Average neurologist salary (non academic)

[Postictal Raiden]

There is a cultural tendency to do fellowship, but there doesn’t seem to be a NEED to do one.

This culture needs to die but instead academicians keep pushing trainees to do more of the glorified slavery. The interesting thing is that these very same academicians have no problem (in fact they support) with the midlevel invasion of the field. All part of a scheme designed to allow attendings to work as little as possible without compromising their pay.

Although I see the value of doing a year of extra training to learn billable skills (EMGs, EEGs, VNGs), I can hardly justify 2-year fellowships in movement, epilepsy, immunology, and oncology.

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[stormylu]

There is a cultural tendency to do fellowship, but there doesn’t seem to be a NEED to do one.

To further clarify, there is a HUGE demand for neurologists (both general outpatient and inpatient) and most places are perfectly comfortable with a doctor right out of residency. There is also usually opportunity to further develop subspecialty interests while outpatient.

 

[DrSatan]

This culture needs to die but instead academicians keep pushing trainees to do more of the glorified slavery. The interesting thing is that these very same academicians have no problem (in fact they support) with the midlevel invasion of the field. All part of a scheme designed to allow attendings to work as little as possible without compromising their pay.

Although I see the value of doing a year of extra training to learn billable skills (EMGs, EEGs, VNGs), I can hardly justify 2-year fellowships in movement, epilepsy, immunology, and oncology.

You can do movement in 1 year. The 2nd year is by & large for research purposes, though some fellows use to to even further find their niche even though one simply do that by staying on as faculty. I believe the 2nd year for the other fellowships is also largely for academia, but I did not research those fellowships & thus cannot confirm.

 

[Splenda88]

This culture needs to die but instead academicians keep pushing trainees to do more of the glorified slavery. The interesting thing is that these very same academicians have no problem (in fact they support) with the midlevel invasion of the field. All part of a scheme designed to allow attendings to work as little as possible without compromising their pay.

Although I see the value of doing a year of extra training to learn billable skills (EMGs, EEGs, VNGs), I can hardly justify 2-year fellowships in movement, epilepsy, immunology, and oncology.

It's not too bad for neurology IMO

Imagine you have to do 2 yrs pediatric hospitalist fellowship as a pediatrician. This one is insane.

 

[Postictal Raiden]

You can do movement in 1 year. The 2nd year is by & large for research purposes, though some fellows use to to even further find their niche even though one simply do that by staying on as faculty. I believe the 2nd year for the other fellowships is also largely for academia, but I did not research those fellowships & thus cannot confirm.

I agree that for the case of movement, the second year is mostly research, but I also noticed that a good number of movement fellowship programs are like that.

Similarly, you can’t find an epilepsy or an MS fellowship at a reputable place that is not 2+ years. They say on their site that the second year is “optional” but it truly is not. I interviewed at two epilepsy fellowships of such. During the interview they tell you they “prefer” candidates interested in doing the second year.

Again, the culture now is all about having trainees undergo as much training as possible while allowing online-trained providers to act autonomously.

 

[Postictal Raiden]

It's not too bad for neurology IMO

Imagine you have to do 2 yrs pediatric hospitalist fellowship as a pediatrician. This one is insane.

Disgusting.

Neurology also has these shameless “Hospitalist” fellowship programs. For the time being, most Hospitalist jobs, even in academia, don’t require any fellowship. However, it can become a thing in the future given that everyone is doing a fellowship.

 

[Captain_Falcon]

So would a 1 year clinical neurophysiology fellowship be the best in terms of improving your ability to do billable procedures & getting something out of another year of training that will help you in practice?

 

[Postictal Raiden]

So would a 1 year clinical neurophysiology fellowship be the best in terms of improving your ability to do billable procedures & getting something out of another year of training that will help you in practice?

1 year of MIXED neurophys fellowship best bang for your bucks. That’s if you want outpatient ofc. There isn’t much role for EMG inpatient.

Other money making paths: Pain, NCC and NIR

MS can be lucrative but not because of the clinical work. Giving dinner talks (blood money) and being involved in pharmaceutical research pay very very well.

 

[Telamir]

Having done a 1 year epilepsy fellowship I think you extract more from it than just EEG reading.

You become very comfortable with weird seizures, seizure syndromes, and very very comfortable with antiseizure medication pharmacology. Additionally, depending on your program you get some exposure to epilepsy surgery, electrocorticography, intracranial EEG recording etc.

That being said I agree more than 1 year is a waste, and I'm very glad I got a 1 year program.

I also agree unless you want to do something very niche and academic you don't really need a fellowship provided you had good training. Stroke to me is the most questionable since you see a ton of stroke during residency anyway, and you typically don't walk away with any interventional knowledge or different skillset.

 

[mrbreakfast]

As someone who is in the job market right now, I am seeing lots of attractive/competitive positions, both inpatient and outpatient and both community and academic, which do not require a fellowship. As one of my mentors says, part of the value of a full-time academic neurohospitalist is freeing up 26 clinic weeks across all the outpatient subspecialists who would otherwise have to cover inpatient services.

