SS3 : What is Neurology : A General Neurologist’s Story

ss3

Session 03

In this episode, Ryan talks with a neurologist, Dr. Allison Gray, as they discuss all things about neurology. Notice that Ryan follows a standard regimen of questions in his episodes so you can compare each of the answers to hopefully help enlighten you in choosing your residency.

Allison is working as a neurologist at a large medical group in a community setting in Colorado.

Here are the highlights of the conversation with Allison:

When Allison knew she wanted to pursue Neurology:

  • Getting fascinated at neuroscience
  • Her father being a neuropsychologist

Why community versus academic:

Being drawn more to clinical practice

Types of patients:

  • Of all ages – teenagers and up (Pediatric Neurology is a separate specialty with a separate board of accreditation)
  • Fairly healthy and dealing with chronic conditions like migraine
  • People very debilitated by acute neurologic problem like stroke or chronic problem like ALS

A typical day in the life of Allison:

8am – 5pm

Sees 10 patients a day (This is a lot for neurologists since they have long examinations and they take long histories.)

Breakdown of her 10 patients-

  • 6 new consults
  • 1 procedure (ex. EMG)
  • 4 follow up visits

On work-life balance:

  • Where she works has emphasis on creating work-life balance
  • Flexibility in setting her schedule
  • Work-life balance is a challenge for her being a mom
  • Getting amazing support from staff who let her do physician work because they take as much administrative stuff off her plate as possible

Traits that lead to being a good neurologist:

  • Being cerebral (focusing not just on what the problem is and the best treatment, but where the problem is)
  • Interest in solving a puzzle
  • Being able to dive into action quickly (ex. stroke patient)

What makes a competitive applicant for neurology:

  • Getting better grades
  • Getting good board scores
  • Depends on geography (Neurology as a whole is not as competitive as orthopedic surgery or radiology)
  • Good shadowing experience
  • Find a way to participate in a neurology elective

Is matching competitive for Neurology?

Middle range – It depends on geography and whether you’re going to a very competitive program at a big name institution.

Do you see any bias between MDs and DOs for Neurology?

None that she’s aware of.

What is residency like for Neurology?

  • Her residency was volume-heavy and she was seeing a great deal of patients
  • Great in-patient heavy doing a lot of in-patient rotations in stroke and acute neurology and Neuro-ICU
  • Out-patient time depends on the academic institution
  • Residency is 4 years (1 year of Internal Medicine and 3 years of Neurology residency)

What she wished she knew going into Neurology?

Appreciating that Neurology was sad sometimes considering there is still no good treatments for Alzheimer’s, Dementia, ALS, etc. So you see people facing very devastating illnesses that are chronic, debilitating, and even deathly. Also, Neurology is acutely devastating sometimes. It really takes guts to see someone suffering.

However, Neurology has a great promise and they’re seeing wonderful new therapies coming out. Compared to 20 years ago, now there’s a huge difference in the way they treat things like MS and genetic disorders.

What do you wish primary care providers knew about Neurology?

Neurologists are here to help and they’re happy to help primary care physicians and they can always ask for help.

Specialties she works the closest with:

  • Neurosurgeons
  • Orthopedic surgery
  • Spine clinic
  • Physical therapy

Special opportunities outside of clinical medicine for Neurology:

Working with industries to discover new treatments

What Allison likes most about being a Neurologist:

  • A wide variety of problems in a day
  • She enjoys helping people and their families in difficult situations.

What she likes least about being a Neurologist:

The difficulty in not being able to offer someone something to fix a problem

Would she have chosen Neurology if she had to do it all over again?

Yes, Allison thinks the brain is the most fascinating thing in the human body because it defines who we are as people and human beings.

