What turned you away from other subspecialties? Why did you choose your subspecialty?

[Cere-berus]

There are lots of information about the different subspecialties regarding training, procedures etc. But I'm looking for insights, experiences, or opinions about what it actually feels like to work in each area particularly Neuromuscular, Movement, Headache, MS, Stroke...

For example, in my limited experience, Movement Disorders programs talk about the variety of pathologies, DBS and Botox. But outside of academia, out in the community you're mostly seeing Parkinson's, you need a neurosurgeon and academic center for DBS, and there's not a lot of volume for botox.

---

Members don't see this ad.

 

[Cere-berus]

Also keep in mind that even if you do Movement or Neuromuscular you will not be doing that 100% of the time and will see general neurology patients as well (a large proportion of which is not neurology as we have discussed). This is absolutely true in a community setting and even in a lot of academic settings an early career Movement or Neuromuscular attending is probably going to get shunted general patients that the senior attendings with the real interesting subspecialty patient population dont want to book in their clinic.

What are your opinions (negative or positive) on Movement vs Neuromuscular? Which patient population would you prefer, I hear neurologist says its more rewarding to work with movement patients.

 

[Neurocrit]

What are your opinions (negative or positive) on Movement vs Neuromuscular? Which patient population would you prefer, I hear neurologist says its more rewarding to work with movement patients.

Hands down if I had to do an outpatient neurology subspecialty it would have been movement.

Neuromuscular in the community is a lot of EMG/NCS which will mostly be normal or routine pathology like radiculopathy, DM neuropathy, carpal tunnel etc. The non procedure visits will be much of the same. Imagine referrals from PCP for clear DM neuropathy with an A1C of 12 because gabapentin hasn't helped much. Try doing that day in and day out. Sure you will get the rare myasthenia patient that is satisfying to diagnose and manage but past that most community neuromuscular attendings refer strange things to academic neuromuscular attendings.

Movement some people disparage as a Parkinsons Disease fellowship. It is true that is a large proportion of what you will see especially in the community but I find those patients satisfying. You can really help them and a good neurologist can make or break a PD patients quality of life and you get to manage a lot of interesting pathology that comes with it like parasomnias, autonomic issues, and psych complications. DBS is interesting of course if you are in a center that does that and in the future there is lots of opportunity I think for non-invasive monitoring of movement symptoms with Apple Watch or other types of actigraphy to really understand how to optimize treatment timing. Other common pathology includes essential tremor which has a wide array of treatments and even some interesting new devices like Cala Trio. Then there is Botox which can really be life changing for patients with cervical dystonia or blepharospasm etc. I feel that at baseline the movement bread and butter is more interesting. Yes there are non neurological patients and/or functional patients in movement but even that can be interesting with fun exam tricks to sort out functional vs. real.

Finally, because of the Botox skills I know movement docs who take on a lot of migraine patients. Undifferentiated headache is not my thing (drink water, use your CPAP, and stop eating 20 Advils a day and then we will talk) but true migraine can actually be rewarding. Its a stretch to call migraine the territory of movement but I think practically they can and do take on these patients so Ill add here that migraine has interesting new treatments too like Cefaly and gammaCore which are non-invasive trigeminal and vagal stimulation devices, respectively.

 

[Neurocrit]

Stroke. Con. Largely inpatient, and in my experience hardly any other provider in the hospital setting is capable of actually being a doctor and make decisions which entail even a small amount of risk, leading to pan-consults.

True. Stroke ends up being "Triage Neurology" for both inpatient and ED which can be stressful.

 

[confused_doc]

Hands down if I had to do an outpatient neurology subspecialty it would have been movement.

Neuromuscular in the community is a lot of EMG/NCS which will mostly be normal or routine pathology like radiculopathy, DM neuropathy, carpal tunnel etc. The non procedure visits will be much of the same. Imagine referrals from PCP for clear DM neuropathy with an A1C of 12 because gabapentin hasn't helped much. Try doing that day in and day out. Sure you will get the rare myasthenia patient that is satisfying to diagnose and manage but past that most community neuromuscular attendings refer strange things to academic neuromuscular attendings.

