Child Neurology Residency Research Articles

The Neurology Fellowship Application Conundrum: Finding Common Ground.

For many neurologic subspecialties, the fellowship application process begins early in the first half of the second year of neurology-specific training (PGY3 for adult neurology residents and PGY4 for child neurology residents). In 2019, the American Academy of Neurology (AAN) published a position statement recommending communication between fellowship candidates and training programs begin no sooner than March 1 of the penultimate year of training and that programs offer fellowship positions no sooner than August 1 of the final year of training. A few pilot subspecialties adopted this timeline for 2021 recruitment for positions beginning in 2022. All United States-based AAN-affiliated neurology and child neurology residents who recently completed the fellowship application process received a survey about their fellowship application experience. Of the 291 residents who responded to the survey, 96% agree that applications should not be submitted before March 1 of the penultimate year of training and 72% believe that August 1 of the final year is a reasonable time to begin offering positions. Nearly half (49%) of residents believe that there is too little time for subspecialty/clinical exposure before applying for fellowship and 88% feel the current process and timeline are stressful. Residents who applied to programs in pilot subspecialties report more time to choose, less stress, and a lower number of time-pressured offers. A large majority of residents (89%) prefer to submit a single application through a centralized system. The survey results suggest that residents who just completed the fellowship application process agree with the AAN recommended timeline for all subspecialties and that all neurology subspecialties should consider adopting a fellowship match. Programs can help facilitate a better fellowship application experience by providing earlier exposure to a broad range of neurologic subspecialties and ensure that residents are given opportunities to attend national meetings and participate in appropriately scoped scholarly endeavors.

Pediatric Critical Care Neurologists in the United States and Canada: A Survey of Clinical Practice Experience.

To describe the characteristics of pediatric intensive care neurologists and their practice in the United States and Canada. We performed a survey-based study of child neurologists who self-identify as 'intensive care neurologists'. The survey included questions about demographics, training, pediatric neurocritical care service and job structure, teaching, academics, challenges, and views on the future of pediatric neurocritical care. We analyzed 55 surveys. Most respondents were 31-50 years of age with ≤10 years of practice experience. Fifty-four percent identified as female. Most completed subspecialty training after child neurology residency. The majority practice at highly resourced centers with >45 intensive care unit beds. Respondents cover a variety of inpatient (critical and noncritical care) services, at times simultaneously, for a median of 19.5 weeks/y and work >70 hours/wk when on service for pediatric neurocritical care. The top 3 challenges reported were competing demands for time, excess volume, and communication with critical care medicine. Top priorities for the "ideal pediatric neurocritical care service" were attendings with training in pediatric neurocritical care or a related field and joint rounding with critical care medicine. We report a survey-based analysis of the demographics and scope of practice of pediatric critical care neurologists. We highlight challenges faced and provide a framework for the further development of this rapidly growing field.

Virtual Residency Interview Experience: The Child Neurology Residency Program Perspective

BackgroundThe COVID-19 pandemic presented many challenges for graduate medical education, including the need to quickly implement virtual residency interviews. We investigated how different programs approached these challenges to determine best practices. MethodsSurveys to solicit perspectives of program directors, program coordinators, and chief residents regarding virtual interviews were designed through an iterative process by two child neurology residency program directors. Surveys were distributed by email in May 2021. Results were summarized using descriptive statistics. ResultsResponses were received from 35 program directors and 34 program coordinators from 76 programs contacted. Compared with the 2019-2020 recruitment season, in 2020-2021, 14 of 35 programs received >10% more applications and most programs interviewed ≥12 applicants per position. Interview days were typically five to six hours long and were often coordinated with pediatrics interviews. Most programs (13/15) utilized virtual social events with residents, but these often did not allow residents to provide quality feedback about applicants. Program directors could adequately assess most applicant qualities but felt that virtual interviews limited their ability to assess applicants' interpersonal communication skills and to showcase special features of their programs. Most respondents felt that a combination of virtual and in-person interviewing should be utilized in the future. ConclusionsResidency program directors perceived some negative impacts of virtual interviewing on their recruitment efforts but in general felt that virtual interviews adequately replaced in-person interviews for assessing applicants. Most programs felt that virtual interviewing should be utilized in the future.

Improving Child Neurology Residents' Communication Skills Through Objective Structured Clinical Exams.

