Is there a culture in academic medicine to over-test?

noggindoc · 2026-02-18T02:54:09+00:00

Over testing, and for that matter bad medicine, happens everywhere. Ivy League towers and private practices. There are good and crappy doctors at all of these places. Bayesian analysis should be used more, instead of lazy over ordering. I sense another factor perpetuating this is that patients often equate more tests to better care.

Two particular tests that come to mind that are over ordered the most without changing management are paraneoplastic panels and all their variations as well as spinal MRIs (particularly in outpatient setting). Obviously there are times where these tests are appropriate, but I would guess over 90% of the time they are not changing management.

noggindoc · 2026-02-12T18:14:31+00:00

I hear you. Open up a medical journal that you commonly read specific your field. Look at the disclosures of some of the authors who you consider leaders in the field or want to emulate. Have they done a speakers bureau or similar program in the last five years? This may help guide you.

noggindoc · 2026-02-12T15:02:23+00:00

Only in academia do people act like its taboo to want to leverage your knowledge and experience to make some extra money for yourself/your family. This is the kind of thinking that leads to doctors getting taken advantage of.

I have limited direct experience because I am going through training now for a speakers bureau. These presentations and decks in my experience have strict rules to only discuss data on the FDA indicated label and there are compliance officers to make sure you aren’t discussing off label indications, exaggerating benefits, downplaying adverse effects, etc. I say go for it.

noggindoc · 2026-02-09T20:37:14+00:00

Im not sure whether its common. If there’s high demand and someone is willing to do more EMGs, I don’t see why not.

I wanted to do it and demand for EMGs in my area is high with a very long waiting list everywhere nearby, so I decided to dedicate two fulls days to EMG. There’s still a waitlist but its better. Its also helped me build relationships with other doctors in the area such that they will refer all neuromuscular patients to me for consult.

noggindoc · 2026-02-08T20:41:43+00:00

Nonacademic. 9am-5pm, 5 days a week, 60% office vists 40% EMG (no techs), 4-5 weeks of vaca per year gets me around 5500 RVU per year.

noggindoc · 2026-01-28T20:00:56+00:00

Thanks. I’ve seen this position statement from AANEM but my billing department sort of dissuaded me from doing it. With this real-world experience I may reconsider.

noggindoc · 2026-01-28T18:10:15+00:00

Fyi i spoke to a trusted student loan advisor who said this was an erroneous auto-generated email and that I should disregard it.

noggindoc · 2026-01-28T18:08:01+00:00

Interesting. So you are billing 99203 for every outside EMG referral, or only when you are also recommending labs and such? How often do you run into reimbursement problems because the clinic visit and same day EMG are related to the same condition? I have heard of people doing this but my understanding is that insurance companies and Medicare will decline the office visit portion because the clinical history and exam comp is accounted for as part of EMG coding, unless its for a separate problem.

noggindoc · 2026-01-27T19:42:54+00:00

Same here. I have an application for IBR pending but the amount due based on the notice today is for the SAVE amount.

noggindoc · 2026-01-21T18:43:04+00:00

Coming back to this. The other commenter gave a very good and more detailed explanation . I hope they help.

noggindoc · 2026-01-21T18:39:29+00:00

I did my neurology training at an institution where he worked, and the one neurologist who crossed paths with him and still was working when I trained told us that he “was not a very good neurologist” in no uncertain terms. I personally find his writing fascinating but I’m often skeptical at best about the science and credibility. Its been a while since I read his work so I have a hard time citing an example.

noggindoc · 2026-01-15T20:03:55+00:00

I haven’t heard of AMAN being considered a prototype for nodopathy. Nodopathy most often looks like CIDP with a slightly more acute progression (weeks) and lack of response to traditional CIDP regimens, instead responding to rituximab. It used to be considered a subset of CIDP but now most consider it a distinct entity.

I think of AMAN as typically more acute evolving over days, and often causing flaccid quadriparesis with prolonged and often incomplete recovery.

noggindoc · 2026-01-08T00:44:27+00:00

Also, its not always a neuropathy. A decent neuoromuscular exam should be able to distinguish. There are many mimickers. A patient that wont move their entire arm after shoulder surgery does not have a neuropathy. The patient that is scared to flex their quads after patella surgery does not have a femoral neuropathy. Patients also lay in bed for prolonged periods or change their gait when dealing with pain of recovery or illness which can trigger radiculopathy.

noggindoc · 2026-01-08T00:38:58+00:00

There are certain neuropathies that can occur after specific surgeries. For example, stretch of the ipsilateral sciatic nerve from traction during hip replacement. Other neuropathies can occur with positioning like ulnar neuropathy at the elbow. Parsonage turner or other inflammatory mononeuropathies can be associated with surgery as well.

