Like CNS >>> PNS... Is Neuro For Me?

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unsung

unsung

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So... this is something that has been on my mind for a Long time.

I was originally attracted to the field via reading the writings of people like Oliver Sacks & V.S. Ramachandran. This preceded my interest in medicine itself by many years.

Human behavior- its broad spectrum of possibilities- has always fascinated me. I have also worked on a psych ward (grunt worker), and really enjoyed the patient population as well as the pathology.

However, there are things that prevent me from wanting to be a psychiatrist. Namely, what I see as "over-prescription" of psychotropic meds. Yes, the acutely psychotic guy could benefit from the anti-psychotic.

But do I really feel comfortable prescribing the young teen/kid with ADHD long-term meds? Often, I'm not convinced the benefits outweigh the risks.
(Not to mention the idea of "arbitrarily" making something like ADHD into a pathology, when it hasn't always been seen as an illness or a disability.)

Also, med side effects (considerable) often seem to get minimized. For the mildly depressed person, I often think psychotherapy & exercise are of more benefit than the med... in which case I think I would feel bad being on the "pill pushing" side of the equation, as opposed to the counseling/behavioral management side.

In summary, I don't like the treatments used in psych, nor do I like the DSM-IV criteria, or foresee myself enjoying memorizing said criteria.

Not to digress too much & start a psych topic in the neuro forum 😉 ...
... So what I'm getting at is, I think my true interests lie betwixt & between psychiatry & neurology.

For the reasons I've listed above, I'm close to "ruling out" psych, and picking neuro by default.

I really want this to work out, but in the back of my mind, I feel like I don't "identify" with a majority of people going into neurology. A significant contingent really seem to like the neuromuscular issues, and even the physical rehab types of issues.

(I have NO interest whatsoever in the musculoskeletal system. And while I will learn what I must, if I must-- PNS is still way more interesting than cardiovascular system-- it's just not something I'm naturally drawn to.)

Even with CNS, I don't have this strong interest in say, epilepsy, or interventional stroke stuff. (Again, all relative. 'Cuz I definitely DO find those topics magnitudes more interesting than most other stuff I've learned in 1st 2 yrs of med school. And... I might even take an interventional elective "for fun"... for what that's worth 😉)

Stuff I have "natural" interest in: Idea of using rTMS to create "virtual lesions" and possibly "unmask" latent creativity, musical abilities, etc. I'm FASCINATED by ideas like this.

Fascinated by case studies of individuals with unusual capacities for memory. Or individuals who develop (or "unmask") extraordinary artistic skills as they decline in other ways. I think you see what I'm getting at.

In some ways, what I'm describing is more like cognitive psychology, or basic science, than the clinical practice of neurology that focuses more on treating pathology (duh) than on figuring out how memory or creativity work.

Also, afaik, the more detailed cognitive assessments fall on the neuropsychologist rather than the neurologist. Which is a little disappointing, as that really is the part that is of most interest to me.

I actually had an IM doc kind of "slight" neurologists by saying to us students that if a guy presents with unusual cognitive signs, we should get a neuropsych eval instead of a neurologist referral. 'Cuz the neurologist is just going to check the CNs (according to him), etc. and do all the basic things we med students would do anyway (albeit a more thorough, nuanced version).

... Does neurology sound right for me?
 
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Absolutely. Look in to programs that have strong Cognitive/Behavioral Departments and do a fellowship in that down the road. Of course you'll have to do a little bit of everything- PNS included- during residency- but for anything in neuro, you need about as wide a base of knowledge as you can get before you start narrowing down into sub-specialty fellowships.
 
I think you should reconsider psych, especially at a highly research oriented program. Yes, you could do behavioral neurology, but I think you'll find a lot more of what you're looking for in psychiatry research.
 
curlygirlie106 said:
Absolutely. Look in to programs that have strong Cognitive/Behavioral Departments and do a fellowship in that down the road. .
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Pretty much. There are also fellowships in neuropsychology.

I share some of your interests and I also agree with your outlook on psychiatry. My main issue with psychiatry is that I think our knowledge of how the brain functions and does what it does is so limited to tackle psychiatric diseases from a sound scientific and theoretical basis. Which is why I think neurology is better suited to tackle brain function and its relation to cognition and cognitive deficits if that's your interest.

Also do not underestimate the PNS, even given your interests. Sensory experience can have so much influence on cognition. There are many paths to tackle the brain, and one of the main pros of neurology is the grasp of anatomy, function and how all the various components of the nervous system are interrelated and all the pathology associated with it. It takes so much time to get to a specialized area, and it can be daunting for us medical students when we already have a clear interest in view but we need to be patient. Also, be bold to try and forge your own path and interests within neurology. I don't think you have made the wrong choice at all of picking neurology. This is coming from another medical student with an interest in neurology btw, if that matters.
 
i matched in neurology this yr

i was actually in the same boat and strongly considered psych and even neuro/psych programs

i had the exact same reservations about psych as you do

in fact, i like CNS>>>>PNS and love psychopathology but like the feeling of being a "real doctor" that you get in fields like Neurology and want to use my medical knowledge...there are many fields in neuro that deal with CNS issues namely alzheimer's/behavioral, sleep, EEG, etc. plus i think something like 1/3 of your boards is psych anyway

you def arent alone, i think neuro is starting to attract many ppl who in past yrs would have done nsgy (now go for neuro icu, stroke +/i NIR) or ppl who would have done psych (behavioral, sleep, etc)

good luck!
 