IntroductionChild neurology has unique challenges in communication due to complex disorders with a wide array of prognoses and treatments. Effective communication is teachable through deliberate practice and coaching. Objective structured clinical exams (OSCEs) are one method of providing practice while assessing communication skills. Yet OSCEs have not been reported for child neurology residents.MethodsWe developed simulated clinical cases centering on communication skills for child neurology residents, all with challenging clinical scenarios (e.g., disclosure of a medical error, psychogenic nonepileptic events). Standardized patients (SPs) portrayed the parents of pediatric patients and, in some scenarios, an adolescent patient. We used a modified Gap-Kalamazoo Communication Skills Assessment Form to assess communication skills. The assessment was completed by faculty, SPs, and the resident, and we measured agreement among raters. Residents were surveyed afterward regarding their experience.ResultsNine cases were developed and piloted. A total of 27 unique resident-case encounters with 16 individual trainees occurred over three annual implementations. Scores on the 360-degree assessment of communication skills showed that residents overwhelmingly underassessed their skills compared to other rater groups. Among 18 responses on the post-OSCE survey, the majority (77%) found the experience useful to their education and felt that the feedback from the SPs was helpful (61%) and the case portrayals were realistic (89%).DiscussionWe implemented simulated cases for assessment and formative feedback on communication skills for child neurology residents. We provide a blueprint to develop this educational activity in other programs.

Developing a New Set of ACGME Milestones for Child Neurology Residency

BackgroundThe Educational Milestones developed by the Accreditation Council for Graduate Medical Education (ACGME) are a construct used to evaluate the development of core competencies during residency and fellowship training. The milestones were developed to create a framework for professional development during graduate medical education. The first iteration of milestones for the child neurology residency was implemented in 2015. In the years that followed, the ACGME received and reviewed feedback about the milestones and set out to revise them. MethodsA committee was assembled to review the original milestones and develop a new set of milestones. The group was also encouraged to not only consider the child neurology residency graduate of today but also the graduate of tomorrow, taking into account growing fields such as genetics and technology. ResultsA diverse group of 12 individuals, including 10 child neurologists (all of whom were current or previous program directors or associate program directors), one child neurology resident, and one non-physician program coordinator, were recruited from programs of varying size across the country. ConclusionsThe committee developed a revision to the child neurology milestones. All changes made were with a focus on how the milestones can be useful to trainees, program directors, and clinical competency committee members. Implementation and further feedback should help guide future revisions. These changes should help trainees, clinical competency committee members, and program directors find more meaning from their use.

Child Neurology Applicants Place Increasing Emphasis on Quality of Life Factors

BackgroundMedical education, residency training, and the structure of child neurology residency training programs are evolving. We sought to evaluate how training program selection priorities of child neurology residency applicants have changed over time. MethodsAn electronic survey was sent to child neurology residents and practicing child neurologists via the Professors of Child Neurology distribution list in the summer of 2018. It was requested that the survey be disseminated to current trainees and alumni of the programs. The survey consisted of seven questions assessing basic demographics and a list of factors applicants consider when choosing a residency. ResultsThere were 284 responses with a higher representation of individuals matriculating into residency in the last decade. More recent medical school graduates had a lower probability of considering curriculum as an important factor for residency selection (odds ratio [OR], 0.746; 95% confidence interval [95% CI], 0.568 to 0.98; P = 0.035) and higher priority placed on interaction with current residents over the course of the interview day (OR, 2.207; 95% CI, 1.486 to 3.278; P < 0.0001), sense of resident happiness and well-being (OR, 2.176; 95% CI, 1.494 to 3.169; P < 0.0001), and perception of city or geography of the residency program (OR, 1.710; 95% CI, 1.272 to 2.298; P < 0.001). ConclusionsOver time, child neurology residency applicants are putting more emphasis on quality of life factors over curriculum. To accommodate these changes, child neurology residency programs should prioritize interactions with residents during the interview process and resident wellness initiatives throughout residency training.

An Objective Structured Clinical Examination of Communication Skills for Child Neurology Residents

BackgroundThe purpose of this study was to implement an objective structured clinical examination for child neurology trainees for formative feedback regarding communication skills. Effective communication skills are essential and teachable, but tools to formally assess them are limited. An objective structured clinical examination is one such tool, but these examinations have not been developed for child neurology residents. MethodsWe developed nine standardized scenarios that highlighted communication challenges commonly encountered in child neurology. Child neurology trainees participated in three objective structured clinical examination events with three scenarios each over three academic years. Standardized patients portrayed patients or their parents. Each trainee–standardized patient encounter was evaluated by an observing faculty member using a modified Gap-Kalamazoo Communication Skills Assessment Form, the standardized patient who provided direct feedback, and by the participating trainee. ResultsWe refined the process of case writing, standardized patient training, and trainee evaluation throughout the three-year pilot. Results indicated rater agreement ranging from 32% to 56%. Trainees reported that the cases were challenging and reflective of real life and that the experience helped improve their communication skills. ConclusionsAn objective structured clinical examination can provide a standardized setting for formative feedback regarding communication skills in child neurology residency programs. The communication challenges posed by common clinical scenarios involving critically ill children, children with undetermined prognosis, and the triad of parent, child, and physician can be realistically modeled in an objective structured clinical examination. We developed cases and a process that were valuable and that we plan to sustain for resident education related to communication skills.

