Advances in neurological education: A time to share

Neurological education in medical schools and residency programs has changed dramatically over the past decade. New mandates from regulatory agencies, such as the Liaison Committee for Medial Education (LCME), Accreditation Council for Graduate Medical Education (ACGME), and American Board of Medical Specialties (ABMS), have had a profound effect on curriculum and evaluation of medical students and residents. In addition, major initiatives in neurological education by the American Academy of Neurology (AAN), the American Neurological Association (ANA), and the Association of University Professor of Neurology (AUPN) have also had an impact on Neurology curricula in medical schools and residency programs, with one goal being the recruitment and retention of high-quality US medical students in Neurology residency training programs. One of the responses of the medical profession to concerns over the delivery of health care has been to tighten the requirements for medical student education, residency education, and physician education. The Accreditation Council for Graduate Medical Education has established six core competencies (medical knowledge, patient care, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice) that all residents must master to complete residency training.1, 2 In addition, the Residency Review Committees will be focusing on outcomes rather than process when evaluating residency training programs.2 The Residency Review Committees have previously evaluated whether residency programs have the potential to educate residents in a specialty by focusing on curriculum, number of faculty, number of patients, variety of conferences, and so forth. In the future, they will focus on whether residency programs are actually teaching the residents, by evaluating performance of these residents in practice. Concerns for patient safety have resulted in limits on work hours for residents.3-7 Lastly, medical schools and residency programs are placing new emphasis on evidence-based medicine and cost-effective health care as possible solutions to the tensions resulting from rising medical costs, advancing technology, and the need to improve medical education.8 The following three sections consider advances in neurological education for medical students, restructuring residency training in Neurology, and teaching Neurology residents how to enter the workforce. In this section, Ralph Józefowicz, MD, Neurology Residency Program Director, Neurology Clerkship Director, and Neural Science Course Director at the University of Rochester, discusses new developments in medical student training. Teaching neural sciences and neurology to medical students has changed significantly over the past 10 years. This section discusses changes in preclinical neural science teaching; changes in the Neurology clerkship; efforts of the AAN, ANA, and AUPN to increase student interest in Neurology; and future directions in neurological education. More and more medical schools are teaching the neural sciences in an interdepartmental course. Not only are neuroanatomy and neurophysiology being taught concurrently in these courses, but at some medical schools, neuropharmacology and neuropathology are being integrated as well. A small number of schools have also integrated psychopathology into a supercourse that teaches brain and cognitive sciences. The main advantage of such integration is that clinical relevance becomes immediately apparent to the students.9 For example, when structure and function of the basal ganglia are taught, appropriate clinical faculty can discuss the neurological and psychiatric diseases that result from dysfunction of the basal ganglia. Recently, the AAN and the Association of Medical School Neuroscience Department Chairs have formed a task force to develop a core curriculum for these integrated neural science courses. In addition to changes in curriculum, methods of instruction are also changing in medical schools. Small-group, problem-based learning formats have replaced some of the lectures in medical school as a way to engage students in active learning and problem solving. Integrated neural science courses are ideal courses for including problem-based learning formats, given the frequency with which psychiatric and neurological disease coexist in the real world. Another enhancement in basic neural science teaching has been the incorporation of neuroimaging into traditional neuroanatomy and neuropathology laboratories. In many medical schools, interpretation of brain computed tomography and magnetic resonance imaging is taught concurrently with cross-sectional neuroanatomy in these laboratories. Only 80% of medical schools require clinical experience in Neurology, and in many of these schools, the experience is only 2 weeks and occurs during the fourth year.10 The primary reason for this is the Liaison Committee for Medial Education standard ED-15, which states “The curriculum should include clinical experiences in Family Medicine, Internal Medicine, Obstetrics and Gynecology, Pediatrics, Psychiatry, and Surgery.” Neurology is not mentioned as a requirement. That said, the AAN, ANA, and AUPN are joining forces to make Neurology a requirement in medical school curricula. In 2000, the AAN Consortium of Neurology Clerkship Directors published