Neurology vs. Anesthesia?

[RxBoy]

OK so I'm a decently competitive US MD candidate approaching the application process and I still am undecided between anesthesia and neurology.... Both of which I love.

I have to admit, I am more clinically based and love patients, something I will def. lose in anesthesia. In a perfect world where money wasn't an issue and helping people was all that mattered, I would probably pick Neurology over anesthesia. But I will also have 200k in student loans and with the new July 2009 law excluding deferment for residents, that loan is just going to get fatter.

I was one of the fortunate med students who got to work in a private clinic during my rotation, it was in a medical office building adjacent to a hospital. It was time consuming (used to work from 8am to 7pm everyday) but I got a great experience. The neurologist there had 2 office units, 1 that did procedures all day (EEG and Carotid duplex run by a tech) and one adjacent unit (with 3 patient rooms) where he did the patient history and personally did EMGs/nerve conductions. He had a pretty good system, new patients were scheduled to do f/u studies. The f/u neuro studies were done at their next appointment, the tech would attach it the patients chart, and the Dr. would interpret it right then and there (as well as the MRI/CBC/ect.) before the f/u assessment. I was in charge of either seeing new patients or seeing consults in the main hospital. Place was always jammed packed. After he closed the office at 5, we would go and see the consults in the main hospital which usually lasted till about 7. Lot to ask for a medical student but honestly time used to fly.

I realized that Neurology can be lucrative. So did I answer my own question... not really. The problem is this, Neurology seems to be a saturated market (no real demand) and this doc I was working for was probably in his 60s with a huge patient base. He even told me about how great the 80's were, when insurance pay outs were actually decent.

Will the same opportunities be available for future neurologists? What is the outlook? I know I know you can't know for sure but if you had to guess? Start salaries are relatively bad for Neurology too, at least from what I hear (140-170ish dep. on location).

Anesthesia on the other hand, although may take a salary loss in the future, will always be in high demand and highly payed relative to other specialities, no matter how many CRNAs the AANA can breed.

I know passion is all that matters, but what if you have passion for both?? If I strictly strictly cared about money I would do radiology... but I hate that field. Neurology is more interesting than GAS, but GAS pays better.


My heart is won with neurology, but mind is won with anesthesia... What to do? I might just apply to both...

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[AlternateSome1]

The problem is this, Neurology seems to be a saturated market (no real demand)

Why do you think the market is saturated?

 

[llogg]

I've actually been told that demand for neurologists is very high. With the continued graying of the population demand will probably continue to grow.

Someone on this board not long ago said that starting out one should not accept less than $150k as a neurologist. And actually, according to this starting salary for anesthesia could be lower than for neuro (even though average salary overall is higher for anesthesia).

The bottom line is that you're certainly not going to starve as a neurologist. You'll almost certainly be able to pay off your student loans as a neurologist. You might have to wait a few extra years to buy your boat as a neurologist. If that outweighs your desire for patient interaction you should probably go anesthesia. If not, welcome to neurology, where you have to deal with jerky surgeons much less frequently.

 

[minstral]

Demand very neurology is and always will be very high. not sure where yougot this form

 

[Spacedman]

I have to admit, I am more clinically based and love patients, something I will def. lose in anesthesia.

hey rxboy,

i'm actually in a very similar position- i've always been interested in neuroscience (enough that i even did a phd it), and i loved seeing patients when i worked in a clinic--- so i assumed that among the neuro-related fields (neurology, psych, anes, neurosurg, neurorads) neurology would be the natural fit.

i'll spare you the gory details, but basically i found that i could barely stand the endless BS & scut on inpatient neurology floors and i loved anesthesia. i was surprised, because i thought i'd have such minimal patient contact. in fact, seeing patients preop (~3-5/day, 15 min each) was one of the most positive interactions i've had with patients in a hospital. also, keep in mind that pain fellowships train both neuro and anes graduates, and (so i've heard) pain clinics are incredibly lucrative and rewarding, if you like those kind of patients.

from your post, it sounds like you had a good exposure to outpatient neurology. that's a really small part of residency, unfortunately, and having to put up with 4+ years of the floors is basically a dealbreaker for me.

btw, did you do an anesthesia rotation?

