A half‐century check‐up for child neurology training

Abstract

Legacy is everything. Honor what is good in the past, fuel what is promising in the future, and you will bring meaning and substance to the present. Nina Schor The ideal approach for child neurology training has become a topic of controversy in recent years, with strong opinions from both sides of the discussion often generating more heat than light. What follows is a dispassionate analysis of our child neurology training requirements. My intent is to facilitate constructive discussion and reframe the questions, not to take sides. We owe it to our trainees and to the children entrusted to us to create the best possible child neurology training. As a neurologist who still sees adult patients, I am not opposed to adult neurology training for child neurologists. The question is not whether a year of adult neurology training still has value for child neurologists, but whether requiring a full year continues to represent the best use of the residents' time given the major changes in the field in the half century since the basic training requirements were initially established. Similarly, it may be appropriate to discuss the optimal amount of preliminary pediatric training for child neurologists. We wrote the rules and they followed us. We set what, in the three years, these young people who were going to be trained in pediatric neurology would do. They would spend a year on the adult neurology service, learning neurology with people who could talk back to them and give them histories. Then we developed a year in which they would understand all of the diagnostic techniques. Electroencephalogram, the air tests, that sort of business, which was important. Then finally, they would take care of the children with neurologic problems. They would have the basic background now. This was on top of their own pediatric training, which we had nothing to do with except to be sure it was a good one. This became the method of training pediatric neurologists. The American Board of Psychiatry and Neurology (ABPN) was founded in 1934, and separate training and certification programs for neurologists and psychiatrists began in 1946. In 1959, Sidney Carter became the first child neurologist to serve as an ABPN director. That same year, the ABPN began to include child neurology topics in its certification examination, which at the time consisted of an eight-hour oral examination.2 During the next eight years, a written examination with child neurology topics was introduced, and in 1967, the oral examination was scaled back to four hours, one of which focused on child neurology. In 1969, the ABPN created its “Special Qualification in Child Neurology” category, awarding 106 “grandfather” certificates to individuals who were already focusing on child neurology.2 There have been a number of modifications to the child neurology certification process since it began. The oral examination was eventually reduced to three hours and later replaced entirely with an expanded written examination. Time-limited certification was introduced. The option of dual certification in pediatrics and in neurology remains, although fewer and fewer trainees opt to pursue certification in pediatrics.3 Two infrequently used alternate certification pathways allowing one year of general pediatrics training to be replaced by either internal medicine or pre-approved neuroscience research were approved, of course without the option of certification in general pediatrics. The six-year neurodevelopmental pediatrics track was approved as a separate pathway. Thus, the certification process has not been stagnant, but the requirement for 12 months of clinical adult neurology training has remained intact. A decade or so ago, the Child Neurology Society's (CNS) leadership and the society's representatives on the Neurology Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) initiated a discussion about the child neurology training requirements that culminated in a series of curriculum modifications in 2014.4 Before then, the focus of the adult neurology training for child neurology residents was largely at the discretion of the individual programs, and some child neurology residents spent most of the time on inpatient rotations. To complicate things further, adult-focused rotations such as adult neurophysiology, neuroradiology, and neuropathology could not be used to satisfy part of the adult neurology requirement because the activities did not include direct care of the patients. The 2014 update specified six months of hospital-based rotations, three months of outpatient experience, and three months of adult-focused electives. Additionally, adult specialty rotations could now include some portion of child neurology, provided that the predominant focus of the rotation remained on adult neurology. Programs were encouraged, but not required, to defer some of the adult neurology rotations into the second and third years of neurology training. By most accounts, these recent modifications have been well received (despite the initial grumbling in some quarters that the changes would degrade the training experience and ruin long-established traditions). However, the introduction of these simple changes in the training requirements may have defused the larger question: Does a child neurology trainee really need a full year of adult neurology and two full years of general pediatric training to