How worthless has Neurology become?

[DrMetal]

How worthless has Neurology become?

At my local community hospital, they've converted to a Tele-Neurology service. A nurse comes in, looks at the patient, does a quick exam, the Neurologist is on an ipad or something.

They recommend ASA/Stain, and then sign off.

I mean, come on. Can we please just accept that Neurology, as a clinical service, is essentially useless? Can we stop the charade?

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[HemeOncHopeful19]

I do find it odd that the field in medicine with perhaps the most emphasis on the physical exam has somehow become ok to do via an iPad, but that every other specialty seemingly has not.

Also you forgot the MRI Brain

 

[NewYorkDoctors]

it's the future of medicine.

we just need those fancy medical tricorders and magical futuristic epidural hematoma treatment devices from star trek and that magical ESRD cure pill and we are in business.

 

[dozitgetchahi]

How worthless has Neurology become?

At my local community hospital, they've converted to a Tele-Neurology service. A nurse comes in, looks at the patient, does a quick exam, the Neurologist is on an ipad or something.

They recommend ASA/Stain, and then sign off.

I mean, come on. Can we please just accept that Neurology, as a clinical service, is essentially useless? Can we stop the charade?

I can’t speak to what happens in hospitals. However, as an outpatient rheumatologist, I have noticed that community neurologists seem to have become progressively less “useful” over the last several years. My last example of this: I was seeing a patient with SLE who had just moved here from far away. He’d also had seizures before, and he was in several anticonvulsants which nobody was monitoring currently. So, I sent him to neurology to get established. It takes him months to see the neurologist…and after he goes there, the note contains some lengthy babble about neuropathy, and literally no discussion of his seizures whatsoever. I send a message to the neurologist and get back some confused response like “oh I was seeing him for seizures?” No ****, dude, why do you think he’s on a laundry list of seizure meds? Did you see my consult order which listed “seizures” as the reason for referral? Did you read my note? (On second thought, I know you didn’t, because nobody ever seems to read other doctors’ notes anymore). You think I’m the one monitoring those seizure meds?

I wish I could say this was a one-time occurrence, but I have seen goofy nonsense like this over and over and over again from neurologists across four different states in which I have worked. I’m not sure if the whole specialty has just gone off the rails or something, but it seems to be very difficult to get a “useful” neurology consultation at this point. The visits/notes seem to be all sound and fury, signifying nothing.

 

[NewYorkDoctors]

I can’t speak to what happens in hospitals. However, as an outpatient rheumatologist, I have noticed that community neurologists seem to have become progressively less “useful” over the last several years. My last example of this: I was seeing a patient with SLE who had just moved here from far away. He’d also had seizures before, and he was in several anticonvulsants which nobody was monitoring currently. So, I sent him to neurology to get established. It takes him months to see the neurologist…and after he goes there, the note contains some lengthy babble about neuropathy, and literally no discussion of his seizures whatsoever. I send a message to the neurologist and get back some confused response like “oh I was seeing him for seizures?” No ****, dude, why do you think he’s on a laundry list of seizure meds? Did you see my consult order which listed “seizures” as the reason for referral? Did you read my note? (On second thought, I know you didn’t, because nobody ever seems to read other doctors’ notes anymore). You think I’m the one monitoring those seizure meds?

I wish I could say this was a one-time occurrence, but I have seen goofy nonsense like this over and over and over again from neurologists across four different states in which I have worked. I’m not sure if the whole specialty has just gone off the rails or something, but it seems to be very difficult to get a “useful” neurology consultation at this point. The visits/notes seem to be all sound and fury, signifying nothing.

yeah this is my biggest annoyance in the community

yes it's easier when its a hospital system and it's all in one EMR...

it's harder in the community as not everyone sends notes

i also seldom get a referral note sent in...

I tried to institute a "please have your PCP efax us a referral and prior workup" and that led to a ****storm of whining *****ing and moaning by patients to my front desk to the point of harassment. ****ing new yorkers. seriously.

in fact my template for my new consults autopopulates as:

"Pulmonary Consultation
Reason for referral: No referral sheet or prior workup sent in by referring physician
Chief Complaint:
PMD: based on the medication list, radiology portal reports, and insurance portal eligibility profile page it seems to be Dr (blank) "

I make ****ing make sure that my consult notes are sent and delivered. I personally send out consultation notes (every single one I write) to the PCP and relevant specialists involved. After I check out I just hit "new consult note" and send a few clicks and efax. Then i have my staff check the efax log and make sure it says SUCCESS on the next day. Whenver another physicians office complains to my front desk saying "they never got anything," I make sure my front desk sends them ANOTEHR COPY with the snapshot of the EFAX SUCCESS on the initial day of consultation.
While a courteous "hey I can't find the copy. please send it again" is fine and all, these other community doctosr front desk just gas light the patients with a "that doctor didn't send me anything." then the gaslit patient *****es and moans to my front desk and to me. I just whip out the proof of efax success and say "did you come here to fight tough guy/gal patient or something? what did you hope to accomplish? it's obviously your PCP's front desk is grossly incompetent and felt going to Page 2 on the inbox was too much work"

Although my notes are very very and somewhat hard to read quickly, I do put in BOLD on top of each problem list box what the recommendations/management items are to make the primary's lives easier. If they want to read the impression i write then more power to them.



