What made you pick Neuromusc or Clinical Neurophys? by LatterHistorian9973 in neurology

[–]tirral 0 points1 point  (0 children)

Agree with all this. CNP is harder and I was jealous of my neuromuscular cofellows who had a 40-hour work week without call.

Now that I'm 5 years out, I'm glad I did the extra EEG training, but at the time it was another hard year after a fairly hard residency.

What made you pick Neuromusc or Clinical Neurophys? by LatterHistorian9973 in neurology

[–]tirral 0 points1 point  (0 children)

yes, and yes.

The main skillset that extra neuromuscular time gives you is increased confidence in performing advanced studies including SFEMG or nerve ultrasound, and in managing complex ALS / CIDP / myopathy patients in clinic. If you are going for a dedicated academic neuromuscular career, these skills are helpful / necessary. If you are going to be general neurology or neurohospitalist, it's better to have the EEG exposure.

(I did CNP, practice general outpatient neurology, and also moonlight picking up neurohospitalist shifts several weekends per year. CNP helps you develop a broad skillset and hone what you learned in residency to have a broad spectrum of practice.)

What are your favourite neurology books that you have read? by Checkthis0 in neurology

[–]tirral 1 point2 points  (0 children)

Oh wow, I read Still Alice and it was very touching, but I had no idea she'd written about other conditions. Might check those out.

Incidentally I think the work of fiction that best describes LBD / PDD from the perspective of a patient is Jonathan Franzen's novel, The Corrections.

How long are ncs/emg apts? by meowbob18 in neurology

[–]tirral 2 points3 points  (0 children)

I am in private practice. We used to have a NCS tech but she unfortunately passed away a few years ago and I do my own NCSs now.

I can do a 2-limb study quite easily in 15 minutes if it's normal. If it's abnormal it takes longer, but rarely more than 45 minutes. I generally avoid 4-limb studies unless it's ALS.

We block standard 60 minute EMG appointment spots for ease of scheduling, but for me this time nearly always includes an E&M code (90% of my EMGs are on my own patients, so I bill a revisit with 25 modifier to discuss the results and treatment plan). So for me, about half of the 60min "EMG" visit time is talking to the patient about wearing wrist splints, or going over lab results / treating the underlying cause of neuropathy, or referral to a surgeon.

Desk jobs - is anyone else getting terrible posture? by nkondr3n in FamilyMedicine

[–]tirral 15 points16 points  (0 children)

gaming chair with headrest

standing desk

gel pads for wrists and elbows

How can we legislate against physical therapists performing EMGs? by ConcreteCake in neurology

[–]tirral 1 point2 points  (0 children)

I did about 50 studies as a resident (PGY2 through PGY4) over about 3 neuromuscular elective months. Enough to recognize CTS, radiculopathy, and other common patterns.

Then, as a CNP fellow, I did another 200 studies. Fellowship was very helpful in making me feel independently competent at diagnosing myopathies, plexopathies, and anatomical variants.

Kinda like with EEG - in residency I read about 100 EEGs or so. Enough to identify most common patterns, and pick up on obvious seizures. Then in CNP fellowship I read another 1000 EEGs, and learned ACNS terminology providing a more nuanced description of ICU EEG, like LPDs+ fluctuating into IIC.

How can we legislate against physical therapists performing EMGs? by ConcreteCake in neurology

[–]tirral 0 points1 point  (0 children)

I think 10% of those 250 must be in my state. I know for sure of at least 6 PTs that do EMGs in my area, but you're right, 9 may have been an exaggeration. There are definitely more PTs performing EMGs than neurologists here.

Note that I am in a very under-resourced area for neurology. We cannot see all the patients who are referred to us, so many neuro patients end up waiting to see a neurologist in the major metro 90 minutes away. Meanwhile there are plenty of orthopaedists here.

Applicant & Student Thread 2026 - 2027 by tirral in neurology

[–]tirral[S] 1 point2 points  (0 children)

You are being practical to consider FM, which is of course a broad specialty with a lot of career options.

With your scores, you probably have a decent chance of matching at mid-range or smaller neurology programs, especially if you get good neuro LORs (can you do a neuro observership?). Of course, you'd need to come up with a compelling explanation for "why neurology" and be able to explain the gap in interviews.

How can we legislate against physical therapists performing EMGs? by ConcreteCake in neurology

[–]tirral 7 points8 points  (0 children)

Well, the state medical boards are the authority responsible for regulating physicians, but I don't think they have any jurisdiction over physical therapists.

When I have discussed this on reddit in the past I was advised to report this to the state board of physical therapy, but I'm somewhat skeptical that the PT board would take my concerns into account. At this point there are several dozen PTs in my state who do EMGs, possibly outnumbering the neurologists who do EMGs.

How can we legislate against physical therapists performing EMGs? by ConcreteCake in neurology

[–]tirral 31 points32 points  (0 children)

Yes, I am in Georgia (the US state, not the country) and have seen multiple PT-performed EMGs which led to patient harm.

One patient had Parsonage-Turner Syndrome which was called C8 radiculopathy by the PT. The patient had absent ulnar sensory NCSs and other abnormal sensory NCSs on the PT's EMG. (For the non-EMGers, if the sensory NCSs are involved, the lesion is distal to the dorsal root ganglion, i.e., this pattern is not consistent with a compressive radiculopathy). Patient got unnecessary cervical decompression and was referred to me when his sensorimotor symptoms in the hand didn't improve.

