Neurology Residency Training Research Articles

Teaching Headache in America: Survey of Neurology Chairs and Residency Directors

To determine the status of headache education in American medical schools and Neurology Residency Training Programs. One hundred and thirty-three programs were identified using the Association of University Professors of Neurology listing. Two hundred and seventeen surveys were mailed to departmental chairs (DC) and residency training directors (RTD) with fax back response sheets enclosed. Two additional mailings were sent to nonresponders. Questions regarding the presence of medical school or resident educational opportunities in headache medicine including lectures and electives were included. Additional questions were asked to assess beliefs about headache education in America. One hundred nineteen surveys were returned. Ninety-five institutions responded including 75 Chairs and 44 RTD. Eighty percent of institutions have formal medical school lectures in headache/migraine. Fifty-five institutions claim to have a headache clinic, 52 within neurology departments. Thirty-two percent offer a headache elective to medical students. Nearly all departments offer formal resident lectures in headache/migraine, and 57% offer a headache elective. Essentially, all individual respondents believe that migraine is a valid neurological disorder and an important subject to teach in medical school. Ninety-one agree or strongly agree that headache is an important public health issue. Twenty-nine percent agree or strongly agree that headache diagnosis and management is adequately taught. Eighty-four percent believe the pharmaceutical industry has influenced migraine education and management. No important differences in response were found between Chairs and RTD. This survey provides the first comprehensive assessment of the status of headache medicine education in academic departments of neurology.

Joe R. Brown, MD (1911–2004)

Dr. Joe R. Brown, a founding member of the American Academy of Neurology (AAN), died on October 30, 2004, in Rochester, MN. Dr. Brown was born in Mount Pleasant, IA, on November 11, 1911. He graduated from the University of Iowa with a BA degree in 1933, and he received his MD degree from the University of Iowa Medical School in 1937. After preliminary training at the Presbyterian Hospital in Chicago, he had residency training in neurology and psychiatry at the Mayo Clinic from 1939 to 1943, during which time he received his MS degree from the graduate …

Neurology residency training in Europe: an Italian perspective

Education is the most important part of medical-science training. Assessment of training programmes and examination of trainees' skills are necessary to guarantee that trainees develop competence. Training programmes vary between and within countries. The impending integration of the medical-job market among European countries highlights the need for people training to be specialists to achieve a certain standard. Here, we review the neurological training programmes in Europe, principally those in Italy, and discuss the standardisation of the training of residents in Italy and the quality control of current residency training, or its absence, in Europe.

Introducing the Resident and Fellow Page

The Neurology Resident and Fellow Section is being introduced at a time of great change in neurology residency training and graduate medical education (GME). A lawsuit has challenged the mechanism by which medical students choose their training programs, new duty hour regulations have changed the resident’s role in patient care, and new competency standards have resulted in new curricula for all programs. Residents face challenges of career decisions, skyrocketing healthcare costs, reduced reimbursement, and increasing financial pressures in both the academic environment and private practice. …

Neurology residency training at the millennium.

Neurology training is changing because of the explosion of information and new treatment modalities that became available during the 1990s, the Decade of the Brain. The Residency Review Committee (RRC) mandated curriculum changes in 1998. During the same decade, the number of American medical graduates (AMG) who entered neurology declined. This occurred as the total number of positions was at an all-time high. An increasing number of positions in the mid-1990s were either filled by international medical graduates (IMG) or remained unfilled (Doug Perry, personal communication, 2001). Funding for residency positions has been threatened and lost because of changes in Medicare funding and reallocation of specialty residency slots to generalist slots within the Veterans Affairs (VA) system.1 In addition, the clinical income used by many academic departments to support teaching and administrative activities has been substantially reduced by managed care. Academic physicians now have less time to teach.2 Similar stresses in other specialties have led to high turnover rates among residency directors.3 In 1999, the Graduate Education Subcommittee (GES) of the American Academy of Neurology (AAN) conducted a survey of adult neurology program directors (ANPD) to ascertain the state of neurology training programs. The goal was to characterize current program content and performance, applicants and the neurology residency matching program (NEMP, “the match”), characteristics of training program directors, and type and amount of administrative support for residents. We wished to identify current trends in neurology resident education and how programs are dealing with major challenges. The GES designed a 45-question survey to assess the issues described above. Survey questions were determined over the course of several meetings by members of the GES, the majority of whom were ANPD or had been in the past. The responses were anonymous, although members of the AAN GES staff were able …

