What's it like to be a Neurologist?

December 15, 2012 12:53 PM

You are a neurologist/know a neurologist/have seen a neurologist/have read really good books with neurologists in them. I want to know everything you can tell me about what it's like a on day to day basis to be a neurologist.

What do you see most often? I hear that migraines are the bread and butter of neurologists...true? I've also heard that it's pretty hard to be a neurologist in private practice, and most work within hospitals...true? What's it like being this kind of specialist in a larger hospital v. being in private practice. What are your hours like? Any anecdotes about (obviously anon.) patients are welcome too.
I'm also interested in what it's like to visit a neurologist. Every detail is helpful, from how long you had to wait to their mannerisms to how they arrived at your diagnosis (if you're willing to share!). For whatever reason, I've been able to find and read several great memoirs (and the novel Saturday) about neurosurgeons, but only Oliver Sacks-like case studies of patients seem to be available that involve neurologists. These are great, but I'd like to hear more day-to-day details about what it means to be in this profession.

I'm writing a book with a main character is a neurologist. I've been doing my research, but would love to hear what the hive has to say.

posted by Calicatt to Health & Fitness (18 answers total)

I went to one once. Wait was about 15 minutes. Sharp-looking female in 4 inch black patent pumps. I went into her office, sat in front of her desk(large, handsome, wooden), and described my symptoms(visual snow). She asked if I had seen a opthalmologist. I said yes. She said she had never heard of it, and that the only thing she could do was offer me Topamax, and then warned me of the side effects, but saying it was good because it would help me lose weight(I was not insulted by this but found it a little off-putting).(She was quite friendly the whole time, not like she was trying to get me out the door, the waiting room was pretty much empty.) She said although migraine with aura without pain is a thing, since my symptoms were constant she thought it must be something else. She did not order an MRI. She suggested followup with a neuro-ophthalmologist, suggesting a doctor in the area that I already had an appointment with. She wrote a Rx and sent me on my way. The visit was quite brief, no more than 10 minutes.

(Some months later, I went to an ENT for a unrelated condition and he had heard of visual snow and immediately sent me for a brain MRI to rule out MS which showed(clearly! bigtime!) that my left occipital lobe crosses the midline and smushes the right side. No one has commented on this. Go figure. Also discussed it with my psychiatrist, still no answers.::shrugs::)

Anything else I can answer about my singular visit, just memail me.
posted by lettuchi at 1:48 PM on December 15, 2012

Neurology appointments are an amazing combination of high- and low-tech.
Low tech: Most of my neurology appointments have consisted largely of hands-on tests from the doctor -- squeeze her hands with mine so she can gauge any difference in grip strength between sides, walk across the room normally and on tiptoes so she can evaluate any telltale differences in my gait, get hit with a reflex hammer all over the place. A neurologist can tell whether you've got carpal tunnel syndrome (nerve problem in the wrist) or cubital tunnel (problem in the elbow) based on which fingers (or sides of the finger!) are numb -- or if it's in your neck, by pressing down on your head to see if you get relief. And lots of talking, asking you questions about what symptoms you've had, what if anything has provided relief, what hasn't worked.
High tech: an EEG done while you're sleep deprived in the hopes that you'll fall asleep (or have a seizure, if they're testing for epilepsy) or a nerve conduction study, where they send electricity through you to test how your nerves are operating.
Neurologist's offices tend to be a little less clinical than most other doctors' offices -- more sitting in chairs or even across the doctor's desk, rather than perched on a table.
Some neurologists handle sleep apnea, which seems to be a pretty good source of revenue, especially if they do sleep studies in-house or sell the durable medical equipment (CPAPs etc) themselves.
Every neurologist I've personally seen has, as in lettuchi's experience, been a well-dressed woman. No surgeon's clogs for them. Usually a lab coat open over an outfit you might see in any office environment.
posted by katemonster at 1:56 PM on December 15, 2012

I went to a neurologist once, when I was 14. The appointment was because I'd had, within a month, two episodes of a rare type of migraine, which is usually inherited, but for which I had no family history. I can't remember how long the wait was. The neurologist was a man in his fifties, and he was warm and quite friendly (I think putting your patients at ease is probably very important for a neurologist). He took a fairly brief medical history, and did some tasks to check out my coordination, a bit like rubbing your belly and patting your head, but different. I remember being a bit aghast at how badly I performed in these but the neurologist reassured me that I'd done fine. I think he checked the reflexes in my knees and my feet (I remember it taking a long time to take off my very tall lace-up boots). I was referred for an MRI, which showed no abnormalities. In hindsight, I presume everyone was wondering if I had a tumor or something, but I didn't really recognise the possibility at the time (a good thing, I would have worried up a storm).
posted by Cheese Monster at 2:11 PM on December 15, 2012 [1 favorite]

