US Neurology Research Articles

Reader response: Burnout, career satisfaction, and well-being among US neurology residents and fellows in 2016.

I read with interest the article by Levin et al.,1 which looked at the burnout rates among US neurology residents and fellows. The study highlighted the importance of work–life balance as a determinant of burnout in this group. A physician in training experiences some unique challenges with respect to work–life balance. During these formative years of training, the young physician encounters a steep learning curve, long work hours, and increased responsibility with respect to patient care. Outside of work, these young physicians are frequently shouldering the responsibilities of a recent marriage and family life, planning their family, or becoming a new parent. Resident salaries have remained stagnant over the years while the cost of living has gone up exponentially. Many physicians in training are also burdened by substantial student loans. All these responsibilities can heavily weigh on them, contributing to stress and burnout at work. Addressing burnout in this group should not just be limited to addressing work-related issues; some broader social issues also deserve due consideration.

Author response: Burnout, career satisfaction, and well-being among US neurology residents and fellows in 2016.

We agree that factors outside the workplace play a potentially important role in emotional exhaustion and burnout among neurology trainees. We concentrated on workplace drivers of burnout, except for one general question about work–life balance, in order to keep the survey length manageable.1 Burnout is associated with poor quality of life and educational debt.2 Work–home interference can be a cause as well as a result of stress during residency.3 A more in-depth study of work–life balance and stressors outside the workplace among neurology trainees could provide additional insights.

Spotlight on the August 1 issue

#### Notable in Neurology This issue features an article that investigates whether Mucuna pruriens , a levodopa-containing leguminous plant, may be used as an alternative source of levodopa and another article that shows that sural nerve injury in transthyretin familial amyloid polyneuropathy is detectable and quantifiable in vivo by magnetic resonance neurography. A featured article examines the prevalence of and factors contributing to burnout, career satisfaction, and well-being in US neurology residents and fellows. ### Poor sleep is associated with CSF biomarkers of amyloid pathology in cognitively normal adults![Graphic][1]</img> This study found that poor sleep is associated with Alzheimer disease (AD) … [1]: /embed/inline-graphic-1.gif

International Issues: Teleneurology in humanitarian crises: Lessons from the Médecins Sans Frontières experience.

Humanitarian emergencies defined by armed conflict, political strife, famine, or natural disaster can devastate populations rapidly. Neurologic disorders accompany these complex humanitarian emergencies but often go unheeded, exacerbated by a scarcity of neurologists. Teleneurology offers the promise of neurologic care remotely in the face of this inadequate local clinician supply. We describe our experiences as voluntary neurology teleconsultants with Médecins Sans Frontières in order to highlight both the promises and challenges of teleneurology in humanitarian contexts. We identified the major advantages of this service as (1) minimal resources and incurred costs while (2) changing a patient's clinical course favorably, and (3) creating a community for the field referrer and neurology specialist. Current challenges include (1) limited diagnostic resources and difficult diagnostic and therapeutic decision-making, (2) need for greater continuity and familiarity between the field site and neurologist, (3) gaps in the US neurology curriculum to provide expertise for all sites, (4) lack of follow-up and feedback from the field to advise future cases, and (5) low frequency of consultations. Growth opportunities include eventual expansion to the development of a community of neurologists who can provide context-specific care and maximize use of multimedia at low Internet bandwidth. Lessons from our experience may help optimize teleneurology's effect and reduce disparities in neurologic care, particularly in humanitarian crises.

Burnout, career satisfaction, and well-being among US neurology residents and fellows in 2016.

To study prevalence of and factors contributing to burnout, career satisfaction, and well-being in US neurology residents and fellows. A total of 938 US American Academy of Neurology member neurology residents and fellows were surveyed using standardized measures of burnout, career satisfaction, and well-being from January 19 to March 21, 2016. Response rate was 37.7% (354/938); about 2/3 of responders were residents and 1/3 were fellows. Median age of participants was 32 years and 51.1% were female. Seventy-three percent of residents and 55% of fellows had at least one symptom of burnout, the difference largely related to higher scores for depersonalization among residents. For residents, greater satisfaction with work-life balance, meaning in work, and older age were associated with lower risk of burnout; for fellows, greater satisfaction with work-life balance and effective support staff were associated with lower risk of burnout. Trainees experiencing burnout were less likely to report career satisfaction. Career satisfaction was more likely among those reporting meaning in work and more likely for those working in the Midwest compared with the Northeast region. Burnout is common in neurology residents and fellows. Lack of work-life balance and lack of meaning in work were associated with reduced career satisfaction and increased risk of burnout. These results should inform approaches to reduce burnout and promote career satisfaction and well-being in US neurology trainees.

