"Neurology: A Dismal Science with a Dismal Prognosis"

[NeuroDocDO]

This article is very disheartening. Please discuss.



Neurology. 2013 Apr 24. [Epub ahead of print]
Economics of neurology 101: The dismal science meets the dismal prognosis.
Ney JP, Nuwer MR.
Source
From the Comparative Effectiveness, Cost and Outcomes Research Center (J.P.N.), University of Washington, Seattle; and Clinical Neurophysiology (M.R.N.), Reed Neuro Research Center, University of Los Angeles, Los Angeles, CA.
Abstract
In the coming decades, we are faced with a massive demographic shift: the nation as a whole is getting older, by leaps and bounds. The number of persons in the oldest demographic, ages 85 and older, is expected to expand from 5.8 million in 2010 to 8.7 million in 2030, to 19 million in 2050.1 Barring miracle cures, these persons will carry a disproportionate burden of chronic neurologic diseases, including dementia, parkinsonism, and stroke. By these measures, the demand for neurologists should increase dramatically.

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[neurologist]

So what?

Since there won't be any "miracle cures," sounds like at least low-paying job security for those neurologists who don't mind taking care of people with chronic, progressive, debilitating, incurable diseases.

What we need to watch out for is the the issue of cost containment and resource management. It's OK if the 85+ demographic increases, but each and every person over 80 should have a mandatory consult to palliative care medicine and the letters D-N-R tattooed on their foreheads in big red letters.

 

[DD214]

There can be a ton of demand but if there isn't any money to pay for our services, well......

 

[neglect]

So what?

So a few things:

1. Less med students are going to go into neurology. We tend to draw the best and the brightest among those for whom no other organ system is interesting. But if these med students see that the writing is on the wall, which it is, and they have 200K debt, then they will choose, rationally, to go into other areas. IMO, neurology also attracts those who are so slothful or stupid that they feel that they are not cut out for internal medicine (not in my group or residency or fellowship though!). These people won't go into neuro. it would be nice to say good riddance, except neurology needs them, and many become very good neurologists.

2. Our reimbursement will be cut. To a large extent this is already happening. We have seen decreases in reimbursement for nerve conduction studies, and now we find that primaries get a 10% bonus for performing the same cognitive work. This is hard to swallow. And hard to maintain a practice on a business level.

3. Our work is cut out for us. As the population ages, and wants to age gracefully, we will be inundated. This will help, because we can negotiate better rates with insurance carriers. But the day-to-day work of being a neurologist will grow more demanding. More urgent consults. Because although primaries pretend that we offer no added benefit, and (see above) certainly some stupid neurologists don't, they need us for many neurologic problems. For example, it is very rare for clear-cut Alzheimer's disease patients to be told that they have Alzheimer's disease, ditto Parkinson's, ditto most everything.

4. Neurology is changing. What if a new disease modifying agent becomes available for Parkinson's disease or Alzheimer's disease? Then it becomes a vital to find qualified individuals to diagnose and manage these neurologic diseases. If by nothing other than default, neurologists are the qualified ones.

Personally, given the recent developments in the economics of neurology, I do not recommend that any student, who could happily choose another field, enter ours. I say this with a great deal of regret. But things are going to change less than they remain the same. And the way things are puts our specialty at in economic disadvantage, which will continue because we are small in number and thus unable to organize ourselves.

 

[Armadillos]

So a few things:

1. Less med students are going to go into neurology. We tend to draw the best and the brightest among those for whom no other organ system is interesting. But if these med students see that the writing is on the wall, which it is, and they have 200K debt, then they will choose, rationally, to go into other areas. IMO, neurology also attracts those who are so slothful or stupid that they feel that they are not cut out for internal medicine (not in my group or residency or fellowship though!). These people won't go into neuro. it would be nice to say good riddance, except neurology needs them, and many become very good neurologists.

2. Our reimbursement will be cut. To a large extent this is already happening. We have seen decreases in reimbursement for nerve conduction studies, and now we find that primaries get a 10% bonus for performing the same cognitive work. This is hard to swallow. And hard to maintain a practice on a business level.

3. Our work is cut out for us. As the population ages, and wants to age gracefully, we will be inundated. This will help, because we can negotiate better rates with insurance carriers. But the day-to-day work of being a neurologist will grow more demanding. More urgent consults. Because although primaries pretend that we offer no added benefit, and (see above) certainly some stupid neurologists don't, they need us for many neurologic problems. For example, it is very rare for clear-cut Alzheimer's disease patients to be told that they have Alzheimer's disease, ditto Parkinson's, ditto most everything.

4. Neurology is changing. What if a new disease modifying agent becomes available for Parkinson's disease or Alzheimer's disease? Then it becomes a vital to find qualified individuals to diagnose and manage these neurologic diseases. If by nothing other than default, neurologists are the qualified ones.

Personally, given the recent developments in the economics of neurology, I do not recommend that any student, who could happily choose another field, enter ours. I say this with a great deal of regret. But things are going to change less than they remain the same. And the way things are puts our specialty at in economic disadvantage, which will continue because we are small in number and thus unable to organize ourselves.

