US Neurology Research Articles

Trends in Gender, Racial, and Ethnic Representation Among US Neurology Faculty

This cross-sectional study assesses changes in gender, racial, and ethnic representation among US neurology faculty from 1972 to 2021.

Education Research: The Current Landscape of Clinician Educator Tracks in Adult Neurology Residency Programs: A National Survey of Program Directors.

As the concept of a clinician-educator (CE) evolves and the multiple competencies of the role become better defined, there seems to be a growing need for targeted training for clinicians pursuing a career in medical education. This study aims to describe the current state of CE tracks in adult neurology residency programs and to identify the barriers to implementation, potential solutions, and program goals and outcomes. We characterized CE tracks using 2 methods. First, we reviewed the websites of all US adult neurology residency programs to determine the availability of a CE track and its characteristics. Second, we administered a 20-item survey to program directors (PDs) of all US neurology residency programs, with questions focused on track availability, characteristics, perceived benefits of CE tracks on resident career development, barriers to implementation, and ideas for national initiatives that may facilitate track development or improvement. Fifty-eight of 177 (33%) PDs responded to the survey. Combining the results of the website reviews and surveys, we found that 34 of 179 (19%) programs have CE tracks. Seventy percent of PDs felt that CE tracks are very impactful or impactful for participating residents' careers, a perception more common among PDs of programs with tracks. The greatest perceived benefit was in preparing residents for educational leadership roles. The greatest barriers to implementation were a lack of teaching faculty, a lack of resources, and limited resident time. The highest ranked idea for a national initiative that can facilitate track development was live and recorded lectures on medical education topics. Although most PDs surveyed agreed that CE tracks are impactful for preparing residents as teachers and education leaders, such tracks are available in only 19% of adult neurology residency programs. PDs report that the benefits of CE tracks extend beyond the participants, with implications for the health of the residency program and the neurology department. While some programs have significant barriers to implementation, national initiatives may help reduce the resource burden on individual programs. Future areas of study include assessing the development and outcomes of national initiatives and analyzing the outcomes associated with CE tracks.

Analysis of Faculty Gender and Race in Scholarly Achievements in Academic Neurology.

Background: Intersection of gender and race and/or ethnicity in academic medicine is understudied; we aim to understand these factors in relation to scholarly achievements for neurology faculty. Methods: Faculty from 19 US neurology departments completed a survey (2021-2022) to report rank, leadership positions, publications, funded projects, awards, and speaker invitations. Regression analyses examined effects of gender, race, and their intersectionality on these achievements. Women, Black/Indigenous/People of Color (BIPOC), and BIPOC women were comparator groups. Results: Four hundred sixty-twofaculty responded: 55% women, 43% men; 31% BIPOC, 63% White; 21% BIPOC women, 12% BIPOC men, 36% White women, 31% White men. Men and White faculty are more likely to be full professors than women and BIPOC faculty. The number of leadership positions, funded projects, awards, and speaker invitations are significantly greater in White compared to BIPOC faculty. Relative to BIPOC women, the number of leadership positions is significantly higher among BIPOC men, White women, and White men. Publication numbers for BIPOC men are lower, number of funded projects and speaker invitations for White women are higher, and number of awards among White men and White women is higher compared to BIPOC women. Discussion: Our study highlights that inequities in academic rank, award number, funded projects, speakership invitations, and leadership roles disproportionately impacted BIPOC women. More studies are needed to evaluate gender and race and/or ethnicity intersectionality effects on faculty achievements, reasons for inequities, recognition, and potential solutions.

Variability in Brain Death Education Across US Neurology Residency Programs (P6-7.008)

Variability in Brain Death Education Across US Neurology Residency Programs (P6-7.008)

Assessment of Neurology Residency Program Websites across North America during COVID-19.