Movement some people disparage as a Parkinsons Disease fellowship. It is true that is a large proportion of what you will see especially in the community but I find those patients satisfying. You can really help them and a good neurologist can make or break a PD patients quality of life and you get to manage a lot of interesting pathology that comes with it like parasomnias, autonomic issues, and psych complications. DBS is interesting of course if you are in a center that does that and in the future there is lots of opportunity I think for non-invasive monitoring of movement symptoms with Apple Watch or other types of actigraphy to really understand how to optimize treatment timing. Other common pathology includes essential tremor which has a wide array of treatments and even some interesting new devices like Cala Trio. Then there is Botox which can really be life changing for patients with cervical dystonia or blepharospasm etc. I feel that at baseline the movement bread and butter is more interesting. Yes there are non neurological patients and/or functional patients in movement but even that can be interesting with fun exam tricks to sort out functional vs. real.

Finally, because of the Botox skills I know movement docs who take on a lot of migraine patients. Undifferentiated headache is not my thing (drink water, use your CPAP, and stop eating 20 Advils a day and then we will talk) but true migraine can actually be rewarding. Its a stretch to call migraine the territory of movement but I think practically they can and do take on these patients so Ill add here that migraine has interesting new treatments too like Cefaly and gammaCore which are non-invasive trigeminal and vagal stimulation devices, respectively.

Would you say academic neuromuscular is interesting or more of the same routine pathology?

 

[Neurocrit]

Would you say academic neuromuscular is interesting or more of the same routine pathology?

If you are a full professor of neurology you will have your collection of inclusion body myositis, myasthenia, myotonic dystrophy, LEMS, etc based on your specific area of expertise but the truly interesting neuromuscular stuff is rare and it takes years to collect a patient profile like that. Starting out and maybe forever depending on the center and whether you move up the food chain you are going to see largely community referrals for anxious tingleopathies, "internal vibration", r/o small fiber neuropathy, non-op lumbar radiculopathy, DM neuropathy etc. Its sort of like the worst type of pain medicine clinic.

I wouldn't want to slog through that for the rare interesting treatable condition like myasthenia. Sort of like panhandling for gold in my mind. Keep in mind that most of rare and interesting things in neuromuscular are certainly interesting diagnoses to make but then you just follow them for years. At the end of the day I still wouldn't be happy with a clinic full of things like facioscapulohumeral dystrophy where I wouldn't be adding much. Just my preference. Some people love it and Im glad someone does especially if they are research focused because we sorely need better treatment options.

 

[DrAtheist]

Hands down if I had to do an outpatient neurology subspecialty it would have been movement.

Neuromuscular in the community is a lot of EMG/NCS which will mostly be normal or routine pathology like radiculopathy, DM neuropathy, carpal tunnel etc. The non procedure visits will be much of the same. Imagine referrals from PCP for clear DM neuropathy with an A1C of 12 because gabapentin hasn't helped much. Try doing that day in and day out. Sure you will get the rare myasthenia patient that is satisfying to diagnose and manage but past that most community neuromuscular attendings refer strange things to academic neuromuscular attendings.

Movement some people disparage as a Parkinsons Disease fellowship. It is true that is a large proportion of what you will see especially in the community but I find those patients satisfying. You can really help them and a good neurologist can make or break a PD patients quality of life and you get to manage a lot of interesting pathology that comes with it like parasomnias, autonomic issues, and psych complications. DBS is interesting of course if you are in a center that does that and in the future there is lots of opportunity I think for non-invasive monitoring of movement symptoms with Apple Watch or other types of actigraphy to really understand how to optimize treatment timing. Other common pathology includes essential tremor which has a wide array of treatments and even some interesting new devices like Cala Trio. Then there is Botox which can really be life changing for patients with cervical dystonia or blepharospasm etc. I feel that at baseline the movement bread and butter is more interesting. Yes there are non neurological patients and/or functional patients in movement but even that can be interesting with fun exam tricks to sort out functional vs. real.

Finally, because of the Botox skills I know movement docs who take on a lot of migraine patients. Undifferentiated headache is not my thing (drink water, use your CPAP, and stop eating 20 Advils a day and then we will talk) but true migraine can actually be rewarding. Its a stretch to call migraine the territory of movement but I think practically they can and do take on these patients so Ill add here that migraine has interesting new treatments too like Cefaly and gammaCore which are non-invasive trigeminal and vagal stimulation devices, respectively.