Are the challenges facing neurology truly unique to neurology? Seems like things can change over night in any and all fields (except maybe derm/plastics).

 

[2heavy]

Fascinating field with reasonable pay and tons of opportunity. Have thought this ever since I studied neuroscience way back in college. Every field is worried about reimbursement, especially anyone doing minor procedures as they will invariably be scaled back on reimbursement. Fortunately, I train with some of the best and brightest which makes it that much better.

 

[neglect]

Are the challenges facing neurology truly unique to neurology? Seems like things can change over night in any and all fields (except maybe derm/plastics).

Perhaps, but the fact is that they did change in neurology.

I'm not bitter. I feel obligated to say that I personally feel fulfilled with my career in neurology. Neurology is a great profession. It is a rich and dignified and interesting field. Even lay people take an interest. Our diseases are generally feared and respected and common. Many of us have the honor of treating them and working on better treatments for the next generations. (Others do fellowships in pain).

I also occupy a position that seems highly privileged by today's standards: I graduated med school with <50,000 dollars in debt with no family. Now my wife works and we live modestly (2000 sq foot house in suburbs, cars circa 2004 and 2009), but we still stress about funds for sending our kids to college.

I say again, most medical students who go into neurology do not consider the financial hit. I certainly didn't. It feels churlish to complain as my take home in 2012 reached very high, but 2012 was my highest salary due to non-repeatable forces (trials that enrolled well, a government welfare check for using EMR, and some legal stuff) and it will be the highest, literally, for years to come. One force that isn't considered, which drastically lowers our ability to earn and makes things much less enjoyable is the EMR. My partners can't type, so they have to slow down markedly. Less patients per hour, less money vs. hiring a med assistant so they can work harder to make more money. Except billings have been cut for NCV and EMGs.

 

[Armadillos]

I say again, most medical students who go into neurology do not consider the financial hit. I certainly didn't.

If you took the medstudents starting residency in a couple months and compared their lifetime earnings, how would you rank Peds, Neuro, Family, Psych, Non-fellowship IM?

It would just seem hard to believe that neuro would expect to be making less than all of those fields (which by total number of MD's is a huge chunk of all doctors).

 

[BlackFrancis33]

This very well written editorial is hard to dispute, IMO. We are a specialty which tethered ourselves to EMG/NCSs to pay for our practices. With a, significant, cut to a single procedure the most integral part of our profession, providing E/M for neurological disorders, now is financially untenable for many. How can you talk to an interested medical student, and rationalize that we are now paid less for seeing common neurological diseases than a primary care physician? Especially, when the procedure we used to support ourselves was cut by 60%. The president of the AAN, called this (paraphrase) the most dismal of fiscal times for neurology at the AAN Annual Meeting.

We now have to go back and do comparative effectiveness research, to prove that we in fact provide better care for patients with the most common neurological illnesses?! Now that is a dismal prognosis.

 

[Neuro321]

As a M4 who will be applying to Neurology, shouldn't this be the exact time the field is encouraging the future generation of physicians to become interested in this field to enter it? A group of young and future physicians who (potentially) could address some (or all) of the concerns mentioned, push the field forward to care for the ever growing aging population and the eventual fall out of neurologic disease as a result?

I do understand the concerns are real. But I also foresee if those in the profession discourage the younger generation, then there is truly no hope. Also, in general, is not the entire landscape of healthcare changing? It is my understanding that very few fields (if any) will look like they did 10 or even 5 years ago by the time Med Students are practicing as Neurologists or other physicians. So is it possible to accurately predict the future in these terms for any specialty?

I appreciate your honest concerns and comments regarding the profession, but as a student, I couldn't see myself interested enough in any other specialty to enter it. It is because "no other organ system is interesting" to me but I surly hope it's not because I am "slothful or stupid that feel that [i am] not cut out for internal medicine."

 

[neurologist]

.

 

[danielmd06]

As a M4 who will be applying to Neurology, shouldn’t this be the exact time the field is encouraging the future generation of physicians to become interested in this field to enter it? A group of young and future physicians who (potentially) could address some (or all) of the concerns mentioned, push the field forward to care for the ever growing aging population and the eventual fall out of neurologic disease as a result?

I do understand the concerns are real. But I also foresee if those in the profession discourage the younger generation, then there is truly no hope. Also, in general, is not the entire landscape of healthcare changing? It is my understanding that very few fields (if any) will look like they did 10 or even 5 years ago by the time Med Students are practicing as Neurologists or other physicians. So is it possible to accurately predict the future in these terms for any specialty?

I appreciate your honest concerns and comments regarding the profession, but as a student, I couldn’t see myself interested enough in any other specialty to enter it. It is because "no other organ system is interesting” to me but I surly hope it’s not because I am "slothful or stupid that feel that [i am] not cut out for internal medicine."

If this is your attitude, won't you pursue neurology anyway?

The competitiveness of the field has nothing to do with what we post on SDN, but rather how much money pops up on the MGMA lists and on google versus other specialties with more or less training (the same as it did when I was applying). .

