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Thursday, June 6th, 2013
Carrying a black medical bag filled with tools—hammers, tuning forks and safety pins among them—the osteopathic neurologist enters the examination room prepared to spend a half-hour or more with the new patient. She takes a complete history and performs a thorough physical examination, using her palpatory diagnosis skills. Because the patient has partial lower-extremity numbness, she removes a tuning fork from her bag.
Striking the tuning fork with her hand, she places it on one of the patient’s big toes and asks if he feels the vibrations. “Tell me when it stops,” she says.
Then she places the vibrating tool against the patient’s ankle. “Can you still feel it? Tell me when it stops,” she says. Next, she places the tool on his knee. “Can you still feel it?” she asks again.
Neurologist Wynde K. Cheek, DO, of Helena, Mont., frequently performs this and other neurological tests to arrive at an accurate diagnosis. Loss of a sense of vibration would be an indicator of peripheral neuropathy, she says. But many different neurological disorders and conditions have similar presentations.
A member of the Board of Governors of the American College of Osteopathic Neurologists and Psychiatrists, Dr. Cheek emphasizes the joy she and other neurologists derive from their profession. Neurology combines the cognitive challenges of diagnosing difficult-to-distinguish disorders with the satisfaction that comes from establishing close, often long-term relationships with patients.
“When I did my first neurology rotation as a student, I absolutely fell in love with the whole concept of how the brain controls the body,” says Anne M. Pawlak, DO, who directs the AOA-approved neurology residency at Garden City (Mich.) Hospital.
“I really enjoy the specialty because I find it intellectually stimulating. I like solving puzzles,” adds Kristi Gill, DO, a chief resident in the AOA-approved neurology program at Botsford Hospital in Farmington Hills, Mich.
Neurology, which attracts a large number of women, is also known for having reasonable work hours. “Although you do have call, the hours are fairly compatible with having a good family life,” Dr. Gill says.
In addition, the demand for neurologists is growing, as baby boomers age and develop more neurological conditions, such as strokes, Alzheimer’s disease and Parkinson’s disease. “There are a lot of jobs out there for neurologists. That’s another reason I went into the specialty,” Dr. Gill says.
Yet in the osteopathic medical profession, neurology remains less popular than a number of other specialties. While a few are competitive, not all of the nine AOA-approved neurology residencies fill.
Fewer medical students are attracted to neurology than to other specialties in part because of the outdated assumption that neurologists simply diagnose disease without being able to offer treatments.
When Dr. Pawlak trained in neurology at Botsford in the early 1980s, neurologists did diagnose many disorders for which they could provide patients only compassion and palliative care. Although the prognosis is still bleak for those suffering from amyotrophic lateral scleroris and Huntington’s disease, for instance, many breakthroughs have occurred during the past three decades.
Progress has been made in addressing multiple sclerosis, for example. “When I started practice, I had to tell MS patients that there was nothing I could do for them,” Dr. Pawlak remembers. “One case that sticks in my heart was a young basketball player who had signed with the Detroit Pistons. The day after he got his offer, he came to see me and I diagnosed his MS. There was nothing I could do to treat him. He had an aggressive form of the disease. Soon he was in a wheelchair, and he died within a couple of years.
“If that young man had been living today, he likely would be on the basketball court.” A couple of oral medications recently approved by the U.S. Food and Drug Administration, as well as several injectable ones, slow the progression of MS and reduce inflammation.
In addition, neurologists today have many interventions at their disposal for treating epilepsy, stroke, movement disorders, sleep disorders and pain, notes J. Mark Bailey, DO, PhD, an associate professor of neurology at the University of Alabama School of Medicine in Birmingham.
Med students’ relative lack of familiarity with neurology also explains why it isn’t one of the top-drawing specialties. “The nervous system is looked at later in the curriculum,” Dr. Cheek says. “By then, students are fatigued from all the other systems they’ve gone through. We also don’t spend as much time on the nervous system, which has completely different terminology that can be intimidating.
“Students either get neuroscience, or they don’t. They either love it or hate it.” At most osteopathic medical schools, moreover, neurology is an elective rotation during the clinical years rather than a requirement, which minimizes students’ exposure to the specialty.
Neurologists also make less money than many other medical specialists, ranking 18th from the top, according to a 2012 Medscape survey. Neurologists earn an average income of $217,000 a year, states Medscape’s 2013 Neurologist Compensation Report. More than 20% bring in at least $300,000 a year, while approximately 15% earn $100,000 a year or less.
Neurology residencies are four-year programs, including an internship year. Students typically match from their fourth year of medical school, but some AOA-approved programs accept candidates from traditional rotating internships.
Because of the increasing number of DO graduates and the electronic application process, all AOA-approved residency programs, including neurology, have become more competitive. Even though neurology is far from being the most popular field, some institutions are having trouble accommodating students who want to serve neurology rotations.
“We’re having a huge scheduling issue trying to fit in all of the students who want to check out our program,” says Botsford’s Dr. Gill.
The neurology residency program in Erie, Pa., affiliated with the Lake Erie College of Osteopathic Medicine draws roughly 30 applicants for two or three openings a year, says director Jeffrey J. Esper, DO.
This is the 14th in a series of articles profiling medical specialties. The others focused on the following specialties:
Dr. Esper requires all serious candidates to have at least a B average in their med school coursework, with a high score in anatomy. In addition, they must have passed the first two steps of the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA). But he doesn’t limit his selection to those above a certain score or percentile.
“I would rather take someone in the 79th percentile who has good interpersonal skills as well as an aptitude for neurology than someone above the 90th percentile who is difficult to work with,” Dr. Esper says.