My first word of advice is that neurology is a very diverse field, and if you have questions about a certain career path ask multiple people about it because one person will tell you "well I don't think I've heard of that so probably not" while another person will say "oh, that's what I do"

I'm the same as you in that I had a tough time with neuro vs psych. One thing I would say right off the bat is spend some time in a clinic with someone practicing behavioral neurology. It has the most overlap with psychiatry I'd say, and treats conditions that in other countries are considered geriatric psychiatry [AZ disease, MSA, lewy body dementia, primary progressive aphasia etc]. The behavioral neurologists don't administer neuropsych tests but they get the results and have to decide how that changes the clinical picture for the patient. I worked with a behavioral neurologist that has an interest in musical perception in neurodegenerative disease. That is an itch she scratches with research, but doesn't come up much in her clinic which is a lot of intricate diagnostic work in figuring out which of the aforementioned diseases a patient has where a less specialized clinician would say "not thinking right and old ---> Alzheimer's"

The best advice I can give is make your decisions on actual observed practice and not theoretical ideas about practice that you might have come up with...you may be surprised. Epilepsy was actually a lot more interesting to me than I had assumed after getting some decent exposure to it.

Finally- the IM doc you talked to sounds like an idiot. Anyone with a cognitive complaint needs a MEDICAL evaluation first to check to make sure it's not a cognitive manifestation of a medical illness [hypothyroidism, MS, pernicious anemia, etc etc]. I'm guessing s/he makes a lot of ******* psych consults or misses a lot of physical illness with behavioral manifestations. A lot of people that trained 20 or 30 years ago have a very outdated idea of neurology and will tell you a lot of crazy bull**** as a result.
 
starmoon said:
I think you should reconsider psych, especially at a highly research oriented program. Yes, you could do behavioral neurology, but I think you'll find a lot more of what you're looking for in psychiatry research.
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I would echo this sentiment. I was an MDPhD in neuroscience and debated between neuro and psych and picked psych in the end. If you like rTMS you should do psych, as I'm not aware of ANY neurologist doing TMS oriented research. If you want more pm me. You sound much more like a psych person than a neuro person esp. with not jiving with the neuro personality.

With regard to your concerns in psych (overmedication etc.), most psychiatrists have similar concerns, however these concerns do not prevent them from practicing biologically oriented, evidence based psychiatry that is increasingly targeting specific neural circuitry as opposed to only phenomenology. As far as DSM goes, DSM-V is going to be much more "dimensional", and the dimensions will be guided by our current understanding of the underlying neurocircuitry involved in various psychiatric syndromes. While it's true the understanding of psychiatric disorders is more limited, in my mind the TREATMENT of psychiatric disorder, ironically, is much much more satisfying. Many, if not most, of the interesting neurological disorders have a progressive, invariably fatal course with very little treatment available, and neurological deficits are usually permanent or semi-permanent. Also, you'll note in neurology that most of neurology deals with blood vessels, the immune system, infections, tumors and PNS. Very little of neurology deals with the actual cognitive process per se. In psychiatry, every pathology has to do with cognition, language, higher order processes, and the medications can often make dramatic improvements. In the end, my experience on neurology at a tertiary center on the inpatient wards was a bunch of comatose patients with progressive neurologic decline and irreversible stroke and discharged to nursing homes. My experience on the psych ward was very sick schizophrenics recovering (however transiently) on clozaril and ECT.

In my opinion the disadvantages of psych are not necessarily the ones you specified, which are pitfalls the field is moving away from, but in the aspect of psychiatric care that involve social science/policy/legal etc. which is typically beyond medical training and sometimes feels esoteric and not scientific. Some people like it, some people hate it. The other issue with psych is the stigma and sensitive issues involved in caring for psychiatric patients, which also tends to be a personal fit. I'd say if you enjoy taking care of psychiatric patients and can work through the stigma, you should definitely consider giving psychiatry another try.
 