 

[grt398]

So I know I’m just a medical student, but I’d strongly advise people consider the well worn, often repeated advice that you should choose a field you’re interested in b/c the future of reimbursement can change dramatically. To play a bit of devil’s advocate, every specialty is getting slammed and I thought it might be useful to start with ROAD and go from there:

Radiology – head over to auntminnie to see their current situation; having worked in Radiology at a Harvard hospital for 2 years prior to medical school, I can definitely say that even residents at top institutions are being forced to do 2 fellowships and still have trouble finding a job they want. CMS continues to cut their fees heavily.

Ophtho – no idea what’s going on in this field

Anesthesia – head over to their forums and you’ll see things aren’t exactly rosy. Ongoing CRNA encroachment and other factors are leading many to discourage students from pursuing this field and expectations for future salaries are in the ~$250k range resulting in an argument that why bother with all the hassle and stress when you can be a hospitalist or EM doc and make the same for half the work.

Derm/Plastics – if you can successfully run a cash business in one of these (and it’s a very competitive market to do so), obviously you’ll be fine regardless.

Path – head to their forums and see the disaster that is the current job market

Interventional cards – CMS taking a machete to reimbursement has massively reduced starting salaries, with no change in workload or call responsibilities. Since cards remains one of the biggest Medicare expenditures, I’d be surprised if the cuts didn’t continue in the future. Feel free to read the thread below if you’re curious:

http://forums.studentdoctor.net/showthread.php?t=972755

GI – no idea about this field but if their high income primarily derives from a single or limited number of procedures, I wouldn’t hold out high hopes (see interventional cards above + cardiac surgery cuts from many years ago)

Spine surgery – the current king of reimbursement; everyone in the field I’ve spoken to expects substantial cuts in the future since they are having a difficult time proving the value of all the (multi-level) fusions being done these days.

Reduced reimbursement for all physicians seems to be the only safe bet going forward. It’s just my opinion, but I wouldn’t be surprised in the future if salaries across all specialties were a lot closer with something like primary care earning $150-200k, medical specialties $200-$250k, gen surg at $250-300k, and things like ortho/neurosurg doing $300-400k, which is along the lines of many academic salaries. Particularly with the massive push for an employment model of healthcare. Add in a likely increase in taxes across the board given the country’s financial situation and more bundling of payment rather than FFS, and I’d really take a close look at whether you want to bank on what may quickly become a relatively small after-tax difference in income.

And thank you to all the attendings who consistently post in the forum for the wealth of information you’ve provided about so many aspects of neurology.

 

[danielmd06]

So I know I'm just a medical student, but I'd strongly advise people consider the well worn, often repeated advice that you should choose a field you're interested in b/c the future of reimbursement can change dramatically.

Absolutely agree.

With the reimbursement climate changing I just want potential applicants to be aware of some pitfalls. It has nothing to do with being angry, or bitter, or jealous of other specialties, but is rather just a desire to educate and be honest with those who are looking into neurology. I am not urging people to always run screaming in the other direction away from neuro, but please be cognizant of what is going on in the field right now if you are interested in joining it.

 

[BlackFrancis33]

Look, I love neurology. I couldn't imagine doing another specialty and if I could go back in time I would still do neurology in a heartbeat. I think that includes many of the attendings you see posting on this forum. But, that doesn't mean these aren't really rough times in neurology. Again, I get paid less than physicians with less expertise to do the same work. The procedure practices used to make up that loss has been gutted. If EEGs get cut significantly next, you may not be able to find a private neurology practice in 5-10 years (especially in metro areas). If it makes you feel better to point out that other specialties are also being similarly cut hang on to that. If you rotate with me as a med student, I will tell you why I think Neurology is a great specialty, but I won't blow sunshine up your a#$ about the current fiscal environment.

 

[grt398]

Look, I love neurology. I couldn't imagine doing another specialty and if I could go back in time I would still do neurology in a heartbeat. I think that includes many of the attendings you see posting on this forum. But, that doesn't mean these aren't really rough times in neurology. Again, I get paid less than physicians with less expertise to do the same work. The procedure practices used to make up that loss has been gutted. If EEGs get cut significantly next, you may not be able to find a private neurology practice in 5-10 years (especially in metro areas). If it makes you feel better to point out that other specialties are also being similarly cut hang on to that. If you rotate with me as a med student, I will tell you why I think Neurology is a great specialty, but I won't blow sunshine up your a#$ about the current fiscal environment.

I appreciate the feedback and it's not about feeling better that other specialties are being cut. With some exceptions (derm/plastics/direct primary care), I actually don't expect private practice to exist in most specialties in 10 years. I'm not saying there won't be multispecialty mega-groups of several hundred or thousand physicians, but there seem to be too many external forces pushing the elimination of small, independent practice and the consolidation of all medical specialties into medical homes/ACO's/whatever you want to call them. It's unfortunate for a variety of reasons and I've been told by physicians in multiple specialties that it's one of the biggest frustrations, along with the endless and growing paperwork, that they face daily. I realize it's a different conversation but PPACA already made inroads to eliminating the outpatient imaging centers and ambulatory surgery centers, I'd be surprised if similar incentives weren't used on an increasing basis, i.e. paying substantially more for the same procedure performed at a hospital than one performed at an outpatient clinic, to fuel further consolidation. There's a lot of other carrots and sticks as well obviously. Regardless of the method used, consolidation appears to be the name of the game since it's a lot easier to "persuade" a dozen large healthcare corporations than several hundred thousand independent practitioners.

