Phd Before Residency To Pursue Clinical Research in Neurology/Neuroscience

[cyneuron]

Hello

I am an IMG and just finishing my medical school. I wanted to get some guidance from the experienced members of this community on my future career path choice in neurology/neuroscience. Will be really great if you may please take few mins to read my post and may help by sharing your thoughts on this.

I am carrying out good clinical research in Neurology (Parkinsonism Neuroimaging - use of fdg pet scans in atypical parkinsonism ; article), along with studying for my steps.
I also plan to do 6 month Junior Resident job in neurology Dept. to gain clinical experience in neurology (during next year while preparing for steps, will be applying for 2011 match).

Now my real interest lies in various exciting fields of translational neuroscience research (haven't zeroed in specific topic, almost everything in current neuroscience research excites me; but will surely be able to choose as i advance further).

Could you guys please advice me which will be a better way to go for a goal of pursuing translational research at intersections of neurology & neuroscience ?

1. A traditional track of Phd followed by postdoc - gives me the hardcore research training to pursue the research in Neuroscience, but will not give me opportunities to apply the clinical skills i have gained during my MD in significant practical manner.

2. A 3-4 Year Phd (i guess an MD can complete Phd in 3 yrs; someone please comment on this), followed by residency in Neurology followed by Academic Appointment Directly or Research Fellowship - will give me the research training i wish to have which to pursue translational research in Neurology, but with the disadvantage that its kinda very long path (similar to MD-Phd). But seems most matching seeing my interest of pursuing translational research.

3. A Residency in Neurology followed by Research Based Fellowship in Neurology - seems also a good option but will not give me the rigorous research training i wish to go through to conduct translational clinical research (though research based fellowship does allow one to carry out translational research).

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[typhoonegator]

Do you really want the PhD? Because you can do good research without it. The PhD track enhances a specific skill-set, and if that is what you want, then go for it. But don't do it just to get those letters after your name -- you'll be miserable.

I think you need to decide if you want to take care of patients or not. If you don't, then residency is extraneous and painful, and you might as well go for the PhD and jump into full time research. If you do, then you gotta get the residency at some point, and you'll probably be better off getting the clinical stuff taken care of without a huge break in between your MD and residency.

As I've said before on this forum, the research world today can be very harsh, and funding can dry up quickly. A fully trained MD doing research has the advantage of being able to support his/her salary during the lean times, if need be. That usually comes with the added headaches of maintaining licensure, clinical duties like clinic preceptorship, and mountains of debt. But you've already got the MD, so in my view it would be a shame to let all that work fade into the background. But, of course, its your call.

 

[cyneuron]

thanks a lot for replying.

The PhD track enhances a specific skill-set, and if that is what you want, then go for it. But don't do it just to get those letters after your name -- you'll be miserable.

I strongly agree with you on this. I do plan to go for phd for this very purpose : get the rigorous training needed to carry out the kind of complex translational research exists today & in coming time.

I think you need to decide if you want to take care of patients or not. If you don't, then residency is extraneous and painful, and you might as well go for the PhD and jump into full time research. If you do, then you gotta get the residency at some point, and you'll probably be better off getting the clinical stuff taken care of without a huge break in between your MD and residency.

As I've said before on this forum, the research world today can be very harsh, and funding can dry up quickly. A fully trained MD doing research has the advantage of being able to support his/her salary during the lean times, if need be. That usually comes with the added headaches of maintaining licensure, clinical duties like clinic preceptorship, and mountains of debt. But you've already got the MD, so in my view it would be a shame to let all that work fade into the background. But, of course, its your call.

Very rightly said. i also don't want to waste my clinical skills by getting completely off from clinics. That is why i am evaluating all these options. Rather this is the very skill set i want to use to do translational research.

So i guess the first track of Phd only & then postdoc after, gets negative here.

So rest of two tracks ? which one in your point of view is better suited seeing my wish of getting rigorous training in research & then applying to clinics ?

which one strikes better balance in today's and tomorrow's harsh world of translational research ?

 

[typhoonegator]

A free-standing PhD can take a long time, depending on how things work out for you. Three years would be quite short. You would be very rusty from a clinical standpoint after that, and might have a hard time getting a residency because you'd be an older IMG who would need time to get back up to speed clinically. Something to think about.