I'm not looking for outpatient jobs but based on postings, it seems the most "valuable" fellowship would be movement disorders. Many places seem to prefer you either have subspecialty training or at least be able to perform/interpret your own NCS/EMGs. Every place seems to expect you to hold some general clinic.

I think for the one vs two year fellowships, it seems there's a clear split where one-year fellowship = private practice and two-year fellowship = academics.

I briefly looked into neurohospitalist fellowships. I don't necessarily think it's a bad idea for some people who want a little more exposure. But for other people, it'd essentially be a fifth year of residency.

 

[Postictal Raiden]

As someone who is in the job market right now, I am seeing lots of attractive/competitive positions, both inpatient and outpatient and both community and academic, which do not require a fellowship. As one of my mentors says, part of the value of a full-time academic neurohospitalist is freeing up 26 clinic weeks across all the outpatient subspecialists who would otherwise have to cover inpatient services.

I'm not looking for outpatient jobs but based on postings, it seems the most "valuable" fellowship would be movement disorders. Many places seem to prefer you either have subspecialty training or at least be able to perform/interpret your own NCS/EMGs. Every place seems to expect you to hold some general clinic.

I think for the one vs two year fellowships, it seems there's a clear split where one-year fellowship = private practice and two-year fellowship = academics.

I briefly looked into neurohospitalist fellowships. I don't necessarily think it's a bad idea for some people who want a little more exposure. But for other people, it'd essentially be a fifth year of residency.

Is "movement disorders a typo? Sure you learn some EMG in movement fellowship but it's more for botox injection rather than peripheral neuropathy localization. In addition, you don't learn EEG in movement disorders

Neurohospitalist fellowships are a scam and an insult to our neurology training. If one comes out of neurology residency not ready to do inpatient neurology (including managing all types of stroke, SE, and neuromuscular emergencies) then he/she must have had subpar training. This akin to requiring IM grads to do a fellowship to do inpatient IM. However, I wouldn't be surprised to see this becomes a trend and eventually a requirement for future neurology graduates. The "hive mentality" is that our residency training is worthless and we need a fellowship, what do I know?

 

[Splenda88]

Is "movement disorders a typo? Sure you learn some EMG in movement fellowship but it's more for botox injection rather than peripheral neuropathy localization. In addition, you don't learn EEG in movement disorders

Neurohospitalist fellowships are a scam and an insult to our neurology training. If one comes out of neurology residency not ready to do inpatient neurology (including managing all types of stroke, SE, and neuromuscular emergencies) then he/she must have had subpar training. This akin to requiring IM grads to do a fellowship to do inpatient IM. However, I wouldn't be surprised to see this becomes a trend and eventually a requirement for future neurology graduates. The "hive mentality" is that our residency training is worthless and we need a fellowship, what do I know?

I think there have been some chatters about IM hospitalist fellowship, but for some reason or another it has not taken off [yet]. Is neurology residency very inpatient heavy just like IM?

 

[xenotype]

I think there have been some chatters about IM hospitalist fellowship, but for some reason or another it has not taken off [yet]. Is neurology residency very inpatient heavy just like IM?

Yes. Neurology residency is about having every permutation of the stroke alert burned into your head until you can do it in your sleep.

 

[Postictal Raiden]

I think there have been some chatters about IM hospitalist fellowship, but for some reason or another it has not taken off [yet]. Is neurology residency very inpatient heavy just like IM?

Yes.

Every program is different but most programs provide more than ample inpatient experience.

I keep logs of my work. I have done 40 weeks on the inpatient stroke service and a similar number on the general service. In addition, I have done 17 weeks of NF (you handle everything on NF). I have been directly involved in more than 1500 stroke cases.

With that said, all of this inpatient work comes at the cost of compromising outpatient subspecialty exposure. You would definitely need an EMG neurophys or neuromuscular fellowship coming out of my program if that’s what you want to do. Same for movement, MS, neuro-onc, neuro-cog.

My issue is with the 2+ years fellowship programs. Absolutely unnecessary unless you want to have a specific niche in academia or do a research heavy career.

As for wanting to do inpatient or general outpatient neuro, doing a fellowship is just a waste IMO.

 

[mrbreakfast]

Is "movement disorders a typo?

Inasmuch as it seems to me that the overwhelming majority of outpatient job postings requiring a fellowship are looking for a movement disorder-trained physician. It's not necessarily the most profitable, but it seems to be the most sought-after. Outside of movement, headache, or epilepsy, I haven't seen any outpatient job postings looking specifically for fellowship training.

Is neurology residency very inpatient heavy just like IM?

It's heavier - potentially much heavier - at most places. My residency has 4 inpatient adult services, and some residents (like me) will spend about as much time/more time on each of them as they will in dedicated clinic time. Also, that's not factoring in call - we do about 80 days of a mix of 15-hour and 24-hour call during residency (not including PGY1), and our night float/call is substantially busier than IM. We also have to do some psych (100% inpatient) and pediatrics (almost entirely inpatient) during residency.

A neurology resident should be expected to handle anything that comes into the hospital. However, that isn't actually the case in reality, just like in IM, where some people are much more confident being the MICU senior than others. In the same vein, every neurology resident should be able to confidently perform their own EMGs and read their own EEGs without fellowship training; how many people can actually do that? Many residents can get good at one, but generally not both.