Anyway, bit of a rant. I'm well aware the current environment sucks, I just wanted to play a bit of the other side and point out that challenges aren't limited solely to neurology.

 

[neurodoc]

So a few things:

...

1. Less [fewer] med students are going to go into neurology. We tend to draw the best and the brightest among those for whom no other organ system is interesting. But if these med students see that the writing is on the wall, which it is, and they have 200K debt, then they will choose, rationally, to go into other areas. IMO, neurology also attracts those who are so slothful or stupid that they feel that they are not cut out for internal medicine (not in my group or residency or fellowship though!). These people won't go into neuro. it would be nice to say good riddance, except neurology needs them, and many become very good neurologists.

Interesting comments...Neuro has never been a popular specialty choice for med students In my school (SUNY Downstate), I was one of only 5 out of more than 200 of my classmates who chose to go into Neuro. I had no problem matching into my first choice residency program. The only other specialty with fewer students was neurosurgery (with two...both matched). Of the 5 of us who matched in neuro, I'd say only one chose neuro because he was "slothful." The rest of us really loved neuro because, as you say, no other organ system is interesting.

You are right to mention med student debt... This is a really big issue today. Most folks don't appreciate the fact that college (including med school) tuition has skyrocketed in recent years. When I went to UCB in the 70's my UG and Graduate tuition was less than $2000/year (I got Bachelor's and Master's degrees from UCB), and my SUNY Downstate tuition was about $3500/year. I started my residency training with a total debt of about $20,000, which I paid off during my residency training (finished in the early '90's).

New med school graduates are coming into residency with enormous debts, in the $100-$200k range, mainly because college and med school tuition has increased 10-15x over the past 20 years. In that same time resident and physician salaries have not increase 10-15x, but more like 2x...

 

[Armadillos]

Look, I love neurology. I couldn't imagine doing another specialty and if I could go back in time I would still do neurology in a heartbeat. I think that includes many of the attendings you see posting on this forum. But, that doesn't mean these aren't really rough times in neurology. Again, I get paid less than physicians with less expertise to do the same work. The procedure practices used to make up that loss has been gutted. If EEGs get cut significantly next, you may not be able to find a private neurology practice in 5-10 years (especially in metro areas). If it makes you feel better to point out that other specialties are also being similarly cut hang on to that. If you rotate with me as a med student, I will tell you why I think Neurology is a great specialty, but I won't blow sunshine up your a#$ about the current fiscal environment.

I know things are grim, but next year are you planning on making less than 160-180k? I hear doom and gloom from a lot of specialties, and then eventually when you press them its like, well I'm only going to be making 210k this year.

 

[danielmd06]

I know things are grim, but next year are you planning on making less than 160-180k? I hear doom and gloom from a lot of specialties, and then eventually when you press them its like, well I'm only going to be making 210k this year.

Ballin' like a nurse anesthetist.

 

[neglect]

If you took the medstudents starting residency in a couple months and compared their lifetime earnings, how would you rank Peds, Neuro, Family, Psych, Non-fellowship IM?

It would just seem hard to believe that neuro would expect to be making less than all of those fields (which by total number of MD's is a huge chunk of all doctors).

I'd rank these, from highest ot lowest: Family > gen IM > Neuro > psych > gen peds. My reasoning is that family can always do procedures and IM can be hospitalists. On the lower side, pediatrics always gets screwed and psych is marginalized by the stigma of mental illness.

I think all these areas should get pay raises, especially psychiatry and peds.

So I know I’m just a medical student, but I’d strongly advise people consider the well worn, often repeated advice that you should choose a field you’re interested in b/c the future of reimbursement can change dramatically. To play a bit of devil’s advocate, every specialty is getting slammed and I thought it might be useful to start with ROAD and go from there:

I agree with your statement, how could one not? But as a med student, I had the option of not considering $ as much as others. I went to state school and my debt was very small. I did choose to enter neurology and take a pay cut - most neurologists are smart and as such could have entered more lucrative fields inside and outside medicine.

But with salaries falling, you are taking more of a hit by going into neurology. Or you'll be working harder, which also sucks. Either way, go into ophtho and only make 250 vs. the 350-400 from 10 years ago. Go into neurology (and take stroke call btw) and make 180 vs the 220 from 10 years ago.

Do what you love, certainly. But do take into account the current realities. Med students have already delayed their entry into the work force by 4 years. When they finally start making money, they start as interns and are paid very little, which delays their/our income again.

 

[mrcmedman]

I'd rank these, from highest ot lowest: Family > gen IM > Neuro > psych > gen peds. My reasoning is that family can always do procedures and IM can be hospitalists. On the lower side, pediatrics always gets screwed and psych is marginalized by the stigma of mental illness.

I think all these areas should get pay raises, especially psychiatry and peds.

But can't neurologists also make a comparable salary to internists as neurohospitalists? I've seen so many jobs on recruiter websites that range from 200-300k.