Training in Neurology: Feedback from Graduates About the Psychiatry Component of Residency Training.

To obtain feedback from early career adult and pediatric neurologists about the psychiatry component of residency training. A survey was developed and administered electronically to 4 cohorts of recently certified American Board of Psychiatry and Neurology diplomates. The response rate was 16% (431/2,677) and included 330 adult neurologists and 101 pediatric neurologists. Fewer than half of the respondents described themselves as extremely or quite satisfied with their psychiatry training whereas 26% of the adult neurologists and 33% of the pediatric neurologists felt slightly or not at all prepared for this component of practice. Four themes were identified in the respondents' suggestions for improving psychiatry training: provide more outpatient experience; provide more time/teaching in psychiatry; provide more experience with both pharmacologic and nonpharmacologic psychiatric treatments; and provide more exposure to patients with conditions likely to be encountered in neurology/child neurology practice. These recent graduates of adult and pediatric neurology residency programs felt underprepared for the psychiatric issues they encountered in their patients. They suggested a number of strategies for better alignment of psychiatry training with the likely demands of practice. A model curriculum recently developed by the American Academy of Neurology's Consortium of Neurology Program Directors and the American Association of Directors of Psychiatric Residency Training also provides guidance for both neurology and psychiatry program directors.

Neuro-Oncology Training for the Child Neurology Resident.

Neuro-oncology is a rapidly evolving subspecialty that involves the management of patients with primary or metastatic central and peripheral nervous system neoplasms, as well as any other disorders or complications affecting the nervous system that result either directly or indirectly from central nervous system or systemic malignancies and related treatment. Neurologists serve a critical role in the multidisciplinary management of these complex patients. As leaders of the Child Neurology Society Special Interest Group in NeuroOncology, we propose ways to provide sufficient exposure, minimize knowledge gaps, and optimize training experiences in neuro-oncology for child neurology residency programs.

Integrative Medicine in Child Neurology: What Do Physicians Know and What Do They Want to Learn?

Pediatric neurology patients frequently use integrative medicine; however, providers may feel uncomfortable or unfamiliar with these therapies. Child neurologist attitudes toward integrative medicine and educational needs in integrative medicine have not been assessed. A national, anonymous survey was distributed to Child Neurology residents (n=294) and program directors (n=71) to assess attitudes toward specific integrative medicine modalities, practices in discussing integrative medicine with patients, and perceived need for a curriculum on integrative medicine; 61 (17%) partially and 53 (15%) fully completed the survey. Comparative analyses applied chi-square and independent t tests. Qualitative content analysis was performed on free text responses. Most providers surveyed consider mind and body practices safe (93% of respondents) and effective (84%), but have concerns about the safety of chiropractic manipulation (56% felt this was harmful), and the efficacy of homeopathy (none considered this effective). Few inquire about patient integrative medicine use regularly. Child Neurology residents are interested in further education on this topic.

Communication Skills in Child Neurology Residency: an OSCE Pilot (853)

Communication Skills in Child Neurology Residency: an OSCE Pilot (853)

Assessment of Awareness of the Early Clinical Features of Spinal Muscular Atrophy (SMA) Amongst Neurology and Child Neurology Residents and Fellows (1164)

Assessment of Awareness of the Early Clinical Features of Spinal Muscular Atrophy (SMA) Amongst Neurology and Child Neurology Residents and Fellows (1164)

Wellness Initiative Societies Empowering Residents (WISER): Reflections on Establishing a Wellness Curriculum in a Child Neurology Residency Program (2635)

Wellness Initiative Societies Empowering Residents (WISER): Reflections on Establishing a Wellness Curriculum in a Child Neurology Residency Program (2635)

Development and Evaluation of a Child Neurology Residency Curriculum for Delivering Bad News (2164)

Development and Evaluation of a Child Neurology Residency Curriculum for Delivering Bad News (2164)

Emerging Subspecialties in Neurology: Sleep medicine fellowship after child neurology residency.