 

[AlternateSome1]

i'll spare you the gory details, but basically i found that i could barely stand the endless BS & scut on inpatient neurology floors and i loved anesthesia. i was surprised, because i thought i'd have such minimal patient contact. in fact, seeing patients preop (~3-5/day, 15 min each) was one of the most positive interactions i've had with patients in a hospital. also, keep in mind that pain fellowships train both neuro and anes graduates, and (so i've heard) pain clinics are incredibly lucrative and rewarding, if you like those kind of patients.

from your post, it sounds like you had a good exposure to outpatient neurology. that's a really small part of residency, unfortunately, and having to put up with 4+ years of the floors is basically a dealbreaker for me.

btw, did you do an anesthesia rotation?

Hold on, outpatient neuro is a big part of my program. We have neurology clinic 1/2 day per week starting as an intern. The majority of the R3 and R4 year is spent in outpatient clinics and electives, and at least 1 and 1/2 to 2 months of PGY2 is spent in the outpatient setting.

 

[RxBoy]

I am currently doing an anesthesia rotation and I do have to admit I love it. The hours are decent even for residents, the job market is great, and there is patient interaction... be it not much but at least more dynamic than radiology. I guess I got sold on anesthesia after the rotation. I had many people tell me the same thing about inpatient neurology when I was asking around. I never experienced it, one thing I do know is outpatient neuro is awesome.

But don't let me sell any other students short on Neuro who are considering it. If your program doesn't have a mandatory rotation, I highly recommend you rotate through it (and try to get outpatient exposure too). Don't take other med students advice that give a bad rap about neurology. One thing I loved about neuro is the respect your own patients give you. You're also a very valuable asset to primary care doctors. When I did my ambulatory (outpatient IM) last month, I realized IM doc's really don't know much about Neuro so they always refer. I knew more about neuro than they did! I had the unfair disadvantage of course of having a fresh rotation in it. There is also something that tells me its going to be the next cardiology. I feel Neuro is still in its infancy. Who knows what 10 years will bring. Anesth you get no respect neither from patients nor surgeons, so if you need admiration its def not for you. But if you love more hands on/dynamic work, pharmacology, and physiology it is def worth rotating in as well. It was a really tough desicion to make, but I'm just going to save my money and only apply to anesthesia. Hope this helps future med students that might someday arrive at my same predicament.

PS: After I did more research into neuro demand, turns out its in high demand especially with the aging population so I appologize. Its just not extremely high based on the fact that the ANA states that there will not be a shortage of neurologists. Anesthesia is extremely high because the ASA states there will be a shortage of anesthesiologists.

 

[exgatr]

I went through the same decision process, and here's my attempt at providing a neutral opinion of both:

Anesthesia:
Pros:
1. Lifestyle- early mornings but done by early afternoon.
2. Money- good pay, although the guys who make 375 are working their
butts off.
3. Work with your hands
4. You can see the results of your work immediately.
Cons:
1. It's hot right now- there is a current shortage but I have the feeling
that this will turn into an oversupply soon.
2. Not mentally challenging enough (for me)
3. Risk
4. No respect- patients and surgeons treat you like a nurse, even
though you're a highly trained specialist.

Neurology:
Pros:
1. It's not hot right now- supply and demand will kick in soon enough.
2. Money- 200-220k from what I've seen
3. Lifestyle- "You think you're having an MS exacerbation? I'll call in a
solu-medrol dose pack and you can come in and see me in clinic in a
week."
4. Diagnosis- this is the part of medicine I like the most
5. Short track to specialty- only one year of IM to deal with
6. Respect- everyone thinks you're a genius when you say "have you
considered a central origin for ______." Insert random physical
finding.
Cons:
1. Many devastating, untreatable diseases.
2. Back pain/disability patients <-- this is a pretty strong argument
against neuro for most people.

