Last month, Neurology Today discussed the changes in neurology residency programs that have resulted from new federal regulations limiting the working hours of all resident trainees and by the rapidly changing US economic and legal climates. This month, Neurology Today interviewed experts on changes in the actual training of residents triggered by new requirements from the Accreditation Council for Graduate Medical Education (ACGME).
Prior to about 1990, neurology had limited formal super-specialization. Most neurologists in practice were trained to diagnose and treat the full spectrum of disease and to include in their armamentarium the performance and interpretation of EEGs, EMGs, and evoked potentials.
The majority of neurology training programs included exposure to all these areas through inpatient rotations and outpatient clinics. How have things changed since then?
THE SIX CORE COMPETENCIES
John Corboy, MD, Associate Professor of Neurology, Director of the University of Colorado MS Center in Denver, and Chairperson of the AAN Graduate Education Subcommittee, has served as a program director for adult neurology for seven years.
“A major influence has been the ACGME introduction of the six core competencies, including patient care and medical knowledge – the ‘basics’ – but now also including professionalism (and ethics), communication skills, practice-based learning, and systems-based practice,” he said.
“Through the AAN committee, we are trying to develop ways in which programs can teach and assess these less concrete topics,” he added.
Neurology subspecialty material has increased considerably over the past decade and program directors now face the daunting task of imparting a substantial clinical education to their residents. Steven L. Galetta, MD, Director of the Division of Neuro-Ophthalmology of the Department of Neurology and recipient of the 2004 American Neurological Association Distinguished Neurology Teacher Award, has served as Director of Neurological Training at the University of Pennsylvania Medical Center in Philadelphia since 1989.
“The fundamental goal of our program has remained the same, namely to train outstanding clinical neurologists,” Dr. Galetta told Neurology Today. “We need to incorporate the methodology of being an apprentice by having our residents observe great clinicians and to provide them with a strong inpatient experience. Additionally, a training program needs to provide residents with a broad exposure to a diverse number of subjects.”
OUTPATIENT SUBSPECIALTY ROTATIONS
To increase the residents' exposure to clinical material, the Penn neurology residency program formed outpatient rotations in neuro-ophthalmology, movement disorders, cognitive neurology, multiple sclerosis, stroke, epilepsy, neuro-oncology, and neuromuscular disease, and most residents spend some time in each rotation. In addition, they created an ambulatory-emergency rotation – a favorite among the residents – in which they see outpatients who need urgent attention.
The Penn program has also made communication skills training a priority. The oral and written proficiencies of residents are evaluated by attendings, colleagues, nursing staff, and secretaries. They have instituted an oral examination in which each resident is formally observed while performing a history and examination on an outpatient; this is repeated during the subspecialty rotations on an informal basis several times.
“We have asked each resident mentor to review periodically the residents' outpatient records,” Dr. Galetta said. “In this process, we examine their written communication skills serially. This past year, we even brought in an English teacher to give us pointers on how to enhance written communications skills.”
Another innovation at Penn is its patient-oriented research curriculum. The residents are taught principles of epidemiology, how to write a research proposal and a case report, and how to interpret the literature. The resident is exposed to different mentors ranging from those in practice or industry to those who conduct clinical or basic research. By the end of training, residents have chosen a mentor and made a formal clinical or basic research presentation before the entire faculty; many use this as a springboard to apply for external funding. “This has been an invaluable program for our residents, regardless of the career path they have chosen,” Dr. Galetta said.
Commenting on curricular changes, Dr. Corboy observed that more about imaging is being taught, and that this is replacing neuropathology within curricula. In addition, he noted a greater emphasis – it is actually a requirement – to provide research opportunities for residents. For example, our Colorado program has a mandatory research component. In addition, there is a formal requirement for one month of psychiatry training, as of this year.”
Justin C. McArthur, MBBS, MPH, Professor of Neurology and Epidemiology at Johns Hopkins University in Baltimore, MD, and Neurology Training Program Director there since 1996, has expanded his training program to meet current demands.
“We have initiated a combined a six-year Neurology-Radiology-Neuroradiology program leading to triple certification in all three areas – with the aim of developing academic neurologists trained in imaging,” he said.