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sluox said:
While it's true the understanding of psychiatric disorders is more limited, in my mind the TREATMENT of psychiatric disorder, ironically, is much much more satisfying. Many, if not most, of the interesting neurological disorders have a progressive, invariably fatal course with very little treatment available, and neurological deficits are usually permanent or semi-permanent. Also, you'll note in neurology that most of neurology deals with blood vessels, the immune system, infections, tumors and PNS. Very little of neurology deals with the actual cognitive process per se. In psychiatry, every pathology has to do with cognition, language, higher order processes, and the medications can often make dramatic improvements. In the end, my experience on neurology at a tertiary center on the inpatient wards was a bunch of comatose patients with progressive neurologic decline and irreversible stroke and discharged to nursing homes. My experience on the psych ward was very sick schizophrenics recovering (however transiently) on clozaril and ECT.
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Laughable. You obviously have very limited experience with Neurology. There are countless treatable neurological diseases (epilepsy, Guillain-Barre, myasthenia, headaches, CIDP, MS, trigeminal neuralgia, Parkinson's, nerve entrapments, meningitis/encephalitis, acute stroke, just to name a few).
I've had plenty of experience with Psychiatry and I see very very few Psych patients that are effectively treated for a significant period of time. Despite all the SSRI's, SNRI's, Seroquel, Abilify, Risperdal, and Lithium that psychiatrists add, these patients return with the same problems and often end up worse off on a cocktail of psychotropic meds and then get admitted for seizures or encephalopathy and then the neurologist is called. Also, the diagnosis and treatment is highly subjective...."bipolar" is way overdiagnosed and overtreated. Psych people love to talk about that schizophrenic that has a great response to radical treatment but that's a very small percentage of pts you see and I've seen plenty of chronic schizophrenics who have been treated without dramatic change.
For the OP, I agree you probably would be more interested in Psych, based on your interests. The PNS is underrated and clincoanatomic localization in PNS lesions to me is more interesting than in CNS disease. A good neurologist should have extensive knowledge of PNS (and CNS) anatomy and disease processes.
 
aaddnl said:
Laughable. You obviously have very limited experience with Neurology. There are countless treatable neurological diseases (epilepsy, Guillain-Barre, myasthenia, headaches, CIDP, MS, trigeminal neuralgia, Parkinson's, nerve entrapments, meningitis/encephalitis, acute stroke, just to name a few).
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Aw beat me to it- neurology as a "diagnose and do nothing" field is a major pet peeve of mine. If out-and-out cure of disease is what someone wants, I think they'd be disappointed in any non-surgical field. We have patients in SNFs, Psych has patients in long-term institutional settings. We also have patients like those mentioned that see a significant improvement in their lives from the care we provide. There are a number of physicians that don't recognize/don't appreciate the benefit of physician care compared to the natural history of a disease and it's so strange to me.

Anyway I think regardless of neuro or psych you'll be more happy eventually in academia than private practice since there will be opportunity to do neuroscience research. Private practice community neurologist and tertiary care inpatient/clinic have much different flavors to them.
 
aaddnl said:
Laughable. You obviously have very limited experience with Neurology. There are countless treatable neurological diseases (epilepsy, Guillain-Barre, myasthenia, headaches, CIDP, MS, trigeminal neuralgia, Parkinson's, nerve entrapments, meningitis/encephalitis, acute stroke, just to name a few).
I've had plenty of experience with Psychiatry and I see very very few Psych patients that are effectively treated for a significant period of time. Despite all the SSRI's, SNRI's, Seroquel, Abilify, Risperdal, and Lithium that psychiatrists add, these patients return with the same problems and often end up worse off on a cocktail of psychotropic meds and then get admitted for seizures or encephalopathy and then the neurologist is called. Also, the diagnosis and treatment is highly subjective...."bipolar" is way overdiagnosed and overtreated. Psych people love to talk about that schizophrenic that has a great response to radical treatment but that's a very small percentage of pts you see and I've seen plenty of chronic schizophrenics who have been treated without dramatic change.
For the OP, I agree you probably would be more interested in Psych, based on your interests. The PNS is underrated and clincoanatomic localization in PNS lesions to me is more interesting than in CNS disease. http://forums.studentdoctor.net/newreply.php?do=newreply&p=10857801A good neurologist should have extensive knowledge of PNS (and CNS) anatomy and disease processes.
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Well... not exactly a rousing vote of confidence for psych, after a long paragraph of psych-bashing! 🙄

I'm glad neuro is diverse enough of a field that there's room for both our interests.

At the same time, it's just WEIRD to me that people going into neuro can be interested in the brain without being interested in behavior. "Interested" in the sense of interested in localizing tumors or finding/fixing "plumbing problems"... all without having an underlying curiosity about the higher-order issues of theory of mind, memory, emotions, and so forth.

THIS is exactly the kind of attitude I'm encountering amongst neuro folks. While the psych people seem more prone to having discussions about such higher-order issues.

But I'm one of those people... who doesn't really buy the artificial division between "mind" and brain. Therefore, I'm of the belief that eventually we will know enough about pathologies such as schizophrenia to understand and treat it from a neuro perspective.

(A psychiatrist did say to me once that anytime we learn more about the pathophys of a particular psych disease... it gets shunted over to be handled by neurologists. :laugh: Too bad for psychiatry, eh?)

This whole division between neuro & psych is so arbitrary. They are estranged... and I am waiting for the rapprochement.

The contingent that feels they should remain separate like to make the argument that the two fields attract entirely different personalities with entirely different skill sets/interests... which this thread sort of illustrates. lol

So I'm glad to hear from those of you who ARE actually interested in both fields! Because we are definitely a minority group.