However, doing a PhD after residency also sounds painful, so I don't know what to tell you. I personally think that if you get a residency at a good academic place, you can attach yourself to a research mentor/field and from there focus on developing a research skill-set that applies to that field. Running 10,000 gels and learning chromatography during your PhD does nothing for you if you end up in a patch-clamp lab.

I personally think that for an MD, the PhD is most useful when you are still relatively unfocused, in order to lay a foundation for a career in research. If you already have an idea of what you want to do, then you might get less out of it, and might be better off getting more focused training through a specific lab during/after residency.

 

[cyneuron]

Will getting an MS (Msc) in neuroscience or related interdisciplinary field be able to give me the research training i am talking about ?

how does this option stand in comparison to doing no Phd before residency ?

 

[typhoonegator]

Education is always great, if you can make it work for you. I'm not sure what you want to do with your life, and I'm not an expert in masters programs in neuroscience, but I don't think there are many people who are already MDs who are going into programs like that.

A masters in clinical epidemiology, biostatistics, or public health could be helpful, depending on your interests. Those programs often contain MDs who are trying to expand their knowledge base from a research perspective.

Its starting to sound like you don't really want to try to go straight from IMG to US residency. A masters degree might be somewhat helpful in building your portfolio, if that is your goal. It certainly doesn't take as much time as a PhD. But I don't know you, so I don't want to give you too much generic advice.

 

[neuronwangyu]

I am an IMG who had similar ideas about Ph.d/M.D when I graduated from medical school. I spent 6 years in a basic science lab (in US) focusing on developmental disorders leading to epilepsy and language deficits. Then, I got publications in Nature, Journal neuroscience and several others. My board score was about 230 and my RL were decent. I have some ideas of epileptogenic research and clinical application but guess what, I almost ended nowhere. As an IMG, don't think about pursuing such a track. Ph.d is very painful and once you finish it, everybody will start questioning your age, clinical ability and intention.

 

[PhakeDoc]

Regarding the 3-4 year PhDs. Let's just say in neuroscience, especially in the systems field, they tend to be longer. I could probably have finished mine in just over 4 if I was really pushing myself, but hey, I wanted to enjoy myself so took a bit longer.

As far as the programs that let you out in 3 years, I'm not sure how effective that is (on average). A lot of the science is about setup/failure and how to maintain and run your own lab (which many of the straight PhDs can pick-up during post-doc). I've seen people get out in 3 years with projects handed to them, but then they struggled when they were out on their own. I paid the price earlier (longer PhD) to hopefully reap the reward later.

The most important thing, though, is to make sure you are getting papers in quality journals during that time. During the latter part of my PhD, I often wondered if I had made the right decision. Well, after getting my interviews, I definitely think the PhD for me was the right thing to do. But everyone must make that decision for themselves.

 

[Amos]

Hello

I am an IMG and just finishing my medical school. I wanted to get some guidance from the experienced members of this community on my future career path choice in neurology/neuroscience. Will be really great if you may please take few mins to read my post and may help by sharing your thoughts on this.

I am carrying out good clinical research in Neurology (Parkinsonism Neuroimaging - use of fdg pet scans in atypical parkinsonism ; article), along with studying for my steps.
I also plan to do 6 month Junior Resident job in neurology Dept. to gain clinical experience in neurology (during next year while preparing for steps, will be applying for 2011 match).

Now my real interest lies in various exciting fields of translational neuroscience research (haven't zeroed in specific topic, almost everything in current neuroscience research excites me; but will surely be able to choose as i advance further).

Could you guys please advice me which will be a better way to go for a goal of pursuing translational research at intersections of neurology & neuroscience ?

1. A traditional track of Phd followed by postdoc - gives me the hardcore research training to pursue the research in Neuroscience, but will not give me opportunities to apply the clinical skills i have gained during my MD in significant practical manner.

2. A 3-4 Year Phd (i guess an MD can complete Phd in 3 yrs; someone please comment on this), followed by residency in Neurology followed by Academic Appointment Directly or Research Fellowship - will give me the research training i wish to have which to pursue translational research in Neurology, but with the disadvantage that its kinda very long path (similar to MD-Phd). But seems most matching seeing my interest of pursuing translational research.