In 2011, osteopathic medical students who matched into neurology as their first-choice specialty scored an average of 472 on COMLEX-USA Level 1 and 493 on Level 2, according to the Osteopathic GME Match Report—For the 2011 Match, published by the American Association of Colleges of Osteopathic Medicine (AACOM).
Most AOA-approved neurology residencies strongly favor applicants who have served rotations in their programs.
Osteopathic medical students who are interested in the neurology residency at Grandview Medical Center in Dayton, Ohio, typically serve a month-long rotation in their third year and an audition rotation in their fourth year, says residency director Michael J. Valle, DO.
“We look for people who have a passion for the specialty,” Dr. Valle says.
Dr. Esper also prefers applicants who have impressed him on their rotations. “If a person has rotated through our service and has shown that he or she is easy to get along with, willing to learn and has an aptitude for the subject, that would give the individual an advantage in terms of getting an interview,” he says. “We look for people who have done well in anatomy, who enjoy doing the physical examination and who are able to correlate their findings with their knowledge of neuroanatomy.”
Excellent communication skills are a must for anyone considering neurology. Neurologists need to be able to elicit thorough patient histories, explain complex conditions to patients and caregivers, deliver dismal or uncertain prognoses with great sensitivity, and interact with many other specialists and primary care physicians.
“Because neurologists do often make devastating diagnoses, how you communicate with patients and their families is of paramount importance,” Dr. Cheek says. “You also have to enjoy educating others because most people don’t understand neuroscience, including patients, loved ones and other physicians.”
Analytical abilities and tenacity are critical, says Garden City’s Dr. Pawlak. Neurologists need a strong general understanding of medicine and must be able to identify underlying causes of neurological presentations.
“Although you do have call, the hours are fairly compatible with having a good family life.”
“You have to like being a detective to be a good neurology candidate,” Dr. Pawlak says. “On a lot of occasions, for example, I’ve been the physician who has detected a patient’s cancer because he or she had numb feet. The nervous system responds to changes in a patient’s body chemistry, and these changes can affect the most distant nerves.”
“Students interested in neurology need to be good at figuring things out and understanding what’s going on beyond the immediately obvious presentation,” Dr. Bailey agrees.
Neurologists also need a great deal of empathy when counseling patients and their caregivers, a trait Dr. Pawlak looks for in candidates. She recalls treating an Alzheimer’s patient who for some reason became agitated whenever his family dined with him in his care facility. Dr. Pawlak helped family members figure out that their father became upset because he had been used to picking up the check when he treated his family to a restaurant meal. He simply needed to be given a slip of paper by the dining room food server to feel calm and in control.
A residency candidate herself just a few years ago, Dr. Gill notes that osteopathic neurology programs take into account the whole person when assessing applicants. “Academic success is important,” she says, “but all of the programs place a huge emphasis on whether candidates are easy to work with, whether they interact well with others, and whether they have the aptitude to sort through a complex array of symptoms to find out what is really going on with the patient.”
To shine on their neurology rotations, students need to interact exceptionally well with patients, take complete histories, be reliable, show initiative, do a lot of reading in the neurosciences, ask probing questions and be engaging with attending physicians, residents and staff, Dr. Gill says.
In addition, relevant research, work and volunteer experiences bolster an applicant’s chances of matching into a neurology program. AACOM’s 2011 match report shows that those matching into neurology as their first-choice specialty had more research experiences than those going into any other specialty.
In many specialties, the physical examination has fallen by the wayside, with physicians ordering a plethora of diagnostic tests. Neurology programs, in comparison, stress the importance of the physical exam. In this regard, DO residents’ training in palpatory diagnosis gives them an advantage over their allopathic counterparts, Dr. Esper says.
In his program, Dr. Esper emphasizes history-taking and physical exam skills. “You get about 85% of the answer as to what’s going on with your patient just by the history and physical,” he says. “Then you order the test to help confirm what you clinically suspect.”
Osteopathic in their whole-patient approach, AOA-approved neurology residencies also incorporate osteopathic manipulative treatment. When time permits, residents use OMT to help patients who have migraines, musculoskeletal pain and other problems.
AOA-approved programs are also known for producing general neurologists who can practice independently, Dr. Valle points out. Neurology programs accredited by the Accreditation Council for Graduate Medical Education, in contrast, tend to prepare residents for specific subspecialty fellowships, he says.
“Our residents have the ability to do their own electrodiagnostic studies and interpret them and manage a whole spectrum of neurologic disease,” Dr. Valle says. Many of his former residents, including Dr. Cheek, are practicing general neurology in small cities and medium-sized towns throughout the U.S.
“You need about 100,000 people to keep one neurologist busy,” Dr. Valle says.
But more and more DO neurologists are pursuing fellowships in such subspecialties as stroke, sleep medicine, movement disorders, seizure disorders and pain management.
A pain management specialist, Dr. Bailey spearheaded the development of a new certificate of added qualification in pain management for AOA-board-certified neurologists. The first examination will be offered in July.
Neurologists have numerous practice options. Some go into solo practice, some join small groups, and others are employed by large hospital systems. Neurologists may work as hospitalists, see only outpatients, or have a combined inpatient and outpatient practice. And many neurologists, like Dr. Bailey, enter academia.
Dr. Gill will start her practice life as an employee of a hospital system in northern Arizona. “I’m going to a smaller community where I’ll be the only neurologist for several miles around,” she says. She will work both in an outpatient clinic and in a 44-bed hospital.
Wherever they practice, neurologists find tremendous excitement in what they do, Dr. Cheek says.
“To be in neurology, you need a pure sense of curiosity about the unknown,” she observes. “It’s kind of like deep space. There is just so much still to explore.”