Hence... the need to be "bold" and forge our own paths... (love that wording, btw.)
 
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Mattchiavelli said:
My first word of advice is that neurology is a very diverse field, and if you have questions about a certain career path ask multiple people about it because one person will tell you "well I don't think I've heard of that so probably not" while another person will say "oh, that's what I do"

I'm the same as you in that I had a tough time with neuro vs psych. One thing I would say right off the bat is spend some time in a clinic with someone practicing behavioral neurology. It has the most overlap with psychiatry I'd say, and treats conditions that in other countries are considered geriatric psychiatry [AZ disease, MSA, lewy body dementia, primary progressive aphasia etc]. The behavioral neurologists don't administer neuropsych tests but they get the results and have to decide how that changes the clinical picture for the patient. I worked with a behavioral neurologist that has an interest in musical perception in neurodegenerative disease. That is an itch she scratches with research, but doesn't come up much in her clinic which is a lot of intricate diagnostic work in figuring out which of the aforementioned diseases a patient has where a less specialized clinician would say "not thinking right and old ---> Alzheimer's"

The best advice I can give is make your decisions on actual observed practice and not theoretical ideas about practice that you might have come up with...you may be surprised. Epilepsy was actually a lot more interesting to me than I had assumed after getting some decent exposure to it.
Finally- the IM doc you talked to sounds like an idiot. Anyone with a cognitive complaint needs a MEDICAL evaluation first to check to make sure it's not a cognitive manifestation of a medical illness [hypothyroidism, MS, pernicious anemia, etc etc]. I'm guessing s/he makes a lot of ******* psych consults or misses a lot of physical illness with behavioral manifestations. A lot of people that trained 20 or 30 years ago have a very outdated idea of neurology and will tell you a lot of crazy bull**** as a result.
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👍 Awesome advice. Thanks.

I started out med school really taking the clinical information taught "at face value." Why wouldn't I? It's like did I really have a reason to "question" the lecturer back when I first learned intro physics?

But I quickly came to find out (once professors started contradicting one another all over the place) that I needed to take everything ANYONE said to me with a grain of salt. Yeah. Learning medicine is not like learning how to do math. lol

One guy will spend an hour talking about how wonderful and safe drug X is... another guy will talk about the great benefits of a particular surgical procedure over meds... and of course, there are the opposing viewpoints. This hit home when I read an article about surgeries being done when they're not indicated/outcomes don't seem to support the procedures... and wait a minute, isn't that the name of the guy who lectured to us??

So yeah. Why would this be different? Medicine is just so broad... and we are all limited in our experiences and perspectives.

Keep the ideas coming, guys. I enjoy hearing your thoughts.
 
Mattchiavelli said:
Aw beat me to it- neurology as a "diagnose and do nothing" field is a major pet peeve of mine. If out-and-out cure of disease is what someone wants, I think they'd be disappointed in any non-surgical field. We have patients in SNFs, Psych has patients in long-term institutional settings. We also have patients like those mentioned that see a significant improvement in their lives from the care we provide. There are a number of physicians that don't recognize/don't appreciate the benefit of physician care compared to the natural history of a disease and it's so strange to me.
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Yeah but at what proportion. With a typical managed care inpatient acute care psych unit, maybe 1 out of 10 will end up in a state hospital. Most will graduate to a partial or outpatient program and at least temporarily (albeit often dramatically) improve. In a typical managed care inpatient acute care neuro unit, maybe 1 out of 10 will graduate to an acute rehab (and then what? years of slow tedious progress?), 9 will end up in SNF or hospice. Inpatient neurology is still LARGELY a diagnosis oriented specialty. And don't tell me I don't have enough neuro exposure. The quote from our neurocritical care fellow is that "yes, most of the patients are vegetables, but we work hard for that 1 out 20 which is a miraculous save." Uhmm, sorry, that's not high enough of a proportion for me.

Now if you are talking about outpatient stuff, then perhaps roughly a similiar proportion of psych vs. neuro patients have good prognosis. But the bread and butter outpatient neuro complaints, i.e. headache, backache, seizure disorders, stroke followup, dystonia, dementia....you can decide what you like yourself, but I found them to be very eh...
 
Please don't pull a Jon Kyle and make up statistics- roughly 8 or 9 patients with mild to moderate stroke admitted to a hospital get d/c'ed home or to acute rehab per a study 10 yrs ago in Stroke. Acute stroke rehab is kind of fun and is also another opportunity where I've seen physicians working with neuropsychologists to develop comprehensive plans for managing patients. Example being a patient I followed with a mild stroke, physically back to near baseline but neuropsych testing revealed some new onset mathematical difficulty which was relevant b/c she managed payroll at her family business. We were able to connect her with someone that specializes in rehab for that kind of recovery which was rewarding. Personally, I see it as discharging patients to rehab instead of a pine box which is a gain in care IMO.

