Are you considering a career as a neurologist? With so many specialties to choose from and your future on the line, it’s one of the most challenging decisions medical students have to make.
This guide will cover the pros and cons of becoming a neurologist, from dealing with patients with chronic, incurable conditions to the massive challenges of neurology residency to the fantastic flexibility and work-life balance afforded to neurologists.
There are so many different factors to account for when choosing a specialty, including how many years you’ll spend in training, whether or not you’ll perform procedures, the level of patient interaction you’ll have, your practice setting, how much you’re paid, the people you’ll work with, your work-life balance, and more.
This series takes a deep dive into the career of a neurologist from the perspective of Dr. Kevin Jubbal. He outlines the factors he considered and why he ultimately did not choose neurology as his specialty. That said, rest assured that this guide includes both sides of the story, outlining the pros and cons of pursuing neurology.
For a completely unbiased look at neurology, including more details into the daily life of a neurologist and the exact steps to take to become one, also check out our guide to How to Become a Neurologist (So You Want to Be…)
Neurology Pros — What I Liked
1 | Tangibility
When I first got to college, I didn’t fully understand the difference between neuroscience and psychology or psychiatry, but once I did, I appreciated how neuroscience was a far more tangible and concrete science.
Of course, I still found and still do find many elements of psychiatry and psychology interesting, but the tangibility of neurology and neuroscience appeals more to my personality.
Psych is something I enjoy far more in principle and theory than in practice. I love learning about evolutionary psychology, gender dynamics, and mature vs immature coping mechanisms and the like, but psych as a rotation required far too much patience and wasn’t fast paced or solid enough for me.
Learning about the psychological underpinnings of human behavior is very different from treating a patient who is violently slamming the table and calling you a Hispanic devil. I mean, I’m not even hispanic.
Neurology is a much harder science than psych, and most of the time, it’s a puzzle with a concrete and definitive end point. You can point to a structure and its lesion and understand what the deficits or symptoms would be.
2 | Length of Training
When you’re in medicine, you’re normalized to certain specialties being their own residency while other specialties require a fellowship after another more foundational residency program.
For example, to do cardiology, you need three years of IM residency and then three years of cardiology fellowship. This is also true of other internal medicine specialties like GI, endocrinology, and many others.
If you look at surgical subspecialties, you have a dedicated residency for plastics, orthopedic surgery, neurosurgery, ENT, and so on. But going back decades ago, they were simply fellowship options after a general surgery residency.
Based on this, one could argue that it’s strange that neurology is its own residency program. However, this means neurology residency only lasts four years and is much more targeted. Your first year in residency, or PGY-1, is an internship in internal medicine.
That said, many neurologists still pursue a fellowship, so that four years becomes five to six, which isn’t so short anymore.
Keep in mind that you’re making nearly $350,000 after four years of residency. Most of the other shorter residencies, like internal medicine hospitalist or family medicine, tend to make closer to $300,000. While it’s true that emergency medicine makes closer to $400,000, most other specialties requiring three to four years of residency are making less.
Also, with one to two-year fellowship options like neuro ICU, vascular, and neurocritical and interventional pain, you can make more than $400,000 a year.
3 | Flexibility
Neurology is very lifestyle-friendly and provides an excellent work-life balance, with the exception of a few subspecialties like stroke. It can be inpatient, outpatient, or both. That said, if you don’t want to deal with inpatient—and there are pros and cons there—then you generally will need to do a fellowship.
Fellowship options also boost your earnings considerably. Residency is miserable, but as an attending, you can work fewer than 40 hours per week. You can also work outpatient without having to work nights or weekends.
4 | Attainable Residency
On a related note, neurology residency is more attainable, as it only narrowly missed being included in the top five least competitive specialties. Neurology placed 6th after pathology, psychiatry, emergency medicine, pediatrics, and family medicine.
View our complete medical specialty competitiveness index.
Plus, if you’re a strong student, you get your pick of whatever city or program you want.