Mentored peer review of standardized manuscripts as a teaching tool for residents: a pilot randomized controlled multi-center study

BackgroundThere is increasing need for peer reviewers as the scientific literature grows. Formal education in biostatistics and research methodology during residency training is lacking. In this pilot study, we addressed these issues by evaluating a novel method of teaching residents about biostatistics and research methodology using peer review of standardized manuscripts. We hypothesized that mentored peer review would improve resident knowledge and perception of these concepts more than non-mentored peer review, while improving review quality.MethodsA partially blinded, randomized, controlled multi-center study was performed. Seventy-eight neurology residents from nine US neurology programs were randomized to receive mentoring from a local faculty member or not. Within a year, residents reviewed a baseline manuscript and four subsequent manuscripts, all with introduced errors designed to teach fundamental review concepts. In the mentored group, mentors discussed completed reviews with residents. Primary outcome measure was change in knowledge score between pre- and post-tests, measuring epidemiology and biostatistics knowledge. Secondary outcome measures included level of confidence in the use and interpretation of statistical concepts before and after intervention, and RQI score for baseline and final manuscripts.ResultsSixty-four residents (82%) completed initial review with gradual decline in completion on subsequent reviews. Change in primary outcome, the difference between pre- and post-test knowledge scores, did not differ between mentored (−8.5%) and non-mentored (−13.9%) residents (p = 0.48). Significant differences in secondary outcomes (using 5-point Likert scale, 5 = strongly agree) included mentored residents reporting enhanced understanding of research methodology (3.69 vs 2.61; p = 0.001), understanding of manuscripts (3.73 vs 2.87; p = 0.006), and application of study results to clinical practice (3.65 vs 2.78; p = 0.005) compared to non-mentored residents. There was no difference between groups in level of interest in peer review (3.00 vs 3.09; p = 0.72) or the quality of manuscript review assessed by the Review Quality Instrument (RQI) (3.25 vs 3.06; p = 0.50).ConclusionsWe used mentored peer review of standardized manuscripts to teach biostatistics and research methodology and introduce the peer review process to residents. Though knowledge level did not change, mentored residents had enhanced perception in their abilities to understand research methodology and manuscripts and apply study results to clinical practice.

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.

Procedural Headache Medicine in Neurology Residency Training: A Survey of US Program Directors.

To survey neurology residency program directors (PDs) on trainee exposure, supervision, and credentialing in procedures widely utilized in headache medicine. Clinic-based procedures have assumed a prominent role in headache therapy. Headache fellows obtain procedural competence, but reliance on fellowship-trained neurologists cannot match the population eligible for treatments. The inclusion of educational modules and mechanisms for credentialing trainees pursuing procedural competence in residency curricula at individual programs is not known. A web-based survey of US neurology residency PDs was designed by the American Headache Society (AHS) procedural special interest section in collaboration with AHS and American Academy of Neurology's Headache and Facial Pain section leadership. The survey addressed exposure, training, and credentialing in: (1) onabotulinumtoxinA (onabotA) injections, (2) extracranial peripheral nerve blocks (PNBs), and (3) trigger point injections (TPIs). Fifty-five PDs (42.6%) completed the survey. Compared to noncompleters, survey completers were more likely to feature headache fellowships at their institutions (38.2% vs 10.8%, P=0.0002). High exposure (onabotA=90.9%, PNBs=80.0%, TPIs=70.9%) usually featured hands-on patient instruction (66.2%) and lectures (55.7%). Supervised performance rates were high (onabotA=65.5%, PNBs=60.0%, TPIs=52.7%), usually in continuity clinic (60.0%) or headache elective (50.9%). Headache specialists (69.1%) or general neurology (32.7%) faculty most commonly trained residents. Formal credentialing was uncommon (16.4-18.2%), mostly by documenting supervised procedures (25.5%). Only 27.3% of programs permitted trainees to perform procedures independently. Most PDs felt procedural exposure (80.0-90.9%) and competence (50.9-56.4%) by all trainees was important. Resident exposure to procedures for headache is high, but credentialing mechanisms, while desired by most PDs, are not generally in place. Implementation of a credentialing process may ensure trainees enter practice with the ability to perform procedures safely and effectively.

