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The Role of Training in Electrodiagnostic Techniques in the Neurology Residency — How Much Is the Right Amount?

ARTICLE IN BRIEF

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IN 61 PERCENT of training programs, neurology residents performed electromyography only when a faculty member was in the room, rather than independently after mastering the technique.

A survey sponsored by the American Association of Neuromuscular and Electrodiagnostic Medicine found that training in electrodiagnostic medicine varies in depth and availability for neurology residency programs. Neuromuscular experts say the inconsistencies in training could have a dire impact on patient care.

Electromyography and nerve conduction studies remain central to diagnosis in neurology, and most residents receive some training in performing and interpreting these studies. But with the growth of new subspecialties and new diagnostic techniques, how much training in the fundamentals of electrodiagnosis is enough?

A new survey suggests that residency programs across the country are answering that question in highly different ways, with some residents receiving many weeks of hands-on experience, while others receive little to none at all. The results were presented in October at the annual meeting of the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM).

“As neurology has evolved, so have the training programs and how we distribute time for residents to learn and be exposed to the many aspects of neurology that they need,” said Eric J. Sorenson, MD, FAAN, professor of neurology at Mayo Clinic in Rochester, MN, and former president of the AANEM. “Unfortunately, electrodiagnostic medicine is one area that has felt pressure of more limited time. The question raised by this study is, how can we ensure that our trainees are getting the high-quality experiences they need to meet the needs of patient care?”

SURVEY RESPONSES

The new survey, which was sponsored by the AANEM Education Committee and led by Peter D. Donofrio, MD, FAAN, professor of neurology at Vanderbilt University, went out to 380 neurology and physical medicine and rehabilitation (PM&R) programs across the country. Questions addressed the length of training, the kinds of techniques residents observed and practiced, the number of procedures they performed, the degree of supervision, and the types of exams that were required before progressing in the training.

Ninety-six programs sent in responses, about two-thirds of which were in neurology and one-third in PM&R. Within neurology programs, residents spent an average of 8.4 weeks in their electrodiagnostic rotation, mainly in the second or third year of residency. But that average included an enormous range, from no training at all to several months or more. In about half of the programs, the training was continuous, while in the other half it was broken up, either within a single year or across two years.

That range of experience was not just time spent in rotation, but also the level of hands-on training the resident received. In 8 percent of programs, residents observed needle electromyography (EMG) examinations, but never performed them. In 61 percent of programs, they performed them only when a faculty member was in the room, rather than independently after mastering the technique. In more than one third of programs, residents performed 10 or fewer exams. Figures were roughly similar for nerve conduction studies.

“The most concerning finding was the variability among programs,” said Dr. Donofrio. “Neurology residents who have received little training and who have had little hands-on opportunity would not be well-prepared to go into practice and perform nerve conduction studies and EMG.”

PM&R residents received far more training than neurology residents, the survey showed. The average length of training was 21.3 weeks, during which residents performed over 100 procedures of each type, with at least one program expecting them to perform at least 250 procedures.

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DR. RAFAEL H. LLINAS: “Electrodiagnosis is difficult, and every single test you do makes you better. The residents also interpret studies of 50 patients, to learn how to become proficient at judging the quality of electrodiagnostic studies they have not performed themselves.”

WHY THERE ARE TRAINING DISPARITIES

“Certainly one reason that PM&R residents receive so much more training than neurology residents is that the Accreditation Council for Graduate Medical Education program committee requires it,” said Ezgi Tiryaki, MD, FAAN, associate professor of neurology at the University of Minnesota and former director of the neurology residency program there. “Because it is a requirement, it drives behavior in the field. There is no such requirement for neurology program certification.”

Dr. Tiryaki currently trains PM&R residents in electrodiagnosis as associate chief of staff for education within the Minneapolis VA Health Care System.

That requirement reflects the history of the field, James Leonard, MD, professor of physical medicine and rehabilitation at the University of Michigan, told Neurology Today. “Our field has always considered electrodiagnosis to be an integral skill to our specialty,” more so than in neurology, “and mastery of this diagnostic skill to be part of our basic residency training rather than something to be mastered during fellowship.”

But neurology residency directors also think that electrodiagnostic training is essential for their residents. “EMG and NCS are irreplaceable,” said Rafael H. Llinas, MD, FAAN, program director of the neurology residency program at Johns Hopkins University and chairman and neurologist in chief at the Johns Hopkins Bayview Medical Center. “Because they are physiologic tests, they can find abnormalities the patient has never noticed.”

At Johns Hopkins, residents are required to do a four-week rotation and perform at least 10 and preferably 25 or more whole studies themselves. “Electrodiagnosis is difficult, and every single test you do makes you better,” he said. The residents also interpret studies of 50 patients, to learn how to become proficient at judging the quality of electrodiagnostic studies they have not performed themselves.

“That is probably the most important thing they learn,” Dr. Llinas said. Performing the procedures helps inform that judgment, he noted. “They can see what parts are the most difficult. When they read reports, the residents are taught to look there first, because if it is done wrong, it is unlikely to be a useful study.”

During his own residency, Dr. Llinas noted, he was required to perform the techniques, interpret the results, and send a preliminary report to the clinical team. After that, the results would be re-read by faculty, who wrote the official report, “and if we were wrong, we'd have to call the clinical team back to report the change. It focused the mind, because we were responsible for it.”

IMPACT ON PATIENT CARE

Elizabeth Raynor, MD, associate professor of neurology at Harvard Medical School, who directs the EMG Fellowship training program at Beth Israel Deaconess Hospital, said: “The wide range in the training programs revealed in the AANEM survey has consequences for patient care, and professional societies have a role in creating standards that would be more broadly observed.

The appropriate scope of training for residents should be determined by a working group on the subject, comprised of experts in the field of EMG who have interest and expertise in education.”

As for the particulars of the ideal training program, Dr. Tiryaki suggested that not only duration, but timing, is crucial. Most residents spend their first year after internship largely focused on hospital-based care and have little exposure to the many other aspects of neurology practice before making a decision about subspecialty. “Naturally, then a lot of residents are drawn to concentrate on stroke or hospitalist medicine,” she said, “because that's what they've experienced, and that's what they know best. Many programs are struggling to get more exposure to all the different facts of neurology into the earliest part of residency.”

Ideally, she said, the first few months of training “would be a kind of boot camp,” with exposure to all the basics of diagnosis, including electrodiagnostics, lumbar puncture, and imaging, and include outpatient care.

“Of all the tests we have, electrodiagnostic tests are a very close extension of the physical examination that we do to determine where the problem lies,” Dr. Tiryaki said. “On the other hand, these are very operator-dependent procedures, and there is a lot of room for technical error. Having less hands-on knowledge of them may make it easier to misunderstand certain findings. In two months you can't train someone to be really good at EMG, but you can give them the exposure to the techniques and the pitfalls. In the lab, once residents deliver the current and get the response themselves, they get engaged — there is a real ‘Aha!’ moment, and a big growth in understanding.”

LINK UP FOR MORE INFORMATION:

• AANEM Training Program Partnership: bit.ly/NT-AANEM