A General Pediatric Neurologist Discusses Her Specialty

Session 41

Dr. Denia Ramirez is a general academic pediatric neurologist. Today she talks with us about her journey to becoming a pediatric neurologist and other things about her specialty.

Several weeks ago, we had a pediatric neurologist on who specializes in headache medicine. But this week we have Dr. Ramirez, who has been out in practice for five and a half years now after her residency in pediatric neurology. She’s in a combined academic and community setting at the University of Tennessee Medical Center (UTMC).

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

[01:33] Her Interest in Pediatric Neurology

When Dr. Ramirez did her pediatric residency in Costa Rica, she was amazed by how a child achieves various milestones. She got interested in how children change. She was interested by how they can shift from being so little and happy to being somebody who’s completely opposed to strangers at eight or nine months old.

Denia’s father-in-law was also a neurologist. So when she met her husband, she got to see more of what a neurologist is like, not only inside but also outside of clinical settings. This is basically what sparked her interest in neurology.

Other specialties that piqued her interest included emergency medicine. But she realized the demands and the amount of time she was going to be out of her home if she decided to go that route was probably too much for her.

[Related episode: Why Do You Want to Be a Doctor?]

[03:20] Traits that Make a Great Pediatric Neurologist

First of all, you have to like kids. And you have to know your neuroanatomy. You have to know your localization well and learn the process in which we’re taught to think to try to reach a diagnosis.

'You have to like it. You have to be dedicated.' These sayings hold true for any single subspecialty.Click To Tweet

For Denia, one of the most wonderful things is that when she’s in the clinic, she’s essentially being paid to play with kids. She loves what she does, and she loves talking to kids. She loves talking to parents, too. So that makes her job much easier.

When she's in the clinic, she's essentially being paid to play with kids.Click To Tweet

[04:40] Types of Patients You See as a Pediatric Neurologist

In terms of the cases you see as a pediatric neurologist, Denia says she sees almost anything. She gets kids with epilepsy, and she helps walk them through the process until they outgrow it. She also sees kids with severe brain lesions or genetic epilepsies. They also see kids with headaches. And there are a lot of very normal kids who had one or two febrile seizures and parents are understandably worried about what that means.

They also see kids with developmental delay, learning problems, or kids struggling in school. Parents want to make sure that their child’s struggles in school are not caused by something bigger that needs to be treated. They see kids with neurodegenerative diseases, kids with difficulty walking, and so much more.

Pediatric Neurology Is a Small Field

Because of how small the field of pediatric neurology is, they’re all very open and supportive of each other. Also, because the field is so small, they don’t always have the luxury of sending their patients to specialists.

You might want to send the kids with movement disorders to be seen by a movement disorder specialist, for example. But in reality, what you do is reach out for a subspecialist to help while you continue to take care of them yourself.

The nice thing about pediatric neurology is that it's a relatively small field. There's not a lot of us.Click To Tweet

[07:00] Generalist vs. Subspecialty

Denia explains why she chose to generalize instead of subspecializing. First, she has already done her residency training once back home and she’d have to repeat it to subspecialize. She felt she was at a point where she really needed to get practicing as an attending.

Additionally, she likes the idea that she gets to have all sorts of patients as a generalist. She doesn’t want to see the same thing over and over as a specialist. She likes that she can see almost anything as a generalist.

'The diversity of patients continues to be good stimulation for my knowledge and my ongoing learning.'Click To Tweet

The Lifestyle of a Pediatric Neurologist: A Day in the Life

A typical day for Denia starts with doing rounds. They don’t have admitting services, but they have consulting services. For the most part, she sees patients at East Tennessee Children’s Hospital, not affiliated with UTMC.

Then she holds clinic between 10 and 11 am. She does reading and goes through a couple of journals to see if there is anything new that can contribute to her knowledge. Then in the afternoon, she sees patients. At the end of the day, she normally checks the charts for the next day. She finishes her notes and then her day is over.

About 50% of her time is spent doing clinics and another 50% is doing rounds. Half of her time is spent in the hospital. Some days, if they don’t have any consults, she spends mornings catching up with any work that isn’t done. She’d call patients and see them in the afternoon.

During the week that you're on call, you have to be available for your residents 24/7 for the entire week.Click To Tweet

In terms of taking call, she makes herself available when it’s needed. At the University of Virginia where she was working recently, they’d do one week of call. Some of them did more weeks of the year, some did less. During the week that you’re on call, you have to be available for your residents 24/7 for the entire week.

Denia says having good work-life balance takes being organized. As long as you keep your priorities, you can do it. Denia still gets to cook every day and go out on weekends. They don’t have kids, but if she did, she thinks she’d be able to do things with her children.

[12:14] The Residency Path of a Pediatric Neurologist

The usual path for pediatric neurology residency includes two years of pediatrics and three years of neurology. In those three years of neurology, you do a year of adult neurology and then the last two years are allocated for pediatric neurology. So it’s five years in total.

The usual path for pediatric neurology residency includes two years of pediatrics and three years of neurology.Click To Tweet

But some people join a pediatric neurology program after they’ve already done a full pediatrics residency. So they’ve already finished three years of pediatrics, and then they do three years of neurology.

Another path available to some is where you do a year of internal medicine, a year of pediatrics, and then the three years of neurology. There are also some residents who start as adult neurologists and really like pediatric neurology. For them to be eligible to become pediatric neurologists, they’re required to do an extra year of pediatrics aside from the year of internal medicine they’ve already done. Then they have to do a year of pediatric neurology. So this path is a little bit longer.