Pediatric sleep medicine is a multidisciplinary field specializing in the diagnosis and treatment of a wide range of sleep disorders in childhood. Child neurology residency training provides highly desired skills keenly applicable for a prospective sleep medicine fellowship applicant. A fundamental neurophysiology background helps foster an advanced proficiency in the scoring and interpretation of overnight polysomnography and multiple sleep latency tests (MSLTs). Attuned skills in differentiating complex paroxysmal movements are key to distinguishing parasomnias from nocturnal seizures. The clinical evaluation for developmental delay is augmented by learning and applying the normative developmental milestones of sleep in evaluating the sleepy, or sleepless, child. Herein the authors provide an overview of pediatric sleep medicine as it relates to the child neurology trainee seeking subspecialty fellowship opportunities.

Faculty Videos of Resilience Narratives at Two Institutions

Burnout and mental health issues among residents are associated with adverse health consequences and suboptimal job performance, e.g. increased medical error. Given role models as key to cultivating resilience, we created faculty resilience narrative videos within resilience skill training programs, hypothesizing such videos would provide new perspectives/insights on resiliency and humanize attendings in a useful way. Child and adult neurology residents at two institutions positively rated the impact of these faculty videos. Such videos are an innovative and practical way to: 1) provide exemplar role models for learning about coping with physician challenges and gaining insights on resilience; 2) access stories of triumph over challenge for inspiration; and 3) work to achieve local culture change by reducing stigma and increase empathy/connection during training. Successful implementation of this video innovation provides good rationale for further evaluation of impact on local culture, faculty experience, and resident attitudes and behavior.

Editors' note: Neurology residency training in 2017: A survey of preparation, perspectives, and plans

In their survey of graduating adult and child neurology residents from 2017, Mahajan and colleagues reported on the subjective lack of preparation of graduating trainees as they take on fellowship or junior faculty roles. Among these findings, although more respondents in 2017 felt prepared to address managerial tasks (e.g., billing and malpractice) than in previous years, fewer than 40% felt knowledgeable about billing, coding, contract negotiations, malpractice insurance, or RVUs. Furthermore, among the adult neurology respondents, 54% felt that the fellowship application process began too early, with 46% feeling as if their limited outpatient exposure negatively affected the fellowship decision-making process. In response, Drs. Ratliff and Shanker reference similar pressures placed on orthopedic surgery residents as they embark on their own journeys into fellowship. Because 87% of neurology residents prefer fellowship applications to start in the second half of the PGY3 year or even later, it would be better to delay the application process until this time in order for residents to make the most informed decision about their future careers. As Dr. Mahajan points out, the process of mandating a single “match day” is challenging because of the differences in neurology fellowship offerings. Nonetheless, some date late in the PGY3 year could be suggested by our organizations as the earliest date a program director can make an offer. This may allow for more outpatient exposure, so our trainees can make a more informed career decision. In their survey of graduating adult and child neurology residents from 2017, Mahajan and colleagues reported on the subjective lack of preparation of graduating trainees as they take on fellowship or junior faculty roles. Among these findings, although more respondents in 2017 felt prepared to address managerial tasks (e.g., billing and malpractice) than in previous years, fewer than 40% felt knowledgeable about billing, coding, contract negotiations, malpractice insurance, or RVUs. Furthermore, among the adult neurology respondents, 54% felt that the fellowship application process began too early, with 46% feeling as if their limited outpatient exposure negatively affected the fellowship decision-making process. In response, Drs. Ratliff and Shanker reference similar pressures placed on orthopedic surgery residents as they embark on their own journeys into fellowship. Because 87% of neurology residents prefer fellowship applications to start in the second half of the PGY3 year or even later, it would be better to delay the application process until this time in order for residents to make the most informed decision about their future careers. As Dr. Mahajan points out, the process of mandating a single “match day” is challenging because of the differences in neurology fellowship offerings. Nonetheless, some date late in the PGY3 year could be suggested by our organizations as the earliest date a program director can make an offer. This may allow for more outpatient exposure, so our trainees can make a more informed career decision.

Editors' note: Surgery and risk of Guillain-Barré syndrome: A French nationwide epidemiologic study