 

[Armadillos]

Ballin' like a nurse anesthetist.

Its true, but when someone like the peds Hem/Onc/ID/Endo/Rheum w/ 6 years post grad training makes 130k-150k, making 200k w/ less training doesnt sound bad at all.

(Not saying they shouldn't make more or neurologists shouldn't make more, but just wonder if neuro is really the personal finance disaster some make it out to be especially given some of the alternative fields Im considering like psych/peds appear significantly worse financially)

 

[grt398]

So here's a quick question for any attendings out there: how much of your practice revenue derived from doing NCVs/EMGs and therefore heavily impacted by the recent cuts? 20%? 40%? more?

 

[DD214]

Most practices run at a 50% overhead, meaning you take home only 50% of your collections after expenses such as rent, staff salaries etc have been paid. This overhead is not very easily cut, meaning that any decrease in collections usually comes straight out of your profits. Therefore, a 20% cut in collections could result in a 40% cut in income. Many outpatient private neurology clinics have been heavily subsidized by income from EMG due to relatively poor reimbursement for routine clinic visits, and the EMG cuts in 2013 pose a very real threat to these practices. Academia isn't safe either as falling revenue will be noticed and salaries for attendings may also be slashed.

 

[neglect]

Its true, but when someone like the peds Hem/Onc/ID/Endo/Rheum w/ 6 years post grad training makes 130k-150k, making 200k w/ less training doesnt sound bad at all.

(Not saying they shouldn't make more or neurologists shouldn't make more, but just wonder if neuro is really the personal finance disaster some make it out to be especially given some of the alternative fields Im considering like psych/peds appear significantly worse financially)

It really depends on where you're coming from. The fact that peds specialists make these salaries (are those right?!) is highly disturbing (are they mixed in with academic salaries?).

To make >200 in neurology while living someplace that has > 2 Korean places, you've got to be working hard: little vacation, > 4 days a week, office hours all day.

 

[grt398]

Most practices run at a 50% overhead, meaning you take home only 50% of your collections after expenses such as rent, staff salaries etc have been paid. This overhead is not very easily cut, meaning that any decrease in collections usually comes straight out of your profits. Therefore, a 20% cut in collections could result in a 40% cut in income. Many outpatient private neurology clinics have been heavily subsidized by income from EMG due to relatively poor reimbursement for routine clinic visits, and the EMG cuts in 2013 pose a very real threat to these practices. Academia isn't safe either as falling revenue will be noticed and salaries for attendings may also be slashed.

I know this is one of the bigger issues and I certainly appreciate the feedback. The reason I asked was that I was curious how the cuts would affect something like MGMA's median compensation per RVU. You can use numbers like that, along with RVUs per year, work hours, etc from multiple sources to build a financial model, normalized for various factors such as the work hours of a neurosurgeon vs. a pediatrician, to estimate income on an hourly and annual basis by specialty. Doing so appears to provide fairly good data as far as I can tell.

So I was thinking that if 20% of your practice was EMG x 60% reimbursement cut, it would end up cutting your compensation per RVU by 12%, which could then be fed through the model to see where things actually stand regarding relative compensation to other fields of medicine.

Any additional feedback from other attendings would certainly be appreciated.

 

[typhoonegator]

To make >200 in neurology while living someplace that has > 2 Korean places, you've got to be working hard: little vacation, > 4 days a week, office hours all day.

My father is 65 years old and still works 6 days a week for 12 hour shifts at the plant for far less than that. They can't unionize and he gets two weeks of vacation a year. He went to college and law school. There are 0 Korean places where my parents live.

I think we're all going to need to modify our expectations in the future. We are not that special.

 

[danielmd06]

I think I've hit my quota for negative comments for the year already. Time to take a deep breath and go to the beach.

Carry on.

 

[neglect]

We are not that special.

This is a depressive type comment. I disagree of course.

I'm wish your father all the best wishes, and if you'd like to compare professions, then let's. I'm willing. Does he employ anyone? Does he take call? Is he a partner or have high level responsibilities to his business, partners, employees? Does he tell people in their 40s that they have a brain tumor or that this is brain death?

We are special! This is not a declaration by fiat or an Orwellian term applied to the special class. We are the result of the best and brightest fed through bottle neck after bottle neck and trial after trial. Don't you dare demean your accomplishments or abilities. Look at yourself, if nothing else, through your father's eyes. First came college, then med school right away if you were lucky. Either way, I know for a fact that you weren't the type who got wasted drunk 4/7 nights, or who partied all day/night. You write too well for that. You spent a fair portion of your pre-med time sitting, reading, studying.

Then med school. Once in, admittedly, it's hard to fail out. But you know you did better than that. And if you think about it, I know you spent hours at a desk. Step 1 was a two day monster affair when I took it, with literally years of preparation and months of specific studying. It remains a monster, as it should. Then hours of ward time. The internship, the residency, and the horror of it. The hours of time spent in the hospital, on rounds, on pre-rounds, in discussion, getting pointed questions. Even now they haven't been able to reduce the stress or the work load, although admittedly I think the responsibility has become less inappropriate.