Nowadays, most programs have a five-year path. When Denia started, there weren’t that many programs that would give two years of pediatrics and three of pediatric neurology. You had to go into two different programs. Some pediatric programs didn’t like it because they were losing a resident to pediatric neurology. But most programs now have the option to do five years as a pediatric neurology resident.

Dual Certification in Pediatrics and Pediatric Neurology

You can be dual certified in pediatrics and pediatric neurology if you do two years of pediatrics and three neurology years. But you have to make sure you meet the criteria that the AAP has established to be able to sit for the peds boards. The reason people like to be dual certified is that they still like to be able to do pediatrics.

Some stand-alone children's hospitals might want you to be dual certified in pediatrics and pediatric neurology.Click To Tweet

Supposedly most people who get dual certified do not end up not using their pediatrics license. Many of those who get dual certified do not go on to sit for re-certification. Unless you’re using it on a daily basis, you’re not going to want to study for the test.

[16:51] Is Matching into Pediatric Neurology Competitive?

Pediatric neurology is a well-kept secret. That could be because the five-year training may seem long to some people. So if you want to get into pediatric neurology, you can get into a very good program with good letters of recommendation. Overall, pediatric neurology is competitive, but not to the point where there are 500 people fighting over one spot.

[18:10] Bias Against DOs in Pediatric Neurology?

When looking at the field of pediatric neurology, Denia hasn’t seen any bias against DOs. If you’re good, you’re good. They don’t care if you’re a DO or MD.

There's no bias. If you're good, you're good. We don't care if you're a DO or MD.Click To Tweet

Subspecialties Within Pediatric Neurology

Once you’re a pediatric neurologist, there are other opportunities that you can specialize in. These include movement disorder, neuron EQ, neuropedic critical care, pediatric neuromuscular, neuroimmunology, epilepsy and neurophysiology, neurodegenerative diseases and white matter diseases, and mitochondrial and genetic diseases.

When she was interviewing and trying to make her decisions as to what she wanted to do, her mentor gave her this advice: “Once you’re done with residency, you essentially can do whatever it is that you want to do.”

Once you're done with residency in pediatric neurology, you essentially can do whatever it is that you want to do.Click To Tweet

And her mentor was right. He also told her she can go wherever she wants, location-wise, since she’s needed everywhere. And Denia thinks he’s been right about that, too. She has a lot of friends in the field who have gone through different paths, and they’re equally successful. It’s a field that is very supportive and has a lot of opportunities.

[21:35] Working with Primary Care & Other Specialties

Primary care doctors could be of help to pediatric neurologists by knowing a bit more about headaches and seizures. Pediatric neurologists end up seeing a lot of children with headaches who could be handled at the primary care level. Another thing is knowing when you refer a child for seizures versus when you use your skills to reassure the parents that those are not of concern?

Ultimately, Denia’s advice for primary care docs seeing these patients is that when you’re in doubt, grab the phone and call up a pediatric neurologist. They’re always available. Don’t order tests if you’re worried that you won’t know how to interpret the test results. You’re opening up a can of worms for you and for that family.

Other specialties she works the closest with include developmental peds, genetics, NICU, and PM&R.

Non-Clinical Opportunities for Pediatric Neurologists

In terms of opportunities outside of clinical medicine, there are people doing outreach and volunteer work. In the next five to ten years, telemedicine will likely be one of the fields to develop in neurology. This gives you the opportunity to see patients on different schedules. This would be great for parents who want to stay longer at home. Or for those who don’t do well being in an office for a certain amount of time.

Pediatric neurologists also have opportunities to work for federal agencies such as the FDA. An ongoing discussion within the field is how they can diversify as child neurologists in the way that other specialties have.

[25:35] What She Wished She Knew about Pediatric Neurology

Denia wished she knew how much the medical field was going to change. That would have helped her anticipate some of the things that came as a surprise. For example, consider the way we measure our productivity and how that’s changing with technology. This not only touches pediatric neurology but medicine as a whole.

She also wishes she would have taken a little bit more time to do all the things she wanted to do before going to medical school. So she tries to pass this onto her students and to the residents.

You need to take time for yourself. It's okay to take breaks.Click To Tweet

The Pros and Cons of Pediatric Neurology

What she likes the most about her specialty is working with the kids. It’s fulfilling to see how kids don’t feel well and then to help them start to recover. Knowing you’ve helped and made a difference in their life is gratifying. What is equally gratifying for her is to see how kids, in the midst of difficulties, continue to push. They’re fighters. It’s amazing to see how they never give up.

'It's amazing how they never give up. Kids never give up. And that is extremely touching.'Click To Tweet

The hardest part of being a pediatric neurologist is delivering bad news. You’re going to have to walk the parents through the process of thinking that their child’s life is going to look different than what they envisioned. But you’re also there to support them and let them know that it’s going to be okay.

The one field she doesn’t particularly enjoy is neuro-oncology. So she tries to stay away from it as much as she can. But if she had to do it all over again, she would still choose pediatric neurology.

If she had to do it all over again, she would still choose pediatric neurology.Click To Tweet

[Related episode: Delivering Bad News Is an Art.]

[29:40] Denia’s Advice for Premeds and Med Students

Grab every opportunity you have to observe and shadow someone in the community. Don’t just always go into the hospital. It has the most extreme cases, and it’s not going to give you a good idea or a real perspective of what child neurology is and has for you.

Try to get a good perspective of what the field has for you because it's broad.Click To Tweet

For medical students: If you’re doing a pediatric neurology rotation, make sure you don’t stick to just inpatient settings. Make sure you also do some outpatient. If you have an interesting patient as an inpatient, talk to your attending physician about getting involved with their outpatient care.

Make sure you express your interest in the field and make it known that you’re ready to get involved. Take as much as you can from your rotations.