Is there a lot of demand for Movement in the community setting? I feel like I see very few Movement trained neurologists in private practice groups near me

 

[Telamir]

If you do any kind of neurology "in the community" (which I take to mean outpatient) with any kind of fellowship you'll always end up doing general neuro + your fellowship.

What may happen if you're a movement disorders guy is you might join a group of 3-4 other neurologists (for example) and see general neuro + movement or your colleagues might send you all their complex movement disorders patients or P.D. patients if they're not super comfortable managing or if it's not their area of interest.

If you're talking inpatient then it's a free for all unless you're at a center big enough to have a segregated stroke service which isn't all that common. Inpatient neuro is truly general neuro. You go from titrating Ketamine/Propofol on super refractory status to confused granny with an UTI to diagnosing new P.D. or choreiform movement disorder, etc. etc. etc.

 

[Neurogeneral]

I have been doing general neuro clinic for the past 4 years and I can’t say I like it enough to continue doing it. I do take care of actual neurology patients (which is very enjoyable btw) but the bulk of my clinic ends up being “junk” referrals. It’s hard to build a practice when many of the patients you see don’t have a diagnosable neurological condition. You also end up with a big inbasket that you have to manage everyday - including countless FMLA and disability paperwork requests and insurance appeals for denied testing that you have to tend to.

I do believe that if you want to do clinic, you should definitely subspecialize. I feel that neuro-immunology and even headache fellowships would be especially beneficial. Back in the day, there were so few medications available for MS and migraines, but there has been explosion of options available to treat patients and make a big difference in their lives. When you are a sub specialist, you can often even dictate which patients you want to see in your clinic. So a headache subspecialist can, for instance, say no to a referral for back pain, lightheadedness, syncope, etc.

 

[Telamir]

The inbox has single handedly ruined outpatient medicine or neurology for me. I hated it so much in residency that since graduating I've not done any outpatient at all despite having done an epilepsy fellowship. I thought maybe in a subspecialty clinic it'd be better but nope, still garbo.

That being said one of my residency classmates stayed at our program (name brand top place yada yada) doing neuroimmunology and I'm not sure it's that much better. They've been telling me nowadays since autoimmune panels have become more common and easier to order people are now showing up to his clinic with neuro symptoms NOS and a mildly positive antibody which is now his issue to sort. While MS is more treatable now than it ever has been it's still a challenging lot. Headache might be better, who knows. I considered it as a fellowship was burned out of pain/fibro clinic so I didn't.

I would think (not having done outpatient before) that even as a subspecialist you can't just "turn down" a lot of these referrals like you say because if you can't fill up your clinic you'll starve anyway so in comes the lightheaded, giddy, tingle, syncope/presyncope brain fogs.

 

[Cere-berus]

I have been doing general neuro clinic for the past 4 years and I can’t say I like it enough to continue doing it. I do take care of actual neurology patients (which is very enjoyable btw) but the bulk of my clinic ends up being “junk” referrals. It’s hard to build a practice when many of the patients you see don’t have a diagnosable neurological condition. You also end up with a big inbasket that you have to manage everyday - including countless FMLA and disability paperwork requests and insurance appeals for denied testing that you have to tend to.

I do believe that if you want to do clinic, you should definitely subspecialize. I feel that neuro-immunology and even headache fellowships would be especially beneficial. Back in the day, there were so few medications available for MS and migraines, but there has been explosion of options available to treat patients and make a big difference in their lives. When you are a sub specialist, you can often even dictate which patients you want to see in your clinic. So a headache subspecialist can, for instance, say no to a referral for back pain, lightheadedness, syncope, etc.

Many neurologists say to not do a subspecialty in something you'll get a lot of experience in during residency, unless you really want to, for instance Stroke or headache. Try to do something that will add a billable skill, or didnt get much training in. Which subspecialty do you think would be best for outpatient community practice?

 

[sharkbaitwhohaha]

The inbox has single handedly ruined outpatient medicine or neurology for me. I hated it so much in residency that since graduating I've not done any outpatient at all despite having done an epilepsy fellowship. I thought maybe in a subspecialty clinic it'd be better but nope, still garbo.