become a competent child neurologist? Whatever one thinks of the current training and certification requirements, one has to admit that the field has changed tremendously in the last half century. When the initial requirements were implemented, child neurology was generally viewed as a subspecialty of neurology rather than a separate discipline. There were few child neurologists when certification began, and many of these individuals saw adults as well as children. Most early training programs had relatively few child neurology faculty members, creating a dependence on the adult neurology faculty for basic instruction. An often-mentioned justification for the year of adult neurology training is how difficult it is to learn history taking and anatomic localization skills while evaluating children. While this notion is somewhat plausible, not all adults are cooperative and not all children are hopelessly uncooperative. What may have been more important for the trainees was the sheer number of adults with focal neurological lesions and the frequency with which the diagnosis was confirmed by autopsy. Today's resident is still likely to encounter more patients with focal lesions on the adult wards than in pediatrics, but the advent of modern neuroimaging techniques made it relatively easy to confirm lesion locations in children. Numerous other advances now compete for curriculum time, although some of these are applicable to both adults and children. In the last half century, our understanding of stroke in children, the neurological problems of neonates, epilepsy management, and neuroimmunology has improved dramatically. Advances in genetics now allow precise diagnosis of rare disorders and, increasingly, sophisticated treatments utilizing gene therapy or specific mechanism-based treatments derived from a deep understanding of the molecular biology of genetic diseases. The need to introduce trainees to these and other advances now drives the need to reassess time-honored approaches. Adult neurology training clearly had value for child neurologists when the certification process began a half century ago, and most of us believe that it remains useful. It may be easier to hone neurological localization skills in adults, and the ability to quickly amass useful experience in disorders like stroke that are more common in adults seems worthwhile. While people will disagree, there may also be some value in the very rite of passage that we are discussing: becoming part of a larger network of neurology colleagues through shared experiences. Perhaps we should ask the question in a fashion that is more constructive: What is the best return on investment for the 12 months now spent on adult neurology training? In a recent survey of child neurology residency directors, 73% of the respondents thought that child neurology residents need fewer than 12 months of adult neurology training.5 Prominent among the topics needing additional training emphasis listed by program directors and residents were genetics, neuroimmunology, fetal-neonatal neurology, neuromuscular diseases, and developmental disorders.6 Similarly, 70% of the surveyed program directors favored increased program flexibility for the adult neurology training requirements.5 Carter's original scheme allowed a year for adult neurology and another year to learn diagnostic tests, which at the time would have included cerebrospinal fluid analysis, electroencephalography, cerebral angiography, and pneumoencephalography.1 One wonders how Carter would have allocated these 24 months had his trainees needed to learn about neonatal neurology, autoimmune neurological disorders and gene therapy, neuro-oncology, and numerous then-unknown genetic disorders. Modern trainees also need to know about computed tomography, magnetic resonance imaging, cranial ultrasound, polysomnography, magnetoencephalography, and a myriad of genetic diagnostic tests. Trainees have three years to accumulate all the information and experience that are needed to become an independent practitioner of child neurology. In one survey, only 2.9% of the child neurologists who were certified by the ABPN between 2001 and 2010 now care for adults, and the majority of the respondents estimated that they used their adult training “less than weekly.”7 Are the adult neurology months so valuable that they trump rotations such as pediatric neuro-ophthalmology, pediatric neuromuscular disease, clinical genetics, or pediatric neuroimmunology? Viewing the issue as a question of relative value makes it easier to consider the potential effects of both change and the failure to change. Reasonable people can disagree on the best approach to training. Whether in favor of change or in support of the status quo, individuals with strongly held beliefs tend to express their views more forcefully, but it does not follow that their opinions are more correct. Neither should we automatically assume that survey data indicate the optimal approach; if a thousand people speak nonsense, it remains nonsense. Perhaps we can agree that none of us has all the answers when it comes to clinical training, that each program may have unique needs and capabilities within the framework of the core requirements, and that it is not heresy to periodically formally assess whether changes are needed. Most child neurologists who attained ABPN certification between 2001 and 2010 would favor reducing the length of adult neurology