I think this sub-forum on SDN is heavily skewed toward inpatient-minded neurologists, but in reality there's a big split. People see a lot of what they want to see, and get good at what they want to get good at - and the rest fades quickly.

My prediction is that we will eventually see a schism in neurology, where inpatient vs outpatient tracks get established during PGY3 year, or where some programs just hire a few more neurohospitalists and give their residents a light inpatient load.

 

[Aldertonghen]

Isn’t a stroke fellowship a bit of a waste as well theoretically? Doesn’t help with billable skills, other than maybe becoming eligible for director or some telestroke roles. But then again on MGMA, stroke neurologists make $75k more than non stroke- is this an inaccuracy, or does this include interventional neurologists that skew the data?

 

[Aldertonghen]

1 year of MIXED neurophys fellowship best bang for your bucks. That’s if you want outpatient ofc. There isn’t much role for EMG inpatient.

Other money making paths: Pain, NCC and NIR

MS can be lucrative but not because of the clinical work. Giving dinner talks (blood money) and being involved in pharmaceutical research pay very very well.

How much more do the money making paths (pain, ncc and nir) make, compared to standard neuro fellowships?

 

[Thama]

Inasmuch as it seems to me that the overwhelming majority of outpatient job postings requiring a fellowship are looking for a movement disorder-trained physician. It's not necessarily the most profitable, but it seems to be the most sought-after. Outside of movement, headache, or epilepsy, I haven't seen any outpatient job postings looking specifically for fellowship training.

As a movement-trained neurologist who was recently on the job market, I don't think this is true. Movement is in demand, but not more demand than other fellowships. By far the most requested fellowship training in job postings are 1) vascular, for stroke centers, and 2) EEG/EMG training, neither of which you get in a movement fellowship. Movement is enough of a niche field that jobs in a particular metro may or may not be readily available in a particular year unless you're OK with doing a lot more general neurology than movement.

 

[voxveritatisetlucis]

It’s pretty surprising that neurology isn’t more popular given the premium that attendings are paid over IM docs (non-sub specialist) and the interesting nature of the work (subjective, but seems much better than IM/FM)

 

[stormylu]

As someone who is in the job market right now, I am seeing lots of attractive/competitive positions, both inpatient and outpatient and both community and academic, which do not require a fellowship. As one of my mentors says, part of the value of a full-time academic neurohospitalist is freeing up 26 clinic weeks across all the outpatient subspecialists who would otherwise have to cover inpatient services.

I'm not looking for outpatient jobs but based on postings, it seems the most "valuable" fellowship would be movement disorders. Many places seem to prefer you either have subspecialty training or at least be able to perform/interpret your own NCS/EMGs. Every place seems to expect you to hold some general clinic.

I think for the one vs two year fellowships, it seems there's a clear split where one-year fellowship = private practice and two-year fellowship = academics.

I briefly looked into neurohospitalist fellowships. I don't necessarily think it's a bad idea for some people who want a little more exposure. But for other people, it'd essentially be a fifth year of residency.

I’m doing my job search right now for mostly outpatient, and I’m looking at only places with 4 day workweeks, minimal call, and who are okay with me not doing any EMGs whatsoever (it’s one of the few things I don’t think I could do well without a fellowship). There are LOTS of opportunities out there. I met someone on the trail who did lots of EEG training while a resident and just asked his program director to extend residency 3 months to do more EMG to get comfortable with it.

There are a LOT of good non-academic (and some academic) jobs who are very willing to hire someone out of residency without fellowship. It seems like more jobs are available for general neurology than there are for specialists too.

The training I’ve found people especially looking for (if you DO feel the need to do fellowship) has been neurophys, headache, and MS, but that might be random based on the places I’m looking at.

This is based discussions with 15 places in the west, interviews and likely offers from 7 out of 7 places interviewed (and an extra bonus offer from a private doc trying the poach me from the local hospital where I interviewed)).

Fellowship is worthwhile for some, but seems extremely overrated.

 

[DrSatan]

I don't think vascular is a wasted fellowship per se. Many jobs prefer a vascular fellowship, especially for people right out of residency. Programs want to be a stroke center of excellence, which I believe having fellowship trained physicians is important for. That said, residency is really very good for stroke preparation at most institutions. I'd personally feel comfortable running stroke codes on my own after residency, though have noticed that my skills have already diminished as I've moved further away from inpatient work.

I'd agree that movement is in demand, but certainly vascular, EEG, & EMG are more in demand. I am wondering who all of these physicians without neurophysiology, epilepsy, or neuromuscular fellowships who feel comfortable reading EEG & EMG are. I have minimal EMG experience (was not interested in residency) & a relatively weak EEG experience (again, on me) & would absolutely not feel comfortable doing these. Further, I've seen wildly different EEG interpretations from trained epileptologists & useless EMGs from neurologists. EEGs & EMGs from neurophysiologists tend to be worse than from those in epilepsy or neuromuscular as well.

Even so, I think it's fair to trust a neurophysiology fellow, but I do not believe that a resident who spent extra elective time on EEG or EMG should feel comfortable reading them outside of residency. Maybe in the inpatient setting, but reading outpatient EEGs or EMGs seems wild to me.