Is it time already to revise the Neurology Milestones?

The Accreditation Council for Graduate Medical Education (ACGME) has mandated a transition from competency-based to milestone-based assessment of residents.1 As of 2014, each accredited US neurology program must track resident progress toward 240 specific achievements or anchor statements in 29 domains. Collectively, these are called the Neurology Milestones.2

Milestone-compatible neurology resident assessments: A role for observable practice activities.

Beginning in 2014, US neurology residency programs were required to report each trainee's educational progression within 29 neurology Milestone competency domains. Trainee assessment systems will need to be adapted to inform these requirements. The primary aims of this study were to validate neurology resident assessment content using observable practice activities (OPAs) and to develop assessment formats easily translated to the Neurology Milestones. A modified Delphi technique was used to establish consensus perceptions of importance of 73 neurology OPAs among neurology educators and trainees at 3 neurology residency programs. A content validity score (CVS) was derived for each neurology OPA, with scores ≥4.0 determined in advance to indicate sufficient content validity. The mean CVS for all OPAs was 4.4 (range 3.5-5.0). Fifty-seven (78%) OPAs had a CVS ≥4.0, leaving 16 (22%) below the pre-established threshold for content validity. Trainees assigned a higher importance to individual OPAs (mean CVS 4.6) compared to faculty (mean 4.4, p = 0.016), but the effect size was small (η(2) = 0.10). There was no demonstrated effect of length of education experience on perceived importance of neurology OPAs (p = 0.23). Two sample resident assessment formats were developed, one using neurology OPAs alone and another using a combination of neurology OPAs and the Neurology Milestones. This study provides neurology training programs with content validity evidence for items to include in resident assessments, and sample assessment formats that directly translate to the Neurology Milestones. Length of education experience has little effect on perceptions of neurology OPA importance.

Lundbeck Adds to Neurology Portfolio with Chelsea Therapeutics Acquisition

H. Lundbeck has agreed to buy Chelsea Therapeutics for US$530 M upfront in order to add the orphan drug Northera™ (droxidopa) to its US neurology portfolio. After previously being rejected by the US FDA, Northera was granted accelerated approval in February 2014 for the treatment of symptomatic neurogenic orthostatic hypotension. Chelsea shareholders will also receive contingent value rights that could pay up to US$1.50 per share dependent on sales levels of Northera in the period 2015-2017, bringing the potential total deal value to US$658 M.

Low Doses of Melatonin Promote Sleep Onset and Maintenance in Older People—An Update

Plasma melatonin levels in young adults are about 10-fold higher during the night than during daylight hours, and these high levels promote both the onset of sleep at bedtime and the speedy resumption of sleep after premature nocturnal awakenings. With aging, melatonin’s nocturnal secretion from the pineal gland declines, as do plasma melatonin levels, total sleep time, and sleep efficiency. A very small dose (0.3 mg) of melatonin is usually sufficient to restore nighttime plasma melatonin levels to those characteristic of young people, and to accelerate the resumption of sleep after premature awakenings. The much larger doses that are marketed can produce side effects that are not observed when the melatonin in the plasma derives solely from its secretion by the pineal. Very high doses may also desensitize melatonin’s receptors in the brain, subsequently diminishing melatonin’s efficacy in promoting sleep. This article updates an earlier summary (Richard J Wurtman, Use of melatonin to promote sleep in older people,US Neurology, 2012;8(1):10–1) of melatonin’s utility in promoting sleep among older people.

