Neurology Residency Programs Research Articles

Education Research: The current state of neurophysiology education in selected neurology residency programs.

Prior research has illustrated there is a knowledge gap in neurology residents' neurophysiology education (EEG and EMG), and we sought to understand whether this is still an issue and to recognize the barriers in order to create solutions and improve education. Surveys were developed for adult neurology residents and one for program directors asking about confidence in neurophysiology knowledge, percent of graduates reaching level 4 ACGME (American Council of Graduate Medical Education) milestones in EEG and EMG, methods of learning used, interest in the subjects, and suggestions for improvements. Twenty-six program directors (19% responder rate) and 55 residents (from at least 16 different programs) completed the survey. Program directors thought that 85% of graduating residents met level 4 milestones in EEG and only 75% in EMG. Structured rotations and more time allocated to education of these topics were frequent barriers mentioned. Postgraduate year 4 residents were 60% and 67% confident in EEG and 64%, 59%, and 62.3% in EMG level 4 milestones. Learning to read EEGs was considered important throughout residents' training; however, this interest and value decreased over time with EMG. In our study, program directors suspect up to a quarter of residents may graduate not meeting level 4 ACGME milestones, and residents expressed lack of confidence in these areas. The educational methods used to instruct residents in EEG and EMG were similar as were the barriers they face across programs. This information hopefully will help fuel curriculum design and interest in these important neurology techniques.

Child Neurology Residency Program Directors and Program Coordinators 2016 Workforce Survey

BackgroundResponsibilities of Program Directors' (PDs) and Program Coordinators' (PCs) roles continue to evolve within Graduate Medical Education (GME). MethodsIn 2016, the authors conducted an anonymous electronic survey of Child Neurology and Neurodevelopmental Disabilities PDs (n = 76) and PCs (n = 68) to address workforce characteristics, challenges related to implementing Accreditation Council of Graduate Medical Education (ACGME) requirements, and institutional support. Responses were characterized with descriptive statistics. ResultsResponse rate was 72% (46 of 76 PDs, 57 of 68 PCs). PD median clinical workloads were five half-day clinics weekly plus three months as hospital attending yearly. Most PDs (61%) reported having less, and many (43%) believed requirements were less, protected time than the ACGME requires. Most PCs have clerical titles (58%), no designated GME career path (79%), inaccurate job descriptions (86%), little to no formal GME training (61%), work-hours exceeding those scheduled (68%), and time allocation below ACGME recommendations (69%). More than half (54%) of hourly PCs reported responding to communications after hours, with nearly all (92%) unpaid for such work. Shared PD-PC concerns include faculty completion of resident evaluations (80%), inadequate protected time (71%), and low PC salary (70%). For both PDs and PCs, median time in the job was four years. ConclusionsChild neurology and neurodevelopmental disability residency PDs and PCs report problems that likely increase turnover and interfere with training. The ACGME should consider revising, formalizing, and disseminating requirements for protected time for PDs and PCs, based on realistic assessments of current administrative requirements, and monitoring compliance as part of program evaluations.

Headache Interest in Academic Neurology Leadership: A Cross-Sectional Study.