core curriculum guidelines for the Neurology clerkship to help medical schools standardize the teaching of neurology to their medical students.11 These guidelines may be found on the AAN Web site (www.aan.com). The Liaison Committee for Medial Education is also requiring that each clerkship define specific diagnoses and conditions that students must see during their clerkship experience, as well as student level of involvement for these patients (observe, examine, or manage). For Neurology clerkships that are only 2 weeks, meeting these specifications will be a challenge. Integration of clinical clerkships is yet another trend in medical schools, and in certain medical schools, the Psychiatry and Neurology clerkships have been merged. In some of these schools, the integration is minimal and primarily consists of several joint conferences. In others, the integration is more complete. In 2004, the AAN Consortium of Neurology Clerkship Directors and the Association of Directors of Medical Student Education in Psychiatry issued a joint statement concerning integrated Neurology and Psychiatry clerkships. Specifically, both organizations reaffirmed the unique nature of each specialty with respect to the diseases that are seen and the approach to the patient, and they urged caution in the design of such conjoined clerkships. The 1990s saw a dramatic decline in the number of US medical students entering Neurology residencies. As a result, the AAN, ANA, and AUPN developed programs to increase interest in neurology among US medical students. Student Interest Group in Neurology (SIGN): The AAN has actively promoted the formation of SIGN groups in all US and Canadian medical schools. Currently, there are more than 143 SIGN chapters exist. SIGN activities include lunch or dinner meetings with Neurology faculty and residents, community outreach programs, shadowing programs with Neurology residents, as well as publication of a SIGN newsletter. AAN Medical Student Prize for Excellence in Neurology: Each neurology department may nominate one graduating medical student for this award, which is typically given at graduation. Medical Student Summer Research Scholarship: Up to 20 scholarships are awarded to first- or second-year medical students to support a summer research project. Medical Student Scholarship to the Annual Meeting: These scholarships provide travel support for medical students to attend the AAN Annual Meeting. Minority Scholars Program: This comprehensive program provides travel scholarships for minority students to attend the AAN Annual Meeting, travel stipends for these students to participate in Neurology clerkships at institutions outside of their own, and honoraria for faculty to speak at minority medical schools. Clinical Neuroscience Pathway: This program encourages neurology departments to establish enriched curricula for medical students interested in neurology as an academic career. ANA Academic Neurology Teaching Scholarship: These fellowships provide junior faculty members with a 2-month mentored fellowship in teaching skills and curriculum design. John N. Whitaker Visiting Professorships: This program provides five awards annually to fund a visit by a senior neurologist to interact with medical students, both formally and informally, to increase their interest in neurology as an academic career. AUPN Recruitment Prize: Two prizes are awarded annually to Neurology departments for recruiting the largest number of medical students into Neurology residencies. Future directions in neurological education for medical students will likely focus on evaluation techniques. Because testing drives the curriculum, developing evaluation techniques that stress outcomes will likely result in positive curricular change. Current evaluation techniques rely heavily on multiple-choice questions, which are excellent at testing knowledge and application of knowledge.12 Skills and attitudes, arguably as important as knowledge for physicians, cannot be tested using the multiple-choice question format and require other methods of evaluation. Objective-structured clinical examinations using standardized patients are used in many medical schools as part of a comprehensive examination or a clerkship examination, and all six core competencies can be evaluated through an objective-structured clinical examination. These examinations consume a significant amount of faculty time and effort, require a significant amount of clinical space, and are costly to mount. The National Board of Medical Examiners (NBME) now requires all medical students to take and pass a clinical skills examination that uses an objective-structured clinical examination format with standardized patients at ten stations. The unanswered question is whether physician performance will improve as a result. In this section, Steven Galetta, MD, Neurology Residency Program Director at the University of Pennsylvania, discusses new developments in residency training. We are witnessing major transformations in Neurology residency training in response to rapid advances in the field of neurology and to external regulatory demands. The AAN has defined the essentials of Neurology residency training and has developed a curriculum centered on the core competencies. In response to these changes, programs have developed new methods and modalities of