With virtual interviews for residency applications, residency program websites have become increasingly important resources for applicants. We evaluated the comprehensiveness of US and Canadian neurology residency program website, comparing this to published rankings of the best neurology and neurosurgery hospitals (for US programs) and number of residency positions (for US and Canadian programs). US program websites were found to be largely more comprehensive than Canadian websites, more extensive websites were associated with better program rankings and fewer residency seats in the US, and US regional differences in comprehensiveness were present. We recommend standardized guidelines to increase website comprehensiveness across programs.

Examining the National Representativeness of the Axon Registry: A Neurology-Specific Patient Registry.

The objective of this study was to determine the external validity of the Axon Registry by comparing the 2019 calendar year data with 2 nationally representative, publicly available data sources, specifically the National Ambulatory Medical Care Survey (NAMCS) and the Medical Expenditure Panel Survey (MEPS). The Axon Registry is the American Academy of Neurology's neurology-focused qualified clinical data registry that reports and analyzes electronic health record data from participating US neurology providers. Its key function is to support quality improvement within ambulatory neurology practices while also promoting high-quality evidence-based care in clinical neurology. We compared demographics of patients who had an outpatient or office visit with a neurologist along with prevalence of selected neurologic conditions and neurologic procedures across the 3 data sets. We performed a cross-sectional, retrospective comparison of 3 data sets: NAMCS (2012-2016), MEPS (2013-2017, 2019), and Axon Registry (2019). We obtained patient demographics (age, birth sex, race, ethnicity), patient neurologic conditions (headache, epilepsy, cerebrovascular disease, multiple sclerosis, parkinsonism, dementia, spinal pain, and polyneuropathy), provider location, and neurologic procedures (neurology visits, MR/CT neuroimaging studies and EEG/EMG neurophysiologic studies). Parameter estimates from the pooled 5-year samples of the 2 public data sets, calculated at the visit level, were compared descriptively with those of the Axon Registry. We calculated Cohen h and performed Wald tests (α = 0.05) to conduct person-level statistical comparisons between MEPS 2019 and Axon Registry 2019 data. The Axon Registry recorded 1.3 M annual neurology visits (NAMCS, 11 M; MEPS, 22 M) and 645 K people with neurologic conditions (MEPS, 10 M). Compared with the pooled national surveys, the Axon Registry has similar patient demographics, neurologic condition prevalence, neuroimaging and neurophysiologic utilization, and provider location. In direct comparison with MEPS 2019, the Axon Registry 2019 had fewer children (2% vs 7%), more elderly persons (21% vs 16%), fewer non-Black and non-White race persons (5% vs 8%), less number of patients with epilepsy (10% vs 13%), more patients with dementia (8% vs 6%), more patients with cerebrovascular disease (11% vs 8%), and a greater predominance of neurology providers in the Midwest (25% vs 20%). The only difference with a non-negligible effect size was the proportion of people younger than 15 years (Cohen h = 0.25). The Axon Registry demonstrates high concordance with 2 nationally representative surveys. Recruiting more and diverse neurology providers will further improve the volume, representativeness, and value of the Axon Registry.

To Subspecialize or Not, That Is the Question for US and European Neurology Trainees

To Subspecialize or Not, That Is the Question for US and European Neurology Trainees

Opinion and Special Article: The Need for Specialized Training in Women's Neurology.

Women's Neurology is an emerging subspecialty that focuses on neurologic disorders across a woman's lifetime. This new domain recognizes that both health and disease are directly affected by hormonal and reproductive changes throughout the life span. This field includes neurologic diseases with a higher prevalence in women and diseases that require specialized management during pregnancy, postpartum period, lactation, and menopause. A survey was sent to US neurology residency program directors to understand the state of training in the area. Their responses highlighted an urgent need for additional education in this field for neurology residents. In this study, we discuss the educational gaps in this area, the clinical benefits of a women's neurology discipline, and the instructional gaps in this area and provide practical recommendations for training programs in women's neurology using 2 innovative fellowship programs.

Nutritional Counseling of Stroke Patients by Neurology Residents, a Call to Action.