Headache disorders are exceedingly common, debilitating neurological conditions, and there is a striking paucity of headache specialists nationally. However, headache education is underrepresented in the curriculum of neurology residency programs and few neurology residents elect to pursue headache medicine fellowships. We aimed to explore the possibility that a low degree of headache interest among neurology department chairs and residency program directors (PDs) underlies this mismatch. We performed a cross-sectional analysis of chairs and PDs associated with ACGME neurology residency programs. Data sources included the ACGME program list, faculty profiles on institutional webpages, Doximity profiles, the American Headache Society (AHS) membership directory, and the roster of United Council for Neurologic Specialties (UCNS) headache diplomates. A headache interest was deemed to be present with the presence of a declared headache or concussion interest, completion of a headache fellowship, active AHS membership, or UCNS certification. Our review included 137 residency programs comprising 127 department chairs, 132 PDs, and 5 faculty who were both chairs and PDs. Of all faculty, 62 (23.5%) were women. Headache expertise was declared by 10 (7.6%) chairs and 13 (9.5%) PDs. Headache fellowship training was pursued by 1 (0.8%) chair and 5 (3.6%) PDs, and among all faculty was the 10th most common subspecialty fellowship pursued. Three (2.3%) chairs and 7 (5.1%) PDs were AHS members. Seven (5.3%) chairs and 10 (7.3%) PDs were UCNS headache certified. An overall headache interest was present in 29 (11.0%) faculty, including 14 (10.6%) chairs and 15 (10.9%) PDs. A graduate degree aside from an MD (eg, PhD, MPH) was more likely to be achieved in faculty without a headache interest (29.4%) than faculty with a headache interest (6.9%, P = .0076). Residency programs where either the chair or PD had a headache interest were just as likely to feature a UCNS headache fellowship program than programs without chair or PD headache interest (25.0 vs 23.0%, P = .83). Current neurology department chairs and residency PDs have low rates of headache interest, which may influence the emphasis of headache education in neurology training. Headache interest is associated with lower rates of other graduate degrees, and future analysis should examine if academic faculty interested in headache are less likely to be in leadership positions because of a lack of research funding, opportunities, or accomplishments.

Opinion and Special Articles: Creation of a diversity and inclusion certificate program for neurology residents.

Neurologists must provide excellent care to an increasingly diverse patient population. According to census projections, the United States will become a majority–minority nation by 2060, with no single ethnic or racial group making up a majority of the population.1 Diversity of gender, sex, sexual orientation, race, ethnicity, socioeconomic status, age, ability, and religion must be acknowledged and understood in order to provide equitable patient care. The authors thank the Partners Neurology Residency Program Director Dr. Tracey Cho and Associate Program Director Dr. Sashank Prasad for their support of the Diversity and Inclusion certificate program.

Author response: A dedicated scholarly research program in an adult and pediatric neurology residency program.

We thank Dr. Meador for the comment on our study examining the effect of the scholarly research program implemented in our neurology residency program.1 We agree that the shifting demands on neurologists relate to the crucial issue of burnout, though academic practice neurologists had lower burnout rates and higher rates of career satisfaction than neurologists in clinical practice.2 However, Dr. Meador previously noted that, in the current climate, younger academic faculty members are uniquely vulnerable to fail in their pursuit of successful research careers based on a variety of factors, including lack of protected time and financial constraints.3 Indeed, the burnout study found that younger neurologists in general experienced more burnout, and academic neurologists experienced more burnout with a higher percentage of time spent in clinical practice and less job autonomy.2

Letter re: A dedicated scholarly research program in an adult and pediatric neurology residency program

I applaud Robbins et al.1 for successfully improving scholarly research in their residency program. In general, education on clinical research is inadequate in medical schools and postgraduate clinical programs.2 Flexner3 stressed that original research, and the critical method of research, should play an important role in medical schools. However, clinical research at academic medical centers is under stress.2 The amount of time spent by academic physicians on clinical research has declined over the last several decades due to increasing demands to provide clinical care.2 Another recent publication provided data to this regard from a 2016 survey of US neurologists.4 The survey revealed that academic neurologists spent an average of 16% of their time on research (median 10%).4 These levels fell drastically from reports done in 1984, which found that academic physicians overall spent 41% of their time on research activities.5 I previously offered recommendations to improve clinical research in academic medical centers,2 including training in clinical research methodology and required research by medical students, residents, and clinical fellows. Efforts like those reported by Robbins et al. can improve the situation and affect the overall clinical research environment of a neurology department.

The State of Diversity and Cultural Diversity Training in Neurology Residency Programs (S6.008)

The State of Diversity and Cultural Diversity Training in Neurology Residency Programs (S6.008)

A Video-Based Introductory EEG Curriculum for Neurology Residents and Other EEG Learners.