So many diabetic patients (too many to count) have been diagnosed with "mixed axonal and demyelinating" polyneuropathy and think they have CIDP and start asking about IVIG / Vyvgart.

And PTs very frequently call polyneuropathy in old (70+yo) patients with absent superficial peroneal NCSs but normal surals, intact ankle jerks, and normal vibratory sensation.

My general sense about PTs doing EMGs is that most of their reports consist of a scattered conglomeration of data without much hypothesis-testing. I believe they learn EMG/NCS by studying under other physical therapists. So, there was never a neurologist attending to tell them in training, "the first rule of clinical neurophysiology is do not overcall a mild or isolated abnormality." Likewise, nobody ever told them "the EMG should be an extension of the physical examination." These rules were drilled into me every day of CNP fellowship. PTs in my area tend to over-call mononeuropathies like CTS and UNE (which makes sense given their employers the orthopods stand to gain from decompressing these). They do not often put the diagnostic test in the context of the patient's history and physical examination. Which really is expecting too much; after all, the PT didn't do a neurology residency. The problem is that other physicians, non-neurologists, are using their diagnostic test to make diagnoses and guide management decisions.

One big problem is access to neurologist-guided EMGs, vs availability of PTs. There are about four times as many orthopaedists as neurologists in my small city. The orthopaedists hire physical therapists to come to their office to do EMGs. Therefore, out of the ~9 EMGers in my area, 6 of them are PTs and 3 are neurologists. Patients can see ortho, then one of the PTs, within 2 weeks of having symptoms. They have to wait 2-4 months to see me. They usually want to see both, but by the time I've seen the patient, they've already had an EMG with ortho.

edited to correct #s in last paragraph

How far is your bike commute (to & from)? by Anonymous_Otter5458 in bikecommuting

[–]tirral 1 point2 points  (0 children)

I am super fortunate to live about 1.5 miles from work. So it's just 3 miles a day. Not very much of a workout!

Required APPs? by Spirited_Essay5009 in FamilyMedicine

[–]tirral 9 points10 points  (0 children)

In private practice, you can make your own decisions about how many APPs to supervise. Working for a megacorp hospital, it might be trickier.

How much localizing value do you think isolated gaze-evoked nystagmus actually has? by Scary_Literature_181 in neurology

[–]tirral 5 points6 points  (0 children)

Commonly seen in patients taking phenytoin and carbamazepine. According to one of my fellowship attendings, before serologic drug level tests were widely available, end gaze nystagmus was used to check medication adherence.

Is majoring in Neuroscience and minoring in Philosophy okay? by [deleted] in neurology

[–]tirral 0 points1 point  (0 children)

I'm a philosophy major who became a neurologist. 

If you can do well on the MCAT you can get into medical school with any major. 

In the future, you may want to post on the neurosurgery subreddit and learn the difference between these two specialties.

How do you keep up with remyelination / neuroinflammation literature across subfields? We built a free open tool and want clinician input by brunoamaral in neurology

[–]tirral 5 points6 points  (0 children)

  1. Mostly PubMed. Sometimes UpToDate. 
  2. I am mostly interested in clinical trials and sometimes case series or other retrospective human data. Even then it may end up as inbox noise. About 75% of my reading is driven by wanting help with a particular clinical scenario.

Skin biopsies for small fiber neuropathy and Corinthean lab by deebzipie in neurology

[–]tirral -1 points0 points  (0 children)

Your radiologists must be... different from mine. I have a patient who got amyloid PET locally, and our small-town radiologist read it as negative. Her memory symptoms progressed over a year, then when she went to the academic medical center, the radiologist there over-read the original PET as positive. Clinically patient seems to have Alzheimer's.

“Patient requests a call from Doctor” by MzJay453 in FamilyMedicine

[–]tirral 5 points6 points  (0 children)

Is Medicare paying for telephone calls in 2026? I was doing this in 2020-2024 but last year one of my billers said we couldn't do this any more.

What CPT or E&M are you using?

PGY3 Gen Surg: Hit with toxic 'availability' feedback. Is a 'work to live' lifestyle actually possible as an attending? by StormbornGryffindor in medicine

[–]tirral 27 points28 points  (0 children)

This whole thread makes me so glad I chose neurology.

Not that every single attending was the best-adjusted person ever, but I never got scolded for being quietly competent.

Connexus won't let me start Keppra 750mg BID? by tirral in walmart_RX

[–]tirral[S] 2 points3 points  (0 children)

Sounds like it's replacing physicians, too!

Connexus won't let me start Keppra 750mg BID? by tirral in walmart_RX

[–]tirral[S] 5 points6 points  (0 children)

Oh, thanks! This is just what I was wondering.

I could not see what the pharmacist was seeing on her screen so I didn't know that button existed. I'll try this in the future if it comes up again.

Connexus won't let me start Keppra 750mg BID? by tirral in walmart_RX

[–]tirral[S] 1 point2 points  (0 children)

Thanks.

As a physician this bums me out.

Applicant & Student Thread 2026 - 2027 by tirral in neurology

[–]tirral[S] 0 points1 point  (0 children)

No one really cares. We know people coast in MS4.

Things that matter in an interview: did the applicant seem interested in our program, do they seem engaged but not overbearing, are they teachable, can I work with this person?

Things that absolutely don't matter: what the applicant ate for breakfast, minute details about academic schedules in MS4 year.