So after college your friends were making money right away as engineers or in finance (and while they worked hard, did they work as hard as you did?). Perhaps they weren't paid much, but more than nothing - which is still better than paying more tuition. Then your friends got raises while you got paid just enough to live on as a resident. Ditto fellowship, which pretty much everyone does. Now you're nearly a decade behind them, and you might have sizable debt, which is a huge tragedy today.

Who does this? Who spends college engaged in non-stop study and stress only to find themselves in med school where they realize that they need to study even harder? Who then spends years as a low apprentice learning the practical application of neuroscience? Who then gets a job where you manage some of the most difficult cases in the hospital and in clinic, where most others fear to tread, where subtle signs and symptoms might herald preventable neurologic catastrophe. And where we can be part of treatments for some of the worst and most feared diseases that afflict mankind.

After reading all this, if you don't think you're special, call your father.

 

[typhoonegator]

Eh, the top performers in any profession are objectively "special". But I've met a lot of pretty dumb physicians too. Either way, it doesn't really matter. We aren't living in a meritocracy by any stretch.

My comment about us not being special was in cross-reference to other medical specialties. I personally can't justify why we should get paid any better than a pulmonologist, or a rheumatologist, for example, just by virtue of the service we provide. And we're all doing a lot better than most of America, so the constant hand-wringing on this forum becomes very tiresome.

 

[FutureDO2016]

I don't know why I read this. It made me sad and discouraged to pursue neurology and I'm just a medical student. Now I know why many neurology positions go unfilled.

 

[Telamir]

http://www.nrmp.org/pressreleasepostmatch2013.pdf

Not exactly that many.

 

[danielmd06]

I don't know why I read this. It made me sad and discouraged to pursue neurology and I'm just a medical student. Now I know why many neurology positions go unfilled.

If anything, neurology positions will probably be cut because of its low reimbursement (hospitals would prefer to keep radiology, ortho, neurosurg etc residency slots), so neuro would actually become more competitive in the future.

 

[danielmd06]

My comment about us not being special was in cross-reference to other medical specialties. I personally can't justify why we should get paid any better than a pulmonologist, or a rheumatologist, for example, just by virtue of the service we provide. And we're all doing a lot better than most of America, so the constant hand-wringing on this forum becomes very tiresome.

Look, it's a cyclical argument. Are we less important than the specialties that pay more? What about residencies with shorter training periods that pay more, like EM? The most important doctors are the primary care doctors, who make the least. I appreciate your attempt at looking at this philosophically, but it rings hollow for people with shrinking paychecks. And for the record, I'm full time sleep medicine, and am actually fairly insulated from these changes where I am working. I want to help protect general neurology and our specialty. If we don't, who will?

And the argument about how we are doing better than others in America so we shouldn't complain is also a weak one, in my opinion. Yeah, yeah, the glass is half full. I get it. I am humbled and grateful for my current job. I love doing what I do. Seriously. But doctors are not sitting around asking for handouts here. We have long training, make great sacrifices, and accrue large debt. We work very long, and very hard. Isn't that the type of job description that should pay more?

Imagine the uproar if you took a random other job (like a teacher) in America and the government cut the salary significantly.

Just saying.

 

[dhavalp]

Look, it's a cyclical argument. Are we less important than the specialties that pay more? What about residencies with shorter training periods that pay more, like EM? The most important doctors are the primary care doctors, who make the least. I appreciate your attempt at looking at this philosophically, but it rings hollow for people with shrinking paychecks. And for the record, I'm full time sleep medicine, and am actually fairly insulated from these changes where I am working. I want to help protect general neurology and our specialty. If we don't, who will?

And the argument about how we are doing better than others in America so we shouldn't complain is also a weak one, in my opinion. Yeah, yeah, the glass is half full. I get it. I am humbled and grateful for my current job. I love doing what I do. Seriously. But doctors are not sitting around asking for handouts here. We have long training, make great sacrifices, and accrue large debt. We work very long, and very hard. Isn't that the type of job description that should pay more?

For the first time in a long time medical school admissions are down:
http://www.nytimes.com/1982/11/23/science/medical-school-admissions-down.html

Think maybe money has something to do with it?

Imagine the uproar if you took a random other job (like a teacher) in America and the government cut the salary significantly.

Just saying.

I think the NY times article you referenced was published in 1982?

 

[danielmd06]

I think the NY times article you referenced was published in 1982?

Yikes.

Nothing helps an argument like a mistake. I read an article two weeks ago about this topic, and didn't double check this one (presuming it was the same). Thank you for the catch. I'll try and get the other...

Edit. I typed in "admissions" and not "applications."

From 2008: http://www.insidehighered.com/news/2008/10/22/medschool

From 2009: http://www.bizjournals.com/sacramento/stories/2009/01/12/focus2.html?page=all

BUT

From 2012 I found this which actually counteracts my claim:

http://health.usnews.com/health-news/news/articles/2012/10/26/med-school-enrollment-on-rise-in-2012

This article says that both applications and enrollment are up. I was aware of the latter, but not the former. I will keep digging and update if I can find something worthwhile. Facts are facts. They are stubborn things. I edited my above statement to correct myself. Again, thanks.