 

[Postictal Raiden]

How much more do the money making paths (pain, ncc and nir) make, compared to standard neuro fellowships?

I don’t have objective data, only anecdotal info.

NCC outside academia should pay north of $450k. NIR 600k+.

Pain is extremely variable. Can range from low 300s to seven figures.

General outpatient neurology and neurohospitalist pay low to mid 300s on average. Therefore, the opportunity loss for doing a fellowship at least in NCC or NIR is easily offset with pay difference.

 

[xenotype]

I don’t have objective data, only anecdotal info.

NCC outside academia should pay north of $450k. NIR 600k+.

Pain is extremely variable. Can range from low 300s to seven figures.

General outpatient neurology and neurohospitalist pay low to mid 300s on average. Therefore, the opportunity loss for doing a fellowship at least in NCC or NIR is easily offset with pay difference.

There aren't a lot of purely NCC jobs outside of academia. You'll work longer hours with more call on most of these jobs than neurohospitalist jobs. A neurohospitalist job that is as busy as an NCC job outside of academia in patient volume/amount of call should be $400k or more if negotiated well. NeuroIR has terrible call and hours along with extreme risk even in routine practice, so the pay is balanced by that. I think most people doing NCC expecting to be paid better for the same work as a 'neurohospitalist' would be quite disappointed at the end result, and their actual work will end up being more similar than they would like.

 

[Splenda88]

It’s pretty surprising that neurology isn’t more popular given the premium that attendings are paid over IM docs (non-sub specialist) and the interesting nature of the work (subjective, but seems much better than IM/FM)

It could be because of lack of exposure... Also, the subject matter in med school was extremely complex (at least for me) . Then again, I was told neuroscience does not have a lot of resemblance with neurology.

 

[Telamir]

It does not.

Someone above also said "stroke neurologists are paid 75k more a yr" that's basically referring to neurohospitalists. You won't find 2 neurohospitalist doing the same job but one getting paid 75k more just cause he's got a stroke certificate.

Inpatient pays a bit more than outpatient typically.

 

[mrbreakfast]

As a movement-trained neurologist who was recently on the job market, I don't think this is true. Movement is in demand, but not more demand than other fellowships.

That's fair. I'm not really actually seeing a lot of outpatient offers (not sure why the recruiters are tagging the ones I do as "neurohospitalist" but whatever) though I'll say the people I know looking for non-fellowship outpatient jobs seem to have no difficulty finding them.

It’s pretty surprising that neurology isn’t more popular given the premium that attendings are paid over IM docs (non-sub specialist) and the interesting nature of the work (subjective, but seems much better than IM/FM)

Few reasons for this:
1) Most med students have little to zero exposure. There aren't many neurology residencies, and many of the ones that do exist suck.
2) The exposure that does exist often sucks, too, because of what academic centers actually see. Inpatient is massive strokes or things like CJD. Outpatient is fifth opinions for neuromuscular or bizarre neuro-immuno cases. Imagine if your only exposure to cardiology was post-arrests in the CCU or POTS patients.
3) We have a tough patient population. Subjective conditions like headache and dizziness can wear on the physician. We see tons of pain. Functional patients are very common. We get so many dumb referrals from APPs.
4) It's a subjective field. I mean, it's not exactly, but while the physical exam can provide objective data, it's not the same as a bunch of lab values. EEG is pretty darn subjective. You can collect EMG data by just listening to the sound the machine makes. The power could go out in the building and a movement clinic could proceed as normal (other than the chart documentation). Etc. Lot of people can't get used to that.

 

[Deecee2DO]

If it uniformly paid 400k starting like Anesthesia, I think it would've been more competitive.

I don't think the gap in salary is large enough. Hospitalists make 250k-300k now which isn't that far off. An American grad with a decent app probably has a shot at the 4 competitive sub-specialties, all of which would only take 2 additional years of training (4 years neuro vs 3+3 IM)

Hospitalists only make 250-300? Thought they started at 300K? 250 is like what PCP IM makes. What are you considering the 4 competitive subspecialties? HO Cards GI and PCC?

 

[Aldertonghen]

That's fair. I'm not really actually seeing a lot of outpatient offers (not sure why the recruiters are tagging the ones I do as "neurohospitalist" but whatever) though I'll say the people I know looking for non-fellowship outpatient jobs seem to have no difficulty finding them.


Few reasons for this:
1) Most med students have little to zero exposure. There aren't many neurology residencies, and many of the ones that do exist suck.
2) The exposure that does exist often sucks, too, because of what academic centers actually see. Inpatient is massive strokes or things like CJD. Outpatient is fifth opinions for neuromuscular or bizarre neuro-immuno cases. Imagine if your only exposure to cardiology was post-arrests in the CCU or POTS patients.
3) We have a tough patient population. Subjective conditions like headache and dizziness can wear on the physician. We see tons of pain. Functional patients are very common. We get so many dumb referrals from APPs.
4) It's a subjective field. I mean, it's not exactly, but while the physical exam can provide objective data, it's not the same as a bunch of lab values. EEG is pretty darn subjective. You can collect EMG data by just listening to the sound the machine makes. The power could go out in the building and a movement clinic could proceed as normal (other than the chart documentation). Etc. Lot of people can't get used to that.