BackgroundPoor diet quality has been found to be an independent risk factor for mortality in stroke. However, it is unknown to what extent Neurologists are trained and are comfortable enough to provide dietary counseling to stroke patients.ObjectiveTo assess the knowledge, attitudes, and practices of neurology residents relating to dietary counseling of stroke patients.MethodsAn online anonymous survey was administered to neurology residents throughout the country between August and November 2019 among a total of 109 (68%) US neurology programs. Self-reported practices and knowledge regarding stroke prevention through nutritional counseling were queried using validated questionnaires.Results453 responses out of a potential 672 were received. A minority of residents (12.3%) consistently offered nutritional counseling to stroke patients. 47.7% considered that it was not the neurologist's role to provide nutritional counseling to stroke patients. 83.4% of residents felt that it was the responsibility of the dietician to provide nutritional counseling, yet only 21.4% of residents consistently referred stroke patients to a dietician. 77.9% of respondents felt nutritional counseling is important for stroke patients, yet 65.6% felt they were not adequately trained to provide nutritional counseling.ConclusionNeurologists in training believe diet to be an important part of stroke prevention, but practical knowledge and training in nutrition are suboptimal. This study suggests the need to include nutrition as an integral part of neurology training, to ensure neurologists feel empowered to be an important part of the team providing nutritional counseling to stroke patients.

Neurology Morbidity and Mortality Conferences and Quality Improvement: Single-Center Experience and National Survey.

Morbidity and Mortality (M&M) conferences are widespread but vary in goals and methodology. Some focus on clinical enigmas while an increasing number utilize quality improvement (QI) tools to effect systems change. Little is known about the current state of US Neurology M&Ms. We surveyed 56 US academic neurology departments regarding their M&Ms to understand the use of QI tools and assess variability. Additionally, we reviewed the evolution of M&Ms in our department. The survey was completed by 44 (80%) departments; 68% reported quarterly frequency with 61% discussing 1-2 safety events per conference. The number of written guidelines or protocols resulting from M&Ms in 2years varied from 0 (14% of departments), 1-2 (45%), to >5 (5%). Institutional culture regarding quality and safety and conference timing were cited by 71% as important in improving participation. In our own department, the M&M format changed in 2014 based on a sentinel patient event combined with improving safety culture across the hospital: neurology M&Ms transformed into thematic quarterly conferences utilizing QI tools. Attendance increased 3-fold, and in 7years, we have generated 26 guidelines or pathways with corresponding decision-support tools, among other improvement efforts, resulting in specific systems changes. Based on survey results and our experience, suggested M&M "best practices" include the use of just culture, peer review protection, safety event analysis with QI methodology, trainee involvement, and logistical optimization. Structured M&Ms incorporating suggested QI-informed "best practices" can be highly effective in driving system change within neurology.

Effect of the COVID-19 Pandemic on Neurology Trainees' Education and Practice

Objective: The COVID-19 pandemic has rapidly changed the neurology training landscape. The study was designed to assess the effects of COVID-19 on the education, practice, and well-being of US neurology trainees.
 Methods: A 36-item survey was distributed to neurology residents and fellows in the United States through various media platforms.
 Results: Over an 8-week period, 286 responses were received, 285 were included. Almost all (93%) trainees were in an academic setting. Tele-neurology use by trainees was minimal (13%) prior to the pandemic; however, during the pandemic 91% reported using it. A majority (84%) of trainees did not receive training in tele-neurology prior to the pandemic. Most trainees felt that the pandemic impacted their education with fewer lectures being available, and 77% resorted to getting lectures from outside institutions. Tele-lecturing with video conferencing was the most common mode of education during the pandemic. A third (33%) of trainees felt that they did not have enough PPE during the pandemic. Most trainees worried about exposing themselves or their families to COVID-19, and had increased stress levels.
 Conclusion: This study demonstrates that most neurology trainees had no training nor exposure to tele-neurology prior to the pandemic, and were rapidly thrusted into tele-neurology during the pandemic. Trainees had an overall negative educational impact, and were stressed during the pandemic. Use of technology and availability of outside institutions’ lectures were most helpful to continue with educational activities during this time.