That being said one of my residency classmates stayed at our program (name brand top place yada yada) doing neuroimmunology and I'm not sure it's that much better. They've been telling me nowadays since autoimmune panels have become more common and easier to order people are now showing up to his clinic with neuro symptoms NOS and a mildly positive antibody which is now his issue to sort. While MS is more treatable now than it ever has been it's still a challenging lot. Headache might be better, who knows. I considered it as a fellowship was burned out of pain/fibro clinic so I didn't.

I would think (not having done outpatient before) that even as a subspecialist you can't just "turn down" a lot of these referrals like you say because if you can't fill up your clinic you'll starve anyway so in comes the lightheaded, giddy, tingle, syncope/presyncope brain fogs.

Lot of doom and gloom, YMMV.

Not all outpatient neurology practices are inundated with inbasket messages. With good training (both MA side and with "training" patients), the volume can be kept very minimal. I handle probably 3-10 a day and most are simple "FYIs" from patients/MAs/other staff and only 1 or 2 of them take more than 5 seconds. A few times a week it will require me calling the patient, but overall I spent <20 mins ALL WEEK dealing with inbasket stuff.

Don't think in patient neurology gets away from inbasket requirement either.

 

[Telamir]

I agree I’m a glass half full of urine kinda guy.

That being said I haven’t deal with an in basket while inpatient. Maybe like documentation clarifications but that’s about it.

 

[deathmerchant]

Agree with @sharkbaitwhohaha above. My MA and staff are well trained and take care of most inbasket/tasks/calling patients stuff. I do little outpatient but probably spend under 30 min a week on these issues.

 

[sharkbaitwhohaha]

Agree with @sharkbaitwhohaha above. My MA and staff are well trained and take care of most inbasket/tasks/calling patients stuff. I do little outpatient but probably spend under 30 min a week on these issues.

For sure it can destroy doctors moral and quality of life but only if you let it or have uncontrolled, poorly trained staff

 

[xenotype]

I would think (not having done outpatient before) that even as a subspecialist you can't just "turn down" a lot of these referrals like you say because if you can't fill up your clinic you'll starve anyway so in comes the lightheaded, giddy, tingle, syncope/presyncope brain fogs.

Basically the scourge of everyone in neurology. The brain fog, tingling, syncope, memory complaint with no legitimate evidence for dementia/ADHD/substance abuse causing cognitive problems. And yet, there are a few outpatient neurologists out there sticking ports in 'POTS' patients and doing IVIG/PLEX and regular IV fluid infusions despite the same patients having a long list of proven functional disorders/PNES/etc and sometimes opiate addiction on top of all of that.

Many neurologists say to not do a subspecialty in something you'll get a lot of experience in during residency, unless you really want to, for instance Stroke or headache. Try to do something that will add a billable skill, or didnt get much training in. Which subspecialty do you think would be best for outpatient community practice?

Movement, CNP, or epilepsy provide the broadest flexibility in my opinion, as long as one went to a heavy volume high acuity residency with a lot of thrombectomies. That said, everyone has to decide what they love and want to be an expert in. I do a lot of acute stroke, but I didn't do fellowship in it and thus wouldn't consider myself an expert the same way a stroke fellowship boarded attending is. I however read continuous/ICU/LTM EEG and have a better background for managing status. Headache for example you'll get a lot of residency exposure to and at a decent residency will be competent in, but you won't have the big bag of tricks that a headache boarded attending has and there are certainly a lot of patients looking for a true expert in headache. Figure out what you like (or what patient population you enjoy) and do primarily that. I tend to like most stuff in general neurology along with acuity, so inpatient is a good fit for variety.

Lot of doom and gloom, YMMV.

Not all outpatient neurology practices are inundated with inbasket messages. With good training (both MA side and with "training" patients), the volume can be kept very minimal. I handle probably 3-10 a day and most are simple "FYIs" from patients/MAs/other staff and only 1 or 2 of them take more than 5 seconds. A few times a week it will require me calling the patient, but overall I spent <20 mins ALL WEEK dealing with inbasket stuff.

Don't think in patient neurology gets away from inbasket requirement either.