3. A Residency in Neurology followed by Research Based Fellowship in Neurology - seems also a good option but will not give me the rigorous research training i wish to go through to conduct translational clinical research (though research based fellowship does allow one to carry out translational research).

In your shoes, I would NOT get the PhD. It won't help you with debt since you are already done with your MD and it might slow down your research training by making you take required graduate school courses, etc. when what you are really after is a combination of what PhD students get (basic science nuts and bolts experimental design training) coupled with post-doc guidance such as setting up your own lab, grant writing, etc. I also don't think you would want such a big break in your clinical training.

Your best bet, if you still have an interest in seeing patients, is to pursue a research oriented fellowship post residency were you can still have some clinical contact but focus mostly on getting your research training. It will be hard at first, since your post-doc peers with have a full PhD under their belt, but if you really want the training you can easily get it.

In terms of PhD training legnth, 3-4 years with high profile publications is possible if you find the right lab with the right projects and a PI that understands your goals and expectations. One of my friends in my program even finished in 2.5 years. There is always the chance it could take 6+ years however. I still think a research fellowship is a better way to go because then you can cut things short if you want to and can really focus on developing the skill set you need.

Also think carefully about what type of research you want to pursue. "Translational" can mean a lot of things. The vast majority of people that do clinical research are MDs with limited formal research instruction.

 

[typhoonegator]

Yeah, the more I think about it, I think Amos has it right.

If you want to become a neurologist, it's best to try to lock that in first. Get residency done, and then do whatever the heck you want -- PhD, MSc, research fellowship, clinical fellowship, private practice, whatever.

If you go for the PhD, that's great, but you're going to be locked in for several years, and there is no guarantee that anyone is going to want to take you for residency after that. That is FINE, however, if you don't care so much about residency and would like to end up with a lab eventually. Would be a waste of your MD, but whatever, its your life.

The MS/MA isn't a terrible idea, but probably isn't going to make you that much more attractive as a residency candidate, it costs money, and has a good probability of not doing much to further your research career.

 

[cyneuron]

thanks so much for so many helpful replies.

i guess you all have reaffirmed what has been going on inside my head. Neurology residency followed by research based fellowship seems to be the best bet for me to have in mind while preparing for my career goals at present....

though i really wish to have rigorous research training on the lines of what MD Phd get ( as it will be almost impossible to get such intensive training after residency or fellowship; and i really think that such training is needed to carry out truly hardcore scientific investigations; clinical research is really not science i guess) , but i guess being an IMG, i really will have a hard time if i get into Phd after MD, and then apply for residency.

as far as option for Phd and then postdocs goes, may be in one more year (when i am done giving my steps & GRE), i will be able to make a final decision if i really wanted to be a researcher than clinician.

 

[typhoonegator]

i really think that such training is needed to carry out truly hardcore scientific investigations; clinical research is really not science i guess)

Careful there. Clinical research is absolutely science. It can have an enormous impact on public health, and is the only way to get your so-called "truly hardcore scientific investigations" from the bench to the bedside.

Hard-core research is not all knock-out rats and test-tubes, my friend. Its also population stratification, additive models, and survivorship biases. You need to broaden your view.

 

[cyneuron]

Careful there. Clinical research is absolutely science. It can have an enormous impact on public health, and is the only way to get your so-called "truly hardcore scientific investigations" from the bench to the bedside.

Hard-core research is not all knock-out rats and test-tubes, my friend. Its also population stratification, additive models, and survivorship biases. You need to broaden your view.

surely sir....may be i took an extreme view or may be wrote it wrongly..

what i meant was from a investigator point of view, not something inherently wrong in clinical research versus science research....

i have personally felt this from my experience while doing clinical research in diabetes, cancer & parkinsonism during my medical school, and from listening to various scientist & reading science research in podcasts & journals...i feel this both in design as well as execution of clinical research....may be i feel this way as i haven't done any science research.

surely the outcomes of clinical research are equally or may be more profound as science research.