Academic Neurology Departments: Structure, Diversity, and Financial Pressures in 2019 vs 2002.

This article provides an overview and update on the current status of academic neurology based on structured insights from departmental leaders across the United States. Academic neurology, at a time when and leaders in academic medicine in general, are facing protean administrative, structural, and financial challenges that threaten all academic missions.1,2 In 2002, the Association of University Professors of Neurology (AUPN) and American Neurologic Association (ANA) jointly surveyed US neurology department chairs on the health of US academic neurology.1 The results showed troublesome findings related to adverse financial pressures on education, research, faculty development, and growth of new programs. In 2016, the AUPN surveyed neurology department chairs to better understand the organization and operations of neurology departments under contemporary health care reform. Results highlight that most neurology departments had fewer than 60 faculty members, a minority of whom were tenured or on a tenure track. Over a third had faculty members on a purely clinical track, with no education or research responsibilities.2 In early 2019, the AUPN partnered with the American Academy of Neurology (AAN) to resurvey academic neurology chairs using most of the 2002 AAN/AUPN survey questions. Survey responses from 2019 were compared with the earlier findings.

Gender and racial trends among neurology residents: an overview

Diversification of academic medicine improves healthcare standards and patient outcomes. Gender and racial inequalities are major challenges faced by the healthcare system. This article reviews the trends of gender and...

Representation of women plenary speakers at the American Academy of Neurology Annual Meeting.

To determine whether women have been equitably represented among plenary speakers at the American Academy of Neurology (AAN) Annual Meeting by counting and categorizing speakers and comparing outcomes to AAN membership and US neurology workforce data. Lists of plenary speakers between 1958 and 2019 (62 years) were obtained from the AAN. The primary outcome measures were numbers and proportions of men and women in aggregate and among physicians. We identified 635 plenary speakers, including 148 (23.3%) women. Specifically, women made up 14.6% (19 of 130) of presidential and 25.5% (129 of 505) of nonpresidential plenary session speakers. The inclusion of women plenary speakers was meaningfully higher (h = 0.33; difference 14.9%; 95% confidence interval 4.2%-26.7%) for nonphysicians (27 of 74 [36.5%]) than physicians (121 of 561 [21.6%]). Although at zero levels for Annual Meetings held between 1958 and 1990 and at mostly low but varying levels thereafter, the representation of women and women physicians has been at or above their proportions in the AAN membership and US neurology workforce since 2017. Comparison of representation by plenary session name revealed an unequal distribution of women, with women physicians concentrated in the Sidney Carter Award in Child Neurology presidential session. Historically and recently, women and women physicians were underrepresented among AAN plenary speakers. As the AAN has taken active steps to address equity, women have been included in more representative proportions overall. However, notable gaps remain, especially in specific prestigious plenary sessions, and further research is needed to determine causality.

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.

Assessing Physician‐Patient Dialogues About Chronic Migraine During Routine Office Visits

