Pursuing Neurology Residency in the US

A lot of people have recently been asking about pursuing a Neurology residency in the US. Since I was in the same confused state of mind last year, I decided to write something about it.

Neurology is a specialty that has a direct induction instead of being a fellowship like other IM sub-specialties. Residency in it is a 4-year program with the first year being in IM which can be either in the same hospital or different depending on the type of program (details below). 

Neurology has a lower mean score of Step 1 among the accepted applicants compared to IM and that is because of "less applicants to number of positions" ratio. 

Scope of Neurology

The reason why few people apply to this field is mainly because it’s not as lucrative as other fields like Cardiology and GI, due to less intervention/procedure opportunities. But this trend is changing, as new treatment modalities are being developed and a lot of research is being done.

Most of the neurological diseases are chronic and so the practice is very outpatient based, but many hospitals in the US still have dedicated primary neurology inpatient services including a Neuro ICU.

Other subspecialties usually just have a consult service in the hospital. There are diverse careers that people can pursue after neurology residency. The most popular one is Neuro-Hospitalist but there are several fellowship opportunities like stroke, neuro-intensivist, neuroimmunology, epilepsy etc.

Applicants who apply to neurology usually have a very strong passion for this field because neuroscience tends to be one of the hardest subjects for most medical students. So, this passion and past history of work in neuroscience is something that program directors are keen to look at. 

Now as international medical graduates, it’s necessary to get US clinical experience in a neurology specific field or at least have related research experience. 

There is a notion that research experience is necessary but that’s not actually the case. There are people who are interested in just the clinical aspect of neurology which is appropriate from a PD’s point of view. 

The best programs will of course only accept candidates who have both a strong research background and good clinical exposure. In any case, the CV should have a neurology focus, otherwise it becomes tough.

I personally did an elective at West Virginia University in neuroradiology and neurology combined. 

The exposure to interventional neurology there really impressed me, but I also liked rest of the neurology setup there. 

We are barely exposed to clinical neurology in our rotations here so having this exposure in the US is what pushed me to pursuing a residency in it. I also did an observership at Tufts Medical Center. 

Neurology Observership Programs

Here’s a list of possible Neurology Observership Programs:

●        Tufts Medical Center

●        University of Nebraska Medical Center

●        Aurora Health

●        Epilepsy Course at Cleveland Clinic

●        University of Missouri - Columbia

●        Henry Ford

●        Mount Sinai – Neurosurgery observership

●        Wayne State University

You have to contact the program coordinators within the neurology department of these places to get more information about them. I am sure there are more places that people can find with their contacts, so this list is incomplete.

Points That Should Be Kept In Mind While Applying For Residency

Please review the following points when applying for residency, I copied it from a post on a Facebook group:

1. Neurology in the US is a 4 year residency program, the first year of which, also known as intern year, is required to be 80% of Internal Medicine, as per ACGME guidelines. This can be achieved by doing either a preliminary IM year or transitional year as a PGY-1. There are also other minor prerequisites but I will not get into those at this time.

2. Neurology residency comes in 2 flavors: Categorical and Advanced. There is no difference in training, just the way the programs are conducted. Categorical means that you do all 4 years of your residency as the same institution which is determined when you match into a program. 

Advanced means that you will have to apply individually for your intern year (PGY-1) as well as the following years of Neurology residency (PGY-2 to PGY-4). This can be either at the same institution or at different program altogether. 

Separate applications will have to be sent even if you are applying to the same institution. Luckily, most programs are now categorical.

3. Categorical programs have guaranteed PGY-1 spots for their residents. For advanced positions, some programs will state whether they will be able to arrange for interviews for both IM and Neurology on the same day or not. 

You will have to apply separately for both disciplines, regardless. There is no guarantee that if you do receive an interview for Neurology at a particular program, their IM department will also extend an invite.

4. It is usually preferable to apply at the same institution for both advanced Neurology and/or prelim IM/Transitional Year spots or atleast in the same city/state, if possible. Otherwise, you will have to arrange to move right at the end of PGY-1 and before you start PGY-2.

5. Since Transitional Year programs are more flexible with their rotations, as long as you are fulfilling the 80% Internal Medicine requirement as outlined by ACGME for Neurology residency, you are good to go. Transitional Year residencies are more competitive, however, especially for IMGs.

6. You can use your personal statement for Neurology when applying to prelim IM/Transitional Year spots. 

These positions are specifically reserved for those seeking other advanced specialties like Radiology, Anesthesia etc. Programs are aware that your goal is to match into an advanced position so you will not be at fault for mentioning that in your PS. In fact, it is encouraged.

7. If you are applying to multiple specialties for backup, please do NOT apply to the same institution. 

Neurology and Internal Medicine are almost always in close communication, so it does not reflect well, if someone is found to be applying to Categorical Neurology and Categorical Internal Medicine positions at the same institution. It comes off as conflict of interest. This does not mean you cannot apply to other programs in the vicinity. Just not the same faculty!

8. IM letters can be used for Neurology applications and vice versa. Neurology Programs will prefer those that have CVs more centered towards the field as this reflects genuine interest. 

US based letters are always given preference but if you have good letters from your attendings back home, and specific to Neurology, they are worth attaching.

9. Rank order lists will also differ for advanced positions. I will post closer to submission time to highlight how that works.