A neurocritical care fellow would really be seeing the sickest of the sick, and I feel like that is saying IM is a depressing field because a lot of ICU patients die. General wards patients can be video EEG monitoring, myasthenic crisis, workup of new onset seizure, mild/mod stroke, stuff like that. Some places have dedicated neurocritical care separate from inpatient neurology and some it's all lumped together and you consult on patients in a medical ICU but the trend is going to separate neurocritical care if feasible. If you do a neurology residency there will be some of that but also some time in epilepsy clinic to hear someone tell you they figured out a co-worker's cellphone ring triggers their seizures.
 
unsung said:
At the same time, it's just WEIRD to me that people going into neuro can be interested in the brain without being interested in behavior. "Interested" in the sense of interested in localizing tumors or finding/fixing "plumbing problems"... all without having an underlying curiosity about the higher-order issues of theory of mind, memory, emotions, and so forth.

THIS is exactly the kind of attitude I'm encountering amongst neuro folks. While the psych people seem more prone to having discussions about such higher-order issues.

But I'm one of those people... who doesn't really buy the artificial division between "mind" and brain. Therefore, I'm of the belief that eventually we will know enough about pathologies such as schizophrenia to understand and treat it from a neuro perspective.

(A psychiatrist did say to me once that anytime we learn more about the pathophys of a particular psych disease... it gets shunted over to be handled by neurologists. :laugh: Too bad for psychiatry, eh?)

This whole division between neuro & psych is so arbitrary. They are estranged... and I am waiting for the rapprochement.
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OK, this is a myth.
Neurology and Psych are not that similar. In neurology, the physical exam is critical, maybe more so than any other specialty. In psych, there is no physical exam. And there are plenty of other major differences. Neurology is actually closer to IM than any other specialty. It used to be a division of IM (and is still at a few places).
Neuro is as close to Neurosurgery as it is to Psych. And that's not very close. Behavioral Neuro is the only subspecialty that is very close to Psych. Yes, there are other neuro subspecialties have lots of patients with Psych disease, but that's not what they are primarily seeing their Neurologist for.
Funny that I only hear Psych people and med students with little experience talk about how Psych and Neuro are so similar. I've never heard anyone experienced in Neurology say that.

"Fixing plumbing problems?" That's called being a doctor.

Yes I am interested in behavior and the mind, but I'm also practical in taking care of patients, and so you don't exactly have time to have "higher-order discussions about the mind" with each one of your patients if you want to see more than three patients in a day. You would be better served in a non-clinical, perhaps research environment if that is your attitude and interest.


Yeah but at what proportion. With a typical managed care inpatient acute care psych unit, maybe 1 out of 10 will end up in a state hospital. Most will graduate to a partial or outpatient program and at least temporarily (albeit often dramatically) improve. In a typical managed care inpatient acute care neuro unit, maybe 1 out of 10 will graduate to an acute rehab (and then what? years of slow tedious progress?), 9 will end up in SNF or hospice. Inpatient neurology is still LARGELY a diagnosis oriented specialty. And don't tell me I don't have enough neuro exposure. The quote from our neurocritical care fellow is that "yes, most of the patients are vegetables, but we work hard for that 1 out 20 which is a miraculous save." Uhmm, sorry, that's not high enough of a proportion for me.
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wow. I know you think you have it all figured out as a med student, but I'm not sure what kind of experience and training you are getting. 1 out of 10 patients on a neuro inpatient ward graduate to rehab??? WTF. the majority of neuro inpatients go to acute rehab or home. I dont know where you came up with your numbers, i guess you are trying to justify your decision in your mind.
Neurocritical care is taking care of a lot of Neurosurgical patients, and yes, they do have high mortality and morbidity. But, is that a reason to not pursue a specialty, bc they have sick patients?
And, comparing an acute psych ward to a hospital ward isn't exactly apples to apples, either, so your analogy doesn't fly.

Now if you are talking about outpatient stuff, then perhaps roughly a similiar proportion of psych vs. neuro patients have good prognosis. But the bread and butter outpatient neuro complaints, i.e. headache, backache, seizure disorders, stroke followup, dystonia, dementia....you can decide what you like yourself, but I found them to be very eh...
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backache is not really neurology. I find anxiety, depression, adjustment d/o, and all the other "i'm stressed out and can't deal with it," to be very "eh".....but to each his own.
and like i said, i think psych would be better for you than neuro.....not sure you are cut out for much clinical work......i'm sure you'll do great. good luck.
 
aaddnl said:
backache is not really neurology. I find anxiety, depression, adjustment d/o, and all the other "i'm stressed out and can't deal with it," to be very "eh".....but to each his own.
and like i said, i think psych would be better for you than neuro.....not sure you are cut out for much clinical work......i'm sure you'll do great. good luck.
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if backache ain't neuro, then anxiety, depression, and adjustment d/o ain't psych either (most of that "meh" stuff can and is handled by FP's these days).

