COMMENTARY

Can I Talk You Out of Neurology?

Andrew N. Wilner, MD

Disclosures

February 17, 2012

Choosing a specialty is one of the most important professional decisions you will make, and many students compile a list of advantages and disadvantages for each specialty they are considering to make that decision a bit easier. If you are considering neurology, however, that's not really necessary.

Having spent 30 years in this field, I see only 1 reason to choose this specialty: because you find the brain and nervous system the most amazing part of the human body, and you want to help people with neurologic disease. That's it. If that's not you, forget about neurology. Here's why.

Low income. According to a recent Medscape survey, neurologists ranked 16th out of 22 specialties in terms of income.[1] If making money is one of your priorities, there are at least 15 better specialty choices.

No glory. At cocktail parties, when you divulge your profession as a neurologist, you will invariably be subjected to the response, "You mean a neurosurgeon?" When you explain that a neurologist doesn't operate on the brain, you will receive a blank look and the question, "Then what do you do?" If your ego requires even a modicum of glory, pick a surgical specialty.

Vast information. I completed an internal medicine residency and took care of many strokes and other neurologic problems before my neurology residency. When I started my formal neurology training, I figured I had a leg up on my co-residents because of all my experience. I was wrong.

The central and peripheral nervous system – its anatomy, physiology, and pathology – combined with an increasing number of therapeutic options for neurologic diseases represent an entirely new universe of information. That's why neurology is the only medical subspecialty that requires its own residency training program after internship.

Slow pace. Obtaining a neurologic history is critical and time-consuming. Many doctors will tell you that the history is often the key to diagnosis. Active listening skills are essential. Are the symptoms of numbness due to a transient ischemic attack or a peroneal neuropathy? Only the history will tell you, and it makes all the difference in the world. If you find it tedious to listen to patients who are, generally speaking, "poor historians," then neurology is not for you.

Time-intensive. The neurologic examination is the most detailed and time-consuming of any medical examination. Patients, even those in their 80s, have told me countless times, "Gee, doctor, no one ever examined me so thoroughly."

According to the Medscape survey, 55% of neurologists spend 25 minutes or more with each patient, compared with only 15% of other physicians.[1] If you are not comfortable carrying a black bag and don't enjoy using your ophthalmoscope and reflex hammer, sling your stethoscope around your neck and find another specialty.

Few procedures. The only invasive neurologic procedure is the time-honored lumbar puncture (spinal tap), which remains necessary to rule out central nervous system infection and provides insight into diseases such as Alzheimer disease, multiple sclerosis, and neuropathy.

Neurologists who are interested in the peripheral nervous system also perform electromyography and nerve conduction tests (EMG/NCV), which are an extension of the physical examination and can greatly assist diagnosis. Neurologists interested in the brain interpret electroencephalograms (EEGs). Although now displayed on a digital monitor rather than paper, EEG interpretation has not changed a whit since my fellowship training.

If you relish procedures like intubation or putting in a central line, you might consider neurocritical care, a new subspecialty that offers more hands-on interventions.

Complex decision-making. During my internal medicine residency, it was not unusual to admit 24 patients while on call and round on all of them in an hour and a half the next morning. In my neurology residency, we admitted only 5 or 6 patients but rounded on them until noon!

Neurologic diagnosis is based on the history and physical examination. There are no diagnostic tests (yet) for Alzheimer disease, epilepsy, Parkinson disease, multiple sclerosis, and most other neurologic disorders. The differential diagnosis may be long and include rare diseases.

Therapeutic options are increasing but are often either very limited (Alzheimer's) or not straightforward (multiple sclerosis). If you enjoy rapid diagnosis and quick decision-making, consider another specialty, like emergency medicine.

So Why Are There Any Neurologists?

The American Academy of Neurology (AAN) has 24,000 international members, so the specialty must have some appeal. According to the academy, there are just over 500 spaces for neurology residents each year.[2]

About 300 of these are taken by American medical school graduates, and the remainder go to graduates of foreign medical schools.

The AAN has posted more than 20 biographies of distinguished neurologists, which include why they chose neurology. These profiles highlight a wide variety of career possibilities, ranging from academic appointments that include teaching, patient care, and research, to Deputy for Medical Affairs to the Joint Program Executive Office for Chemical and Biological Defense.

Allow me to share with you my own experiences that propelled me into neurology.

The mystery of the brain. As part of the interview process for my internship, I sat in on grand rounds and witnessed a brain cutting. It was fascinating to hear the patient's history, see the CT scan (rather rudimentary at that time), and watch the tennis-ball–sized hemorrhagic stroke appear as the pathologist methodically sliced through the brain with a gleaming, broad-bladed knife.

As the years have progressed, so has neuroimaging. MRI has become an essential part of the neurologic workup for many patients, and advances in MRI sequences and more powerful 3-Tesla and 7-Tesla magnets have added a level of detail to brain visualization that was unimaginable in those days.

Evolving technologies such as positron emission tomography (PET), single-photon emission computed tomography (SPECT), magnetoencephalography (MEG), and functional MRI (fMRI) provide windows into the brain's normal and pathologic function that greatly facilitate earlier and more accurate diagnosis. If you are curious about how the brain works, new tools are evolving that will equip you to solve some of nature's best-kept secrets.

Neurology and psychiatry. During a 1-year stint when I worked in the emergency room, I did everything -- from suturing lacerations to delivering babies. But for me, the most memorable experience was caring for a young woman who had unexplained weakness.

When I resorted to calling a neurology consult, I was amazed at how thoroughly and confidently the neurologist examined the patient. His conclusion that her problems were psychiatric and not neurologic seemed almost magical to me.

If you are interested in understanding and treating the problems of the mind and the brain, then neurology is for you.

Helping people. Neurology is no longer about bestowing long names on untreatable diseases. Therapeutic advances are incremental but are occurring at a rapid rate. Today's neurologists provide meaningful therapy to patients as well as the benefits of accurate diagnosis and prognosis.

Although therapeutic options in neurology are still limited, they are expanding rapidly. In 2011, new drugs for stroke prevention and epilepsy received FDA approval. In 2010, the first oral drug for multiple sclerosis was approved that appears more effective than any of the old drugs that all require injections. In 2012, at least 2 more oral drugs will likely be approved for multiple sclerosis, another for stroke prevention, and possibly another for epilepsy.

Favorable epidemiology. Several neurologic diseases, such as Alzheimer's, Parkinson's, and stroke, are common among the elderly, a growing population. In many communities, neurologists are few and far between, and it is unlikely that you will ever be out of work.

Conclusions

To be successful in any medical specialty, dedication and discipline are necessary. In my experience, a mastery of neurology demands exquisite attention to detail and relentless curiosity.

In return, a career in neurology offers the reward of an insight into the world's most awesome creation, the human brain and nervous system, coupled with an opportunity to help people who suffer from neurologic disease.

If the idea of becoming a neurologist engages you, the AAN has good advice for medical students. Best of luck!

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