International electives in neurology training

To ascertain the current status of global health training and humanitarian relief opportunities in US and Canadian postgraduate neurology programs. There is a growing interest among North American trainees to pursue medical electives in low- and middle-income countries. Such training opportunities provide many educational and humanitarian benefits but also pose several challenges related to organization, human resources, funding, and trainee and patient safety. The current support and engagement of neurology postgraduate training programs for trainees to pursue international rotations is unknown. A survey was distributed to all program directors in the United States and Canada (December 2012-February 2013) through the American Academy of Neurology to assess the training opportunities, institutional partnerships, and support available for international neurology electives. Approximately half of responding programs (53%) allow residents to pursue global health-related electives, and 11% reported that at least 1 trainee participated in humanitarian relief during training (survey response rate 61%, 143/234 program directors). Canadian programs were more likely to allow residents to pursue international electives than US programs (10/11, 91% vs 65/129, 50%, p = 0.023). The number of trainees participating in international electives was low: 0%-9% of residents (55% of programs) and 10%-19% of residents (21% of programs). Lack of funding was the most commonly cited reason for residents not participating in global health electives. If funding was available, 93% of program directors stated there would be time for residents to participate. Most program directors (75%) were interested in further information on global health electives. In spite of high perceived interest, only half of US neurology training programs include international electives, mostly due to a reported lack of funding. By contrast, the majority of Canadian programs that responded allow international electives, likely due to clearer guidelines from the Royal College of Physicians and Surgeons of Canada compared to the Accreditation Council of Graduate Medical Education. However, the number of both Canadian and US neurology trainees venturing abroad remains a minority. Most program directors are interested in learning more information related to global health electives for neurology residents.

The globalization of US and Canadian neurology residency training

Neurology is becoming increasingly global, including practice, research, and education. Indeed, more than one-third of attendees at the American Academy of Neurology (AAN) annual meeting come from abroad (personal communication, AAN, September 10, 2013), and in 2012, approximately 64% of all manuscripts submitted to Neurology® came from outside the United States (personal communication, Kathy Pieper, September 9, 2013). There is a growing interest in global health electives by US and Canadian medical students and residents, who are increasingly seeking opportunities for international electives. In this issue of Neurology , Lyons et al.1 report the results of a survey to assess opportunities for global health electives in neurology residency training programs conducted by the AAN Graduate Education Subcommittee and the Member Research Subcommittee. They found that such electives are few, occurring in just over half of the responding programs; lack of funding appears to be the major obstacle in setting up such electives. Although only 61% of neurology program directors completed the survey, which may have skewed the results, 3 major themes emerged from the comments posed by the survey respondents.

Supply and demand analysis of the current and future US neurology workforce.

This study estimates current and projects future neurologist supply and demand under alternative scenarios nationally and by state from 2012 through 2025. A microsimulation supply model simulates likely career choices of individual neurologists, taking into account the number of new neurologists trained each year and changing demographics of the neurology workforce. A microsimulation demand model simulates utilization of neurology services for each individual in a representative sample of the population in each state and for the United States as a whole. Demand projections reflect increased prevalence of neurologic conditions associated with population growth and aging, and expanded coverage under health care reform. The estimated active supply of 16,366 neurologists in 2012 is projected to increase to 18,060 by 2025. Long wait times for patients to see a neurologist, difficulty hiring new neurologists, and large numbers of neurologists who do not accept new Medicaid patients are consistent with a current national shortfall of neurologists. Demand for neurologists is projected to increase from ∼18,180 in 2012 (11% shortfall) to 21,440 by 2025 (19% shortfall). This includes an increased demand of 520 full-time equivalent neurologists starting in 2014 from expanded medical insurance coverage associated with the Patient Protection and Affordable Care Act. In the absence of efforts to increase the number of neurology professionals and retain the existing workforce, current national and geographic shortfalls of neurologists are likely to worsen, exacerbating long wait times and reducing access to care for Medicaid beneficiaries. Current geographic differences in adequacy of supply likely will persist into the future.

The Current State of Sleep Medicine Education in US Neurology Residency Training Programs: Where Do We Go from Here?