It is difficult to provide standardized formal education in EEG because of time limitations and the availability of expert teachers. Video-based miniature lectures are a useful way to standardize the foundational principles of EEG and support learning during EEG/epilepsy rotations. A curriculum of 10 EEG teaching videos was developed based on concepts outlined in the Accreditation Council for Graduate Medical Education Neurology Milestones. The videos were short (6-17 minutes) and made available to residents rotating through an EEG/epilepsy rotation in two neurology residency programs. Residents were instructed to review the videos and then apply their newly learned skills during EEG reading sessions. A survey about the process was completed at the end of the year. Twenty-one residents participated in the curriculum, and 15 (71%) responded to the survey. Two-thirds of respondents (10/15) said that they watched all of the videos, and 87% (13/15) watched at least half of the videos. All of the respondents used the videos as introductions to EEG concepts, and approximately half of respondents returned to the videos as a refresher after the rotation was over. Nearly all respondents either agreed or strongly agreed that the curriculum was a useful component of the rotation and helped them to understand difficult concepts. All strongly agreed that they would recommend the curriculum to other residents. A video-based approach to EEG teaching could complement existing curricula and ensure that learners have access to foundational miniature lectures when and where they need them.

Spotlight on the April 4 issue

#### Notable in Neurology This issue features an article that reports unilateral cerebellothalamic tract ablation in essential tremor by MRI-guided focused ultrasound, and another that advocates the Narcolepsy Severity Scale as a reliable and valid clinical tool. A featured Contemporary Issues: Innovations in Education article examines a scholarly research program as part of an adult and pediatric neurology residency program. ### Reduction in time to treatment in prehospital telemedicine evaluation and thrombolysis![Graphic][1] Mobile stroke treatment units (MSTUs) represent a new frontier in stroke care with the ability to deliver prehospital thrombolysis. The authors' MSTU, with physician presence via telemedicine, demonstrated substantial reductions in … [1]: /embed/inline-graphic-1.gif

A dedicated scholarly research program in an adult and pediatric neurology residency program.

To describe and assess the effectiveness of a formal scholarly activity program for a highly integrated adult and pediatric neurology residency program. Starting in 2011, all graduating residents were required to complete at least one form of scholarly activity broadly defined to include peer-reviewed publications or presentations at scientific meetings of formally mentored projects. The scholarly activity program was administered by the associate residency training director and included an expanded journal club, guided mentorship, a required grand rounds platform presentation, and annual awards for the most scholarly and seminal research findings. We compared scholarly output and mentorship for residents graduating within a 5-year period following program initiation (2011-2015) and during the preceding 5-year preprogram baseline period (2005-2009). Participation in scholarship increased from the preprogram baseline (24 of 53 graduating residents, 45.3%) to the postprogram period (47 of 57 graduating residents, 82.1%, p < 0.0001). Total scholarly output more than doubled from 49 activities preprogram (0.92/resident) to 139 postprogram (2.44/resident, p = 0.0002). The proportions of resident participation increased for case reports (20.8% vs 66.7%, p < 0.0001) and clinical research (17.0% vs 38.6%, p = 0.012), but were similar for laboratory research and topical reviews. The mean activities per resident increased for published abstracts (0.15 ± 0.41 to 1.26 ± 1.41, p < 0.0001), manuscripts (0.75 ± 1.37 to 1.00 ± 1.40, p = 0.36), and book chapters (0.02 ± 0.14 to 0.18 ± 0.60, p = 0.07). Rates of resident participation as first authors increased from 30.2% to 71.9% (p < 0.0001). The number of individual faculty mentors increased from 36 (preprogram) to 44 (postprogram). Our multifaceted program, designed to enhance resident and faculty engagement in scholarship, was associated with increased academic output and an expanded mentorship pool. The program was particularly effective at encouraging presentations at scientific meetings. Longitudinal analysis will determine whether such a program portfolio inspires an increase in academic careers involving neuroscience-oriented research.