I read a blog by a neurologist: Dr. Grumpy in the House
posted by vegartanipla at 2:45 PM on December 15, 2012 [4 favorites]

If you were a neurologist in a very large practice, you could potentially specialize in any number of things- headaches, MS, Parkinson's, epilepsy, stroke, aging/dementia, concussion, critical care (at a hospital), neuro-oncolgy. A private clinician might not be able to specialize so much.
posted by ThePinkSuperhero at 3:03 PM on December 15, 2012 [1 favorite]

My experience--they're sort of like detectives looking for clues and trying to guess what might be going on. I've always felt sort of dissatisfied but can't really blame them. They're not so much like other doctors that can order a test and tell you what is what like--your ankle is definitely broken.

Mine said you can look at an MRI and see that a person should be impaired but they are fine. You can have a patient that is barely functioning but nothing is showing on the scans.

There's this little set of tests all of them do--stand on one foot with eyes closed, pull their fingers apart, push their hands together, squeeze their finger, doctor scratching the sole of your foot with a tool in their office that looks like a pointy stick with a weight on one end, slide your bare foot down the shin on your other leg. . . all the neuros I've seen do pretty much the same test and do it in a routine like way that shows that it is a thing they do all day.

I always have this hope that as they're putting me through the paces--that they have something to say to me when they're done. That has not been the case for me, just some scribbling on their pad and hmmming but nothing really telling coming from the tests.

My neuro is very sweet, always very concerned but never able to tell me why I have the problems I have. I have seen several and they all seem to be the same. Trying hard to understand what I feel but unable to give me answers. I love my neuro also because he is a doppleganger of my college boyfriend, so somehow I feel more comfortable with him tickling my feet and such. Ha!
posted by dottiechang at 3:06 PM on December 15, 2012

My experience:

I saw a pediatric neurologist when I was 14, because they were worried I was having absence seizures. I got two EEGs -- one on my first visit, and another when I had not been allowed to sleep all night. My neurologist was a tall, handsome middle-aged man who was quite sweet. He concluded that I wasn't having seizures, so yay.

I've only seen my current neurologist once, because I was having migraine aura symptoms without pain. My neurologist is young, practical and pleasant enough, although reserved. Before my appointment, her clinic had called me several times and sent me a few letters, all telling me that I would not be getting pain meds on my first visit, so don't bother with that drug-seeking crap.

Since my episodes were causing me no pain, I felt a bit guilty about the appointment. Especially when I had to check off medications from a huge list of painkillers, indicating which ones I had taken (none of them besides aspirin, Tylenol, and ibuprofen, it turns out). The nurse who took my vitals told me that atypical migraine was common enough, and that I didn't need to feel like a whiner for seeing a neurologist about it.

After speaking with the neurologist for about 20 minutes about the episodes, she said my symptoms were pretty classic acephalgic migraine, ran me through the touch-your-nose-while-doing-another-trick tests, and scheduled me for an MRI. She was fairly confident that it would reveal nothing in particular, but "you have to make sure". Before she sent me on my way, she said that "If the MRI is clear, you don't need to come back unless your symptoms become more frequent or worsen". The MRI was not a party, but the only abnormality it revealed was a snot-filled sinus.

My mom's experience:

My mother went to the same neurologist for a few years, trying to address her issues with Sjogren's syndrome complications, and neuropathy in her feet and hands. He gave her a few MRIs, she was on and off all sorts of drugs. Eventually, she felt as though she was running to stand still with that guy, so she asked her primary care doctor for a reference to a neurologist in the same health system as my neurologist (which is Duke Health). Her new neurologist team gave her a bunch of nerve conductivity tests and etc, and found out that her diagnosis was quite a bit different than the one she was getting treated for. They scheduled her for pretty regular treatments of IV immunoglobulin, and I'll be damned if the woman can't walk straight again. It's astonishing what good the neurology team has done for her.
posted by Coatlicue at 4:30 PM on December 15, 2012