To evaluate the current state of sleep medicine educational resources and training offered by US neurology residency programs. In 2010, a 20-item peer reviewed Sleep Education Survey (SES) was sent to neurology residency program directors surveying them about sleep medicine educational resources used in teaching residents. Pearson product momentum correlation was used to determine correlation of program attributes with resident interest in pursuing a career in sleep medicine. Of the programs completing the survey, 81% listed a formal sleep rotation and 24% included a forum for sleep research. A variety of innovative approaches for teaching sleep medicine were noted. Program directors noted that 5.7% residents entered sleep medicine fellowship training programs in the preceding 5 years. Programs that had a more substantial investment in sleep medicine teaching resources were more likely to report residents entering a sleep medicine training program. This is the first report providing an analysis of the current state of sleep medicine training in US Neurology Residency Programs. Our data provide evidence that investment by the residency program in sleep education may enhance the ultimate decision by the neurology trainee to pursue a career in sleep medicine.

Spotlight on the January 8 issue

#### Notable in Neurology this week This issue features an article that describes the epileptology and cognitive regression seen in MECP2 duplication syndrome; another characterizes the topography of tau pathology, using [11C]PBB3 PET, in patients with amyotrophic lateral sclerosis/parkinsonism-dementia complex on Japan's Kii Peninsula. A featured Contemporary Issues article analyzes US neurology residents' survey reports on educational debt, fellowship application, and readiness for practice. ### Development and validation of a score to detect paroxysmal atrial fibrillation after stroke Paroxysmal atrial fibrillation (pAF) in patients with acute stroke frequently escapes routine diagnostic …

The Current State of Sleep Medicine Education in US Neurology Residency Training Programs: Where Do We Go from Here?

The Current State of Sleep Medicine Education in US Neurology Residency Training Programs: Where Do We Go from Here?

Telemedicine in Leading US Neurology Departments

To determine the current practice and plans for telemedicine at leading US neurology departments. An electronic survey was sent to department chairs, administrators, or faculty involved in telemedicine at 47 neurology departments representing the top 50 hospitals as ranked by U.S. News and World Report. Current use, size, scope, reimbursement, and perceived quality of telemedicine services. A total of 32 individuals from 30 departments responded (64% response rate). The primary respondents were neurology faculty (66%) and department chairs (22%). Of the responding departments, 60% (18 of 30) currently provide telemedicine and most (n = 12) had initiated services within the last 2 years. Two thirds of those not providing telemedicine plan to do so within a year. Departments provide services to patients in state, out of state, and internationally, but only 6 departments had more than 50 consultations in the last year. The principal applications were stroke (n = 14), movement disorders (n = 4), and neurocritical care (n = 3). Most departments (n = 12) received external funding for telemedicine services, but few departments (n = 3) received payment from insurers (eg, Medicare, Medicaid). Reimbursement (n = 21) was the most frequently identified barrier to implementing telemedicine services. The majority of respondents (n = 20) find telemedicine to be equivalent to in-person care. Over 85% of leading US neurology departments currently use or plan to implement telemedicine within the next year. Addressing reimbursement may allow for its broader application.

Neurocritical care education during neurology residency

Limited information is available regarding the current state of neurocritical care education for neurology residents. The goal of our survey was to assess the need and current state of neurocritical care training for neurology residents. A survey instrument was developed and, with the support of the American Academy of Neurology, distributed to residency program directors of 132 accredited neurology programs in the United States in 2011. A response rate of 74% (98 of 132) was achieved. A dedicated neuroscience intensive care unit (neuro-ICU) existed in 64%. Fifty-six percent of residency programs offer a dedicated rotation in the neuro-ICU, lasting 4 weeks on average. Where available, the neuro-ICU rotation was required in the vast majority (91%) of programs. Neurology residents' exposure to the fundamental principles of neurocritical care was obtained through a variety of mechanisms. Of program directors, 37% indicated that residents would be interested in performing away rotations in a neuro-ICU. From 2005 to 2010, the number of programs sending at least one resident into a neuro-ICU fellowship increased from 14% to 35%. Despite the expansion of neurocritical care, large proportions of US neurology residents have limited exposure to a neuro-ICU and neurointensivists. Formal training in the principles of neurocritical care may be highly variable. The results of this survey suggest a charge to address the variability of resident education and to develop standardized curricula in neurocritical care for neurology residents.