Elan D. Louis

[Author Photo]The readers and staff of Seminars in Neurology are privileged to be provided with an outstanding issue on the neurological exam and its historical background under the guest editorship of Dr. Elan D. Louis. Dr. Louis is an Assistant Professor of Neurology at the Sergeivsky Center and Department of Neurology at the College of Physicians and Surgeons, Columbia University. After receiving his undergraduate degree from the University of Pennsylvania, he attended medical school at Yale and then received a masters degree in epidemiology from the Columbia University School of Public Health. He spent a year at the Cold Spring Harbor Laboratory in the Eukaryotic Molecular Genetics Section and then obtained residency training in neurology at the New York Neurological Institute at Columbia-Presbyterian Medical Center, followed by a fellowship in movement disorders and neuroepidemiology.

Graduating neurology residents’ experience with use of intravenous tPA for acute ischemic stroke

45 Background: Intravenous tPA was approved as a treatment for acute ischemic stroke in 1996. One potential barrier to increased use of tPA has been lack of experience and training among neurologists. To date, there has been no formal assessment of neurology residents’ experience with tPA during their training. Methods: A 12 item survey was sent in March 2000 to all graduating neurology residents as identified by AMA-GME files. Follow-up surveys were sent in April and May to non-responders. Survey items established residents’ experience and confidence with assessment of the acute stroke patient and use of tPA. Responses were assessed using a 5 point Likert scale. Presence of a dedicated stroke team, ongoing stroke clinical trials, and post-residency career plans were also assessed. Results: Of 398 graduating residents for whom addresses were available, 287 (72%) responded. 80% of respondents had personally treated a patient with tPA; 33% had done so without direct faculty supervision. 12% had neither treated nor observed a patient being treated with tPA. 89% had cared for an acute stroke patient in the first hours after administration of tPA. 73% felt comfortable independently treating acute stroke patients with tPA. 65% of residents had formal NIHSS training. Nearly all residents felt confident in their ability to identify hemorrhage (99%) and early infarct signs (94%) on CT. Residents whose institutions had a stroke team were more likely to have provided post-tPA care (93% vs 71%, p<0.001), to have had formal NIHSS training (69% vs 44%, p<0.001), and to feel comfortable independently treating patients with tPA (75% vs 62%, p=0.08). There was no association between career plans (academics vs private practice) and any survey items. Conclusion: One fifth of graduating neurology residents had never personally treated an acute stroke patient with tPA; one in ten had never seen tPA administered. One quarter did not feel comfortable independently treating with tPA. Experience with current treatment for acute stroke should be considered an essential part of neurology residency training. Stroke teams may be helpful in accomplishing this goal.

Graduating neurology residents’ experience with use of intravenous tPA for acute ischemic stroke

45 Background: Intravenous tPA was approved as a treatment for acute ischemic stroke in 1996. One potential barrier to increased use of tPA has been lack of experience and training among neurologists. To date, there has been no formal assessment of neurology residents’ experience with tPA during their training. Methods: A 12 item survey was sent in March 2000 to all graduating neurology residents as identified by AMA-GME files. Follow-up surveys were sent in April and May to non-responders. Survey items established residents’ experience and confidence with assessment of the acute stroke patient and use of tPA. Responses were assessed using a 5 point Likert scale. Presence of a dedicated stroke team, ongoing stroke clinical trials, and post-residency career plans were also assessed. Results: Of 398 graduating residents for whom addresses were available, 287 (72%) responded. 80% of respondents had personally treated a patient with tPA; 33% had done so without direct faculty supervision. 12% had neither treated nor observed a patient being treated with tPA. 89% had cared for an acute stroke patient in the first hours after administration of tPA. 73% felt comfortable independently treating acute stroke patients with tPA. 65% of residents had formal NIHSS training. Nearly all residents felt confident in their ability to identify hemorrhage (99%) and early infarct signs (94%) on CT. Residents whose institutions had a stroke team were more likely to have provided post-tPA care (93% vs 71%, p Conclusion: One fifth of graduating neurology residents had never personally treated an acute stroke patient with tPA; one in ten had never seen tPA administered. One quarter did not feel comfortable independently treating with tPA. Experience with current treatment for acute stroke should be considered an essential part of neurology residency training. Stroke teams may be helpful in accomplishing this goal.