But why exactly is neurology less competitive than other specialties? Here are a few reasons.
- Neuroanatomy can be a big turnoff for many students
- A fair number of schools don’t have neurology as a required core rotation, and that means less exposure to the field
- There’s a stigma of “diagnose and adios,” where you as a physician say: “I can’t help you with that,” but we’ll get to that later in the article
- Neurology used to have lower compensation, but because of the shortage of neurologists in recent years, compensation has increased to nearly $350K according to Doximity.
5 | Job & Future Prospects
Another pro of neurology are the job prospects.
First, it’s much easier to get a great job, even in a big city, since it’s not a very popular specialty and few US physicians go into it.
Second, a number of neurologists are betting—I think reasonably—that reimbursement will jump over the next ten or so years as neurology gains more therapeutics and infusions. This is driven in large part by a better understanding of neuroscience, and this pattern is similar to what we saw happen in medical oncology in the early 2000s.
And third, there’s a great deal we still don’t know in neurology. Compared to many other medical fields, we’re likely to see rapid progress in neurology in the coming decade and beyond.
Even in the last few years, there have been many advances, such as a new class of migraine medications and incredible gene therapy for spinal muscular atrophy.
6 | Hands-On Specialty
Unlike other specialties, the physical exam for neurology counts for a lot.
When practicing PEX (pseudoexfoliation syndrome) in medical school, I always found the neuro exam and the MSK (musculoskeletal) exams the most fun and helpful clinically.
The brain is like a computer, and once you learn the coding, and the testing for said coding, it’s very fulfilling to discover findings on PEX.
7 | Broad Knowledge
I’ve always appreciated physicians who possess knowledge across many different domains rather than having a singular narrow focus. That said, I used to consider myself to be more of a narrow and deep kind of guy rather than broad and shallow.
However, I am enjoying learning about the human body through the lens of longevity, exercise physiology, and the interplay between various organ systems. I see the utility and enjoyment in connecting different systems rather than having a narrow focus.
With neurology, it’s important to be well-rounded. If you’re covering the neuro ICU, you still need to recognize diabetes and liver injuries just like internists. Neurological conditions can affect all systems, so neurologists tend to have a solid understanding of internal medicine, psychiatry, ophthalmology, and musculoskeletal, in addition to other areas.
You’re not as broad and well-versed as an IM doctor, but you are often more knowledgeable than many other specialists. That said, this depends. If you are a neuro hospitalist, and depending on the hospital culture, the neurology admitting team can manage a large number of general medical problems. But in other places, the neurologist needs to give up a lot of “body” medicine, meaning internal medicine diseases.
Some of my best teachers from medical school were neurologists. In my experience, they tend to be quirky and great educators.
Neurology Cons — What I Didn’t Like
1 | Bread & Butter
A common mistake I see medical students make is idolizing a specialty based on the cool, sexy zebras you see in that field, meaning the rare cases, instead of the bread and butter, meaning the most common presenting cases you’ll see day in and day out.
While neurology does perhaps have more interesting zebras than other specialties, they’re still not the norm.
If you can’t see yourself dealing with the bread and butter of a specialty, then DON’T DO IT!
Neurology sees a great deal of headaches, seizures, strokes, and AMS, but there’s also Parkinson’s, dementia, multiple sclerosis, and so on. You’ll be working with a great deal of tech on these diseases, such as EMG, EEG, and many more. This can be very interesting, but it’s certainly not for everyone.
When it comes to inpatient, you’ll see a number of strokes and seizures. With outpatient, you’ll see a great deal of headaches and also more seizures. While MS, movement disorders, and Guillain-Barré syndrome (GBS) are more interesting, they are not as common.
There’s also a wide variety of acuity. You can face full-on emergencies, like strokes or neuroICU, as well as less urgent conditions, like dementia, movement, and neuro-ophthalmology.
2 | Theory vs Practice
There’s neurology in medical school, and then there’s neurology in real life medical practice.