I will admit when I see another consultant's notes in my inbox (RARE), I just check it in without a second glance. but when the patient VISITS me later, you can be sure I am reviewing it and transcribing the general idea into my note





but I digress...

yes I would agree that the Community neurologists aroud my neck of the woods seem more interested in doing (unnecessary) carotid dopplers and TCDs, pseudomotor autonomic testing, saline trigger point injections, EMGs, EEGs, portable sleep studies than tackling the harder cases.

I mean I get it.. more procedures more money. the "physical exam only and talking it out cases" just take more time and billing a higher 99215 has diminishing returns versus 99213 + procedures, but they seem to dislike treating movement disorders and dysphagia/dementia as much as a community GI hates irritable bowel syndrome...

heck I'm the one that is getting outpatient SLP, MBS, barium esophagrams etc.. done AFTER the patient has aspirated and had pneumonia already despite a glaring long term chronic dysphagia history... even after the same patient has seen GI and neurology in the community already. I mean SLP is a hospital based only service and there are myriad scheduling barriers (especially for low motivation patients) so its a lot of hard work.... but is important at the end of the day.

 

[DrStephenStrange]

This needs to be moved to the neuro forum for better discussion

 

[DrStephenStrange]

 

[DrMetal]

it's the future of medicine.

Yeah, I know it. And I know my specialty (hospital/internal medicine) will also go tele- , virtual- , NP-driven in the near future.
I fully realize much of medicine has become a facade, an illusion of things getting done, when nothing is really getting done.

But inpatient neurology has become the most egregious offense of this. I wish we'd recognize that and not consult them at all.

I have noticed that community neurologists seem to have become progressively less “useful” over the last several years.

It's astonishing. You'd think neurologists would/should have the greatest impact in the outpatient setting, where they can follow a patient for years (monitoring for progression of dementia, MS, ALS, etc). But no, they can't even seem to do that.

I run a small outpatient clinic. I rarely consult neurology. I'll manage mild dementia myself, staring meds. Moderate to advanced, I order PT/OT/SW/HH, no more meds. I usually have an easy time convincing families there's nothing to do but supportive care, and that a Neurologist would have nothing to add.

This needs to be moved to the neuro forum for better discussion

They'll tell us to just start ASA/Statin and get the MRI.

 

[DrMetal]

No. We hate you b/c you don't do jack. Aside from reading EEG/EMGs (much of which is BS), a neurologist does nothing that a well trained internist couldn't do. We consult Neurology b/c we have to, it's a facade.

It's interesting, Neurology used to be a subspecialty of IM. Don't know why/how they branched out on their own.

 

[dozitgetchahi]

Do you have a substantive response to the points we have raised above?

 

[dozitgetchahi]

No. We hate you b/c you don't do jack. Aside from reading EEG/EMGs (much of which is BS), a neurologist does nothing that a well trained internist couldn't do. We consult Neurology b/c we have to, it's a facade.

It's interesting, Neurology used to be a subspecialty of IM. Don't know why/how they branched out on their own.

I agree with the EMG bit. In rheumatology, I end up ordering a fair number of these for myositis, ?neuropathy situations with SLE/vasculitis, etc. I know EMGs can be nuanced studies with a lot of subjectivity etc etc BUT…there is one local neurologist who basically reads every single study as “normal” even in patients where things are clearly, blatantly, not normal. It just comes across as lazy, and probably incompetent too.

 

[DrStephenStrange]

No. We hate you b/c you don't do jack. Aside from reading EEG/EMGs (much of which is BS), a neurologist does nothing that a well trained internist couldn't do. We consult Neurology b/c we have to, it's a facade.

It's interesting, Neurology used to be a subspecialty of IM. Don't know why/how they branched out on their own.

Yet no one wants to do Neurology.

Yet we get consulted for altered mental status in patients with end-stage renal disease, intubated and sedated with a sodium of 128.

Yet these same IM internists are quick to call brain death in a patient with all their brainstem reflexes and following commands.

Good luck with the refractory seizure patients.

Good luck with refractory migraine patients.

Good luck with MS, NMO, MG, psychogenic patients, AIDP/CIDP with all its variants, etc.

Good luck recognizing subtleties on MRIs that perfectly explain patient's symptoms when radiologist completely missed them.

I hope you are ready for some tough discussions about what is going on with their brain.

I hope all of you realize that neurology does not only take care of TIAs/strokes.

Edit: Yet these same well-trained IM internists stop Eliquis that the patient has been taking for years because the patient has a stroke.

These same well trained IM internists called a stroke alert because the patient's left pinky toe is tingling.

I would also invite @Thama @Telamir @BlueBleck @Chibucks15 @Postictal Raiden to this thread

 

[dozitgetchahi]

Yet no one wants to do Neurology.

Yet we get consulted for altered mental status in patients with end-stage renal disease, intubated and sedated with a sodium of 128.