The Duke neurology advanced practice provider residency: Its time has come.

I read with interest Morgenlander and Blessing's1 experience with developing a 1-year neurology residency program for advanced practice providers (APPs), namely nurse practitioners (NPs) and physician assistants (PAs), in their institution. While I laud the authors in their effort and believe that APPs with formal training in neurology shall improve patient care, I disagree this is the way forward to address the growing shortage of neurologists. An APP with additional training in neurology is still an APP unable to independently diagnose and treat complex neurologic disorders with confidence. While APPs with additional training in neurology are a useful addition to the neurology workforce, they should not be a substitute for additional residency-trained neurologists. Congress needs to act now to alleviate this shortage. That should be the message we send out.

Neurocritical Care Education During Residency: Opinions (NEURON) Study.

The American Academy of Neurology (AAN) has established a core curriculum of topics for residency training in neurocritical care. At present there is limited data evaluating neurology residency education within the neurological intensive care unit. This study evaluates learner concerns with the neurological intensive care unit. The Communication Committee and Resident & Fellow Taskforce within the Neurocritical Care Society (NCS) developed an online survey that consisted of 20 selection and free-text based questions. The survey was distributed to NCS members and then to neurology residency program directors. Statistical analysis of neurocritical care exposure were completed with t or Fisher exact test with p-value <0.05 considered significant. A total of 95 individuals from 32 different residency programs (36.5% response rate) responded to the questionnaire. Most individuals train with neurocritical care attendings, fellows and advanced practitioners and have neurocritical care exposure during multiple years of residency training. 54% of responders cite improvement in education as a means to improve neurocritical care training. Those that raised concern had no difference in time in the neurocritical care unit (9.4 weeks vs 8.8 weeks), exposure to trained neurointensivists, neurocritical care fellows or advanced providers (p value 0.53, 0.19, 0.83, respectively). There is significant learner concern regarding education within the neurointensive care unit. Although there are educational guidelines and focused neurocritical care educational materials, these alone do not satisfy residents' educational needs. This study demonstrates the need for educational changes, but it does not assess best strategies nor curricular content.

Impact of Neurosurgery Medical Student Research Grants on Neurosurgery Residency Choice

Recent decades have seen a rapid expansion of involvement of medical students in biomedical research during medical school training. Research within medical school has been shown to influence medical students with regard to medical knowledge, career development, and residency specialty choice. The objective of this study was to evaluate the impact of neurosurgery medical student research grants on neurosurgery residency choice and provide an insight on the demographics of grant awardees. In this retrospective study, a search of award recipients was performed using data available on the American Association of Neurological Surgeons, Congress of Neurological Surgeons, and Neurosurgery Research and Education Foundation websites. Searched years included the first cycle of American Association of Neurological Surgeons/Neurosurgery Research and Education Foundation (2007) and Council of State Neurosurgical Societies/Congress of Neurological Surgeons (2008-2009) grant awards until the 2015-2016 cycle, which is the latest award cycle to date. The initial search yielded 163 research grants that were awarded to 158 students between the years of 2007 and 2016. Among the 163 grant recipients, 126 (77.3%) were men. Among the 88 recipients who entered postgraduate residency programs, 51% (45 of 88) matched into neurosurgery residency. When considering both neurosurgery and neurology residency programs, the percentage increased to 59.1% (52 of 88). Neurosurgery grants for medical students are highly successful in producing future neurosurgeons with >50% of grant recipients matched into neurosurgery. Women are underrepresented in neurosurgery grants and neurosurgery residency programs. This situation can be improved by providing insight about the field early in medical school, perhaps through increased use of neurosurgery medical student grants.

The Duke neurology advanced practice provider residency: Its time has come.