The biggest issue I have with neurology is that no matter how cool it is in theory—and I LOVED learning about the nervous system—in my opinion, the actual practice is nowhere near as interesting as the theory.
One of the realities of medicine is that the book learning of medicine can be very different from the clinical practice of medicine, and that’s both for better and worse.
For my taste, it’s a bit slow and dull.
3 | Residency
Neurology has a reputation for having one of, if not the most, difficult non-surgical residency.
Oftentimes, a neurologist is expected to be an expert on rare diseases that no one has ever heard of based off of some obscure imaging finding. Becoming that person does have a price in training.
You essentially complete two intern years, one for IM, and one for neurology. PGY2 is known to be particularly brutal, as you’re already expected to have a great deal of knowledge despite lacking experience.
The two intern years, large censuses, stroke call, and need to possess a very large body of knowledge make neurology residency uniquely challenging.
You’ll face frequent 24 hour call, and beyond that, things like limited outpatient rotations, limited electives, and you won’t always deal with the nicest people. There are programs that do light float rather than 24 hour call, but you’ll have to be very intentional about finding one of them.
Around 3/4 of your rotation is inpatient, which means longer hours, usually 60 to 80. When you’re in the ICU, you’ll spend 80 hours every week there, if not more. Electives and outpatient are closer to 40 to 60.
Many also say that fellowships are becoming more and more the norm, so depending on what you choose, you’ll be in training for at least 5 or 6 years after medical school.
However, I hear mixed things about this. Others say that your job prospects are actually better as a general neurologist than as a subspecialist.
The tradeoff here is, as a general neurologist in a heavily populated area, you will see lots of bread and butter headache and vague neuropathy patients, while the more interesting cases get referred to subspecialists.
That, coupled with the fact that most neurology fellowships are often only one year, are relatively uncompetitive, provide a compensation boost, and are heavily outpatient focused, means there’s quite a bit of incentive to subspecialize.
4 | Long Chart Review & Patient Histories
It makes sense that, with neurology, you’d need to spend a greater portion of your time on chart review and patient histories, given the nature of the conditions you’re treating and the puzzles you’re trying to solve.
However, it requires a certain type of patience that I, fortunately or unfortunately, do not possess.
5 | Not Procedural
While I found it fascinating in theory, I never seriously considered neurology because I knew that I wanted to do something more procedural.
It’s for this reason that neurosurgery was actually much higher on the list, as I was choosing between plastics, ortho, and neurosurgery when deciding which surgical subspecialty I wanted to pursue. Neurosurgery took much of my love of neuroanatomy and neuroscience and, naturally, applied it in a highly procedural way.
Now, some will say there are many procedures. For example,
- LPS (Lipopolysaccharide)
- Nerve blocks
- Chemodenervation
- Trigger point injections
- EMGs (Electromyography)
- Nerve conduction studies
Then there’s also lots of interpretation of procedures. For example:
- TCD (Transcranial Doppler Ultrasound)
- PSG (Polysomnogram)
- EEG (Electroencephalogram), including during intraoperative monitoring during neurosurgery procedures, evoked potentials, vestibular testing, and autonomic testing
However, in my opinion, most of these aren’t very exciting. But with fellowship training, you do get to the exciting stuff with things like mechanical thrombectomy via neuro-IR fellowship, intrathecal chemo via neuro-oncology, or intraoperative EEG via neurophys/EEG/epilepsy.
6 | Outcomes – Diagnose and Adios
There’s a stereotype of “diagnose and adios” in neurology because many conditions, especially the more serious ones, have minimal treatment options and tend to be a bit… dark.
Neurologists will tell you they can do a lot. For example, with a stroke, you start with tPA and thrombectomy, and then after that, neurologists can help guide recovery until patients graduate to PM&R colleagues. They can also help reduce the risk of the next stroke.
But overall, the specialty’s outcomes and solutions aren’t quite the same as other specialties. And if that patient doesn’t get to the hospital in time, as they say, time is brain; you can’t do much after the damage has been done.
