Pursuing Passion in Neurology—A Residency Director Weighs In

Session 128

Dr. Danny Bega is the Director of the Neurology Residency Program at Northwestern Medicine. Today, he shares his experiences as a Movement Disorder specialist. If you haven’t yet, please share this podcast along with other podcasts on Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:24] Interest in Neurology and Movement Disorder

Danny loves the aspect of patient interaction in neuroanatomy. He found neurology was such a good fit. Shortly after their electives when he saw videos on Parkinson’s disease and movement disorder, he was just amazed by how the right therapy could make significant changes in just a short period of time.

Eventually, he wanted the role of a primary care doctor and the longevity of care involved. He loved the idea of dealing multiple areas of their quality-of-life-related issues. But he didn’t want to know everything about everything like a primary care doctor has to do.

He wanted to specialize in some subset of problems. For instance, you’ll be knowing Parkinson’s disease patients really well for a longer period of time. But you’re also dealing with more than just the tremors as you have to address other things like anxiety, depression, and cognitive issues.

'You become their primary care doctor for a patient but you get to focus a bit more.'Click To Tweet

[04:10] The Biggest Myths Around the Specialty

In neurology, the most common misconception people have is the difficulty in dealing with issues you can’t treat and that you can’t do anything for people. But people realize that pretty quickly.

If you’re managing someone’s high blood pressure, you’re not curing it, but only managing it. They do the same thing. They don’t cure patients of their Parkinson’s but they manage it. They make their daily quality of life better and they reduce morbidities.

'The research happening in neurology today, as well as the neurosciences, is far and above every other field.'Click To Tweet

[06:30] Traits of Being a Good Movement Disorder Specialist

You have to have that sense of wanting to be a primary care provider for your patients. Realize it’s not just going to be focused on handling the movement disorder.

The movement disorder part is fun and that’s what draws Danny into this field. It’s very visual which a lot of people enjoy. But the majority of their time is spent on managing anxiety, depression, cognitive issues, urinary issues, autonomic instability, social work issues, etc.

'The day-to-day management is much beyond the movement disorder.'Click To Tweet

A big part of the academic side is clinical trials. You really can’t do movement disorders in an academic setting without being involved and participating in clinical trials. There is so much happening with new development in movement disorders.

[07:55] Types of Patients and a Typical Week

Danny handles two rare diseases that he gets to see a lot because he’s running both clinics. These issues involve genetic conditions and Reiter conditions that can affect whole families.

He gets to do different procedures per day. They do some procedures for patients with dystonia as well as botulinum toxin injections. They may also do deep brain stimulation for Parkinson’s disease or central tremor where they program the brain stimulators. Ataxia is another deep disorder that they handle.

'There's a lot of movement disorders that you'll see even in one day.'Click To Tweet

A typical week for Danny is different every day. He spends half of his week in the clinic seeing patients. The other half of his week is split between doing administrative stuff for residency or teaching and clinical trials.

[10:32] Percentage of Diagnosed vs Undiagnosed Symptoms

About 75% of his patients are either coming for a second opinion or to establish care for a diagnosis that someone else suspected or was already given to them. While about 25% are coming for their first evaluation of new symptoms.

Most of them are coming to establish care. It’s rare that he sees patients only once and doesn’t see them again.

[11:13] Taking Calls

It’s very rare for them to get emergency calls. So it’s really rare that he gets paged at night or on a weekend. If they do get calls on a weekend, it would only be as minor as a prescription refill. He also does a general neurology consult service a few times a year, usually a week at a time up to 3-4 times a year.

'Most of the things can wait until Monday during work hours to deal with because they're usually not urgent issues.'Click To Tweet

[12:12] The Training Path

For neurology, you do one year of internal medicine and then three years of neurology. Following this, you do a fellowship. Depending on what you’re interested in, there’s something for everybody in neurology.

'There are a lot of fellowship opportunities in Neurology. It's one of the great things about the field.'Click To Tweet

Some examples of subspecialties include neurocritical care, stroke, movement disorders, and procedural fields like neuromuscular and EMG.

Movement disorder involves one or two-year fellowship done after residency. One year is like a clinical movement disorder fellowship.

Danny did two years, one year was a standard clinical fellowship and the second year was incorporated with a master’s in science and clinical investigation. This gave him more expertise in running clinical trials. Some people do the second year to gain more expertise in deep brain stimulation. So it depends on what you really want.

These aren’t ACGME-accredited fellowships so there’s a lot more flexibility in what you can do in terms of how the fellowship can be shaped. This is actually true for many fellowships.