teaching, procedures for evaluation, and rotations to expand clinical training. Perhaps the greatest challenge for program directors over the past decade has been structuring clinical training so that it encompasses the explosion in subspecialty neurology. Clinic experiences traditionally have provided residents with exposure to a wide variety of neurological conditions. Popular methods have included sending residents to work in a group practice staffed by attending physicians on a rotating basis. This setting often includes full-time academic physicians mixed with private practice neurologists to provide the residents with a broad perspective on treatment options. For large patient populations such as those with epilepsy, subspecialty days can be arranged and staffed by appropriate subspecialists. Several programs use the “firm system” in which groups of residents are assigned to groups of faculty members for the duration of their training. Whereas in this format residents have the advantage of providing longitudinal care, exposure to a limited number of attending physicians may impart a narrow perspective. Alternative arrangements include clinics in which residents rotate through a different specialty area every day. This type of rotation is particularly helpful for junior residents who are trying to choose a specialty area for subsequent training. Other clinic models have each resident linked to a specific attending physician on a weekly or monthly basis. Most programs have developed outpatient subspecialty groups to offer residents the diverse clinical experience necessary for comprehensive preparation for practice. TheUniversity of Pennsylvania (PENN) has created 1-month rotations in neuroophthalmology, movement disorders, cognitive neurology, multiple sclerosis, stroke, epilepsy, neurooncology, and neuromuscular disease. Residents attend the clinic daily and evaluate both new and follow-up patients to gain a longitudinal perspective of the subspecialty. In addition to the traditional neuropathology rotation, neuroradiology and interventional neurology are now also offered as electives. Other institutions, such as Johns Hopkins University and New York University, have developed combined training programs in neurology and radiology as the field of interventional neurology continues to expand. There also has been a rising demand for exposure to urgent neurological care and to outpatient neurology. In response, PENN created an ambulatory emergency service. The service is staffed by a senior resident who answers calls from outpatient services requesting immediate neurological evaluations. This rotation provides residents with an opportunity to field calls from referring physicians and patients and to assess the urgency of a variety of neurological problems. Follow-up care is provided by residents in their clinics and supervised by members of full-time and associate faculty. As neurologists assume increasing primary care of patients with serious problems, such as stroke, intracranial hemorrhage, encephalitis, there is a corresponding need for residents to acquire greater intensive care unit experience. This move toward neuro-intensive care training corresponds with dramatic advances in stroke, neuroimaging, intensive care unit medicine, and neurological therapeutics. Such programs will need to be staffed with physicians specialized in neuro-intensive care to address the rising demand for this type of training. Because a great deal of clinical experience is necessary to pack into any one residency program, and considerable specialized expertise may be difficult to find in any one setting, we are seeing a number of fruitful partnerships develop. PENN and Johns Hopkins University, for example, have developed a formal partnership to facilitate exchange of elective rotations between programs. Residents are offered the option of taking 1-month electives sponsored by the primary program. Our two training programs also hold a joint annual research conference to expose residents to a broader array of potential mentors. Some programs offer specialized training to residents outside of their institution. A rotation in multiple sclerosis is available at the University of Texas-Southwestern, and an epilepsy program at Wake Forest University has been offered for many years.13, 14 Several sponsors, including pharmaceutical companies, the AAN, and others, provide external funding for prolonged visiting professorships. The Mayo Clinic and University of Colorado sponsor visiting professorships that last for several days. Such interactions enhance resident exposure to a wider variety of material and diversity of viewpoints. International exchange is another mechanism by which residency training may be enhanced. Several global neurological outreach programs have been initiated by large US institutions to improve health care delivery and education in both developed and underdeveloped countries. PENN has partnered with Botswana to provide clinical care across a variety of specialties. Senior Neurology residents may elect to do 4- to 6-week rotations at the Princess Marina Hospital in Gaborone, Botswana, supervised by full-time PENN Department of Medicine faculty. In this setting, they serve as one of just a few neurological providers in the entire country. Residents are exposed to large numbers of patients with