The money is also probably a big reason why. In developing countries like where I’m from, Neuro has a higher pay per hour than Derm, gas and even some fully surgical fields like ENT, partly because of the supply/demand. The training required to be a neurologist is extensive: 7-9 years after medical school (out of which 3 are in medicine), which is more than neurosurgery (6 years) and ortho (3 years)- and this leads to incredible supply shortages. The training includes extensive EEG and EMG stuff built in, so every neurologist can do them at a fairly high level. This is before additional research years or certain fellowships.

But the pay and prestige are incredible for working essentially banker hours (and that’s a reason many IMGs go for neuro in the US, and then return). This makes neurology (and cardiology) harder to get than neurosurgery, derm, ortho and pretty much every field one can think of. Neurology is a tough field in terms of subject matter and patient population, and that is taken into account.

What I’ve noticed is that the US heavily favours procedures over cognitive reasoning, both in terms of compensation as well as the duration of training. It’s certainly quite different.

 

[Deecee2DO]

Yes broadly speaking. Not to say Rheum/Allergy is a walk in the park either

From talking to my seniors, ~250k base is what they were being offered this year. 300k base usually means open icu/central lines and intubations/nights/locums/midwest. I know Splenda here has a great gig but that’s been the experience from our program

Oh ok thats good to know! Yeah Allergy id say is the next most competitive after the big 4 (PCC GI Cards HO) due to limited number of programs and incredible lifestyle, 2 yr fellowship and really solid attending pay. Every allergist i know personally in pvt practice works 30-45 hrs per week and hits ~400K+/yr. I think the outlook for allergy is actually really good and i personally think it will get more popular and competitive as people begin to see how underrated it is

 

[Splenda88]

Yes broadly speaking. Not to say Rheum/Allergy is a walk in the park either

From talking to my seniors, ~250k base is what they were being offered this year. 300k base usually means open icu/central lines and intubations/nights/locums/midwest. I know Splenda here has a great gig but that’s been the experience from our program

If one is restricted geographically, I can understand why one would take a 250k gig. The market for HM is hot right now, so no once should work for less than 280k unless you want to live in some of the attractive big cities (NY, Miami, Houston, Dallas, Phenix, Southern Cal etc...)

My gig is ok (not great). One of my former co-residents has what I would call a great gig in the midwest. He would go to work at 10 am and be out 5pm everyday.

If your seniors are getting 250k base, they will make close to 300k with RVUs.

 

[Aldertonghen]

Oh ok thats good to know! Yeah Allergy id say is the next most competitive after the big 4 (PCC GI Cards HO) due to limited number of programs and incredible lifestyle, 2 yr fellowship and really solid attending pay. Every allergist i know personally in pvt practice works 30-45 hrs per week and hits ~400K+/yr. I think the outlook for allergy is actually really good and i personally think it will get more popular and competitive as people begin to see how underrated it is

What would be the neurology equivalent of allergy-immunology in terms of work hours, outlook and possibly pay? Perhaps neuroimmunology?

Does anyone here know about neuroimmunology pay? The lifestyle is incredible, the variety of patients even more so (you pretty much see the entire spectrum of neurology), infusions are possible, good research (if very boring: there’s a set methodology for discovering new autoantibodies and it becomes mundane after a while) and the people are less needy than epilepsy/MS with better prognosis. Sounds like a great future field, especially when combined with 1 year of neuromuscular (which has a LOT of immunomodulatory treatment), or epilepsy to gain EMG/EEG capabilities on the side.

While the general consensus is that it is primarily an academic subspecialty, the last 2 years has seen neuroimmunologists heading towards private practice (atleast the fellows at the place where I did research).

 

[Spinothalamic]

What would be the neurology equivalent of allergy-immunology in terms of work hours, outlook and possibly pay? Perhaps neuroimmunology?

Does anyone here know about neuroimmunology pay? The lifestyle is incredible, the variety of patients even more so (you pretty much see the entire spectrum of neurology), infusions are possible, good research (if very boring: there’s a set methodology for discovering new autoantibodies and it becomes mundane after a while) and the people are less needy than epilepsy/MS with better prognosis. Sounds like a great future field, especially when combined with 1 year of neuromuscular (which has a LOT of immunomodulatory treatment), or epilepsy to gain EMG/EEG capabilities on the side.

While the general consensus is that it is primarily an academic subspecialty, the last 2 years has seen neuroimmunologists heading towards private practice (atleast the fellows at the place where I did research).

It sounds like you are separating out neuro-immunology from MS, which suggests that you are actually referring to autoimmune neurology, which is only a fellowship at a few tertiary/quaternary care facilities. I agree that it is very interesting and a great future field but I would disagree with “incredible” lifestyle outside of perhaps a select few people who have a really good research/clinical combo gig. Those patients are very complex and require a lot of detective work and management outside of the actual billable hours. Many of these docs in academic institutions are always being called about complex cases in the hospital and getting referrals for anything that other neurologists can’t figure out or are too lazy to figure out, so you have to be familiar with very broad differentials including genetic syndromes sometimes requiring whole exome, etc. The “autoimmune encephalitis” that isn’t responding to PLEX might just be primary psych or Niemann-Pick type C or LBD. But it’s complex so it “must be autoimmune” and it is your job to prove the negative.

