Jobs: mainly in-pt vs mainly out-pt?

[drandie]

---

Members do not see this ad.

Looking for some thoughts...

Just starting my PGY3 year in neuro and finally have the time to consider some career ideas. Problem is, residency has skewed my perspective so much that I have no idea what kind of job to start looking for.

To give you some idea... most of our clinic patients are low income, frequently non-compliant patients with serious psych overtones to their primary neuro complaint, and any attempted workup and treatment for their chronic daily HA or low back pain is met with insurance pushback and the complaints are often treatment resistant. Inpatient service for us is cap-less, with residents carrying huge patient loads and getting very sick patient transfers from outside hospitals and ERs all night on call. So outpatient = bad. Inpatient = worse.

This year is more inpatient attending clinics for me (which should be awesome), but then again I find myself hoping patients just don't show up so I have some time to read.

I need to be able to look forward to hours I can control and a patient load that's manageable. Do neuro jobs like that exist? Am I just burned out? And being as burned out as I am, do I really need to do a fellowship in clinical neurophys before I get out there and start paying back my loans?

Just need some perspective from someone who's out there already (and hopefully loves their job).

Any comments are appreciated.

 

[AznTrojan]

you really have to find out what's best for you..

for me.. i personally hated outpatient neurology.. which is why i chose a fellowship in neurocritical care.. give me an acute TBI or stroke or crashing guillan barre patient over another dementia work-up or headache patient..

 

[neurologist]

I need to be able to look forward to hours I can control and a patient load that's manageable. Do neuro jobs like that exist? Am I just burned out? And being as burned out as I am, do I really need to do a fellowship in clinical neurophys before I get out there and start paying back my loans?

Just need some perspective from someone who's out there already (and hopefully loves their job).

Any comments are appreciated.

Yes, they exist. There are a couple of key elements:

1. Stay away from academic and/or large urban hospital environments; they will just work you to death and once you have burned out they will simply replace you with fresh just-out-of residency meat. Plus, they generally don't pay well. It's better to work in a smaller market where you are more appreciated.

2. Try to find a place where inpatient hospitalists do all the direct patient care and admissions and neurology is a purely consultative service. This eliminates 99% of all hospital scut work. Just make sure the hospitalists aren't *****s.

3. Work with a group that has a reasonable number of other neurologists (at least 6-8) so call is reasonable.

4. Not many neurology practices use them, but good NP or PAs can be a real plus at managing "high-maintenance" but not overly complex patients that can suck up a lot of your time.

5. Develop a subspecialty interest so that over time you can carve out a subspec niche and minimize the crap general neurology that you see in outpatient clinic. (something procedural like sleep, EMG or pain is an added plus, since it generates revenue). Keep in mind, however, that this may take a couple years to develop, so you will have to have some patience.

6. Find a good pain management clinic to refer to -- one that actually does pain management and not just interventional procedures.

7. Somewhat related to #6, never be afraid to tell patients "I'm sorry, I don't prescribe opioids."

That pretty much describes my current job, and I am quite happy with it. Because I am hospital-employed, I don't have total control over my schedule, but there is enough flexibility to keep me happy. (I also probably make a bit less $ than if I were in private practice.) Yes, there are occasional days where I work late or have a hellish call, but generally I am not getting killed on either the in- or outpatient sides.

Good luck with the job search.

 

[drusso]

6. Find a good pain management clinic to refer to -- one that actually does pain management and not just interventional procedures.

7. Somewhat related to #6, never be afraid to tell patients "I'm sorry, I don't prescribe opioids."

Good luck with the job search.

Dumping on your pain management colleagues will not earn you any respect in your community. If *you* wouldn't accept the medico-legal risk to prescribe for a patient, why you would expect someone else to take that risk?

I make medication management recommendations, occassionally initiate and stabilize patients on opioids, but will not prescribe indefinitely. Moreover, good pain management should be multi-modal incorporating appropriate interventional procedures and not just pharmacological management. There is a strong trend away from the "pill mill" model.

 

[neurologist]

Dumping on your pain management colleagues will not earn you any respect in your community. If *you* wouldn't accept the medico-legal risk to prescribe for a patient, why you would expect someone else to take that risk?

It's not dumping. You're supposed to be a pain management specialist. So manage the whole complex of pain. In my construct of things, this includes medication management.

I make medication management recommendations, occassionally initiate and stabilize patients on opioids, but will not prescribe indefinitely.

If *you* wouldn't accept the medico-legal risk to prescribe for a patient, why you would expect someone else to take that risk? Wait . . . where have I heard that before? 😛

 

[drandie]

Thanks, neuro. Until now, I haven't really been able to formulate any job preferences when I've been asked, so I may just use that list verbatim 🙂

Sounds like you would encourage a neurophys fellowship then, huh? I do really love EMG, and would appreciate the break from constant patient dialogue. But - if I'm not a "neuromuscular specialist", how much EMG would I really end up doing? In my program, the attendings who do EMGs also manage all the ALS/MND and MG patients, and although I love the testing, I DON'T want to carve out a neuromuscular niche.

I admit, I'm trying to get out of doing a fellowship if the added year won't get me that much farther. Alternatively, I've always been a very competitive med student / resident and it would kill me to find out that I'm "less competitive" now because I'm not fellowship-trained. Then again, I'm ready to get OFF the highly-competitive academic track and have a job similar to the one you seem to hold.

Any thoughts on this?

 

[aaddnl]

Drandie,
You should do what you want to do. I agree with what Neurologist wrote--if you want more independence, variety, and a better practice setup, stay away from tertiary academic institutions and large metropolitan practices. when looking at a practice, it is very important that you think you would like and trust the people you would work with. as far as a fellowship goes, dont listen to people who say you have to do a fellowship. if you are smart, competent and get good training in residency, you don't really need it for what it sounds like you are wanting to do. the only caveat to that would be if you don't get enough EMG/EEG training in residency, you may need to do neurophys fellowship. that's one of the main reasons why many people going in to private practice do a neurophys fellowship. so you should focus on getting extra elective training in those areas in residency if this is what you plan on doing. even if you do decide to do neurophys, it doesnt mean you are necessarily the "neuromuscular guy." if you are joining a large practice, it would be good to carve out a niche, but you will still do a lot of general neuro at most places. If you are joining a smaller practice, it's less important but still nice to have an area you focus on for your own interests. as far as job competitiveness goes, you will be highly sought after in most areas of the country where neurologists are in high demand--the only exception to this would be large metros.