In the end I chose neuro, because I think it'll be the next big thing in medicine, I like going to work every day, and people think I'm a genius (which can't be further from the truth)

 

[gonogo]

In the end I chose neuro, because I think it'll be the next big thing in medicine, I like going to work every day, and people think I'm a genius (which can't be further from the truth)

Why do you think it's the next big thing? What do you mean exactly?

 

[copacetic]

Why do you think it's the next big thing? What do you mean exactly?

consider why, how, and what cardiologists did to cardiovascular surgeons.

 

[Phantom Spike]

In the end I chose neuro, because I think it'll be the next big thing in medicine, I like going to work every day, and people think I'm a genius (which can't be further from the truth)

That bit about being considered a genius, while not really being one, is definitely true in my case. Simply having a neurologist on consult, even for something as run-of-the-mill as delerium in an Alzheimer's patient with a UTI, seems to make everyone, especially the families, feel better, although the neurologist really adds nothing except another note to the chart most of the time. A neurologist doesn't really do anything an internist can't in the management of a TIA or a diabetic polyneuropathy, but not having one on board is still unthinkable in most cases. That does make one feel a little redundant at times, but at least you know you'll always have a steady stream of patients.

 

[ushush]

bump

 

[JP2740]

Why do you think it's the next big thing? What do you mean exactly?

I'd like an answer here too.

 

[Chocolateagar04]

I'd like an answer here too.

Ok so I went through the 100% exact same dilemma as the OP and also think its the next big thing.

I had a really good anesthesia app. I had done an audition in august, performed strong and applied early and everything. I did a neuro rotation in mid September-mid October at a hospital that had an anesthesia program i was interested in. I did it just so I can find excuses to leave the neuro rotation so I could go do Anesthesia but then I realized I fell in love w/ Neuro and ended up hating Anesthesia for the following reasons:

1. Neuro is inherently the most fascinating field. I realized whenever I would see articles on curing Alzheimer, how sleep affects functioning, paraneoplastic syndromes, anything behavioral neurology related (even the far off stuff from V.S. Ramachandran-look him up) I would just be totally fascinated. I looked at the journal of neurology and I looked at the journal of anesthesiology and I found myself way more interested in the neurology. Its so up and coming with therapy especially in the behavioral sector and there is so much going on (http://casemed.case.edu/alumni/publications/mailers/mailer2-9-2012b.htm). I felt liek Anesthesia was kind of stagnant. Of course it is also making advancements but not as exciting as neurology. I liked how a lot of the patients you see in neurology are the "interesting" cases during my medicien floor months. Yeah you have your seizures, headaches but Id much rather deal w/ that then routine anesthesia because I feel like a real doctor and its really not that difficult to manage. And alot of ppl say "oh you can't treat anything , you cant treat dementia or MS or seizures" but do we really treat heart disease? Not really we just kind of manage it.

2. I value personal independence a ton. I like how in Neurology it gives you the option of having your own clinic, being a neuro-hospitalist, specializing from such various things like sleep, crit care, pain med, neurophys, epilepsy, interventional, behavioral, etc etc. Basically you can make neurology what you want it to be. And the call schedule isn't even bad. Most places I've been to have home call for their advanced residents and its because of the nature of a neuro call. Unless its about a stroke and TPA there aren't that many its not that bad. Anesthesia call was the worst especially if you're in a busy level 1 trauma center.

3. Alluding to my statement before neurology, although specific, is so diverse in what you do. You can specialize in movement disorders and see mostly those kinds of patients but still on other days do more of a general neurologist role and round on patients in the hospital and things like that.

4. I didn't know this before making my decision and I'm glad I did ..... Neurology is in CRAZY demand right now. As the original poster said his neurologist he worked for was in his 60s. Many of the neurologists are old timers and looking to retire. Most residents I talk to say its not about if you will have a job but which one to pick. Most of the richest doctors I know personally are neurologists and they seem to have a decent amount of free time.