While it’s true that therapies in neurology are a great deal better now than 20 or 30 years ago when “diagnose and adios” was much more accurate, you’re still dealing with a lot of dementia and stroke, which tend to have worse outcomes, and modern medicine still has many limitations.
Many of the conditions in neurology have limited treatment options, and it can take a serious toll on your mental health and wellbeing to not be able to adequately help your patients. Inpatient encounters especially are with very sick or nonverbal patients, while outpatient are with people who often have chronic diseases. This isn’t necessarily uncommon for most specialties, but it also isn’t universal.
Don’t get me wrong; there are a number of areas where you can make a huge difference in someone’s life. For example, catch and fix their stroke in time, ameliorate their chronic headache, keep them from having seizures, improve spasticity, improve Parkinson’s symptoms, and more.
And while you may not be able to cure a patient, you can still be there for them and their family and offer educated support during a difficult time.
7 | Lower Compensation
While becoming a doctor means a guaranteed six figure salary, monetary compensation alone is not a good reason to become a doctor due to the massive opportunity cost of your education. That said, while money isn’t everything, it’s certainly a major perk, especially if, like most students leaving medical school, you’re saddled with a tuition debt that’s also in the six figures.
Although a six figure salary is certain, the annual compensation doctors receive in the US varies wildly depending on your chosen specialty. If you absolutely love a specialty, you can overlook a lower compensation since it provides other value. But if you’re already lukewarm about a specialty, then low compensation will definitely turn you off of it.
Especially if you specialize in child neuro, you’ll be making around $280,000. Pediatric specialties pay worse than adult specialties because of the fee-for-service model of US healthcare. More procedures means more money earned, and since children are more resilient and require fewer interventions and procedures, pediatric specialties make less money.
And unfortunately, a general neurologist’s pay isn’t great.
On average, you’ll make a bit more than a hospitalist or a psychiatrist as a general neurologist, but unless you go into neuro-ICU or endovascular, you’ll never make cardiology money, and on top of that, you have to work very hard for your money in the high-paying neuro specialties like neuro IR, stroke, and neurocritical care.
For some perspective, according to Doximity, neurosurgeons make $763,908, cardiologists make $565,485, and neurologists make $348,365 a year. While they both specialize in the brain, neurosurgeons make well over $400,000 a year more than neurologists, and cardiologists make over $200,000 more a year.
Is Neurology the Right Career for You?
So, is neurology right for you?
Well, there are different strokes for different folks (…pun intended).
There are bad aspects of every specialty. Choosing your specialty is about pairing the type of challenges you are most willing to face in your day-to-day with whatever excites you enough to get you out of bed in the morning.
What specialty has a downside you can live with and an upside that you love?
Unfortunately, neurology does have quite a few downsides:
- Many neuro patients have progressive, untreatable diseases, and you will feel powerless to help them.
- You tend to get a number of patients with vague complaints that don’t necessarily line up with a known pathology, as well as a lot of psych patients that can be difficult to work with.
- The majority of neurology is outpatient, so if you don’t like clinic, it’s probably not for you.
Finally, a number of students are deciding between neuro and IM, and here’s what I’ll say:
It’s all about the tradeoffs.
In internal medicine, you can be a generalist, but keep in mind you’ll rarely work up patients all the way if you’re living in a big city. Every time you get an interesting case, they’ll be scooped up by a specialist, and if you’re inpatient, you’ll be managing their chronic medical conditions, blood pressure, sugar, and pain.
So if you want to do an IM subspecialty, you’ll have to give up the rest of the body and lose your love of generalist medicine. In neurology, you’ll also give up the rest of the body just like an IM specialist.
While the two specialties have some similarities, they’re different enough that once you get to your rotations, you’ll hopefully gravitate toward one over the other.
At the end of the day, only you can decide whether or not the pros outweigh the cons.
If you want to learn more about neurology, check out So You Want to Be a Neurologist.
