Neurology Nuts and Bolts: Constructing Your Career - Types of Careers: General Neurology

Transcript

[MUSIC PLAYING] Hello, and welcome to the Neurology Nuts and Bolts podcast, a podcast all about constructing your career in neurology.

I'm your host, Sagari Betté, a movement disorder specialist at the Parkinson's Disease and Movement Disorders Center of Boca Raton.

Today, as part of the Types of Career series, we're going to be talking with Dr.

Renata Chalfin, a general neurologist and founder and director of Ideal Neurology Clinic, about going straight into general neurology practice after residency without doing a fellowship.

Thank you for joining us, and thank you for taking the time to speak with us today, Renata.

Thank you.

I'm going to dive right in with the big question, which is, how did you decide to pursue a career in general neurology?

Yeah, so I've always been interested in everything, and I think that is one of my strengths and one of my weaknesses, in that I just-- I can't get satisfied by only doing one thing all the time.

I get bored easily.

And some people approach that by going into more acute things, but me, I like the mystery of general neurology.

So when I started residency, I knew I liked all the different aspects of it, and I committed myself throughout residency to do everything because I saw that some of my friends who would go into different subspecialties, whether it was MS or epilepsy or whatever, it seems like that was pretty much all that they saw afterward, and I didn't want to restrict myself.

I didn't want to narrow myself to only seeing one type of patient.

So yeah, that's kind of how it came about.

So this is something you knew about yourself pretty early on?

Yeah, I think so.

I mean, before I even knew I wanted to go to medical school, because when I was going through college, I thought I was going to do research.

And actually, I think that's where I realized this about myself because in research, in a PhD program, which is what I was in, you become a specialist in a very, very, very narrow field.

Field is not even the right term for it, right?

Like a very narrow topic.

You become an expert in just that one topic.

And in college, I majored in neuroscience, and so I did some experiences with other doctors and with a neurologist.

And I really enjoyed learning about everything.

Do you think it's essential for others who might be thinking about this path to also know early on that they'd like to be a general neurologist rather than a subspecialist, or could they decide later?

I think they could decide later, of course.

Everyone has their own path.

When I, during my residency, because I knew I liked everything, I kind of launched myself into everything, right?

So when they had many subgroups where people could get more experience in reading EEGs or learning epilepsy and do extra electives in different fields, I really tried to participate in all of those because I knew that it would be applicable to me in my practice.

Even EMGs, which in my program were usually performed by the fellows, on my rotations, I tried to participate as much as I could to get as much experience.

So although you did not yourself do a fellowship, would you recommend a fellowship for someone pursuing a career in general neurology?

And if so, which fellowship?

I don't think so.

And that's not to say that it's bad if somebody does a fellowship.

Obviously, it's not.

It could only be good because you're getting even more training.

It's more just we've been in education and training for our whole lives by this point.

And most of us are in our early to mid to late 30s.

And another year or two of fellowship, I don't know if the return on investment is high enough to say that you should get one.

I think that you should get one if you are interested in going into academia because that was one obstacle that I ran into.

When I finished residency, I was offered a position at my program, but only if I did at least a part time fellowship.

They had this thing where they felt like none of their faculty could be faculty without a fellowship.

But for me, I wasn't so gung-ho about that.

So it wasn't as important.

What advantages do you think practicing general neurology has over subspecializing?

Oh, I think it's so much more fun, no offense, to people who subspecialize.

But I mean, we get all-- there's good and bad, right, of course.

But we get all the referrals from physicians who have no idea what's going on.

And so I feel a little bit like Dr.

House when I see a patient for the first time and they come in complaining of walking difficulty.

And their primary might have told them, oh, it could be Parkinson's.

Or they might have told them, oh, it could be multiple sclerosis, which is a favorite of some primaries, right?

But when you see them, it's not at all Parkinson's, or it's not at all multiple sclerosis.

Or it's something completely different.

