Radiology- Torn between MSK and Neuro fellowship

[MrRentgen7]

Like title says, currently a rising R3 in East Coast torn between Neuro vs MSK for private practice.

I really love the procedural aspect of MSK and the MRs are really interesting if you know what you’re doing in my opinion. I think I find MSK more interesting than Neuro overall but not by an extreme amount. What worries me a bit is being stuck reading a plain film predominant specialty the rest of my life.

Neuro, in contrast, is interesting enough and has the potential to be an RVU generating machine in private practice. I know you shouldn’t choose a fellowship based on money but money is an important thing to at least consider if there is a big difference. Which I’m not 100% sure there is? I do know that if you have a set minimum number of RVUs you need to read per day Neuro will achieve that much more easily and some of my upper levels have told me that some groups give bonuses at the end of the year based on RVU generation , which again, Neuro comes out on top.

Another way I think about it is when I’m 50 and most of Radiology just becomes routine I dont want to look back and say “Damn if I would’ve done Neuro instead my life would be much cushier right now”. I have heard that Neuro might have more call/worse hours too though?

What are y’alls thoughts on MSK vs Neuro?

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[maxxor]

Like title says, currently a rising R3 in East Coast torn between Neuro vs MSK for private practice.

I really love the procedural aspect of MSK and the MRs are really interesting if you know what you’re doing in my opinion. I think I find MSK more interesting than Neuro overall but not by an extreme amount. What worries me a bit is being stuck reading a plain film predominant specialty the rest of my life.

Neuro, in contrast, is interesting enough and has the potential to be an RVU generating machine in private practice. I know you shouldn’t choose a fellowship based on money but money is an important thing to at least consider if there is a big difference. Which I’m not 100% sure there is? I do know that if you have a set minimum number of RVUs you need to read per day Neuro will achieve that much more easily and some of my upper levels have told me that some groups give bonuses at the end of the year based on RVU generation , which again, Neuro comes out on top.

Another way I think about it is when I’m 50 and most of Radiology just becomes routine I dont want to look back and say “Damn if I would’ve done Neuro instead my life would be much cushier right now”. I have heard that Neuro might have more call/worse hours too though?

What are y’alls thoughts on MSK vs Neuro?

Do you like taking call, because Neuro is becoming the default for ER coverage, especially if the hospital is a stroke center.

You’ll have worse hours in neuro.

On the flip side, it can be hard to find a 100% msk job.

 

[MrRentgen7]

Do you like taking call, because Neuro is becoming the default for ER coverage, especially if the hospital is a stroke center.

You’ll have worse hours in neuro.

On the flip side, it can be hard to find a 100% msk job.

I don't mind reading outside of the specialty for either. I can read a CT CAP any day of the weeks with no problems.

Apart from worse hours and more call in Neuro any other factors you think that differentiate the two or that could help me better make a decision for private practice based on your experience?

 

[maxxor]

I don't mind reading outside of the specialty for either. I can read a CT CAP any day of the weeks with no problems.

Apart from worse hours and more call in Neuro any other factors you think that differentiate the two or that could help me better make a decision for private practice based on your experience?

I mean it depends on who / what you like interacting with.

Do you like dealing with orthopods or neurologists/NSG?

I find neuro disease depressing as all hell so I couldn’t do it even though I think neuro imaging is super cool from a technical image acquisition aspect.

The other nice thing about msk relative to neuro is the average acuity is way less. I liked procedures and did a procedure heavy fellowship so that was cool to break up the days / weeks but it is even more challenging to find a private practice job that does significant msk procedure work because of competition from pmr or the orthos themselves.

 

[Cognovi]

I like the higher average acuity of neuro, the lack of procedures, and the lack of plain film drudgery.

 

[guytakingboards]

Like title says, currently a rising R3 in East Coast torn between Neuro vs MSK for private practice.

I really love the procedural aspect of MSK and the MRs are really interesting if you know what you’re doing in my opinion. I think I find MSK more interesting than Neuro overall but not by an extreme amount. What worries me a bit is being stuck reading a plain film predominant specialty the rest of my life.