Again, it’s an awesome field, but definitely not one to pursue for lifestyle or money. Sure, you could combine it with other specialties that have associated procedures, but there is an opportunity cost to doing fellowship.

Based on your posts over the past several months, it sounds like you will benefit from more real world clinical experience. You have posted so much about salary, various random fellowships like critical care EEG or pain/EMG or combining heavy-duty academic research with weekend telestroke. To be honest, I was the same way and would spend a lot of time just researching all the possibilities and trying to plan out my future career. It was fun. Also I was of the mindset of “it won’t bother me if I do a few years of extra fellowships” or “I want to combine two totally random fellowships because it could be useful”. I was drawn to the craziest cases but realized that if you want to see the most complex cases at an academic medical center, it will become your life, it will be very hard to take any vacation, and you will be paid less than other neurologists who don’t even put 25% of the thought into cases that you do. Also you will be involved in research whether you like it or not. I really respect those doctors but ultimately found it wasn’t for me. The only thing that helped me decide was time and clinical experience—not opinions of other people on a random forum. So I would recommend keeping that in mind instead of being so hyperfocused on something that can’t be solved from browsing the internet. Even though it’s tough.

 

[sharkbaitwhohaha]

It sounds like you are separating out neuro-immunology from MS, which suggests that you are actually referring to autoimmune neurology, which is only a fellowship at a few tertiary/quaternary care facilities. I agree that it is very interesting and a great future field but I would disagree with “incredible” lifestyle outside of perhaps a select few people who have a really good research/clinical combo gig. Those patients are very complex and require a lot of detective work and management outside of the actual billable hours. Many of these docs in academic institutions are always being called about complex cases in the hospital and getting referrals for anything that other neurologists can’t figure out or are too lazy to figure out, so you have to be familiar with very broad differentials including genetic syndromes sometimes requiring whole exome, etc. The “autoimmune encephalitis” that isn’t responding to PLEX might just be primary psych or Niemann-Pick type C or LBD. But it’s complex so it “must be autoimmune” and it is your job to prove the negative.

Again, it’s an awesome field, but definitely not one to pursue for lifestyle or money. Sure, you could combine it with other specialties that have associated procedures, but there is an opportunity cost to doing fellowship.

Based on your posts over the past several months, it sounds like you will benefit from more real world clinical experience. You have posted so much about salary, various random fellowships like critical care EEG or pain/EMG or combining heavy-duty academic research with weekend telestroke. To be honest, I was the same way and would spend a lot of time just researching all the possibilities and trying to plan out my future career. It was fun. Also I was of the mindset of “it won’t bother me if I do a few years of extra fellowships” or “I want to combine two totally random fellowships because it could be useful”. I was drawn to the craziest cases but realized that if you want to see the most complex cases at an academic medical center, it will become your life, it will be very hard to take any vacation, and you will be paid less than other neurologists who don’t even put 25% of the thought into cases that you do. Also you will be involved in research whether you like it or not. I really respect those doctors but ultimately found it wasn’t for me. The only thing that helped me decide was time and clinical experience—not opinions of other people on a random forum. So I would recommend keeping that in mind instead of being so hyperfocused on something that can’t be solved from browsing the internet. Even though it’s tough.

this is wonderful insight. Other early neurology residents should note this post.

Autoimmune neurology IS very interesting, but DOES have a huge amount of "prove its not autoimmune" which frequently necessitates the whole MRI B/C/T/L wwo, CSF with ALL the studies, EEG/LTM, trial of IVIG/steroids "just to see" and the demanding parents/family members/patients.

AND, you'll be stuck with all the hardest cases other good neurologists couldn't figure out. It was not until I started outpatient private practice (after training at a large academic center) that I appreciated the easy cases. PGY1-4 thinking they want to be the authority and being sub-sub-specialized should really be cognizant of how mentally exhausting it is to have the hardest cases with mounds of outside records to review before their first office visit.

 

[Aldertonghen]

It sounds like you are separating out neuro-immunology from MS, which suggests that you are actually referring to autoimmune neurology, which is only a fellowship at a few tertiary/quaternary care facilities. I agree that it is very interesting and a great future field but I would disagree with “incredible” lifestyle outside of perhaps a select few people who have a really good research/clinical combo gig. Those patients are very complex and require a lot of detective work and management outside of the actual billable hours. Many of these docs in academic institutions are always being called about complex cases in the hospital and getting referrals for anything that other neurologists can’t figure out or are too lazy to figure out, so you have to be familiar with very broad differentials including genetic syndromes sometimes requiring whole exome, etc. The “autoimmune encephalitis” that isn’t responding to PLEX might just be primary psych or Niemann-Pick type C or LBD. But it’s complex so it “must be autoimmune” and it is your job to prove the negative.

Again, it’s an awesome field, but definitely not one to pursue for lifestyle or money. Sure, you could combine it with other specialties that have associated procedures, but there is an opportunity cost to doing fellowship.

