chronic headache patients. There is a reason why the availability of a clinical psychologist is a program requirement for any UCNS accredited headache program. I am UCNS certified in headache medicine and also operate a headache clinic. No, its not all acupunture, scented candles and peach tea oil massages. Truth is, I'd be happy if some of these patients actually spent their money on such things versus three packs of cigarettes per day or the occasional ball of cocaine. The axis II disorders can make these individuals difficult to deal with and is a gateway for medication overuse, the bane of any headache clinic. There is a great deal of drama with some of these patients, obesity, lower socioeconomic status, other painful conditions that confound the headache therapy (disabling back pain, fibromyalgia, etc)


There are a number of very fun things that I do day to day. I once had patient that suffered from new daily persistent headache. One Haldol infusion later, I had her headache free for at least two months, the first time in 17 years! I think that we can all agree that nothing could be more miserable than cluster attacks. I administered a sphenopalatine block and watch the patient get up, take up his sunglasses and grab his head in shear amazement that the pain was gone! I do a variety of peripheral nerve blocks and it is always awesome to watch these work for patients.

All of that being stated, the patients with Axis II disorders can be exhausting. A good number of may patients drag drama into the clinic that is near unbelievable, some of it you'd think I was making up if I told you. That does not mean that these patients are impossible to treat, just require some patience. You have to grow a thick skin as well and let it go. After they figure out that you are their advocate and just trying to help, it eventually goes well.

 

[Vader]

I'm new to posting here, so hello everyone! Sorry if this is redundant. I'm a PGY2 Neuro resident starting to think about what type of practice I would like to go into. I'm having a hard time, because my thoughts keeps jumping back and forth about what I would like to do. Thought maybe you all could give me some pros and cons about various subspecialities.

I do know that lifestyle is important to me, because my family is high priority for me. In general, not too excited about procedures (I do kinda like EMG/NCS though). I thought I might like sleep, but concerned that there maybe limited opportunities for this subspecialty. But then again, Neuromuscular and Movement Disorders sound interesting. But, then, at times I like the pace in a hospital environment (Neurohospitalist not NCC). I considered that I would enjoy joining or starting a headache practice with a holistic approach. Ie. a center with psychologists, anesthesia, other naturopathic medicine (acupunture?). With this, though, I'm sure I would end up with a significantly lower salary and of course headache is saturated with pysch patients. I don't think that MS or Epilepsy are for me, but I haven't done a dedicated rotation yet in these fields. I know that I do not enjoy research. As you can see, I am all over the place. Any thoughts??

This is normal at this stage in the PGY2 year. I didn't have my epiphany until mid-way through PGY2, and then it was an evolutionary process to figure things out. The key is to find what you really love doing and this takes some self-reflection time. Unfortunately, many people don't have a lot of free time during PGY2 year to take that step back to obtain perspective.

Keys to a successfully obtaining a lower salary: Obtain work based on "salary" only rather than "income guarantee". Pretty much anything "procedure-less" will give you a lower salary (I'm looking at you, Behavioral Neurology). Academics will also give you a lower salary. Doing multiple fellowships will enshrine a lower salary for a few more years (but with potentially higher earning potential if they include learning billable procedures). Working in a saturated geographic area will generally give you a lower salary. Working only a couple days per week will give you a lower salary. Neglecting your practice in whatever chosen area you're in will give you a lower salary.

Remember, fellowship is primary a time to learn additional skills and knowledge that you have not already obtained during residency. My 2 cent advice is to go with whatever you really enjoy doing and what helps fulfill your goals 10 years from now. If you plan to have a family, kids, etc., lifestyle factors such as hours, amount of call, vacation time all play a big role. The work schedule can be arranged in pretty much any subspecialty to be compatible with your life. Realize though that there is nearly always a trade-off between amount of time off/flexibility and remuneration.

Hope this helps... and good luck!