Sub-specialty opportunities for a Neurologist:

  • Epileptologists
  • Neuromuscular specialists
  • Behavioral neurologists
  • Headache specialists
  • Movement disorder specialists
  • Sports neurology
  • Neuro-infectious disease specialists

The future of Neurology:

  • Expanding the knowledge of the nervous system and its treatments
  • Huge number of new therapies coming out

Some pieces of advice for those thinking about entering Neurology:

  • Explore both sides of Neurology – inpatient and outpatient.
  • Do an elective and go to another institution to see what neurology is like there.
  • Get to see as much as you can because there is a wide variety in neurology and you don’t want to miss out on what you think it encapsulates just by seeing a piece of it.

Links and Other Resources:

ryan@medicalschoolhq.net

Transcript

Introduction

Dr. Ryan Gray: The Specialty Series Podcast, session number 3.

Whether you’re a premed or a medical student, you’ve answered the calling to become a physician. Soon you’ll have to start deciding what type of medicine you’ll want to practice. This podcast will tell you the stories of specialists from every field to give you the information you need to make sure you make the most informed decision possible when it comes to choosing your specialty.
Now welcome back to the Specialty Stories Podcast if this is not your first time joining us. If this is your first time joining us, welcome. We are a podcast dedicated to helping you decide what medical specialty you want to pursue. The path through premed and medical school is hard enough, we’re here to help make your decision a little bit easier when it comes to choosing a residency. Today we’re going to talk to a neurologist, and discuss all of the things about neurology. If you’ve listened to the other podcasts, I follow a pretty standard regimen of questions so that you can go back and listen to each one, and compare each one because they’re answering- all the physicians that I have on are answering questions- are answering all the same questions, and so today is going to be no different. So let’s go ahead and dive in.

Neurology as a Specialty

Dr. Allison Gray: Hi everybody, I’m Allison Gray, I’m a community neurologist.

Dr. Ryan Gray: Allison, when did you know you wanted to pursue neurology?

Dr. Allison Gray: During medical school we had a neuroscience course in our first year and I was particularly interested in that, I loved it. I thought the brain was really fascinating both when it was normal and also when it was not normal. And I also grew up talking about the brain, so sometimes I think that becoming a neurologist was in my genes. My father’s a neuropsychologist and we talked growing up all about traumatic brain injury and so I think it was sort of- I don’t know, maybe my destiny or something. But I think it was in the genes if you will.

Dr. Ryan Gray: Yeah are you based in a community setting? An academic setting? What kind of situation are you in?

Dr. Allison Gray: I am based in a community, I’m here in practice in Colorado, and I work for a large medical group but in a community setting.

Dr. Ryan Gray: Now a question that I haven’t asked before but I want to start asking is what made you decide community versus academic?

Dr. Allison Gray: That is a great question. I think that I have always been drawn more to clinical practice and clinical medicine since becoming a medical student. I think I have an appreciation for research, and the importance of research, and the fact that that propels us forward in terms of our understanding of medicine, and future treatments, and even diagnoses. But I think I’ve always been more drawn to the clinical practice piece of things as opposed to research. I do enjoy teaching, but again, when I think about things, the clinical aspect, taking care of patients on a daily basis is what really gets me excited about work. So that was more of my draw toward a community practice setting as opposed to academics.

Dr. Ryan Gray: What type of patients do you treat?

Dr. Allison Gray: I treat patients of all ages from teenager and up, so I don’t treat kids. Pediatric neurology is a separate specialty with a separate board accreditation. I treat people from about the age of fifteen, or really sixteen up until as old as people can get. And I treat people who are fairly healthy and dealing with a chronic condition, something like migraine, to people who are very debilitated by an acute neurologic problem like stroke, or a chronic really devastating neurologic condition like ALS or other things too. So I would say a wide variety, a really wide spectrum.

Dr. Ryan Gray: Describe a typical day.