Neuro, in contrast, is interesting enough and has the potential to be an RVU generating machine in private practice. I know you shouldn’t choose a fellowship based on money but money is an important thing to at least consider if there is a big difference. Which I’m not 100% sure there is? I do know that if you have a set minimum number of RVUs you need to read per day Neuro will achieve that much more easily and some of my upper levels have told me that some groups give bonuses at the end of the year based on RVU generation , which again, Neuro comes out on top.

Another way I think about it is when I’m 50 and most of Radiology just becomes routine I dont want to look back and say “Damn if I would’ve done Neuro instead my life would be much cushier right now”. I have heard that Neuro might have more call/worse hours too though?

What are y’alls thoughts on MSK vs Neuro?

I don't really get the "neuro might have more call/worse hours" bit. If you're in a reasonable group of any sort, PP or academic, the amount of call is going to be relatively balanced. Can't imagine a neuro section/person agreeing to take more call just because neuro is a heavy portion of call. An MSK person is just going to cover more general/body call because stat MSK is such a small portion of call.

There's a lot of different PP compensation models out there and quite a few don't have (or have signficant) RVU bonuses. My group doesn't have productivity bonuses. The lowest RVU generator makes as much as the highest RVU generator. One of my buddy's groups has a minimal production bonus, like $10k over a quarter for being 2 standard deviations over average. I wouldn't base decisions on this particular point.

The one thing I think is semi-relevant is that neuro training is advantageous for swing shifts and deep nights in a way that MSK isn't. Basically everyone can use another neurorad. The same can't be said about MSK. An MSK person really only fits if the group needs more MSK subspecialty readers OR is willing to do a lot of general.

I'd say do what you enjoy more. As the saying goes "do what you love and you'll never work a day in your life".

 

[Gadofosveset]

Some good points here.

You’re almost certainly going to read both unless you go into academics, in which case the salary issue is secondary.

Maybe you’ll get some skew toward your subspecialty if you find a group that does this, but everything is on the table on call. I would pick the one that you gravitate to and which seems like a better training experience.

My take is that when you’re 50 you will not look back and regret a financial difference between the two. You will only regret loss of time and/or putting up with bad experiences.

 

[Tiger100]

MSK used to have a better job market.
These days you can get a good job with both. So do whatever you like more. IMO, Neuro is more interesting.

 

[Radrunner89]

Fresh R3 here also deliberating between MSK and neuro. I find neuro a bit more interesting but the neuro rotations at our program (busy community program) can be a beatdown. Part of it is just the overall volume, but specifically the number of code strokes can be relentless. It's hard to really savor that intracranial mass you're trying to read on brain MR when you get constantly interrupted 1 by the code strokes. Ct tech calls when CT head is done, then calls again once CTA source images are done, and then of course I have to call someone if something is positive (a minority of cases).

I've been leaning toward MSK just because I worry the lifestyle in neuro will suck. If I were to stick at our program after residency (which I'm not primarily due to location/wanting to go back home), I would definitely not go into neuro. Even our neuro staff admit going to into neuro is probably not the best decision.

I'm wondering what neuro is like at other programs or other private practice groups. Is it common to be the code stroke guy for multiple hospitals everyday, every 3rd day etc. I know this is going to be a bit specific to each practice, but am trying to get a sense of how neuro is at other places before I completely write off the specialty I was most interested in upon entering residency.

 

[guytakingboards]

I'm in a large multi-specialty practice with multiple neuro readers reading off common lists each day. Code strokes are part and parcel of neuroradiology but I don't find them to be as disruptive and annoying as your experience. As a matter of protocol, we don't get called unless the clinician or tech elevates the study. The standard stroke CT drops on the list, we read it and call the findings. When the CTA drops we read it and call if necessary.

If I'm in an interesting case and a stroke drops, I probably won't be bothered unless the other neuro readers are unavailable. Usually the CT strokes are picked up by someone on the list pretty quickly.

I think of MSK like pure outpatient neuro. A lot more chill but sometimes to the point of tedium and boredom. Our hospital neuro shifts certainly keep us more engaged, with the stats and procedures.

 

[Radrunner89]

I'm in a large multi-specialty practice with multiple neuro readers reading off common lists each day. Code strokes are part and parcel of neuroradiology but I don't find them to be as disruptive and annoying as your experience. As a matter of protocol, we don't get called unless the clinician or tech elevates the study. The standard stroke CT drops on the list, we read it and call the findings. When the CTA drops we read it and call if necessary.