Based on your posts over the past several months, it sounds like you will benefit from more real world clinical experience. You have posted so much about salary, various random fellowships like critical care EEG or pain/EMG or combining heavy-duty academic research with weekend telestroke. To be honest, I was the same way and would spend a lot of time just researching all the possibilities and trying to plan out my future career. It was fun. Also I was of the mindset of “it won’t bother me if I do a few years of extra fellowships” or “I want to combine two totally random fellowships because it could be useful”. I was drawn to the craziest cases but realized that if you want to see the most complex cases at an academic medical center, it will become your life, it will be very hard to take any vacation, and you will be paid less than other neurologists who don’t even put 25% of the thought into cases that you do. Also you will be involved in research whether you like it or not. I really respect those doctors but ultimately found it wasn’t for me. The only thing that helped me decide was time and clinical experience—not opinions of other people on a random forum. So I would recommend keeping that in mind instead of being so hyperfocused on something that can’t be solved from browsing the internet. Even though it’s tough.

I did refer to autoimmune neurology yes, not MS. I agree that I just matched into residency and am still very naive and clueless about fellowships and how neurology sub specialties work in general- which is why I’ve found this forum and your posts (along with xenotype, thama etc) incredible. I worked as a research fellow in autoimmune neurology (at I guess a top 2 place in the US for it) and I thought my mentor really had a great setup- perhaps the location did play a big role.

I agree about time and experience being the best things for arriving at a decision; my worry is basically that I’ll have too less time to decide what I want and then actually put together a decent application (research, rotations) for fellowship- especially if it’s a tough fellowship to get like NCC. I can only get electives for 2 or 3 of these subspecialties before having to decide in PGY3. I don't have electives in PGY1, and PGY1 (IM year) is actually around 10-11 months inpatient, and my seniors have said that it will be too late if I wait until second half of PGY2 (which is when I would get my first electives) for certain fellowships (especially NCC, pain and NIR). So I am trying to plan out my future even if it is very likely to be futile.

 

[Telamir]

To add on to autoimmune neurology:

It's pretty much inextricable from M.S. You will have to see M.S. unless you have a very specialized clinic at an academic center and even then you will likely have to see M.S. because you will likely need some "volume". Additionally, as alluded to above you will see a TON of referrals from the community for "autoimmune encephalitis" over someone behaving oddly or with neuro symptoms NOS with a couple of nonspecific white matter sports and those can get quite taxing. You would be managing some pretty dangerous drugs that a lot of people aren't comfortable managing, and you will be following labs/screenings for your patients. As with M.S., patients with autoimmune neurologic disease are "needy". Nothing against them, it's just a genuinely scary thing to have and they will contact you for a variety of concerns and you may end up managing other issues such as spasticity.

I'd consider it more "neuro rheumatology" than "allergy medicine" in terms of hours and difficulty of the work.

My friends/classmates who do neuroimmunology (be it M.S., or more on the autoimmune neurology spectrum) in top academic institutions with TONS of protected time (20-40% research time) always complain about what I mentioned above. Not to mention, it's easy to get pigeonholed into this sort of practice forever. None of them can see stroke to save their lives or are proficient outside their niche.

 

[Telamir]

I also saw that you did research at Mayo Rochester. As someone who is familiar with the Mayo system please keep in mind that Mayo in general is a bubble, a very unique practice and VERY atypical of what to expect in the "real world".

 

[Aldertonghen]

I also saw that you did research at Mayo Rochester. As someone who is familiar with the Mayo system please keep in mind that Mayo in general is a bubble, a very unique practice and VERY atypical of what to expect in the "real world".

Thanks for the insight. Yes, my experience here is basically limited to Mayo, and that might have led to some incorrect opinions. I guess autoimmune neurology (or neuroICU, or just about anything) is probably not as cush and razer-focused on their specialty out in the real world. And I guess there will be less incredibly complex (and fascinating) cases out there than at Mayo. Hopefully residency (which isn't at Mayo but at a state uni) will give a clearer picture.

 

[elanmorin]

You'll figure it out and you'll be fine. Just don't do something stupid like a critical care movement disorders fellowship.

 

[Thama]

You'll figure it out and you'll be fine. Just don't do something stupid like a critical care movement disorders fellowship.

Critical care movement disorders: for when you need to treat that chorea with propofol

 

[mrbreakfast]

Autoimmune neurology IS very interesting, but DOES have a huge amount of "prove its not autoimmune" which frequently necessitates the whole MRI B/C/T/L wwo, CSF with ALL the studies, EEG/LTM, trial of IVIG/steroids "just to see" and the demanding parents/family members/patients.

Agreed. Very cool in theory, but in practice seems to occasionally evolve into "this patient is clearly messed up and we don't know why." Other esoteric subspecialties like neuro-infectious disease are similar IMO.

I agree about time and experience being the best things for arriving at a decision; my worry is basically that I’ll have too less time to decide what I want and then actually put together a decent application (research, rotations) for fellowship- especially if it’s a tough fellowship to get like NCC. I can only get electives for 2 or 3 of these subspecialties before having to decide in PGY3. I don't have electives in PGY1, and PGY1 (IM year) is actually around 10-11 months inpatient, and my seniors have said that it will be too late if I wait until second half of PGY2 (which is when I would get my first electives) for certain fellowships (especially NCC, pain and NIR). So I am trying to plan out my future even if it is very likely to be futile.