5. You are definitely respected for your knowledge. I don't like how in Anesthesia they ahve nurses that can basically do your job. I didn't go to medical school to become a glorified nurse. There is nothing wrong with nurses and infact I respect their knowledge so much that I feel this way. The thing is with neurology there are nurses and PAs but in the end of the day no one will know the central nervous system like you do. No one else will be able to sign off on sleep studies and interpret EMGs without you. I did not like how in Anesthesia a nurse could literally do the whole job w/o me. Yeah MD's will tell you that oh CRNAs aren't that good and blah blah blah but honestly they know their ish and they can do a lot. The outlook DEFINITELY is not good for anesthesia and its just a matter of simple economics. If you can hire someone to do a job cheaper you would. People are going to try to tell you otherwise but I've done my research talked to anesthesiology residents attendings and concluded that anesthesiologists will still make a ton of money but not as much and you won't have the freedom to choose where you want to work. Having the ability to choose the city I work in and/or practice I join was important to me.

6. I'm a mathematical inclined person and Neurology is the most logical field of medicine which is weird because there are so many gray areas too. I assume this is why you liked anesthesiology as well because Anesthesia is also very logical. Everything is so physio based in anesthesia that whatever you do simply makes sense and it isn't so protocol driven. In that sense Anesthesia is really good but Neurology isn't far off. Neurology is just very anatomy driven but is still very logical in the way that you assess patients.


OK that is all. I know a lot of ppl will take offense to what I have said and disagree with some things but I've thought about this a lot and even took the risk of applying to neurology super late because I realized its almost like a secret specialty and I needed to go for it.

 

[JP2740]

4. I didn't know this before making my decision and I'm glad I did ..... Neurology is in CRAZY demand right now. As the original poster said his neurologist he worked for was in his 60s. Many of the neurologists are old timers and looking to retire. Most residents I talk to say its not about if you will have a job but which one to pick. Most of the richest doctors I know personally are neurologists and they seem to have a decent amount of free time.

Thanks for the well-thought out post, but I just have a really hard time believing this part in bold.

 

[Chocolateagar04]

Ya I can understand that.

That's why those national figures
Don't make sense to me. Albeit one of the 3 filthy rich neurologists is also an actor on the side. One does pain
But didn't get trained fellowship wise. The other one has some real estate investments.

 

[JP2740]

Haha gotcha. Liked the post. That was a bit misleading though. Thanks for the contribution. These are the thoughts I need to push me into Neuro

 

[aaddnl]

Very good post. You are absolutely right about neurology. There's great variety, so many fellowship options. As a general neurologist doing inpatient and outpatient you treat acute stroke and status and you do emg/EEG/Botox/sleep/pain if you want. Most places you go are in great need of a neurologist especially general neurologist. Most other docs including Internal medicine/FP are not comfortable managing a nebulous "neurologic problem" and it will often be something routine for you. Anesthesia is a good field but it's a lot different. Not nearly as much real patient interaction, have to take crap from surgeons, and even tho they know a lot more and are much more trained than CRNAs, a lot of hospitals are going to be hiring crnas for economic reasons as you say. Neurology is a lot less likely to be threatened by mid levels as you mentioned. Anyway, it's good to hear your enthusiasm and don't let residency jade you too much, it's mostly inpatient heavy and not always that similar to what many practicing neurologists do. Good luck

 

[EdLongshanks]

As an MS1 I have several questions about this specialty that it appears I would like to go into.

1) I like being an employee and don't really care to take on the headaches of business management. Do Neurologists have a good chance of making good money without starting their own clinic?

2) If a hospitalist/neurologist works exclusively or mainly for the hospital, does he end up spending most of his time on "consult for unspecified pain" or does he get to do interesting stuff a reasonable amount of the time.