Dr. Allison Gray: A typical day. For me I start work at 8:00 and I finish up around 5:00 although that’s sort of in quotes because they can be later, it depends on how busy the day has been. I will see ten patients in a day and it’s funny, so if you hear from a dermatologist he might see fifty patients in a day but ten’s actually a lot for a neurologist. We have long examinations, and we take long histories, so we have longer visits I think than a lot of people. So I’ll see about eight- sorry no, six new consults, one might be a procedure, something like an EMG, and then four follow-up visits.

Work Life Balance as a Neurologist

Dr. Ryan Gray: Do you feel like your work life balance is appropriate? Do you feel like you have enough time for family?

Dr. Allison Gray: To be honest I think I am in a good position compared to other positions that I could be in. I think that where I work there is a real concern and emphasis on creating work life balance, and so there’s for example built in charting time to my day where I have a few minutes to actually catch up between patients. I have some flexibility in setting my schedule. I think that where I am in life is a challenging place. I have a young child at home, and I am a physician so I have a busy and demanding career, and so work life balance is a challenge especially right now, but I think that where I am there is a drive to really try to protect work life balance as much as possible for physicians. And part of that also is the support that I get where I work. I’m lucky enough to have an amazing support staff that helps me in my day, a range of LPNs, and medical assistants, and nurses who really let me do physician work. In other words they try to take as much administrative stuff off of my plate as possible to really let me make decisions that really a physician needs to make.

Dr. Ryan Gray: What traits do you think lead to being a good neurologist?

Dr. Allison Gray: I think to be a good neurologist you have to be a bit cerebral. I think you have to like thinking about things sometimes for long periods of time. So what I’m getting at is in neurology we focus not just on what the problem is and how best to treat it, but where the problem. There’s a concept called localization in neurology where someone will come in with a certain set of symptoms and we need to figure out what part of the nervous system is affected. And so to do that I think that requires some interest in solving a puzzle, and some interest in being a bit cerebral. And on the alternative, or the opposite side of the coin, as a neurologist you really need to be able to sort of dive into action quickly and where that comes in is stroke. And in neurology we talk about this concept of time is brain. So when someone is having an acute stroke you have about four and a half hours to get them to the hospital where they can be a candidate for something called TPA which is a clot buster. So without getting into a lot of detail, the importance here is that you need to be able to act quickly, and jump off your feet, and dive in and try to help people, but also be able to sit back and think about things. So it’s kind of- it demands a bit of both.

Competitive Applicants for Neurology

Dr. Ryan Gray: What makes a competitive applicant for neurology?

Dr. Allison Gray: For neurology, as for most specialties now, it’s important to have good grades in medical school, and that can vary certainly by medical school because some medical schools have pass or fail, but I think a lot have honors or high honors, so certainly getting better grades is a good thing. The other of course importance is getting good board scores. And so your USMLE step 1, step 2 CK, step 2 CS is really more of a formality. But those are all really important. And it also really I think depends in terms of how competitive a program is, it really depends on the geography. It depends on where you are. So neurology as a whole is not as competitive as something like orthopedic surgery, or ophthalmology, or radiology. But when you want to apply to a very competitive program, something at a big name academic center, that will raise the level of competition. So I think to be a competitive candidate you want to have had some experience if you can really shadowing a neurologist if you can. Now neurology at almost every medical school is a requirement for students, and so most everybody will have had a chance to work with a neurologist, but if you haven’t it’s so important that you do find a way to have and participate in a neurology elective. So getting that exposure, that clinical exposure. It’s sort of like when you’re a premed, you need that clinical exposure to show that you have interest in the field. You need the board scores, you need the grades, and I think you need to be a nice person. That’s my personal bias because I think neurologists are a nice group of people. I think it’s an important thing, but that’s probably a lesser point.

Dr. Ryan Gray: Is matching competitive for neurology?

Dr. Allison Gray: It is, again but because of geography. I think again it’s probably somewhere in the middle range. The last time I looked neurology was around as competitive as internal medicine. But what makes it more competitive is if you’re going to go to a very competitive program, something that- a big name institution.