to argue that the physical exam is what makes neuro so monumentally distinct from psych, well, slightly archaic. You can still tease your intellectual side, but we know that imaging is doing a lot of the exam these days too. look, both field are *intellectual* if that's what you crave...in practice, psych has more intellectual appeal because there's less clear-cut pathophys.

so yeah, to say there is more black and white in neuro and less gray (no pun intended), is absolutely accurate. If more gray stimulates you, then go for psych. Some cringe and see it as shooting in the dark, others revel in finding the light. If you like 2D, go for neuro. It's more cut and dry and less subjective, as stated. Some people like subjective...It means more flexibility, somewhat less liability, more creativity, however you want to see it. Both fields, in either case, provide ample nesting twigs and feathers for md/phd'ers.

for the most part, there is a lot of personality difference in the two fields and i don't disagree with those who joke that neuro is psych's nerdier cousin...the famous scene goes like this: A neurologist and a psychiatrist walk into a museum and ponder over the same painting. The neurologist obsesses over the dimensions of the frame and the precise proportions of the characters relative to each other, the size of the brush strokes, etc and starts making all sort of measurements with his ruler to quantify the work. The psychiatrist goes on and on about the hue of the yellows and the underlying message the painter was trying to portray to us about his illness, the angle of the brush strokes and how they reveal the painter's thought process, obsessing with the facial expressions of the characters and extracting the painter's underlying paranoia. Whichever you find more exciting, you play with.

As a residency, neuro is on the whole, not as lifestyle friendly, mostly owing to the acuity and workload of stroke incidence and the icu rotations (and if your goal is outpatient neuro, going through that ain't fun). Lifestyle in both is comparable if you are wanting to do outpatient. Neuro hospitalists obviously have it harder then consult-liason psychiatrists (also a species of "hospitalists").

If you're hell-bent on the interface of med/neuro and psych and aren't a research or neuropsychiatry person, you do a psychosomatic/consult-liason fellowship.
 
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I came across this article http://neuro.psychiatryonline.org/cgi/content/full/17/3/304 , which is a pretty nice summation on the differences between psychiatry and neurology.

In sum, neurology is rooted in the anatomy and physiology of the brain and the diseases that are actually tractable based on our knowledge of anatomy and physiology. Psychiatry approaches the brain/mind from a meta-narrative point of view. In other words, neurology is more rooted in the hard sciences whereas psychiatry is more rooted in the social sciences. If you're interested in investigating the brain/mind, the choice depends on the approach you'd like to take, and imo the hard sciences (especially theoretical neuroscience/ analysis of brain in terms of functional circuits) will make the biggest inroads in terms of understanding the brain and the mind/brain connection.

I also don't get those "if you're interested in the mind do psychiatry". I call bs. If you're dealing with epilepsy, you WILL deal with consciousness (basically the "ultimate" problem in neuroscience and what actually makes a mind) and perception or if you're working on strokes, you will deal with language, decision making, reasoning. That's as "high" as you can get in terms of cognitive function.

Of course neurology also tends to attract those who find the nervous system very interesting without actually being particularly fascinated by the mind (I find that very weird and I have a hard time sometime believing that these people can exist :laugh: ) and that's basically because they love the inherent logical construction of the nervous system and the very rigorous and logical thinking process that goes in, say, localizing a lesion. If you like both, then that's even better.
 
if backache ain't neuro, then anxiety, depression, and adjustment d/o ain't psych either (most of that "meh" stuff can and is handled by FP's these days).
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not quite. backache is usually a diagnosis handled by PM&R/Ortho/Pain, as it is often a musculoskeletal problem. Anxiety, depression, and adjustment d/o are most definitely psychiatric problems.
Yes, FP's see and handle some epilepsy, headaches, etc also, but I'm not denying those are neuro problems.


to argue that the physical exam is what makes neuro so monumentally distinct from psych, well, slightly archaic. You can still tease your intellectual side, but we know that imaging is doing a lot of the exam these days too.
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that was only one example of a major difference. there are several more examples listed in the next post, related to the point that neurology is grounded on diseases based on actual objective findings, etc., or "rooted in the hard sciences whereas psychiatry is more rooted in the social sciences" as they put it. but i would still argue the examination is a big difference. In psych there is no physical exam. In neurology, it is critical. And the neurologist is usually called when the imaging is negative. "imaging doing a lot of the exam these days" is an unfortunately common view held by inexperienced practitioners who rely too heavily on imaging studies (and often incorrect radiology interpretations) rather than their own clinical assessment. but that's another discussion.

for the most part, there is a lot of personality difference in the two fields and i don't disagree with those who joke that neuro is psych's nerdier cousin
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I don't disagree with those that joke that Psych is Neuro's effeminate cousin who wants to hear and talk all about your feelings.....:laugh:
 
unsung said:
So... this is something that has been on my mind for a Long time.

I was originally attracted to the field via reading the writings of people like Oliver Sacks & V.S. Ramachandran. This preceded my interest in medicine itself by many years.

Human behavior- its broad spectrum of possibilities- has always fascinated me. I have also worked on a psych ward (grunt worker), and really enjoyed the patient population as well as the pathology.