You'll be fine. Just like specialty decision in med school, I think you should focus on eliminating things in addition to finding things you like. . You'll see autoimmune, stroke, and neuromuscular stuff in PGY1 year on your inpatient neurology blocks, and you can't make a decision on outpatient until you're exposed to the clinic inbox full-force...really I think the only truly time-sensitive subspecialties where you need early exposure are neurophysiology and neuro-ophtho.

Also, you can always apply to fellowship as a PGY4. Whatever program you're at will almost certainly be happy to offer you a one-year contract as a general outpatient attending to bridge the gap. And if you're thinking NIR, your decision isn't whether you want to do NIR, it's whether you want to do stroke - you can decide on NIR after.

 

[mrbreakfast]

I worked as a research fellow in autoimmune neurology (at I guess a top 2 place in the US for it) and I thought my mentor really had a great setup- perhaps the location did play a big role.

Be wary that the most ivory of towers - e.g. Mayo - are not representative of reality. A super-specialist needs lots of fancy lab tests and equipment, but what he or she really needs is a layer of academic neurologists who only let the actually appropriate referrals pass through to the specialist. You won't necessarily have that in reality. A movement disorder specialist is going to get a lot of referrals for people who can't walk well, only some of whom will actually have PD; a neuromuscular specialist is going to see a lot of straightforward (but often advanced) neuropathy; a neurohospitalist is going to see a lot of toxic/metabolic encephalopathy; a MS specialist is going to see a lot of people who don't have a neurological problem. Etc. Everyone is going to see functional patients.

You will see a good variety in your clinic in residency. It's mostly bread-and-butter, but at my residency new diagnoses from resident clinic included ALS, CJD, NMO, CIDP, GBM, etc.

 

[Aldertonghen]

T

Be wary that the most ivory of towers - e.g. Mayo - are not representative of reality. A super-specialist needs lots of fancy lab tests and equipment, but what he or she really needs is a layer of academic neurologists who only let the actually appropriate referrals pass through to the specialist. You won't necessarily have that in reality. A movement disorder specialist is going to get a lot of referrals for people who can't walk well, only some of whom will actually have PD; a neuromuscular specialist is going to see a lot of straightforward (but often advanced) neuropathy; a neurohospitalist is going to see a lot of toxic/metabolic encephalopathy; a MS specialist is going to see a lot of people who don't have a neurological problem. Etc. Everyone is going to see functional patients.

You will see a good variety in your clinic in residency. It's mostly bread-and-butter, but at my residency new diagnoses from resident clinic included ALS, CJD, NMO, CIDP, GBM, etc.

That’s true. I don’t mind functional patients as much tbh, although I am surprised by the sheer number of records every patient here has. Takes me half an hour just to skim through 100-200 pages of them, for just 1 patient.

 

[mrbreakfast]

That’s true. I don’t mind functional patients as much tbh, although I am surprised by the sheer number of records every patient here has. Takes me half an hour just to skim through 100-200 pages of them, for just 1 patient.

I don't mind functional patients much as long as I can get them early in the disease course and help. But the bad ones are some of the most challenging/frustrating patients to treat, which is part of why subspecialists try to avoid general clinic.

And in terms of records, that will also partially be a Mayo thing. You'll get fourth opinion referrals with insane records (potentially several thousand pages) but you'll also get clinic patients with nothing, or better yet, the classic "I've seen other neurologists but won't give you their records because I want a fresh set of eyes."

 

[JohnnyDoc]

Is it possible for outpatient neurology private practice to earn more than neurohospitalists/telestroke?

 

[Telamir]

Sure. If you have crazy high volumes and high on procedures. This has been asked/talked about a lot. Search the forums. =)

 

[Captain_Falcon]

What's the perfect # of patients seen in an outpatient setting each day / overall for a full work week (e.g. 4.5 day clinic, no weekends)?

 

[mrbreakfast]

I think that depends largely on your practice, how fast you are, and your definition of "perfect," but to me it seems most people slot 40-60 minutes for new patients and 20-30 minutes for follow-ups. I know some people slot shorter visits, but I think that (excluding headache follow-ups) there is a minimum time you can allot for the typical neurology patient.

The above is for general clinics. Some subspecialty clinics (particularly academic) take longer per patient.

 

[DD214]

most people slot 40-60 minutes for new patients and 20-30 minutes for follow-ups

That's a great way to maybe pay your overhead and have nothing left to pay yourself

 

[deathmerchant]

Is it possible for outpatient neurology private practice to earn more than neurohospitalists/telestroke?

Depends on many factors. A well run multi-physician practice with 20+ patients plus procedures can get you to >400k+
Solo private practice will require a lot of work to get to 400k.

 

[voxveritatisetlucis]

Depends on many factors. A well run multi-physician practice with 20+ patients plus procedures can get you to >400k+
Solo private practice will require a lot of work to get to 400k.

How does one go about joining a group like this? Is it residency strength or networking that matters more?