And so you have to-- it's a challenge.

And I like challenges.

I think most people who go into medicine have to challenge somewhat, right?

Because you wouldn't be able to survive without the challenges.

Well, I think most people who go into neurology definitely love a challenge.

So I think that would resonate.

Yeah, it's a challenge for everybody.

But then when you stay general, you get to see everything.

And you get to see the people before they're referred to the subspecialists, because people usually see the general neurologist first, usually.

So usually we get the people that we really have to-- diagnosis is really important.

And that's the exciting part of medicine in my mind.

And then a lot of times we get people who haven't really tried much in terms of treatment yet.

And so we're usually the first line in treating them.

And we get to reap the benefits of seeing people improve a lot.

So it can be exciting that way, too.

As a general neurologist, you're honing your skills in treating all neurological disorders.

But when do you decide, if ever, to refer patients to a neurology subspecialist?

Oh, yeah.

So obviously I have to know my limits.

And as soon as I start to feel-- not as soon as.

I mean, if I've been treating somebody and I feel like what I'm doing is not helping anymore or not helping much or there's something missing, I'm feeling like I'm not quite-- all the puzzle pieces are not fitting.

That's when I will refer them to a subspecialist.

If they're more initial diagnosis of Parkinson's disease, then I'm OK treating them initially with CINEMAT or with AS-ELECT or whatever it might be.

And then as things go on, I might go on up to date and be like, well, if this doesn't work or if that doesn't work.

But past that, I don't want to start playing trial and error too much with people if they're struggling.

So if I feel like I'm not helping them, then that's when I'll usually refer them.

The problem comes in that there aren't always subspecialists around.

Thankfully, I have you guys for the Parkinson's and movement disorders.

But other subspecialties might not have an appointment availability for months or even more than a year.

And so I still have to manage the patient until they can get in.

And sometimes even when they get in to see the subspecialist, especially when they go to an academic center, they don't feel satisfied with the care that they get sometimes.

And so they end up coming back to me anyway.

And I end up still having to manage them or take what the academic center recommended and try to apply it to the patient.

Apart from this issue of the lack of subspecialists to refer your patients to, what other challenges do you see as a general neurologist as medicine is becoming increasingly subspecialized?

I think the biggest challenge is staying up to date with all the newest medications and newest treatments for all the different subspecialties.

When I graduated residency, I felt pretty confident about all the multiple sclerosis options that were out there and which ones were the best and which ones should be used and which patients.

But now that I'm a few years out, I'm sure there have been advances that I've missed just because I'm not in that field.

I'm not going to the multiple sclerosis society meetings and stuff like that.

And so being aware of all the newest advances is probably the biggest challenge because there have been so many advances in all the different subspecialties.

And how are you meeting that challenge?

How are you staying up to date on all the advances across neurology?

Yeah, so always reading, always being in touch with other people.

So if I see a patient that might benefit from a new treatment, I will sometimes reach out to a colleague who is a subspecialist in that field and say, would you try this for this patient?

And just kind of always trying to be in communication with either other subspecialists or always reading up on my specific patients because going to conferences right now with the little ones is a little bit harder.

So hopefully when I start going to conferences again, that'll be even easier.

But for now, it's really just reading a lot and staying in touch with colleagues.

Are there particular types of reading material that you would recommend as being more high yield?

Well, up to date, of course, is always useful for just general stuff.

And then once I see something on up to date, like, oh, there's a new medication for such and such, then I will look more into it.

I'll read the studies, maybe, that the drug was approved.

I'll speak to some of the people that were involved.

A lot of times if the studies were published either in neurology in the Green Journal or New England Journal or whatever, I'll try to read the original studies and make my own conclusions and talk to friends and ask them, is this something that you agree with or not?

As part of your practice, do you perform and interpret your own testing?

My practice is still in the early stages.

So I don't have my own EEG or EMG equipment or things like that.