Quality improvement in neurology residency programs. Report of the Quality Improvement Committee of the Association of University Professors of Neurology.

The neurology residency programs in the United States are facing a crisis of quality. The Association of University Professors of Neurology (AUPN) approved the Quality Improvement Committee to examine this situation and make recommendations, which have been accepted by the AUPN. The recommendations are (1) that the educational goals of neurology residency training be dissociated from patient-care needs in academic medical centers and (2) that minimum levels of quality be applied to residents in neurology residency programs and to these programs themselves. These minimum criteria should include minimum educational criteria for entry into the program, minimum criteria for advancement from one year to the next in the program, and minimum criteria for performance of the graduates of neurology residency programs for program accreditation. The implementation of these recommendations will require a shift of funding of the care of indigent patients from the graduate medical education budget to direct patient-care sources. These recommendations will significantly improve the quality of neurologists and neurologic care in the United States.

On the production of neurologists in the United States

Based primarily on a survey of all neurology residency training programs in the United States conducted in 1985-1986, the average annual production (incidence) of general neurologists for 1980-1986 was 363.6 and of child neurologists for 1982-1986, 53.8. About 1/4 of these general neurologists and 1/3 of child neurologists are women; about 1/4 of either are foreign medical graduates, predominantly foreign-born. Data routinely published by the AMA well match the questionnaire information. First postgraduate year of training was in internal medicine for 2/3 of general neurologists. Board certification have recently averaged 290.9 (general) and 37.1 (child) per annum. From life-table calculations, prevalence of general neurologists in 1990 is estimated at 7,500 fully-trained and 5,500 board-certified, and of child neurologists near 1,100 trained and over 600 certified. The number of neurologists is predicted to plateau near the year 2020 at some 13,700 trained, including 1,700 child neurologists, and 9,800 certified (1,100 child). The maximal prevalence rate for all neurologists will be 4.75 per 100,000 population in 2010, declining then to 4.42 by 2050; those rates provide shortfalls of 30% and 35%, respectively, compared with previously calculated needs for neurologists.

Neurology residency training programs in the United States.

A survey of 127 neurology residency training programs (124 approved by the Accreditation Council for Graduate Medical Education; 3 by the American Osteopathic Association) in the United States indicated that 80% were sponsored by medical schools. Of the 2,700 MD neurology faculty in 1982, 3/5 were full-time. As of 1982, there were 1,300 neurology trainees, including 334 fourth-year postgraduates (PG4s); 21% were women, and 3% held DO degrees. From 1960 through 1983, about 5,000 PG4s were produced, and for 1984 through 1990 the program directors estimated that this number will be about 3,000; our own projection, however, was only 2,400.

Neurologists in the United States—past, present, and future

Neurologists in the United States were enumerated for each year from 1935 to 1984 on two bases: board certification (including Child Neurology and Psychiatry and Neurology) and completion of PG4 neurology residency training. The annual incidence of new neurologists was calculated at less than 200 until 1970; then it rose steadily to 380 in 1980, and plateaued thereafter at 385. The estimated number of neurologists present at one time (prevalence) was 1,500 in 1950, 2,400 in 1970, 4,600 in 1980, 8,100 in 1990, and 11,000 in 2000. These numbers for total neurologists will plateau at 12,200 by about 2010, at which time the number of certified neurologists will also plateau at 9,900. Both numbers are notably less than our prior estimate of needs: 16,500 neurologists by 1990, 19,100 in 2010.

An ambulatory neurology clerkship for third-year medical students. A 20-year perspective.

Prompted by a variety of social, technologic, and economic pressures, the ambulatory teaching of medicine is having a renaissance. The required neurology clerkship at the West Virginia University School of Medicine, Morgantown, has been taught to medical students for more than 20 years in an ambulatory setting. This was initially begun out of necessity when we had no neurology residency training program. Our inpatient service was staffed by a single attending neurologist and two inexperienced medicine house staff members, usually at the postgraduate 1 and 2 levels of training. Placing the students in the ambulatory arena allowed for an equitable division of the teaching responsibility among all the attending neurologists, each of whom spent one day each week in the clinic. It soon became apparent that this was an effective teaching mode although, then, it was not in the mainstream of the inpatient-oriented philosophy of teaching medical students. We have