3) If a neurologist wants to supplement his income, is there a part-time way to make some extra bucks? For example, a ER doc can always moonlight at an Urgent Care center.

4) Gomers?

 

[typhoonegator]

1) You can do fine working for a hospital physician's organization, but because of caps and resource re-allocation, you typically will not do as well as you would in private practice, where your take-home is typically closer to what you bill. There are exceptions to this, as with all things.

2) Working for a physician's organization, you can still spend most of your time in clinic. For instance, an epilepsy attending at a big hospital will have clinic days essentially every week, as well as perhaps one month as ward attending and one month as consult attending. Alternatively, you could join the neurohospitalist movement and only manage inpatient services a predetermined number of weeks per year. Or you could be an intensivist and make all of your salary in 10-12 weeks. The balance of your time will be expected to be devoted to admin, teaching, and research pursuits, depending on your track.

3) A lot of community neurologists moonlight as neuro coverage at local hospitals. For many hospitals, there are few neurologic emergencies that require you to come in in the middle of the night, and so you can do a week of coverage in which you answer pages/calls, help triage patients, and then stop by the hospital in the evening and round on the consults. Not a bad way to make an extra couple grand per week.

4) GOMER: Get Outta My ER. Read "The House of God" by Samuel Shem (Stephen Bergman)

 

[EdLongshanks]

4) GOMER: Get Outta My ER. Read "The House of God" by Samuel Shem (Stephen Bergman)

I'm sorry, I was speaking in shorthand. I know what Gomers are and I can quote the House of God rules. When discussing specialties in the House of God, the terns discuss the gomer-factor of each specialty. That was my question.

 

[typhoonegator]

I'm sorry, I was speaking in shorthand. I know what Gomers are and I can quote the House of God rules. When discussing specialties in the House of God, the terns discuss the gomer-factor of each specialty. That was my question.

Then yes, neuro has tons. Gom-factor 5. Especially in resident clinics.

I recall a consult I saw in clinic, that pretty much by itself drove me to pick a subspecialty without any clinic exposure. New patient, 46 years-old complaining that her legs hurt all the time. Can't describe the symptom characteristics or quality. Can't define how high it goes up her leg. Can't grade it on a scale of 1-10. Interferes with her ability to walk or do work. On disability. Started after her previous employer moved her out of her cubicle, which increased her stress. EMG, NCS, MRI, labs, freaking Fabry workup, multiple skin biopsies, sweat testing, all normal. Stance, gait, reflexes, tone, bulk, sensation, all normal. Wants an ankle brace. Of all things, not narcotics, not revenge, but an ankle brace.

An ankle brace? I ask her why she needs an ankle brace. "Because I can't walk". Why can't she walk? "Because I need an ankle brace." Wasn't she able to walk into the office today? "Well, I can't walk far." Why can't she walk far? "Because I need an ankle brace." What happens if she tries to walk far without an ankle brace? "Don't know, because I'm not going to try until I get the ankle brace." What is she afraid will happen if she tries to walk without the ankle brace? "My legs will hurt." How will an ankle brace help with the pain, given that everything short of IV lidocaine has been unsuccessful? "My friend has one." Why does her friend have an ankle brace? "Because her legs hurt, and the brace makes it better." Does her friend have the same problem she does? "She has fibromyalgia." Which leg does she want the brace for? "Probably the left." Why not the right? "Well, I don't want to wear them on both."

Honest to God, this is basically word for word, except it took over 20 minutes.

Imagine this patient coming back to your clinic every 6 months, with nothing that you do improving her symptoms, ability to return to work, or ability to function in society. Now, some patients you can help, and some even have fascinating diseases or presentations. But it is very difficult to prevent your clinic from having a sizable proportion of the above, particularly until you gain seniority or subspecialize yourself into a tiny slice of neurology.

 

[JP2740]

I'm sorry but what the hell? that's hilarious.

 

[EdLongshanks]

Then yes, neuro has tons. Gom-factor 5. Especially in resident clinics.