If I'm in an interesting case and a stroke drops, I probably won't be bothered unless the other neuro readers are unavailable. Usually the CT strokes are picked up by someone on the list pretty quickly.

I think of MSK like pure outpatient neuro. A lot more chill but sometimes to the point of tedium and boredom. Our hospital neuro shifts certainly keep us more engaged, with the stats and procedures.

Thanks for the insight, it's good to know the setup at our institution isn't necessarily representative. I could see the total lack of acuity leading to a little boredom; I think doing the busiest shifts everyday for a month (instead of rotating different shifts throughout the week like staff do) probably falsely colors my impression of it as a career. So it sounds like the radiologists do the LPs and myelograms at your practice (as opposed to NP/PA)? And do the neuro rads in your group stick to just neuro or do they do some general rads too?

Our MSKs guys do a fair number of procedures, mostly outpatient with the occasional joint aspiration on inpatient. Strictly outpatient MSK I agree will get a little bored. I (maybe incorrectly?) assume most MSK rads still do a fair bit of general radiology at most PP.

 

[guytakingboards]

Thanks for the insight, it's good to know the setup at our institution isn't necessarily representative. I could see the total lack of acuity leading to a little boredom; I think doing the busiest shifts everyday for a month (instead of rotating different shifts throughout the week like staff do) probably falsely colors my impression of it as a career. So it sounds like the radiologists do the LPs and myelograms at your practice (as opposed to NP/PA)? And do the neuro rads in your group stick to just neuro or do they do some general rads too?

Our MSKs guys do a fair number of procedures, mostly outpatient with the occasional joint aspiration on inpatient. Strictly outpatient MSK I agree will get a little bored. I (maybe incorrectly?) assume most MSK rads still do a fair bit of general radiology at most PP.

It's a mix. The neurorads have traditionally done the LP/myelos at hospitals (where a neurorad is on-site) but we've hiring and incorporating PA's into our workflow at the busier hospitals. They see consults and can do thyroids/thora/para/LP's. The PA knocking out 1-2 of my LP's can be super helpful if the list is terrible or there are 4 LP's total.

I used to do more general than I do now. You should not expect pure neuro in PP.

PP MSK is a very different beast to academic MSK. In academics, full MSK procedure days are common. In PP, its fairly uncommon to do a lot of MSK procedures. Maybe arthrograms here or there but anything more is rare for a couple reasons. 1) it takes resources to do MSK procedures efficiently and well 2) MSK procedures typically don't reimburse well and MSK rads reading MRI/CT is a better use of their time and 3) in the private world the clinicians (ortho/pain/PM&R) want to do/keep all the lucrative procedures and don't want their radiology group competing with them.

My MSK partners tried to build up an MSK procedure service line and just got referred the tough cases that other people didn't want to do. Pretty fruitless endeavor.

Yes, most MSK rads do a fair amount of general radiology in PP.

 

[MadRadLad]

I'm in a large multi-specialty practice with multiple neuro readers reading off common lists each day. Code strokes are part and parcel of neuroradiology but I don't find them to be as disruptive and annoying as your experience. As a matter of protocol, we don't get called unless the clinician or tech elevates the study. The standard stroke CT drops on the list, we read it and call the findings. When the CTA drops we read it and call if necessary.

If I'm in an interesting case and a stroke drops, I probably won't be bothered unless the other neuro readers are unavailable. Usually the CT strokes are picked up by someone on the list pretty quickly.

I think of MSK like pure outpatient neuro. A lot more chill but sometimes to the point of tedium and boredom. Our hospital neuro shifts certainly keep us more engaged, with the stats and procedures.

Neurotrauma and stroke/vascular care are some of the more rewarding parts of radiology in my opinion. You can make huge impacts on patient care based on your initial reads.

 

[Tiger100]

Neurotrauma and stroke/vascular care are some of the more rewarding parts of radiology in my opinion. You can make huge impacts on patient care based on your initial reads.

Not really. YMMV.

 

[maxxor]

Not really. YMMV.

Agree.

I always felt like the most interesting neuro imaging cases were also the most depressing for the patient.