Dr. Ryan Gray: Do you see any bias from your experience between MDs and DOs for neurology?

Dr. Allison Gray: I don’t. I trained mostly with MDs but I certainly don’t appreciate really any bias in my field in that regard. I think there are probably- this could be wrong but I think that there are probably more MD neurologists out there than DOs, but that may be wrong. That may just be because of my experience working with people, and probably more of the neurologists I know happen to be MDs, but no bias that I am aware of.

Dr. Ryan Gray: I think part of that is probably just sheer number of MD graduates and DO graduates as well.

Dr. Allison Gray: That could very well be.

Dr. Ryan Gray: What is residency like for neurology?

Neurology Residency

Dr. Allison Gray: That varies a lot to be honest. When I interviewed I saw a wide range, and in talking with other neurologists in the country I’ve seen a lot of different things. I did my residency at Mass General Hospital in Brigham and Women’s Hospital in Boston so my residency was very volume heavy. I saw a great number of patients and it was very inpatient heavy, meaning that I did a lot of inpatient rotations in stroke, in acute neurology in the neuro ICU, the neuro intensive care unit. There is also certainly outpatient time in every neurology residency, but I think depending on the academic institution where you do your training, you may find that some are more outpatient heavy and some are more inpatient heavy. Mine was a more inpatient heavy, but there are other programs around the country where it’s really- there are no neuro ICUs that you’re exposed to, and more of your neurology training may be primarily in the outpatient setting.

Dr. Ryan Gray: How many years is it?

Dr. Allison Gray: Neurology residency is four years. It’s a year of internal medicine, and then three years of neurology residency. Back in the day, and I don’t know when that is, but years ago you actually had to complete three years of internal medicine and then do a separate neurology residency for three years. Nowadays it’s one year of internal medicine and then you have the three years of neurology afterwards.

Dr. Ryan Gray: What do you wish you knew then going into neurology?

What I Wish I Knew in the Beginning

Dr. Allison Gray: I think I didn’t appreciate that neurology is pretty sad sometimes. I think in medical school and even before medical school, my thinking was that oncology was probably really the most sad if you will of all the specialties out there, and we all know that cancer is very difficult, and it can be devastating, and people can die. And so that was my thought that oncology was really sad, and I think in neurology there is a lot that is really devastating, and even in this day we’re not always great at fixing things. So for example we still don’t have good treatments for Alzheimer’s dementia. We still don’t have good treatments for ALS, Lou Gehrig’s disease. And so you see people in neurology who are faced with very devastating illnesses that are chronic and debilitating and even deathly, and that is I think something that I was aware of but wasn’t quite as aware of as I wish I had been if you will. The other thing that I learned is that neurology is very acutely devastating sometimes, so it’s one of- it’s one area in which someone can go from being happy and fully functional to being very debilitated, and it can happen very quickly, and so stroke for example is an example of that. And some people have very minor strokes and can do very well, and other people have really devastating strokes or bleeding in their head that can be really life-changing or fatal, and helping a family through that process can also be very difficult. I think that neurology has a lot of really great promise and we’re seeing wonderful new therapies come out, and we’re actually starting to be able to really make a difference in people’s lives if you compare twenty years ago and now, there’s a huge difference in how we treat things like Multiple Sclerosis. Even genetic disorders that we’re now finding- that researchers and scientists in the community and in academic centers and in labs are finding treatments for. There’s so much promise coming and already even here in a lot of these very difficult diseases. But there are also a lot of difficult things that we still have trouble with, and that’s a hard thing, and it takes guts and it takes courage sometimes to walk that path with a family and when the patient is really suffering.

Dr. Ryan Gray: What do you wish primary care providers knew about neurology?