Yet these same IM internists are quick to call brain death in a patient with all their brainstem reflexes and following commands.

Good luck with the refractory seizure patients.

Good luck with refractory migraine patients.

Good luck with MS, NMO, MG, psychogenic patients, AIDP/CIDP with all its variants, etc.

Good luck recognizing subtleties on MRIs that perfectly explain patient's symptoms when radiologist completely missed them.

I hope you are ready for some tough discussions about what is going on with their brain.

I hope all of you realize that neurology does not only take care of TIAs/strokes.

We do. We just wish you’d step up to the plate and to a better job with all of it.

 

[DrStephenStrange]

Do you have a substantive response to the points we have raised above?

Sure I'll bite. But I should not have to.

 

[NewYorkDoctors]

Sure I'll bite. But I should not have to.

it's okay. if you are still Neurology PGY2 (based on DO class of 2022 probalby yes) then I hope you become an academic (useful) neurologist.

but seriously many community doctors (regardless of specialty or subspecialty) as a whole are just trying to pass the buck along and take shortcuts.
after all, who is going to sue the said community doctor for passing the buck to another specialist?
one gets sued for NOT referring to another specialist it seems...

 

[chessknt]

Even the best neurologists in my area are useless outside of their niche of stroke or movement disorders or whatever small population nonsense they actually bothered to learn. I try to give people the benefit of the doubt but the only specialty less useful than neuro for inpatients seems to be psych. Even on the outpatient side they are mostly useless, I have yet to have a single patient get anything answered by them, having to go to Mayo or somewhere else where neurologists still apparently think. They seem to exist solely to own their own MRI machines and do EMGs and MRIs every 3 months.

 

[NewYorkDoctors]

Even the best neurologists in my area are useless outside of their niche of stroke or movement disorders or whatever small population nonsense they actually bothered to learn. I try to give people the benefit of the doubt but the only specialty less useful than neuro for inpatients seems to be psych. Even on the outpatient side they are mostly useless, I have yet to have a single patient get anything answered by them, having to go to Mayo or somewhere else where neurologists still apparently think. They seem to exist solely to own their own MRI machines and do EMGs and MRIs every 3 months.

that is indeed very lucrative. I rotated through a private practice neurology practice in my IM residency. they had TWO MRI machines and two dedicated neuro-radiologists. good times indeed MRI away on everything and print money without the same radiation concerns as the nuclear pharm stress tests of the cardiologist.

in between do some MSK U/S, saline trigger point injections, some EEG/EMG reading, some infusion for MS meds. what a great set up financially.

but those attendings routinely made sure to make helpful recommendations and tried to reassure the patients for non-neurological issues rather than gaslight the patients one way or the other

 

[DrMetal]

Yet we get consulted for altered mental status in patients with end-stage renal disease, intubated and sedated with a sodium of 128.

A silly consult, always, we should be taking care of it on our own, in the same way we should be taking care of simple TIAs/Strokes. We consult you b/c hospital policy mandates it. It's dumb. And you guys do nothing to help out, only to say it's not organically neurological. Thanks.

Good luck with refractory migraine patients.

It's psychosomatic. These patients need a psychiatrist or therapist more than a neurologist; nobody's brave enough to tell them that.

Good luck with MS, NMO, MG, psychogenic patients, AIDP/CIDP with all its variants, etc.

This is where you might help, but only in the outpatient setting. And what you do exactly to fix it? Throw steroids at it, Pretty much nothing that a PCP couldn't do.

Good luck recognizing subtleties on MRIs that perfectly explain patient's symptoms when radiologist completely missed them.

BS. A neuroradiologist is always better at reading scans, you guys are delusional. And it's his signature at the bottom of the report, not yours.

Speaking of refractory seizures, the gif in your signature is giving me one. How ironic. Quick, someone consult Neuro for me so they can admire my disease.

 

[chessknt]

it's okay. if you are still Neurology PGY2 (based on DO class of 2022 probalby yes) then I hope you become an academic (useful) neurologist.

but seriously many community doctors (regardless of specialty or subspecialty) as a whole are just trying to pass the buck along and take shortcuts.
after all, who is going to sue the said community doctor for passing the buck to another specialist?
one gets sued for NOT referring to another specialist it seems...

He is in his first year of neurology and has already mastered the entire field of IM after his single year in it. You can tell the way he thinks a Na of 128 could cause a patient to be so obtunded to need an airway and that ESRD has any bearing at all on mental status. I've seen BUN 215 in an ESRD patient who was mentating completely fine, if anything it increases my expectations for mentation.

 

[DrStephenStrange]

A silly consult, always, we should be taking care of it on our own, in the same way we should be taking care of simple TIAs/Strokes. We consult you b/c hospital policy mandates it. It's dumb. And you guys do nothing to help out, only to say it's not organically neurological. Thanks.

Wow, we actually agree on something.
But I have seen hospitalists mismanage strokes so many times that I would still be more comfortable that we take a look at what you guys are doing.

It's psychosomatic. These patients need a psychiatrist or therapist more than a neurologist; nobody's brave enough to tell them that.