neurological disorders that are common to Botswana including tuberculosis, human immunodeficiency virus infection, and cryptococcal meningitis. Faculty and medical students from PENN rotate alongside the Neurology resident. The University of Rochester (UR) has partnered with Jagiellonian University College of Medicine in Kraków, Poland, to improve neurological education at that institution. Senior UR Neurology residents travel to Kraków for a month each year to teach neurology to Polish medical students and gain experience in lecturing, leading small groups, and conducting Attending Rounds on this elective. The UR residents are supervised by a senior UR Neurology faculty member, and UR medical students contribute by teaching physical examination and presentation skills to the Kraków students. Medical education has benefited from a variety of digital resources (Table 1).15, 16 The Internet has been adopted by many programs to widen exposure to educational materials. A variety of subspecialties have created Web sites so that residents and other practitioners can obtain valuable educational material online. Several AAN Web-based programs are available for bioethics education,17 and PENN has incorporated the case-based bioethics syllabus into weekly resident meetings. The AAN has also developed practice parameters, which may be incorporated into a management conference format.8 Web-based teaching programs are available from subspecialty societies on subjects such as headache, epilepsy, and neuroophthalmology.18, 19 The neuroophthalmology Web site Neuro-Ophthalmology Virtual Educational Library (NOVEL) provides an enormous collection of slides, videos, and audiotapes.20 Other institutions have developed similar types of Web-based educational material with offerings such as simulated eye movement abnormalities and a syllabus for neuromuscular disease.21, 22 A powerful search engine of available Web sites for neurology and neurosciences may also be found at neuroguide.com (see Table 1). The accessibility of medical literature on the Internet has further expanded medical education. With it comes the need to instruct residents on how to analyze the value of publications. Recently, attention has been directed toward development of a research curriculum to teach the residents the basic principles of epidemiology, biostatistics, and methods of clinical investigation. At PENN, this has been dubbed the Patient Oriented Research Program (PORC). During the academic year, we teach residents how to write a research proposal and a case report. We show them how to critically evaluate medical literature and how to incorporate such findings into clinical practice. In this epidemiological program, residents are asked to co-lead with a faculty member one meeting per year. This approach exposes residents to a variety of potential mentors ranging from those in practice and industry to those who conduct clinical and basic research. By the end of their residencies, we expect our residents to have chosen one research mentor and to have made formal clinical or basic research presentations before the entire faculty. Presentations may be as simple as a case report and review of the literature or as complex as bench experimentation. This curriculum has been valuable to our residents regardless of their choice of career. Many of our residents have used this experience to apply for external funding support or to launch their specialty interest. We find this curriculum to be an effective way to conduct journal club and to teach the basics of writing a clinical or research report. Many programs offer sufficient elective time so that a resident may spend several months in the laboratory. However, some programs offer extended training options for those residents who desire further preparation for an academic career. At UR, a flexible 6-year program is available. After 1 year of postgraduate internal medicine, the resident spends a year in clinical neurology. The remaining 4 years of training are individualized to permit sufficient clinical training to complete Board requirements and to allow for at least 2 years of laboratory experience. The ANA's long-range planning committee has recently proposed the development of a flexible research track for adult Neurology residency training.23 The goal of this new initiative is to allow training programs to more efficiently prepare neurologists for a career in clinical or laboratory investigation. The program incorporates neuroscience didactics early in residency training and 6 months of laboratory experience in the third and fourth postgraduate years. Training is completed after a 12-month fellowship period during which the trainee will complete a research project and apply for a K award. The development of the Accreditation Council for Graduate Medical Education's six core competencies in neurology has produced not only changes in how we define our methods of training, but also changes in our evaluation system (Table 2). In response, the AAN has developed a curriculum based on the six core competencies.24 The organization has outlined the content of subjects to be taught and has identified the needed personnel. It also has proposed the mechanics of training, created resources available for education, and possible methods of evaluation. 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