Working With Other Specialties

Dr. Allison Gray: That is a hard question to answer, that’s a great question, Ryan. What do primary care- what should they know? I think know that we are here to help. I work in, as I said, a large medical group and so we have primary care physicians who reach out to us all the time and ask for help. I think when I was in private practice maybe I didn’t have that relationship with primary care providers in the community as much, and so maybe- I think that most neurologists are happy to help primary care physicians with some of the problems that come up that we have referred to us. So for example migraines are peripheral neuropathy, these are standard things that come up for a lot of patients out there in the world. And so having- letting primary care physicians know that if they have a question they can call us and ask us for help I think is a great thing to be able to do if you have a question, you’re sitting in the office. Sometimes even rather than sending someone for a consult, you can pick up the phone and call, and I think most of us are happy to help.

Dr. Ryan Gray: What other specialties do you work the closest with?

Dr. Allison Gray: We work with the neurosurgeons, we work with orthopedic surgery who do carpal tunnel release for carpal tunnel syndrome. We work with the spine clinic because we see people who have pinched nerves in their neck or their back, something called Radiculopathy and the spine clinic helps with other treatments for that. We work with physical therapy a lot, a lot, a lot, a lot. There are quite a lot of specialties that we work pretty closely with, and then certainly primary care, but that’s not a specialty I know.

Dr. Ryan Gray: Are there any special opportunities outside of clinical medicine for neurology?

Dr. Allison Gray: I think there are neurologists out there who are working heavily with industry now, and helping to come up with treatments for some of these very difficult neurologic diagnoses that we deal with, for example ALS, or Alzheimer’s, or genetic disorders. There are so many of these that really still need a lot of good treatments, even Huntington’s. And so I think some neurologists are actually going to work industry now which is an interesting road and something that makes a difference for a lot of people, but in a different way than standard clinical practice.

Pros and Cons of Neurology

Dr. Ryan Gray: What do you like the most about being a neurologist?

Dr. Allison Gray: I like the variety. I like seeing a young person with migraine and then an elderly person with Dementia all in the same day. I think that there is just a wonderful variety of problems that affect people that are in the central nervous system, the brain and the spinal cord, and also in the peripheral nervous system, in our nerves and muscles and spinal roots. It’s interesting to be in a field where there are so many different problems that can affect different parts of the body, but that are all sort of if you will part of one system, the nervous system. But I love the variety. I also do enjoy helping people and their families in difficult situations where sometimes there really isn’t a cure and the best thing you can do is to really be there and be supportive. I think that is a challenge but it’s something that I enjoy.

Dr. Ryan Gray: And on the flipside, what do you like the least about being a neurologist?

Dr. Allison Gray: Probably it’s a similar thing which is the difficulty in not being able to offer someone something to fix a problem. So being able to diagnose something, there’s a satisfaction there, but if you can’t offer someone a treatment or much hope for there being a treatment in the next few years, that’s a very difficult thing. And so that’s also something probably that I like the least.

Dr. Ryan Gray: If you had to do it all over again, would you choose neurology?

Dr. Allison Gray: I think I would. As I still people and myself too, I think that the brain is really the most fascinating of anything in the body. It defines us, it defines who we are as people and as human beings, and I find that it’s really interesting when it’s normal and when it’s not. So I think when I think about other organs, and other specialties, there’s nothing that interests me I think as much as neurology.

Dr. Ryan Gray: Another question that I haven’t really asked before, and we’re only three episodes in so I’m still modifying this as we go. As a general neurologist, what sort of specialists, sub-specialists, sub-specialty opportunities are there for neurologists?

Dr. Allison Gray: There are a lot. Neurology is becoming more sub-specialized all the time. Just to name a few there are epileptologists, people who are specialized in seizure disorders, there are neuromuscular specialists, people who are specialized in problems of the muscles and nerves in our bodies. There are behavioral neurologists, people who specialize in dementias and other behavioral problems. There are headache specialists, there are movement disorder specialists who help treat problems like Parkinson’s disease. So there are- and it’s exploding, there are more and more all the time. There are people who are specialized in MS, and neuro immunologic problems.