And while I will stand corrected on the one sentence...my original opinion still holds. Nor do I think it loses too much steam because of my error.

 

[dsoz]

Look, it's a cyclical argument. Are we less important than the specialties that pay more? What about residencies with shorter training periods that pay more, like EM? The most important doctors are the primary care doctors, who make the least. I appreciate your attempt at looking at this philosophically, but it rings hollow for people with shrinking paychecks. And for the record, I'm full time sleep medicine, and am actually fairly insulated from these changes where I am working. I want to help protect general neurology and our specialty. If we don't, who will?

And the argument about how we are doing better than others in America so we shouldn't complain is also a weak one, in my opinion. Yeah, yeah, the glass is half full. I get it. I am humbled and grateful for my current job. I love doing what I do. Seriously. But doctors are not sitting around asking for handouts here. We have long training, make great sacrifices, and accrue large debt. We work very long, and very hard. Isn't that the type of job description that should pay more?

For the first time in a long time medical school admissions are down:
http://www.nytimes.com/1982/11/23/science/medical-school-admissions-down.html

Think maybe money has something to do with it?

Imagine the uproar if you took a random other job (like a teacher) in America and the government cut the salary significantly.

Just saying.

I am not arguing against you, but I do need to comment on your statement bolded above. With the financial crisis that we have been going through in the past few years, there are many professions that are paying less.than they used to.

Point 1: my friend is a mechanical engineer. Three years ago he lost his job due to lack of construction jobs. He spent 9 months on unemployment, and finally found a job that paid 80% of his former position.

Point 2: In my area, the three largest school districts have laid off teachers for the past 4 years. If added together, there have been probably over 600 teachers laid off in that time. Further, in order to cut costs, each of those districts have incorporated furlough days into the calendar. One district has put in 16 furlough days, this is nearly 10% of the school year. That means that salaries are cut by about 10%. This is on top of rising health care costs that have made take home pay checks SIGNIFICANTLY lower (from an already low starting point).

Case 3: my friend is a veterinarian. She has been forced to go from full time to 3 days a week due to lower case load at her clinic. That is a 40% reduction in hours.

Case 4: I work with a population that is high poverty level. Many of the families have pulled their older kids out of school (11th and 12th grades) so they can work minimum wage jobs (or lower paying field work). Otherwise they cannot afford to pay rent and have food. There are one bedroom apartments that have two or three family units living together. Sleep where you can find space. Each person works two or three part time jobs.

Times are tough all over. Being a physician is still one of the best jobs around. Not many physicians are standing on the side of the road with a cardboard sign that reads "will diagnose illness for food." But it may come to this if our country keeps spending money wastefully on foreign oil and stupid military actions.

TL;DR the sky is falling, but it is falling for many other people too.

 

[danielmd06]

I am not arguing against you, but I do need to comment on your statement bolded above. With the financial crisis that we have been going through in the past few years, there are many professions that are paying less.than they used to.

No argument that we are not alone, and I agree that we seem to overspend on defense.

I am sympathetic to those who are hurting right now, believe me.

 

[Dharma]

To make >200 in neurology while living someplace that has > 2 Korean places, you've got to be working hard: little vacation, > 4 days a week, office hours all day.

Sorry to drag this one out from the underworld, but… for real? Is 200K in neuro that hard to pull off these days? I think it's probably harder to land a job in a spot with more than 2 Korean joints than anything else (because that kinda sounds like midtown Manhattan and not many other places on the East coast).

 

[neglect]

Sorry to drag this one out from the underworld, but… for real? Is 200K in neuro that hard to pull off these days? I think it's probably harder to land a job in a spot with more than 2 Korean joints than anything else (because that kinda sounds like midtown Manhattan and not many other places on the East coast).

Yes, NYC and LA, SF, SD, Orange CO, DC, Baltimore, Atlanta, Boston, Philadelphia, Chicago, across the bridges from NY. I think it is hard to avoid. They are everywhere. I literally googled Korean places in Savannah GA and had a few hits.

Easier to find decent Korean than to make 200,000/year, but it can be pulled off and you don't need to stay to 8 PM.

 

[Dharma]

What's with the compensation reports showing higher than that? (Glad there are more Korean spots though. Love me them "freebie" dishes they put out!)

 

[clausewitz2]

Somewhat tangential, but the prevalence of Korean places should not be underestimated; even Lexington, Kentucky has five of them. There is culture outside of NYC, never fear.

 

[chessodoc]

Wasn't the MGMA-Meritt Hawkins salary like 240-280....last year? Lots of doom and gloom

 

[Dharma]

Wasn't the MGMA-Meritt Hawkins salary like 240-280....last year? Lots of doom and gloom

I want to hear a bit more about this. Compensation seems to hover around the 220 in Medscape's survey as well. I know these are just surveys, but what gives?

 

[Notch3]

When it comes to compensation for neurology (and really for all specialties), it really is a "you eat what you kill" world. It comes down to how much you want to work. You can work in academics, take minimal to 0 call, work ~30hrs a week and make $180K. Or you can work your butt off and make $400K. You guys have to remember that about 1/3 of neurologists stay in academics and will make less but most will work less hours. This can easily drive down the overall average.