The acknowledgment that specialization in neurology based on a clinician's extensive background in neuroscience contributes to expertise in patient care was a motivating factor in developing neurology residency programs. The increasing demand for more and better access to neurologic care has created a health care environment ripe for innovation. Advanced practice providers currently do not have the opportunity during primary training to gain much experience in neurologic care. We discuss the challenges and benefits of developing a 1-year neurology residency program for nurse practitioner and physician assistant graduates at our institution. We propose that providing advanced practice providers with specialty skills through neurology residency programs such as ours will be integral to meet the growing clinical need for neurologic care.

Impact of a dedicated scholarly research program on an adult and pediatric neurology residency program (S3.008)

Impact of a dedicated scholarly research program on an adult and pediatric neurology residency program (S3.008)

Headache Education in Adult Neurology Residency: A Survey of Program Directors and Chief Residents.

This cross-sectional study reassesses the status of headache didactics and clinical training in adult neurology residency programs in the United States to determine if program directors and chief residents feel that current training in headache is adequate. Headache is among the most common new complaints to both the neurology and primary care clinic and represents a significant economic burden. However, headache remains both under-diagnosed and under-treated. Of those who seek treatment only 28% report they are very satisfied with their management. One possible cause for dissatisfaction is inadequate education of treating physicians. Two studies in 2002 and 2005 that collectively surveyed all 125 adult neurology residency programs concluded that more evidence was needed to evaluate the adequacy of headache education in these programs. A survey of neurology residency department chairs and program directors in 2005 also evaluated the status of headache education in adult neurology training programs and concluded the same. We surveyed 133 neurology residency program directors and 213 chief residents. Program directors and chief residents were asked about the amount of headache didactics, amount of clinical exposure to headache, perceived adequacy of current training and if plans existed to increase headache education through didactics or clinical exposure. Seventy-two program directors (54%) and 117 chief residents (55%) responded. Twenty-six percent of programs reported a mandatory headache clinic. Of these, 35% of programs reported <2 weeks of clinic, 54% of programs reported 2-4 weeks, and 12% of programs reported > 4 weeks of clinic. Fifty-one percent of program directors felt more than 4 weeks of clinical exposure to headache was needed to adequately prepare neurology residents. Ninety-six percent of program directors surveyed believed their residents were adequately prepared to diagnose and treat headache disorders. Twenty-one percent had plans to increase didactic time and 26% planned to incorporate more clinical exposure. Despite a modest increase in headache didactics in neurology residency programs over the last decade, many program directors and chief residents report that their programs do not include what they believe to be adequate educational experiences in headache. Although the overwhelming majority of neurology residency programs reported that residents were adequately prepared to diagnose and treat headache disorders, about a fourth of programs still felt the need to increase the amount of didactic and clinical exposure dedicated toward the management of headache disorders.

Education Research: Neurology resident education: Trending skills, confidence, and professional preparation.

To survey US-trained graduating neurology residents who are American Academy of Neurology members, in an effort to trend perceived quality and completeness of graduate neurology education. An electronic survey was sent to all American Academy of Neurology members graduating from US neurology residency programs in the Spring of 2014. Of 805 eligible respondents, 24% completed the survey. Ninety-three percent of adult neurology residents and 56% of child neurology residents reported plans to pursue fellowship training after residency. Respondents reported a desire for additional training in neurocritical care, neuro-oncology, neuromuscular diseases, botulinum toxin injection, and nerve blocks. There remains a clear deficit in business training of neurology residents, although there was notable improvement in knowledge of coding and office management compared to previous surveys. Although there are still areas of perceived weakness in neurology training, graduating neurology residents feel generally well prepared for their chosen careers. However, most still pursue fellowship training for reasons that are little understood. In addition to certain subspecialties and procedures, practice management remains deficient in neurology training and is a point of future insecurity for most residents. Future curriculum changes should consider resident-reported gaps in knowledge, with careful consideration of improving business training.