Went to a neuro for back problems and eventual surgery. My guy was a hoot. Late 40's, big guy, wore cowboy boots and hat, rode a Harley to work. Had tons of maps framed all over in his office, organized chaos at his desk. Waiting room was casual, and I was examined in a typical exam room. He was very hands-on--palpated, pushed, pulled, measured, etc. Saw him twice, had an MRI, then surgery. He came up to the room afterward with a big chunk of tissue in a jar to show me what a whopping amount he had removed. Said he couldn't believe I wasn't in excruciating pain. Asked me if I wanted it for a souvenir! Saw him for the all clear, and he pronounced me, "One tough pony and good to go." I'm told he's one of the top dogs in the Pacific Northwest, and he struck me as highly intelligent, super busy, compassionate, and having a great sense of humor.
posted by BlueHorse at 5:49 PM on December 15, 2012

If my 2 visits to a neurologist were typical (I hope not), being a neurologist in private practice is a lot like selling cars. I left the office feeling very much like I had just been targeted by a very refined high pressure sales pitch. At first, he seemed to be really interested in finding an explanation for my complaint (an odd sort of tremor). But as soon as he saw that my history included headaches, he got all excited and distracted. "We can get you into a Botox treatment program! You'll only have to come every 2 - 3 months! 27 injections! Your insurance will cover it! The FDA approved it!" [He handed me the clipping, which he kept tucked under the glass of his tidy desk, next to his kids' picture.] I very much got the impression that his objective was to find an expensive, long term, recurring treatment that my insurance would pay for. I felt like a potential billing opportunity, not a patient. Since it was clear that he was not interested in trying to help me with the more complicated and less lucrative problem I had consulted him for, I didn't go back. I felt pretty angry that he had wasted my time.

The neurologist's wife is a doctor in a different specialty -- I left with a referral to see her, too, and with scripts for several tests at the diagnostic facility owned by the neurology practice. It was clearly a very efficient money-making machine.

Funny you say you're writing a book -- as I sat in the waiting room for 45 minutes, I had the thought that a great book could be written about the patients coming and going. Everyone looked like they had a very interesting story -- people with mobility impairments, odd gaits and tics, assistive devices, family members helping. Everyone was being very nice to everyone else, and the room was full of trouble, courage and compassion.
posted by Corvid at 7:03 PM on December 15, 2012

Point of fact the majority of trained, board certified neurologists hate dealing with headaches and really don't bother.

As a neurologist (which is entirely different from a neurosurgeon) you deal mostly with various kinds of strokes and epilepsy. It's considered to be a depressing field because once you establish the diagnosis of brain damage and map out the deficit there usually isn't a whole lot that can be done to improve the lives of your patients.

Some neurologists, like any other branch of medicine, rely on gimmicks as mentioned above, as neurology is a lower (but not low) paid medical specialty.

Neurologists are fairly hands on and perform the formal neurological exam for nearly all of their patients in order to map out brain function from top to bottom. Some imaging and interpretation, some history taking and interviewing, but mostly the 5-10 minute physical exam composes the majority of patient time.
posted by hobo gitano de queretaro at 8:31 PM on December 15, 2012

I interviewed someone recently about medical policy and somehow neurological exams came up. This guy had been practicing in a busy hospital since the 1970s, and he remarked on how quickly younger doctors go to the MRI/CATscan machines now, rather than do an extensive physical examination first or at all. He said it was a technical skill that needed to be trained and then practised extensively and a good neurologist could tell a lot from the examination already, rather than just looking at a scan first. Part of it was the cost factor - the machines are still expensive enough that it's cheaper for a hospital to have a physical examination, but partly he thought it was a worthwhile clinical skill to have.

I have been to a neurologist for suspected MS and she did the physical examination first which does indeed feel very basic but she was good at explaining what she was looking for to satisfy my curiosity. On youtube, you can see non-typical examinations and it's fascinating to see how the eyes don't track or the hands don't synch up like they should. My daughter goes to a neurologist for migraines, and she had both the scan and the physical tests done, but her follow-ups are very brief now - ten minutes to double-check any changes in symptoms or her other medications and then a prescription. There is no physical examination at all.
posted by viggorlijah at 1:24 AM on December 16, 2012

Many of your patients are really scared. Their bodies and minds are often doing strange-to-them things. Some are recovering from traumatic illness while others have that ahead of them. A good Neurologist has a factual, compassionate nature and can explain really difficult things to completely distraught people.
posted by dantodd at 2:20 AM on December 16, 2012 [1 favorite]

Went to a neurologist appointment with my wife at the local university hospital. She was having stroke like symptoms that were caused by migraines. I swear I was in an episode of House. 2 young doctors came in and examined her and did all the squeeze my finger, look left, look right tests. Then the old cranky neurologist came in spit out a few sarcastic sentence wrote her a script then left. The two young docs stuck around and offered an extended explanation and hinted at an apology for the neurologists behavior.
posted by jmsta at 6:37 AM on December 16, 2012