Ever since I reached PGY3 yr, my co-residents and I have been receiving job recruiting emails from all over the country every other day. Some places do list their starting salaries and it can range anywhere from $180K - $400K. My colleagues and I have been approached by local neuro groups here as well as our PD asking some of us to stay on board as faculty after we finish. One of the private groups here is offering $400K but they cover multiple hospitals, have their own full 8-5 clinic M-F, and essentially work harder than residents. And of course it also depends on where you want to settle. Popular metro places like SF, LA, San Diego or NYC, you'll look at making less for more work.

So the money is there if you want it. It just comes down to what makes you happy.

 

[neglect]

What is the value of a neurologist within medicine? There are many ways of looking at this and it informs salary. Having a good neurologist to diagnose and treat these difficult conditions (think of a young person before and after a difficult MS diagnosis) is, of course, invaluable. But in terms of finances, you only will be able to bill that case a few hundred dollars. Overhead is about 50% and some years up to 60s. But consider the entire ecosystem of medicine here. And that's what you should do: medicine is a huge ecosystem and we occupy a niche.

You, as a neurologist, have just brought a new MS patient into the system. If you're good, or if alternatives are far, then they will stay. Otherwise, they might go. Consider just how much money the system makes on a new MS patient within the first year if they stay: home infusion, pharmacy revenue, specialty pharmacy revenue, monitor progression with MRI brain, C-, T-, technical fees and professional fees, other specialty consults (urology, psych, perhaps even an EMG/NCV), lab draws, the meds themselves. Add it all up. Now the hospital system doesn't make money on the med, that probably goes to Biogen (I'm kidding but also not kidding). You have just brought in a ton of downstream revenue. This is like an ecosystem's water supply, allowing other niches to prosper. And take any neurology service or outpatient day. You'll find the exact same thing feeding neurosurg, endovascular, ortho, rehab, radiology, cardiology, vascular, home services. Consider all the professional fees (which is what is eaten by the providers) which are dwarfed by the technical fees.

Many neurologists in practice have noticed this discrepancy: we lick the grass for dew while providing downsteam rain for the system. So they own MRIs, EEGs, vestibular machines, sleep and trial and infusion centers, and even legal to capture the flood. This is what capitalism looks like in our highly regulated market. Guess who hates this competition? Hospital systems, who have a seat at the regulatory tables, and have screwed oncology groups so much that they've all joined hospital systems, so much that prices have actually risen globally.

As more neurologists enter hospital systems, you have to think about things from the health care admin's perspective. Now you will hear things like "eat what you kill." And your billing, if you are working very hard clinically, will end up in the 400s to perhaps 500s. If you have a life, then expect to bring in less, perhaps much less. And take away at least half for rent/lights/know-nothing-secretaries-who-screw-you. (And you can also count on dissatisfaction from having your salary depend on patient reviews, like you're a restaurant, and all the rest of the uncompensated stuff that goes with taking care of patients: threats of lawsuits, phone calls, difficult families/situations.) The hospital admin's entire job is to keep your salary low and their salary high - while dealing with none of that.

So I urge you all to reject that model. Embrace the idea that you are a rainmaker because you are. The systems in the midwest and south know this, so they offer huge salaries - salaries that you could possibly make if you're working very hard, but are generally impossible to maintain. Where, then, do these salaries come from?

Get it?

In nearly a decade of practice I've never seen this explicitly discussed with hospital admins, even though they know. You have to bring it to their attention. Just know that every hospital admin is a parasite who offers nothing to the system but has attached their lamprey sucker to the technical fees that you bring in. For them, this is a zero sum game. Every dime you take is a dime less for them. And they win because they want money more than you do. Why else did they become admins?

 

[TUGM]

^^^ That's what I'm talking bout!

 

[TUGM]

(Well technically, Neglect is talking about it)... But I am whole heartedly agreeing!

 

[Duon89]

One of the private groups here is offering $400K but they cover multiple hospitals, have their own full 8-5 clinic M-F, and essentially work harder than residents. And of course it also depends on where you want to settle. Popular metro places like SF, LA, San Diego or NYC, you'll look at making less for more work.

So the money is there if you want it. It just comes down to what makes you happy.

I am just a 3rd year interested in neuro then doing movement. And with that career goal, my salary would be around 180-230K considering the fact it would be mostly outpt.
My question is that..I just can not really see how one can actually make $400K (or even mid 300s) as a general neurologist? how is the balance between outpt and inpt in this "offer" you guys are talking about? Is it like M-F 8-5 clinical and then 5pm-12 am inpatient?

I can see how Neuro hospitalist can make around 270K. And maybe NeuroCC will make even more. And I feel like, unless you do Neuro-->NeuroVasc/CC --> Neurointervention, I dont see how one can make $400 in this field

I mean I am glad to find this is a possibility. I mean, who does not want more money?? But I think I am very skeptical about this $400K. Sorry. And I think 180K is still a lot or enough to sustain a good life with a car, house, kids, and LOANs, etc.