Inbasket for inpatient is basically nothing, like less than 30 seconds spent on it a week. If inbasket isn't an issue (FMLA, prior auth, etc), I would still have to deal with pain complaints, vague non-neurologic dizziness/paresthesia, and the constant treadmill of patients with outpatient. On top of that, you physically have to see more patients outpatient to get equivalent pay to inpatient work, with a significantly higher documentation burden as a result. I could do it if there was a reasonable schedule (20f/40n min, 0.8-0.9 FTE, no call) for >300k AND the inbasket was well managed as you refer to. These jobs generally only exist in BFE for a reason. Otherwise, its a worse deal for me personally than simply doing neurohospitalist/locums/tele. The need is certainly there, but the system won't pay reasonably for it and/or attaches numerous ways to destroy one's quality of life to the average outpatient deal. Plenty of outpatient docs doing >$400k in PP, but they see a huge amount of patients and generally take some call on top of that.

 

[Aldertonghen]

Basically the scourge of everyone in neurology. The brain fog, tingling, syncope, memory complaint with no legitimate evidence for dementia/ADHD/substance abuse causing cognitive problems. And yet, there are a few outpatient neurologists out there sticking ports in 'POTS' patients and doing IVIG/PLEX and regular IV fluid infusions despite the same patients having a long list of proven functional disorders/PNES/etc and sometimes opiate addiction on top of all of that.


Movement, CNP, or epilepsy provide the broadest flexibility in my opinion, as long as one went to a heavy volume high acuity residency with a lot of thrombectomies. That said, everyone has to decide what they love and want to be an expert in. I do a lot of acute stroke, but I didn't do fellowship in it and thus wouldn't consider myself an expert the same way a stroke fellowship boarded attending is. I however read continuous/ICU/LTM EEG and have a better background for managing status. Headache for example you'll get a lot of residency exposure to and at a decent residency will be competent in, but you won't have the big bag of tricks that a headache boarded attending has and there are certainly a lot of patients looking for a true expert in headache. Figure out what you like (or what patient population you enjoy) and do primarily that. I tend to like most stuff in general neurology along with acuity, so inpatient is a good fit for variety.


Inbasket for inpatient is basically nothing, like less than 30 seconds spent on it a week. If inbasket isn't an issue (FMLA, prior auth, etc), I would still have to deal with pain complaints, vague non-neurologic dizziness/paresthesia, and the constant treadmill of patients with outpatient. On top of that, you physically have to see more patients outpatient to get equivalent pay to inpatient work, with a significantly higher documentation burden as a result. I could do it if there was a reasonable schedule (20f/40n min, 0.8-0.9 FTE, no call) for >300k AND the inbasket was well managed as you refer to. These jobs generally only exist in BFE for a reason. Otherwise, its a worse deal for me personally than simply doing neurohospitalist/locums/tele. The need is certainly there, but the system won't pay reasonably for it and/or attaches numerous ways to destroy one's quality of life to the average outpatient deal. Plenty of outpatient docs doing >$400k in PP, but they see a huge amount of patients and generally take some call on top of that.

I thought headache was mostly a useless fellowship as we get a ton of headache patients in clinic (atleast at my continuity clinic certainly). Something like pain on the other hand seems to add a lot of procedures though, and sort of goes decently with gen neuro- and also pays more (350-400k outpatient).

 

[Neurogeneral]

I beg to differ about a headache fellowship being useless. When I was in training doing continuity clinic, it was just the usual rotating between TCAs, beta blockers, topamax, valproate, SNRIs, etc and of course, the triptans. This was somewhat limiting.

However, since then, there have been so many new preventative and abortive treatments. In headache fellowships, you become quite comfortable using all these newer drugs and even the more older off-label ones that you wouldn’t normally prescribe in residency. You become comfortable with getting these newer drugs approved and the utilizing the various drug programs that provide them at discounted rates. You learn the finer and nuanced details to quickly provide relief to the typical migraine patient and even to those that appear to have an intractable form/variant. You become comfortable treating neuralgiform cephalgias, autonomic cephalgias, facial pain, etc. You become comfortable with nerve blocks and Botox. You become comfortable coordinating IV infusions to treat status to keep your patients out of the ER. Headache patients are plenty and you will have no difficulty building your practice up and even at some point, turning down other non-headache referrals. Our administration allows the headache boarded neurologists to see only headache patients if they wish to do that. Many neurologists also do not like seeing headache patients and they will happily let you see them.