In their retrospective, nationwide, case-crossover study of more than 8,000 cases of Guillain-Barre syndrome (GBS) (2009–2014), Rudant et al. reported on the association between surgery and postoperative risk of GBS. The authors found a significant 53% higher odds of postoperative GBS in the 60 days following any surgery (adjusted OR 1.53, 95% CI 1.25–1.88), although this may be driven in part by orthopedic and gastrointestinal surgeries. Also interesting was the observation that (generally) longer procedures were associated with a greater probability of postoperative GBS (OR 2.22, 95% CI 1.48–3.34 for surgeries lasting ≥120 minutes vs no surgery). Although the mechanism by which surgery mediates this risk remains unclear, Dr. Steiner suggests that the type of anesthesia (epidural vs general) may play a role. Citing earlier literature, Dr. Steiner notes that a substantial proportion of patients had undergone epidural anesthesia before the onset of GBS. Dr. Steiner suggests that local damage from the anesthetic agent or reagent may have contributed to nerve root injury and/or inflammation. Unfortunately, anesthetic technique is not documented in the claims data of the present investigation. Therefore, the investigators are unable to comment on whether epidural anesthesia may have played a role in the development of GBS in their nationwide data set. In their survey of graduating adult and child neurology residents from 2017, Mahajan and colleagues reported on the subjective lack of preparation of graduating trainees as they take on fellowship or junior faculty roles. Among these findings, although more respondents in 2017 felt prepared to address managerial tasks (e.g., billing and malpractice) than in previous years, fewer than 40% felt knowledgeable about billing, coding, contract negotiations, malpractice insurance, or RVUs. Furthermore, among the adult neurology respondents, 54% felt that the fellowship application process began too early, with 46% feeling as if their limited outpatient exposure negatively affected the fellowship decision-making process. In response, Drs. Ratliff and Shanker reference similar pressures placed on orthopedic surgery residents as they embark on their own journeys into fellowship. Because 87% of neurology residents prefer fellowship applications to start in the second half of the PGY3 year or even later, it would be better to delay the application process until this time in order for residents to make the most informed decision about their future careers. As Dr. Mahajan points out, the process of mandating a single “match day” is challenging because of the differences in neurology fellowship offerings. Nonetheless, some date late in the PGY3 year could be suggested by our organizations as the earliest date a program director can make an offer. This may allow for more outpatient exposure, so our trainees can make a more informed career decision.

Objective Structured Clinical Exams (OSCE) are a feasible method of teaching how to discuss a nonepileptic seizure diagnosis

ObjectivePresenting the diagnosis of psychogenic nonepileptic seizures (PNES) can be a difficult task, but disclosing this information effectively is important to optimize patient outcomes. We sought to develop a standardized method to teach neurology residents how to introduce the diagnosis of PNES via an objective structured clinical examination (OSCE) with a standardized patient (SP). MethodsIn conjunction with the New York University School of Medicine Simulation Center (NYSIM), we designed an OSCE in which a resident had to inform a SP of her diagnosis of PNES and discuss a treatment plan. The SP was provided with details to gradually disclose depending on what the resident said about the history of her episodes, triggers for her episodes and her history of sexual abuse. Each encounter was observed by an attending physician who provided real-time feedback to the resident after the session. Additionally, the SP completed an objective written checklist of items the resident should have covered in the session and gave them verbal feedback. ResultsTwenty-six adult neurology (n = 22), child neurology (n = 3), and neuropsychiatry (n = 1) residents participated in this OSCE in 2018 and 2019, with full data available for 25 participants. Residents reported the OSCE was very useful (mean Likert score of 4.9/5). They felt moderately prepared (mean Likert score 3.8/5) and rated their performance as a mean of 3.3/5. On the SP's checklist, most residents were rated as Well Done in the domains of information gathering, relationship development, and education and counseling. Only in the domain of psychosocial assessment were most residents rated as Not Done (only 7/25 inquired about past trauma as a risk factor for PNES). SignificanceThe OSCEs are a feasible and useful way to teach neurology residents about discussing PNES, as they allow for provision of real-time practice and feedback in a safe environment without real patients.

Neurology residency training in 2017: A survey of preparation, perspectives, and plans.

To survey graduating US neurology residents on the topics of debt, fellowship interview process, future plans, and their readiness for practice and business management tasks. An electronic survey was sent to all US American Academy of Neurology member adult and child neurology residents graduating in June 2017. The response rate was 23.4% (n = 159). Of the 143 residents who provided information about student loans, 57% reported having debt (median $180,000). Ninety percent of respondents reported plans to pursue a fellowship after residency; 57% intended to stay at their home institution for additional training. Among respondents from adult neurology programs, 87% preferred to begin the fellowship application process after the first 6 months of the third postgraduate year. Almost half (46%) of adult neurology program residents felt they did not have enough outpatient exposure prior to making fellowship decisions compared to 14% of child neurology trainees. Although reported readiness to perform specific tasks (coding and office management) increased since 2007 (p < 0.05), only 36% of all respondents reported receiving business management training during residency. Trainees completing residency report considerable educational debt. A large majority of residents feel the fellowship application process occurs too early. Despite improvements over recent years, the majority of residents continue to feel ill-prepared for specific practice management tasks. These results suggest a need to better understand the effect of educational debt on career choices, an examination of the timing of the fellowship application process, and the incorporation of additional business management training during residency.