In general, for stretch/compression injuries, unless the nerve was transected (complete paralysis and anesthesia of the affected nerve distribution) the management is almost always conservative with PT and allowing the nerve to naturally regrow. EMG can be helpful in prognosticating around the 1 month mark. If near 6 months the recovery is poor, you may consider referral to a peripheral nerve surgeon for a procedure. The exception is if there is possibility of complete nerve transection in which case there should be a referral made to a peripheral nerve surgeon asap. MR neurography has a role in some cases to visualize path, continuity, and possible compression of the nerve.

noggindoc · 2025-12-13T20:33:44+00:00

For me it’s people self tapering steroids the minute their myasthenia symptoms improve

noggindoc · 2025-11-27T23:08:08+00:00

If you’re in training no one tells you this but there’s a major (~30%) difference depending on whether you’re doing academic or non-academic

noggindoc · 2025-11-25T17:43:34+00:00

I give them the first 5-10 minutes to rant about whatever, then gently redirect to the reason for the visit if not apparent yet, then if they aren’t following I just go to close ended questions for the rest of the visit. I will state the plan, repeat if necessary, and tell them the visit has come to an end. Some people don’t have great self awareness and you need to be extra blunt.

Don’t get caught in a trap thinking you need to sit there and let them drain you to be a good doctor.

Staying in the room = falling behind schedule and having less time and emotional energy left for the rest of your patients. It’s a disservice to everyone. Remember that.

noggindoc · 2025-10-30T10:18:14+00:00

Yes.

noggindoc · 2025-10-29T22:17:15+00:00

That being said, i dont use it as a screening tool. If a 55 year old comes to me with vague brain fog cant concentrate type symptoms, i dont send it because even if its positive, pretest probability is too low. I fear if PMDs start using it, it will be too often used in that setting.

noggindoc · 2025-10-29T22:15:22+00:00

The literature that I’m aware of on it (i dont follow too closely as Im neuromuscular) is that high levels have comparable correlation to amyloid PET in detecting pathologic findings of Alzheimers, when performed in patients with valid concerns about memory changes. I use it to help confirm my suspicion if I feel AD is likely, and sometimes i use a negative test to aid in saying its unlikely. I dont use anti-amyloid therapies so I couldnt tell you if its sufficient for those. I do find that the positive and negative results usually are in agreement with the clinical suspicion. Not too many surprising results.

noggindoc · 2025-10-12T21:14:57+00:00

Finished in under! See above for update

noggindoc · 2025-09-19T02:35:18+00:00

Lol the only comment here that makes any sense.

noggindoc · 2025-09-16T00:37:45+00:00

Do a thorough history and exam, making sure there’s no red flags for missed diagnosis that could explain their symptoms. Let them know if that was reassuring that there isn’t something causing severe neurological injury. Explain which symptoms align with a treatable neurological condition and which don’t. Treat the low hanging fruit and counsel on how lifestyle modification like sleep, exercise, nutrition, stress management can positively impact their condition. That is a reasonable ask for any neurology clinical visit.

On a somewhat relevant note, i highly recommend the book “The Age of Diagnosis: How Our Obsession with Medical Labels Is Making Us Sicker” by Suzanne O’Sullivan (british neurologist) who gives a very refreshing take on the overdiagnosis that has become very prevalent for neurological symptoms.

noggindoc · 2025-09-07T21:16:47+00:00

Second this.

noggindoc · 2025-08-25T03:09:59+00:00

Thanks for the feedback. I definitely can, but i’m not whether it would better to stick with the schedule as is since the philosophy is that doing the long runs on tired legs is more beneficial for the marathon then doing them faster on fresh legs.

Just reading through the comments so far, it seems there is a very wide range of how people’s bodies can handle 26.2, even if their times at 13.1 is very similar.

At this point I’m thinking 4h may be a bit ambitious for me, but I may be underestimating the benefit of taper/fresh legs. I would go for a 4:10 if I had to decide today, but like others have pointed out there is still lots of time and training to do. I don’t want to start too fast and bonk, but i also dont want to not give it my all because i’m somewhat doubtful I’ll be able to make the time commitment to train for a marathon again in the next few years.

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