So You Want to Be a Neurologist

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So you want to be a neurologist. You like the idea of the brain, knowing all of its intricacies, and the idea of being a brainiac yourself. Let’s debunk the public perception myths, and give it to you straight. This is the reality of neurology.

Welcome to our next installment in So You Want to Be. In this series, we highlight a specific specialty within medicine, such as neurology, and help you decide if it’s a good fit for you. You can find the other specialties on our So You Want to Be playlist.

What is Neurology?

Neurologists are the physicians that specialize in the non-surgical management of a variety of central and peripheral nervous system disorders. For surgical management, neurosurgery is the specialty you’re looking for.

Neurologists manage everything from headaches and migraines to the most devastating and incurable diseases like amyotrophic lateral sclerosis, or ALS, and Huntington’s disease. Strokes, which are the fifth leading cause of death and the first leading cause of disability in the United States, are diagnosed and treated by neurologists.

Many believe that neurologists primarily diagnose conditions, but cannot do much to treat any of them. While there are several conditions for which modern medicine has limited management options, research in neurology is rapid and our therapies are improving.

For example, strokes used to be untreatable, leaving patients with lifelong disability. However, in the past few decades, our understanding of strokes has improved drastically. As they say, “time is brain”, and rapid interventions such as tPA and endovascular thrombectomy are now understood as critical in favorable outcomes.

Care for Parkinson’s disease has been revolutionized with deep brain stimulation. Epilepsy care has improved through new anti-seizure medications, vagus nerve stimulation, and epilepsy surgery. Brain tumors of all types now have a multitude of treatment options. ALS is still a devastating illness, but clinical trials for novel therapies are showing tremendous promise.

When you think about the patients requiring neurological care, it makes sense that it’s a specialty with less rosy outcomes. A substantial portion of diseases in neurology are chronic and progressive, but neurologists help their patients live a life of dignity and enjoy the time they have left in a meaningful way.

The bread and butter of neurology consist of stroke, seizures, headaches, and dementia, but there’s a great deal more to it, as we’ll explore shortly with the wide variety of fellowship opportunities.

There are a few ways to categorize neurology:

Inpatient vs Outpatient

Inpatient neurologists work in the hospital setting, treating admitted patients with seizures, acute demyelinating disease, stroke, complications pre-op or post-op from neurosurgery, neuromuscular disorders, meningitis, encephalitis, and more. The lifestyle of an inpatient neurologist is similar to that of a hospitalist – it’s common to work 7 days on and then have 7 days off, or 2 weeks on followed by 2 weeks off.

Outpatient neurologists work in the clinical setting, managing patient’s chronic neurologic conditions including headache, peripheral nerve disorders, Parkinson’s disease, dementia, epilepsy disorders, myasthenia, ALS, stroke prevention and rehabilitation, and more. As is usually the case in an outpatient practice, you can expect 9 to 5, Monday through Friday, regular business hours.

Academic vs Community vs Private Practice

As an academic neurologist, you’ll be working at an institution affiliated with a medical school or teaching hospital, which generally means a large tertiary center with comprehensive stroke, epilepsy, and ALS treatment centers. In academic neurology, a fellowship is generally advised, and compared to other practice settings, you’ll be more narrowly focused on that fellowship subspecialization. As with any academic setting, you’ll also be teaching medical students and residents in addition to doing research on the side. Compensation in academia is usually about 30 percent less compared to community or private practice.

Community neurologists usually have clinic in addition to a weekly call schedule. They normally see less acute patients either pertaining to general neurology or their fellowship, which is most commonly headache, neurophysiology, neuromuscular, and movement.

Private practice neurologists focus on less acute neurology, including pathologies such as headache, neuropathy, less severe Parkinson’s disease, and well-controlled seizure disorders in their clinics. They also usually take call for stroke or general neurology at local hospitals. While the pay is higher, you’re more likely to have more demanding call, needing to service multiple hospitals in a given radius.

How to Become a Neurologist

After 4 years of medical school, neurology residency is another 4 years. Your first year in residency, or PGY-1, is an internship in internal medicine. After all, a strong internal medicine foundation is prerequisite to be successful as a neurologist.

During your second through fourth years of residency, you’ll be focused exclusively on neurology.

As a PGY-2, you’ll be focusing primarily on inpatient coverage of stroke, general neurology, epilepsy, and neuro-critical care. As a PGY-3, you’ll begin having more outpatient clinic exposure, but still lean towards inpatient, while also begin working on fellowship applications. As a PGY-4, you’ll be more evenly split between inpatient and outpatient, and this is also when most residents focus on research.

You can do either a categorical or advanced residency. Categorical means you do all 4 years at a single program, whereas for advanced programs, you’ll do your intern year as either a preliminary year or transitional year and then do neurology residency at a different program.

Medical students that apply to neurology are stereotypically the quirky nerds who have a strong interest in reading, tend to talk a lot, and enjoy explaining to others what they’ve learned.

In terms of competitiveness, neurology is considered less competitive, ranking at 16 out of 22 specialties. The average Step 1 score is 232, the average Step 2CK is 245, and the match rate is 97%.

Subspecialties within Neurology

After completing residency, you can subspecialize further with fellowship.

Vascular Neurology

Vascular neurology is almost entirely inpatient in nature. This is the subspecialty for neurologists that love staying on top of research and have a deep interest in vascular anatomy and acute care. This is a 1-year fellowship, although some programs are 2 years in duration when research is involved.

If you love the high acuity of inpatient and love acute lesion localization, then this may be the field for you. But you will be called at odd times for stroke emergencies, which may be unfavorable to many.

