41: A General Pediatric Neurologist Discusses Her Specialty

Session 41

Dr. Denia Ramirez is a general academic Pediatric Neurologist. She talks about her journey to becoming a pedi neuro doc and other things about her specialty. Several weeks ago, we had a pediatric neurologist who specializes in headache medicine. She has been out in practice now for five and a half years after her residency in pediatric neurology. She is in a combined academic and community setting at the University of Tennessee Medical Center (UTMC).

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[01:33] Her Interest in Pediatric Neurology

When she did her pediatric residency in Costa Rica, she got amazed by how a child gains milestones. She got interested in how things changed, and how they can shift from being so little and happy to somebody and completely against anybody who's a stranger at eight or nine months old. Her father-in-law was also a neurologist. It was around that time when she met her husband. So she got to see more of what a neurologist is not only inside but outside. This is basically what sparked her interest in neurology.

Other specialties that piqued her interest include emergency medicine. She realized the demands and the amount of time she was going to be out of home if she decided to go that route was probably too much for her. Since she still had to take care of family and do other things as well.

[03:20] Traits that Lead to Becoming a Great Pediatric Neurologist

First of all, you'd have to like kids. Not only for peds but also for adult neurology, you have to know your neuroanatomy. You have to know your localization well and learn the process in which we're taught to think to try to reach a diagnosis. More often than not, you're going to hear people you have to be smart to do this or that subspecialty.

"You have to like it. You have to enjoy it. You have to be dedicated. That holds true for any single subspecialty you get yourself into."

For Denia, one of the most wonderful things is when she's in clinic, she's essentially being paid to play with kids. She loves what she does and she loves talking to kids. She loves talking to parents. She loves to work with them and this makes her job much easier.

[04:40] Types of Patients

Denia says she sees almost anything. Child neurology has been a relatively new thing. She gets kids with epilepsy and the whole spectrum of those kids. There are those who come every six months. She helps them walk through the process and helps them until they outgrow it. She also sees kids with severe brain lesions or have genetic epilepsies. They also see kids with headaches. A lot of very normal kids who had one or two febrile seizures and parents are understandably worried and concerned about what that means. They also see kids with developmental delay with learning problems or kids struggling in school. Everybody wants to make sure that they're not missing something that is bigger. They see kids with neurodegenerative diseases. They see a lot of other different things like difficulty in walking, kids with ataxia, and so much more.

"The nice thing about pediatric neurology that is a relatively small field, there's not a lot of us."

Being a very small field, Denia says how they're so open and very supportive of each other regardless of the training program. And as much as they want kids with movement disorders to be seen by a movement disorder specialist, for example, but you don't always have that luxury. You reach out for them but you continue to take are of those kids.

[07:00] Generalist vs. Subspecialty and A Typical Day and Work-Life Balance

Denia cites three reasons for choosing to generalize instead of specializing. First, she has already done her residency training once back home and she'd have to repeat it. She felt she was at a point where she really needed to be more productive and do something. Additionally, she likes the idea that she gets to have all sorts of patients. Melinda adds she doesn't want to be stuck in a small bucket of things she sees over and over. She likes that she can see almost anything.

"The diversity continues to be a good stimulation for my knowledge, for my learning, and for continuing learning."

A typical day for her would be doing rounds. They don't have admitting services but they have consulting services. For the most part, she sees patients at East Tennessee Children's Hospital, not affiliated with UTMC.

Then she holds clinic between 10 and 11 am. She does reading and goes through a couple of journals to see if there is anything new that can contribute to her knowledge. Then in the afternoon, she sees patients. At the end of the day, she normally checks the charts for the next day. She finishes her notes and then her day is over.

She describes 50% of her time is spent doing clinics and another 50% is on doing rounds. Half of the time would be spent in the hospital. Some days, if they don't have any consults. she spends mornings catching up with any undone work. She'd call patients and see patients in the afternoon.

In terms of taking calls, she's available when it's needed but she doesn't have to be available. At the University of Virginia where she was at recently, they'd do one week of call. Some of them did more weeks of the year, some did less. It basically varies depending on your track. And then on the week you're on call, you have to be available for your residents 24/7 for the entire week.

Denia says having good work-life balance. As anything in medicine, you have to be organized at it. As long as you're organized, as long as you keep your priorities, you can do it.Denia still gets to cook everyday and go out on weekends. They don't have kids but if she had kids, she still thinks she'd be able to do things with her children.

"In peds neurology, once you're comfortable with it, it's easy to get yourself into that process."

[12:14] The Residency Path of a Pediatric Neurologist

The classical path includes two years of pediatrics and three years of neurology. In those three years of neurology, you'd do a year of adult neurology and then the last two years are allocated for pediatric neurology. So it's all five years in total. Some people join a program after they've decided they wanted to do pediatrics. They've finished the whole three years of pediatrics and then they'd do the next three years.

Another path available to some is you can do a year of internal medicine, a year of pediatrics, and then the three years of neurology, whether adult neurology or pediatric neurology. There are some residents who start as adult neurologist and really like pediatric neurology. For them to be eligible to sit for child neurology, they're required to do an extra year of pediatrics aside from the year of internal medicine they've already done. Then they''ll have to do a year of child neurology and they're done. This path is a little bit longer.

Nowadays, most programs have the five-year path. When Denia started, there weren't that many programs that would give two years of pediatrics and three of pediatric neurology. You had to go into two different programs. Some pediatric programs didn't like it because they were losing the resident. But most of the programs now have the options where they can do five years as a pediatric neurology resident.