To assess physician-patient communication and identify the frequency of use of specific communication techniques by analyzing recordings of routinely scheduled medical encounters for patients with clinician-identified chronic migraine. Chronic migraine is an under-diagnosed, under-treated, and highly burdensome disease. Effective medical communication is integral to optimal medical care, including providing accurate diagnoses, creating effective treatment plans, and enhancing patient adherence. Communication patterns during office visits may be a target for intervention to improve outcomes for people with chronic migraine. This was a prospective, observational study based on analysis of audio recordings collected during neurologist-patient chronic migraine dialogues. Twenty neurologists from a US neurology panel maintained by Verilogue, Inc., a research organization specializing in healthcare dialogues, were invited to identify patients with chronic migraine and record clinical encounters with their patients. Both new patient visits and follow-up visits were included in this analysis. Neurologist-patient dialogues were audio-recorded, anonymized, transcribed, and analyzed by a sociolinguist for the presence of prespecified communication parameters, strategies, and specific language indicative of optimal migraine-related medical care. Fourteen out of the 20 invited neurologists (70.0%) accepted the study invitation and recorded 35 encounters with patients eligible for the study. The patient sample was 91.4% female (n = 32/35), with a mean age of 46 years. On average, there were 17 headache-related questions per visit; 82.0% of questions were closed-ended (n = 369/450). Headache/migraine frequency was elicited in 77.1% of the dialogues (n = 27/35), but headache days per month was assessed in only a single dialogue. Only one neurologist utilized the ask-tell-ask technique. Headache-related disability was discussed in 22.9%of the dialogues (n = 8/35), with only one using open-ended questions. None of the dialogues discussed ictal vs interictal headache-related disability. Chronic migraine was mentioned in 8.6% of dialogues (n = 3/35) and treatment plans were discussed in 37.1% of the dialogues (n = 13/35). Results from this preliminary study showed that the majority of the neurologist-chronic migraine patient dialogues did not assess elements crucial for diagnosis and treatment (eg, headache days per month and headache related disability) or use standard communication techniques (eg, open-ended questions, ask-tell-ask). We recommend intervention studies designed to assess the benefits of improved communication on diagnostic accuracy, treatment decisions, and patient reported outcomes.

Sex Differences in Academic Rank and Publication Rate at Top-Ranked US Neurology Programs

Women are underrepresented in academic neurology, and the reasons for the underrepresentation are unclear. To explore potential sex differences in top-ranked academic neurology programs by comparing the number of men and women at each academic faculty rank and how many articles each group has published. Twenty-nine top-ranked neurology programs were identified by combining the top 20 programs listed on either the 2016 or 2017 Doximity Residency Navigator tool with the top 20 programs listed in the US News and World Report ranking of Best Graduate Schools. An internet search of the departmental websites was performed between December 1, 2015, and April 30, 2016. For each faculty member on a program site, the following biographical information was obtained: first name, last name, academic institution, sex, academic faculty rank, educational leadership (clerkship, fellowship, or residency director/assistant director), and year of medical school graduation. To compare the distribution of men vs women and the number of publications for men vs women at each academic faculty rank. Secondary analyses included Scopus h-index, book authorship, educational leadership (clerkship, residency, or fellowship director/assistant director), and clinical activity as inferred through Medicare claims data in men vs women after controlling for years since medical school graduation. Of 1712 academic neurologists in our sample, 528 (30.8%) were women and 1184 (69.2%) were men (P < .001). Men outnumbered women at all academic faculty ranks, and the difference increased with advancing rank (instructor/lecturer, 59.4% vs 40.5%; assistant professor, 56.7% vs 43.3%; associate professor, 69.8% vs 30.2%; and professor, 86.2% vs 13.8%). After controlling for clustering and years since medical school graduation, men were twice as likely as women to be full professors (odds ratio [OR], 2.06; 95% CI, 1.40-3.01), whereas men and women had the same odds of being associate professors (OR, 1.04; 95% CI, 0.82-1.32). Men had more publications than women at all academic ranks, but the disparity in publication number decreased with advancing rank (men vs women after adjusting for years since medical school graduation: assistant professor [exponentiated coefficient, 1.85; 95% CI, 1.57-2.12]; associate professor [1.53; 95% CI, 1.22-1.91]; and full professor [1.36; 95% CI, 1.09-1.69]). Men had a higher log Scopus h-index than women after adjustment (linear coefficient, 0.44; 95% CI, 0.34-0.55). There was no significant association between sex and clinical activity (linear coefficient, 0.02; 95% CI, -0.10 to 0.13), educational leadership (OR, 1.09; 95% CI, 0.85-1.40), or book authorship (OR, 2.75; 95% CI, 0.82-9.29) after adjusting for years since medical school graduation. Men outnumber women at all faculty ranks in top-ranked academic neurology programs, and the discrepancy increases with advancing rank. Men have more publications than women at all ranks, but the gap narrows with advancing rank. Other measures of academic productivity do not appear to differ between men and women.