Not necessarily. We've treated them in clinic many times.

This is where you might help, but only in the outpatient setting. And what you do exactly to fix it? Throw steroids at it, Pretty much nothing that a PCP couldn't do.

This shows how much you don't know. I would trust any Neuro PGY2 or above managing these rather than a "well-trained" internist.

BS. A neuroradiologist is always better at reading scans, you guys are delusional. And it's his signature at the bottom of the report, not yours.

Would you look at this, we once again agree. But they still miss things all the time. That's why we always review our own images. I have had to call neuroradiologists many times (in my short 2 years as a resident) to make corrections in their readings. They are only human; they miss things too especially with the sheer volume of images they have to read. Nothing against neuroradiologists.

Speaking of refractory seizures, the gif in your signature is giving me one. How ironic. Quick, someone consult Neuro for me so they can admire my disease.

I should have had that Pokémon scene that had to be pulled from tv way back. Maybe then we would have a reason for some of the things I am reading on here.

I guess you did not have anything to say about everything else I said. And once again I agree with you for not responding.

 

[NewYorkDoctors]

He is in his first year of neurology and has already mastered the entire field of IM after his single year in it. You can tell the way he thinks a Na of 128 could cause a patient to be so obtunded to need an airway and that ESRD has any bearing at all on mental status. I've seen BUN 215 in an ESRD patient who was mentating completely fine, if anything it increases my expectations for mentation.

yeah as a resident or fellow, those consults are always annoying when nothing "organic to the specialty/subspecialty" is in play because it just seemed like extra work for no extra pay or potential for a PMID.

once the poster becomes an attending and the poster's license is in play (or if the poster is private and makes the easy quick money for an easy consult), I am sure drstranges tune will change.

"thanks for the easy consult internists"

 

[DrStephenStrange]

He is in his first year of neurology and has already mastered the entire field of IM after his single year in it. You can tell the way he thinks a Na of 128 could cause a patient to be so obtunded to need an airway and that ESRD has any bearing at all on mental status. I've seen BUN 215 in an ESRD patient who was mentating completely fine, if anything it increases my expectations for mentation.

I never said I did. But I don't think I need to be an expert to know that there are many reasons for this pt to be altered that do not require a neurologist. Everyone is different, one patient's BUN of 215 is not the same as another's.

 

[dozitgetchahi]

Even the best neurologists in my area are useless outside of their niche of stroke or movement disorders or whatever small population nonsense they actually bothered to learn. I try to give people the benefit of the doubt but the only specialty less useful than neuro for inpatients seems to be psych. Even on the outpatient side they are mostly useless, I have yet to have a single patient get anything answered by them, having to go to Mayo or somewhere else where neurologists still apparently think. They seem to exist solely to own their own MRI machines and do EMGs and MRIs every 3 months.

I agree with all of this.

Tertiary care seems to be the only place you can find a neurologist who is actually using their brain anymore. Out in the community? Good luck.

 

[MD46]

I agree with all of this.

Tertiary care seems to be the only place you can find a neurologist who is actually using their brain anymore. Out in the community? Good luck.

“neurologist who is actually using their brain anymore”
the irony of that statement intrigues me.

 

[DrStephenStrange]

I agree with all of this.

Tertiary care seems to be the only place you can find a neurologist who is actually using their brain anymore. Out in the community? Good luck.

Not saying this to disagree with you because I don't think I have seen enough neurologist's work out in the community yet to speak on it. However, our neurology residency program is community based, and our neurology attendings, I would say are some of the most passionate, knowledgeable, driven, hardworking, and caring people I have met. I would trust any of them with my life.

 

[CptNemo]

A pet peeve of mine is that neuro often cites "uremia" as being the cause of encephalopathy in my well dialyzed patients whose BUN happens to rise to the 50-60s in between dialysis sessions (because they are actually eating protein) or for CKD patients who live with BUNs in the 50- low 100s range. In fairness, a lot of the consults I get are done by PGY2s or 3s - and, if we are lucky, we get a generic addendum from the attending (who may or may not have seen the patient) a few days later. I do get the sense that the inpatient service is an afterthought. I've had much better experiences with neuro on the outpatient side.

It usually then leads to an easy nephrology consult for me where I either find that 1) the patient is on a combo of a crap ton of baclofen, gabapentin, and opiates or 2) they've been in the ICU for weeks with various infections on various ABx (cefepime, ertapenem, which can cause neurotoxicity) or 3) I tell them to keep looking for other causes (as nothing is obvious except for the fact that it is not uremia causing the encephalopathy).

Normally, I wouldn't mind the easy consults, but then the problem is that the surgeons or ACCM really anchor to what neuro says, so they strongly request dialysis for "uremia" in patients with CKD 3B who have no dialyzable meds on board... and then they get angry at me for not wanting to dialyze.

 

[Splenda88]

I send a message to the neurologist and get back some confused response like “oh I was seeing him for seizures?” No ****, dude, why do you think he’s on a laundry list of seizure meds? Did you see my consult order which listed “seizures” as the reason for referral? Did you read my note? (On second thought, I know you didn’t, because nobody ever seems to read other doctors’ notes anymore). You think I’m the one monitoring those seizure meds?

