Wednesday, November 25, 2009

Julia ponders a career in Neurology

As one of our school's rare 3rd years over-eager enough to attempt Neuro before 4th year, the mantle falls to me to talk about the good and negative aspects of this specialty. That… and Jesse is trying to steal away my tiara for himself. For shame.

Jesse's MRI confirmed some long-held suspicions...

3 Reasons for going into Neurology:

1. You might actually get to see your kids grow up.
It’s no psych, but damn it’s good to be a neurologist. During my time on this rotation, on most days it seemed possible for the non-call residents to get their patients tucked in and notes written by mid-afternoon. Plenty of time for David to get home and watch the nanny take care of the kids. Definite life-style points.

2. Fascinating pathology
While the neuro hospital floor is primarily dominated by strokes and seizures, consults come from all over the hospital. Although much of this will inevitably end up being delirium (or even nothing), every now and then the illusive and coveted zebra appears. The brain truly is a wonderful and enigmatic organ, and just because everyone keeps cheering that we’ve made so much progress in the past 10-20 years it doesn’t mean you still wont be surprised.
For example, I will truly never forget the consult on a patient with anoxic brain injury where, about 15 minutes into the interview, I realized the patient was confabulating everything! Because of his brain damage, he had gaps in his memory where he would fill in with false information. If the lie is subtle enough, it can be difficult to discern the confabulations from the truths. But then again, sometimes the lies are so outrageous they become readily apparent. No sir, I dont believe I've asked you these same questions 30 years ago...

Anyways, just remember the next time you see a patient who just had a right-sided intraparenchymal hemorrhage (i.e. brain bleed), it probably is worth it to ask them to draw a clock face.

3. Informative physical exams
Depending on which specialty you go into, the physical exam could either be a crucial component of the clinical picture or only a necessary hassle for billing purposes. For example in surgery the physical exam boils down to two things: bowel sounds = good, no bowel sounds = bad. Neurology lets you do a bit more. If you like solving puzzles, this is where it’s at. If you’re savvy enough with your physical exam skills and knowledge, not only can you identify at which level of the nervous system the lesion is located, you could probably tell something about exactly where in the brain or spinal cord you expect it to be. Some party trick, huh? Then you order the appropriate scan plus labs to get a more definitive answer. Neurologists out in the community or away from a major academic center may be the true LOTPEs.

It's (reflex) hammer time

3 Reasons to stay away from Neurology:

1. You can't cure a lot of the things you diagnose
Here’s a quote from a real-life attending: “Hmm… you know, I’ve never really felt the need to cure anything—sometimes it’s enough to just be able to tell them what it is.” While this is true, in some cases just being able to put a name on what ails you is therapeutic enough, it may not be very satisfying to you. Not mention, even if you do locate a resectable lesion, the patient gets bounced to neurosurgery. Sigh, those guys hog all the glory (and reimbursement). So if you’re on your neuro rotation and find yourself feeling a little too excited and relieved by meningitis because you can kills the buggers with antibiotics, then maybe this isn’t the field for you.

2. Medically sanctioned elder abuse
The patient might look like your favorite grandparent or that sweet little old lady down the street, but if they’ve got a decreased level of consciousness you can be sure you’ll be giving them a strong pinch! The idea is that you’re looking at their ability to sense, localize, and/or withdraw from painful stimuli. Keyword: Painful. Abnormal posturing (e.g. decorticate – flexor, decerebrate – extensor) can tell you something about the severity of what’s going on in the ole think-box. However, when my patient’s tearful and terrified wife is standing right there, it can be a pretty uncomfortable to do what would be considered elder abuse in any other situation.

Your heart sounds great ma'am. Just FYI, I may or may not need to jab you with a sharp stick in the near future.

3. Half your patients are delirious
For me, this is the biggest problem in neuro. Inpatient neuro is dominated by strokes, withdrawal, seizures, delirium, coma, and bad ass brain tumors. In short, most of your patients are going to have some sort of altered consciousness, so the normal exchange of the physician-patient relationship is lacking. Oncology is another specialty where there is a relatively low “cure” rate, but in the battle against cancer you the provider can learn so much from your patients. For me, this is probably the most challenging aspect to deal with day in and day out in neurology. It's hard feeling connected to my patients when they're accusing you of stealing their Jello to give to our alien overlords.


D said...

Hm...I think you mean "nanny's executive assistant's aide." Raising the kids will clearly be tertiary support staff work.

Jesse said...

2 of your 3 cons look like pros to me.

Old MD Girl said...

I don't think your stats on Onco are accurate. When I did an elective there, the attending told me that he loved Onc because he got to cure 1/2 of his patients, which was a lot better than you did in most of medicine.

Guess it depends on whether your patients are breast patients or sarcoma patients.....

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