[14:00] How to Be Competitive for Residency

They look at the application as a whole including performance on clerkships. They also look at letters of recommendation and the AOA, research, etc. There isn’t one thing required of any particular applicant.

'We don't expect that every applicant has published 10 papers. It's more about finding consistency with your goals and what you've done.'Click To Tweet

If you come in saying you really want to have a research-focused career and apply for all these grants, it’s important to see you’ve done some research in medical school or some type of interest to back it up.

If you’re coming in saying you want to be a medical educator, it’s much less important for them to see that you’ve got research. What’s more important is you’ve shown some initiative with regard to medical education.

They’re looking for people with diverse backgrounds. They realize that people have different strengths. So it’s never a bad idea to reach out whether through email and tell them about your interest. Or attend some meetings like the American Academy of Neurology meeting to reach out and talk about your interest.

All this being said, there’s not a one-size-fits-all applicant. To them, it’s important to find people with different strengths and show consistency in their application. Moreover, they also try to assess red flags and make sure they’re clear on what those were all about and why they had those issues.

In terms of the potential of Step 1 going pass/fail, Danny personally thinks it wouldn’t affect the application unless someone has a really stand-out strong score or fail. Most people are within a big range and they don’t rank them based on it.

[18:05] Message for DO Applicants

It’s important for your program to represent what they offer. They really look at the reputation of the program. They think those programs can help sell those students a bit by making sure they know about those programs.

There are a lot of DO programs out there and they start to make them feel more comfortable by inviting programs that they have heard of or know of. So it’s important those programs reach out to them as well.

[19:12] Working with Primary Care Physicians

There’s a lot of overlap in the management of patients. They both deal a lot with psychiatric and social issues as well as autonomic function, and blood pressure issues. Therefore, a good collaboration is very important.

For Danny, the skill of the primary care doctor doesn’t matter to him as much as their accessibility to him. If they can communicate easily through a charting system or phone call, as long as they can see one another and coordinate their care, this makes it so much easier for patients. And that’s most important.

'We're both dealing with pretty broad areas of the patient's day-to-day life so we have to make sure we're working together and collaborating.'Click To Tweet

[20:25] What He Wished He Knew and The Most & Least Liked Things

Initially, Danny didn’t realize how critical the relationship would be with family members of the patients and how important other staff members are. They rely on a lot of different people to manage even the simplest problems.

'We can't do it all as neurologists. Having a good supporting staff makes such a big difference.'Click To Tweet

Moreover, you have to be patient with how long treatments can work. While there’s so much happening, there are also a lot of failures in the research for some of these diseases. It takes a long time for studies to happen and to be completed.

He didn’t realize going into this field that you’d also become the diagnostic tool yourself when it comes to movement disorder. They order lab tests but movement disorder is a visual field. You diagnose patients based on your own expertise and pattern recognition. It’s rare that they rely on imaging, for instance, to make a diagnosis.

“You start to become your expertise. The more familiar you become and the more you see, you become more expert and you become a better tool yourself in making the diagnosis.”Click To Tweet

Patients come to see Danny so he can see them and make the diagnosis. Because there’s no better tool than an expert clinician judgment in movement disorders. So this makes you indispensable and the key part of the evaluation. And this is what he really likes about his field.

On the flip side, what he likes the least is the social and nonmotor related things that are really difficult to manage. For example, the really advanced dementia patients who are relying a lot on supportive care are really difficult to manage. Some of the motor issues like autonomic instability can be very difficult to manage as well. So there are symptoms that Danny just finds much more challenging to treat.

[23:50] Major Future Changes in the Field

Currently, they’re involved in about 20 different clinical trials for movement disorders, many of which are on modifying treatments. They’re very hopeful that there’s something to slow down and beat progression in these different diseases.

'There's a lot of hope. There's a lot of trials happening right now.'Click To Tweet

[25:05] Final Words of Wisdom

If he had to do it all over again, Danny would still have chosen the same specialty. It’s a field where you’re always excited to see the next patient and the next video. Everybody will look different and everything is an opportunity to learn more.

Finally, he encourages premed students, medical students, and residents to follow your passion to what gets you excited. You can make any field in medicine what you want it to be.

'Find out first what excites you and then worry about the details and the specifics of the lifestyle and salary. You'll be happier if you follow your passion and interest.'Click To Tweet

If you find yourself excited about neuroanatomy, give neurology a chance. Within neurology, there are so many different kinds of lifestyle and career tracks. There’s so much variability but this is something you figure out later.

That being said, follow that passion. Talk to as many people in the field. Get a lot of input from people in different stages of their careers.