Residency programs differ somewhat in terms of their in-patient and out-patient care needs. “We have increased the number of pediatric and adult residency slots by two (now a total of eight each year) in order to capitalize on the tremendous increase in admissions – 25 percent in three years – and to make it possible to meet the work hours restrictions,” Dr. McArthur said. “We have also opened two neuro-ICU units with 31 beds without increasing the number of weeks our residents work in the unit.”
Peter D. Donofrio, MD, Professor of Neurology and Acting Chairman of Neurology at Wake Forest University in Winston-Salem, NC, noted that more teaching is done on the consultation service because of the high incidence of neurological complications of systemic illnesses. “Additional training is being done in the outpatient setting because fewer patients with neurologic disorders are admitted to the hospital.”
Dr. Corboy noted, “There has been a move to incorporate more outpatient training, and this has since become required by the Residency Review Committee (RRC).”
But even the character of outpatient training has shifted because of regulatory changes, he explained: “Gone are the days when a trainee could just spend a month with Dr. Jones in private practice learning movement disorders. RRC requirements mandate that all trainers have formal agreements with the home department. Furthermore, Medicare has tightened the auditing of residents' time for which they pay the local Graduate Medical Education division. If time spent with formal trainers is not documented, Medicare will not pay for that month.”
PROFESSIONALISM & ETHICS
The core competencies have imparted responsibilities for training program directors that extend beyond the objective clinical subject matter. But what is the ideal way to teach more abstract material such as professionalism, ethics, and communication? James L. Bernat, MD, Professor of Medicine (Neurology) at Dartmouth Medical School and former Chair of the AAN Ethics, Law and Humanities Committee, said, “The best way for residents to learn professionalism is for them to observe it in the day-to-day practice of their attendings. Residency is a form of apprenticeship in which those in training are still modeling their behavior, in essence learning by emulating those around them.”
The AAN Committee has developed a case-based curriculum that has been implemented by a number of neurology training programs in the US. Lori Ann Schuh, MD, Neurology Residency Program Director at Henry Ford Health System in Detroit, MI, was trying to figure out how to address the core curriculum requirements when she came across the AAN's Ethical Dimensions of Neurologic Practice: A Case-Based Curriculum for Neurology Residents.
“I read part of it and realized that the cases were interesting, relevant to clinical practice, and had extremely well written case notes, so even without training in ethics, I felt comfortable leading case discussions on these topics,” she said. “Although I did not have a strong interest in ethics prior to facilitating this course, I was impressed by how much I learned from the curriculum and realized this would have been really useful to me as a clinician for the past 10 years.”
Examples of cases include: Truth-telling and Disclosure; Presymptomatic Genetic Testing; Persistent Vegetative State; Brain Death and Stopping Treatment; Physician-assisted Dying; Clinical Trials; Mistakes; and Professional Misconduct of a Sexual Nature. This course, held for one hour per week during a ten-week block, every three years, is offered to each neurology resident once during training. Other courses held on alternating years of training are End-of-life Palliative Care and Psychiatry.
Dr. Bernat reflected on the manner in which neurologists are best influenced. “Those of us that teach have a tremendous responsibility to teach by example, by demonstrating respect to patients and family members, by remaining calm and honest, and by showing professionalism.”
AT HOPKINS AND UPENN, A RESIDENCY EXCHANGE PROGRAM
The Departments of Neurology at Johns Hopkins University and the University of Pennsylvania have partnered in an exchange program to offer a greater variety of educational opportunities for their residents.
Beau M. Ances, MD, PhD, a PGY-4 resident at the University of Pennsylvania Neurology Training Program, participated in the program last October. “I spent one month at Hopkins under the preceptorship of Justin McArthur, MD, PhD, who is a world expert and master clinician in the field of Neuro-AIDS, he said. “Dr. McArthur is also a neuroscientist who has perfected the punch biopsy technique used in related neuropathies. He allowed me to create an individualized rotation and work with a variety of other experts on his team as well as to tour with the Infectious Diseases group at Hopkins.”
Dr. Ances, who plans to go on to a fellowship in Neuro-AIDS next year, took advantage of the program at Hopkins, which has a well-developed inpatient and outpatient service. “This rotation provided me with an invaluable experience,” he said. Faculty and house staff also meet once a year to discuss cases at Winterthur, an estate in Delaware located at a geographical mid-way point.
Said Dr. Ances: “As a resident, you are trained to think about patient cases in a certain way, but when you discuss them with residents at another program you learn that there is more than one way to approach them.”