I recall a consult I saw in clinic, that pretty much by itself drove me to pick a subspecialty without any clinic exposure. New patient, 46 years-old complaining that her legs hurt all the time. Can't describe the symptom characteristics or quality. Can't define how high it goes up her leg. Can't grade it on a scale of 1-10. Interferes with her ability to walk or do work. On disability. Started after her previous employer moved her out of her cubicle, which increased her stress. EMG, NCS, MRI, labs, freaking Fabry workup, multiple skin biopsies, sweat testing, all normal. Stance, gait, reflexes, tone, bulk, sensation, all normal. Wants an ankle brace. Of all things, not narcotics, not revenge, but an ankle brace.

An ankle brace? I ask her why she needs an ankle brace. "Because I can't walk". Why can't she walk? "Because I need an ankle brace." Wasn't she able to walk into the office today? "Well, I can't walk far." Why can't she walk far? "Because I need an ankle brace." What happens if she tries to walk far without an ankle brace? "Don't know, because I'm not going to try until I get the ankle brace." What is she afraid will happen if she tries to walk without the ankle brace? "My legs will hurt." How will an ankle brace help with the pain, given that everything short of IV lidocaine has been unsuccessful? "My friend has one." Why does her friend have an ankle brace? "Because her legs hurt, and the brace makes it better." Does her friend have the same problem she does? "She has fibromyalgia." Which leg does she want the brace for? "Probably the left." Why not the right? "Well, I don't want to wear them on both."

Honest to God, this is basically word for word, except it took over 20 minutes.

Imagine this patient coming back to your clinic every 6 months, with nothing that you do improving her symptoms, ability to return to work, or ability to function in society. Now, some patients you can help, and some even have fascinating diseases or presentations. But it is very difficult to prevent your clinic from having a sizable proportion of the above, particularly until you gain seniority or subspecialize yourself into a tiny slice of neurology.

ROFL. Did you ever figure out what she was actually trying to accomplish?

 

[human being]

Then yes, neuro has tons. Gom-factor 5. Especially in resident clinics.

I recall a consult I saw in clinic, that pretty much by itself drove me to pick a subspecialty without any clinic exposure. New patient, 46 years-old complaining that her legs hurt all the time. Can't describe the symptom characteristics or quality. Can't define how high it goes up her leg. Can't grade it on a scale of 1-10. Interferes with her ability to walk or do work. On disability. Started after her previous employer moved her out of her cubicle, which increased her stress. EMG, NCS, MRI, labs, freaking Fabry workup, multiple skin biopsies, sweat testing, all normal. Stance, gait, reflexes, tone, bulk, sensation, all normal. Wants an ankle brace. Of all things, not narcotics, not revenge, but an ankle brace.

An ankle brace? I ask her why she needs an ankle brace. "Because I can't walk". Why can't she walk? "Because I need an ankle brace." Wasn't she able to walk into the office today? "Well, I can't walk far." Why can't she walk far? "Because I need an ankle brace." What happens if she tries to walk far without an ankle brace? "Don't know, because I'm not going to try until I get the ankle brace." What is she afraid will happen if she tries to walk without the ankle brace? "My legs will hurt." How will an ankle brace help with the pain, given that everything short of IV lidocaine has been unsuccessful? "My friend has one." Why does her friend have an ankle brace? "Because her legs hurt, and the brace makes it better." Does her friend have the same problem she does? "She has fibromyalgia." Which leg does she want the brace for? "Probably the left." Why not the right? "Well, I don't want to wear them on both."

Honest to God, this is basically word for word, except it took over 20 minutes.

Imagine this patient coming back to your clinic every 6 months, with nothing that you do improving her symptoms, ability to return to work, or ability to function in society. Now, some patients you can help, and some even have fascinating diseases or presentations. But it is very difficult to prevent your clinic from having a sizable proportion of the above, particularly until you gain seniority or subspecialize yourself into a tiny slice of neurology.

Funny story.