International Issues: A guide to US academic global health programs in neurology.

Global health programs advocate for a better understanding of health disparities, often prompting medical trainees to practice medicine in an international setting. The relevance of global health electives in neurology is highlighted by the increasing burden of neurologic diseases in low- and middle-income countries (LMICs), representing 84% of the world's population.1,2 Cerebrovascular disease is the second leading cause of morbidity and mortality worldwide, and dementia, meningitis, migraine, and epilepsy are in the top 50 factors in disability-adjusted life years. Neurologists therefore play a key role in global health, caring for patients with acute neurologic disorders and neurologic sequelae of both noncommunicable and communicable diseases. Despite this, there are only 0.03 to 1.09 neurologists per 100,000 people in LMICs, with large inequalities in access to care, compared to 4.75 per 100,000 population in high-income countries.3 Through developing collaborative relationships and a cross-cultural exchange of knowledge, US neurology trainees can play a role in addressing these disparities in neurologic care.

Use of an Electronic Medical Record to Track Adherence to the Mediterranean Diet in a US Neurology Clinical Practice.

ObjectiveWe describe our experience with routinely capturing and analyzing Mediterranean diet data via structured clinical documentation support tools built into the electronic medical record and describe adherence to the Mediterranean diet in patients at risk for either stroke or dementia in a US neurology clinical practice.Patients and MethodsThe Mediterranean diet is associated with a reduced risk of stroke and dementia. The Department of Neurology at NorthShore University HealthSystem routinely evaluates patients at initial and annual outpatient visits using structured clinical documentation support (SCDS) tools built into the electronic medical record (EMR). For patient evaluations in our Vascular Neurology and Brain Health subspecialty clinics, SCDS tools in the EMR include the validated 14-item questionnaire for Mediterranean diet adherence (PREvención con DIeta MEDiterránea [PREDIMED]) that autoscores, auto-interprets, writes to the progress note, and electronically captures data. Our study population includes patients seen at these clinics from July 1, 2015, through November 29, 2017.ResultsAt their initial office visit, 25.5% (95/373) of Brain Health patients scored 10 or more points (“strongly adherent”) on the PREDIMED (median, 8; range, 0-14) whereas 6.7% (55/829) of Vascular Neurology patients achieved a score of 10 or more points (median, 6; range, 0-12). By contrast, 34.7% (2586/7447) of individuals in the original PREDIMED cohort were strongly adherent to the Mediterranean diet.ConclusionPREDIMED scores can be electronically captured to tailor nutrition interventions by assessing baseline adherence at the time of their initial neurology clinic visit. Patients in our Midwestern US clinics were weakly adherent to the Mediterranean diet. This suggests a major opportunity for nutrition intervention and education in US neurology clinical practices, toward preserving and improving brain health.

Editors' note: Burnout, career satisfaction, and well-being among US neurology residents and fellows in 2016

In “Burnout, career satisfaction, and well-being among US neurology residents and fellows in 2016,” Levin et al. studied the prevalence of and factors contributing to burnout, career satisfaction, and well-being in US neurology residents and fellows. They found that burnout is common in neurology residents and fellows and that the lack of work–life balance and lack of meaning in work were associated with reduced career satisfaction and increased risk of burnout. Commenting on the article, Dr. Sethi suggests that addressing burnout among US neurology residents and fellows should not be limited to addressing work-related issues, but also broader social issues such as family, loans, and salaries. Levin et al. agree and suggest that a more in-depth study of work–life balance and stressors outside the workplace among neurology trainees could provide additional insights. In “Burnout, career satisfaction, and well-being among US neurology residents and fellows in 2016,” Levin et al. studied the prevalence of and factors contributing to burnout, career satisfaction, and well-being in US neurology residents and fellows. They found that burnout is common in neurology residents and fellows and that the lack of work–life balance and lack of meaning in work were associated with reduced career satisfaction and increased risk of burnout.