 

[PhakeDoc]

As someone who has been heavily involved in basic science research and now clinical research, clinical research is quite demanding, though perhaps in a different way. Sorry, can't delve in to more specifics b/c I don't want to "blow" my anonymity. Let's just say I initially used to think what you did. Now, no more.

surely sir....may be i took an extreme view or may be wrote it wrongly..

what i meant was from a investigator point of view, not something inherently wrong in clinical research versus science research....

i have personally felt this from my experience while doing clinical research in diabetes, cancer & parkinsonism during my medical school, and from listening to various scientist & reading science research in podcasts & journals...i feel this both in design as well as execution of clinical research....may be i feel this way as i haven't done any science research.

surely the outcomes of clinical research are equally or may be more profound as science research.

 

[Head]

Contrary to what some of the other posters are saying, I would look at it this way. Though Neurology is not the most competitive field, it is sometimes hard for IMG's to get into decent US residencies. I'm not sure how competitive you are, but a PhD with significant publications would be looked at as a huge plus when you are applying. I really don't think most residency programs would care too much how long you've been away from clinical work.

If you are a fairly strong candidate without the PhD, I would just try to get into the best neuro residency you can and go the research fellowship after residency route (without pursuing PhD). That is the path that I have taken (though I'm not an IMG) and it has several advantages. The most important, in my mind, is that you will often find that your clinical interests greatly shape your research interests and you will not know them until after you've completed residency. You may find, for example, after residency that you hate taking care of Parkinson's patients. Now your 6-7 years to get that PhD are wasted because you have no interest in seeing the patients you are researching in the lab. The other major advantages are financial and time, as the path to independent research post-residency is much more accelerated. As a research fellow you will make about $50-$75k for the first couple of years. You can then apply for a K award which will pay about $75k for 3-5 years while you try to transition to independent funding. Though frowned upon at most academic institutions, you could also moonlight during this time, further supplementing your salary. If you compare this to the PhD/postdoc route, you'll find it much more appealing. I also think that once you are established as an independent researcher, most people don't care whether you have the PhD as long as you have solid publications.

 

[cyneuron]

interesting comment from here :

" I disagree whole-heartedly. Though neurology is historically the specialty that has been concerned with brain-behavior relationships, this is largely due to the fact that neurologists are the ones who have had access to people with focal brain damage who manifested interesting behavioral deficits. Now that the lesion method has largely fallen out of favor due to the emergence of functional brain imaging, neurology no longer has a special relationship to cognitive neuroscience research. Neurology research now is largely concerned with things like inflammation and cell death. It's sort of like internal medicine for the brain. In other words, clinically, it doesn't matter where the lesion is or what interesting behvioral deficit it produces, your neurologist will still give you aspirin and Plavix. Some neurologists will be versed in and even do research on localization of brain function, but (sadly) this is a dying breed. Psychiatry, on the other hand, is all about how the brain gives rise to the mind. Granted, in the past there was relatively little known about the brain bases of mental illnesses, but this is changing very fast. There is an immense quantity of functional brain imaging research going on in psychiatry departments these days, much more than in neurology departments (and the NIH sees this type of research as more relevant to solving problems like drug addiction and schizophrenia than problems like stroke and epilepsy). I agree that general surgery is less relevant, though as a neurosurgeon you can do a lot of very interesting work recording electrical activity in the human brain, but why spend all of that time and effort just to be able to stick some wires into someone's brain. You can just as easily do that as a psychiatrist who collaborates with neurosurgeons - you just can't put the electrodes in yourself. The other great thing about psychiatry is that you actually can have time to do research, since it is one of the less demanding specialties in terms of clinical committments and call. Also, the last year of psychiatry residency is mostly elective, which gives you some time to spen in the lab.

I would definitely consider doing an MD-PhD. Try to find a program that is strong in cognitive neuroscience research. There are many, including WashU, UCLA, UPitt, Iowa, UCSD, Penn, Harvard (MIT). More and more MD-PhDs are heading in this direction - and most of them are going into psychiatry."

have requested drstrangeglove (author of above) if he may elaborate on this perspective of psychiatry residency as a pathway for neuroscience research....

 

[typhoonegator]

This person is painting with a pretty broad brush. I would be careful about following the opinions of someone who puts down another specialty in order to elevate their own.

I personally stopped reading after "Neurology research now is largely concerned with things like inflammation and cell death". Please.

Psychiatry is a broad and interesting field, but they are by no means the only people with the time and inclination to think about higher-order brain function.