However, there are things that prevent me from wanting to be a psychiatrist. Namely, what I see as "over-prescription" of psychotropic meds. Yes, the acutely psychotic guy could benefit from the anti-psychotic.

But do I really feel comfortable prescribing the young teen/kid with ADHD long-term meds? Often, I'm not convinced the benefits outweigh the risks.
(Not to mention the idea of "arbitrarily" making something like ADHD into a pathology, when it hasn't always been seen as an illness or a disability.)

Also, med side effects (considerable) often seem to get minimized. For the mildly depressed person, I often think psychotherapy & exercise are of more benefit than the med... in which case I think I would feel bad being on the "pill pushing" side of the equation, as opposed to the counseling/behavioral management side.

In summary, I don't like the treatments used in psych, nor do I like the DSM-IV criteria, or foresee myself enjoying memorizing said criteria.

Not to digress too much & start a psych topic in the neuro forum 😉 ...
... So what I'm getting at is, I think my true interests lie betwixt & between psychiatry & neurology.

For the reasons I've listed above, I'm close to "ruling out" psych, and picking neuro by default.

I really want this to work out, but in the back of my mind, I feel like I don't "identify" with a majority of people going into neurology. A significant contingent really seem to like the neuromuscular issues, and even the physical rehab types of issues.

(I have NO interest whatsoever in the musculoskeletal system. And while I will learn what I must, if I must-- PNS is still way more interesting than cardiovascular system-- it's just not something I'm naturally drawn to.)

Even with CNS, I don't have this strong interest in say, epilepsy, or interventional stroke stuff. (Again, all relative. 'Cuz I definitely DO find those topics magnitudes more interesting than most other stuff I've learned in 1st 2 yrs of med school. And... I might even take an interventional elective "for fun"... for what that's worth 😉)

Stuff I have "natural" interest in: Idea of using rTMS to create "virtual lesions" and possibly "unmask" latent creativity, musical abilities, etc. I'm FASCINATED by ideas like this.

Fascinated by case studies of individuals with unusual capacities for memory. Or individuals who develop (or "unmask") extraordinary artistic skills as they decline in other ways. I think you see what I'm getting at.

In some ways, what I'm describing is more like cognitive psychology, or basic science, than the clinical practice of neurology that focuses more on treating pathology (duh) than on figuring out how memory or creativity work.

Also, afaik, the more detailed cognitive assessments fall on the neuropsychologist rather than the neurologist. Which is a little disappointing, as that really is the part that is of most interest to me.

I actually had an IM doc kind of "slight" neurologists by saying to us students that if a guy presents with unusual cognitive signs, we should get a neuropsych eval instead of a neurologist referral. 'Cuz the neurologist is just going to check the CNs (according to him), etc. and do all the basic things we med students would do anyway (albeit a more thorough, nuanced version).

... Does neurology sound right for me?
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Yes, IMHO, Neurology does sound right for you. There are more subspecialties in Neurology than any other field outside of Internal Medicine. If you want to focus on cognitive-behavorial Neurology, check out University of Florida at Gainsville. (there are other programs that have an emphasis on this aspect of neurology as well).
All docs talk smack about docs in other specialties. Try to filter out the bashing and figure out what the reality is. I'd recommend rotating at U of F if possible, to see if that quenches your thirst. Good luck!
 
aaddnl said:
there are several more examples listed in the next post, related to the point that neurology is grounded on diseases based on actual objective findings, etc., or "rooted in the hard sciences whereas psychiatry is more rooted in the social sciences" as they put it.



I don't disagree with those that joke that Psych is Neuro's effeminate cousin who wants to hear and talk all about your feelings.....:laugh:
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That's another one that's a little, how shall we say it, haha...Psych isn't any more rooted in the social sciences than neurology is rooted in myocytes. Let's see, PsychOlogy might be what IS rooted in social sciences.

Don't tell me the FSMB has no clue its handing out licenses to glorified social workers LOL. In either case, clearly both specialties carry their own stereotypes. One of the classic neuro ones is the "3 D's"...Diagnosis, Disability, Death...Not entirely true, but stereotypes have some origination validity to them. In the end, it's all about what you're most comfortable with.

As for being neuro's effeminate cousin, well yeah, you can practice that kind of psychiatry if you want (low liability, cash-only, low overhead psychotherapy practice on Madison Ave, hell yeah, be as feminine as you want going to Aruba once a month). You can also tease your big masculine butchy beer-guzzlin' side managing the methicidal pt in the ER and the death row dude, all under the auspices of psychiatry (addictions, forensics, ER psych, and so on). Funny some see it as touchy-feely while others are actually scared sh&tless of the patient population psych manages. :laugh:

To the OP, the bottom line is, both fields have a lot of chronic type patients who are managed by symptom control (but then again, so does GI, so do a ton of other fields). Both are shamelessly bashed by IM. However, neither should give a crap because they make the same amount of money (or more) for less misery. Neither, save interventional neuro, makes a ton of money, but what they lack in income they make up for enjoying their lives (especially psych). Be *that* social worker. In med school I heard of more than one internist and EM resident switching to psych, even a cardiologist an attending of mine knew of...Rarely do you hear of it the other way around. And though I do not have the study to cite, psychiatrists are rumored to be among the happiest with their choice of specialty.
 