I wish I could say this was a one-time occurrence, but I have seen goofy nonsense like this over and over and over again from neurologists across four different states in which I have worked. I’m not sure if the whole specialty has just gone off the rails or something, but it seems to be very difficult to get a “useful” neurology consultation at this point. The visits/notes seem to be all sound and fury, signifying nothing.

Based on my limited experience, hospitalists do

 

[DrStephenStrange]

A pet peeve of mine is that neuro often cites "uremia" as being the cause of encephalopathy in my well dialyzed patients whose BUN happens to rise to the 50-60s in between dialysis sessions (because they are actually eating protein) or for CKD patients who live with BUNs in the 50- low 100s range. In fairness, a lot of the consults I get are done by PGY2s or 3s - and, if we are lucky, we get a generic addendum from the attending (who may or may not have seen the patient) a few days later. I do get the sense that the inpatient service is an afterthought. I've had much better experiences with neuro on the outpatient side.

It usually then leads to an easy nephrology consult for me where I either find that 1) the patient is on a combo of a crap ton of baclofen, gabapentin, and opiates or 2) they've been in the ICU for weeks with various infections on various ABx (cefepime, ertapenem, which can cause neurotoxicity) or 3) I tell them to keep looking for other causes (as nothing is obvious except for the fact that it is not uremia causing the encephalopathy).

Normally, I wouldn't mind the easy consults, but then the problem is that the surgeons or ACCM really anchor to what neuro says, so they strongly request dialysis for "uremia" in patients with CKD 3B who have no dialyzable meds on board... and then they get angry at me for not wanting to dialyze.

Not sure how other neuro residencies do things, but I know Neuro residents work some of the longest hours out of any residency programs and therefore sometimes we can miss things especially when we have 30-40 patients on our list. Still not an excuse to miss things such as the ones you mentioned above, and this is why an attending should always see the patient and sign on the resident's notes. At least at our program, our attending sees every single patient that we see. If attending does not see a patient, we usually mention that in our notes that the attending did not see because of whatever reason, and that they will see the following day. However, I think we still usually do a good job at catching some of the things that you mentioned, and our notes usually says something like "encephalopathy is likely multifactorial in the setting of ESRD with BUN of ... Cr of ... and sedation or other drugs such as ... and ammonia ... and other causes. We don't typically tend to blame one thing for encephalopathy unless we truly cannot find anything else despite thorough workup.

 

[dozitgetchahi]

Not saying this to disagree with you because I don't think I have seen enough neurologist's work out in the community yet to speak on it. However, our neurology residency program is community based, and our neurology attendings, I would say are some of the most passionate, knowledgeable, driven, hardworking, and caring people I have met. I would trust any of them with my life.

That’s good. I wish the rest of the practitioners of your specialty lived up to all of that. You will have a chance to go out and do it right once you’re through with training.

 

[Splenda88]

A silly consult, always, we should be taking care of it on our own, in the same way we should be taking care of simple TIAs/Strokes. We consult you b/c hospital policy mandates it. It's dumb. And you guys do nothing to help out, only to say it's not organically neurological. Thanks.



It's psychosomatic. These patients need a psychiatrist or therapist more than a neurologist; nobody's brave enough to tell them that.



This is where you might help, but only in the outpatient setting. And what you do exactly to fix it? Throw steroids at it, Pretty much nothing that a PCP couldn't do.



BS. A neuroradiologist is always better at reading scans, you guys are delusional. And it's his signature at the bottom of the report, not yours.

Speaking of refractory seizures, the gif in your signature is giving me one. How ironic. Quick, someone consult Neuro for me so they can admire my disease.

Why all the heat toward neurologists?

The locum neurologists at my hospital are good.

 

[Splenda88]

Do people consult neurologists for encephalopathy? Where do you guys practice?

 

[DrStephenStrange]

Do people consult neurologists for encephalopathy? Where do you guys practice?

My favorite encephalopathy consults: Patient came in combative got Haldol and a **** tone of benzos, now too somnolent and cannot protect airway requiring intubation and sedation. Consult neurology for altered mental status - we cannot for the love of God figure this out.

Edit: Often said patient also came in with drugs in their system.

 

[DrMetal]

But I have seen hospitalists mismanage strokes

And pray tell, how do you 'manage' strokes? Here's a news flash: There's no such thing as management of a stroke. It happens, it is what it is. All we do afterwards is medications to prevent the next one, PT/OT/Speech for rehab, etc. Barring the minute cases where tPA and IR is indicated, we don't fix them. A neurologist can't do a damn thing about it. But nobody wants to admit this, so we consult away as per some silly hospital protocol or order set. Hence why neurology as so quickly become a tele-medicine service, we know it's a ruse.

This shows how much you don't know. I would trust any Neuro PGY2 or above managing these rather than a "well-trained" internist.