You can be dual certified in pediatrics and pediatric neurology if you do two pediatrics and three neurology years. But you have to make sure you meet the criteria that the AAP has established for you to be able to sit for the peds boards. The reason people like to be dual certified is because some still like to be able to do pediatrics.

"Some stand-alone children's hospitals would ask you to be dual certified in pediatrics and pediatric neurology."

Denia cites what her mentor told her that there is so much shortage that you end up not using your pediatrics board even if you're eligible to do it. As for Denia, she doesn't think she would sit for the boards in peds. And what she has heard from those who did it, is that they're not sitting through the re-certification. Unless you're doing it for a daily basis, you're going to end up studying for a test.

[16:51] Is Matching Competitive?

Although competitive, Denia says there's plenty of opportunities. Pediatric neurology is a well-held secret. It could be because the five-year training may seem so long. But it really isn't as Denia would describe it. If you want to get into a field, you can get into a very good program with good letters of recommendation. But not to a point where there's one slot and 500 people are fighting for it.

[18:10] Bias Against DO's and Other Subspecialty Opportunities

Denia hasn't seen any bias against DO's, speaking for her field.

"There's no bias. If you're good, you're good. We don't mind how you ended up finishing med school."

Once you're a pediatric neurologist, there are other opportunities that you can specialize in including movement disorder, neuron EQ, and neuropedic critical care, pediatric neuromuscular, neuro immunology, epilepsy and neuro physiology, neurodegenerative diseases and white matter diseases, and mitochondrial and genetic diseases.

When she was interviewing and trying to make her decisions to what she wanted to do, her mentor gave her this advice.

"Once you're done, you essentially can do whatever it is that you want to do."

And her mentor was indeed right. He also told her she can go wherever she wants to go since she's needed everywhere. And Denia thinks he's been right about that. She has a lot of friends in the field who have gone through different paths. And they're equally successful. It's a field that is very supportive and has a lot of opportunities.

[21:35] Working with Primary Care & Other Specialties and Special Opportunities Outside of Clinical Medicine

Denia explains that you need to work with them on getting rid of lot of myths regarding headaches. They see a lot of headaches. And they see a lot of children with headaches who could be handled at the primary care level. Another thing is when do you refer a child for seizures and when do you use your skills to reassure the parents that those are not of concern?

Ultimately, Denia advice is that when in doubt, grab the phone, Give them a call. They're always available. Don't order tests because you're worried that you don't know how you're going to interpret the test. You're opening a can of worms for you and for that family.

Other specialties she works the closest with include developmental peds, genetics, NICU, and PM&R. And in terms of special opportunities outside of clinical medicine, there are people doing outreach and volunteer work. In the next five to ten years, Denia sees telemedicine being one of the fields that is going to develop within neurology. This gives you the opportunity to still see patients in a different schedule. This would be great for parents who want to stay longer at home. Or for those who don't do well being in an office for certain amount of time. That said, you can provide the care from the convenience of your house.

There are also opportunities working for federal agencies such as FDA. An ongoing discussion within the field is how they can diversify as pediatric neurologists in the way that other colleagues have.

[25:35] What She Wished She Knew and The Most & Least Like Things

Denia wished she knew how much the medical field was going to change then it would have helped her anticipate some of the things that came as a surprise to them. For example, how to measure for productivity. This not only touches pediatric neurology, but medicine as a whole. She also wished she would have taken a little bit more time to do all the things she wanted to do before going to med school. So she tries to pass this onto her students and to the residents.

"You need to take time for yourself. It's okay to take breaks."

What she likes the most about her specialty is working with the kids. She feels it's fulfilling to see how kids don't feel well and they let you know where they don't feel well. And then they'd feel better and start to recover. Knowing you've helped and have made a difference in their life is gratifying. What is equally gratifying for her is to see how kids, in the midst of difficulties, continue to push. They're fighters. It's amazing to see how they never give up.

"It's amazing how they never give up. Kids never give up. And that is extremely touching."

On the flip side, the least liked thing about her specialty is to deliver bad news. For years, she has tried to develop within her field in terms of research to say that she may be delivering bad news but people are doing something about it. She's trying to be part of the change so they can finally say what they can offer. You're going to have to walk the parents through the process of thinking that their child's life is going to look different than what they envisioned. But that's okay and you're there to support them.

The one field she doesn't particularly enjoy is neuro oncology. So she tries to stay away from it as much as she can. But if she had to do it all over again, she still would have chosen pediatric neurology.

[29:40] Denia's Advice for Premeds and Med Students

Denia recommends grabbing every opportunity you have to observe and shadow someone in the community. Try not to go into the hospital. It has the most extreme cases and it's not going to give you a good idea or a real perspective of what child neurology is and has for you.

For medical students, Denia recommends that if you're doing your peds neurology rotation, make sure you don't stick to the inpatient. Make sure you also go to outpatient. If you have an interesting patient as an inpatient, talk to your attending physician to let you get involved with it. Make sure you do a rotation. Make sure you express your interest and you're ready to get involved. Take as much as you can from those rotations.

"Get a good perspective of what the field has for you because it's broad."

[32:45] Final Thoughts

Tell me what you think about this episode and shoot me an email at ryan@medicalschoolhq.net. If there's a particular specialty you'd like to hear sooner, rather than later, shoot me an email again. And if you have somebody you wish to recommend for me to interview, hit me up!

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