training to six months.7 Most child neurology program directors favor increased program flexibility in the required adult neurology training.7 Child neurology residents indicate that adult neurology training negatively affects their wellness, mood, and work-life balance, particularly when all 12 months of adult neurology training are completed during the PGY3 year. They also acknowledge a small positive effect on their sense of autonomy.8 In most programs, child neurology residents share the night and weekend adult neurology call duties during adult neurology rotations, including the non-clinical rotations in many programs.4 Neither the ACGME nor the ABPN specifically requires child neurology residents to participate in adult neurology night call, and a few programs, including my own, do not require their residents to do so. Is adult night call an essential part of child neurology training? Is such duty advisable given the increasing complexity of the patients and the technology in many hospitals? Does the activity contribute to the resident's future competency as a child neurologist? Providing adequate supervision and readily available backup should make it safe for child neurology residents to participate in adult neurology night call. But surveyed residents feel unsafe because of inadequate supervision, perceive a lack of career relevance, and report a lack of prioritization of education.8 It seems likely that some supervising adult neurologists assume a certain level of background knowledge and basic training in adult medicine on the part of the on-call residents, most of whom completed an internal medicine internship before starting their neurology training. How quickly and effectively can the supervising neurologist adjust these assumptions when supporting residents without the preliminary internal medicine training? How willing are they to provide additional resident support if it requires more after-hours involvement in the patient's care? What is the competence return on investment for the time a child neurology resident spends caring for patients with conditions that they will not often see in the future? In my own program, we halted adult neurology night call after concluding that the activity did not provide enough long-term educational value to compensate for the possible practice risk and the negative effect on resident wellness. The change has had a stunningly positive effect on the residents' morale and sense of well-being. Time will tell whether we have hindered our residents' long-term professional development, but we do not think so. We should have suitable training standards for both adult and pediatric neurology residents, with requirements designed to ensure that all trainees of accredited programs achieve a basic level of clinical competence. But residency programs have varying needs and capabilities, and 70% of surveyed program directors favored increased program flexibility for the adult neurology training requirements.5 Some training programs could probably produce competent child neurologists without allocating a full year to adult neurology, while other programs may continue to benefit from a more robust contribution from adult neurology colleagues. Is there a way to introduce more flexibility in the training requirements without jeopardizing the overall quality of the training? In the case of the adult training for child neurologists, for example, might it be possible to specify both a minimum and a maximum number of adult neurology months, perhaps six and 12 months? [Correction added on 18 February 2023, after first online publication: In the preceding sentence, ‘five’ was changed to ‘six’.] With this approach, a program would be required to provide at least six months of adult neurology training, but could opt instead to maintain the current 12 months. A major reduction of the required adult neurology training would result in loss of the “special competence” certification designation. Since fewer than 3% of child neurologists provide general adult neurology care,7 it seems unlikely that this change would upset very many people. A more practical consideration is the effect that reduced exposure to adult neurology would have on the trainees' ability to pass the current neurology certification examination, which is already weighted toward adult neurology topics. Is this concern a reason to maintain the status quo or a reason to develop a more focused test? These issues should be part of any discussion. And by the mid-1960s, it was not clear which specialty—neurology or pediatrics—would absorb child neurology. Dialogs developed between the members of the American Board of Pediatrics—Randolph Byers of Harvard and Ralph Platou—and the ABPN. This was to see who was going to be the big papa. Representing adult neurology was Frank [Francis] Forster and me. Based on the necessity for formal training in neuroanatomy and neurophysiology for pediatric neurologists, obviously lacking in a pediatric residency, these discussions led to the development of certification in 1967 by the ABPN, with a designation of Special Competence in Child Neurology. So when you got your certificate, this is what it said. And you were really trained in two fields. Peace was made because pediatrics could have it and neurology could have it…. The ability to do this made peace between the higher-ups in neurology and in pediatrics. The pediatricians—the big-shot pediatricians didn't give a