Epilepsy

Epilepsy is a 2-year fellowship for the brainiacs of neurology. You’ll be reading EEGs and working with neurosurgeons for either intra-operative EEG monitoring or for managing seizure patients with vagal nerve stimulators or responsive neurostimulation devices.

This is primarily an outpatient practice, unless you work at a large epilepsy center, where they do admit patients to the epilepsy monitoring unit to better characterize seizures and see whether surgical treatment is warranted.

Movement Disorders

Movement disorders is a 1-2 year fellowship and is purely outpatient in practice. These are the experts in treating Parkinson’s, Huntington’s, tic disorders, tremors, dystonias, and more.

This subspecialty comes with a great lifestyle, with an 8-5 practice. Botox injections are often a key procedural aspect of this specialty and can add to the practitioner’s compensation significantly. If you work at a larger center, you’ll also help manage devices like deep brain stimulators for Parkinson’s tremors with the neurosurgeons.

Neuro-Critical Care

Neuro-critical care is a 2-year fellowship and is a newer and rapidly growing subspecialty of neurology. These are the specialists of extreme neurologic illness such as brain hemorrhages, large strokes, neuromuscular crises, acute spinal cord injury, and dealing with neurosurgery post-operative care and complications.

This is for those who love the exciting, fast-paced nature of the ICU and want to practice both neurology and internal medicine elements.

It’s more procedure heavy than other parts of neurology, dealing with more lumbar punctures, intubations, central line placements, chest tubes, external ventricular drains, and more. The call can be demanding as the patients are all very sick and can decline rapidly if not monitored carefully.

Neuro-Interventional Surgery/Radiology

Neuro-interventional surgery and radiology is for those who want to specialize in minimally invasive procedures for large vessel strokes, aneurysm coiling, and arteriovenous malformations. It’s quite demanding and has a steep learning curve for neurologists because it’s purely procedural.

This is an additional 1 or 2-year fellowship for which you can take one of three paths. Either through neurology followed by vascular neurology or neuro-ICU fellowship, neurosurgery residency, or radiology residency followed by neuroradiology fellowship. It is the most competitive subspecialty of neurology and the lifestyle can be demanding as you may be called at odd hours to activate an endovascular team to perform endovascular procedures. At the same time, it is the highest paying.

There are several other fellowship options to choose from as well, including neuro-immunology, neuromuscular diseases, neurophysiology, neuro-ophthalmology, neurocognitive and neurodegenerative diseases, neuro-oncology, neuro-rehab, headache, sleep, pain, neuro-infectious diseases, and neuro-endocrinology.

What You’ll Love About Neurology

Neurology is a great specialty with a lot to love. About 80% of neurology is outpatient, which means you’re less likely to work weekends, and you’re more likely to have a regular 8-5 practice. However, note that most private practice neurologists have to take call for local hospitals.

Neurology is concerned with the most fascinating organ system of the human body, and we’ve seen dramatic improvements in our understanding of the brain and spinal cord in just the last 20 years. And that’s likely to continue, as neurologic diseases are consistently in the top 3 most funded diseases by the NIH each year.

If you enjoy building strong longitudinal relationships with your patients, neurology has you covered. Most neurology pathologies are chronic in nature, and you’ll be seeing your patients often for many months to many years.

What You Won’t Love About Neurology

While neurology is a great specialty, it’s certainly not for everyone. Despite the immense research funding being poured into the field, neurologic diseases are debilitating in nature as treatment options aren’t as robust as they are in something like cardiology. With less favorable outcomes, neurologists may need to be more comfortable with palliative and hospice care, which can be emotionally challenging for many and can lead to burnout. Neurology consistently ranks at the top in terms of burnout.

The lifestyle can be demanding, especially with a community practice. In addition to having a busy clinic, you’ll have to take stroke calls at local hospitals.

Neurologist compensation is in the lower third of all specialties, making on average $280,000 per year. This is in large part because you’re dealing with primarily chronic illnesses and there are fewer procedures in neurology compared to something like gastroenterology or cardiology.

And because of the wide breadth of neurology, the overwhelming majority of neurologists pursue a fellowship. That means your training will last at least another 5 or 6 years after medical school, which is on the longer end for a non-surgical specialty.

Should You Become a Neurologist?

Should you go into neurology? If you’re the type of person that loves the complexity of neuroscience and enjoys using the physical exam and deductive reasoning to come up with a diagnosis and treatment plan, neurology may be a good fit.

If you want to be part of a specialty that’s rapidly growing, evolving, and focusing more on holistic longitudinal treatment now rather than the “diagnose and adios” mentality of the past, consider this specialty.

In terms of patient population, you should be comfortable with longitudinal relationships with sensitive patients who may have debilitating and sometimes terminal illness, which isn’t as rosy as some other specialties. You’ll be their primary provider, guiding them to live the rest of their life meaningfully.

Those that go into neurology also tend to be on the intellectual side of things, enjoying discussing the nuances of the physical exam, strange labs, and unique imaging findings.

Are you interested in neurology? To get into medical school and match into a strong neurology residency, you’ll need to score well on your class tests and standardized exams. If you need help acing your MCAT, USMLE, or other exams, our tutors can maximize your test-day performance. If you’re applying to medical school or neurology residency, our Insiders can share the ins and outs of what it takes and how to navigate the highly competitive process most effectively. We’ve become the fastest-growing company in the industry, and it’s no surprise. Our customers love us because we’re committed to delivering results, period.

If you enjoyed this article, check out So You Want to Be a Neurosurgeon, or another specialty on our So You Want to Be playlist. Much love, and I’ll see you guys there.

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