I would also be careful about the panacea of fMRI. http://www.wired.com/wiredscience/2009/09/fmrisalmon/

Bottom line: you ask a broad question like yours on a big forum like this, you're going to get a wide variety of replies. In the end, you're going to have to decide for yourself how to proceed.

 

[cyneuron]

This person is painting with a pretty broad brush. I would be careful about following the opinions of someone who puts down another specialty in order to elevate their own.

I personally stopped reading after "Neurology research now is largely concerned with things like inflammation and cell death". Please.

Psychiatry is a broad and interesting field, but they are by no means the only people with the time and inclination to think about higher-order brain function.

I would also be careful about the panacea of fMRI. http://www.wired.com/wiredscience/2009/09/fmrisalmon/

Bottom line: you ask a broad question like yours on a big forum like this, you're going to get a wide variety of replies. In the end, you're going to have to decide for yourself how to proceed.

thanks for replying sir...

i quoted drstrangeglove as this perspective was surely new & interesting to me (i guess new to lot of people)....

he surely presents an interesting observation whose ground realities may be argued upon here. though following lines may be a little too extreme view.

" Neurology research now is largely concerned with things like inflammation and cell death. It's sort of like internal medicine for the brain. In other words, clinically, it doesn't matter where the lesion is or what interesting behvioral deficit it produces, your neurologist will still give you aspirin and Plavix."

googled psychiatry residency & related stuff

surely psychiatry residency allows you to have one full year (PGY 4) to have research elective (or other clinical experience one may wish) (quoting from here : Residency Programs in Psychiatry: The Training Experience )

also, of note is that there is a separate category of Research Fellwship in Neuroscience after psychiatry residency, with quite promising opportunities. interested people may have a detailed look here : Research Training Opportunities In Psychiatry

will be really great to hear other people views on this perspective...

 

[dl2dp2]

I think a lot of topics in research in neurology and psychiatry are overlapping in both techniques and even diseases. I was initially very excited about many neurology research projects when I read about them in the green journal.

However, I would caution you about going into a clinical discipline simply because of the research in it. You can do neurology research as a psychiatrist, but you can't practice neurology. Same vice versa. Make sure you like neurology practice. When I did my 3rd year rotation in neurology I found it really painful to deal with all the irreversible brain damage and lack of effective therapy. There is also a strong emphasis of internal medicine in neurology, which makes sense, as neurology is going in the route of cardiology, in emphasizing interventional techniques, procedures and intensive care. Do you care about managing people's vents and intracranial pressures? Do you care about managing headaches and back pain? Do you care about infections and autoimmune disorders? I decided that even though I am intellectually interested in these subjects, I just don't want to deal with the daily grind of management for these patients.

Psychiatry on the other hand is a much cleaner field in some ways. You sit down and talk to someone and try to figure out how their cognitive process works. The part of psychiatry that is often painful to med students involves the SOCIAL aspects of medicine--family structure, financial stressors, work environment, abuse, addiction, etc., which some people find interesting, and others find intolerable. Also even though treatments in psychiatry are much more immediate in some ways, the pathophysiology of psychiatric disorders are much less clear. Psychiatry clinically is much less of a "science" as you would say.

The clinical practice/scope/style in these two fields are really quite different and you won't know until you tried both. You can do translational research in both fields in any topic you want--you can collaborate and have a mentor in neurology even if you practice as a psychiatrist. However, if you committed into being a neurologist and end up hating the clinical practice, it would be very very bad.

 

[Fencer]

A PhD will enhance your application, and the quality of residencies you might be able to get. However, you will need to complete it with no more than 5 yrs of break from Medical School graduation. Often, the first year after med school graduation for an IMG consists of taking the exams and coming to the US. Thus, effectively, you need to complete the PhD in 4 yrs. That means that you need extra focus and a lot of assertiveness to keep yourself ontrack. I also recommend that you still try to attend Neurology Grand rounds as well as to shadow one of the Neurology clinicians on your last 1.5 - 2 years for a 2-4 hrs per week.

Despite the extra training, it will prepare you for a lasting academic career.