damn about neurology. And the big-shots in neurology didn't give a damn about pediatrics. That's a cold way to put it, but that wasn't about who was going to get the end people involved and where were the new people coming from. Much of the recent discussion about child neurology training has focused on the number of months of adult neurology training. Strangely, the question of whether one really needs two years of general pediatric training to be a competent child neurologist seldom arises, even though many of the arguments for reducing the time spent on adult neurology training would seem to apply equally to the general pediatrics training. The lure of dual board certification has diminished as fewer and fewer physicians pursue board certification in pediatrics and many of those who do opt against recertification. To some extent, we have already answered the question of whether two years of general pediatrics training are essential to becoming a competent child neurologist. The individuals who complete a single year of general pediatrics as a part of the internal medicine-pediatrics track or the research track are not eligible for certification in general pediatrics, but there is little evidence that they have difficulty passing the neurology board examination or that they lack clinical competence in child neurology. We know little about whether the training time deters people from becoming a child neurologist, but the duration of training seems to be less important than the influence of a role model or an intellectual interest in the topic. However, the residency length may diminish the number of child neurologists who complete fellowship training. Ninety-three percent of adult neurologists complete a post-residency fellowship, while only 56% of child neurology residents do additional training.9 Does anyone seriously think that our lower fellowship numbers are unrelated to the existing five-year training requirements? This again raises the issue of relative value. What would serve a child neurologist better, the current two years of general pediatric training or a single year coupled with a later year of specialized training in neurology? Could our traditional training requirements unwittingly promote lack of diversity within the profession? There is evidence that limited exposure to neuroscience and clinical neurology may contribute to a lack of diversity within neurology.10 But medical education is expensive, and groups that are poorly represented in child neurology tend to be the same groups that have been historically excluded from wealth-building endeavors. A recent analysis of 2014–2019 Association of American Medical Colleges resident data demonstrated that Black residents were significantly more likely to have debts than other individuals (e.g., 60% versus 35% with pre-medical education loans and 50% versus 25% with consumer debt). Several other groups were also more likely to have debt than were White and Asian trainees.11 It seems reasonable to ask whether an additional year with a low resident's salary could disproportionately affect students who are more indebted. What is the optimal amount of adult neurology training for child neurology residents? Is it possible to allow child neurology training programs more flexibility when deciding the amount of adult neurology training? Should each program reassess the need for their child neurology residents to cover adult neurology night call? Could our traditional training requirements unwittingly contribute to the lack of diversity within the profession? Is there a case for shortening the traditional preliminary pediatric training? Perhaps we could allow individuals who complete a clinical fellowship following residency to qualify for ABPN certification with one year of general pediatrics training, similar to the current research fellowship track. Could there be untoward economic consequences to these changes, such as limitation of the scope of practice or the curtailment of employment opportunities? Are these concerns offset by increased resident wellness and improved preparation for future practice? Because several organizations play key roles in child neurology training, revising the requirements would likely necessitate a series of initiatives rather than a single process as discussed here. These discussions need not occur simultaneously. Ultimately, it does not matter what any one person thinks, because the issues are far too important to be decided by a few individuals with the loudest voice or a readily available editorial platform. We need leaders who are wise enough to seek a consensus and strong enough to push for needed changes. This is my challenge to you, the leaders of the profession: create a series of high-level panels of all reasonable stakeholders to analyze and address these complicated questions, then work to implement any changes the groups recommend. Whether we choose to act or to sit idly on the sidelines will be our legacy. Tradition is wonderful, but every half century or so, we need to systematically analyze whether we are doing things the best way. E. Steve Roach: Conceptualization; data curation; formal analysis; funding acquisition; methodology; project administration; writing – original draft; writing – review and editing. The author is the editor-in-chief of the Annals of the Child Neurology Society, but the expressed opinions do not reflect the official policy of the Child Neurology Society.