Neurological examination
HealthApril 06, 2020

5 questions to ask yourself if you're considering specializing in neurology

By: Heidi Moawad, MD

During rotations, you've probably seen at least a few patients with neurological emergencies like strokes and seizures as well as patients who present with confounding neurological complaints such as episodic speech deficits. If these experiences have piqued your interest in specializing in neurology, it's time explore in earnest what it takes to become a neurologist.

First make sure you know the basics. Neurology is a clinical specialty with a four-year residency-training program. Many neurologists then go on to a clinical fellowship or a postdoctorate research fellowship. Neurologists take care of patients in the outpatient setting, in the hospital and in the intensive care unit. Many neurologists also conduct clinical or basic science research alongside patient care.

To dig deeper into whether specializing in neurology is right for you, consider how well the specialty fits with your strengths and interests. Start by asking yourself the following five questions.

1. Do you love teaching and learning?

Neurology is often stereotyped as a specialty that appeals to doctors who are intellectual. It's true: Intellectual pursuits are central to neurology, and neurologists never stop learning. The process of putting together seemingly unrelated physical findings to locate a lesion and make a diagnostic and treatment plan is a cerebral one. Becoming a neurologist means you appreciate that diagnostic tests provide answers to only some questions and that it takes a meticulous physician to put the results into perspective. This requires constant learning and improving.

In neurology, learning goes hand in hand with teaching; neurologists are always called on to teach. According to a 2018 article published in the Neurologist, this begins during residency, when neurology residents are expected to help medical students learn to recognize neurological emergencies that can be subtle but which require immediate attention and action.

2. Are you comfortable with ethical dilemmas?

Patients who need to see a neurologist often have some level of disability while also usually maintaining a fairly good level of ability, a situation that can set the stage for ethical dilemmas. Ethical questions are an inherent part of neurology patient care, and a neurologist can't get flustered over them.

Being comfortable handling ethical issues requires empathy and an acceptance of the harsh reality that life isn't fair. For example, as one Continuum article discusses, the neurological examination can uncover asymptomatic vision loss, which then necessitates a serious, potentially painful conversation about driving. As a neurologist, you'll have to weigh the comfort and day-to-day happiness of your patient with their own safety and the safety of everyone else on the road. You have to do this while being mindful of your patient's emotional needs and possibly holding their hand if they cry over the gut-wrenching realization that their health is limiting their freedom.

3. Are you able to deal with uncertainty?

As you've probably realized, patients and their neurological illnesses don't fit neatly into the disease descriptions in your medical textbook. A neurological diagnosis can take time.

As a neurologist, you'll initiate treatment as you carefully track symptoms to determine whether your patient has multiple sclerosis or whether something else is causing their subcortical lesions. You have to manage this process while reassuring your patient that the uncertainty will eventually be settled. If you can handle this uncertainty and use it as motivation to bring about the best outcome for your patients, then neurology might be right for you.

4. Can you interact with patients at their worst?

If you become a neurologist, some of your patients will tell you that they hate you. That's a tough pill for any doctor to swallow. But confusion and irrational behavior are often part of neurological disease, and as a patient's mental status fluctuates with illness and treatment, moods and cognition can change and may include violent outbursts. Neurologists surveyed for a paper published in the Neurologist said that disruptive behavior, threatening actions and ongoing disagreements about the plan of care had pushed them to terminate the patient relationship.

It takes a confident physician to withstand these emotional fluctuations. In fact, I remember feeling elated when a patient told me that I was the best neurologist who ever took care of him, insisting that I was even better than some pretty prominent doctors. It didn't take long for him to change his tune when he developed a fever and his inflammatory brain lesions grew. I was swiftly demoted to the worst doctor ever. You need to be able to not take things personally if you're interested in specializing in neurology.

5. Can you value incremental improvements in patient quality of life?

It's true that many neurological conditions are not curable. But a patient whose Parkinson's disease is managed can feel better and do more enjoyable activities when the disease isn't left to run the show. A patient with migraines may have more peaceful relationships and can be more confident and productive at work when their symptoms are well controlled. And a patient with good seizure control might be able to socialize without worrying about having a seizure at a party.

None of these examples are cures. And each of these patients feels the impact of their disease and has to make constant life adjustments to maintain optimal results. But if you're thinking about becoming a neurologist, you have to be able to appreciate these outcomes as true victories because, even if things aren't completely perfect, they help people live their best lives.

Heidi Moawad, MD