 

[surag]

Will getting an MS (Msc) in neuroscience or related interdisciplinary field be able to give me the research training i am talking about ?

how does this option stand in comparison to doing no Phd before residency ?

let me add some perspective... I got my BS in neuroscience at a pretty high end institution...everyone told me an MS is worthless. you wont gain much to be honest. I think it woudl have been an interesting choice say if you had not yet attended medicine, but honestly an MS program isnt worth it especially for an MD. most neuro MS programs are one year and course intensive...nothing you learn in it is worth the time as everything taught is mostly off textbook. If you do 2 year research MS program then you'll be doing one years worth of classwork and a year project...the value of this(through an MS) is not worth the 2 years. you're better off with a fellowship(of which I dont know much about but is better than an MS)

i too am not sure what I want to do, I have been mulling the MD/PhD route as well or just a plain MD. I see a lot of neurology residents having accomplished either and being succesful. One way to gain insight is to look at the better researchers out there today in neuroscience who are MDs and see what they've done. From my research I see mostly MDs doing a few years of fellowship work and then doing a neurology residency. I think thats an excellent way to go about things.

 

[cezzz]

Do you really want the PhD? Because you can do good research without it. The PhD track enhances a specific skill-set, and if that is what you want, then go for it. But don't do it just to get those letters after your name -- you'll be miserable.

I think you need to decide if you want to take care of patients or not. If you don't, then residency is extraneous and painful, and you might as well go for the PhD and jump into full time research. If you do, then you gotta get the residency at some point, and you'll probably be better off getting the clinical stuff taken care of without a huge break in between your MD and residency.

As I've said before on this forum, the research world today can be very harsh, and funding can dry up quickly. A fully trained MD doing research has the advantage of being able to support his/her salary during the lean times, if need be. That usually comes with the added headaches of maintaining licensure, clinical duties like clinic preceptorship, and mountains of debt. But you've already got the MD, so in my view it would be a shame to let all that work fade into the background. But, of course, its your call.

Well many grad student, said that the PhD is doesn't need to take so long. Rather, if the PhD was less a major life work and more of a proof of understanding & ability in the field it could be done faster. A shorter PhD would shorten the lengthly grad-school post-doc post-doc junior-faculty tenure-review process, and add younger minds to the independent research pool. Leaving the PhD-student role and becoming employed earlier would add stability to one's personal life more quickly.

 

[strangeglove]

Could someone please say why a neurologist needs to know how the orbitofrontal or anterior cingulate cortices work in order to provide good clinical care (as distinct from being able to impress/educate/pimp their attendings/residents/medical students)? As we all know, lesion localization is superfluous in the era of MRI. Not a put down. Just an observation.

I have great respect for the ability of neurologists to prevent the death, demyelination and hyperexcitability of neurons. I wouldn't want a neurologist taking care of me who didn't know about this stuff. However, I could care less if my neurologist knew nothing about how the anterior and mediodorsal thalami differ in their functions (except, of course, that this could mean that he/she may not have paid attention to other things in residency that are actually clinically relevant).

 

[Fencer]

As we all know, lesion localization is superfluous in the era of MRI. Not a put down. Just an observation.

Clearly, you have not seen a sufficient number of brain MRIs littered with white spots in FLAIR in people with new complaints not explained by MRIs. Lesion localization tells you when you are missing something. More than once every week, I see a case where localizing the lesion (with time course) allowed me to persist beyond and find the correct diagnosis.

 

[strangeglove]

Clearly, you have not seen a sufficient number of brain MRIs littered with white spots in FLAIR in people with new complaints not explained by MRIs. Lesion localization tells you when you are missing something. More than once every week, I see a case where localizing the lesion (with time course) allowed me to persist beyond and find the correct diagnosis.

I don't quite understand what you're saying; you seem to contradict yourself in your statement that "you have not seen a sufficient number of brain MRIs littered with white spots in FLAIR in people with new complaints not explained by MRI."

In any case, I've seen enough to know that anyone with a complaint that is ultimately related to FLAIR hyperintensities would get an MRI in the first instance, and that nobody would start treating somebody for something like MS if the abnormalities were only evident from the history/physical. I understand that they may treat residual deficits that were previously diagnosed on MRI that are no longer evident, but in order to track the timecourse of a deficit, it is not necessary to know the relationship of that deficit to the function of specific brain areas.