Dr. Ryan Gray: Sports.

Dr. Allison Gray: Sports medicine and sports neurology, yes people who are specialized in traumatic brain injury. There are people who are specialized even in neuro infectious disease. So it’s really an exciting time to be a neurologists. Because there’s more and more that we’re learning and more and more that we can treat now, there is more and more available for people to specialize in and explore.

The Future of Neurology

Dr. Ryan Gray: What do you see as the future for neurology?

Dr. Allison Gray: So I think that’s a great segue into that question. There is more and more that we’re learning about the nervous system, and how nerves communicate, and how things break down in the nervous system. And we’re being able to better identify targets for therapies that can be used. So for example there are autoimmune conditions where the body produces antibodies that can attack the brain in different places. And for years those probably existed and we couldn’t do anything about them, and in recent years we actually have treatments that can target these problems, and we’re now coming up with- not me particularly but people are coming up with treatments for genetic disorders to fix neurologic problems. So I think the future is just expanding our knowledge of the nervous system and the treatments really because neurology has lagged behind a lot of fields, probably neurology and psychology together have lagged a lot behind other fields in terms of our understanding of the nervous system and the brain, and therefore then being able to target problems that come up in that system. And so I think that in the next twenty years we’re going to see a huge number of new therapies come out that will really make a difference for some of these really debilitating neurologic problems that are afflicting a lot of people in our society.

Words of Wisdom to Premeds Considering Neurology

Dr. Ryan Gray: Any last words of wisdom for those that are thinking about entering neurology?

Dr. Allison Gray: I think being- getting a chance to explore both sides of neurology, inpatient neurology and outpatient neurology, is really important. Because some programs are really inpatient heavy and others might be outpatient heavy, I think it’s really great to be able to even do an away elective. Go to another institution and see what neurology is like there. So really get a chance to see as much as you can because there is such a variety in neurology, and you don’t want to miss out on what you think neurology encapsulates by just seeing a piece of it. It’s a wonderful specialty, and endlessly challenging, and interesting and exciting with so much promise in the future. So I think it’s a really exciting field and really a field that can make a lot of difference for a lot of people in their lives. So I think it’s fabulous if you’re interested, keep up that interest and explore.

Final Thoughts

Dr. Ryan Gray: Alright that was Allison Gray, general neurologist. She also has a sub-specialty in TBI, traumatic brain injury, though we didn’t cover that today. I wanted to hit the general neurology topic for you. If you are a listener of The Premed Years Podcast you would recognize Allison, she’s often on there, she is obviously my wife and a frequent guest on The Premed Years. So thank you to Allison for joining me here on the Specialty Stories Podcast to share what a neurologist is, and what a neurologist does, and what you the premed and medical student should be thinking about as you go on this journey into neurology if that’s something you are interested in.

I look forward to your feedback. If there are any questions that you think I should be adding, anything I should dive deeper into. I do like to keep this podcast more formal than my Premed Years if you listen to that one, because I want students to be able to compare episode to episode, and I don’t want to dive too far into different tangents and discussing cool things, although I want to every time but I’m trying to keep to specific questions that you can compare easily as you move forward and you’re going through this journey trying to figure out what you want to do. So if there are any questions you think I should be adding, please let me know. Shoot me an email, Ryan@medicalschoolhq.net. I would love for you to share this podcast with your friends, and family, and premed advisors, and fellow medical students. Share it on Twitter, and Instagram, and Snapchat, whatever you cool kids are doing these days, and yeah if you would like to leave us a review in iTunes I’ll take one of those as well.

This is the third episode of the Specialty Stories Podcast, the last episode of 2016. I hope you have a happy and safe holidays, and we will see you next year here at the Specialty Stories Podcast and Med Ed Media. Remember this podcast is part of the Med Ed Media network. You can see everything and hear everything that we’re doing over at www.MedEdMedia.com. Have a great week.

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