My dad is a neurologist. His bread and butter is headaches, migraines, strokes (this might be number one actually), and dementia. He is very interested in philosophy of the mind, so he finds things like Tourette's, the placebo effect, and personality disorders very interesting. He loves reading anything by Oliver Sachs. He runs a large practice in central and southern Indiana, and yes, almost all of their work is in hospitals. He has many, back to back, regularly scheduled appointments. About ten per day. He does a few ER visits each day. He takes lots of scribbled notes during appointments and then dictates them into a recorder after. He tests knee reflexes with a little hammer like in the movies. For stroke patients, he asks them to draw a clock (I used to file paperwork in one of his offices, so I saw lots of sad clocks in the notes that look like this. He would also have patients draw spirals to measure tremors.

Now he works from 8am to 5:30pm every weekday except one day per week when he has a half day. He also is on call of one weekend per month. But when he was starting out he worked 70-80 hours per week, so I rarely saw him when I was little. Not sure if that's the norm anymore.

Feel free to me-mail me if you have any questions.
posted by BusyBusyBusy at 7:40 AM on December 16, 2012 [1 favorite]

My experiences with a neurologist (in private practice in a one-doctor office, but affiliated with a hospital, FWIW) are in line with some of the other comments, but I'll add that the first time I saw her she tested my cognition with one of those "What year is it? What street are we on?" verbal tests, and because she saw a lot of young patients the waiting room was full of "brain toys" (sorry, no coffee yet) like big wooden beads that you push along a metal wire track. I assume it was a way of observing their motor skills, etc. Besides the hands-on testing, she experimented with different meds much more actively than other doctors I've had.

Oh, and I've never seen a doctor's office with more pamphlets and hand-out literature. Some were from pharma companies, others were general information about disorders, but there were research study notices and other things around the office.

(The office is burned into my memory because I was the first appointment of the day on 9/11, about two hours after the planes flew into the WTC.)
posted by Room 641-A at 7:42 AM on December 16, 2012

Response by poster: These are fantastic. It's great to hear of the varieties of personality along with the similarities of practice.

My character is probably most like lettuchi's (professional, pump-wearing woman)but it's very helpful to hear about others in the field. the differences in people experience says a lot and is very useful.

Anyone else out there with thoughts to share? Would love to hear more!
posted by Calicatt at 9:02 AM on December 16, 2012

I did a neurology rotation as a medical student that included an inpatient and outpatient portion to the experience, and also I consult neurologists regularly as part of my work in the ER. As far as the ER stuff goes, I don't often need them except as a question on the phone or a follow up visit, but when I need them, I need them immediately - and that is when strokes come in within the treatment window for clot busting drugs. Most stroke patients do not come in until after this window has closed or are ineligible for the treatment for other reasons. On the rare occasion where the stroke patient comes in quickly with a clear "last known well" time, we rush them to the CT scanner and through blood work etc. as quickly as possible, and there's a fascinating new technology we use for 'telestroke' consults. That means I can get a neurologist on a video screen who is in a remote location (like at another hospital) who can examine the patient and help to make the decision on the treatment. It's pretty amazing.

In terms of my rotation in med school, based on my experience I'd say it's not at all difficult to have a private practice in neurology. They are in high demand and are often booked out for months. I definitely have an admiration for people who are willing to do this as a career and for the ones who really know what they are doing. They have to deal with a lot of patients who have concurrent psychiatric issues/personality disorders (i.e. pseudo seizures). There is a lot of malingering and so forth, including many patients who do not have insight that their problem is 'functional' and not organic in nature. Unfortunately things like headaches, numbness and tingling are all subjective. Good neurologists are experts at knowing when symptoms are physiological or psychological. They have methods (including specific physical exam moves) to differentiate the two, here are some examples.

I also found particularly the hospital practice to be terribly depressing, but also the outpatient practice. There are just so many patients with neurologic issues who medical science cannot help at this time (i.e. ALS, a lot of the dementias, MS to some extent). And on the inpatient side you have to see some of the most awful things in medicine, like brain injuries, aneurysmal head bleeds, brain tumors, doing brain death exams. I remember a lot of long, sad, "family meetings". It was not my cup of tea but as I say, I'm quite glad they like what they do.
posted by treehorn+bunny at 8:44 PM on December 16, 2012

Ian McEwan's novel Saturday takes place in one the day in the life of a neurosurgeon. There's much more to the book than just the doctoring aspect, but McEwan spent time with neurosurgeons researching the book. You might find it of interest.
posted by PaulBGoode at 9:06 PM on December 16, 2012