The question still stands: Can someone provide a specific example where they thought: "because I knew that brain region X subserved function Y, I was able to help a patient in Z way"? I'm rather curious about this.

I think one place where structure-function relationships are important in neurology is the area of rehabilitation. Here, it is important to know what specific deficits result from a lesion and how these deficits will impact long-term functioning. Related to this is the ability to understand how other regions can take over the function of the damaged area. I my experience, this sort of stuff is left to the rehab doctors, after people are discharged from the acute stroke unit.

My point in saying all of this is not to bash neurology. My reason is to help the OP understand that if he/she is interested in the relationship between mind and brain and how this information can be used to help people who are suffering from disease, that neurology is less interesting a place than psychiatry.

 

[typhoonegator]

Could someone please say why a neurologist needs to know how the orbitofrontal or anterior cingulate cortices work in order to provide good clinical care (as distinct from being able to impress/educate/pimp their attendings/residents/medical students)? As we all know, lesion localization is superfluous in the era of MRI. Not a put down. Just an observation.

I have great respect for the ability of neurologists to prevent the death, demyelination and hyperexcitability of neurons. I wouldn't want a neurologist taking care of me who didn't know about this stuff. However, I could care less if my neurologist knew nothing about how the anterior and mediodorsal thalami differ in their functions (except, of course, that this could mean that he/she may not have paid attention to other things in residency that are actually clinically relevant).

We care for patients, not neurons. If I wanted to know just enough about my chosen organ of interest to squeak by in clinical care, I wouldn't have become a physician. People who tend to say things like "lesion localization is superfluous" usually don't have a clue what we do on a day-to-day basis. You'd be shocked how often the clinical picture and the MRI are disconcordant, and you're left relying on the good old reflex hammer and tuning fork.

Additionally, there is this thing called the peripheral nervous system, which doesn't localize very well on MRI.

Finally, I would argue that behavioral neurologists care a great deal about the orbitofrontal and anterior cingulate cortices, because lesions or degeneration in those areas can be reasons people come to their offices.

 

[typhoonegator]

The question still stands: Can someone provide a specific example where they thought: "because I knew that brain region X subserved function Y, I was able to help a patient in Z way"? I'm rather curious about this.

Fine, I'll bite. Patient with old R MCA stroke comes into ED with acute worsening of chronic LUE weakness. UA shows UTI. ED gets ready to send patient back to rehab with diagnosis of stroke recrudescence in setting of UTI. ED calls neurologist as a courtesy. Neurologist (me) diagnoses patient with Wallenberg syndrome. MRI does not show the lesion, but it doesn't matter, because the patient has a Wallenberg syndrome nonetheless. CTA shows clot in the basilar, which had worked its way up and caused the lateral medullary stroke. We admitted him to the unit, and started anticoagulation (rather than sending him back to rehab).

We likely prevented a top-of-the-basilar syndrome in this patient because of clinical localization. MRI was actually detrimental, because it could have been falsely reassuring.

 

[Fencer]

I don't quite understand what you're saying ... that neurology is less interesting a place than psychiatry.

I did not express myself clearly. My point was to contradict your statement regarding brain MRIs becoming the localizer instead of the neurologic examination. Neuro-imaging provides the confirmation for your exam. Lesion localization (based on examination) and time course (based on history) are the two necessary elements to make the differential diagnosis for each patient PRIOR to any test.

Behavioral neurology is a field that is advancing considerably. Psychiatry and Neurology assess different aspects of Brain physiology (function). However, there is a higher degree of precision and reproducibility in Neurology than in Psychiatry. Excitement is something very personal...

 

[surag]

My point in saying all of this is not to bash neurology. My reason is to help the OP understand that if he/she is interested in the relationship between mind and brain and how this information can be used to help people who are suffering from disease, that neurology is less interesting a place than psychiatry.

Since when did psychiatry ever become anythin beyond behavior as well as and separately, medication? I dont know that psychiatry focuses on the mind in a neurscientific sense-and that is what the OP is interested in, as I am.

I am not nearly as interested in psychiatry because it seems to pertain more to behavior and medicine related to controlling/modifying said behavior through prophylactics.

It seems to me that from a medical and clinical perspective, more than any other field including neurosurgery/psychiatry neurology offers a researcher the best bridge between basic neuroscience and clinical neuroscience.