Residents probably work harder than attendings, but only b/c the have to. Log back here after practicing as an attending neurologist for 10 years, tells us how many strokes you've fixed. Your specialty is futile. So is mine in many ways, but at least I make that admission, and least we do occasionally cure something.

Why all the heat toward neurologists?

The locum neurologists at my hospital are good.

I believe you. But what's your definition of good? Now the new definition of good with respect to a Neurologist is one who actually shows up in person.

 

[Splenda88]

My favorite encephalopathy consults: Patient came in combative got Haldol and a **** tone of benzos, now too somnolent and cannot protect airway requiring intubation and sedation. Consult neurology for altered mental status - we cannot for the love of God figure this out.

Edit: Often said patient also came in with drugs in their system.

I don't consult neurologist for encephalopathy. My impression is that a lot of these consults might be coming from midlevels or physicians who don't want nurses to keep bugging them.

For instance, the other day, I saw how a nurse and the charge RN forced a nocturnist to call neurosurgeon at 5 am even if the norturnist told them he will notify him at 7am. Trauma patient s/p MVA with a repeat CT head that said: Interval development of diffuse axonal injury and 2mm of epidural hematoma. The nocturnistt received 3 calls in a span of 10 minutes until he caved in.

Neurosurgeon note at 7:45 am: "I review the CT, nothing to do"

 

[DrStephenStrange]

And pray tell, how do you 'manage' strokes? Here's a news flash: There's no such thing as management of a stroke. It happens, it is what it is. All we do afterwards is medications to prevent the next one, PT/OT/Speech for rehab, etc. Barring the minute cases where tPA and IR is indicated, we don't fix them. A neurologist can't do a damn thing about it. But nobody wants to admit this, so we consult away as per some silly hospital protocol or order set. Hence why neurology as so quickly become a tele-medicine service, we know it's a ruse.

I agree it's not that hard, and many hospitalists do those on their own competently. But when certain Hospitalists just don't know when to start DAPT vs ASA or Plavix alone, when they stop anticoagulant in a compliant patient coming in with new stroke and ending up with another bigger stroke, or when they start Lipitor 80 on a patient with LDL of 10, and when the stroke looks clearly cardioembolic and they want to get pt out quickly without doing an echo, it kinda give me a pause a little bit.

I believe you. But what's your definition of good? Now the new definition of good with respect to a Neurologist is one who actually shows up in person.

I believe this may be due to how bad the shortage is to find general neurologists. 80-90 percent of neuro grads end up doing a fellowship with many leaving general neurology behind afterwards. This leads to the small amount of general neurologists left stretched out thin. Many just take teleneuro gig on the side on top of their actual job. It has gotten so bad, that Hospitals are even recruiting people in residency. I have gotten offers even when I was a PGY1, with some offering up to 100K with bonus while in residency. So I don't think this is entirely due to Neurologists being lazy.

 

[NewYorkDoctors]

Not saying this to disagree with you because I don't think I have seen enough neurologist's work out in the community yet to speak on it. However, our neurology residency program is community based, and our neurology attendings, I would say are some of the most passionate, knowledgeable, driven, hardworking, and caring people I have met. I would trust any of them with my life.

perhaps the best to discern things (regardless of specialty/subspecialty) is

academic / research based / tertiary care center based / or somewhat affiliated with education but has enough pride to stay up to date on on things and give a ****

versus

community based / solo or small group private practice / do NOT stay up to date or give a **** enough to do things "by the book" thoroughly and completely.


the usual dichotomy is research versus nonresearch but the lines are not so clear cut sometimes.

sounds like you have a great non-tertiary care non-bench research group of clinicians who really care about the discipline and your education. just carry it forward.

 

[Splenda88]

One of the neurologist that comes to my site told me he got paid $3600/day. That is a pretty good deal for a 4-year residency.

 

[MD46]

I think its not fair to bash a resident in training who doesnt have enough experience or insight into the field of neurology yet to defend his points or make one.

Also honestly speaking from an Internist or a Primary care physicians point of view things are being over simplified.

I could argue here that more than 90% of the consults we as heme oncs get from the hospital are also things a “good internist” should be able to handle. Why consult us then? Reason is we have way more insight and depth of knowledge than the average internist/hospitalist in regards to the disease in question. The number is higher for almost all Oncology things.


I think we should respect each others specialities and opinions. Each speciality is important in its own way, I will also go ahead and say this that most hospitalist arent jack of all trades out side of run of the mill inpatients PNA, CHF ex, COPD ex, HTN urg/emg , DKA etc. For most things no one is making you consult a speciality (out side of stroke and MI) so why consult for a platelet of 120k, Hb of 10.9, wbc of 2.7 etc where there is an obvious explanation.

 

[CluvK]

It is funny to see all the discussions here. Just to share a story. Back in my IM PGY-2 year, I was pre-rounding on a patient, and noticed some muscle twitches at the left corner of their mouth. The patient had a history of seizures, but seemed quite alert. Unsure of what was happening, I grabbed a passing neurology resident for a quick look. Within seconds, the resident identified it as a seizure, and we jumped into action administering Ativan and fosphenytoin. Then my attending came in like "what are you guys doing here". That day, l learned a new term- "Epilepsia partialis continua."