In the beginning, I had a tech that would come to people's homes and perform the EEG, and then I would read it myself.

While I was doing my telestroke side gig, I also read EEGs.

One day, I hope that my practice will be able to offer some of those things as I grow and have the resources for them.

Until then, I'm just kind of trying to stay up to date.

You touched on earlier a little bit about how you chose your particular practice, or at least what led you away from an academic center.

Could you go into a little more detail in terms of how you decided to start your own practice rather than joining another neurology practice?

Yeah, I think that has to do with my stubbornness.

But basically, I knew where I wanted to live, because I was starting a family, and my husband and I wanted to come back to our hometown, where we would be close to both of our families and have better support than we did in residency away from them.

And so I started calling all the practices in the area.

And I got offers from a lot of them, but none of the practice situations felt ideal to me.

A lot of them had non-compete contracts, so that meant that if it didn't work out and we wanted to part ways, I would have to move away in order to be able to continue to practice, or I'd have to wait a year or two or three, which just didn't seem feasible to me.

And I knew I wanted to stay.

I didn't want to have to leave or commute really far distance just to be able to practice.

Or the other problem I ran into was other practices just were run a little bit more like an assembly line, like people would see four to eight neurology patients an hour, which is craziness to me, because you're just starting to get to know the person, let alone how could you make a diagnosis on such a complex system.

So I really wanted to do something different.

And during residency, I did a lot of reading about the ideal medical practice movement and direct specialty and direct primary care, and just all the ways that physicians around the country are trying to change things so that them and their patients get a better experience.

And that really appealed to me.

And so I decided that I would just jump off the deep end and just go ahead and just start my own practice and see how it goes.

And thankfully, my mom actually is a medical biller.

And so she helped me with that aspect of the practice.

And thankfully, patients started loving it.

And so they've really started streaming in, especially if they've already seen another doctor and not had the experience that they wanted.

Is your type of practice environment something that you would recommend to others who are considering a career in general neurology?

Or would you recommend that they really explore all of their options?

Good question.

I don't know.

I think it's still early to say.

It's definitely a challenge.

And it's definitely not the easy way.

Like I said earlier, I like a challenge.

And so for some reason, I flock to them.

If you want to just practice and not worry about all this other stuff and don't care about all of the workflows and don't necessarily care about all the details of your patient's experience and you just want to go to work, do your job, get paid, and come home, then probably I would not recommend starting your own practice because there is a lot to it.

You have to figure everything out for yourself.

I had to figure out all my own intake paperwork and office policies and workflows and scheduling and EMRs.

I started off with paper charts originally.

And then I switched to an EMR and having to decide and negotiate and apply for insurance contracts if that's what you want to do.

And then learning the billing side, it's a lot.

I happen to love to learn.

And I think, again, most physicians also like to learn because you have to learn a lot in order to get to where you are.

But that's something that I enjoy.

I enjoy learning and figuring all that stuff out.

And I don't mind taking a big pay cut in the meantime while the practice builds up.

But not everyone is going to be in that same situation.

Speaking of finances, would you say that your financial situation overall is comparable to if you had joined a pre-existing practice or a large university-based academic center?

Or are you better off financially or maybe a little worse off financially?

I would say overall, I am probably as good or better off.

But that is with the caveat that I practice the way I want to practice.

And if I were practicing under a different group, for example, I might have to see a ton more patients in order to be able to make the same amount of money.

And the reason for that is most other practices have a lot higher overhead.

For example, there was a period of time where on the side, I was seeing patients for another practice just as an independent contractor.

And they had really good insurance contracts.

So they were getting good rates for each of their appointments.

But because of all the overhead of all the staff and everything that they offer, the take-home ended up being the same or even less than what I was getting on my own with either lower insurance or no insurance.

I don't think you can compare like that because it's apples and oranges.

But I will tell you this, if I wanted to make a lot of money, I could join a different practice and just keep my head down and see a ton of patients and not necessarily make those patients very happy and make more money than I'm making now.