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digfast said:
This article was so long-winded that I simply could not finish it. This may actually be a great litmus test for whether you can do psych or not. If you can read the entire thing and maintain your interest, then psych is a possibility in your future. If (like me), this article simultaneously annoys you (because of the serpiginous character of its narrative) AND bores you, then the mechano-physiologic nature of neurology may be a better fit. Whew. Took me forever to write that.
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👍
Oh yeah, psych admissions and progress notes take longer (although I've known neuro exams and notes to be rather elaborate and extensive in their own special neuro way). You just can't win! A urologist I was rotating with once stopped in his tracks, looked at me, and said, "psych and neuro? BO-RINGGG." I called him a d$$$ck.
 
I'd like to add that psychiatrists DO perform physical exams, and what I've seem most frequently is the AIMS exam [which is a neuro exam]- this is one of those things I want to call irony but I don't think is.

That article was cool but I think it oversimplified in some areas- for instance in managing a patient w/parkinsons there is a dynamic between too off [bradykinetic and rigid] and too on [dyskinetic, uninhibited behavior possibly getting the patient arrested]. Idk I see all management of disease with medication as a balancing act between desired effects and intolerability.
 
Mattchiavelli said:
I'd like to add that psychiatrists DO perform physical exams, and what I've seem most frequently is the AIMS exam [which is a neuro exam]- this is one of those things I want to call irony but I don't think is.

That article was cool but I think it oversimplified in some areas- for instance in managing a patient w/parkinsons there is a dynamic between too off [bradykinetic and rigid] and too on [dyskinetic, uninhibited behavior possibly getting the patient arrested]. Idk I see all management of disease with medication as a balancing act between desired effects and intolerability.
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too off is from too little dopamine and too on from too much? Or that untreated parkinson's goes to develop dyskinesia and dysexecutive like symptoms? I don't know i'm just asking 😛



Anyway, i think that the question between psychiatry and neurology research could also depend on the kind of research you'd like to do. If you want to do research on the neuropsychological mechanisms and imaging of psychosis a psychiatry residency would be better i guess? 😛 For example experimental/cognitive/neuropsychology/neuroscience investigates a lot of "basic functions" like visual/auditory/tactile sensation/perception, attention and consciousness, spatial and proprioceptive functions, learning and memory, language, motor cognition, performance and volition, executive functions etc. I guess that if you want to do research on these more basic functions neurology would be closer (i think? Especially behavioral neurology).

If you want the "highest" more "fluffy" stuff like emotions and affective neuroscience, personality, reasoning, judgement, interpretations,social cognition, attitudes, beliefs and attributions etc. you could gain more research insights in psychiatry (If you can concetrate in an objective way and overcome the sometimes extremely disturbing manic or borderline behaviour of an irritated patient lol. Another bad think with present-day psychiatry is that there is no "objective" data of any kind to incorporate on a research paradigm. Except for the quite valuable psychometric ones but still, psychiatrists don't like them for some reason. Experiments accompanied by imaging and TMS are very promising but still they are not largely prefered by psychiatrists. These techniques look very promising though).


Research on the "more basic neuropsych funtions " is still rapidly developing (its remarkable that we still don't know a lot about tactile perception, vision, motor cognition or consciousness) the more "social psychology/social cognition" ones (which are more related to psychiatry IMO) are still very very new from a neuroscience perspective and for that reason they are also quite interesting and exciting. I'm trained as a psychologist not a doctor but i have gained experience in both neurological and psychiatric wards so these are my 2 cents. But still, first of all it is the type of practice and patients you'd like to see rather than the research interests IMO. You could still be a neurologist and do the "emotional" stuff (Damasio anyone? 😛) and you could still be a psychiatrist and investigate basic motor functions and volition (i know a psychiatrist who does just that). So, everything could offer something in the end regardless of the residency 😛
 
PETRAN said:
too off is from too little dopamine and too on from too much?
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Fair question- patients on levodopa/carbidopa [Sinemet] can develop levodopa-induced dyskinesia [which is choreiform, as opposed to the parkinsonian "pill rolling" tremor] after being on therapy a while, which will become more apparent usually with their peak plasma concentration of drugs. This will cause some patients to delay starting that medicine until side effects are intolerable, which is at a different point for different people. So you could say starting the med is a balance of too off vs too on b/c stiffness and bradykinesia might be less tolerable in someone trying to keep an active lifestyle vs someone with life goals of going to church on sundays and reading some books during the week.

Michael J Fox is doing it in this interview- I have seen worse in some clinics I've been in and it can be very disfiguring.
http://www.youtube.com/watch?v=ECkPVTZlfP8&feature=related
 
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