 

[chessknt]

Do people consult neurologists for encephalopathy? Where do you guys practice?

Only when I can't figure it out. Like if someone is off sedation for 4 days, has brainstem reflexes but won't do anything with normal labs and a normal CT and a normal EEG then i consult neurology and ask them WTF is going on why does this person not care about the 10.5 mm piece of hard plastic sitting in the glottis. Because if someone is going to do an LP I'd like to know what weird ass labs to order on it. I never get an answer of course they just shrug their shoulders and tell me it isnt a stroke but hey, I have to try and CYA when I tell the family that nobody in the hospital knows why grandpa won't wake up any more.

 

[dozitgetchahi]

I don't consult neurologist for encephalopathy. My impression is that a lot of these consults might be coming from midlevels or physicians who don't want nurses to keep bugging them.

For instance, the other day, I saw how a nurse and the charge RN forced a nocturnist to call neurosurgeon at 5 am even if the norturnist told them he will notify him at 7am. Trauma patient s/p MVA with a repeat CT head that said: Interval development of diffuse axonal injury and 2mm of epidural hematoma. The nocturnistt received 3 calls in a span of 10 minutes until he caved in.

Neurosurgeon note at 7:45 am: "I review the CT, nothing to do"

I don’t consult them for encephalopathy. Likewise, I don’t care how they manage dementia, because I know nobody’s got a solution for that.

BUT

I would really like to see them do a good job on the rest of the bread and butter they should be good at. Like seizures. And basic movement disorders. And holy god, don’t ask Your Local Neurologist to manage even a garden variety case of MS anymore, because apparently that always needs a subspecialist now.

This isn’t about bull**** consults for encephalopathy or whatever. It’s about me consulting them when I have a lupus patient with a brain MRI with white matter changes, me asking them if it’s possible they have MS or is it just SLE (or is it nothing), and getting no useful response. Or me sending them a seizure patient, on seizure meds, and getting back some nonsensical note babbling about neuropathy, with nothing done to follow the seizures.

As a rheumatologist, this would be like me whiffing hard on RA, or basic cases of lupus, etc etc. I shouldn’t be sucking at things that I should be really good at as a board certified rheumatologist. Furthermore, I’m well trained and I feel pretty confident tackling the harder and more obscure stuff in my specialty, like exotic varieties of vasculitis, antisynthetase syndrome, etc. But lots of community neurologists these days seem to suck at their bread and butter, and they won’t even try to manage anything slightly obscure themselves. (Off to tertiary care with you.) Now I get that the quality of physicians and medical care in general seems to have declined of late, and we can debate the reasons for that. But for whatever reason, it seems to be much more noticeable in the specialty of neurology than it is in others. And I’m wondering why that’s the case.

 

[VA Hopeful Dr]

I don’t consult them for encephalopathy. Likewise, I don’t care how they manage dementia, because I know nobody’s got a solution for that.

BUT

I would really like to see them do a good job on the rest of the bread and butter they should be good at. Like seizures. And basic movement disorders. And holy god, don’t ask Your Local Neurologist to manage even a garden variety case of MS anymore, because apparently that always needs a subspecialist now.

This isn’t about bull**** consults for encephalopathy or whatever. It’s about me consulting them when I have a lupus patient with a brain MRI with white matter changes, me asking them if it’s possible they have MS or is it just SLE (or is it nothing), and getting no useful response. Or me sending them a seizure patient, on seizure meds, and getting back some nonsensical note babbling about neuropathy, with nothing done to follow the seizures.

As a rheumatologist, this would be like me whiffing hard on RA, or basic cases of lupus, etc etc. I shouldn’t be sucking at things that I should be really good at as a board certified rheumatologist. Furthermore, I’m well trained and I feel pretty confident tackling the harder and more obscure stuff in my specialty, like exotic varieties of vasculitis, antisynthetase syndrome, etc. But lots of community neurologists these days seem to suck at their bread and butter, and they won’t even try to manage anything slightly obscure themselves. (Off to tertiary care with you.) Now I get that the quality of physicians and medical care in general seems to have declined of late, and we can debate the reasons for that. But for whatever reason, it seems to be much more noticeable in the specialty of neurology than it is in others. And I’m wondering why that’s the case.

After spending a few days with a community neurologist when I was in med school, I kinda get why they often act as they do.

At least 50% of the new patient referrals we saw were clearly psychiatric in nature. Dude wrote more SSRIs than anti-seizure meds. Lots of people in the community refer to neurology for utter nonsense. That doesn't excuse doing a poor job on legit neuro cases, but I can understand.

 

[DrMetal]

After spending a few days with a community neurologist when I was in med school, I kinda get why they often act as they do.

At least 50% of the new patient referrals we saw were clearly psychiatric in nature. Dude wrote more SSRIs than anti-seizure meds. Lots of people in the community refer to neurology for utter nonsense. That doesn't excuse doing a poor job on legit neuro cases, but I can understand.