100%.

I would be able to do that.

But at the same time, with my own practice, I have the possibility that I will grow and be able to offer more but still give patients that experience that they want.

And at the end of the day, go home feeling satisfied that I did the best that I could.

Is there anything else that you think our listeners should know about this career choice, either in terms of the practice of general neurology itself or the particular practice environment that you've chosen?

I think I'm still figuring it out myself.

If anybody has any more questions or anything, they are welcome to reach out to me.

And I'm happy to talk.

I love talking about this stuff with other people, especially if other people are trying to do something similar or whatever, and bouncing ideas off of each other and things like that.

I think we can all use peer mentors.

It's a balance between being able to-- when I was in training and I was telling people-- because I would tell people, I think I want to start my own practice.

I said that even while I was in residency.

And a lot of my attendings told me not to do it, because I wouldn't be able to survive.

And they were being realistic.

They weren't trying to discourage me.

They were just being realistic, because insurance reimbursement has gone way down.

And especially for somebody like me, who likes more the cognitive aspect of neurology, and what I mean by cognitive, I don't mean behavioral neurology.

I mean the evaluation and management of a patient, rather than the procedures that you can do.

Because it's the procedures that insurance companies will still pay a ton of money for-- EEGs and ambulatory EEGs and Botox.

And well, I guess people don't make a ton of money off therapeutic Botox.

But whatever procedures that they might do, they usually don't last so long.

And they don't require the use of the physician's time.

And then they make the physician a lot of money.

But I'm more interested in the evaluation and management.

And insurance companies don't really value that for some reason.

They pay the bare minimum for that.

For someone like me, who likes that aspect and is less interested in the procedures, it's tough to survive with insurance being the way it is and with the health care system the way it is.

Because patients want to use their insurance.

And they feel entitled to using their insurance, as they should be.

Because they're paying usually a ton of money for their insurance.

Or they're staying in a job that they wouldn't stay in for any other reason, except for they have good health insurance benefits.

And then they go to see a doctor.

And they either get only 10, 15 minutes with that doctor.

And they don't feel like-- they don't feel heard.

Or they have to go to a doctor outside their network and pay out of pocket anyway.

It's a broken system, as everyone always says.

And the longer I'm in it, the more I realize it's true.

But so it's hard as a practice owner to balance that and decide, well, in order to survive, in order to be able to pay my rent, I really need to not take insurance.

But then that means that I'm maybe seeing patients that are either better off.

And I'm not seeing patients that aren't able to pay.

Or I'm seeing the patients that are a little bit more complicated because the simpler ones already went to the insurance neurologist.

And they were satisfied within the 10, 15 minutes that they got to see them.

So it's something that I'm still grappling with as far as my practice and future steps, which direction I'm going to go with it.

But I'm thankful that I have that ability to decide those things.

Because I'm the practice owner at any time, if I decide, I really should start taking this insurance.

Or I really should start seeing, I'm able to see a few patients pro bono or whatever, then I can do that whenever I want because I'm the boss.

Whereas if I was working for another practice or in academia, you don't really have a say in any of those things.

And patients might complain to you about x, y, or z.

And you really have no control over what to do about it.

So those are just some thoughts.

Certainly.

Thank you for that comprehensive response.

And I would like to direct our listeners who are interested in more about the finances of practice to take a look at that particular series.

We do have an interview on outpatient billing and coding.

We also do have more information on concierge and direct care neurology in our types of careers series.

Renata, I want to thank you so much for joining us today and providing insight into your career in general neurology and guiding others to hopefully join you in that pursuit.

It's been a pleasure speaking with you.

Thank you.

It was a pleasure speaking with you too.

[MUSIC PLAYING] Neurology Nuts and Bolts podcast was created and produced by Sarah Schaefer.

It is not recorded as an official podcast of any institution or organization.

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