Not saying that this some “golden” fellowship without pitfalls and even redundancies from typical residency training. I know that it is not difficult to start someone on a CGRP antagonist, but I feel that there is a great value in a headache fellowship if one is interested only in doing clinic and in headache medicine.

 

[Neurogeneral]

Basically the scourge of everyone in neurology. The brain fog, tingling, syncope, memory complaint with no legitimate evidence for dementia/ADHD/substance abuse causing cognitive problems. And yet, there are a few outpatient neurologists out there sticking ports in 'POTS' patients and doing IVIG/PLEX and regular IV fluid infusions despite the same patients having a long list of proven functional disorders/PNES/etc and sometimes opiate addiction on top of all of that.


Movement, CNP, or epilepsy provide the broadest flexibility in my opinion, as long as one went to a heavy volume high acuity residency with a lot of thrombectomies. That said, everyone has to decide what they love and want to be an expert in. I do a lot of acute stroke, but I didn't do fellowship in it and thus wouldn't consider myself an expert the same way a stroke fellowship boarded attending is. I however read continuous/ICU/LTM EEG and have a better background for managing status. Headache for example you'll get a lot of residency exposure to and at a decent residency will be competent in, but you won't have the big bag of tricks that a headache boarded attending has and there are certainly a lot of patients looking for a true expert in headache. Figure out what you like (or what patient population you enjoy) and do primarily that. I tend to like most stuff in general neurology along with acuity, so inpatient is a good fit for variety.


Inbasket for inpatient is basically nothing, like less than 30 seconds spent on it a week. If inbasket isn't an issue (FMLA, prior auth, etc), I would still have to deal with pain complaints, vague non-neurologic dizziness/paresthesia, and the constant treadmill of patients with outpatient. On top of that, you physically have to see more patients outpatient to get equivalent pay to inpatient work, with a significantly higher documentation burden as a result. I could do it if there was a reasonable schedule (20f/40n min, 0.8-0.9 FTE, no call) for >300k AND the inbasket was well managed as you refer to. These jobs generally only exist in BFE for a reason. Otherwise, its a worse deal for me personally than simply doing neurohospitalist/locums/tele. The need is certainly there, but the system won't pay reasonably for it and/or attaches numerous ways to destroy one's quality of life to the average outpatient deal. Plenty of outpatient docs doing >$400k in PP, but they see a huge amount of patients and generally take some call on top of that.

I think the overhead in outpatient is higher, which means more patients need to be seen to generate the same net revenue. Whereas as a neurohospitalist, you don’t (at least not directly) contribute to the rent for the clinic, pay the MAs, receptionists, office manager, office supplies, etc.

I do half a day of clinic and half a day of inpatient rounds everyday (along with EEG/EMG). The revenue that I generate from the hospital is double my revenue from the clinic.

 

[JohnnyDoc]

Is clinical neurophysiology still a financially viable options despite the recent cut in reimbursement for eeg and emg?

 

[xenotype]

Is clinical neurophysiology still a financially viable options despite the recent cut in reimbursement for eeg and emg?

Places still need these studies to actually be done and read, and will pay for them in some cases beyond what they actually bill for. Straightforward EMGs can still be profitable if you crank through them with techs. Ambulatory EEGs IMO are a total waste of time at the actual rates they are compensated for now. I'm not going to read a 72hr EEG with 20 events on it for 50$, but I'll do it if the hospital group I work for actually pays me 150$ per 24hrs of EEG to read.

 

[Neurogeneral]

Is clinical neurophysiology still a financially viable options despite the recent cut in reimbursement for eeg and emg?

Yes these diagnostics are still financially viable. Routine EEGs still pay decently for the amount of time you put into them. Continuous EEGs of course do not reimburse well anymore. I only order them if absolutely needed.

In regards to doing EMG, you just have to be efficient with your time. If you have a tech, you can see clinic patients or see consults in between while the nerve conductions are being done. Or if you have two machines, you and the tech can rotate between machines and do nearly twice as much EMGs.

And frankly, while the reimbursement may not be ideal anymore, I usually enjoy doing EMGs all day much more than being in clinic.