Neurology has evolved from a contemplative and diagnostic discipline relying largely on individual clinical acumen into a complex, technology-dependent, treatment-oriented, and multi-branched medical subspecialty. Moreover, neurologists in practice today require more than just medical skills and knowledge to survive in an environment of managed care, increasing expenses, decreasing revenues, and high malpractice exposure. Traditional Socratic training program curriculums may no longer provide adequate preparation for the variety of challenges that face young physicians ready to embark on professional careers. How have neurology residency programs in the US adapted to these changes, and what are they doing to keep clinical neurology viable?
Although the Accreditation Council for Graduate Medical Education (ACGME) addressed such concerns with a redesign of training requirements a few years ago when it created six broad competency areas, the response has been variable.
For neurology training programs, already swamped with regulatory paperwork, the additional administrative responsibility is not minor. From interviews with residency program directors around the country, it is apparent that there are diverse philosophies as to how best fulfill this burden and to address the needs of neurologists-in-training as they emerge into the real world of 21st century medicine.
Joel C. Morgenlander, MD, Associate Professor of Medicine and Chief of Clinical Services of the Division of Neurology at Duke University School of Medicine in Durham, NC, and Director of Residency Training for the past 11 years, has revamped his approach to establish comprehensive practice readiness as the pervasive objective.
INTEGRATING BUSINESS EDUCATION
“The integration of business education begins on day one when residents are given a handheld Peripheral Brain program, which includes the single specialty neurology exam incorporating bullets for E/M coding,” he said. “Teaching neurologists how to document properly is more readily accomplished early on, before resentment and frustration to this task builds. Most neurologists are compulsive and are doing the work already.”
Dr. Morgenlander incorporates business issues into daily rounds and conferences for his housestaff and faculty. “If you leave practice management issues to the last minute, residents will recognize that you don't value their importance.”
“I look at this issue as part of my obligation to my residents,” he explained. “I need to make sure that they understand why business is not an abstraction. If they finish this program and don't have a sense of billing, coding, and how to run a practice, I will have cheated them out of part of their education.”
His curriculum includes discussions of coding issues including E/M, CPT, modifiers, and ICD-9; front-end processes including scheduling, insurance verification, authorization, and pre-certification; and back-end processes such as carrier policies, bundling, medical necessity, claim adjudication, denials management, and managed care contracting. “The residents' understanding of some of these concepts is basic but builds throughout training,” said Dr. Morgenlander. He also invites outside experts to discuss issues such as how to evaluate a practice opportunity, what to consider in purchasing health, life, and disability insurance policies, and how to handle risk management issues.
ACADEME OR PRIVATE PRACTICE
Although those who complete neurology training at Duke are split evenly between careers in private practice and in academics, Dr. Morgenlander does not believe there is a distinction in the need for this type of training. “It used to be that if you were going into academics when you trained, you were told that ‘it will be taken care of for you.’ But it has become clear that if you delegate these tasks, they will be performed with less accuracy and efficiency. By prioritizing coding and billing practices, you can assist the hospital in getting their greatest profit margin. This ultimately may translate into a new neurology resources such as neurovascular equipment or an expanded sleep laboratory … it's a win-win situation.”
Dr. Morgenlander also regards this capability as a patient care issue. “If you have a patient with a multifocal motor neuropathy who can't get IVIG because a carrier has denied it as not medically necessary, it affects your patient. It may be an annoyance, but if you want to truly care for your patients, you need to understand how to code and then work with the carriers to understand the medical literature.”
Other neurology program directors are beginning to offer similar training. Patrick S. Reynolds, MD, Assistant Professor and Neurology Residency Program Director for the Wake Forest University Department of Neurology in Winston-Salem, NC, and member of the AAN Graduate Education Subcommittee, said, “Ten years ago when I was a resident, we received no training in this area. Now, we have formal lectures on subjects such as coding and billing and negotiations of contracts; additionally, a resident sits on our departmental clinic operations committee to receive first-hand exposure to the practical aspects of running our practice.”
EFFECT OF LIMITED WORK HOURS
Each program director reflected on the new rules that limited work hours and triggered many operational adjustments. John Corboy, MD, Associate Professor of Neurology, Director of the University of Colorado MS Center in Denver, and Chair of the AAN Graduate Education Subcommittee said: “There is a clear upside in terms of sleep and attentiveness. This has resulted, however, in a culture shift in which inpatients are passed off frequently between physicians, and continuity of care has been significantly altered.”
“In addition, conference attendance has been adversely affected – as residents must go home after being on-call for 24 hours – and clinics have disruptions due to resident absences.”
The regulation has also resulted in an increased level of supervision of the residents, Dr. Corboy said. The benefits include enhanced care for the patient, but may have caused unintended consequences such as delaying independent decision-making by the residents and increasing the workload of the attending and supervising physicians.
“On the inpatient services now, the residents have maximum work hours and restricted call; the attendings do not,” Dr. Corboy continued. “In essence, we have become the continuity of care.” Dr. Corboy also noted that inpatient training has become more intense in the sense that inpatients are sicker – in part due to who gets admitted to the hospital – and because there are more interventions on sicker people with their attendant neurological complications.
Dr. Corboy wondered: “With the decreased workloads of residents, and resultant increased workloads of the faculty, not to mention more documentation and more supervision, will potential academic neurologists just skip it and enter practice or industry?”
But Steven L. Galetta, MD, Director of the Division of Neuro-Ophthalmology of the Department of Neurology, and Director of Neurological Training at the University of Pennsylvania Medical Center in Philadelphia since 1989, noted that 75 to 80 percent of University of Pennsylvania-trained neurologists enter academics. “Residents realize that there has been a closing of the gap in salaries in recent years and that they will be slightly more sheltered from the malpractice crisis in academic settings,” said Dr. Galetta, recipient of the 2004 Distinguished Neurology Teacher Award from the American Neurological Association.
TEACHING ABOUT RISK MANAGEMENT
As for preparing residents for the troubled med-mal environment, most programs do not offer or are just beginning to consider formal preparation. “At Wake Forest, risk management is provided to residents as a common curriculum during the last week of June each year before they begin residency training,” said Peter D. Donofrio, MD, Professor and Interim Chair of Neurology at Wake Forest University School of Medicine.
Dr. Reynolds added: “In addition, we provide our residents with lectures regarding risk management issues in their ongoing lecture series and the subject is discussed in our monthly morbidity and mortality conference.”
“Neurology is getting really exciting. There has been an explosion of therapeutics in the past three to four years,” said Dr. Galetta, “and it is no longer a specialty in which nothing can be done for the patient. Consequently, there has been an unbelievable improvement in the quality and number of applicants.”
Dr. Corboy agrees. “It is an exciting time in neurology training, in part because of the major advances in basic science and treatment options – such as a new drug for MS for example. But it also is very challenging, with work rule changes for residents, increasing demands for teaching – especially in ways in which we ourselves are not trained, for example, the core competencies – and all the financial constrictions. But at the end of the day, when I might be very frustrated with a number of things, and I ask myself what I would do if I left medicine or neurology, the answer always is, ‘I can't see that happening, because this is what I am.’”
Next month's column will focus on curricular changes in neurology training programs.