A great mentor once told me, the difference between a Psychiatrist and a Neurologist is: in the absence of any true medical pathology, the Psychiatrist will admit as much and treat the relevant mental health condition. The Neurologist wont recognize the paucity of true medical/neurological disease, will make some crap up after fake reading an EEG, then proceed to treat something that's not there. The neurologist is the true charlatan! [This conversation was over whiskey, of course.]

I see this a lot in military medicine, unfortunately, where (because we fear anything neurological, TBI related), we're very quick to send people to neurology for silly things like pseudo-seizures (which are clearly psychosomatic). Sure as crap, the neurologist reads the EEG, calls it epilepsy and starts anti-epileptics on someone who really needs a psychiatrist instead.

 

[rokshana]

This shows how much you don't know. I would trust any Neuro PGY2 or above managing these rather than a "well-trained" internist.

Would you look at this, we once again agree. But they still miss things all the time. That's why we always review our own images. I have had to call neuroradiologists many times (in my short 2 years as a resident) to make corrections in their readings. They are only human; they miss things too especially with the sheer volume of images they have to read. Nothing against neuroradiologists.

this is m\id level thinking...your Dunning Kruger is showing...

 

[dozitgetchahi]

After spending a few days with a community neurologist when I was in med school, I kinda get why they often act as they do.

At least 50% of the new patient referrals we saw were clearly psychiatric in nature. Dude wrote more SSRIs than anti-seizure meds. Lots of people in the community refer to neurology for utter nonsense. That doesn't excuse doing a poor job on legit neuro cases, but I can understand.

Oh I agree, and as a rheumatologist I totally get it, because we get inundated with that sort of nonsense also and it can be hard to distinguish signal from noise.

I also think that when you see so much nonsense all the time, it can be harder to spot when something “real” is going on. So I agree that there is an element of this there.

 

[greatnt249]

They'll tell us to just start ASA/Statin and get the MRI.

You forgot the echo with bubble study even if they just had an echo within the past few weeks...and they're in atrial fibrillation and not on anticoagulation.

 

[Splenda88]

You forgot the echo with bubble study even if they just had an echo within the past few weeks...and they're in atrial fibrillation and not on anticoagulation.

You guys are really after neurologists.

I don't know if it's appropriate for physicians to disparage their colleagues if we don't really know what they do.

I really don't think 2 wks of neurology as a med student and 4 weeks as an IM resident give me a full understanding of what neurologists do.

We should not be like many (probably most) surgeons who think anyone can do our jobs (non surgical specialties), but no one can do theirs.

 

[greatnt249]

You guys are really after neurologists.

I don't know if it's appropriate for physicians to disparage their colleagues if we don't really know what they do.

I really don't think 2 wks of neurology as a med student and 4 weeks as an IM resident give me a full understanding of what neurologists do.

We should not be like many (probably most) surgeons who think anyone can do our jobs (non surgical specialties), but no one can do theirs.

Since I'm the one responsible for interpreting the aforementioned test which, under those circumstances, is exceedingly unlikely to reveal any new clinically-pertinent information that will change the management of said patient, my comment stands. It's less a disparagement of the specialty as a whole and more of a call to, as others have stated, "do better" as a physician. I've seen enough "cookie cutter" consult notes asking for tests with low clinical yield to feel safe in coming to the conclusion that, in many cases, it's less about the diagnostic yield and more about stamping a note in the chart ignoring what tests may have already been done, which then tends to back whatever hospitalist is taking care of the patient into a corner as to what to do.

 

[dozitgetchahi]

You guys are really after neurologists.

I don't know if it's appropriate for physicians to disparage their colleagues if we don't really know what they do.

I really don't think 2 wks of neurology as a med student and 4 weeks as an IM resident give me a full understanding of what neurologists do.

We should not be like many (probably most) surgeons who think anyone can do our jobs (non surgical specialties), but no one can do theirs.

I don’t think I can do their job, at all. They do a lot of things I can’t and that’s why I need them to pick up the ball when I send them a patient and actually do the work.

My first priority as a consultant is to try to make a positive difference in the patient’s symptoms, to bring clarity to the situation, and to try to help out the doc asking for help - and if I can’t, at least to try to get the patient to someone who can. They should be doing this too.

 

[DrMetal]

You guys are really after neurologists.

I don't know if it's appropriate for physicians to disparage their colleagues if we don't really know what they do.

Awww c'mon, what fun would SDN be then? It's fun ragging on my 2 most hated specialties (Neuro and Emergency medicine)

Here's the thing: we all know Neurology is not an effective in-patient service, really. We also know this about Rheum and Endocrine, hence most community hospitals don't have a staff endocrine or rheum for inpatient consults (academic ones do). Which is fine most times, we get a patient through their DKA or Lupus flare, they follow up with their outpatient Rheum or Endocrine, and this is where they get helped the most by those specialists (in the outpatient setting).

Rheum and Endocrine will admit that much. And the hospital doesn't have a mando rule to consult Endocrine on every DKA, or Rheum for every lupus flare admission.

But for some reasons, Neurologist wont admit how useless they are in the inpatient setting, and hospitals continue to require neuro consults for every weak TIA admission. Go figure.