Abstract TP313: Virtual Stroke Patient Simulation Training for Residents and Medical Students Improves Knowledge, Skill Sets and Confidence in Acute Stroke Care

Introduction: At most teaching hospitals, first- and second-year residents respond to a “Stroke Alert” where “Time is Brain.” Interpreting neurologic signs and symptoms and acute management of stroke is complex. In many medical specialties, simulated instruction improves performance and addresses patient safety needs without harm to, or practice upon, a real-live patient. Thus, we designed a virtual stroke patient simulation training course: to boost knowledge, skill sets, and confidence in managing hyperacute stroke scenarios with this new first-responder audience in mind. Hypothesis: We hypothesize that performance outcomes, as measured by Declarative and Procedural (Skill Sets) Knowledge and Confidence will improve over the 1.5-day period of a virtual stroke patient simulated training course. Methodology: Incoming Neurology residents and medical students with minimal exposure to stroke care underwent the aforementioned stroke simulation course at the Center for Advance Medical Learning and Simulation (CAMLS) in Tampa, Florida, USA. It included 3 lectures on acute stroke care by USF faculty and 10 simulated scenarios of “Stroke Alerts” using standardized actors and electronic patient simulators. After each scenario, debriefing reviewed participants’ performance in Declarative and Procedural (Skill Set) Knowledge and Confidence. Results were analyzed using Likert scale on data collected prior to, and after, the course. Results: A repeated measures ANOVA demonstrated that, compared to pre-testing, post-testing data for Declarative and Procedural (Skill Set) Knowledge (F=14.05, p=.002) and Confidence (F=33.37, p&lt;.001) of Acute Stroke management improved significantly for both residents and medical students alike. Conclusion: In conclusion, simulation training for acute stroke management is statistically and significantly effective for neurology residents and medical students. Simulation training addresses patient safety needs without harm to, or practice upon, real-live patients. Neurology residency programs across the country should consider designing similar programs or utilizing ours at CAMLS for optimal stroke care among beginning residents at the front line of stroke patient care.

In memoriam: Richard T. Johnson, 1931–2015

In memoriam: <scp>R</scp>ichard <scp>T</scp>. <scp>J</scp>ohnson, 1931–2015

Program Director Survey: Attitudes Regarding Child Neurology Training and Testing

BackgroundAs a result of major clinical and scientific advances and changes in clinical practice, the role of adult neurology training for Child Neurology and Neurodevelopmental Disability (NDD) certification has become controversial. The most recently approved requirements for board eligibility for child neurology and neurodevelopmental disability residents still include 12 months in adult neurology rotations. The objective of this study was to assess United States child neurology and neurodevelopmental disability residency program directors' opinions regarding optimal residency training. MethodsThe authors developed an 18-item questionnaire and contacted all 80 child neurology and neurodevelopmental disability program directors via e-mail, using SurveyMonkey. ResultsA total of 44 program directors responded (55%), representing programs that train 78 categorical and 94 total resident positions, approximately 70% of those filled in the match. Respondents identified multiple areas where child neurology residents need more training, including genetics and neuromuscular disease. A substantial majority (73%) believed child neurology and neurodevelopmental disability residents need less than 12 adult neurology training months; however, most (75%) also believed adult hospital service and man-power needs (55%) and finances (34%) would pose barriers to reducing adult neurology. Most (70%) believed reductions in adult neurology training should be program flexible. A majority believed the written initial certification examination should be modified with more child neurology and fewer basic neuroscience questions. Nearly all (91%) felt the views of child neurology and neurodevelopmental disability program directors are under-represented within the Accreditation Council for Graduate Medical Education Residency Review Committee. ConclusionsThe requirement for 12 adult neurology months for Child Neurology and Neurodevelopmental Disability certification is not consistent with the views of the majority of program directors, who favor more training in subspecialized fields of child neurology.